At Cook Children’s SPORTS Rehab, we’ve noticed a shift in what we see in our clinic. Over the past decade, the three major changes we’ve seen are the number of overuse injuries, the amount of early sports specialization and the way we treat concussions.

The first two issues I mentioned go hand-in-hand. It’s no coincidence that we are seeing more overuse injuries at the same time we are seeing early sports specialization. Overuse injuries come from repetitive micro-trauma to tendons, bones, and joints caused by repeating the same type of activity over and over.

If kids are playing the same sport all year around they are repeating the same movement patterns over and over again. Growing up in the 1980s and 1990s there wasn’t the opportunity to play year round sports like there is now. You may have had a favorite sport, but you had to wait for that season to roll around, and in the mean time you would play another sport if you wanted to stay active.

Now, if your favorite sport is baseball, you can find leagues to play in all year round, and the same is true for most other sports. As a result of this early specialization, we are seeing more and more overuse injuries in our young athletes.

In our baseball and softball players we are seeing more elbow and shoulder injuries, and the number one risk factor for overuse injuries of the shoulder and elbow is the volume of throws. If an athlete is playing baseball year round, the volume of throws is going to be significantly greater than an athlete that takes a break to play another sport.

A recent study showed that 15-19 year olds accounted for 56.7 percent of the ulnar collateral ligament reconstructions (Tommy John) performed between 2007-2011.This means over half of these surgeries are being performed on patients who haven’t even finished their freshman year of college. While early specialization is a contributor to the uptick in these overuse injuries it is not the only factor. Things like poor mechanics, poor flexibility and inadequate strength all contribute to overuse injuries. As more and more kids participate in athletics there becomes more and more need for good conditioning and injury prevention programs. Increased sports participation is a great problem to have, because that means our kids are being active, but it also increases the need for our coaches, and we as parents, to be more aware of ways to keep our kids safe from these overuse injuries.

Treatment of concussion has been a popular topic in the news as of late, and this is an area that has changed significantly over the last decade and continues to evolve as we learn more about these injuries. Ten years ago we tried to grade concussions based on the severity. The concussions were graded 1-3 based on the patient’s symptoms and whether they lost consciousness. In some cases of Grade 1 concussions, the athlete was allowed to return to activities the same day as the injury.

We then switched to saying the athlete either has a concussion or they don’t, and all athletes that were deemed to have a concussion were disqualified from participation until cleared by a physician. In most cases we would shut these athletes down completely; limiting TV, school, phone time and interaction with other people in an attempt to let them get complete cognitive rest until their symptoms resolved. Then once symptoms resolved we would start a return to school and return to play protocol.

Now kids still have to be cleared by a physician, and they still have to follow a return to play protocol, but we have realized that completely isolating these kids while they recover and limiting their interaction with friends was doing more harm than good.

So after a brief period of brain rest (approximately three days), we start slowly integrating kids back into activities of daily life as tolerated. It is important to have a physician that deals with concussions involved in the patients return to activity so that they are getting the appropriate accommodations at school and home to allow for the appropriate amount of rest, but that will still allow enough activity to stimulate the patient enough to promote recovery and keep them from becoming isolated.

For more on the specifics of how treatments have changed for all of these areas, and for information on other changes in sports medicine, we would love for you to attend our annual Cook Children’s Sports Medicine Symposium July 21, 2016.

SPORTS Symposium

Education is the key to keeping our young female athletes in their sport vs. being on the sideline with an injury. To learn more Cook Children’s has an annualSPORTS Symposium to educate those who work with our athletes: Coaches, athletic trainers, physical therapists and school nurses.

Please join us on July 21, 2016, to learn more about the female athlete in the morning and what is sending athletes to the ER in the afternoon.

Click here to register and attend the event. Click here to register for the Web cast.

Early Bird Special Ends June 30, 2016

Girls are made differently than boys. They have different hormones, looser ligaments and a wider pelvis. They also have a menstrual cycle and this plays a larger role than some may realize. Females need to have regular menstrual cycles to keep their bones healthy and growing at a normal rate.

When girls go through intense training, barely any breaks in the year from sports and possible diet changes, this makes having a regular period difficult. Because of this, females are placed at risk for sport injuries due to weak bones, less energy and fatigue.

Are girl’s muscles and bones weaker than boys?

During an adolescent growth spurt there is an imbalance of bone growth and bone strength, making female bones weaker than boys. Adolescent females do not use the muscles in the back of their thighs when landing from a jump as often seen in males. This increases risk for serious knee injuries. Females use the large quad muscle in the front of their thighs to land from a jump. Females also have less control of their muscles during adolescence.

What are common facts and injuries of the female athlete in different sports?

