As the summer shifts school sports to off-season training, the attention of most teen athletes turns to strength and conditioning. Kids hoping to be bigger, stronger and faster for next season hit the weight room to build muscle.

While strength and conditioning is an important element for overall athletic health and performance, some young and impressionable athletes believe that bulking up is best accomplished through supplementation. But many experts say supplements in the hands of teens can be useless and unnecessary at best and dangerous at worst. Many teens lack professional oversight or knowledge of proper use and dosage, and have a natural tendency towards risky behavior where “more is more.”

We asked Nicole Pitts, D.O., a sports medicine physician at Cook Children’s Medical Center - Prosper, to weigh in on the subject. After all, elite athletic performance is a subject she knows a lot about, both personally and professionally. At just 14, Dr. Pitts became a professional tennis player. Although now retired from the sport, she has yet to walk away from competition altogether. When she isn’t helping young athletes prevent and recover from their injuries, you’ll find her playing the professional pickleball circuit. 

Timing is Everything

In her practice, Dr. Pitts says she finds the most prevalent supplements used by teens include creatine and protein shakes to feed muscle growth and energy drinks as a pre-workout.

Creatine and protein do play critical roles in muscle building, especially for athletes.

During weightlifting and resistance training, muscle fibers will undergo microscopic damage. Protein helps repair and rebuild that damage by producing amino acids, the building blocks of muscle. At the end of that tearing down and building back process is a stronger and bigger muscle.

Creatine is a natural substance found mostly in muscle cells. It aids in energy production during high-intensity workouts or heavy lifting, and also plays a role in muscle repair and growth. While researchers don’t yet know the effects of long-term use, especially in young people, creatine as a supplement is fairly well-researched and generally safe for adults.

But there is more to muscle building than popping a pill or swigging a shake.

“You do need protein as an athlete, but it also comes down to how much and when. It’s about timing, too,” Dr. Pitts said. “Let’s say you’ve done a big workout. It’s really important to get that protein within about 30 minutes. If you’re not getting a good amount of protein after your workout and you’re waiting until hours later, you’re missing that critical part of muscle building and muscle recovery.”

Creatine and teenagers

Proper supplement dosing is a factor, too. Creatine’s overuse, which is a danger in the hands of adolescents, can cause negative side effects.

“There is no U.S.-based sports medicine organization that endorses creatine use and supplementation under 18 years old because of the safety and efficacy of it,” Dr. Pitts said. “There can be side effects like water retention, bloating, muscle cramping and kidney injury, especially in people with previous kidney concerns.”

Other overuse side effects include anxiety, breathing difficulty, diarrhea, nausea, vomiting, fatigue and rash.

Powders and shakes might be a quick and convenient source for upping protein intake, but they can be full of not-so-good-for-you additives like artificial flavors and coloring, excess sodium and thickening agents.

The same can be said for energy drinks.

“The problem with pre-workout energy drinks is there's just so many types out there, and they have so many variations on ingredients,” Dr. Pitts said. “Most commonly, it's caffeine or guarana, but there's also a lot of sugar in them. Teens may be drinking coffee followed by an energy drink and they’re not always looking at how much caffeine they’re consuming by doing that.”

Too much caffeine can lead to increased heart rate, vomiting, dizziness and muscle damage.

Buyer Beware

While the U.S. Food and Drug Administration (FDA) does have some regulatory oversight of the dietary supplement market, it does not test or approve dietary supplements or their labels. Unlike medication that must be proven safe and effective before being marketed to the consumer, there is no law that requires the FDA to approve dietary supplement safety before it hits the market. This means that certain supplements containing unverified, hazardous, and unmarked ingredients might find their way onto store shelves.

Bottom line? The buyer must beware.

This is why Dr. Pitts says the safest and healthiest way for teens to fuel their bodies for peak performance comes down to four key ingredients.

Here is her recipe for success:

Nutrition through whole food sources

Teens should aim for 5 to 6 ounces of protein foods over the course of the day. Foods rich in muscle-building protein and creatine include pork, beef, fish, shellfish and animal milk. Eggs, turkey, chicken, beans, nuts and nut butters are also good sources of protein.

“Drinking 8 to 12 ounces of chocolate milk within 30 minutes of exercise is good because we know it’s a whole food source without a lot of additives and it has the right carb to protein ratio,” Dr. Pitts said. “There’s also Greek yogurt and peanut butter. Especially in kids, we try to stick to more whole foods rather than protein shakes.”

In addition to protein, a well-balanced diet will include dairy, fruits, vegetables, grain and oils. Read more here about how much of each of these your child should get in a day.

Timing

For best results, consume at least 25 grams of protein within 30 minutes of strength training.

“This can be pulled from the total amount of protein intake per day,” Dr. Pitts said. “You just want to time things so that you get a portion of it all at once right after a workout.”

Sleep

To boost energy, forego the supplements and get some sleep. Dr. Pitts suggests at least 8 to 9 hours of sleep per night to give athletes all of the energy and focus they need to perform their best. Sleep also aids in muscle recovery.

Hydration

Poor hydration will equal poor performance no matter your athletic ability. In addition to staving off energy draining dehydration, water helps lubricate joints for increased mobility. If your child is working out for more than an hour or is a heavy sweater, add electrolytes or salt to their water to help them retain important minerals. Proper hydration starts long before a workout or big game, so plan ahead and have them drink at least 8 glasses of water the days leading up to their workouts of big games and keep hydrating before, during and after the event.

Couple this recipe with lots of hard work, determination and sportsmanship, and your teen athlete will be well on their way to reaching their full potential every time they step onto the playing field.

Cook Children’s Orthopedics and Sports Medicine Walsh Ranch is expanding to include an outdoor sports complex designed to help young athletes train for peak performance. The John and Tracy Sellers Sports Complex is slated to open Oct. 12 and will include a 30-yard football field, a quarter-mile track, a pitching mound and an agility training area.

Funding for the expansion was generously provided by John and Tracy Sellers, the Walsh Foundation and the James and Dorothy Doss Foundation. The complex expands the offerings of Cook Children’s comprehensive orthopedic, rehabilitation and sports medicine facility in Walsh, which already includes a training gym where these specialties work side-by-side daily to rehab, train and care for the whole athlete.

“This sports complex will be an extension of that and give our athletes more options for training and recovery,” said Stefanie Perry-Charles, site administrator at Cook Children’s Orthopedics and Sports Medicine Walsh Ranch. “We want to be the one-stop-shop for them as they work to get back in the game, build their skills and improve their performance.”

To truly condition the body and test and develop athletic performance, experts say it is best to train in the same environment in which the athlete plays, from the type of field to common game-time temperatures. For example, running in a flat and air conditioned gym does not replicate the same force and stress to the ankles, feet, back or knees that a runner encounters on an outdoor track while wearing spikes.

The John and Tracy Sellers Sports Complex brings a next-level approach to training and recovery, where athletes can hone their skills on surfaces and in conditions similar to what they encounter in their sport.

“Our gym is beautiful and it's an ideal and safe place to initiate rehabilitation following an injury or surgery,” said Richard Ashlock, PT, DPT, SCS, sports clinical coordinator at Cook Children’s Orthopedics and Sports Medicine Walsh Ranch. “However, taking athletes outside where the temperature is different and we have a surface that's a little bit closer to what they're going to use gives them that extra real-life conditioning for peak performance and allows us to really test their readiness to return to a sport after injury.”

Programming and use of the facility will be open to all young athletes and sports teams throughout North Texas looking to level up their game, not just those recovering from an injury.

In addition to rehabilitation services, the John and Tracy Sellers Sports Complex will offer injury prevention programs, sport and position-specific training led by certified athletic trainers and adaptive training for differently-abled kids and teens. Teaching athletes the connection between nutrition, conditioning, preparation, form and recovery to prevent injuries will be a major focus of all programming.

“We want to prevent injuries before they happen,” said Carolyn Snow, MS, LAT, ATC, OTC, sports medicine coordinator at Cook Children’s Orthopedics and Sports Medicine. “The new programs will provide the athlete with the tools needed to safely return to sports after an injury. We want to give kids the tools that they need as young athletes to understand how to move their body correctly which includes teaching them the right exercises and stretches that will benefit them the most. We will also have the ability to help develop diet and nutrition plans. All of this together will help to develop them into the best athlete that they can be.”

It’s programming parents have asked for.

“We recognized the need for therapy services in this area, but we've also had parents asking about injury prevention, strength and conditioning and education programs in an effort to prevent injuries from happening,” said Carolyn Mullins, manager of rehabilitation services at Cook Children’s Orthopedics and Sport Medicine Walsh Ranch. “When parents see one child experience an injury and the rehabilitation that is necessary to return to their activities, they often ask what can be done to help prevent the same from happening to another child athlete.”

The complex will also offer sports camps during school breaks and homeschool physical education programs.

“The homeschool program will be beneficial for the students who need PE credit but may not be ready or have not had the opportunity to go into an organized sport,” said Sarah Connors, MHA, director of practice operations, Cook Children’s Orthopedics and Sports Medicine. “This will give the student the opportunity to be exposed to a variety of sports and activities. Hopefully, finding an activity or sport that interests them and they want to learn more about.”

By Heather Duge

Valerie Shorten, BSN, RN, and her son, Marquis Shorten, are no strangers to overcoming obstacles. Each one has led them to where they are today.

Marquis faced a life-changing diagnosis at Cook Children’s in 2022 – the same hospital where his mother Valerie works. She was determined to become a nurse after her brother was killed.

“I always thought about what I could have done to help him had I been there,” Valerie said. “That’s when I knew nursing was my calling.”

Nursing Journey

In 2011, Valerie found out about an open position at Cook Children’s – a place she had visited a few years before when Marquis had a minor injury while playing with his brother.

“I remember how caring everyone was and thinking with three boys it was probably not the last time I would be there,” Valerie said.

After 15 months of working in Food Services, she applied for a secretary position in the Neonatal Intensive Care Unit (NICU). In May 2021, she graduated from nursing school and started as a nurse resident at Cook Children’s -- 10 years to the day of her first day in the cafeteria. She rotated through all the ICUs and the emergency department in one year. Now she is a nurse in the Cook Children’s NICU.

“I know that no one chooses to come into this hospital,” Valerie said. “You never know what a person is going through, so I make sure I always give the kind of treatment I would want for my child.”

Shocking Diagnosis

In April 2022, Valerie was in the middle of her nursing shift when she received a text from Marquis that read “My spine hurts.” She told him to take ibuprofen since she thought it could be related to his running.

“Marquis is a runner and was No. 1 in the district,” Valerie said. “He was slated to run in the regional meet to see if he would qualify for state. I thought the pain could be from a pulled muscle or running injury.”

Valerie told him to rest and let her know if it worsened. Eventually, Marquis drove himself to the ED at Cook Children’s and at that point could not feel his right leg.

“I met him at the ED but didn’t think it was anything too severe,” Valerie said.

An MRI revealed a spinal epidural hematoma, which is like a pooling of blood on the spine, and Marquis underwent emergency surgery. If too much time passed, Marquis could have become paralyzed.

“Everything was a blur and I remember being overly emotional as Marquis continued to lose the feeling in his legs,” Valerie said. “But I knew he was at the right place.”

Marquis was quickly wheeled to the operating room where Medical Director of Neuro-Trauma, and pediatric neurosurgeon Daniel Hansen, M.D., removed the large blood clot that was compressing the spinal cord.

Recovering Physically and Mentally

Valerie became anxious thinking about Marquis's mental state when he woke up and realized all he worked for was not going to happen that year at the regional track meet, if at all. 

“A nurse pulled his father, DeMario, and me aside and told me that when Marquis woke up, he asked when he would leave that day because he had a track meet in a few days,” Valerie said. “The real pain came when all the times were posted from the race he missed.”

Valerie and DeMario helped Marquis work through his emotions but did not let him stay down too long.

“I told him he could decide to lay there and be sad or decide what’s going to happen next,” Valerie said. “My life motto is that you are the writer of your story.”

Nurses realized how hard it was for Marquis to face the reality that he missed the regional meet and was not sure what running would look like in the future. During the 10-day stay in the Pediatric Intensive Care Unit, Marquis says the nurses went above and beyond to bring him comfort. On a particularly hard day, the café was out of Chick-fil-A milkshakes, so the nurses gathered all the supplies and made him one.

“They did everything I needed before I even asked for it,” Marquis said. “They fixed my pillows a certain way, brought me the Gatorade flavor I liked with a straw, broke up pills because I couldn’t move my neck to swallow and positioned my toes for me when I couldn’t move them.”

Back on Track

Valerie says everyone was surprised at how fast Marquis progressed. Throughout his healing journey, he used a brace, walker and wheelchair. After lots of hard work in physical therapy, he was cleared to jog four months after surgery and in January 2023 ran in his first race since surgery at Texas Tech University.

“My parents kept me going,” Marquis said. “My track coaches Jesse Heard and Sa’Donna Thornton also were there for me. Coach Heard gave me a love for track and all he instilled in me is a big reason why I treat everyone with kindness. He has sacrificed countless hours just to help me succeed. Coach Thornton played a huge part in helping me gain my confidence back and keep my positive outlook on the situation. I knew God had a plan and it would turn out OK.”

A Lifelong Dream Come True

Marquis says coming back from a major surgery has only made his passion for running stronger, and he wanted to prove to everyone he was just as good. He has accomplished that and more. When he graduated high school in May 2023, he received the Optimist Award. This fall, Marquis will attend Texas Christian University on a full-track scholarship – a goal he set for himself at only 10 years old.

“Marquis decided in fourth grade that he would one day attend TCU,” Valerie said. “Jokingly, I expressed how his father and I did not budget for TCU. At the time, our fourth grader looked at me on the car ride to school and said, ‘Don't worry, I'm going to get a scholarship.’ His dreams came true.”

