Warm-Ups & Stretching

Physical therapist assistant Kim Barb, OPTA, of Cook Children’s Pediatric Specialties Walsh Ranch, says it’s important to stretch and warm up before playing or practicing, as doing so prepares the body for fitness. After a game or practice, incorporate flexibility stretches with static stretches and holding positions, like the typical hamstring stretch, calf stretch and quad stretch. A five- to eight-minute dynamic warm-up prepares the muscles for a better stretch.

Why?

• To increase blood flow
• To improve muscle flexibility
• To prevent injury and tearing of muscles, sprains and strains
• To improve performance

Agility drills prepare the muscles and joints for running, jumping, cutting and footwork.

Examples of agility drills are:

• Soldier kicks
• Knee hugs
• Hamstring scoops
• Skipping
• Hip openers

ACL-Injury Prevention for Soccer Players
Barb recommends strengthening large muscle groups typically used in soccer, such as the hamstrings, quadriceps and the gluteals (including the glute medius, minimus and maximus), with exercises such as squats, lunges and hamstring curls.

Strengthening exercises can help prevent the risk of injury by teaching muscles and joints to be stable and strong. Strengthening hip and core muscles also helps with the reactive forces created when making contact with other players.

Single-leg balance drills increase stability by training your body to stay balanced on one foot while moving, cutting and changing directions.

Examples of single-leg balance drills are:

• Stand on one foot and pass the ball.
• Stand on one foot and head the ball.

Plyometric drills teach athletes how to land with control – a skill that boosts the body’s ability to absorb impact and protect the joints. According to Barb, landing with poor alignment can cause the knees to cave inward, a position known as “knee valgus.” This inward collapse is a common culprit behind serious injuries, making proper landing technique an essential part of any training routine.

Examples of plyometric drills are:

• Box jumps
• Lateral bounds/skater lateral hops
• Depth jumps

Turf Burn Prevention & Treatment

These raw, red friction burns can be very painful, says Cook Children’s physical therapist Jessie Fernandez, PT, DPT, OCS, COMT, of Cook Children’s Rehabilitation (South).

If you have turf burn:

• First, be sure to clean it with soap and water to rinse out any dirt or debris and help to prevent infection.
• Next, treat the burn with an injury ointment, such as Neosporin.
• Cover it with a dressing or bandage. Waterproof bandages can help prevent the bandage from falling off during exercise.

Players can wear tighter-fitting, sliding shorts underneath their regular shorts to reduce the risk of skin damage when sliding on the field. Staying hydrated and keeping skin moisturized can also help reduce the risk of turf burn.

Whether your child plays on a natural grass field or turf, it’s important to continue practicing on the same surface so the athlete can get used to controlling their body on it. Turf fields absorb shock less effectively than natural grass, so running, jumping and playing on them will feel different.

What to Know About Concussions and “Second Impact Syndrome”
The American Academy of Pediatrics (AAP) defines a concussion as “a type of mild traumatic brain injury (mTBI) caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth.”

This sudden movement can cause the brain to move or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells. 

A concussion can sometimes be hard to spot. After all, it’s an internal injury.

There are times when a concussion is more easily identified, such as if an athlete loses consciousness. But it’s important to know that anytime there is a blow to the head, a concussion is possible.

“Monitor the athlete immediately after but be aware that sometimes it can take one to three days for symptoms to come on,” Fernandez said.

Immediate symptoms to watch out for and not to delay emergency medical treatment:

• Severe headache
• Blurred vision
• Trouble walking
• Confusion
• Slurred speech
• Unresponsiveness

Symptoms to watch after one to three days:

• Dizziness
• Headache
• Nausea
• Sleep changes, like sleeping too much or not enough
• Changes in mood or emotions
• Difficulty concentrating

Symptoms often resolve on their own, but one extremely important thing for parents to know about is second impact syndrome, which is when a person has a second concussion occur prior to resolution of symptoms from a previous concussion. This is the reason children and teens must sit out of a sport while recovering from a concussion.

“Playing through something like a knee injury is not ideal, but playing when you have concussion symptoms can be extremely dangerous, and can cause permanent brain damage or even death,” Fernandez said. “It’s just not something to mess around with.”

This is why Fernandez says that if there are any symptoms or concerns, the athlete should wait to return to play until they resolve. Usually, return-to-play protocols are overseen by a physician, athletic trainer, or physical therapist to work on the step-by-step process.

While neck strengthening and stability exercises can help prepare players for planned contact, like heading the ball, Barb notes that many concussions are harder to prevent because they stem from unexpected collisions that a player can't brace for.

