Pointing Out the Top 10 Pediatric Sports Musculoskeletal Injuries

The Top 10 Sports Musculoskeletal Sports Injury list is a ranking that I'm guessing most athletes don't want to make, and most parents don't want to miss.

How to best know if you belong on this list?

Trust your finger tips.

Speaking at the 2016 American Academy of Pediatrics National Convention and Exhibition, I was asked along with good friend and colleague Hank Chambers to share insight on identifying and managing the Top 10 Pediatric Sports Musculoskeletal Injuries with a Case-Based Review.

Our Top 10 aptly started at the top of the body (neck) and ran down to the bottom (foot/ankle) with several injuries in between.

We looked at:

• stingers
• shoulder pain
• elbow injuries
• wrist injuries
•  low back pain
• hamstring avulsion injuries
•  acute knee injuries
•  shin pain
• ankle sprains
• heel pain in growing children.

Some were fairly serious and activity threatening, others were more of a nuisance.

A pretty diverse offering of injuries, so one would tend to think that there would be little that actually brings them together.

However, for those listening to the talk, they heard us mention a similar refrain over and over again.

The value of your finger tip.

In helping to determine a type of pain that merits medical attention in the first place, and helps sort out the particular diagnosis, the more localized the pain, the greater the potential concern.

For example,. if a child is reporting pain in the lower leg and uses a wave of the hand to indicate that the discomfort runs along the entire inner shin, then there is one level of concern.

However, if that same child takes the tip of their index finger and points directly and emphatically to a single spot on the inside of the shin bone, my concern is amped up several degrees.

While none of us have x-ray vision, that finding of finger-tip pain is a pretty good surrogate and does tend to correlate with a higher potential of a bone injury, be it a fracture, stress injury, or damage to a apophysis where a tendon attaches to a bone growth region.

So, no matter the body part, from elbow to wrist to foot or ankle, if any young athlete opts to use a finger tip to identify their pain, then use your finger tips to dial up your sports medicine specialist and seek out immediate and appropriate evaluation.

How to Protect the Knees of Young Athletes

What is going on with all these serious knee injuries in youth sports?   Why do young women seem to tear their Anterior Cruciate Ligaments more than young men?  

If your daughter (or son) lands with the knee caving in towards the other knee, then this article is a must read

The Anterior Cruciate Ligament (ACL) is a support ligament inside the knee that travels from the femur (thigh bone) to the tibia (shin bone), limits excessive forward motion of the tibia, and is crucial to overall knee stability.

Seemingly innocent, non-contact movements such as landing from a jump, twisting, cutting, or knee hyperextension are the most common mechanisms for ACL tears.

Studies involving several sports (basketball, volleyball, soccer) indicate that young women tear the ACL at a higher rate than young men. Several theories abound as to the reason, and a more popular thought is that abnormal landing mechanics can increase injury risk.

A preferred landing or turning occurs with the hip, kneecap and second toe lined up. Land or turn with a knee that "collapses" inside of the hip and second toe (much like the picture above) and the knee injury risk goes higher.

Tearing an ACL brings up some difficult decisions.  The athlete can select sports that do not involve cutting or jumping, or if they wish to continue higher-risk activity, surgical reconstruction with 6-9 month rehabilitation periods may be needed. Without activity modification, very few young, active athletes can return to high-level sports without frequent knee pain, instability and swelling.

Does the increased chance  of injury mean that young athletes should not play higher-risk sports?

Of course not.

I definitely think that the higher risk potential requires that certain precautions be taken to help protect the knees.

How can an athlete protect his/her knees?  

Sports-specific ACL injury reduction and knee neuromuscular training programs have been developed based on good studies that show significant reduction in ACL injuries.

Contact me for further details and specific drills/exercises particularly designed for use in weekly soccer practice warm-ups and can be applied to other jumping sports such as basketball and volleyball.

Other Knee Friendly Techniques include:

• Land from a jump on both legs as single-leg landing brings about a higher risk for ACL tear
• Land or cut with the knee slightly bent (not completely straight)
• Strengthen the hamstring muscles- these support the ACL in reducing forward tibia (shin bone) motion
• Controlled plyometric exercises (bounding and leaping) may strengthen the legs and reduce risk of ACL tears
• Make certain the athlete has good basic jumping and landing skills before starting full speed on-field play
• Knee braces have not been shown to prevent an ACL injury

Getting Defensive about ACL Injuries in Soccer

Soccer players, coaches and families take notice:  two video analysis reviews of Anterior Cruciate Ligament (ACL) injuries confirmed long-time suspected vulnerability with off-balance single-leg landing, but also added a new twist: certain defensive movements may also be a previously unrecognized culprit.

Both the April 2015 British Journal of Sports Medicine (analyzed males only) and May/June 2015 Sports Health (analyzed both males/females) articles found that around 3/4 of all ACL tears occur when the opposing team had the ball and the injured athlete was defending. The Sports Health group found that females were more likely to be defending when they injured their ACL in comparison to male counterparts.