“The most gratifying part of my job is seeing kids through their illness to the other side,” Dr. Hansen said. “For Marquis, that means a life that is everything he has always wanted.”

With school back in session, many kids are once again suiting up for fall sports and hitting the field, track or court for competition. Doing so offers a child many benefits. Along with being an outlet for exercise and physical activity, playing sports gives kids an opportunity to develop meaningful friendships, practice resilience and learn the value of hard work and perseverance.

But, like with most activities, there are risks. Sustaining a concussion is one of them.

What is a concussion?

The Centers for Disease Control defines a concussion as “a type of traumatic brain injury 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.” While sports, especially contact ones, carry an obvious risk of head injuries, a concussion can happen any time of year from any type of sport, recreational activity or play.

A 2018 report from the American Academy of Pediatrics evaluating three national injury databases estimated that 1.1 million to 1.9 million recreational and sports-related concussions occur every year in the United States in children 18 years of age or younger. When it comes to sports-related concussions for high schoolers, boys tackle football tops the incidence list with girls’ soccer coming in second, according to the report.

“A lot of concussions go unreported or undetected,” said Nicole Pitts, D.O., a sports medicine physician at Cook Children’s Pediatric Specialties in Prosper. “Usually 2 in 10 high school athletes who play contact sports, including soccer and lacrosse, get a concussion.”

Signs and symptoms

A concussion can sometimes be hard to spot. After all, it’s an internal injury. There are no visible cuts, bruises or breaks. Parents and coaches must rely on how a child feels and behaves to spot the signs and symptoms, which could have a delayed onset and last for days, weeks, months or more.

If your child takes a blow to the head, here are the signs and symptoms that they may have a concussion:

• Persistent headache or increasing head pressure
• Drowsiness or difficulty waking, characterized by grogginess, haziness, sluggishness or foggy feeling
• Dizziness and balance issues
• Blurry or double vision
• Weakness, numbness or reduced coordination
• Persistent vomiting, including nausea
• Slurred speech or slowed responses
• Convulsions or seizures
• Confusion, forgetfulness or difficulty recalling events before or after the injury
• Restlessness, agitation or heightened sensitivity to light and noise
• Behavioral or personality changes
• Loss of consciousness
• Asymmetrical pupil size (one pupil larger than the other)

What to do if you suspect your child has suffered a concussion

If you suspect your child has suffered a concussion, first and foremost, pull them from the game or activity.

“If they're in a game and you suspect they’ve had a concussion or had a blow to the head, or they're having any of those symptoms, even if you’re not sure, but suspect it, they need to be removed from the game immediately,” Dr. Pitts said. “That's the most important thing, and they should not be put back into play in that game or any activity on the same day at all.”

Have them evaluated by a professional, like a physician or athletic trainer, right away, especially if they lose consciousness, are confused and disoriented, are vomiting continuously and have trouble talking.

What's next

The clinical protocol for concussion treatment and rehab includes two strategies for evaluating an athlete’s recovery and readiness to get back in the game. The first 24 to 48 hours after a concussion should be a time of rest for the athlete, followed by a gradual and staged reentry to school and sports using the return-to-learn and the return-to-sports strategies. Athletes should remain in each stage for a minimum of 24 hours and should be able to complete the activities each stage allows with little to no exacerbation of concussion symptoms before moving to the next.

“We'll get them back into school first and once they're back in school and able to do all of their school activities and they're not having any symptoms, then we’ll start them on a return-to sports protocol,” said Carolyn Snow, MS, LAT, ATC, OTC, sports medicine coordinator at Cook Children’s Orthopedics and Sports Medicine. “We don't want to do any sports activities until they’re symptom-free.”

Dr. Pitts utilizes these clinical strategies with her concussion patients in Prosper. Cook Children’s Orthopedics and Sports Medicine concussion clinics at Walsh Ranch, Hurst and Mansfield also follow the return-to-learn and return-to-sports clinical protocols, in addition to utilization of a concussion testing tool called ImPACT to help determine a child’s readiness to return to activity. This computerized test measures memory, attention span, and visual and verbal problem-solving. Dr. Pitts is also certified to administer the ImPACT test.

Recognizing the signs and symptoms of concussion early on, and taking immediate action can help protect your young athlete’s mind from further or more serious injury. Getting the proper treatment and rehabilitation can minimize the long-term consequences from concussion and get them safely back in the game when the time is right. 

Before they can pump weights in the school gym or march with the band this summer, teens in Texas need to complete a form that aims to catch any underlying health concerns.

The annual UIL pre-participation physical evaluation form applies to junior high and high school student athletes and marching band members for the 2023-2024 school year. The form has two parts:

1.      Medical history – a list of yes/no questions about headaches, dizziness, chest pain, seizures, allergies and more. This portion must be filled out every year by the student and parent or guardian.

2.      Physical exam – performed by a physician to check the student’s lungs, joints, vision, weight, heart rate, blood pressure and more. UIL requires the physical exam before the 7th, 9th and 11^th grades. Some districts, including Fort Worth Independent School District (FWISD), require it annually.

Doctors at Cook Children’s say the physical exams are an important safeguard for student athletes. Sports physicals give doctors the chance to check for a variety of concerns – everything from poor eyesight and asthma to a lingering sprain or even a serious heart condition.  

“The goal of a sports participation physical is to review each child’s health history, to perform a thorough exam, and to identify health issues that could predispose the participant to a high risk of having symptoms or an injury while playing sports,” said Ann Natterer, M.D. at Cook Children’s Pediatrics Cityview in Fort Worth.

Why go to your regular pediatrician for this exam?

Dr. Natterer points out several advantages, including patient privacy and getting up-to-date with routine care, such as vaccinations.

“The pediatrician knows the child the best, has access to past medical history, and is also in a better position to facilitate any follow-up evaluations that may be necessary,” she said.

The pediatrician sees the big picture during a sports physical, said Wuroh Timbo, M.D. at Cook Children’s Pediatrics Lake Forest in McKinney. Your teen’s doctor has the files to track changes over time in weight, heart rate, medications and other parts of health history. Your teen’s doctor also knows about any previous illnesses, such as rheumatic fever, which can cause heart valve damage.

“And I think also just having an already established rapport with the families,” Dr. Timbo said. “It’s way easier to communicate with someone you already know. You’re going to get better information and give better information when there’s already a previously established relationship.”

Dr. Timbo recommends that parents make the appointment for their teen’s sports physical as early as possible. Getting the physical exam done early in the summer beats the rush that typically happens just before football workouts and band practice start. In other words … don’t put it off. It’s better to find out in May rather than in August if a student athlete needs vision correction, an inhaler or physical therapy, for instance.

What to Expect

It takes about 15 minutes, Dr. Timbo said, to go through a sports physical. Blank spaces on the UIL form allow the doctor to make note of any abnormalities with the patient’s eyes, ears, throat, lymph nodes, pulse, lungs, abdomen, back, feet and joints.

A sports exam gives patients the chance to ask questions or report any problems that impact their athletic ability. Knee pain and heel pain are the two most common complaints that Dr. Timbo hears. Sometimes the athletes tell him they’ve noticed shortness of breath or frequent headaches.

“Whether it’s something like exercise-induced asthma that we hadn’t caught before, or it’s an injury that re-aggravates every time they do a certain movement, we want to know, and we want to come up with a treatment plan to address it,” he said.

After the exam, the doctor checks one of three options on the UIL form: cleared for participation, cleared after completing additional evaluation or rehabilitation, or not cleared due to concerns. A referral might be needed for further tests with a specialist.

FWISD Director of Athletics Lisa Langston, Ph.D. said a physician’s clearance offers some assurance that the students can safely practice and compete in sports activities. Thanks to the required physical exams, she said, conditions such as cardiac issues and hernias have been detected through the years.  

“The students understand it’s all about their health and wellbeing. We’re not just doing lip service,” Dr. Langston said.

Dr. Timbo urges his patients to listen to their bodies. Speak up if something feels off. Understand that the annual sports physical is geared to pick up on any medical condition that might hinder their performance. Some underlying conditions could even be life-threatening, such as heart rhythm disorders that might lead to sudden cardiac arrest. 

“All doctors want their patients to be active,” he said. “Athletics is good for the body, good for the heart and teaches great life lessons on the ability to work in teams, resiliency and concentration. But we as physicians want to make sure that they’re safe to participate in these activities.”

They grow up so fast. One minute you’re rocking your baby in your arms and breathing in their sweet baby smell from the top of their head, and the next you’re carting them off to the doctor for their teen physical and wellness check.

In many ways, for both parents and kids, it feels like an altogether different experience from their yearly infant and child well-checks. But, in reality, it’s not different at all, save for the fact that your baby has matured into a teen who now values a certain level of modesty and privacy when it comes to their bodies. This can make the routine check of the genital area which is a part of every physical a bit “cringey,” as your teen might say. Let’s face it, it’s uncomfortable for parents, too, as they come to terms with their child’s increasing independence.

“I think parents think they're different and I think the only reason that they feel it's different is that, of course, the teenager at this point now does a lot of stuff on their own, meaning they have their privacy,” explained Bianka Soria-Olmos, D.O., Medical Advisor for Digital Health. “The parent isn't in full knowledge of things like bowel habits or genital development and abnormalities because they’re not changing a diaper or helping with bath time every day.” 

What to Expect

When Dr. Soria-Olmos examines the genitals during a patient wellness check — be it for a baby, child or teen — she says she is inspecting for the same things. Is the child following a normal developmental path? Are they entering puberty too early? Are there any visible abnormalities of the genitalia? These exams are general visual inspections. Nothing invasive.

For boys, pediatricians examine the penis, testicles and scrotum. When inspecting the scrotum, they may ask your child to turn their head and cough as the pediatrician feels the scrotal sac.  This helps reveal inguinal hernias or tumors. Slightly embarrassing for your teen? Yes, but absolutely necessary. Undetected inguinal hernias can rupture and be very painful, or even dangerous, for your teen.

Inguinal hernias are particularly dangerous for teen boys playing sports, as a direct blow to the genitalia could lead to hernia rupture. This is why most teen boys are required by their school to have physicals prior to playing contact sports, but they’re important even if your kiddo isn’t suiting up each week for Friday night football.

“I remind my parents of kiddos who say, ‘I'm not playing sports, so I don't need that check,’ that we still need to make sure that we have a normal anatomy and that we don't have a hernia,” Dr. Soria-Olmos cautioned. “Because an undiagnosed hernia, even if not playing sports, can be dangerous.”

Girls will also undergo a visual exam of their genitals to make sure their development is coming along at a normal pace. Unless there is a complaint of pain or other concern, Dr. Soria-Olmos says teen girls do not need an internal gynecological exam. The American College of Obstetricians and Gynocologists recommends women begin having regular Pap smears at age 21.

Alleviating Embarrassment

You can help your teen gain some level of comfort with these exams by talking to them prior to their physical about what to expect and why these checks are necessary. Dr. Soria-Olmos makes this discussion a regular part of her patients’ yearly wellness checks as they grow and mature. She also uses it as a springboard to talk about body safety and the difference between an appropriate medical exam under the consent and supervision of their guardian versus inappropriate touching.

In addition to a genital exam, all of the normal body system checks occur, too — ears, eyes, nose, throat, mouth, abdomen, back, legs, arms and thyroid glands. You’ll hear the same questions about your teen’s nutrition, sleeping habits and physical activity as you did when they were younger. If mom or dad has expressed concerns or the doctor detects any red flags about mental health, sexual activity, alcohol use, drug use, smoking, signs of an eating disorder or other risky behaviors, your pediatrician may broach these subjects with you and your teen.

“We only talk about this when the physical is done,” Dr. Soria-Olmos said. “And then always gauging the parent’s comfort for allowing their teen to have a conversation with or without the parent in the room.”

If you have a concern about your teen, or feel they may be more comfortable talking to the doctor about an issue, it’s okay to alert your pediatrician ahead of time so that they are aware your teen might have something they want to discuss.

“Ideally, I try to foster this type of open communication,” Dr. Soria Olmos said. “We are all here together to help the child. It’s important that mom, dad and doctor are all on the same page about what is going on with their teen.”

While this new phase of life may be tricky to navigate and, at times, uncomfortable for both you and your teenager, it shouldn’t deter either of you from getting these important health checks. In addition to protecting their health, it teaches your teen to be responsible for taking care of their bodies as they move out from under your wings and into adulthood.

Heat illness during sports practice or competition is among the leading causes of death in the U.S. for high school athletes, according to the Centers for Disease Control and Prevention (CDC). Scorching summer sun and high temperatures put athletes at increased risk for heat illness, no matter their fitness level. 

Coaches and directors of marching bands are currently conducting practices, rehearsals and scrimmages ahead of football season. This summer, North Texas experienced lengthy stretches of triple-digit temperatures and drought. Rainy days have tampered down the heat, but the humidity is still high.

Students’ primary preparation begins with hydration – not just during and after practice. Drinking water and clear liquids must begin hours, even a day, before the exercise and exertion, said Jason Terk, M.D. of Cook Children’s Pediatrics Keller Parkway.

“If you're not dealing with a full tank, you are not going to be able to catch up or keep up,” Dr. Terk said. “Those leading the practices must also build in enough breaks for rest, shade and hydration.”

Keeping pace with science and research, the University Interscholastic League (UIL) sets guidelines around heat stress and athletic participation for high schools. Their recommendations follow research from the American Academy of Pediatrics Committee on Sports Medicine. UIL now recommends water availability for athletes in unlimited quantities. Cold water is best. Additionally, practice schedules should include 10-minute water breaks for every 20-30 minutes of exercise in the heat.

Dr. Terk is a self-proclaimed marching band nerd and is an unofficial chaperone for Keller High School’s marching band.

Guidelines Make Sense

“In 15 years of doing this, the last nine of them at Keller High School, I have no reported heat-related emergencies,” said Ryan Heath, director of the marching band.

