SPORTS MEDICINE UPDATE
From the Northern California Regional Pediatric Conference, Pediatric Sports Medicine, presented by Kaiser
Permanente, Sutter Health, and the UC Davis Health System
| UNIQUE CHARACTERISTICS OF THE PEDIATRIC ATHLETE — J. Andy Sullivan, MD, Professor, Department
of Orthopedic Surgery, University of Oklahoma College of Medicine, Oklahoma City
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| Key reference: Care of the Young Athlete (3rd ed; Sullivan JA, Anderson SJ, eds); collaborated with American
Academy of Pediatrics (AAP); designed for pediatricians
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| Benefits of sports participation: promotion of self-esteem; learning to play by rules; cooperation and competition; outlet
for stress; cardiovascular benefits; expectation that fitness habits developed in childhood will carry over into adult
life
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| Determining readiness for participation: children can acquire fundamental skills (eg, skipping) by 6 yr of age;
readiness depends on sport, developmental level, and demands; getting started — soccer (all children can run; most
can kick ball); basic gymnastics; hand-eye coordination not well-tuned until 9 yr of age
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| Ages of development: 2 to 7 yr of age — time of basic skill acquisition; children egocentric; 6 to 9 yr of age — balance
improves; vision still immature; 10 to 12 yr of age — able to learn strategy and master complex skills
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| Take-home points: history key; for 80% of participants, preparticipation physical evaluation (PPE) their only contact
with health care provider that year
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 | Klippel-Feil syndrome: fusion anomalies in neck; short neck and low hairline; high scapula; decreased range of
motion (ROM) in neck; detected by anteroposterior and lateral and cervical spine x-rays (may see 2 vertebrae
fused); 20% of affected patients have renal anomaly (perform ultrasonography to confirm function in both kidneys)
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| Congenital scoliosis: vertebral bodies not normal (problem of fusion or partial formation); wedge-shaped vertebrae
cause curve; collision sports (eg, hockey, wrestling, boxing, football) contraindicated; spondylolisthesis — vertebral
body slips (usually L5 slips forward on L4); cause of low back pain; spinal fusion for scoliosis — speaker allows
play 1 yr after spinal fusion (other physicians may allow after 6 mo); discourage collision sports (contact
sports permitted)
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| Burnout: ≈75% of children drop out of organized sports by 15 yr of age; reasons — lack of fun; player stuck on
bench
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| Injury in organized sports: at <10 yr of age, youth sports safer than most playground activities; injury rates change at puberty
(children strong enough to cause injury); if injury defined as trauma that keeps player from participating in practice
or game, girls’ cross-country running has highest frequency of injury (due to overuse syndromes); otherwise, football,
wrestling, and gymnastics associated with increased frequency and severity of injury; younger children tend to break
arms and clavicles; in older children, leg injuries more common
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| Growth and size: children grow and mature at different rates; sometimes age less important than size in determining
ability to participate
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| Epidemiology: second leading cause of death in youth sports; risk worsened by obesity, chronic illness, and poor
conditioning
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| Prevention: timing of practice crucial; wearing light clothing; limiting intensity of training (especially during heat
wave); hydration — many children dislike drinking large amount of water, but water best prevention; sports
drinks have too much sugar and salt; especially important during tournaments; consider — diluting powdered
sports drink to half or quarter strength, then add sugar-free powdered lemonade
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| “Training” defined: adaptive response to applied demand
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Weight Training
| Common misconceptions: 1) prepubescent children cannot benefit; 2) causes loss of flexibility; 3) high risk for
injury
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| Power lifting: lifting maximal amount of weight in single lift; contraindicated (high injury rate)
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| Definition: progressive repetitive load-bearing at low intensity over significant period
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| 7-11 principle: find amount of weight that person can lift in 3 sets of 7 repetitions; when easy, increase progressively
to 3 sets of 11 repetitions; then increase weight and drop back to 3 sets of 7 repetitions; allows body time
to adapt to increased repetitive load; avoid — rapid loading; maximal loads
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| At risk: physis — if adult hit on outside of knee, medial collateral ligament tears (may damage medial meniscus or
anterior cruciate ligament); in prepubescent child, weak link is physis (not medial collateral ligament); stress
fractures — occur because body asked to do too much too soon (eg, running cross country when not in shape);
can occur in tendons or physis; gymnasts can develop stress reaction in distal radial physis in upper extremity
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| Benefits: enhanced performance and increased endurance; decreased risk for injury because muscles stronger; increased
bone mineral content — for girls, calcium like putting money in bank for retirement (put in body early in
life, then start drawing it out); supplemental calcium and vitamin D not harmful; more importantly, lifetime of
aerobic training (eg, walking, cycling, running) increases bone mineral content; some athletes (especially gymnasts,
ballerinas, and swimmers) do not deposit enough bone mineral content (poor eating habits aggravating factor);
strength training can increase strength up to 20% to 30% (no increase in muscle mass)
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| Requirements: adequate supervision; regimen based on 7-11 principle, gradually increasing resistance
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| Gains: induced gains — increase in strength related to intensity and volume of loading (increased amount of neuromuscular
activation); helps coordination; mild muscle hypertrophy; androgens not needed; loss of flexibility or
ROM does not occur; changes induced — transient (regress if training ceases)
