Managing Sports Injuries in Children

from School Health Reporter, Winter 2006

By K. Brooke Pengel, MD, Pediatric and Adolescent Sports Medicine, The Children's Hospital

Imagine an elite 8-year-old gymnast. Or a competitive 10-year-old hockey player. Perhaps a 12-year-old soccer player on a traveling team.

In the last few decades, more and more young children and adolescents are participating in organized sports. Each year, more than 25 million young people participate in organized sports. Children and adolescents frequently play one competitive season after another, occasionally with overlapping practices and competitions. This article is designed to provide parents, coaches and health-care providers with a better understanding of the emotional and physical impact competitive sports can have on youth.

Recognizing the Signs of “Burnout”

The pressure to compete and to win in youth sports has the potential to be overwhelming and unhealthy. The term “athletic burnout syndrome,” or “overtraining syndrome,” occurs when athletes are training under excessive pressure.  The terms refer to a physical and emotional state that is often characterized by chronic fatigue, anxiety, depression and/or loss of previously mastered skills. Burnout in children is fortunately uncommon, as participating in sports has primarily positive effects on young individuals.  Children can learn about teamwork and about handling victory and defeat. Participation builds social skills and often leads to increased self-esteem. However, when extreme pressure is placed on a young athlete, this can result in a negative experience, despite the overall benefits of sports participation.

Children who specialize in one particular sport at an early age are often most at risk for burnout. The athlete may be self-motivated, but occasionally a coach or parent will overzealously pressure the talented child. Success and  “winning at all costs” may be valued over fun. The American Academy of Pediatrics released a position statement in 2000 that cautioned against early specialization in sports, citing that “research supports the recommendation that child athletes avoid early sports specialization. Those who participate in a variety of sports and specialize only after reaching the age of puberty tend to be more consistent performers, have fewer injuries, and adhere to sports play longer than those who specialize early.”

Early recognition of the signs of burnout is one of the keys to the initial treatment. Emphasizing enjoyment over winning and focusing on performance and skill enhancement rather than the score or outcome are extremely important. Ideally, preventive measures can be instituted early in sports participation. Parents can encourage other noncompetitive sports or social activities, or they can schedule short breaks from the sport.

Types of Sports Injuries: Acute and Chronic

With increased demands placed on a growing skeleton, young athletes are particularly prone to musculoskeletal injury. Injuries can be classified into two main categories:  acute and chronic.

Acute Injuries

An acute injury generally occurs suddenly, usually as a result of one specific event that is easily remembered by the athlete. Examples of acute injury include contusions, muscle strains, ligament sprains, fractures and dislocations.

Symptoms of acute injury

• Sudden, severe pain
• Swelling and bruising
• Extreme tenderness to touch
• Deformity or obvious dislocation/fracture
• Inability to bear weight or use the extremity
• Difficulty moving the extremity

Injuries in children can occur at areas of growth in the bone, commonly referred to as growth plates or growth centers. The growth plates that add length to the bone are located at the ends of the long bones. Growth plates can be particularly vulnerable to injury at specific ages. For example, acute growth-plate fractures usually occur in early adolescence, as the ligaments are mechanically stronger than the growth plate.

A representative case occurs in athletes who twist their ankles. The most common mechanism is an inversion force, which can cause a growth-plate fracture in the fibula in a young athlete. In contrast, older adolescents and adults usually sustain soft-tissue injuries such as ligament sprains. In young athletes, fibula fractures are often mistaken for ankle sprains, which often require less aggressive treatment. That is, fibula fractures in the very young athlete are best treated with a course of immobilization, usually in a cast. In contrast, it is often best to minimize the period of time for strict immobilization for a sprain.  Injuries in the upper extremities often follow a similar pattern to ankle injuries. For instance, growth plates in the forearm, elbow and upper arm are vulnerable to fracture at young ages, and as skeletal maturity ensues, soft-tissue injuries such as sprains and strains are often more likely to occur.