There are two parts to Heath’s preparation for marching season, the music-only rehearsals indoors and the music-plus-marching outside.

“Our district has great guidelines related to temperatures and that dictates what our hours are,” Heath said. “We work to schedule the outdoor part in early morning or in the evening before sundown.”  

Keller Independent School District bases decisions on the National Weather Service’s Wet Bulb Globe Temperature Forecast. Its measurements can help manage workload in direct sunlight and capture temperature, humidity, wind speed, sun angle, and cloud cover (solar radiation). Many of us are more familiar with the “heat index” that only measures temperature and humidity, and does so in the shade.  

Heath starts the discussion with his students in the spring, about summer training for the fall marching band season. When rehearsals get underway, he expects students to have done enough summer activity so they can complete a one-mile run in 10 minutes. Heath says the measurement ensures band students have the cardiovascular endurance required, to play an instrument successfully and march simultaneously. He came up with it after consulting medical professionals and other  experts.

“We don’t have a certain training regimen,” Heath said. “But this is an athletic activity as much as sports and my expectation of participants is they maintain good physical health and stay hydrated.”

For safety precautions, he requires students to have a hat, sunglasses, a gallon of water, and sunscreen when they report for outdoor marching rehearsals. Without those, they cannot participate. He also says, during the first weeks of marching practice many parents show up with extra pop-up tents, ice packs and more water to help monitor students’ response to the heat. Many of the parents are doctors, nurses, nurse practitioners and others with professional expertise.   

Ease Into Practice  

“I played high school football and we practiced for three hours with one water break,” said Daniel Guzman, M.D., pediatric emergency medicine physician with Cook Children’s Medical Center. “I’m happy to see that we have advanced from the archaic ‘it will toughen you up’ to water breaks are important for players’ safety.”

Dr. Guzman’s youth sports career included summer practices in South Texas. He knows now just how dangerous it was and how preventable heat emergencies are.

“Exertional heat illness is one of the leading causes of death each year. Parents need to be aware and informed about their children’s practice schedules and the team’s policy on modifications of practice depending on the level of heat that day,” Dr. Guzman said. “At what temperatures do we modify our practice schedule?  It is within a parents’ right to know what these policies are and what are children being taught about rest and hydration to keep them safe.”

Dr. Guzman says coaches and band directors can help student athletes by acclimatizing to heat during the first seven to 14 days of practice. He says athletes can become more heat tolerant, but are never out of danger. Coaches should be careful and watch closely, while athletes need to self-restrict activity if they begin feeling badly – the sooner the better – to avoid emergencies.

“It’s important to be careful when pushing these young athletes to their limit and be mindful that most kids won’t say they feel bad or need to stop,” Dr. Guzman said.

Early Warnings

What are the earliest signs of heat illness? Dr. Guzman says it usually begins with muscle cramps, lightheadedness, headache, abdominal cramps and nausea. If you ignore these early signs, your condition could become emergent quickly. If you are too sweaty and looking pale, Dr. Guzman says that means it is time to get in the shade and drink something with electrolytes, like a chilled sports drink, to replace salts. It’s really important to treat the symptoms quickly, especially if the athlete is confused.

The color of urine is a good monitor for sufficient hydration. Dr. Guzman says it should be clear and not dark. If urine begins to look brown, red or tea-colored, there could be serious issues underway, like the medical condition called rhabdomyolysis (rhabdo). Rhabdo occurs when injured muscle tissue breaks down rapidly and releases proteins and electrolytes into the bloodstream. In large amounts, the substances can damage kidneys and other organs, cause rapid heart rate and even death.  

“The process makes the blood sluggish. Everything just aches and patients often say it’s too painful to move, they have achiness everywhere, flu-like discomfort,” Dr. Guzman said. “Kids can complain of feeling sluggish and weak. They should skip practice if this occurs and seek medical attention.”

Athletes that have dark-colored urine with or without any other symptoms should consider it a significant cause for concern. Blood tests can measure the level of substances released into the blood stream to diagnose rhabdo. One measurement important to Dr. Guzman is creatine kinase (CK). Normal ranges can vary among patient populations. Generally, he wants to see it under 300-350 micrograms per liter (mg/L). In the emergency department, he has seen patients whose CK is 1,000-2,000 mg/L range and he recalls one athlete with over 10,000 mg/L.

“The treatment is to continue IV hydration two times the normal amount until the patient feels better and the creatine kinase begins to decrease to normal levels,” Dr. Guzman said “Big muscular kids are the ones that concern us the most. Working out vigorously can break down all that muscle and create a dangerous situation.”

Avoiding heat illness among sport and marching-band athletes is a group effort among coaches, band directors, parents and kids. Respecting any outdoor activity for the possibilities and concerns related to heat stress is vital to the safety of student participants. Be cool this summer – literally!

Early Signs of Heat Stress

• Muscle cramps
• Lightheadedness
• Headache
• Abdominal cramps
• Nausea

Reminders for Athletes and Parents

• Monitor your body’s need for water or cooling breaks.
• Avoid worrying about being the ‘weak link.’
• It is okay to say, “I can't go anymore.”

RELATED: The Facts About Fainting in Children (checkupnewsroom.com)

But what is the healthiest way for young competitors to muscle up? If you are raising an athlete, chances are you’ve heard a coach tell your child to do just that. Bulk up. Gain weight. Get stronger. Improve your power.

The natural inclination of any driven young athlete can be to hit the weight room and add calories to pack on the pounds. But it’s not that cut and dry.

“When we tell a 14-year-old to bulk up, they’re immediately going to think that they need to start lifting heavier and heavier weights,” said Jacky Arrow, PT, DPT, SCS, COMT, Cook Children’s clinical coordinator of sports rehab. “They may start trying things they have seen others doing and that they may not really know how to do. Weightlifting is great, but it could lead to issues and injuries if it isn’t done appropriately, and done with supervision and the right technique.”

All Things Are Not Equal

Muscles aren’t one size fits all. Every sport and what it requires of the athlete and their body size, shape and structure is different. What football demands of a future Division-1 lineman isn’t the same as what baseball demands of a pitcher, or soccer demands of a goalie, or tennis demands of a pro.

“There’s an important need in all sports for a general level of physical preparedness,” said Savana Turner, ATC, a certified athletic trainer at Cook Children’s. “We need to move well, have good mobility in our joints, have good strength and good flexibility. Then, when we’re getting into the higher levels of sports, a sprinter needs a different level of power than maybe a baseball pitcher. They need to be working on very differentiated programs that have the same base level, but can be specialized more into strength versus power versus endurance, depending on what their sport requires.”

Things like age and genetics also factor into a kid’s ability to bulk up. A child’s body can only do so much until it reaches a certain maturity. While kids and teens can improve their performance in a given sport by learning how to most effectively use the muscles they have, it isn’t until they hit puberty that they can see a change in muscular size associated with their strength programming.

“No scientific evidence indicates that participation in a supervised resistance training program will stunt the growth of children or damage developing growth plates,” said Nicole Pitts, D.O., a sports medicine physician at Cook Children’s-Prosper. “Although there is no evidence-based minimum age for participation in a youth resistance training program, all participants should be able to accept directions and follow safety rules. Generally, when youth are ready for sports participation, approximately ages 7 or 8, they are ready for some type of resistance training as part of a well-rounded fitness program. Then, I would say, they can progress to heavier weight around puberty but should wait to do powerlifting or Olympic lifting until they reach skeletal maturity.”

For some, making a big jump in size just isn’t in the cards.

“Some kids are just not going to get big,” said Carolyn Mullins, PT, rehab services manager at Cook Children’s Medical Center. “It’s not in their genetic makeup, and they need to keep those things in mind and be safe about choices that they’re making. You can push and push but if your body’s not built to be a lineman, then your body just isn’t built to be a lineman, and there is not a safe way to do it.”

Before your athlete jumps into the weight room or adopts a diet plan, the most important thing to have in place is supervision. Lean on professionals to design a program that is appropriate for your child and considers their age, progression through puberty, body type and sport.

Know the end game, too, be it increased velocity for the pitcher or girth for the lineman. Is the goal to add weight or gain muscle? What is the definition of “bulking up” for your coach, trainer and sport? Are you looking for more upper body strength or lower body strength, and why? Understanding what you are trying to accomplish and having a plan supervised by a professional will help you reach your goal while minimizing your risk.

The Building Blocks for Bulk

You need three things to build muscle.

●     Strength and resistance exercises that challenge the muscle.

●     A well-balanced diet that includes muscle-feeding protein.

●     Time for muscle recovery and rest so that muscle fibers can rebuild, making you less prone to injury.

Dr. Pitts, who knows a thing or two about the needs of elite athletes as a former professional tennis player, recommends starting your muscle-building journey by using your own body weight as resistance. Once you’ve mastered that, you can progress to very light resistance using lower weights with high repetitions before puberty. As you get older, you can increase both of these.

A good muscle-building program will include both training and nutrition. Without adequate nutrition, you don’t have the building blocks to increase muscle strength and size. But the right nutrition without the right training and practice won’t get the job done either.

Food is Fuel

All calories are not equal when it comes to a well-balanced diet that promotes muscle growth. A diet full of sugary drinks, junk foods and fast food may help you pack on the pounds, but it can lead to fatigue and poor performance, even for kids who seem to have an endless well of energy.

“Our society has been greatly impacted by childhood and adult obesity, so general advice to ‘gain weight and bulk up’ can be very challenging to navigate,” said Rachel Hill, RD, CSO, LD, CNSC, a registered dietitian at Cook Children’s Medical Center. “Being an active teen does not eliminate the risk that comes with a weight that is too heavy for the child’s frame or eating a diet that far exceeds the body’s needs or is laden with junk foods. While the risks of eating a junk food diet may not be obvious to a teen at first glance, they are robbing their body of essential nutrients for optimal growth, development, function and performance.”

As a general rule, kids should eat a diet rich in whole foods that includes a mix of carbohydrates, protein and fat. Doing so will not only fuel your body with healthy, energizing calories but also give you the vitamins, minerals, fiber and other nutrients you need for peak performance. Once puberty hits, males often require more protein and females more iron.

“Athletes need about 1 to 1.4 grams of protein a day per kilogram of body weight to help with muscle building and repair,” Dr. Pitts said. “It’s a little bit more than their non-athletic peers. So for a 150-pound athlete, having about 80 grams of protein, or 20 extra grams of protein compared to someone else a day, is ideal. If you end up going beyond that, the body doesn't always utilize it. A lot of times athletes will take three times the amount of protein that they need a day.”

Beware of using supplements to add protein. This can actually add more protein than the teen body needs. Supplements also may contain substances like creatinine, which can cause renal failure if used improperly and is not recommended for teens, according to Dr. Pitts.

When it comes to powering the athlete, timing is key. What you eat before, during, and after activity helps fuel your performance and recovery.

“The foods we eat provide fuel for our bodies in the form of calories,” Hill said. “Calories come from three sources: carbohydrates, protein, and fat. While all three are important for a well-balanced diet, carbohydrates are most important prior to a workout to provide enough fuel for the workout. Without enough carbohydrates, the body defaults to breaking down muscle to fuel the workout. Incorporating a little bit of protein into the pre- and post-event snacks can also help protect muscle mass.”

Teen athletes should eat a meal or snack at least 30 minutes before and after exercise to fuel their performance and protect the hard-earned muscle mass they’ve built.

Take A Break

Allowing time for your muscles to rest and recover isn’t slacking, it’s actually muscle-building. If the muscle fibers broken down during activity aren’t given the chance to rebuild, you’ll actually interrupt the muscle-building process, end up losing mass and make yourself prone to fatigue-induced injury. If you are strength training, don’t work the same muscle group two days in a row. Put one to two days of rest in between. The American College of Sports Medicine recommends two to three non-consecutive days of strength training per week for teens.

Dr. Pitts also warns about specializing in a single sport too early. Branching out into other sports creates a well-rounded athlete with cross-trained muscles and skills. It also protects the athlete’s mind and body from burnout.

“Taking care of your body as a whole is really important and is a really difficult thing for a child or a teenage athlete to keep in mind,” Arrow said. “It’s that end-game mindset. Sleep. Drink water. Eat a well-balanced diet. Participate in a broad variety of activities. Taking time off from your sport and focusing on moving well over putting more weight on the bar is the key.”

The bottom line if your teen wants to be an athlete to be reckoned with? Train well. Eat healthy. Play hard. Rest. And, above all, enjoy the game!

Last year saw more kids coming to the Emergency Department for playground falls, sports injuries and pedestrian accidents with kids walking or riding their bike to school.

We took a look at Trauma Department registry for the week of Aug. 21-28 when Fort Worth ISD began. It’s important to remember that these numbers are based on what the Trauma department saw and not reflective of every kid who went to the ED during this time frame.

Here’s a quick glance at we saw last year:

Falls

By far and away, the most injuries seen last year were falls with 29 occurring during the week and seen by both the ED and our Trauma department. Eight of the falls happened at an elementary school and one at a football field.

Sports Injuries

We saw six sports-related injuries reporting to Trauma during this time period, with four of those injuries on the football field. Injuries ranged from concussions to leg injuries.

Miscellaneous

No matter how hard we try, kids get hurt. The six injuries seen by Trauma that occurred during the week ran the gamut of categories that were all their own, including placing a finger in fan to running into a wall during gym glass.

Car wreck

We were fortunate last year, only one child was taken from the ED to Trauma after a car crash. Still though the early part of school can be a risky time as parents are rushing to get back on a school schedule. Remember to make sure everyone is buckled up and follow the slower speed limits during school hours.

Pedestrian/bicyle injuries

This one almost needs an asterisk. Maybe it’s because during the first week of school, not as many kids are walking yet. But during the first week, only one child was hit by a car and seen by Trauma. However, In September four kids were hit by a car riding a bike, including one at an elementary school, and seen by our Trauma department.

