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.”

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. 

Your child is a real go-getter; maybe they’re a straight-A student or a star athlete. Lately, though, they have trouble breathing during very inopportune times, like before a test or a big track meet. You have seen their primary care doctor and you have seen a pulmonologist. Maybe they are put on an inhaler, but it doesn’t seem to be working like you hoped. So what’s going on?

Have you heard of vocal cord dysfunction? Well, there is a new name for it: exercise-induced laryngeal obstruction (EILO) and inducible laryngeal obstruction (ILO). That’s a mouthful.

Whenever there’s a “trigger” (i.e. exercise, stress, certain odors), the vocal cords narrow and it feels like you can’t get a good breath in no matter what you try to do. It isn’t life-threatening because your vocal cords are actually still open, but they aren’t open enough to fill your lungs. It’s scary. Your child is panicking and now you are, too.

What are the symptoms of EILO/ILO?

• Chest/throat tightness
• Difficulty inhaling
• Noisy breathing
• Shortness of breath

That sounds an awful lot like asthma, doesn’t it? You’re right; EILO/ILO and asthma sound very similar, but there are a few differences. Let’s compare the two:

You have ruled out asthma with your physicians and ruled in EILO/ILO. 

What do we know about EILO/ILO?

Onset can occur at any age, but most commonly, EILO and ILO are diagnosed in 12 to 18-year-olds.

It is most prevalent in our young athlete population and it can lead to anxiety about playing sports because of the fear of not being able to breathe. The same thing can happen around stressful situations like an upcoming AP history test or a choir performance.

Speech Therapy

What can be done to help these kids get back into their sports, extracurriculars, and high-demand classes? Speech therapy and/or physical therapy is the answer! And it’s all about breath.

With speech therapy, we look at how the child is breathing and teach them a variety of strategies to make their breathing more efficient.

We work on rescue breathing techniques that will blow the airway open during an active EILO/ILO episode as well as preventative breathing strategies that will keep the airway open during exercise or stressful activities. We also focus on diaphragmatic breathing or belly breathing, so the child can optimize the amount of air they are getting into their lungs at rest and during physical activity.

With physical therapy, we can look at the athlete’s movement patterns, posture, endurance, and strength that may be impacting their breathing. Oftentimes, stiffness or weakness through the trunk and core changes a person’s breathing pattern, causing them to have difficulty controlling their breath (especially during high-intensity activities).

This can lead to increased fatigue, tension around the neck and/or shoulders, and EILO symptoms. Another area of focus is cardiovascular endurance training to avoid the feeling of “hitting a wall” during exercise.

Through guided exercises, improvements can be achieved by reducing compensations or our body’s way of cheating through movements, training the proper muscle groups, and supporting proper muscle use and form during athletic movements.

What is the common goal? To give the child the skills they need to get back to the activities they love. If your child is experiencing any of these symptoms, reach out to their primary physician to discuss a potential referral to an ENT (otolaryngologist) or pulmonologist for further diagnostic testing.

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.”

Buffalo Bills defensive back Damar Hamlin suffered cardiac arrest after a hit during Monday evening’s game. The Bills said in a statement that he was given CPR on the field and his heartbeat was restored. On Tuesday, the Bills said Hamlin was in critical condition.

This incident stunned the sports world and community at large, and reiterates the importance of being prepared for a cardiac emergency, especially in sports and school settings, with CPR and an AED.

More than 530 schools in North Texas have partnered with Project ADAM at Cook Children’s to become a “Heart Safe” school. The program trains school staff members on CPR, how to use an automated external defibrillator (AED), and helps create an emergency plan. It also provides resources and support to become a Heart Safe school, which is renewed every year through training and requirements. Project ADAM is a free resource to schools and the community.

The likelihood of sudden cardiac arrest in children and young athletes is known to be enhanced by athletic participation. On average, a seemingly healthy young person suffers a sudden cardiac arrest every three days in the U.S. and it's the leading cause of death in exercising young athletes.

Athletic personnel need to recognize the threat to young athletes and properly prepare for sudden cardiac arrest. Every school or organization that sponsors athletic activities should have an AED, trained coaches, and written Emergency Action Plan.