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| Risks: most injuries occur at home (some at school); unsupervised situations; strains more common than overuse injuries
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| Proper program: medically safe; guided by appropriate education about technique; properly supervised; individualized
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Unique Characteristics of Child’s Musculoskeletal System
| Response to fracture: children heal quickly; weak point frequently bone-tendon junction (instead of breaking patella,
they pull cartilaginous sleeve off distal end of patella [sleeve fracture])
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| Overuse injuries: apophysitis; epiphyseal injuries; stress fractures — occur from “too much too soon”; nearly always
diagnosable from point tenderness and history; bone scan “hot” in area of stress fracture (discontinue sports
participation); if scan not hot, play permissible
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| Return to play: depends on diagnosis; patient first must be healed and rehabilitated (speaker does not do much formal
rehabilitation in prepubescent children); requirements — all ROM back; no pain; must be able to do maneuvers necessary
for specific sport; determine whether risk for harm increased; repeat injury — bracing usually not preventive
(even in professional sports organizations such as the National Football League, knee braces not effective for preventing
knee injuries); taping may prevent recurrent ankle injuries
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| Brachial plexus injury (“burners”): common; mainly in football players; head cranked to one side, stretching
brachial plexus; “lightning feeling” in hand and burning sensation in arm; in severe case, acute neurologic loss (patient
may have weakness or residual tingling, or may not want to move); neurologic examination may be normal;
neck and shoulder should have normal ROM; allow return to play if strength sufficient and pain absent; return to
same game? — speaker tends to keep player out, unless injury fairly minor (no neurologic change observed, no decreased
sensation, pain gone, neck has normal ROM with helmet off and shoulder normal); unusual to need to remove
player from game because of burners
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| Acute transient quadriplegia: cause unknown; no way of predicting; patient hit or smashed to ground and then
cannot move arms or legs; may occur in football or wrestling; if patient has weakness or sensory loss, high liability
for allowing athlete to continue to play; second episode may cause permanent disability; not common before
high school
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| How to ensure safety: well-coached and supervised activity; appropriate playing surface and venue; good protective
equipment (eg, helmets; many deaths each year from all-terrain vehicle [ATV] injuries)
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| Physically challenged athletes: “let these kids play” (good for health and psyche)
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| OVERVIEW OF THE SPORTS PREPARTICIPATION PHYSICAL —Jamie Saben, MD, Assistant Clinical Professor
of Orthopedics, University of California, Davis, School of Medicine; Family Medicine and Sports Medicine, Sutter
West Medical Group, Davis
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| Key reference: Preparticipation Physical Evaluation (3rd ed); endorsed by AAP and other leading medical societies
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| Goals: purpose of PPE to make sure student athlete healthy and safe to participate in chosen sport (not to find
reasons to bar participation; if problem identified, address it); primary objectives — to screen for life-threatening
or disabling conditions, and for conditions that may predispose to injury or illness (eg, incompletely rehabilitated
ankle injury, undiagnosed shoulder dislocations, recurrent concussions)
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| Qualification of examiners: medical doctor or doctor of osteopathy preferred; physician assistant or nurse practitioner
may perform PPE under supervision of physician
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| Frequency of evaluation: every 2 to 3 yr in older student athletes (every 2 yr in younger athletes); PPE indicated
when entering middle school, high school, or new school; administrative protocols may require annual PPE (typically,
update does not have to be comprehensive); include vital signs and problem-focused examination; ask —
did you injure yourself last season? anything you want me to look at?
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| Timing: ideally, 6 wk before season starts (more than enough time to work up any athlete not cleared right away)
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| Ideally: PPE performed by personal physician (knows student athlete best; not always possible); 2 choices — 1)
physician’s office, or 2) station-based PPE (“coordinated team medical approach”); preferable for physician to
evaluate 1 athlete at a time
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| Station-based PPE: coordinated or team approach; physician’s office provides most privacy; many examinations
performed in school gyms and training rooms (little privacy); preferably, one physician per student athlete (better
rapport; patient may feel more at ease asking questions); appropriate attire (girls should wear sports bras under
shirts; boys and girls should wear shorts); separate areas for examining boys and girls (at least curtains for privacy);
have private area off to side in case sensitive issue arises; use of multiple physicians helps speed process;
know what happens to athlete if not cleared immediately and what needs to be done to ensure follow-up; purpose
of examination to identify who can participate right away, who needs follow-up, and who should be disqualified
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| Medical history: most important feature of PPE; complete history identifies 75% of problems; questionnaire in
new monograph — ≈50 questions (grouped by condition); allergies; cardiovascular conditions; key areas for participation
and clearance and risk for sudden death include cardiovascular problems, musculoskeletal problems,
and asthma; neurologic conditions (concussions, seizures, and burners or stingers); any “yes” answer must be explained
(if explanation omitted by patient, ask question again and document explanation); questions looking for
red flags — did you get injured last season? did you miss any games or practice? if injuries have occurred, what
kind? (history of broken wrist or knee surgery helps guide physical examination); ever passed out when exercising?
