Lauren Shull MDR PGY3 The theory of sport specialization is based on an interpretation of a study done by Ericsson In his study how many hours of practice were thought to be required to reach mastery level of a skill ID: 580969
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Slide1
Overuse Injuries in the Era of Sport Specialization
Lauren Shull, MD-R
PGY-3Slide2
The theory of sport specialization is based on an interpretation of a study done by Ericsson. In his study, how many hours of practice were thought to be required to reach mastery level of a skill?
100
1,000
10,000100,000Slide3
A 12 year old male basketball player presents to your office with a chief complaint of anterior knee pain. he states that the pain worsens with running and jumping. On physical exam, he has extreme tenderness on palpation of the inferior patella. You also notice that his quadriceps seem tight. he has good range of motion of the knee joint. What is this patient’s diagnosis?
Osgood-
Schlatter
disease
Sinding
-Larsen-Johansson syndrome
Osteochondritis
dissecans
of the knee
Stress fracture of the tibiaSlide4
A 15-year old soccer player comes to your office for evaluation of right foot pain. She has recently started playing soccer again after taking several months off. She has not yet purchased new cleats for the season. She does not have any history of previous injury to the foot. On exam, she has tenderness to palpation and percussion over the 2
nd
and 3
rd metatarsals. You suspect a stress fracture. What aspects of the patient’s history puts her at risk for a stress fracture? Female Recently starting soccer
Wearing old cleats All of the above
A&B onlySlide5
A 13yo male comes to your office for a sports physical for baseball. He currently pitches for a recreation league team and a travel team. This year, he will also be trying-out for the Junior Varsity team at the local high school. When not pitching, he usually plays catcher. Last year, he played in over 100 games, and pitched more than 120 innings. What advice should you counsel both the patient and parent in regards to prevention of overuse injuries?
He should pitch no more than 100 innings per year.
Take at least 2 months off from pitching per year.
Play on only 2 teams at one time.
Limit total number of games to 100 per calendar year.It is ok to continue playing if you experience elbow pain only if college coaches are watching.Slide6
Objectives
1. Discuss
the benefits of youth sport participation.
2. Define the theory of sport specialization and how it applies to current sport participation trends in the United States. 3. Recognize common overuse injuries in pediatric athletes. Slide7
Disclosures
No financial disclosures to report. Slide8
Youth Sports ParticipationSlide9
Benefits of Sports Participation
Image from Project Play from The Aspen InstituteSlide10
Youth Sports Participation by the Numbers
In 2007, 21.47 million children between the ages of 6 and 17 participated in competitive sports.
Participation is starting at younger ages. Girls begin participating on average ½ year later than boys. By the age of 9, basketball is the most popular competitive sport. Upward trend in year-round participation Activity in youth organized sports is on the rise but youth are becoming less active. Slide11
Changing landscape of Sports programs
Agency sponsored
Club sports
Recreational sportsIntramural sports Interscholastic sports Slide12
Sport SpecializationSlide13
What is sport specialization?
Aspects of typical definition
High volume and intensity of training
Duration of training at a young ageMinimal rest or time offStructured training with emphasis on physical development Exclusion of other sports Goal is to optimize opportunities to develop athletic skills in 1 sport to enhance chance of competing at the next levelSlide14
Theory of Sport Specialization
Based on interpretation of a study by Ericsson from 1993
High volumes of deliberate practice at a young age was the strongest predictor of becoming an expert performer Led to the “10,000 hour rule” Expert status for musicians, mathematicians, and chess players NOT athletes No specific number of hours was proven as enough to master a task. Slide15
Who specializes and why?
Children who are older and slightly more physically developed are more likely to specialize early.