“If you go up for a ball and someone hits you on the side of the head, you’re not prepared for that or it’s likely that you’re not stabilizing your neck muscles and that’s when the problem arises.”

Children initially begin to walk between the ages of 12 and 15 months. In the early stages of walking, you may notice your child “waddling” with their feet wide and their arms out like an airplane. Once a child has become more comfortable with walking, you may notice them becoming “brave” and attempting to walk fast or even run. As a child goes through these stages of development, you may find your him or her falling several times during the day.

It’s normal for children to fall frequently as they are learning to walk. In the early stages of walking/running, a child is learning to plan movements, find their balance and explore new-found independence.

As children gain more control of their body, you will find they begin to walk with a narrower base and their arms are at their side. A child will walk/run with decreased hesitance and you should notice less falls. This will occur within the first 2-3 years of learning to walk.

When should you be concerned about your child’s falling? There are many different reasons why children lose their balance throughout the day.

• Pay attention to when your child is falling and ask yourself a few simple questions:

• Did the type of shoe he or she is wearing change? Often times children have difficulty finding their foot placement with new shoes, especially ones that are heavy (such as a boot) or non-supportive (such as a sandal or slip-on shoe.

• Are they only falling when reaching a curb or changing surfaces? Sometimes vision can play a big role in a child’s ability to maintain balance with walking and running. If you suspect a visual deficit, you should contact an eye care specialist.

• Does your child only fall when playing with peers their age? Children have to think constantly about their next move when walking/running during play. You may find that they will trip or fall when attempting to keep up with peers their age. This could be the cause of decreased coordination, meaning they are having a difficult time organizing movements during play, causing them to fall.

• Try to pay attention to how your child is falling, sometimes a child may have a difficult time clearing their toes when walking/running and will fall. This would be good to mention to your pediatrician for possible referral to a physical therapist.

If your child is falling more than 10 times per day and doesn’t fit into the above categories, it may be beneficial to talk to your pediatrician about a physical therapy evaluation to assess your child’s needs.

About the author

Morgan Hubbard, 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. If you would like to schedule an appointment or speak to our staff, please call 682-885-4063.

I’ll be honest. I haven’t paid much attention to the NBA Finals this year. I’m much more impressed that the Rangers are over .500 at this point and in thick of playoff contention for a Wild Card spot…

Anyways, the NBA Finals are heading into Game 6, with the Toronto Raptors up 3-2 over the Golden State Warriors. When I heard on Monday afternoon that Kevin Durant was planning to play in Game 5, my stomach dropped. If you aren’t aware, Kevin Durant suffered what was called a “mild calf strain” on May 8, during a game against the Houston Rockets in the Western Conference semifinals. What was initially labeled as a “mild” injury, was later in the month described as worse than first thought by head coach Steve Kerr.

Even Durant said he originally thought the injury was worse than a strain. This past Sunday, the day before Game 5 of the finals, Durant practiced with his team for the first time since the injury. It was the perfect making of a sports fairytale – a team down 3-1 in the series desperately seeking a win to avoid losing the championship, the injured hero boldly rushing his return to save the team and hopefully deliver a championship… except the opposite happened.

In the second quarter, Durant pulled up suddenly on a crossover move and then dropped to the floor clearly in pain. Replay appeared to show his calf cramp and shrivel up. He had to be helped off the floor and ultimately left the arena on crutches and in a boot. On Wednesday, Durant confirmed what I feared: an Achilles tendon rupture.

Now that he's had surgery, you can likely rule him out for the entire 2019-2020 season. Recovery from an Achilles tendon rupture and returning to high level sport is roughly 12 months after surgery. So naturally, the questions begin. Who is to blame? Did he rush his recovery? Was he truly ready?

We will likely never know, but I do think this offers a great opportunity to talk about the importance of allowing adequate time for full recovery. In my role as a sports physical therapist at Cook Children’s, I have the pleasure of working with kids and young adults of all ages usually trying to return to some level of sport. My day is typically filled with cases such as the volleyball player with an ankle sprain, the baseball pitcher with elbow pain, the soccer player recovering from an ACL reconstruction, the basketball player with a hamstring strain or the football player who fractured his leg.

I love my job. I love helping these patients get back to doing what they love. But I also recognize that I have a great responsibility to make sure that each patient is genuinely ready to resume their chosen sport.

The physicians I work with depend on my feedback to determine readiness. I’ve been “the bad guy” on more than one occasion and told a patient that I didn’t think he or she was quite ready to play in the tournament that weekend. It’s a tough position to be in, and I recognize that sometimes it’s not received well by both the parents and child, but I always come back to the responsibility and trust instilled in me to make sure that their child is truly ready to play.