Now, while certain forwards who are reluctant (or lazy) to come back on defense may be silently rejoicing at this news, let's take a deeper look at the particular defensive situations that produced ACL injuries:

• Tackling to separate the ball from an opponent, which often requires last minute adjustments in body position and technique
• Cutting to track an opponent
• Pressing situations where the defending player typically made a sidestep cut in order to reach the ball or to tackle an opponent

Non-contact pressing mechanism (right knee). (A) At−160 ms, the defending player is running forward at high speed towards the opponent in possession of the ball. (B) At initial contact, he strikes the pitch with his right heel and makes a sidestep cut in an effort to reach the ball or to tackle the opponent, but no player contact. (C) At 80 ms, he rotates the trunk towards his left leg and puts the entire load on his right leg. (D) At 240 ms the right hip and knee joints are in abducted positions and the ankle joint is in eversion (dynamic valgus without collapse). From Walden, et al,BJSM, April,2015

In addition to defensive play, being out of balance with single-leg movements was also a more common culprits:

• Regaining balance after kicking
• Landing after heading

In both the defensive or out of balance situations, the injured knee was more apt to be in a valgus (bent inward towards the opposite knee) and straight position.

"Danger position": inward movement (valgus) and straighter right knee relative to right hip and ankle.

So, what teaching points can be made for younger soccer players?

No, we are not going to give any excuses justifying not playing defense (probably much to the chagrin to some players....).

The results of both studies indicate that ACL injury preventive interventions should place focus on keeping the knee in a flexed (bent) position and having the kneecap centered right under the hip and over the foot without any collapsing inward through:

• General postural and neuromuscular control of the core and lower extremities;

• Footwork and running technique during changes of direction in defensive playing actions, mimicking the pressing situation;

• Maintaining balance during shooting, passing and ball clearing;

• Jumping and landing technique during heading duels;

• Promoting fair play in order to avoid fierce tackling from behind

The findings of these two studies further underscore the importance of evidence based ACL injury prevention studies that can readily be found without charge on the web.

Players and parents, do you ask your coaches and trainers to include these training techniques? Coaches and trainers, are you adding value to your program by emphasizing injury prevention? Any other drills that you think would contribute to proper balance, defensive postures, landing and tackling techniques?

Potential Signs of a Serious Knee Injury in Young Athletes

Suffering a knee injury can put a sudden damper on athletic activities and even influence the ability to get around the house and attend school. The following article does not attempt to make individual diagnoses, but rather to list some potential findings that suggest a more serious knee injury in a younger athlete.

• Immediate and large swelling above the knee cap
  • Rapid onset of swelling within the first hour after an injury that is located about the kneecap is called a suprapatellar effusion and may be the result of significant damage within the knee joint.
  • Common injured structures that lead to a suprapatellar effusion include:
    • Torn ligaments (Anterior or Posterior Cruciate Ligaments)
    • Dislocated kneecap
    • Fracture of the lowest part of the thigh bone or the top part of the shin bone
    • Disruption of the cartilage that covers the end of the thigh bone or top of the shin bone
    • Torn meniscus (shock absorbing pad on inside or outside of joint between thigh bone and shin bone) may occasionally lead to a large swelling, but not as common as other injuries
  • Any large scale swelling of the knee accompanied by fever, chills, redness at the knee joint and/or obvious warmth to the touch may suggest an infected joint and is a medical emergency requiring immediate medical evaluation in an emergency room equipped with orthopedic specialist coverage.

• Inability to fully straighten the injured knee
  • Lack of full knee extension may be caused by the following injuries:
    • Disruption of the knee extensor apparatus, which includes the quadriceps muscles in front of the thigh, the kneecap, and the patellar tendon which connects the kneecap to the shin bone.
    • A torn meniscus or ligament that is displaced and is trapped between the thigh bone and the shin bone
  • Trying to walk on a knee that lacks full extension may cause further and possibly permanent damage to the joint cartilage. Thus, any injured athlete who cannot fully straighten the knee should use crutches until having an appropriate medical evaluation and regaining the ability to fully straighten the knee

• Open skin at the injury site
  • Disruption of the skin, even the smallest of cuts or abrasions, may represent an open fracture that requires immediate medical attention from an emergency room visit to prevent more serious infection and a complicated recovery course.

• Big time pain, numbness, weakness, or tingling below the knee
  • Any pain that seems out of control, or any findings of numbness and tingling below the knee or weakness of the foot or ankle muscles could suggest more serious damage to the knee or the nerves and blood vessels around the knee and indicates the need for emergency medical evaluation.

• The young athlete who tries to play on an injured knee but just isn't as fast, as aggressive, or as graceful and ends up limping during activity
  • There may not be swelling, lack of extension, fever/chills, open skin, or big-time pain, weakness or numbness and tingling, but still seeing young athlete limp and not play at the best due to knee injury are both signs of a potentially more serious knee injury. 
  • Removing the athlete from play and seeking pediatric sports medicine specialist evaluation is highly recommended before allowing a return to play.

In any case of a suspected serious knee injury in young athletes, removal from play, placing on crutches, and seeking appropriate medical attention are all sensible initial steps for parents and families. Obtaining an accurate diagnosis and comprehensive treatment plan in an efficient manner is paramount for optimal long-term function and healing.  If any doubts after a knee injury to a young athlete, do not hesitate to contact your sports medicine specialist provider or head to the emergency room if necessary.