According to Safe Kids Worldwide, more children are hit by cars during September than any month of the year. Kids walking or riding their bikes, scooters or skateboards can be dangerous when not done correctly. The next few weeks, while everyone is getting adjusted to kids going back to school, can prove especially hazardous.

The experts at Cook Children’s remind parents that bike helmets should be worn at all times for kids riding a bike to school. Bike helmets should sit on the top of the head with the chinstrap fastened, holding the helmet in place if the child is to shake his or her head or fall.

Sharon Evans, Trauma/Injury Prevention Outreach Coordinator at Cook Children’s, said the ride or walk to school can be especially dangerous for children who simply aren’t ready to go alone.

“Most children don’t have the cognitive skills to crossing streets safely until at least the age of 10,” Evans said. “They haven’t yet developed the depth perception or the ability to maturely judge the speed of an object.”

Evans said there are several reasons why children 10 and younger shouldn’t ride bikes, scooters or skateboards to school:

• Easily distracted by friends and toys.
• Can’t determine the direction of sounds. Some children may be listening for sounds and may not realize that some newer model electric/hybrid vehicles may not make much of a sound at all. This can be especially dangerous if the children are wearing earbuds.
• Can’t judge the speed or distance of a moving vehicle.
• Don’t understand how long it takes for a vehicle to stop.
• Have too narrow a field of vision.

Even when kids reach 10, Evans encourages parents to accompany them to school whenever possible.

Does your child look like one of these pictures when they head off to school?

Then this article is for you to improve the future of your child’s spine.

Backpacks are routinely bought because of how pretty they are, what super hero or cartoon character is on them, or how much can they hold. These are all very important to your child, but there are a few more criteria that parents should be looking at:

Top 10 things to know about a backpack to prevent injuries:

1. The American Academy of Pediatrics recommends that a backpack should not weigh more than 10 to 20 percent of the child’s body weight. If the child is complaining of discomfort, always keep it less than 10 percent of their body weight.
2. Put heavier items closer to the child’s body in the backpack, so that it does not pull the backpack away from their spine.
3. Parents should pick up their child’s backpack on a regular basis to feel its weight.
4. Backpacks should be worn with one strap on each shoulder, not hanging off one shoulder.  Use the abdominal strap if one is provided.
5. The backpack’s straps should be fitted snuggly over the child’s shoulders.
6. Make sure the backpack is positioned literally on the back - between the shoulders - and not resting on the child’s lower back or hips.
7. Have the appropriate size backpack. If the straps are tight and the back pack hangs down past the hips, the back pack is too big for this child.  It should rest above the hip line.
8. If your child has pain in their shoulders, neck or back- there are options with back packs with wheels.You might also ask the school to provide one set of books for school and one set for home.  These modifications sometimes require a physician note for the school.
9. If your child has more to carry than is recommended for the backpack, they can carry some items in their hands to balance the weight on the body. Make sure that they are not carrying more than 10 percent of their body weight.
10. If your child is complaining of pain after the backpack is removed and does not go away, seek a physician consult.

Please check out the below links to assist you with keeping your child happy and healthy this upcoming school year!

Dana S. Harrison, PT, MPT, Cook Children’s SPORTS Program/Rehab Manager

Related links:

• Cook Children's Sports Performance Orthopedic Rehab Team Specialists (SPORTS)
• Backpack safety for pre-grammar school
• Backpack safety for elementary school
• Backpack safety for teenagers

About the author

Dana Harrison, PT, MPT is Cook Children’s SPORTS program/Rehab manager. 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.

"Should my child play football?"

"Should my child play football?"

You may be asking yourself this question with all the recent news about the dangers of chronic traumatic encephalopathy or CTE. A study in the most recent Journal of the American Medical Association (JAMA) found that 110 of 111 NFL players whose brains were studied after their deaths showed they had CTE. CTE is a disease that gets worse over time, affects the brain and is linked to frequent head trauma. CTE is not related to just concussive hits, but repetitive sub-concussive trauma as well. Symptoms of CTE can present as trouble with mental tasks, changes in mood and or behavior.

CTE findings were mainly present in the athletes from the professional level however they were present in both high school and college athletes as well. The study had some limits in that there were some potential biases in choosing the participants from the professional level. As the families of these professional athletes may have notice symptoms while the athlete was still alive, motivating them to donate the athlete’s brain to the study. The study also does not represent the whole group of athletes exposed to football at the college or professional levels.

Now you ask yourself, does this carry over to our middle school and high school football players? Well sadly at this time we still don’t have all the answers and more studies need to be done, but this helpful information going forward.

The Centers for Disease Control and Prevention (CDC) estimates 1.6 million to 3.8 million concussions each year.

So should your child be playing football or any contact sport for that matter?

While the war on concussions is alive and well, the scariest part is that our youth are the ones most susceptible. But what do we do with our youth in the meantime? As parents, you are the ones that ultimately decide what activity your child plays.

I am not recommending that you pull your children out of football or that football shouldn’t exist. As someone that helps treat children with post-concussive symptoms, I urge you to at least educate yourself on the sport your child is asking to play or you are asking your child to play. Here are five questions you should be asking…

1. What is a concussion and how do they happen?

A concussion is an injury to the brain that comes from a hit, a fall or an injury that shakes/ jars the head. Concussions are not only football injuries. They can happen in any sport or in daily life.

2. What can I do to be proactive?!

• Put the safety of your child ahead of winning.
• Make sure the coach is teaching the correct fundamentals.
• Proper tackling form can diminish the likelihood your child will hit their head.
• Helmets are not weapons.
• Despite claims, no helmet has been proven to prevent concussions.

3. What does a concussion look like?

Concussions are injuries to the brain and they are not injuries that you should play through.

Concussions can present in many different ways. The most important thing to watch for is if your child is not acting like his or her normal self. Children may also present or complain of:

• Vision changes - such as sensitivity to light and intolerance to reading.
• Dizziness/ Vertigo.
• Memory loss.
• Loss of consciousness (Fainting).
• Vomiting.
• Changes in mood.
• Lowered attention span.
• Changes in hearing and balance.

4. When should we seek help?

• If there is any sign of concussion you should seek immediate medical attention.
• Any suspicion of a concussion should be treated as a concussion until proven otherwise.
• Find a sports medicine physician that specializes in concussion management to ensure that signs and symptoms are not missed.

5. Who else can help treat the symptoms of concussions?

Concussions may require an overall specialized, team approach:

• Physician to make sure there's nothing more serious going on and to manage the care of the patient.
• Speech and Language pathologist – can help with memory, organization skills and higher level language skills.
• Audiologist - to help with hearing and balance.
• Occupational Therapist- can help if patients have trouble using their hands, writing in school or visual/ spacial management.
• Physical Therapist- can help balance, dizziness and safely return to sport.
• Ophthalmologist- can help with visual problems.

Click to learn more about Cook Children’s ImPACT program.

Other Resources:

• Impact Concussion Management
• What every parent needs to know about concussions
• Helmets Don't Prevent Concussions
• SPORTS resources
• Cheerleader injuries

Our Experts:

Ryan Blankenship, PT, MPT, SCS, is a SPORTS physical therapist at Cook Children’s. Cook Children’s SPORTS Rehab is a leader in the community in sports injury. Additional information and helpful tips can be found on the Cook Children’s SPORTS Rehab website. Cook Children’s SPORTS Rehab is a leader in the community in sports injury prevention.

Ricardo Guirola, M.D., specializes in Rheumatology and Sports Medicine. Dr. Guirola takes care of athletes and being part of their active and directed therapy. As part of his education, Dr. Guirola obtained a Master's of Education. He uses those skills to teach families, students, residents, nurses and other physicians. Outside of his medical practice, Dr. Guirola spends times with family, runs and plays soccer and tennis.

Contributing Author

Alan Littenberg, PT, DPT, is a sports physical therapist at Cook Children’s SPORTS Rehab. 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 to get your child back on the field as safely and fast as possible

Physical therapists are trained to see such a wide range of patients with varying needs:

What kind of training does a physical therapist receive?

Becoming a physical therapist takes graduate level education. Prospective PTs first earn their bachelor’s degree in a self-selected area while completing prerequisite courses in the various sciences, psychology, and math. They then go on to attend PT school and earn their DPT (Doctor of Physical Therapy). DPT programs vary in length from 2 ½ - 3 years of year round education. By the time a PT starts his or her career, he or she will have roughly 7 years of collegiate education behind them. Physical therapists must also pass a national board exam. In the past, a PT degree has been a bachelor’s and then a master’s degree, but the scope of practice has grown tremendously necessitating the move to a doctoral level of education.

What about physical therapy assistants (PTAs)?

Physical therapy assistants work closely with physical therapists to implement treatments and plans of care. PTAs must earn an associate’s degree and also pass a national board exam.

Where do PTs and PTAs work?

You’ll find physical therapists and assistants in a variety of locations. The most common include outpatient clinics, hospitals, and rehab facilities, but you’ll also find us in home health, schools, nursing homes, working closely with professional and collegiate sports teams, and even in places like the emergency department. Physical therapists are also active in research.

Can physical therapists specialize in one area?

Physical therapists can attain board certified specialization in various areas. These include cardiovascular and pulmonary, clinical electrophysiology, geriatrics, neurology, oncology, orthopaedics, pediatrics, sports medicine, and women’s health. Achieving board certified specialization requires passing a thorough written examination and either the completion of a yearlong residency or proof of at least 2,000 hours of patient care in the chosen field, among other things.

What about additional training?

To maintain their licensure, PTs and PTAs must complete continuing education. Physical therapists may also choose to pursue advanced training in areas such as manual therapy, treatment of certain conditions or certain body parts, performing specialized examinations, working with athletes from a particular sport, and staying up to date with the best ways to manage pain.

The American Physical Therapy Association’s vision is “Transforming society by optimizing movement to improve the human experience." Physical therapists are highly educated professionals trained to identify problems with movement and function of the human body. We work to restore and improve normal body motion. We educate and empower our patients and families to be active participants in their recovery process. We also instruct on future injury prevention. We love to see our patients succeed and meet their goals. We love to help them improve their quality of life. It’s no wonder physical therapy is consistently ranked one of the happiest and most rewarding careers. It’s a wide and diverse profession and truly has the ability to transform lives.

Our physical therapists at Cook Children’s are ready to help your child/adolescent achieve their goals. Check out our website on how to get an appointment.

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.

In SPORTS, we’ve noticed an increasing trend of children specializing in sports earlier on in their lifetime. Often times, parents, coaches and kids think that the earlier they specialize and spend increasing amounts of time in one sport, the higher the chance they have of making it to “The Big Time.”

The truth is, specialization prior to adolescence can cause increased injury rates, early burn out on the sport, as well as 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 sports other than the one they went pro in 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 overuse injuries, the American Academy of Pediatrics (AAP) recommends:

1. Delay sports specialization until at least age 15-16 to minimize risks of overuse injury.
2. Encourage participation in multiple sports.
3. If a young athlete has decided to specialize in a single sport, a pediatrician should discuss the child's goals to determine whether they are appropriate and realistic.
4. Parents are encouraged to monitor the training and coaching environment of "elite" youth sports programs.
5. Encourage a young athlete to take off at least three months during the year, in increments of one month, from their particular sport. They can still remain active in other activities during this time.
6. Young athletes should take one to two days off per week to decrease chances of injury.

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 is 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.

Related articles:

• Does your child play one sport
• 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

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

Pamela Sherman, M.D., is a highly specialized and skilled orthopedic hand surgeon at Cook Children’s who has more than 3,000 hand patient visits per year. In order for her patients to be successful after her surgeries she relies on highly specialized rehab therapists called hand therapists. A hand therapist can be a licensed physical or occupational therapist. To become a hand therapist requires many hours of training beyond the basic education of a physical or occupational therapist. The hand therapists at Cook Children’s work closely with Dr. Sherman in her outpatient clinics to provide collaborative and comprehensive care to the patients and families.

Hand therapy is the art and science of evaluating and treating injuries and conditions of the upper extremity (shoulder, arm, elbow, forearm, wrist, and hand). The Cook Children’s SPORTS program is staffed with hand therapists at three locations across Tarrant County whose expertise is treating children with an injury or condition that affects the arm or hand.  The hand therapists work with the kids  from birth to 21 years to assess their needs and develop a treatment plan that allows them to return to their normal activities. 

Injuries of the hand are quite common, but steps can be taken to prevent some of them from happening.  Here are a few tips to help prevent hand and arm injuries:

1. Wear protective gear, such as elbow pads and wrist guards, during sports activities.
2. Make sure children do not play near treadmills or other exercise equipment.  Be sure to turn off the equipment and/or unplug them from the power source.  
3. Supervise children when using knives or sharp scissors. 
4. When using a game controller, put pillows in your lap to rest your arms on. 
5. Take regular breaks when performing a repetitive task.  This can help prevent overuse injuries.
6. Change positions often if you are going to be holding an object for an extended amount of time.
7. Review your body mechanics and posture when performing a task.

About the author

Cara Smith, PT, CHT, is a certified hand therapist and the Hand Therapy Program coordinator for the SPORTS program at Cook Children's. Cook Children's offers hand rehabilitation services for all ages, diagnoses and stages of care. We help rehabilitate children/adolescents with a wide variety of congenital conditions and traumatic injuries.

For more information, call 817-347-2925. Cook Children's hand rehabilitation services are under the direction of our Sports Performance Orthopedic Rehabilitation Team Specialists (SPORTS). 

Cook Children's offers three SPORTS Rehab locations for hand therapy:

750 Mid Cities Blvd., Suite 130, Hurst, TX 76054

1919 8th Ave., Fort Worth, TX 76110

801 Matlock Rd., Mansfield, TX 76063

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

“My daughter plays select soccer and can’t afford to take any time off for her injury without the risk of losing her starting position on the team.”

Statements like this are commonplace in my world as a sports physical therapist. And while I genuinely believe that parents and coaches have their minds in the right place when it comes to wanting their child to be the best, the idea that this means you must specialize in your sport early in life is not supported.