We have tests and measures in physical therapy that we use to assess readiness, and we also can simulate game time situations in a controlled environment. I can never 100% guarantee that reinjury will not occur, but I want to be as close as possible. I don’t want that basketball player with the history of a hamstring strain to fully tear his hamstring. I don’t want that volleyball player with an ankle sprain to not have full strength back, change the way she jumps, and then land awkwardly and tear her ACL. On the day of their last appointment with me, I always tell each patient that I genuinely hope they never see me again in the clinic.

My motivation and ultimate goal is that each and every patient has full strength, control, awareness and confidence upon finishing physical therapy. If your child has suffered an injury, we are here to help. Our physical therapy staff collaborate with your physician to create and customize our plan to get your child back in the game. We have their best interests at heart and want to do everything possible to avoid reinjury. The process may feel long, but patience and persistence will certainly pay off.

If you would like to schedule an appointment, refer a patient or speak to our staff, please call our offices at 866-205-7270.

I hear this almost daily as a pediatric physical therapist. However, tummy time is more important than ever these days.

Our babies today tend to have more time on their backs than on their tummies. The Back to Sleep Campaign instructs parents to place children on their backs in their cribs to prevent SIDS (Sudden Infant Death Syndrome). We also have car seats that transport easily into shopping carts and strollers, bouncy seats, swings and rockers. Even when babies are nursing or taking a bottle, they are held in a parent’s arms, essentially on their back. All of this leads to decreased tummy time. But if we have all of these safety precautions and modern conveniences, then why make a baby cry on her tummy?

• Tummy time promotes neck and trunk strengthening for head control. It can be a baby’s first workout.
• Tummy time prevents babies from getting a flat spot on the back of their heads. These flat spots can lead to changes in head shape, facial appearance, and jaw alignment. In more significant cases, children may require the use of a special helmet to reshape their head. In tummy time, babies are taking pressure off the back of their heads and learning to move.
• Tummy time allows a baby to visually explore their surroundings.
• Babies learn to move, roll and reach side to side while on their tummies. These are all the first steps to bigger things like walking, running and climbing.
• In tummy time, babies push up on their hands and arms. They are building strength in their shoulders and hands. This time in weight bearing plays into handwriting, gripping and sensory development.

Tips for Tummy Time

Tummy time is not always easy, but there are definitely ways to help make it a success.

1. Start early. Even newborn babies can play on their tummies. It’s never too soon to let babies learn to explore on their tummies, getting that sensation of weight bearing on their stomachs, pushing with their hands and toes.

2. Build them up! If your baby is having a hard time lifting their head up, you can lay them on your chest while you are reclined on the couch. You can also place a rolled up blanket or towel under their chest to lift them a little and help make it easier for them. As they build their neck strength and head control, you can try laying them flat on their tummies again.

3. Get on the floor with them! Infants of all ages love faces. Especially the faces of those who care for them. A child will follow and respond to a caring face at a younger age than they will a toy. Getting on the floor with them and talking with them will often help them stay on their bellies longer without fussing.

4. Perform tummy time frequently. To start, a few minutes of tummy time after every diaper change is great. Each day, try to add 5 more minutes to their tummy time practice. With these short but frequent times, they will begin to build their strength and tolerance for tummy time.

5. Don’t give up! As tummy time becomes part of a baby’s routine, they will gain strength and learn to move and explore. Once it’s part of a baby’s routine, his strength will build quickly. He will be getting all of the wonderful benefits of moving, exploring, feeling and seeing the world from his tummy. And watch out! You might soon find that your baby actually loves being on his tummy!

About the author

Carrie Carney is a physical therapist at Cook Children's. Physical therapy focuses on large motor and functional skills to enhance development restore function and prevent disability from pediatric conditions, illness or injury. Cook Children's offers Rehabilitation Services in Fort Worth, Hurst and Mansfield.

If you have paid attention to football over the last several years you know that there have been many rule changes geared toward preventing concussions.

Most of these rule changes have been spurred on by a huge law suit that was brought against the NFL by a large group of former players, in which the NFL will wind up having to pay out more than 1 billion dollars. The bottom line and what is portrayed in the movie is that there was research that brought into question the harmful effects of repetitive head trauma related to football. The NFL rather than looking into this and aiding this research in an effort to find out more, put its efforts into discrediting the research and trying to cover their own interests.

The research they were trying to discredit dealt with the autopsies done on the brains of former NFL players that displayed a condition called Chronic Traumatic Encephalopathy or CTE. CTE is a progressive degenerative disease found in people who have suffered repetitive brain trauma, including sub-concussive hits to the head that do not cause immediate symptoms.