• Dance: 90 percent of dancers will get injured in their career: stress fractures and foot injuries are common.
• Cheerleading: Cheerleading has become a highly competitive, sometimes dangerous sport. Cheerleading has the greatest number of catastrophic injuries including head injuries (concussions), skull fractures, neck injuries, heat illness, and electrolyte imbalance.
• Gymnastics: Injuries in this sport produce the highest number of injuries requiring surgery. Commonly wrist pain, stress fractures of the spine and ankle sprain.
• Volleyball: These players typically have better form and less injuries. Common injuries include jumper’s knee and ankle sprains.
• Soccer: Huge female athlete participation with ACL strains being the most common injury.

The most common injury is an ACL (anterior cruciate ligament) injury in the knee:

• Females are four to five times more likely to have a non-contact ACL injury than males. This is sad because studies show that 65 percent of athletes (male and female) will no longer player soccer within seven years after an ACL injury.
• Adolescent female soccer players are at the greatest risk for negative long term effects, with more than 22 percent needing revision surgery or surgery on the other knee after an ACL injury.
• At least two-thirds of ACL tears occur when an athlete is cutting, pivoting, accelerating, or landing from a jump; tear occurs within the first 40 milliseconds after initial ground contact. This impacts the female athlete a great deal when you look at the sports many of them are competing in such as gymnastics and soccer.

Female athletes may be faced with more obstacles, but there are ways your female athlete can reduce the risk of injury, including:

• Do not allow knees to go inward during jumping, landing, cutting and pivoting.
• Land softly with knees slightly bent.
• Core/trunk control needs to be part of training.
• Increase awareness when adolescents have a growth spurt as they may be more at risk for injury.
• Monitor menstrual regularity.
• Maintain a balanced diet and stay hydrated.
• Train on dry/safe surfaces.

As a female athlete myself, I’m proud of the strides we’ve made toward equality on the playing field. But we also face new challenges as we compete at a higher level. Make sure to follow the above tips and stay safe.

SPORTS Symposium

Education is the key to keeping our young female athletes in their sport vs. being on the sideline with an injury. To learn more Cook Children’s has an annual SPORTS Symposium to educate those who work with our athletes: Coaches, athletic trainers, physical therapists and school nurses.

Please join us on July 21, 2016, to learn more about the female athlete in the morning and what is sending athletes to the ER in the afternoon.

Click here to register and attend the event. Click here to register for the Web cast.

Early Bird Special Ends June 30, 2016

Last night, NBC 5 Investigates released an enlightening report looking at the rates of concussions in North Texas districts. This report showed a much higher rate with more than 2,500 concussions reported in just 41 districts.

There are still a lot of misconceptions about concussions, what they are and what they might mean to your student athlete.

Here are 5 concussion MYTHS:

1. It was just a “mild” concussion.

Concussions are brain injuries, period.

One might classify a concussion as mild if symptoms were brief and not severe. However, you cannot predict whose symptoms will be severe based on the way the child was injured or even the symptoms right after the injury.

Even seemingly minor trauma can cause headaches and other symptoms for weeks.

2. If the child/athlete didn’t lose consciousness, it wasn’t a concussion.

Symptoms of concussion vary from child to child but passing out or blacking out are not required to make the diagnosis. Basically if a child has a fall or other injury that results in any neurologic symptoms, they can be diagnosed with a concussion.

Some examples of concussion symptoms are headache, nausea/vomiting, vision changes or problems with concentration and memory. Some of these symptoms may take time to develop, so it’s possible to diagnose a concussion a few days after the injury.

3. Concussions are only a problem for football players.

Almost all sports can cause concussions, including the cheerleaders on the sideline of the football games. Some other sports that are known to have higher incidents are soccer, baseball and softball. Other common causes are kids riding bikes and falling off playground equipment.

4. All concussions need either an MRI or CT of their head.

Most concussions can be diagnosed based on telling your doctor the story of the injury and the related symptoms along with a physical exam. Imaging is not necessary because a CT or MRI will most likely be normal even in the midst of a severe concussion.

Also remember that a CT of the head does not come without risk. While we should perform them when necessary, we should make sure we are not using them in situations where they will not provide useful information.

5. Don’t let your child sleep after a concussion.

Treatment of concussions is evolving. If you suspect your child has sustained a concussion, you should immediately seek medical attention and advice from a doctor about how you should treat your child’s symptoms.

There have been some changes in the treatment of concussions. First, we no longer require that you keep someone with a concussion awake for a set period of time. In fact, after their evaluation, the doctor may recommend that you allow them to sleep in order to help their brain heal. Your doctor might also prescribe some time away from TVs and other screens, school or homework or other activities that might cause their brain to work harder.