Early sport specialization is defined as choosing to play only one sport, often without any breaks during the calendar year, while the body is still changing and growing.

As we are in the thick of another year of the NCAA college football national championship and bowl games, let’s revisit last year’s undisputed national champions as an example of one sport vs. multiple sport athletes. In early 2015, a social media post went viral detailing Urban Meyer’s recruiting record during his time as head football coach at Ohio State. Of his total of 47 recruits, 42 were multisport athletes in high school. Only 5 of his recruits played football alone.

Did you know?:

• Three-time Super Bowl champion, NFL Hall of Famer and Dallas Cowboys Ring of Honor inductee Troy Aikman played shortstop and pitched on his high school baseball team. He was drafted by the New York Mets out of high school and came close to choosing baseball over attending the University of Oklahoma, and later UCLA, to play football.
• Two-time women’s soccer Olympic gold medalist and 2012 FIFA World Player of the Year Abby Wambach credits her success as a soccer player to playing basketball in her youth.
• Eight-time NBA All Star and two-time NBA MVP Steve Nash did not start playing basketball until he was 12 or 13 and instead thanks his soccer background for his success in basketball.
• Six-time MLB All-Star Joe Mauer of the Minnesota Twins played football, basketball, and baseball in high school and was named USA Today High School Player of the Year in multiple sports.

An athlete like Tiger Woods, who started playing golf before the age of 2, is an extremely rare occurrence. It is by no means the norm and should not be expected.

In theory, specializing makes sense. After all, practice makes perfect, right? Wrong! In reality, research has shown the following:

Early specialization leads to overuse injuries.

More and more orthopedic experts are speaking out to shine light on the world of pediatric sports injuries. They have become increasingly alarmed by the skyrocketing rates of injuries in kids and some go so far as to describe it as an epidemic. Each year, roughly 3.5 million children, 14 years of age and younger seek medical treatment for sports injuries.

Of these, at least half can be attributed to overuse injuries. Repetitive activity leads to increased stresses on a growing child’s bones and muscles and can result in injuries such as Little League elbow, Little League shoulder, shin splints, Sever’s disease, Osgood-Schlatter disease, runner’s knee, jumper’s knee, or even stress fractures in areas like the back (spondylolysis or spondylolisthesis), hips, and feet.

So what’s the first line of prevention? Rest. Children should have at least two months off each year to recover from their specific sport. And if we’re talking about baseball, it’s recommended for those athletes to have three to four months of absolutely no throwing or overhead sports.

Early specialization interferes with healthy growth and development.

Playing a competitive sport is stressful, and just as the body must adapt to the changes and demands physically, handling the stresses around winning, losing, practice schedules, traveling, etc… in addition to regular schoolwork can be emotionally draining as well. Children may also struggle with identity and view themselves as solely an athlete. Playing a wide range of sports promotes diverse relationships and allows for a wide variety of experiences.

Early specialization increases the risk of burnout.

Playing only one sport, especially at a competitive or select level, can lead to burnout as a result of stress and physical and emotional demands. A history of injuries can also increase that anxiety. If a sport stops being fun or a child feels pressured to succeed, it can certainly lead to a desire to quit.

Early specialization reduces the chance that children will maintain an active lifestyle as an adult.

In 2013, researchers from The Ohio State University released a study that found that children who specialized in one sport early in life were more likely to be inactive as adults. Committing to a certain sport at too young of an age can lead to early burnout, quitting, and being reluctant to then rejoin physical activities as an adult. A history of injuries also contributes to an aversion towards exercise and a preference for a sedentary lifestyle.

Early specialization doesn’t guarantee future athletic success.

Consider these statistics from the NCAA regarding athletes during the 2013-2014 school year.

                              Estimated Probability of Playing in College

                           Estimated Probability of Playing Professionally

When you look at the numbers, the odds of playing a sport in college and especially professionally just aren’t in your favor.

So what does this mean for our kids?

• No, we shouldn’t put them in a bubble and shield them from sports. Athletic activity is extremely important.
• Children should learn the fundamentals of various sports and enjoy the experience.
• Sports should be fun at every age.
• Sports should create positive habits for later in life.
• Sports shouldn’t cause repetitive injury.

And if your child happens to be one of the lucky few who go on to play in college or even professionally, a history of playing multiple sports is clearly of great benefit.

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.

“This is not fun!”

“I don’t want to play anymore.”

Are these lines you’ve heard your young athlete say? Have you found yourself asking questions like – “What could cause a talented, young athlete to lose their passion for playing a sport?” “Or why would they throw everything away after we’ve worked so hard?”

Your young athlete may be feeling a sense of overtraining or burnout from their sport.

What is overtraining or burnout?

Overtraining occurs when an athlete does the same skill over and over again with limited rest, causing a loss of enjoyment or withdrawal due to increasing physical demands. This could be specialization in one sport, high volumes of training, or demands of coaches, trainers, parents, or self to achieve a specific skill level, time, or score in their sport. A child may sense these demands as too much, leading to physiological and mood changes affecting self-esteem, levels of stress and ultimately leading to physical and emotional exhaustion.

Overtraining can also increase your child’s risk for injury. Often young athletes are putting in long hours to perfect their sport and participate in competitions or tournaments. This repetitive stress and physical exhaustion on a growing, undeveloped body can promote weakness and breakdown of body support structures, placing the athlete at risk for overuse or repetitive stress injuries. A study performed by the American Academy of Pediatrics (AAP) found that athletes who spend more than twice as much time in sports than in free play, who intensely specialize in a single sport, or who played more hours per week than their age, are more likely to have overuse injuries and potential emotional burnout.

Not all athletes that request to stop a sport are burned out. Some request to stop due to time constraints, interest in trying something new, lack of playing time, or boredom. That is why it’s important to be aware of signs of burnout or overtraining.

What are some causes of overtraining/burnout?

• Early specialization in a sport
• Lack of rest
• Lack of life balance
• Loss of fun
• Excessive negative or unclear feedback from coaches and/or parents
• Poor relationship with coach or teammates

What are signs of overtraining?

• Loss of desire to play
• Tiring quickly
• Resisting working with coaches and teammates
• Not reaching training goals
• Chronic injuries

What can I do to help?

It is important to switch focus back to the fun of the game. This can happen by starting pick-up games and reducing the pressure to exceed. This transitions the focus to building teamwork, bringing awareness to proper fitness and health, developing friendships, and having fun.

As the athlete’s parent, you are their support system and second voice. Talk to your athlete and their coach about promoting a good life balance and placing fun back into the game. For example, recommend reducing the number of competitions if your child is training 6-7 days a week for multiple hours a day.

What if you’re the parent and coach? Children model those around them. Teach them based on how you conduct yourself in your passion for the sport, the importance of life balance and rest, and how to create open lines of communication with teammates and coaching staff. Reward the positives, but also use the negatives for learning experiences and education.

Change the mindset of “win-at-all-costs” and motivating through a focus on winning, humiliation/anger when they fail, or pressure to get the athletes mind back in the game. Instead, promote a positive atmosphere where there is a balance of the serious, competitive side and fun side. Try to regain the fun, or positively support and guide them as they transition interest to another sport, position, or activity. There is even a possibility that through this process of finding their passion, they might return to that same sport because they want to, not because they were forced. Also, by reducing the monotony of training and allowing your child to try different sports or positions, you can promote varying levels of strengthening, muscle memory, and physical and mental growth.

It is important to be aware that it is OK for an athlete to become serious about their sport and invest time and energy into pursuing their sporting goals as long as they maintain a passion for what they’re doing. If the passion and fun for the sport is removed, there is a risk for heartache, unhappiness and ultimately burnout.

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

Jenny Arey, PT, DPT, OCS, CMPT, is a SPORTS physical therapist. She's a board certified orthopedic clinical specialist and certified manual physical therapist. The SPORTS Program at Cook Children’s offers educational material for parents, coaches, trainers and nurses for sports-specific injuries. Our team of experts have specialized training in pediatrics and collaborate together to share their knowledge in growing bodies and dynamic training principles. 

Researchers in Pediatrics found that only track and field and swimming were safer as far as the number of injuries to athletes, but because of the high risks of cheerleading stunts the injuries were often times dangerous.

The study found:

• The most common injuries are concussions at 31 percent, but lower than all other girl sports.
• About one third of those injured, were participating again in a week.
• Forty-one percent of cheerleaders were out for one to two weeks.
• Eleven percent were out more than three weeks.
• Five percent were out for either the season or were career ending injuries.
• Most of the injuries were to girls, but boys also were injured because they were usually at the base of the formation.

The Cook Children’s Emergency Department admitted six cheerleading injuries from Oct. 9, 2014 to July 28, 2015, a low number compared to a sport like football. But four of those six required surgery at Cook Children’s.

Amanda Vick, PT, DPT, a Cook Children’s SPORTS physical therapist, was a cheerleader in high school. She points to the focus of cheerleading become a year-round sport, including athletic competitions, summer camps and competitions, leading to the increase in the number of injuries.

Plus, cheerleading has changed over the years to include high level gymnastic tumbling runs and stunts. Most common injuries seen at Cook Children’s are fractures, strains, sprains and concussions. She says more regulations could help lower the amount of injuries in cheerleading.

“Cheerleading has not historically been recognized as a sport, at many levels,” Vick said. “This means cheer may not be under the control of an athletic department. Cheerleading does not have to follow certain rules and regulations that other sports monitor and improve for safety. Therefore, increasing safety awareness is key for protecting cheerleaders.”

Due to this change in the demands of cheerleading, it is important for coaches and cheerleaders to understand proper techniques during stunts and tumbling, strengthening, leg and arm alignment, core activation and different risks related to floor surface and practice time.

Read more on Vick’s advice to protect cheerleaders here.

About the source

Amanda Vick, PT, DPT, is a Cook Children's SPORTS physical therapist.The SPORTS Program at Cook Children’s offers educational material for parents, coaches, trainers and nurses for sports-specific injuries. Our team of experts have specialized training in pediatrics and collaborate together to share their knowledge in growing bodies and dynamic training principles. 

Cheerleading has changed in the past 30 years from yells and claps to routines with high level gymnastic tumbling runs and stunts. It has also become a year-round sport with summer camps and cheerleading competitions. This has increased the number of injuries, especially in females. Most common injuries are fractures, strains, sprains, and concussions. Due to this change in the demands of cheerleading, it is important for coaches and cheerleaders to understand proper techniques during stunts and tumbling, strengthening, leg and arm alignment, core activation and different risks related to floor surface and practice time.

Cheerleading has not historically been recognized as a sport, at many levels. This means cheer may not be under the control of an athletic department.  Cheerleading does not have to follow certain rules and regulations that other sports monitor and improve for  safety. Therefore, increasing safety awareness is key for protecting cheerleaders.

Loading, body mechanics and alignment

The way in which a cheerleader lands when tumbling is also very important in preventing injuries. Soft landings are the way to go. A soft landing is best with knees slightly bent and weight more on the toes rather than heels. Do not allow the knees to go in or forward over the toes; instead, keep toes and knees pointing forward with upright chest and tightened core. Tumbling and stunting on a softer surface is always preferred rather than a hard or wet surface.

Injuries have been related to improper loading due to decreased strength, body awareness and lack of proper alignment with body mechanics.  Loading refers to the pressure or weight a cheerleader has through their arms, legs, and spine while holding a stunt and landing a tumbling pass.

Cheerleaders need  to be aware of their body mechanics. Body mechanics is proper body movements to prevent or correct posture problems, reduce stress on the body, and enhance physical capabilities.   Strengthening cheerleaders’ cores, legs and arms will improve body mechanics and decrease injuries.

Here are some proper basing and spotting techniques from the bottom up, to address proper alignment for good loading and body mechanics: 

• Keep feet shoulder width apart with toes forward or slightly out; heels on the ground.
• Knees should never go forward past the toes or inward.
• Hips should stay over feet with equal weight.
• Trunk stays upright- do not bend or arch the back/spine when spotting a stunt.  
• Arms directly above shoulders; not behind your head when spotting a stunt.

Cheerleaders can be strong too

As cheerleading has become more about stunts and tumbling, it requires strength, balance and stability.  Coaches should be focused on strength-building conditioning, which includes core stability and proper lifting techniques. It is also beneficial for coaches to attend safety certification classes, such as those offered by the American Association of Cheerleading Coaches and Administrators (AACCA). Prior to any cheerleading event, a proper warm up with aerobic activity and dynamic stretching is necessary to prevent injuries. Stretching after cheerleading is just as important to decrease injuries. The longer the practice, the higher the risk for injury is. Most injuries happen between 61 and 90 minutes of practice.

Increasing awareness of concussions 

Cheerleaders are at high risk for sustaining concussions, which is a head injury/trauma to the head when hit.  Cheerleaders sustain concussions with a fall from high heights, being hit in the head when basing, or landing on their head during tumbling.  It is important to stop cheerleading if there is a possibility of a concussion. Signs to watch for include: headaches, dizziness, visual blurriness/double vision, memory issues, decreased coordination and balance problems. If these symptoms are present, the cheerleader should seek medical attention immediately.

Most concussions heal in about a month, however if cheerleaders continue to have the symptoms, they may need active rehabilitation. It is never good to return to cheerleading too early; it may make their full recovery longer.  If a cheerleader has any signs or symptoms of a concussion, they should not be allowed to return to cheerleading until cleared by a physician.  Cheerleaders are 3-6 times more likely to have a second impact concussion after having their first concussion;  the second impact concussion can have more severe complications.