Individuals with CTE may show early symptoms of dementia, such as memory loss, aggression, confusion, and depression. Just this past week Ken Stabler former Super Bowl winning quarter back for the Oakland Raiders who played 15 years in the NFL and who died in July was found to have stage 3 CTE.

While there is much more research that needs to be done to fully understand the potential long term effect of concussions and repetitive head trauma the current evidence can’t be ignored. One of the scariest things about concussions is how much we don’t know.

While the NFL is portrayed in a pretty bad light in the movie, in their defense I don’t think they reacted much differently to concussions than the majority of the population does. For the longest time I think a lot of people (myself included) had the attitude of “Oh it’s just a concussion.”

Working with concussion patients in clinic I have heard parents say, “I played football and got a few concussions I didn’t realize that it was a big deal.”

There are many athletes who might get a concussion, recover well and never have any other problems, but there are also patients who have an extremely difficult time recovering. We see patients take months to recover and report constant headaches, dizziness, blurred vision, difficulty concentrating in school, and mood swings.

We have seen patients whose parents report a complete change in their personality where they are much more angry and aggressive than they were before the injury. The scary thing is we don’t know how a person is going to react after a concussion, or how many concussions are too many, or if the repetitive sub-concussive trauma that they sustain is enough to cause problems later in life.

I played football when I was younger. I’m not coming out against playing football, but when I played you couldn’t start playing tackle until your eighth grade year which means 13-14 years old. We have to remember that elementary age through high school kids still have brains that are developing and we need to protect them.

The longer they play full contact football the more hits and more traumas they are exposed to, so I think we need to pay close attention to when we let our kids start playing tackle football. We also need to keep a close eye on how our kids recover if they do sustain a concussion. The longer and more difficult a patient’s recovery is the first time they have an injury, the more likely they will have a long, difficult recovery if they sustained another concussion.

Finally, how many concussions are too many? The answer is we don’t know for sure. What we do know is that concussions are mild traumatic brain injuries. We also know that CTE is a condition found in people who have suffered repetitive brain trauma. So how many concussions constitute “repetitive trauma?” That is a question we cannot answer for sure, but one that I think parents should think long and hard about before letting their kids back on the field.

SPORTS resources:

• The Cook Children's SPORTS program
• Football injury prevention
• What every parent should know about concussions
• There's no such thing as 'just' having your bell rung
• Top 10 questions parents have about sports injuries
• Injury Prevention Guide
• Strength training in children/adolescents
• Young athlete's injury prevention guide
• Rise of overuse injuries in school-age athletes
• The basics of sports injury prevention for kids
• Preventing children's sports injuries
• Pain that won't go away

“Stop Slouching!”

Why is my kid’s posture so poor?

THE PROBLEM

Do you get sick and tired of telling your child to sit up straight? Do you ever wonder why so many kids these days have slouched posture and often complain of back pain?

Let’s take a moment to think about a child’s typical day during the week.

1. They spend six hours a day at a desk in school. Most of this time is spent writing notes or typing with their hands in front of them and their head looking down.
2. When they are not in school, much time is spent playing video games, playing on their smartphones, surfing the Internet on the computer or texting. Again, arms are in front of them and head is down
3. They carry around a backpack that often weighs almost as much as they do and often times wear it low, resting on their low back or bottom. Backpacks should weigh no more than 10 percent of their body weight, be worn on both shoulders and fit snuggly to their back.

In April of 2012 – Archives of Pediatric and Adolescent Medicine published an article stating that only 51 percent of children went outside to walk or play per day with either parent.

Another national study found that the average American age 8-18 plays video games for greater than 13 hours per week. Studies also show that children today spend half as much time outdoors as their parents did when they were young. These kids prefer to stay inside to watch TV, surf the Internet, listen to music and even do their homework, rather than go play outside.

How it affects the kids

The positions discussed above, which kids are in for a large majority of their day, place the muscles on the front of their chest into a shortened position. After a while, it is difficult to stretch those muscles back out to attain proper posture independently. Tight muscles on the front of their chest cause them to continue to sit with their shoulders rounded forward and thus the cycle continues. The muscles in the front of their neck also become tightened, pulling their head forward. A forward head can also cause the muscles at the base of the skull in the back of the head to become tense.

Unfortunately, the inactivity caused by the increased time spent indoors also contributes to a poor core. The core consists of the muscles around the center of your body that help your back stay up straight. Without an active core, it is very difficult to maintain good posture and fatigue will set in quickly. A weak core in combination with prolonged periods of inactivity will likely lead to a cycle that is difficult to break, causing poor posture.