Another type of growth plate present in young individuals is referred to as an apophysis, where the junction of a muscle tendon unit inserts onto growing bone. This type of growth plate does not add length to the bone, as do the growth centers that are located at the end of the long bones.  An example of an acute injury to an apophysis would be an avulsion fracture, where a portion of the bone is pulled off or avulsed, resulting in a fracture. A common location for this type of injury is in the hip, where the muscle-bone junctions are active growth centers until the late teens.  The injury is characterized by acute pain, perhaps with a “popping” sensation, during a vigorous running or jumping episode, such as running to first base. Weight bearing becomes difficult, and motion about the hip is limited.

Although parents and those caring for young athletes worry about acute injuries resulting in fracture, most of the injuries are soft tissue in nature and tend to heal without complication. Contusions, strains and sprains are common and can be diagnosed once the possibility of a fracture has been eliminated.

Management of Acute Injury

The initial evaluation and management of sports injuries often rests on individuals who have not received formal training in sports injury care. Adhering to common principles of management, however, can ensure excellent outcomes even in cases of severe injury. There are specific situations in which immediate care should be sought. If the child has a suspected fracture with a deformity or a dislocation, if he has persistent numbness or tingling in a limb, or if the skin color near the injury is blanched or blue, the child should be taken to an emergency room immediately. For less severe injuries, it is safe to initiate home care for the injury. The RICE method of treating injuries is commonly known.

R - REST: Discontinue the painful activity.

I - ICE: Place an ice pack or bag on the injured area for 20 or 30 minutes at a time. Do not use ice directly on the skin. Ice helps to reduce swelling. Heat is not indicated for the treatment of an acute injury as it tends to increase bleeding and swelling.

C - COMPRESSION: Compression also can reduce swelling of the injured area. Compression can be achieved with an ace wrap, air cast or splint.  A splint also can function to protect the area from further injury.

E - ELEVATION: Elevation is an important technique to reduce swelling. To be most effective, the injured body part should be elevated above the level of the heart.

The RICE method of treating injuries is an excellent initial step. Medicines such as ibuprofen or acetaminophen, which are generally safe and well-tolerated, can be used for pain control. If the athlete responds to the treatment and is able to regain motion and function quickly – within a day or two – then it is probably safe to continue care at home. However, if there is continued concern about the injury because of persistent swelling, pain and dysfunction, a medical evaluation is warranted. Parents may choose to see their primary-care provider for the initial evaluation. Parents or the health-care provider may initiate a referral to a specialist. There are several types of physicians who specialize in the treatment of sports-medicine injuries. Both orthopedic and primary-care physicians may have specialty training in sports medicine.

The health-care provider overseeing the treatment for the injury will guide the athlete through rehabilitation.  Both acute and overuse injuries require a stepwise progression through the phases of rehabilitation. The severity of the initial injury and pain often will predict how rapidly an athlete will progress through the phases.

PHASE 1: Limit additional injury and control pain and swelling

PHASE 2: Improve strength and flexibility (range of motion) of the injured structures

PHASE 3: Progressively improve strength, flexibility, proprioception and endurance training until near-normal function is attained

PHASE 4: Return to exercise and sports symptom-free

Chronic Injuries

Chronic injuries are often referred to as overuse injuries as they occur when a certain area of the body is overused when playing a sport over a period of time. With increased participation, the incidence of overuse injuries in young athletes is remarkably and steadily increasing.  Approximately 30 percent to 50 percent of all pediatric sports injuries can be categorized as overuse. Overuse injuries tend to occur when tissue such as bone, cartilage or tendon is damaged by repetitive sub maximal loading.  Without adequate time for recovery, the tissue is not able to adapt to the demands placed on it. The body responds to the repetitive stress with an inflammatory response that damages the tissue and causes pain.