American Academy of Pediatrics recommendations for preventing injuries:                                              

• Cheerleading should be designated as a sport in all states, allowing for benefits such as qualified coaches, better access to medical care and injury surveillance.
• All cheerleaders should have a pre-season physical, and access to qualified strength and conditioning coaches.
• Cheerleaders should be trained in all spotting techniques and only attempt stunts after demonstrating appropriate skill progression. 
• Pyramid and partner stunts should be performed only on a spring/foam floor or grass/turf. Never perform stunts on a hard, wet or uneven surface. Pyramids should not be more than 2 people high.
• Coaches, parents and athletes should have access to a written emergency plan.
• Any cheerleader suspected of having a head injury should be removed from event and not allowed to return until cleared by a health care professional.

Related links

• The Cook Children's SPORTS program
• Cheerleading Injury Prevention
• Top 10 questions parents have about sports injuries

So who is considered a “running” athlete? Cross-country and track first come to mind, but don’t forget sports such as soccer, football, or lacrosse. A typical soccer game played at the varsity level can consist of 7-9 miles, if an athlete plays the entire game. And in the peak of the season, a cross country athlete might run 20-30 miles per week or more.

Each sport comes with its own recommendations of training intensity for kids. The number one rule to remember when it comes to fitness in kids is to emphasize fun and safety. When running stops being fun or aches and pains become commonplace, that’s when we need to worry we’re pushing our kids too far. Keep these tips in mind to help prevent injuries.

• Invest in a good pair of running shoes, socks, and appropriate clothing. Most local running stores have employees trained in gait (walking) and running analysis. They make educated recommendations on proper footwear for each individual. Running shoes should be changed every 300-500 miles or if breakdown is occurring. Moisture wicking (not cotton!) socks and clothing are also important to prevent blisters and help with body heat regulation.
• Maintain a well-balanced diet, and drink plenty of water every day – not just race/game day. Proper nutrition is important in all kids but especially in athletes.
• Avoid running in extreme heat or cold. High humidity should also be avoided. If you are running in warm weather, remember to wear bright, reflective clothing made of wicking material, and be sure to hydrate often. If running in cooler weather, dress in thin, wicking layers, and don’t forget gloves and a hat. Hydration is still crucial in colder temperatures, too.
• Stretch both before and after running. It’s important to stretch the major muscle groups in your legs – quads (thighs), hamstrings (back of your thighs), calves, and hips. Dynamic stretching  prior to running is an excellent warm-up, while static stretching can be used as part of a cool down. Foam rolling is also beneficial for these muscle groups.
• Follow intense running/workout days with an easy or rest day. Youth should have 1-2 rest days per week.
• Running should not be your only form of exercise. Cross training is very important. Biking, swimming, and elliptical are excellent alternatives.
• Build your mileage gradually - no more than a 10 percent increase per week. The most common injures that affect runners are typically the result of overuse. Too sharp of an increase in mileage can predispose runners to injuries like shin splints, tendinitis, or even stress fractures.
• Taking a walking break is not a sign of failure. Walk/jog intervals can help with increasing overall endurance.
• If possible, avoid running on uneven or slanted surfaces (like the sides of roads).
• Be alert and aware of your surroundings. Run with a partner or let someone know which route you’ll take. If you listen to music while running, keep one ear free. Avoid running at night.
• Work with coaches/trainers on proper running technique. Many local running stores also offer free classes on running form.
• Don’t ignore pain! “No Pain, No Gain” does not apply. Unfortunately, aches and pains from running can happen. Don’t ignore it or think it will go away.

If your child is having pain from running or you are concerned about risk of injury, a visit to a physical therapist can be extremely beneficial. At Cook Children’s, our SPORTS physical therapists have experience with the common injuries that affect runners. We also have staff members who are active runners and understand the demands of the sport.

About the author

Melissa Bro, PT, DPT, 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.

If you have a young runner, sign them up for the Cook Children's 5K at 9:30 a.m. on Saturday, Feb. 27, 2015, as part of the traditional Cowtown running weekend.

I am shocked at the number of patients we see where bad posture plays a role in their pain and physical limitations. Whether it be sports injuries, overuse injuries or postural dysfunction, the trend is younger patients are starting to report more injuries. I see technology driving our kids to be more active in an online space than it does in a physical space.

So I would like to take a minute to address how to get our kids active again, but not just any activity. I want to talk about core activity.

What is the core?

The core is a muscular system that works synergistically to provide support and power generation to the body in all positions and with every activity. Think of a soda can to explain the core. The can has a front (deep abdominals), back (multifidi muscles), top (diaphragm muscle) and bottom (pelvic floor muscles). And just like the can, as long as no one pokes a hole in it, it is very strong. As soon as someone creates a weak spot in the can/core, it can easily be crushed.

When do you use your core?

The core should be used during all of life’s daily tasks, but we lose this ability as children when no one teaches us how to use the core during modern-day tasks such as playing on your Ipad or texting your friends.

How do I train the core of a child?

Return to the basics. Too often we see young athletes who have been given formal instruction in how to pitch a ball or perform a round-off back handspring, but little or no training on what it means to use their core functionally. Schools have our kids doing pushups before teaching how to plank. Physical therapy can definitely help patients of all ages with core training, but there are also some things you can do at home. For really young children (3-6yrs) this can mean returning to games that require you to hold positions, such as Twister or Untying the Knot. For slightly older children (7-12yrs), yoga or even just plank holds (3 positions) help build core strength and endurance. For our teens and young adults more formalized training for power generation and power transfer using the core can be very beneficial.

What does a strong core mean?

For your child a strong core means improved performance in their activities whether that is football, dance or band. It can mean no pain when sitting in class or when trying to be active with peers.

For parents, a strong core means fewer complaints from your child, better posture, and less risk of injury while your child is performing their activities.

If you or your child would like help with core training, please contact your physician and seek a referral to Cook Children’s Physical Therapy Department.

More SPORTS resources related to this topic:

• Top 10 questions parents have about sport injuries
• Young athlete's injury prevention guide

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.

Richard Roberts, M.D., a neurosurgeon at Cook Children’s, wonders what it’s worth for your child to play sports with a reputation for head trauma.

“I think the fact that when the NFL players sued the league initially and won, the judge said the settlement (more than $700 million) wasn’t big enough,” Dr. Roberts said. “That says a lot about this growing issue more so than anything else.”

The issue discussed in the NFL cases has been CTE (chronic traumatic encephalopathy), a progressive, degenerative brain disease that has been found in some athletes with repetitive brain trauma.

Research is currently being done to study just how playing contact sports such as football mainly, but also soccer, can cause damage to an athlete’s head. But is it worth it for parents to wait for the results of this work.

“Amateur sports are different than professional sports because no one is feeding their family with the activity that they are doing,” Dr. Roberts said. We need to look beyond the short term and really understand what could happen in the long term. That potential for long term problems should be the primary thought, not the secondary thought.

“What is the actual incidence? We don’t know. But if it was your kid, how much would you be willing to risk? Even if it was 1 in 10, would you roll the dice on your own kid?”

Dr. Roberts has previously worked at Children’s Hospital in Philadelphia and Charity Hospital in New Orleans. While he saw concussions at the other hospitals, he’s never seen parents argue with him about concussions as he has seen at Cook Children’s.

“Part of what I’ve seen which is different here than other places is that I do get push back from parents who I think underestimate the severity of some of these injuries,” Dr. Roberts said. “Some of it is that they want their kids to play and I think some of it is the short term nature of some concussions.”

Children get concussions and they do well relatively quick, so opposed to having a broken arm which is in a cast or needing surgery and having stitches for three weeks, kids hurt their heads, they are knocked unconscious for five minutes, but then feel essentially better soon after. This apparent sign of improvement makes it difficult for some parents to grasp that their child may have a fairly significant brain injury.

“The more we understand concussions and the more we see people who have hurt their heads for various reasons, soldiers, professional athletes, anyone who has suffered a head injury, I think that we are seeing that in adulthood they are starting to have more cognitive issues,” Dr. Roberts said. “Now the science is not perfect yet. We can’t say to a football player you had three concussions and that’s why you have dementia. We can’t say to the soldier you were exposed to be a bomb blast and that’s why you have dementia because it could be multifactorial. It could be that you have the right genes to make you this way later on. But the percentage seems higher in people who have had traumatic brain injuries.”

Dr. Roberts says parents should be concerned after head injury one. He knows you have to let kids live their lives and be kids, but the brain wasn’t made to get beat up like happens sometimes in sports.

It’s not known for sure that after one concussion, people are more likely to get more, but Dr. Roberts’ suspicion is that it is likely the case.

And when does he have a serious heart-to-heart with the parents and the athlete?

“After two. We discuss no longer participating in the activities which could cause further injury because the likelihood of you having a head injury in your lifetime is still pretty high,” Dr. Robert said. “You are going to hit your head on a tree branch or you are going to fall off your bicycle or someone is going to run into you. You are going to be stepping out of the car and slip or walking across ice and fall down. My opinion after behavior has shown us that you are going to get injuries in a particular sport, you should probably not be playing in that sport because you are not able to protect your head.”

Dr. Roberts has seen strong reactions from both the parents and the kids after being told he or she should quit playing their respective sport. And it’s not just football as most people expect. It’s with the gymnast who has fallen off the bars and knocked herself out or the soccer player who has headed the ball and gotten knocked unconscious.

But football still remains king in Texas – in popularity and in concussions.

So what can be done about it?

Dr. Roberts is not sure there’s a good answer to that question. Building better equipment helps, but then armoring players probably makes them feel invincible and they hit harder. If you take away the facemasks or hard shell football helmets, he expects you will return to the old days – less concussions, but more skull fractures and in the process, immediate deaths on the playing field.

For now, Dr. Roberts wants parents to monitor their kids closely and to take the recommendations from their doctor closely. If they say it’s time to stop – stop!

“All the steps that sports are taking to make it safer are positive,” he said. “I think that everybody involved has to think less about return to play and more about long term health.”

About the source

Richard Roberts, M.D., is a neurosurgeon at Cook Children's. When a child with a neurological disorder requires surgery, the experts at Cook Children's Medical Center offer comprehensive care and state-of-the-art technology. With the help of such state-of-the-art equipment as the revolutionary intraoperative MRI (iMRI), our neurosurgeons are able to determine effectiveness of surgical procedures for cranial and spinal nerve disorders and tailor the treatment to each child's unique needs.

The more frightening thing is the amount of patients that we don’t read about who are undergoing the same surgery. More and more, young baseball players ages 15-19 years old are sustaining this same injury and having to undergo this surgical procedure.

Ulnar collateral ligament reconstruction used to be an injury that we saw in ball players later in their careers. John Smoltz played for the Atlanta Braves and was recently inducted into the Baseball Hall of Fame. His career benefitted from Tommy John surgery. Currently, he's the only player inducted into the Hall of Fame who received Tommy John surgery. But he warns against the number of young people receiving the surgery today, calling it an "epidemic."

"I want to encourage the families and parents that are out there that this is not normal to have a surgery at 14 and 15 years old," Smoltz said. "That you have time, that baseball is not a year-round sport. That you have an opportunity to be athletic and play other sports. Don’t let the institutions that are out there running before you guaranteeing scholarship dollars and signing bonuses that this is the way….

I want to encourage you, if nothing else, know that your children’s passion and desire to play baseball is something that they can do without a competitive pitch. Every throw a kid makes today is a competitive pitch. They don’t go outside, they don’t have fun, they don’t throw enough — but they’re competing and maxing out too hard, too early, and that’s why we’re having these problems. Please, take care of those great future arms.”

So are his concerns warranted? In short, yes.

A recent study showed that 15-19 year-olds accounted for 56.7 percent of the ulnar collateral ligament reconstructions performed in the U.S. between 2007-2011.

This is a scary statistic considering this means that over half the UCL reconstructions done in the U.S. are performed on patients who haven’t finished their freshman year of college. So why has this become so much more prevalent in younger athletes?

I think the simple answer is the volume of pitches being thrown. If we look at the trends with today’s young baseball players, more often than not they are playing year round, playing on multiple teams, and at times playing on multiple teams at the same time. At some point kids have to put down the baseball and give their arm a break.

Little leaguers who pitch have a major disadvantage compared to their major league counterparts: they are still growing. This means that each time they take the mound they are pitching with a new body. As kids grow taller, it means they have longer limbs that they have to control, and this takes more strength and more coordination, strength and coordination that often doesn’t keep pace with how fast the athlete is growing.

So how do we reverse the trend of these young baseball players dealing with this terrible injury? Here are four recommendations.

1.Decrease the volume of throws

2.Don’t pitch with fatigue

3.Don’t throw breaking pitches (until skeletally mature enough and skilled enough to do it correctly)

4.Delay specialization (play multiple sports)

Decrease the volume of throws

Decreasing pitch volume I feel is the most important of these three recommendations. It’s not just following pitch counts it’s avoiding playing multiple positions with a high volume of throws. I have had many patients come in and say “we follow all the recommended pitch counts,” but as I dig deeper I find out that, yes, they are following pitch counts, but the child is playing catcher when he isn’t pitching. The bottom line is that it isn’t just pitch count alone, it is the total volume of throws we need to think about.

Don’t pitch with fatigue

Making sure our players aren’t pitching fatigued is also a big part of keeping our young throwers safe. If a player is fatigued and continues to pitch, even if they haven’t reached their pitch count, they are putting themselves at risk. The National Athletic Trainers’ Association (NATA) Position Statement on Prevention of Pediatric Overuse Injuries cited a study showing that a greater percentage of pitchers with shoulder or elbow injuries started at another position and pitched with arm fatigue. So if a player has been out in the hot sun playing short stop in the first game of a double header it probably isn’t a wise decision for him to pitch in the second game

Don’t throw breaking pitches (until physically mature enough and skilled enough to do it correctly)

I think most parents of young baseball players have at least heard the recommendations to avoid curveballs and sliders until the player is older, but for some reason we still have young pitchers throwing these breaking pitches. Another study cited in the NATA Position Statement on Prevention of Pediatric Overuse Injuries showed the risk of elbow pain increased 86 percent in youth pitchers throwing sliders, and the risk of shoulder pain increased 56 percent for pitchers throwing curveballs. We as parents need to remember our kids are going to watch their favorite big league pitcher and want to throw all the same pitches it is up to us as parents to step in and say you aren’t ready for that.

