Three Sports Medicine Articles Co-Edited by Dr Koutures in January, 2016 Pediatric Annals

Pleased to see publication of three outstanding articles on Reducing Cumulative Arm Overuse Injuries in Young Throwers, En Pointe Readiness, and EKG Screening in Athletes for the January, 2016 edition of Pediatric Annals. This Sports Medicine themed edition is the first of a 2 part series, with the second set of articles running in February, 2016.

Some of the following content may require a subscription to Pediatric Annals for full access.

Click here to access my Guest Editorial co-written by trusted friend and colleague Valarie Wong, MD

The discipline of pediatric sports medicine deals not just with musculoskeletal care, but rather encompasses a host of medical and orthopedic concerns to optimize safe and lifelong participation in sports and activities. Pediatric health care providers' well-known general medical and anticipatory guidance skills absolutely make them a natural and trusted part of the sports medicine team.

lick here to access the article: Reducing Cumulative Arm Overuse Injuries in Young Throwers by John Schlechter, DO

Overuse injuries are preventable when underlying contributors (GIRD, scapula dyskinesis) are addressed and enforced pitch counts are consistent with recommended limits. The single most important and modifiable risk factor in preventing injury in young throwers is activity modification and adequate rest periods prior to the onset of arm pain.

Click here to access the article: Assessing Readiness for En Pointe in Young Ballet Dancers by Jeffrey Lai, MD and David Kruse, MD

As with any medical evaluation, a proper history and physical examination are the first steps in assessing readiness for dancing en pointe. Age, years of dance training, and hours per week of training are important details to collect during the history, as are the ballerina's dance aspirations. Prior injuries, especially to the lumbar spine, hips, knees, feet, and ankles, should be recorded. The physical examination focuses on anatomy and flexibility, whereas functional assessments of technique, strength, and postural control also help determine pointe readiness

Click here to access the article: Use of Electrocardiogram as Part of the Preparticipation  Exam by Kelly Chain, MD and Andrew Gregory, MD

Sudden cardiac death (SCD) is the leading cause of death in young athletes during sports participation. During preparticipation evaluation (PPE) visits, clinicians are receiving more questions about incorporating electrocardiogram (EKG) screening to detect potentially lethal heart conditions. Many families are aware that several countries in Europe routinely use EKG screening and wonder why the United States has not instituted this recommendation. What are the pros and cons of preparticipation EKG screening in the US, and how might athlete-specific criteria assist in reviewing EKGs conducted in young athletes?

Injury Prevention Tips for Adolescent Dancers

The following Injury Prevention Guidelines summarize findings from the article The Adolescent Dancer: Common Medical Conditions and Relevant Anticipatory Guidance by Kathleen Linzmeier, MD and Dr. Koutures which is published in Adolescent Medicine State of the Art Reviews, April 2015 and is copyright from the American Academy of Pediatrics.

1)      The American Academy of Pediatrics recommends a rest period from organized physical activity that includes a minimum of 1 full day off per week and 2 to 3 months off per year.

2)      Emerging evidence suggests that the risk of injury increases when the number of hours of organized sport/dance activity per week exceeds the age of the child in number of years (eg, a 14-year-old girl should not exceed 14 hours per week of organized dance activities).

3)       Single sport or activity specialization at young ages can increase the risk of physical and emotional overuse, frequently leading to burnout and complete cessation of activity. Particular warning signs may include decreased interest in dance activities, lower school grades and attendance, less social interaction, changes in appetite or sleep, and mood alterations such as irritability, anger, or lack of fun or new activities.

4)      Incorporating recommended weekly and annual rest intervals along with varying the types of organized activities can reduce the potential for burnout.

5)      Medical practitioners may be asked for their opinion on the readiness of young dancers to begin dancing en pointe, which is an advanced ballet skill that places extreme stress on the lower leg, ankle, and foot

6)     Readiness recommendations focus not on chronologic age but on the presence of adequate whole body strength and balance (especially of the foot and ankle), lack of current restricting injuries, sufficient “pre-pointe” dance class exposure (minimum 3-4 years), and the future goals of the dancer.

6)     Screening tests that can assess appropriate proximal strength, proprioception, and placement of extremities not only for pointe but for higher-level leaping

7)      Medical professionals should maintain an open dialogue about adequate intake of calories and essential vitamins and minerals, and maintenance of healthy weight to best support ongoing dance activities.