Athletes who specialize in one sport, particularly those who play throughout the year, are often susceptible to this type of injury. In each consecutive season, repetitive maneuvers are required of certain body parts; this may lead to fatigue and injury. Examples of overuse injuries include tendonitis, bursitis and stress fractures.

Symptoms of Chronic Injuries

• Pain when performing the activity or sport
• Intermittent swelling
• Decreasing performance
• Dull pain even at rest

Growth plates can be susceptible to both chronic and acute injuries. Accounting for a patient’s age during an evaluation is critical to ensure that the proper diagnosis is made. An overuse injury to the growth plate in the wrist in gymnasts is well-described in the literature. The injury comes on gradually, and is characterized by steadily increasing pain that eventually affects performance. The diagnosis is based on an exam showing tenderness over the growth plate and radiographs showing a widened, irregular growth plate.

The apophysis is particularly prone to overuse injury, a phenomenon labeled as apophysitis, or inflammation of the muscle tendon insertion onto the growing bone. One of the most common types of apophysitis is Osgood-Schlatter disease, which refers to pain and inflammation over the apophysis in the shin bone located just below the knee.  This growth plate near the knee tends to be most active in the 10- to 13-year-old age group. Athletic children in this age group often complain of chronic, activity-related pain and swelling directly over the growth plate. A similar scenario occurs in the heel bone in children usually from 9 years old to 11 years old, when the apophysis is most active in the heel.

A stress fracture is another good example of an overuse injury related to cumulative stress on the musculoskeletal system. Common locations where athletes develop stress fractures are in the tibia, fibula and metatarsal bones of the foot. A typical example would be an athlete, such as a runner, who gradually develops localized pain in the one of these locations. Eventually, pain occurs at rest.  Examination often reveals that the athlete can identify the painful area with the tip of a finger. True point tenderness is one factor that may help distinguish a stress fracture from the more common overuse injury in the shin (often referred to as shin splints). A true case of “shin splints” likely represents inflammation of the muscles/bone interface of the anterior compartment of the leg that occurs as a result of repetitive heel strikes.

Preventing Sports Injuries

Identifying risk factors for injury and instituting changes or modifications is important in preventing injury.  Examples of risk factors pertaining to young athletes are listed in the chart below. An extremely common training error for young athletes is the lack of preseason conditioning and preparation. Adolescents often begin intense, competitive sports participation after being inactive for months. They are often ill-prepared for the intense level that is expected of them at the beginning of the season.

• Inadequate pre-participation physical exams
• Hazardous playing fields
• Conditioning and training errors
• Lack of, improper, poorly fitted or inadequate safety equipment
• Playing while injured or overtired
• Declining fitness levels of children
• Grouping teams by age instead of size
• Poor nutrition
• Rules and officials
• Improper technique (e.g., in tennis, improper swing can lead to tennis elbow)
• Inadequate supervision
• Psychological stress
• Weather conditions
• Growth (e.g., bones grow faster than ligaments and tendons; inflexibility can lead to injury)

During the physician’s visit to gain sports clearance, there may be acute or chronic musculoskeletal problems that can be rehabilitated prior to returning to or beginning sports. The physician may want to enlist the expertise of a sports-medicine-oriented physical therapist, an individual who often makes a dramatic difference in the speed of recovery for active adolescents.

There are many reasons why a health-care provider may refer the athlete to a sports-medicine specialist for further care. For example, if the diagnosis is in question or if the athlete is not responding to initial treatment, a referral is warranted. The sports-medicine specialist reviews the original diagnosis and either clarifies the problem or tailors the rehabilitation program to ensure as rapid a recovery as possible. Serious injuries, especially injuries involving the growth plate, where future growth could be compromised, should be referred. Additionally, a specialist is helpful if there is some uncertainty as to the safety for a young athlete to return to the competitive sports environment. Finding a skilled sports-medicine specialist can make a substantial impact on the outcome after a sports injury. Improving the outcome can have important long-term emotional and physical benefits.