What to do

Have a homework station set up for kids. Doing homework on the bed or floor often makes posture worse and increases the curvature of their back while they are sitting. Kids should sit in a chair where their feet can touch the floor and their hips and knees are at 90 degrees. The table height should be so that their forearms are able to rest comfortably while they are working so that their shoulders can relax.

They should be in the same sitting posture for the computer and the screen should be at eye-level to keep their head in a good position as well. There are shelves made to lift computer screens up to eye-level, however, a large dictionary will often do the trick, as well.

The American Heart Association’s recommendation for physical activity for children is at least 60 minutes of moderate-vigorous intensity aerobic activity at least every day. As a parent, try to encourage your child to be active for at least one hour a day, either at school or at home. If you cannot find the time for your child to perform 60 minutes of straight activity, try to perform at least 30 minutes of activity twice per day.

It is never normal for a child to experience back pain or consistent headaches. If your child is experiencing either of these symptoms and is not actively being treated by a healthcare provider, please discuss these concerns with their doctor. Physical therapy can assist with improving posture and core strength to eliminate back pain.

Related information

• Cook Children's Sports Performance Orthopedic Rehab Team Specialists (SPORTS)
• Dynamic stretching
• The basics of sports injury prevention for kids
• The essential backpack 

From birth, your child is undergoing changes at a rapid pace and many factors may influence these changes, including your child’s genetic makeup, the environment in which you raise your child, nutrition, and medical care, to name a few. 

Though there are ranges in which kids attain developmental milestones, a delay in achieving certain skills does not necessarily mean that your child is ‘developmentally delayed.’ One should remember that "normal" is expressed in many different ways.

A child’s body systems can be categorized into motoric, sensory and cognitive components and can encompass a wide variety of changes, not to mention the defining personality and emotional changes that are occurring at the same time.

Typical development does occur in stages and can help you track your child’s progress, as listed below:

• Developmental milestones by age/dimension:
  • 3 months:
    • Physical development: Your baby is beginning to explore his/her environment and will start to push up on his/her arms and lift the head up against gravity for a short period of time.
    • Speech development: As you feed your baby, you will notice he/she will refine his/her ability to suck and swallow, will coo to the sound of your voice and smile, and turn his/her head in response to sound.
    • Play development: When playing with your baby, you will notice he/she will be able to follow toys with his/her eyes and reach for them. Your baby will also be able to position his/her head in the middle during interaction with people/environment.
  • 6 months:
    • Physical development: As your baby gets stronger, he/she will be able sit up with the use of his/her hands, will be able to explore his/her environment with rolling from back to stomach. When you hold your baby, notice that your baby can tolerate supported standing with full weight through his/her legs.
    • Speech development: What an exciting time for progress with your baby’s communication! Your baby will now start to babble in order to get your attention. Make sure to keep cereals and pureed foods handy, as your baby is now ready to eat these items.
    • Play development: ‘Tummy’ time is important during this stage of development and you will notice your baby reaching for objects when placed on his/her stomach, and will be able to hold onto his/her feet during play when placed on his/her back.
  • 9 months:
    • Physical development: Your baby is getting stronger during this age and should be able to sit up and reach for toys without a loss of balance, can transition from the floor to sitting, and can crawl using opposite hand/knee movement.
    • Speech development: During this time, your baby will be able to visually recognize familiar people and toys when named; and will now begin eating mashed table foods.
    • Play development: At this time, your baby will use both of his/her hands to play with toys, and will start mimicking others.
  • 12 months:
    • Physical development: During this time of rapid growth, your baby’s leg strength will truly begin to progress with pull-to-stand movements and walking alongside furniture with two-handed support. Your baby may begin to stand independently and take a few steps!
    • Speech development: Get ready to hear ‘mama’ and ‘dada’ frequently as your baby now will be able to call you by name and will be able to follow 1-step instructions!
    • Play development: With play, your baby will be able to use a pincer grasp to hold onto tiny objects/toys, and be able to grab and release toys/objects; at this time, your baby will also be able to start feeding himself using his/her finger.

Though the above characteristics of movement, speech, and play development are TYPICALLY observed in normal developing babies, do not be alarmed if milestones are not met right on time. Some kids develop at a more rapid rate while others may take more time.