Delaying Specialization

There is an interesting study finding that more of the successful, Hall of Fame–type pitchers come from up north, where Hall of Fame hitters come from all over — a lot of them from the South. The gist of the study was that because there are several months of the year in these northern states that it is too cold to be outside playing baseball these pitchers couldn’t participate in baseball year round. During the winter months they had to put the baseball down and do something else. Once again referring back to the NATA’s position statement they state, “Young athletes who participate in a variety of sports tend to have fewer injuries and play longer, thereby maintaining a higher level of physical activity than those who specialize before puberty.” Delaying specialization is also a big part of decreasing volume, because if kids are playing another sport they will get that nice break that they need from throwing.

This blog by no means touches on all the factors that lead to these injuries, and the four recommendations are by no means the complete list of ways to prevent these injuries, but following these recommendations is a good place to start to keep, our young ball players’ arms nice and healthy.

Resources

• Baseball Injury Prevention
• Top 10 questions parents have about sports injuries
• Young athlete's injury prevention guide
• Strength training in children/adolescents

“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 

Why is it important for my child to be treated for a finger injury?

Just because your child’s finger may not look like it is broken, it is still important to have it looked at by a professional. The bones of the hand are quite small, and fragile. But, the bones aren’t the only thing in the hand that can be injured. There are also several ligaments and tendons in the hand that are at risk for injury. A ligament connects bones to other bones and their job is to support the bones and joints, and in some cases, prevent certain movements. If a ligament is injured and not allowed to heal, it can cause the bones to be unstable which can lead to further injury.

When should I get help for my child that has injured their hand or finger?

• If your child’s finger looks like it is out of place.
• If there is any bruising, swelling, or pain that lasts more than a couple of days.
• If your child is unable to bend or straighten the finger.
• If your child is favoring that hand or finger and doesn’t want to use it in everyday activities.

If your child injures their finger and it looks to be out of place, you should seek immediate attention from a medical professional. Do not try to put the finger back into place on your own. You could cause further damage.

Water sports are great because it allows one to exercise at a high intensity, there is not that much stress on the back and legs. It is great for a whole body work out and allows someone, in one hour, to be able to burn as many calories as in a one-hour run.

Typically, one doesn’t think of swimming as a sport that leads to many injuries. Swimming is an overhead sport and the human body is not made to handle a lot of overhead activities. Swimming too much can lead to overuse injuries. The main ones are shoulders pain and occasionally knee pain.

The training for competitive swimmers has changed in recent years. Training now requires swimming a lot of laps. All this swimming leads to more overuse injuries, like the ones we see in baseball pitchers and runners. Shoulder pain is the major problem swimmers will “swim” into because using the same muscles over and over can lead to the muscles in the chest and back being unequally strong. These muscles not being equal can lead to bad swimming form which will then lead to shoulder pain. Swimming strokes that can lead to shoulder pain are freestyle, back stroke and butterfly. Swimmers that participate in breast stroke are as at risk as other strokes for shoulder pain, but can also develop knee pain. This comes from the knee cap shifting and rubbing on other parts of the knee joint leading to knee pain.

It is important for coaches and parents to know how to keep their young swimmers safe, what to look for, and what questions to ask their kids to ensure that they are staying safe and not injuring themselves.

KNOW WHAT’S BEST FOR YOUR YOUNG SWIMMER:

Parents and coaches can help their swimmers by being an extra pairs of eyes, because the young athletes don’t know any better.

Rest: Athletes participating in overhead activities should not participate in these activities for at least three months out of the year. This means that it is good for parents to encourage their child to try different sports, specifically ones that don’t involve overhead activities.

Warmup: Ensure that your swimmer is warmed up properly. It is never good to get into a pool cold. The type of warm up is important too. Make sure that the warm ups are active and not passive stretches. There are a lot of traditional stretches that swimmers do to warm up their arms. These warm ups target parts of the shoulders that keep the joint stable. It is important to warm up and actively stretch the muscles themselves and not the shoulder joint.

Hydration: Lastly, make sure to drink a lot of water. Being in a pool dehydrates the body on top of the sweating that occurs while working out.

THINGS TO AVOID:

• Incorrect swimming form
• Excessive training without rest days
• Swimming the same stroke every time

WHAT TO WATCH FOR:

• GREEN LIGHT- Good: Muscle soreness is OK if it last 2-3 days
• RED LIGHT- Bad: If soreness last more than 2-3 days, or gets worse, and/or is sharp

(If it is a red light item one should seek help from a medical professional)

NOW WHAT:

Young Kids AGE: 5-9

• Training should not exceed 60 minutes and no more than three times a week.
• Learn how to properly perform the basics of the strokes.

Older Kids AGE: 10-16

• Training should not exceed 120 minutes and no more than 6 times a week.
• Learning how to decrease wasted energy with strokes.

PROPER WARM UP:

• 5 minutes of light swimming
• 15 minutes of active stretching
• 10 minutes of stroke and breathing exercises in the pool

At Cook Children’s, our SPORTS physical therapists are trained in proper rehabilitation of overuse injuries and work to restore full function and safely guide return to athletic activities. If your child has a history of injuries from swimming or you are concerned about risk of future injury, talk to your pediatrician about a referral to physical therapy.

Learn more here:

• USA Swimming
• Ovoiding overuse injuries
• Swimming Injury Prevention

Primary headaches are the result of problems with pain sensitive structures in your head. These include migraines, tension headaches, chronic daily headaches, cough headaches and exercise headaches.

Secondary headaches usually point to an underlying condition activating the pain sensitive nerves in the head. These include sinus pressure, concussion, dehydration, ear infection, flu, tooth pain, etc. More serious causes of headaches can occur, for which you would need to see a doctor immediately.

Physical therapy is well suited to help patients with headaches. Most primary headaches can be related to or made worse by muscular tightness in the neck, base of skull, and head. This tightness can be due to trauma, joint stiffness, joint instability, poor posture or overuse. Physical therapists can address this muscular tightness in several ways. We work on increasing the flexibility of the muscles involved, improve the strength of the musculature in the area, and mobilize stiff joint segments. We also address the child’s posture and stability of the area by retraining the musculature to work in symphony with each other to achieve good posture and stability of the neck and shoulders during static and dynamic activities.

Here are four ways for kids to improve their headaches:

1. Be aware of your posture. How are you sitting when at school? Where do you do your homework or read? Is it on your bed, or couch, or on a desk? Try to improve your posture by sitting up straight, preferably in a chair that offers low back support and keeps you upright. Make sure that the computer or books are close enough that you can read easily without looking down or sticking your chin forward.
2. Take mini breaks throughout the day. A good rule of thumb is a 2 two- minute break for every 30 minutes. During this time, get up walk around your space, stretch.
3. Stretch. Your muscles tend to tighten down to match the movement they are allowed during the day. If they don’t move much, they will begin to tighten. Neck and shoulder stretches are important to loosen the muscles you use to hold your head up and use your arms during the day. The stretches should be held for at least 30 seconds for better results.
4. Build strength in the muscles of the neck and shoulders. The stronger your muscles are, the better they can handle the stresses of the day. Exercises could include chin tucks, shoulder shrugs, lat pulls, rowing, pushups and tricep dips.

If you have any questions, please feel free to contact your pediatrician.

About the author

Bruce Morgan, PT, is a SPORTS physical therapist 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.

As parents before we just shrug off our children’s injury as nothing too serious, it helps to know exactly what a sprain is.

The American Academy of Orthopedic surgeons define a sprain as a stretch and/or tear of a ligament, the fibrous band of connective tissue that joins the end of one bone to another.

Technically a torn ACL or a torn MCL in the knee is a sprained knee, but we never shrug those injuries off. So why are we so dismissive of ankle sprains? Admittedly a sprained ankle is typically not as severe of an injury as a torn ACL, because an ACL when torn will not heal on its own and requires a surgical reconstruction, but that is a topic for another blog.

Just as with any injury when dealing with an ankle sprain we need to start by determining the severity of these injuries. Ankle sprains are typically divided into three grades based on the severity and presentation of the injury.

Grade 1: Ligaments are stretched, but not torn, ligaments are tender to touch, but no laxity is noted, and the patient is able to walk with little to no pain.

Grade 2: Ligaments are stretched and at least partially ruptured, there is moderate pain and swelling, mild to moderate bruising, some range of motion loss, the patient has pain with walking, and there is mild to moderate laxity noted.

Grade 3: Ligaments are completely torn, there is severe swelling, severe bruising, significant loss of motion, the patient is unable to bear weight or walk on the ankle, and there is significant laxity noted.

The severity of the sprain will definitely influence how we treat these injuries.

So why is it important for my child to rehab an ankle sprain?

The number one predictor of ankle injuries is a previous ankle injury. So what this tells me is that more often than not we aren’t addressing that initial injury effectively. Each ligament sends information to the brain letting us know if our joints are in good alignment or not. This is why we don’t have to look at our feet when we walk to know that our foot is in a good position to take a step. Any time a ligament is torn or stretched we lose some of our awareness of where the joint is in space. If a ligament is completely torn or stretched we aren’t getting those signals until our joint is potentially already in a bad position. After injury we have to do something to make sure that we re-establish that joint awareness, and that is where Physical Therapy comes in.

How can physical therapy help my child recover from an ankle sprain?

Initial focus in physical therapy will reduce swelling and inflammation with RICE (rest, ice, compression, and elevation), and regaining ROM. While this first phase is very important, the portion of rehab that really helps to prevent recurring injuries is the strengthening and proprioceptive (or balance) training. The balance exercises are the exercises designed to retrain joint position awareness by training the muscles to recognize and stabilize where our joint is in space. The balance and strengthening exercises are what will truly help a patient return to higher level activities like jumping and cutting in sports.

When do I get help for my child who has an ankle sprain?

• Any time an injury causes notable laxity or instability on exam.
• Any time a patients is unable to walk without pain.
• Any time balance is negatively affected.
• That means grade 2 sprains and above should automatically get help and any grade 1 sprain with balance deficits should also do rehab. If there is ever any doubt, error on the side of caution and contact your physician.

At Cook Children’s, our SPORTS physical therapists are trained in proper rehabilitation of all grades of ankle sprains and work to restore full function and safely guide return to athletic activities. If your child has a history of frequent ankle sprains or you are concerned about risk of future injury, talk to your doctor about a referral to physical therapy.

SPORTS resources

• Ankle sprains
• 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

Even highly competitive and high intensity training can be healthy, but can it become unhealthy?

One of the dangers of intense training can be a lack of food intake to keep up with the demands of the sport. Have you seen the pictures of food in front of Olympic swimmers? They often eat up to 10,000 calories per day. Yet, our young teenage athletes, in an attempt to manage their weight or achieve a particular body image sometimes cut calories to levels even below their less active peers.

This is when their health could be in danger.

Certain sports may put athletes at higher risk to engaging in unhealthy behaviors. Think about those where body image plays a large role such as dance or gymnastics. Those competing in sports that classify participants based on weight class can also be at risk. Even participants in sports that don’t fall into these categories can have pressure put on them to “lose a few pounds” in order to improve.

These problems can arise in boys and girls, but girls can have particular health consequences that need to be considered.

What is the female athlete triad?

• Energy deficiency (not eating enough food)
• Loss of periods
• Low bone mass (osteoporosis)

Energy deficiency -This can be the result of simply not consuming enough food or it can be a conscious method to decrease calorie intake for weight loss. In more severe cases it can be the results of an abnormal body image or an eating disorder.

Loss of periods -The calorie deficiency can lead to decreased production of hormones that help periods to be regular. This can lead to missed periods or for periods to stop altogether. Missed periods are often the symptom that brings attention to the overall problem. Because of this, I recommend you check in with your athletes intermittently about their periods. Despite the weird and embarrassed look on faces (it translates, “Mom, can you believe he’s asking this?”), I ask at every check-up.

Low bone mass - Decreased hormones and intake of calcium can lead to thinning of the bones. When severe, this can cause stress fractures, which are fractures that occur with very little or no trauma. In addition, girls are supposed to building up bone density in this time frame and the long term implications of not doing so could have severe consequences.

What can you do?

Pay attention to your athletes and their eating habits.

If you see any of the following, set up a visit with your pediatrician to address your concerns:

1. Weight loss or disorder eating habits.
2. Irregular periods or no periods.
3. Injuries from mild activity or that tend to linger.

Together you and your pediatrician can gather a team around your athlete to ensure their health for now and into the future.

Some potential members of the team could include a:

1. Pediatrician
2. Dietician
3. Counselor
4. Coach or trainer

One of the tops reasons is that younger kids are doing more than their growing bodies can withstand. Children are no longer just playing outside for fun. They are playing at a higher skill set than in the past, often times with parent coaches who aren’t formally trained to stretch their players in the correct manner. Make sure your young athlete stretches for his or her game.

Other causes of injury include weakness to the gluteus medius, loose joints, tight muscles, decreased balance and motor control and coordination.

I’ve spent the first two paragraphs talking about the injuries, but I actually feel the ACL has gotten a bad reputation because it’s a very important ligament that allows an athlete to run, jump and cut. Many non-contact ACL injuries can be avoided if athletes understand the issues that lead to ACL tears.

If you have a child who is an athlete, it’s important to know the proper way to stay safe during athletics and preventing ACL injuries. Below are 6 steps to preventing an ACL injury.

1.Strengthen your gluteus medius - The gluteus medius (located in the buttocks) weakness are common culprits in ACL injuries. This is one of the muscles that stabilizes your hips and in terms of ACL injuries prevents the knee from pointing too far inward when landing during jogging, hopping or cutting. A good way to know if this muscle is working the correct way is to watch the knees while performing squats or single leg squats. If the knees point inward past the inside of the ankle, the athlete may have weakness in his or her gluteus medius. To strengthen the gluteus medius, the athlete should perform exercises that cause his or her hip to come away from the body such as side steps, clamshells, or side lying leg raises.