Concussions are much more common than we previously thought. I believe that the UIL will make changes to better track the risk of concussions for our high school athletes, which will hopefully lead to better ways of evaluating and treating concussions. In the mean time, don’t buy these common concussion myths.

You may have seen articles and video clips in the news lately discussing whether kids should be lifting weight.

“Is it safe?” “How much weight is too much?” “What is the injury risk?”

The longstanding belief has been that strength training could cause damage to the growth plates (or epiphyseal plates) in bones, but recent research is beginning to shift that thought. There’s even a book that’s recently been published by a famous Jeopardy contestant advocating for the importance of strength training in kids as it promotes healthy bone density and body composition as well as improved overall fitness and may even aid in injury prevention.

On paper, that sounds great! With childhood obesity rates continuing to rise, shouldn’t we be doing everything possible to make our kids healthier?

Let’s look at this from a few different angles…

First of all, physical therapists, physicians, athletic trainers and most clinicians are familiar with something known as the SAID principle. This principle states that when stressors or loads are applied on the body, there is a Specific Adaptation to Imposed Demands (SAID) that occurs over time.

And what does that mean? Basically, if you do an activity over and over again, your body will change to adapt to the activity.

For example, a baseball pitcher will have noticeable differences in muscle mass and range of motion in his throwing arm vs. his opposite side. Just as a marathon runner in the peak of season will have heightened endurance for long distance running but would most likely struggle with sprinting.

In the same way, if you spend long amounts of time in front of a computer screen, watching TV, or playing video games, your body and posture will adapt to that positioning over time. So if we can promote improved strength and cause positive changes in the body as kids are growing, why shouldn’t we be encouraging weight training?

FORM. FORM. FORM.

I cannot emphasize this point enough. When a new patient comes into the clinic, before I even bring them back, I like to create a picture in my head of what is going on. “Why does their back hurt?” “Why did they tear their ACL?” “Why do they keep spraining their ankle?”

It seems that 99.9 percent of the time, their problems can be traced back to not being taught proper form and never developing correct mechanics. It never ceases to amaze me when a high school athlete tells me he back squats almost double his body weight, yet when I ask him to show me a squat without weight, he has no core control, hip weakness causing poor knee alignment, and a complete lack of calf flexibility (among other things).

I cringe when I think of what he looks like with weight added. Then there’s the junior high athlete telling me he’s working on bench press, yet his core control is almost completely absent. And let’s not forget the adolescent girl who struggles to control her knee position when she stands up from a chair, but then is working on weighted squats and lunges as part of her off season training.

When we look at proper training, we should be teaching our kids how to recruit the appropriate muscles first before we ever add any resistance. Learning proper muscle recruitment and training the correct pattern is known as motor learning. Studies show that there’s a strong window of opportunity for this between the ages of 10 -13, but that doesn’t mean it’s not something that can’t be addressed at any age.

Show me a proper squat, lunge, bench press, dead lift … with good form repetitively before any weight is added. If you can’t do that, adding weight is only going to encourage bad habits and increase injury risks (just as the SAID principle states). How often do we hear stories of high school or college athletes who appear “strong” yet a simple direction change, and they fall to the ground and end up with a torn ACL?

So to summarize… yes, I am all for promoting physical activity in kids. Weight lifting has definite benefits, but it needs to be done in a controlled environment. Kids NEED to be taught how to lift weights correctly. If problems are identified or there is any pain, a referral to an appropriate health care provider like a sports medicine physician or physical therapist is crucial. The earlier that children learn correct motor patterns, the more successful they will be in future sports. And above all, physical activity should be fun.

About the author

Melissa Bro, PT, DPT, SCS, is a physical therapist for the Cook Children's SPORTS Rehab program. Our physicians, therapists, nurses and technologists work exclusively with kids and understand the unique needs of a growing athlete's bones, muscles, body and mind. As a part of Cook Children's integrated pediatric health care system, our patients have access to a multitude of pediatric specialty areas with board certified doctors, as well as laboratory services, nutritional consultations and sports medicine counseling.

Patients benefit from this integrated system because it allows our staff to use all of the system's resources during treatment. It also improves communication between the various departments whose physicians are focused on caring for children and adolescents.

Ball sports and games have many benefits for kids besides being a lot of fun. Playing ball helps kids develop skills:

Increased coordination with both hands

How?

o Stand in one place and dribble a basketball.

o Run while dribbling a ball.

o Playing/bumping a volleyball.

Increased hand eye coordination

How?

o Playing catch.

o Batting practice.

o Playing mini golf.

o Playing a racquet sport like tennis or ping pong.

Improved balance

How?

o Kicking a ball while standing in place.

o Kicking a ball while running.

o Jumping and reaching to catch a throw.

There are great ball options for kids of all ages and abilities. 