There are some red flags to watch for and may indicate a possible need to make an appointment with your baby’s pediatrician, and potentially be referred to a developmental therapist (physical, speech, or occupational). These include (not inclusive of all signs):

• Stiff movements that are consistent throughout the first 3-6 months
• Decreased arm movement or asymmetrical arm movements that lasts through 9 months
• Rounded back
• Difficulty with or inconsistent visual tracking or lack of turning towards auditory stimuli
• Difficulty putting full weight through legs or needed hand support during sitting at 12 months
• Frequent toe-walking at 12 months onwards

Remember, each child is unique and though it is crucially important to monitor your child’s development, it is also important to allow your child to develop at his/her own pace and realize that ‘normal’ can be defined differently for each child.

[Source: Developmental milestones handouts (Cook Children’s), Pathways Awareness Foundation 2006, endorsed by the American Academy of Pediatrics, revised 09/10]

About the author

Radhika Trivedi, PT, MSPT, DPT, is a physical therapist at Cook Children's. Physical therapy focuses on large motor and functional skills to enhance development restore function and prevent disability from pediatric conditions, illness or injury. Cook Children's offers Rehabilitation Services in Fort Worth, Hurst and Mansfield.

What is the core?

“Core” is the word we use to describe the muscles in the middle part of your body. It includes muscles in your stomach, back, hips, and around your shoulder blades. They are not your “six-pack” that you might be able to see from the outside. They are deeper in your body. Even though you can’t see them from the outside the same way you might see big biceps, they are just as important, if not more so.

What does the core do?

All of these muscle groups work together to help keep your body stable. They create a good base for your arms and legs to work on. They help you have good posture, which distributes forces evenly throughout your body. They also work to transfer forces to and from your legs and your arms, like when you kick or throw a ball.

Why is it important?

Having a weak core is a lot like having a chain where the middle link is broken. Your body just can’t work very well without it? Or something like that. When your core doesn’t do its job, other muscles, bones, or ligaments have to do the work. The problem is that they were not designed for that job, so they aren’t very good at it. Without your core muscles working to keep your spine stable, you may be more likely to have injuries like back pain. Having a weak core has also been linked to other injuries, such as anterior cruciate ligament (ACL) tears, shoulder injuries and ankle injuries to name just a few.

What if my child doesn’t play any sports? Is the core still important?

It is still very important to have strong core muscles. We use these muscles even when we are resting. They work hard to keep us strong while sitting in school, riding in the car, and playing outside with friends. The core muscles are so important that they should activate before any movement of your arms or your legs in order to keep your spine stable, even if it is just reaching into a cabinet to get a cup.

So what can I do?

• Make sure to talk to your child’s doctor before starting any exercise programs.
• Encourage your children to sit with good posture using their core to align their body. This means their shoulder blades should be pulled down and toward each other. Their heads should be in a line over their shoulders. They should be drawing their belly button in toward their spine, and they should not have a big curve in their lower back.
• Sitting on Swiss/Therapy balls while sitting at a table or while playing video games so it can activate the core muscles while doing homework or having play time.
• Have plank competitions as a family to engage everyone’s core. 
• Get moving … taking family walks, riding bikes, swimming, getting involved in physical activities such as Karate, dance, gymnastics to name just a few.
• Pilates and yoga classes are both good ways to work on core strength once your child has learned the basics.

Hopefully this article helped to explain a little bit more about the core. If you child is having pain, or is having a difficult time with the ideas above, consider talking with your doctor about a referral for physical therapy.

About the author

Jacky Arrow, PT, DPT, SCS, is a physical therapist for the SPORTS program at Cook Children's. 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.

The role of warming up and its impact on performance is debated regularly. Sometimes the coaches of our kids’ sports teams do not find the time to have the athletes perform an appropriate warm up prior to practice. They may not see enough benefit to use precious practice time for warming up. However, participating in sporting activities, practice or competition, without an appropriate warm up can not only decrease performance, but also place the athletes at risk for injury.

Much of the recently published evidence shows that static stretching (i.e. holding positions for set amounts of time) can decrease the muscles ability to respond to the stresses it experiences during activity. Static stretching may be of more benefit post workout or when only focused on increasing muscular length for improved flexibility.

A dynamic warm up or dynamic stretching is a method of warming up in which the athlete moves throughout available range of motion with stretches in a controlled manner. It has many benefits that are not seen with static stretching such as increasing blood flow to the muscles, increasing internal temperature, and preparing muscles for the sport specific movements they will need for the activity. This sort of warm up increases blood flow to the muscles and stretches them through specific motions that will be used while participating in their sport. In addition, most dynamic stretches target large muscle groups or multiple muscle groups together.

To successfully complete a dynamic warm up, athletes should follow some important steps. An appropriate warm up usually takes approximately 15 minutes.