Cardiac emergency preparedness training empowers people to use the AED device. Texas requires all schools to have an AED, but often people don’t know where it is located, how to use it in an emergency or rely solely on the school nurse to use the device.

Danielle Moyé, M.D., pediatric cardiologist and physician director for Project ADAM at Cook Children’s, encourages schools, parents and the community to see the large impact an AED and CPR can make on a person’s life if utilized effectively. She shared answers for a few common questions.

What causes cardiac arrest?

Cardiac arrest can be caused by different factors. In an exercise setting, cardiac arrest occurs secondary to an arrhythmia which prevents adequate circulation and perfusion of blood and oxygen to the brain and body.

Why is it important to quickly respond to cardiac arrest? How does it affect the person’s outcome?

Timing is of utmost importance when it comes to cardiac arrest. The rhythm that one is in during cardiac arrest is not a perfusing (pump) rhythm. This means that there is not adequate oxygen and blood flow to the brain and body. Restoring sinus rhythm is critical to prevent irreversible organ damage.

When do you use an AED vs administering CPR?

CPR should be administered as soon as a person is found down without a pulse. While awaiting an AED, appropriate CPR can result in continued blood flow and perfusion that the heart is not doing on its own.

Once an AED is available, pads should be placed on an individual’s chest and once turned on, CPR may be paused briefly while the AED is assessing the underlying rhythm. If the person has a shockable rhythm, the AED will recommend delivery of a shock which can restore sinus rhythm. This is a lifesaving device that the world should know about and everyone should familiarize themselves with.

What should parents and caregivers be aware of if their child participates in sports and other physical extracurricular activities?

As mentioned above, parents and caregivers need to be aware of sudden cardiac arrest. They should encourage the schools and sporting facilities to be aware of the risk, have respect for this risk, and arm themselves with knowledge on good CPR, the locations of AEDs, and have an emergency action plan in place should one need it.

What do you see as a cardiologist that you wish more people knew about?

I unfortunately, have seen many episodes of cardiac arrest associated with exertion and at rest. The patients that have the best outcome are those who had a prompt intervention with an AED. I wish every school and every facility had an AED in place and a team dedicated to responding to these types of emergencies.

Sign and symptoms of pediatric heart disease

Sudden cardiac arrest (SCA) is when the heart suddenly and unexpectedly stops beating. SCA often occurs in active people with no history of heart conditions. In children, common causes are genetic, congenital or related to a sudden blow to the chest. If treated quickly, using an automated external defibrillator (AED), it is possible to restart the heart and increase the chances of survival.

Pediatric heart disease has warning signs and symptoms that can go unnoticed. It is important to recognize the following:

• Fainting or near-fainting during or after exercise, emotion or surprise
• Dizziness or lightheadedness
• Extreme fatigue associated with exercise
• Extreme shortness of breath associated with exercise
• Discomfort, pain or pressure in chest during or after exercise
• Skipping or racing heartbeats
• High blood pressure
• Congenital heart abnormality
• Family history of sudden death prior to age 50 or known heart abnormalities

Not all episodes of sudden cardiac arrest are preventable because many of the kids do not have symptoms until they have the episode. For this reason, secondary prevention strategies are important.

About Project ADAM

Project ADAM, which is nonprofit and nationwide, aims to educate school systems, nurses, coaches, trainers, parents and others about pediatric sudden cardiac death and to establish emergency programs to help provide a timely and lifesaving response as emergency medical services are on their way to an incident.

Project ADAM was started in 1999 after a 17-year-old Wisconsin student named Adam Lemel collapsed and died while playing basketball. His parents helped start the Project ADAM program at the Children’s Hospital of Wisconsin in his memory. Cook Children’s is one of 35 hospitals and program sites providing free cardiac resources, including training and AED devices.

RELATED: How to Become a Heart Safe School

Videos:

• Chapter 1: The Adam in Project ADAM
• Chapter 2: Understanding Sudden Cardiac Arrest
• Chapter 3: Being Prepared in a Cardiac Emergency
• Chapter 4: Implementing Project ADAM in Your School
• AED Drill
• Learn How to Save a Life using an AED and Hands Only CPR!

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)

"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

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

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

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.

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