(screening for arrhythmia); has relative died unexpectedly at early age? (as children or <50 yr of age; screening
for sudden cardiac death); hard to catch breath during exercise or more out of breath than friends? cramp up
easily? taking any supplements? youth risk behavior — additional items in questionnaire; similar to home, education,
activities, drugs/ alcohol, and sexuality (HEADS) assessment; covers mood, substance abuse, and supplements;
ask, do you feel safe? if answer “no,” address
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| Vital signs: document height, weight, and blood pressure (BP); athlete functionally one-eyed? use Snellen vision
chart; note differences in pupil size (later, if injury occurs, knowledge helpful in determining whether asymmetry
normal or sign of intracranial condition)
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| Mouth: high-arched palate of Marfan syndrome; stigmata of bulimia (self-induced vomiting); leukoplakia caused
by smokeless tobacco
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| Cardiovascular system: feel radial and thermal pulse at same time (screening for coarctation); heart murmurs — diastolic
murmur cause for concern; loud systolic murmur may need further work-up; any murmur that gets louder with Valsalva
maneuver, or with change in position from squatting to standing (murmur of hypertrophic cardiomyopathy)
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| BP: norms different for children than adults; >90th percentile on multiple readings requires rescreening
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| Determining clearance: ≤14% of athletes need further evaluation; categories — 1) cleared without restriction
(majority); 2) cleared, but needs further evaluation (can participate, but needs check-up); 3) not cleared (pending
further evaluation); includes family history of sudden death and chest pain, athlete at increased risk of injuring self
or others if cleared that day, myocarditis, acute febrile illness, severe diarrhea; 4) not cleared (for certain types of
sports or all sports)
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| Medical conditions and sports participation: increased rate of atlantoaxial instability in Down syndrome
(problem typically presents with related neurologic signs; x-rays indicated); functionally one-eyed athletes — if vision
worse than 20/40 in worse eye, protective goggles indicated (if good eye knocked out, patient functionally
blind); in some cases, patients must be excluded from sports that put eye at risk
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Suggested Reading
No authors listed: Preparticipation Physical Examination. 3rd ed. New York, NY: Vendome Group, LLC, 2004;
Best TM et al: The pediatric athlete—are we doing the right thing? Clin J Sport Med 16:455, 2006; Coady CM,
Micheli LJ: Stress fractures in the pediatric athlete. Clin Sports Med 16:225, 1997; Corrado D et al: Trends in
sudden cardiovascular death in young competitive athletes after implementation of a preparticipation screening program.
JAMA 296:1593, 2006; Demorest RA, Landry GL: Prevention of pediatric sports injuries. Curr Sports
Med Rep 2:337, 2003; Herman MJ: Cervical spine injuries in the pediatric and adolescent athlete. Instr Course
Lect 55:641, 2006; Latz K: Overuse injuries in the pediatric and adolescent athlete. Mo Med 103:81, 2006; Luckstead
EF, Patel DR: Catastrophic pediatric sports injuries. Pediatr Clin North Am 49:581, 2002; Patel DR,
Greydanus DE: The pediatric athlete with disabilities. Pediatr Clin North Am 49:803, 2002; Pontell D et al:
Sports injuries in the pediatric and adolescent foot and ankle: common overuse and acute presentations. Clin Podiatr
Med Surg 23:209, 2003; Singh A, Silberbach M: Consultation with the specialist: cardiovascular preparticipation
sports screening. Pediatr Rev 27:418, 2006; Soprano JV: Musculoskeletal injuries in the pediatric and adolescent
athlete. Curr Sports Med Rep 4:329, 2005; Stracciolini A, Metzl JD: Pediatric sports injuries. Phys Med Rehabil
Clin N Am 11:961, 2000; Stricker PR: Sports training issues for the pediatric athlete. Pediatr Clin North Am
49:793, 2002; Stricker PR: Sports training issues for the pediatric athlete. Pediatr Clin North Am 49:793, 2002;
Sullivan JA: Academic health centers. Orthopedics 27:1028, 2004; Sullivan JA, Anderson SJ (eds): Care of
the Young Athlete. Elk Grove Village, IL: American Academy of Pediatrics, 2000; Sullivan JA: Fractures of the lateral
condyle of the humerus. J Am Acad Orthop Surg 14:58, 2006.
Educational Objectives
| The goal of this program is to educate the listener about pediatric sports medicine. After hearing and assimilating this
program, the clinician will be better able to:
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| 1. Explain the role of childhood development in readiness for sports participation.
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| 2. Recognize and manage common sports injuries in children.
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| 3. Perform an appropriate preparticipation physical evaluation (PPE) in student athletes.
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| 4. Prevent catastrophic sports injuries in children.
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| 5. Perform an appropriate PPE in children with disabilities.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any
identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary
business or commercial interest. For this issue, the faculty reported nothing to disclose.
Acknowledgements
Drs. Sullivan and Saben were recorded at the Northern California regional pediatric conference, Pediatric Sports
Medicine, presented October 7, 2006, in Sacramento, CA, by Kaiser Permanente, Sutter Health, and the UC Davis
Health System. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production
of this program.
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