1. Perform light aerobic activity to increase cardiac output and blood flow.

2. Follow with dynamic stretches to stretch muscles that will be needed for participation.

3. Optionally follow up with agility drills as desired. Examples include: butt kicks, high knees, skips, etc.

When performing dynamic stretches, it is important to monitor form and control. If dynamic stretches are performed without appropriate control, muscles can be stretched too far too quickly and pose a threat to injury. If you have an injury or need further guidance, please see a medical professional, such as your primary care physician or pediatrician.

Related articles

• Does your child play one sport?
• Cook Children's Sports Performance Orthopedic Rehab Team Specialists (SPORTS)
• Dynamic stretching
• The basics of sports injury prevention for kids
• Rise of overuse injuries in school-age athletes 
• Top 10 questions parents have about sport injuries
• Young athlete’s injury prevention guide

About the author

Amanda Stukey, PT, DPT, is a physical therapist for the SPORTS program at Cook Children's. 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.

Her day begins bright and early around 7 a.m. with cuddles from Mommy and then it’s time for her bottle feeding at 8. Other activities for the morning include a visit from the respiratory therapist (RT) for her breathing treatment and morning “massage.” Her “massage” is part of her chest physiotherapy where they use an oxygen mask to firmly pat her on her chest and back to help expand her lungs and break up any mucus she may have. This is one of Avery’s favorite parts of the day. We love to watch her as she lies in her bed on her stomach and dozes off to sleep as the RTs work their magic.

She may also get a visit from occupational or physical therapy for a morning workout where they work on fun things like learning to put her feet in her mouth and building her core strength to help her learn to roll over and sit up. They also have taught us about infant massage and given us stretches we can do with Avery to help her with her flexibility.

After her morning workout, she has likely worked up an appetite so it’s time to eat again. This time, a speech pathologist may come to give Avery her bottle. Learning to eat after 6 months is tough, so a speech pathologist is working with us on what bottles and nipples to use, positions to try when feeding her and different combinations of breast milk and formula to use. All of these things play an important factor in helping Avery to swallow efficiently and effectively and not having her food go down the “wrong way” which can cause aspiration and an infection in her lungs. We are about to introduce her to solid foods which will be another fun adventure!

Once she’s done eating, it’s usually time for a visit from Daddy, where she likes to squeeze in her afternoon nap on his lap. All the activity from the morning often wears her out for a few hours. She is, after all, a baby who needs her rest so she can grow healthy, new lung tissue.

In the afternoon, she may get a visit from the Child Life specialist for some “smile therapy” where we work on coaxing a smile out of her or arts and crafts activities with her footprints. The music therapist may come by to sing and play music while Avery works on her babbling.

Interspersed throughout this busy day of therapy visits, eating, naps and playtime, she also receives countless visits from the NICU staff and our family, all stopping by to see her outfit of the day and get an update on how she’s doing.

The late afternoon and early evening is reserved for family time where she plays on her play mat, works on tummy time or hangs out in her Bumbo® or exersaucer. By the time Shawn and I are ready to go home and sleep, Avery is usually asleep, worn out from all of the day’s activities. After all, she has to get a good night sleep so she can wake up and do it all over again the next day.

Related links:

• Avery's story - part 1
• Avery's story - part 2
• Avery's story - part 3
• Avery's story - part 4
• Avery's story - part 5
• Avery's journey - part 6

Strength:  As these athletes push themselves to achieve the lifting goals set by coaches, is their form being supervised by someone trained to observe any breakdowns?  Complex lifts such as cleans, snatch, push-jerks, etc. put enormous strain on the athlete’s muscles, especially when they are younger and still developing, but if their form is poor it also makes them susceptible to back, shoulder, knee and neck injuries. Often the athlete lacks the core strength and stability to provide a solid foundation so that the body can move correctly. Core strengthening should be an integrated part of every strengthening program. Unfortunately, many of our athletes are never taught to control their core in basic sitting and standing postures, but yet we expect that they will somehow find their core while in the weight room or on the field. If you think core strengthening is all about abs, then you are missing the bigger picture.

Conditioning/ nutrition/ hydration: Cardiovascular conditioning is often an area that coaches hit pretty hard in the offseason, and most athletes have been working on some kind of conditioning program. However, the nutrition and hydration components of this area are often over-looked. Understanding how to fuel your body for peak performance is just as important as knowing how to perform the activity. Working with a nutrition/dietitian specialist can give your athlete the tools needed to unlock their full potential.