Potential for scholarships or professional contracts Only 0.2-0.5% of high school athletes ever make it to the professional level 6% high school athletes will play in the NCAA Positive feedback from parents and coaches Parents are strongest influence on the initiation of sports
Coaches are the strongest influence for specializationSlide16
Disadvantages of Specialization
Burnout
Social isolation Withdrawal from sports Lack of fun at earlier ages Performance pressure in older athletes Increased risk of injury Undermines the development of a wide range of comprehensive motor skills which may be helpful for injury prevention. Slide17
Overuse Injuries
Degree of Specialization
Risk
of InjuryRisk of SeriousOveruse InjuryRisk of Acute InjuryLow specialization (0 or 1 of the following):Year-round training (>8 months per year)
Chooses a single main sportQuit all sports to focus on 1 sportLowLow
Moderate
Moderately specialization (2
of the
following):
Year-round training (>8 months per year)
Chooses a single main sport
Quit all sports to focus on 1 sport
Moderate
Moderate
Low
Highly specialization (3/3 of the
following):
Year-round training (>8 months per year)
Chooses a single main sport
Quit all sports to focus on 1 sport
High
High
LowSlide18
Overuse Injuries Slide19
Overuse Injuries
15% of all adolescent injuries affect the
physes
and apophysesTend to be more common during peak growth velocity Develop due to repeated mechanical loading that exceeds remodeling capability of the structure under stress Slide20
Physeal Injuries Slide21
Factors contributing to overuse injury
Growth related factors
Susceptibility of growth cartilage to repetitive stressAdolescent growth spurtExtrinsic factors Training progression Inappropriate equipment/footwearImproper sport technique Psychological factors-adult and peer influences
Other intrinsic factors
Previous injury
Previous level of conditioning
Anatomic factors
Menstrual dysfunction
Psychological
and developmental factors Slide22
Key Historical Points
Playing on more than 1 team
One sport or multiple
Private coach or personal trainerAdditional cardiovascular training or strength training New technique Days of rest from activity each week Type of footwear and when last replaced
Previous injuries and treatment Slide23
Symptom guided grading of overuse injury
Injury
Severity
Symptom CharacteristicGrade 1Symptoms occur at the end of the activity, or only at initiation, then diminishGrade 2
Symptoms develop during activity, late onset, diminish after activity is completedGrade 3Symptoms develop during activity, early onset and persist during remainder
of activity, diminishing after activity has ended
Grade 4
Symptoms develop during activity and limit training frequency,
intensity, or duration
Grade 5
Symptoms prevent training Slide24
General Principles of Overuse Injury Diagnosis and Treatment
Diagnosis
Careful physical exam
X-rays should be obtained if unsure of the injury Most X-rays will be read as normal, especially early on in symptoms Treatment
Restriction of activity Slide25
Osgood-Schlatter
disease
Apophyseal injury Due to inflammation of the growth plate at the upper end of the tibia Typically presents with anterior knee pain
20-30% bilateralSlide26
Osgood-Schlatter
Disease
Diagnosis
Treatment Focuses on reducing pain and swelling Limit activity until participation is pain-freeMost patients able to return in 2-3 weeks Formal physical
therapy Adequate stretchingFocus on the quadriceps and hamstrings Slide27
Sinding-Larsen-Johansson Syndrome
Similar to Osgood-
Schlatter
Disease Involves the superior attachment of the patellar tendon and the inferior pole of the patellar bone Tightness of surrounding muscles leading to reduced flexibility of the knee joint Slide28
Sinding-Larsen-
Johanssen
Syndrome
Diagnosis Localized pain at the bottom of the patella that worsens with exercise X-rays show irregular bone edges inferior patella Treatment
Formal physical therapyQuadriceps strengthening
Improving flexibility of surrounding muscle groups
Patellar strapSlide29
X-ray Findings in Anterior Knee Pain
Osgood-
Schlatter
DiseaseSinding-Larsen-Johansson SyndromeSlide30
Sever’s Disease
Calcaneal
apophysitis
Usually occurs during the growth spurt of adolescence Calcaneus grows faster than the surrounding muscles and tendons Conditions that make a child more at risk include: pronated footflat or high arch
short leg syndrome obesitySlide31
Sever’s Disease
Diagnosis
Pain that occurs during or after exercise and is relieved by rest
May worsen with wearing cleats Swelling and redness of the heel “Squeeze test”
X-rays are normal Treatment
Short period of rest
Ice when sore
Proper stretching
Heel cups or supportive shoe inserts Slide32
Stretches for Sever’s
Disease
“Kiss the Wall” Stretch
Standing Calf Stretch
Towel Stretch Slide33
Stress Fractures
Often overlooked as “growing pains”
More common in lower extremities Tender to palpation and percussion Risk factors include previous stress fracture, increasing intensity or length of work-out, improper shoes, and starting intense training program after period of inactivity Slide34
Stress Fracture
Diagnosis
Pain on exertion
Tenderness on palpation ImagingSlide35
Osteochondritis
dissecans
Occurs in young people whose growth plates haven’t yet closed
Loosening of the bone and overlying cartilage Most commonly affects the knees, hips, elbows, and ankles Slide36
Osteochondritis
Dissecans
Diagnosis Symptoms may include a joint that “locks” or “gets stuck” X-rays may show small pieces of bone that have separated Treatment
Conservative treatment at 1st Long period of rest