For kids 3 and under

Once babies can sit on their own, they can begin to roll a medium sized ball. As they grow, they will begin to use two hands to attempt to catch by pulling a ball closet to their body. Kicking is something that we should start to see with toddlers. At first your little one will walk into a ball to move it forward. As your child matures they will begin to lift one leg to kick. This requires balance and is a good challenge for toddlers and preschoolers. As their balance improves they will be able to the kick the ball harder and farther and in a straight line.

For grade school kids

At this age, kids are ready to be challenged with balls of different shapes and sizes like soccer balls, footballs, baseballs and tennis balls. These balls can be thrown and caught, but also can be used in more complex ways as part of a game. A great way to get this age group active is to create a game that they can play with friends.

For the preteen and teenagers

If your child is not yet involved in a team sport, it is important to continue to encourage them to be active with their friends, including games that include ball skills.

Sports are beneficial whether played on formal teams or as part of pick-up game with friends. Sports not only challenge your child physically, but encourage them to work on things like taking turns and being a good sport. Activities like soccer, baseball, and basketball require children to coordinate their own movements with the movements of other children in order to be successful. Teamwork and compromise are great skills for all kids to work on and will benefit them in many areas of their life.

So whether it is on their own, with siblings and friends, or as part of a team, encourage your kids to be active this summer and get involved with ball games. Remember that all kids should be getting at least one hour of physical activity a day and they will need lots of water when playing outside in the Texas summers. 

About the author

Kate Mcgee, PT, DPT, is a physical therapist at Cook Children's. Physical therapy at Cook Children's focuses on large motor and functional skils to enhance development, restore function and prevent disability from pediatric conditions, illness or injury. Cook Children's has Rehabilition Services in locations in Fort Worth, Hurst and most recently in Mansfield.

Posture
Posture is often overlooked with athletes. Posture is the result of a balanced muscular system that can control various aspects of timing and force to generate power needed for throwing and hitting. Breakdowns in posture will lead to increases in injury. Good posture is the optimal position for your muscles to work effectively without creating a risk for injury.

It is common for athletes to concentrate on the muscles in their chest and arms, while forgetting about the muscles in their backs. Weakness in your mid and upper back and tightness in the chest leads to the shoulders rounding forward, which puts the rotator cuff muscles around your shoulders in an ineffective and dangerous position. The muscles in a baseball player’s back, along with the rotator cuff, are essential in maintaining control of the shoulder during throwing.  During off days it’s good for all baseball players to strengthen the mid and upper back muscles.

Strength
With throwers, it is important to remember that strength and control in your legs and core are just as important as in your shoulders. Most of the power for throwing begins in your legs and core. By improving your core strength and activation you can throw harder without your shoulder and arm working harder. Working on your strength in your core and legs on off days will help you with performance and lower the risk of injury.  Flexibility in your hips and legs allows them to use their available strength.

Warm-ups
Before games use active warm-ups to prepare the muscles in both your arms and legs for the stresses of a baseball game. After the game always stretch your calves, hamstrings, quadriceps, hips, shoulder internal rotation and shoulder cross body adduction to prevent loss of motion. Remember that post-game stretches should be held for 30 seconds and should be steady with no bouncing.

Pitch counts
Pitch counts are an important way to prevent injury in pitchers. It’s important to note that increased performance and speed of pitching, actually increases the stress put on the body of a pitcher. Every pitch puts small amounts of damage on the elbow and shoulder. The body needs time to be able to heal this damage. I am not advocating that pitchers should not throw to their full potential. However, they should not pitch too much during a game or too frequently without adequate rest days. The following pitch counts are recommended by the American Academy of Orthopedic Surgery:

• 8-10 year olds - 50 pitches/game, 75 pitches/week
• 11-12 year olds - 75 pitches/game, 100 pitches/week
• 13-14 year olds - 75 pitches/game, 125 pitches/week
• 15-16 year olds - 90 pitches/game, 150/160 pitches/week
• 17/18 year olds - 105 pitches/game, 150-160 pitchesweek

The more times a baseball player pitches in a single game, the longer the player should rest. While resting from pitching, baseball players should not play catcher. The two players that throw the most during a baseball game are pitchers and catchers, and for both positions, the most important component of healing is the rest time.

Throwing technique
Pitch counts are not the only reason that pitchers should stop pitching during a game. With youth pitchers, throwing form is a huge factor in preventing injuries. Throwing form should not suffer from fatigue. When pitchers start to sacrifice form, they should be taken out of the game and rested. Common issues that arise from fatigue are dropping the elbow, leaning away from the throwing arm and the elbow lagging behind the shoulder. Quality pitching coaches are important to establishing good throwing form. Safety should always be the number one priority, when deciding between keeping a player in the game and resting them.