Flexibility: This is one of the most overlooked areas of a good training program for a football player getting ready for middle or high school ball. There is nothing glorious about stretching. There is also nothing glorious about missing a majority of the season while sitting on the bench due to a pulled hamstring. Flexibility training is about preparing the body to perform.  Dynamic stretching (moving stretches) prepares the body for immediate performance and should be used before any type of physical activity. Static stretching (prolonged holds) help prepare the body for tomorrow’s workout and promotes having the muscle length needed to achieve the greatest power. Use of a foam roller can also help improve flexibility by preparing the muscles for stretching.

Neuromuscular control: Why is it that the pros make it look so easy?  The ability to cut-back, stop-start, and change directions centers on the way an athlete’s brain can control the body. A physical therapist or trained professional can use any number of functional movement assessments to see how the body is moving and recommend corrective exercises and/or cues to improve these patterns. Learning the best patterns means the athlete can generate more power, more quickly, and in more directions. The best movement patterns also keep the body in the best alignment, and less likely to become injured.

Overtraining: The AAOS also recommends avoiding the pressure that is now exerted on many young athletes to over-train. Listen to your body and decrease training time and intensity if pain or discomfort develops.

See a physician if you begin having pain. This will reduce the risk of injury and help avoid “burn-out.”

Related links:

• Football injury prevention
• SPORTS resources
• Does your child play one sport?
• 9 ways to prevent injuries in young athletes
• Cheerleader injuries
• Top 10 questions parents have about sports injuries
• Young athlete's injury prevention guide
• Strength training in children/adolescents (5-15 years)
• Rise of overuse injuries in school-age athletes
• The basics of sports injury prevention for kids
• When growing pains are not growing pains
• Preventing children's sports injuries

About the author:

John Stanley, a physical therapist and SPORTS Rehab Clinical Coordinator at Cook Children's. The Cook Children's Sports Performance Orthopedic Rehab Team Specialists (SPORTS) program offers care to children and adolescents with orthopedic or sports-related injuries.

These days many of the kids’ sporting associations, coaches, and sometimes even parents seem to be treating kids as little adults. However, kids are not just small grownups. Children are still growing, which makes them more prone to injury. They are also developing their strength, coordination and endurance as they grow. Kids participating in sports together, even though they may be the same age, vary in size as well as physical and psychosocial maturity.

Recently, there has been an increasing trend in younger children specializing in one sport. Specialization prior to adolescence can cause increased injury rates, early burn out on the sport and unwanted psychological stress for the athlete.

Counter to current trends, studies have shown that athletes at the elite level were more likely to start competing at a later age and compete in other sports until late adolescence. Research also supports that children who participate in a variety of activities and don’t specialize until reaching puberty are more likely to be more consistent in their performance.

Participating in a variety of sports helps with coordination, skill development, and gives the child a chance to rotate use of specific muscles to decrease the risk of overuse injuries.

It’s important for athletes, parents and coaches to be aware of the signs and symptoms of an overuse injury. These can include:

• Pain
• Swelling
• Changes in form
• Decline in performance
• Weight loss
• Anorexia
• Sleep disturbances.

Children also have the added risk of injuring their growth plates. What may cause a sprained ankle in an adult has the potential to fracture a growth plate in a child. These injuries have the possibility to disturb growth of the injured bone and cause deformity. A young athlete should never attempt to “push through” an injury. Too much stress on the bones or muscles can lead to tissue breakdown and further injury.

To prevent these injuries, the American Academy of Pediatrics (AAP) and American Academy of Orthopeadic Surgeons (AAOS) recommend: 

1. The athlete should be coached by properly trained people who are knowledgeable about proper form and technique.
2. Athletes should only participate at a level consistent with their abilities and interest levels.
3. It is important that the athlete is participating in activities they enjoy. The athlete’s desires should control their intensity of participation.
4. Athletes should not play one sport or type of sport (i.e. throwing) year round.

Young athletes should be followed by a health care team who can monitor the athlete’s body composition, cardiovascular system, sexual maturation and evidence of emotional stress. It’s recommended that children participating in high levels of activities have an ongoing nutritional assessment to look at total calories, balanced diet and intake of calcium and iron to ensure adequate intake for growth.

If at any time your young athlete is having pain or any of the symptoms above, please seek appropriate medical attention.

More resources from the Cook Children's Sports Performance Orthopedic Rehab Team Specialists (SPORTS):

• The basics of sports injury prevention for kids
• Rise of overuse injuries in school-age athletes 
• Top 10 questions parents have about sport injuries
• Young athlete’s injury prevention guide

About the author

Amanda Stukey, PT, DPT, is a physical therapist for the SPORTS program at Cook Children's. 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.