2.Strengthen your hamstrings- Another important thing that should be looked at is the strength of the hamstrings (large muscles at the back of your thigh) in relation to the quadriceps (large muscles at the front of your thigh). When the quadriceps are significantly stronger than the hamstrings it can pull your tibia (shin bone) too far forward causing stress on the ACL. This is common with female athletes.

3.Stretch your quadriceps- When the quadriceps (large muscle on the front of the thigh) is too tight, it is similar to them being stronger than the hamstrings. It creates a forward pull on the tibia (shin bone). To stretch this muscle, grab the shin to bend the knee and hold it for 30 seconds repeat this 3 to 5 times. Make sure your young athlete stretches when he or she has been active. Stretching when not warmed up, is not as effective.

4.Work on your balance- Balance is another important part of any injury prevention program. People often think that their balance is poor but do not realize that it can be improved. Children who can’t stand on one leg for 1 minute without placing their toe to the ground, need to work on their balance. Have your child practice standing on one leg for a minute. Once this becomes easy, have your child try doing this with his or her eyes closed. For safety, always make sure your child has something steady to grab onto if he or she starts to lose balance.

5.Strengthen your core- Like the gluteus medius, the core assists with control of legs when athletes are active. It is important to have good control if you are an athlete. There are many ways to strengthen the core but some examples are planks, side planks and/or exercises on a stability ball.

6.Wear good shoes- Proper shoes are especially important if your child has flat feet. Shoes that are too flexible or without arch support may cause an increased risk of injury. If your child has flat feet ask the shoe salesman for shoes that help with control to help prevent injuries.

Following surgical repair, ACL injuries require 6 to 9 months of rehabilitation. However, athletes can prevent non-contact ACL injuries by strengthening their muscles properly, having a good stretching routine, working on balance, and wearing supportive shoes. Although it is important to properly maintain all leg muscles these are six of the most important ways to prevent an ACL injury.

SPORTS resources

• Anterior knee pain
• Top 10 questions parents have about sports injuries
• Injury Prevention Guide
• Strength training in children/adolescents
• Core beliefs
• 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
• Pain that won't go away

The answer is complicated.

Yes, it's very important for toddlers ages 1-3 to interact with other kids their age and challenge their balance, strength and coordination. Sports are a great way to promote these skills and literature shows that athletes who play sports at a younger age are more likely to be active adults than their peers who don't participate in sports.

However, organized sports  may not be the best solution for children 3 and under, and aren't the only way to teach our children these skills. The list below describes activities for toddlers and some benefits of these activities for their development.

Swimming: Helps strengthen the arms and legs, as well as improve coordination since the child has to use both arms and both legs at the same time. Learning swimming at an early age helps promote good water safety habits later in life. You can practice swimming in a "parent and me" swimming class. 

Dance: Improves balance, coordination, strength and flexibility. You can practice in a class setting or by having a "dance party" or playing a game of "freeze dance" at home.

Biking: Between ages 2 and 3, kids should be able to begin riding a tricycle. For young kids, there are tricycles that offer a parent guide bar to help kids move and steer. You can practice biking in your neighborhood or on trails.

Soccer: Most teams start between ages 3-5; however, kicking a ball in the backyard with your toddler is a great way to help them learn to run, develop core strength and balance on one foot for a short period of time.

Basketball: Helps kids develop hand-eye coordination when dribbling and shooting and improve running and jumping skills, as well. You can play with an adjustable hoop in the driveway, or sing up for a community team (which will generally begin between ages 3-5).

T-Ball: Teaches running, balll skills and coordination skills. Using larger balls for young children will help them be successful with catching and throwing.

Yoga: Helps improve flexibility, which is very important since toddlers are growing quickly and develop tight musles quickly. Yoga can also improve strength (especially in the core muscles) and balance. Several toddler yoga videos can be found online, and classes are available throught out the DFW area.

Gymnastics: Another way to gain strength, balance and flexibility, gymnastics is a sport that children can begin learning as early as 18 months old. Many gyms have special toddler and preschool classes, as well as "parent and me" classes.

Yard games: The old staples of "tag" and "hide and seek" are great for teaching turn taking and problem solving, as well as practicing and running and climbing. Taking your child to a local playground also offers a wide variety of ways to practice climbing stairs, running, swinging, balance, etc. 

With all of these, safety is a primary concern. Toddlers are at high risk of injury when practicing new things. Contact your pediatrician if you feel like your child is having difficulty learning new skills and they may refer you for evaluation by a physical therapist to evaluate your child and help them learn these new skills.

About the author

Jodi Burgett PT, DPT, CPST, is the clinical coordinator of Neurodevelopmental Physical Therapy 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.

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.

"Any form of weightlifting before age 8 is not recommended, as there are other methods of strength training without the use of weights," said Dana Harrison, PT, MPT, manager of Cook Children's Sports Performance Orthopedic Rehab Team Specialists (SPORTS). "Studies show that kids who don't begin intense training until high school actually perform better at the college level."

According to the American Academy of Pediatrics (AAP), a child's balance and postural control skills reach maturity around age 7 or 8, making weight training unnecessary before then. The AAP also recommends children wait to weightlift until they have a proficient level of skill in the sport for which they are training. Trying to improve your child's soccer skills by weight training won't help much in the first year or two of playing.

For school-age children, the goal of sports training should be developing a well-rounded skillset that includes not only just muscle strength, but also balance, coordination, agility, flexibility, stamina and cardiovascular fitness. Exercicse routines for children should include calisthenics, running, jumping, stretching and sports-specific practices. Children also should play a variety of seasonal sports such as soccer in the fall, baseball in the spring or volleyball in the summer. Focusing solely on one sport, skill or muscle group as a child can lead to muscle or bone damage that increases the risk of osteoarthritis later in life.

"One of the biggest problems we see with kids is overuse injuries," Harrison said. "Coaches are training young kids like college athletes, trying to do too much, too soon. Before age 8, sports and other activities should be about having fun."

Related links

• SPORTS resources
• Does your child play one sport?
• 9 ways to prevent injuries in young athletes
• Cheerleader injuries
• Dance injury prevention
• 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
• Pain that won't go away

About the source

Dana Harrison, PT, MPT is Cook Children’s SPORTS program/Rehab manager. 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.

Profession

Physical therapists are highly educated professionals trained to identify problems with movement and function of the human body. The physical therapists at Cook Children’s have either doctorate or master level education. Our physical therapists and physical therapist assistants are constantly advancing their training through continuing education and advanced certifications. We collaborate regularly with your doctors to ensure the highest level and quality of care.

Together, physical therapists and physical therapist assistants work to restore and improve normal body motion. We educate and empower our patients and families to be active participants in their recovery process. We also instruct on future injury prevention. The American Physical Therapy Association’s vision is “transforming society by optimizing movement to improve the human experience.” At Cook Children’s, our physical therapists and physical therapist assistants really do transform lives.

Patients

Our physical therapists see children for many different reasons. Some examples might include:

• Complaints of knee pain while running or back pain from sitting too long.
• Shoulder pain from playing a musical instrument.
• A difficult time recovering from surgery.
• Recovering from a broken bone.
• Growing pains after a quick growth spurt.
• Lack of endurance after a long hospital stay.

Physical therapy can help with all of these things and more. Physical therapists look to find what is causing the pain or difficulty. We then guide the recovery process and help restore normal function through the use of manual (hands-on) therapy, stretching, strengthening and neuromuscular re-education.

Cook Children’s

At Cook Children’s, our SPORTS (Sport Performance Orthopedic Rehab Team Specialists) physical therapists and physical therapist assistants have experience with pediatric specific problems. We recognize that children are unique and not just “small adults.” Kids require specialized care. We take time to perform focused evaluations and customize each child’s treatment. We seek patient and family input in the entire recovery process. We understand the importance of one-on-one time with your child to give them the attention they deserve.

Pain is never normal, and pain from activity should not be ignored. If you think your child may benefit from physical therapy, talk to your doctor or contact our department.

About the author

Melissa Bro, PT, DPT, 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.

More and more young athletes are experiencing pain while participating in sports. Some have traumatic injuries like sprained ankles and torn ligaments, while others experience overuse injuries like low back pain and tennis elbow. All of these athletes can suffer from significant pain on and off the field. No athlete is exempt.

All sports require a baseline of flexibility, strength, stability and endurance, as well as a time of rest between activities to safely perform the required activities. With the rise in athlete specialization in a single sport, played year-round, we have seen an increase in injuries and pain in these young athletes. These young athletes are also starting at a much younger age. Many more stress injuries have resulted, such as ligament tears, shoulder strains, stress fractures and back strains. In addition, there has been a rise in chronic pain (pain lasting longer than 3 months) among younger athletes. I never heard of a teenager with chronic pain when I was growing up! How do we deal with this growing population? “No pain, no gain?” “Just grin and bear it, the pain will go away?” “Slap some ice on it and get back out there?” There needs to be a better way. Fortunately, there is!

The best plan is obviously prevention. However, for the purpose of this article, we will assume the athlete is already experiencing pain. In this case, there are several things to be done. Pain should not be ignored! Our body is trying to tell us there is something wrong. Acute pain should be addressed with the gold standard: Rest, Ice, Compression and Elevation (RICE). We are typically willing to ice, compress and elevate, but many times rest is not followed properly. “He’s our best pitcher!” “If she’s not playing, we will lose our chance to make it past district!” “I really want to play, so I won’t tell coach about the pain.” If we do not allow the tissue to heal properly, the tissue can become weaker and will be at a higher risk for being injured again, maybe even worse than the first time. Now that pain is being addressed properly, what do we do? Now is the time to work on the basics again:

Flexibility: Muscular flexibility is vital. Tight muscles are much more prone to injury than flexible muscles. Tight muscles can be damaged during high velocity movements. Also, tight muscles can alter how our joints move, making other structures more prone to injury, such as ligaments, joints and bones.

Strength: Muscular strength is also very important. Strong muscles allow our bodies to perform the tasks that we put them through. Strong muscles also allow greater protection from injury.

Balance/control: And don’t forget about core strength! This is maybe the most missed strengthening component in most sports and possibly the most important muscle group for any sport! A weak core places an increased stress on other body parts and increases our risk for injury. How can we expect a soccer player to avoid ankle or knee injuries if he/she can’t even balance on one foot?

Return-to-sport: If the athlete’s strength is improving and the pain is under control, we can work on sport specific activities. This is where a physical therapist or athletic trainer with a strong knowledge of sports performance is vital. Coaches properly trained in technique can do this as well as long as they are able to spend dedicated one-on-one time with the athlete.

If pain from a recent injury is not properly dealt with, or the injury leaves the athlete with pain that lasts more than 3 months, chronic pain may develop. Now our focus as a physical therapist is more on return of function versus the pain itself. Seeing a physician that specializes in pain, such as Dr. Artee Gandhi and Dr. Aimee McAnally at Cook Children’s, can be beneficial as well. The physician could prescribe or recommend one or more of the following treatments in conjunction with the physical therapy:

1. Medications to reduce pain or inflammation while working on regaining function.

2. Biofeedback therapy with a psychotherapist, such as Wayne Martin, LCSW, psychophysiologist at Cook Children’s, to help the athlete learn how to relax muscles, reduce stress and visualize performance for relief of pain and return to normal activities.

3. Pediatric massage therapy to address tension and/or increased sensation.

4. Acupuncture therapy to help control pain.

Related links:

• Football injury prevention
• Baseball injury prevention
• Softball injury prevention
• Basketball injury prevention
• Soccer injury prevention
• Hockey injury prevention
• Gymnastic injury prevention
• Tee-ball injury prevention
• Swimming injury prevention
• Tennis injury prevention
• SPORTS resources
• Does your child play one sport?
• 9 ways to prevent injuries in young athletes
• Cheerleader injuries
• Dance injury prevention
• 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
• Pain that won't go away

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.

That’s great. I appreciate all the efforts to protect the well-being of those players.

But today, I want to focus on our youth and how to make sure injuries can be prevented at the 14 and under level. In 2012, the City of Fort Worth estimated 10,000 volunteer coaches managing youth sports teams throughout the Fort Worth and Tarrant County, under the age of 14. The report said “most of these coaches are parents or other family members who have not been specifically trained on how to coach youth sports or youth sports safety.”

Sports activities help children and adolescents stay fit, learn about teamwork and develop self-confidence. However, with the number of youths participating in sport activities increasing, the rate of injuries is also steadily rising for this group. Each year, approximately 775,000 children under the age of 15 are treated in emergency rooms for sports injuries across the nation.

How can injuries be prevented?

According to the American Academy of Pediatrics, it is recommended that children wait until 6 years of age before participating in team sports. Young children could sustain injuries because they do not understand the concept of team play. In addition to age, sports injuries can result from not following recommended procedures for the young athlete before, during and after their sporting activities.

Here are nine recommendations for lowering the risk of injury to the young athlete.

1. Get a sport physical from a physician for your child.
2. Coaches/instructors/athletic trainers should have annual education on specific sporting activity and guidelines.
3. Make sure your child has well-fitted safety/protective equipment and shoes.
4. Have an Emergency Action Plan in place and practiced as a drill.
5. Follow a pre- and post-practice/game dynamic warm-up program.
6. Take the time teach the correct technique of skills.
7. Take rest breaks and drink water frequently during activities.
8. Know the signs of overtraining.
9. Maintain good mental health.

If you are coaching youth sports or you are the parent of a youth participating in sports, please read all of the “young athlete’s injury prevention guides” from our experts at Cook Children’s Sports Performance Orthopedic Rehab Team Specialists.

Additional training for coaches both recreational and professional:  City of Fort Worth Training Video complete with a pre/post-test.