8)      Physicians should respect the anatomic and emotional changes that occur during puberty without hesitating to modify or change focus to more basic skills to allow compensation for changes in movement patterns and coordination.

Is My Daughter Ready for Pointe Work? A Dance Medicine Physician Perspective

The decision to initiate pre-pointe training is a sentinel event in the progression of a young dancer. Dancing en pointe which involves full-weight bearing on the toes, is fundamentally rigorous, can lead to a variety of lower body injuries, and signifies a high level of commitment to ballet that should not be taken lightly.

Relying on reaching a certain to start (ie: "we start pointe at age 11") is not sensible and supported by many dance medicine authorities. Rather, there is the concept of developmental age which takes into account dance experience, mechanics, strength, commitment, and nutrition/sleep for a more individualized assessment of readiness.

Many wonderful musculoskeletal screening recommendations have been made by respected authorities, and I will definitely reference them below and do use them in my clinical practice.

Before moving the focus on movement patterns, I like to take a step back with dancers and families to discuss fundamental concepts emphasizing sufficient sleep, dance-specific nutrition and balance of dance classes and adequate time off for recovery. If a young dancer is not ready to accept these key foundations for success, then I'm not certain she is ready for the rigors and "sacrifices" of point work.  Jeff Russell has an amazing review of how psychosocial traits of dancers, nutrition and fatigue all can contribute to injury and I highly recommend the read.

• Dancers must accept the unique physical and mental demands of point work leading to a need for increased sleep (minimum 8-9 hours a night)
• Adequate calcium (1000-1500 mg/day) and iron (15 mg/day) needs can be best addressed by 4-6 servings of dairy foods and 3-4 servings of meat/protein per day
• Minimum of 1-2 days off a week from organized activities to enhance recovery

Returning to the discussion of musculoskeletal readiness, The International Association for Dance Medicine and Science (IADMS) proposes the following guidelines:

• Not before age 12.
• If the student is not anatomically sound (e.g., insufficient ankle and foot plantar flexion range of motion; poor lower extremity alignment), do not allow pointe work.
• If she is not truly pre-professional, discourage pointe training.
• If she has weak trunk and pelvic ("core") muscles or weak legs, delay pointe work (and consider implementing a strengthening program).
• If the student is hypermobile in the feet and ankles, delay pointe work (and consider implementing a strengthening program).
• If ballet classes are only once a week, discourage pointe training.
• If ballet classes are twice a week, and none of the above applies, begin in the fourth year of training.

Prospective point dancers can benefit from a focused musculoskeletal screening examination, and the great team at Childrens Hospital of Kings Daughters has a nice visual which illustrates some of the following:

• Measuring range of motion of the ankle, foot and especially the great toe. 
  • Limitations in great toe range of motion can lead to injuries not only in the foot, but at the ankle and knee
  • The Pencil Test can measure foot plantarflexion
  • Loose tissues on the outside of the ankle, often from past ankle sprains, may not be able to handle the stresses of pointe leading to fractures of the talus (lower ankle bone) or 5th metatarsal bone on the outside of the foot
• Assessing strength and endurance of the "proximal" structures (hip, buttock, quadricep and hamstring muscles) where weakness leads to abnormal stresses on the inside of the knee, shin, and foot/ankle
  • The Airplane Test has been associated with readiness for pointe work
  • Single leg squat alignment, where hips, kneecaps, and 2nd toe should all stay in line, is a great measure of that proximal strength
    • Collapse of the knee inward, excessive internal rotation of the shin, or significant collapse of the arch/rolling in of the foot are problem findings that should be addressed before starting pointe.
• I also like to put dancers perform plie in 2nd position- ideally inside of knee should be lined up over 2nd toe with minimal rolling in of foot. 
  • Inability to maintain this alignment is another problem area that should be addressed before starting pointe.
• If there is any history of past injury, the dancer should have completed a full rehabilitation program culminating in unrestricted return to dance before contemplating pointe work. 
  • The biggest risk to future injury is under-rehabilitated or lingering past injury

In any type of injury prevention and readiness assessment, communication is the name of the game. The results of a thoughtful medical and musculoskeletal assessment from a dance medicine specialist can be discussed with instructors and this collaboration is a wonderful medium to best prepare a young dancer when she is ready for pointe work.