May require casting or bracing
Surgery may be necessary Slide37
Youth Baseball and Overuse Injuries Slide38
Baseball in the Age of Specialization
Approximately 5 million children ages 6-17yo participate in organized youth baseball leagues in the US
Since 1990s, increase in independent baseball and travel teams
Typically for pitchers, talent recognition occurs in the latter years of high school (ages 15-18).Peak performance in mid-late 20sRetirement before age 40 In the 21st century, approximately ¼ of UCL surgeries are performed on youth or high school pitchersSlide39
Little League Elbow
Medial epicondyle
apophysitis
Most commonly occurs in pitchers, but may also occur in other overhead or throwing sports Valgus overload or overstress injury Slide40
Little League Elbow
Treatment
Rest, rest, rest
6-8 weeks Apply ice to help with swelling Refine throwing technique Strengthening arm, upper back, and core muscles
Diagnosis
Pain on the medial (inner) side of the elbow when throwing
Difficulty fully extending the elbow
Tenderness over the medial epicondyle
Often normal X-rays Slide41
Little League Elbow Prevention
Pitch Type
Age
Fastball8 + 2Changeup10
+ 2Curveball14 + 2
Knuckleball
15
+
3
Slider
16
+
2
Forkball
16
+
2
Screwball
17
+
2Slide42
Tommy John Surgery Slide43
Little Leaguer’s Shoulder
Proximal humeral
epiphysitis
Salter Harris type 1 physeal injury Occurs most commonly between 11and 16 years old Most prominent symptom is lateral arm pain in the upper arm when throwing Slide44
Little Leaguer’s Shoulder Diagnosis
Tenderness to palpation around the upper arm and some loss of flexibility
X-rays are usually normal during the initial phase May progress to stress fracture of the proximal humeral growth plate Loss of range of motion and global muscle weakness Slide45
Little Leaguer’s Shoulder Treatment
Initial treatment is immediate restriction from activities
6-8 weeks
Gradual return to play Truncal core strengthening and isometric upper extremity exercisesSlide46
Guidelines for Youth Pitchers
No competitive baseball pitching for at least 4 months per year
Pitch no more than 100 innings per year
Avoid pitching on multiple teams with overlapping seasonsDo not play both pitcher and catcher Play other sportsDiscontinue pitching if complaints of elbow or shoulder pain Slide47
Pitch counts and Days of Rest
Age of Athlete
Pitch Limits
Per Day10 & under7511-1285
13-169517-18105
Number
of Pitches Thrown
Days
of Rest
1-20
0
21-40
1
41-60
2
60+
3Slide48Slide49
Conclusions
Participation in youth sports has numerous benefits that go beyond the well-known health benefits.
Sport specialization is a growing trend in the nation. Overuse injuries are common in pediatric athletes and the mainstay of treatment is restriction from activity. Youth baseball pitchers are at especially high risk for overuse injuries if recommendations for adequate rest and pitch counts are not followed. Slide50
The theory of sport specialization is based on an interpretation of a study done by Ericsson. In his study, how many hours of practice were thought to be required to reach mastery level of a skill?
100
1,000
10,000100,000Slide51
A 12 year old male basketball player presents to your office with a chief complaint of anterior knee pain. he states that the pain worsens with running and jumping. On physical exam, he has extreme tenderness on palpation of the inferior patella. You also notice that his quadriceps seem tight. he has good range of motion of the knee joint. What is this patient’s diagnosis?
Osgood-
Schlatter
disease
Sinding
-Larsen-Johansson syndrome
Osteochondritis
dissecans
of the knee
Stress fracture of the tibiaSlide52
A 15-year old soccer player comes to your office for evaluation of right foot pain. She has recently started playing soccer again after taking several months off. She has not yet purchased new cleats for the season. She does not have any history of previous injury to the foot. On exam, she has tenderness to palpation and percussion over the 2
nd
and 3
rd metatarsals. You suspect a stress fracture. What aspects of the patient’s history puts her at risk for a stress fracture? Female Recently starting soccer
Wearing old cleats All of the above
A&B onlySlide53
A 13yo male comes to your office for a sports physical for baseball. He currently pitches for a recreation league team and a travel team. This year, he will also be trying-out for the Junior Varsity team at the local high school. When not pitching, he usually plays catcher. Last year, he played in over 100 games, and pitched more than 120 innings. What advice should you counsel both the patient and parent in regards to prevention of overuse injuries?
He should pitch no more than 100 innings per year.
Take at least 2 months off from pitching per year.
Play on only 2 teams at one time.
Limit total number of games to 100 per calendar year.It is ok to continue playing if you experience elbow pain only if college coaches are watching.Slide54
References
1. Brenner
J. Overuse Injuries, Overtraining, and Burnout in Child and Adolescent Athletes.
Pediatrics. 2007; 119: 1242-1245.2. DiFiori J. Evaluation of Overuse Injuries in Children and Adolescents. Curr Sports Med Rep 2010: 9; 372-378. 3. Feeley B, Agel J, LaPrade R. When Is It Too Early for Single Sport Specialization? Am J Sports Med 2015. 4. Ferguson B, Stern P. A Case of Early Sports Specialization in an Adolescent Athlete. J Can
Chiropr Assoc 2014: 58; 377-383. 5. Fleisig G, Andrews J, Cutter G, Weber A, Loftice J, McMichael C, Hassell
N, Lyman S. Risk of Serious Injury for Young Baseball Pitchers: A 10-Year Prospective Study.
Am J Sports Med
2011; 39: 253-257.
6.
Goncalves
C, Coelho e Silva M,
Carvalho
H, Goncalves A. Why do they engage in such hard programs? The search for excellence in youth basketball. J Sports Sci Med
2011: 10; 458-464.
7.
Jayanthi
N,
LaBella
C, Fischer D,
Pasulka
,
Dugas
L. Sports-Specialized Intensive Training and the Risk of Injury in Youth Athletes: A Clinical Case-Control Study.
Am J Sports Med
2015: 43; 794-801.
8.
Jayanthi
N, Pinkham C,
Dugas
L, Patrick B,
LaBella
C. Sports
Specialiation
in Youth Athletes: Evidence-Based Recommendations.
Sports Health
2013: 5; 251-257
.
9.
Lyman S,
Fleisig
G, Andrews J,
Osinski
E. Effect of Pitch Type, Pitch Count, and Pitching Mechanics on Risk of Elbow and Shoulder Pain in Youth Baseball Pitchers.
Am J Sports Med
2002: 30; 463-468. Slide55
References
10.
Makhni E, Morrow Z, Luchetti T, Mishra-Kalyani P, Gualtieri A, Lee R, Ahmad C. Arm Pain in Youth Baseball Players: A Survey of Healthy Players. Am J Sports Med 2015: 43; 41-46. 11. Merkel D, Molony J. Recognition and Management of Traumatic Sports Injuries in the Skeletally Immature Athlete. Int J Sports Phy Ther 2012; 7: 691-704. 12. Myer G, Jayanthi
N, Difiori J, Faigenbaum A, Kiefer A, Logerstedt D, Micheli L. Sport Specialization, Part 1: Does Early Sport Specialization Increase Negative Outcomes and Reduce the Opportunity for Success in Youth Athletes? Sports Health
2015: 7: 437-442.
13.
Niemeyer P, Weinberg A, Schmitt H,
Kruez
PC,
Ewerbeck
V,
Kasten P. Stress Fractures in the Juvenile Skeleton. Int J Sports Med 2006; 27: 242-249. 14.
Paterno
M, Taylor-Haas J, Myer G, Hewett T. Prevention of Overuse Sports Injuries in the Young Athlete.
Orthop
Clin
N Am
2013: 44; 553-564.
15.
Seefeldt
V, Ewing M. Youth Sports in America: An Overview.
President's Council on Physical Fitness and Sports Research Digest
1997.
16.
Wojtys
E. Sports Specialization
vs
Diversification.
Sports Health
2013: 5; 212-213.
17.
Yang J, Mann
B,Guettler
J,
Dugas
J,
Irrgang
J,Fleisig
G, Albright J. Risk-Prone Pitching
Acitivities
and Injuries in Youth
Basebal
: Findings from a National Sample.
Am J Sports Med
2014: 42; 1456-1463. Slide56
Specialization is costly
Privately insured
young athletes are
twice as likely as publicly-insured athletes to be highly specialized in one sportsRate of serious overuse injuries in athletes who come from families that can afford private insurance is 68 percent higher than the rate in lower-income athletes who are on public insurance (Medicaid). research presented in April 2014 by Loyola University at International Olympic Committee World Conference on Prevention of Injury and
Ilness in SportSlide57
Specialization supported by myths
not facts
Parents / Coaches think it will help their kids:
Have fun #1 reason why kids say they play sports (Michigan State survey 1989)Yet 21% of kids “pressured to play” with an injury at least once (Minnesota Amateur Sports Comm 1993)
athletic role can become so consuming and controlling that their childhood essentially disappears (Malina, 2010; Mostafavifar 2013).
Have a lot of friends
Specialized athletes end
up socially isolated from her family, peers,
other community.
(
Weirsma
, 2000).
Stay active / healthy
AAP recommends 60
minutes of moderate- and vigorous physical activity
But
NOT
getting
solely from participating in organized youth
sports (Leek 2010)
children who spend more time in free, unstructured play suffer significantly fewer overuse injuries per research at Loyola University
specialization reduces
the chance that children will stay
active
as
adults (
Difiori
2014)Slide58
Specialization supported by myths
not facts
Parents / Coaches think it will help their kids:
Be the best boys age 10 to 12 who play multiple sports, instead of specializing early, are more physically fit and have better gross motor coordination than those who specialize (Franzen 2012).Have the best chance to succeedOlympic world-class athletes started training, competing, and participating in international competitions later and competed in more sports other than their primary sport than peers performing at a national level. (Vaeyens 2009)
Make a good living aka “make us rich”Median pay for all 17000 pro athletes in 2004 = $48,310Slide59Slide60