As competitive youth sports programs adopt volumes and intensities that are more typical of adult sports programs, the number of injuries increases and that number has increased five-fold since 2000.3 Examples of sports with low risk are swimming and diving, examples of sports with mid-level risk are girls and boys' lacrosse, and examples of high-injury risk sports are girls' gymnastics and boys' football. Each high-risk sport represents double the injury rate of other youth sports.4
There has been a flurry of recent activity in the popular media and in medical investigations dedicated to awareness of injury risk in collision sports. Mid-level risk sports such as lacrosse may be growing in popularity in part because they provide a lower risk alternative to the injury rate of more traditional collision sports.5
Why Risk Is Higher
Pediatric athletes are at greater risk for developing bony injuries such as apophysitis or avulsion fractures than adults because the open physeal plates are two-to-five times weaker than the surrounding fibrous tissue. This serves as a stress riser or weak point in the kinetic chain, resulting in structural failure.6 The young athlete will frequently develop bony injury or possibly an acute tissue failure rather than those degenerative overuse tendinopathies typically seen in the adult athlete.
Developmentally the young athlete's bones undergo rapid change during growth spurts and this makes them vulnerable to stress injury.7 During periods of rapid axial growth, the bone mineralizes faster than the surrounding soft tissue can lengthen, which makes the child temporarily profoundly inflexible and less tolerant to the external forces encountered during sports. With the change in bone length comes an obligate position change of the joints and associated soft tissues. There is, then, a need for retraining of the athletes' proprioceptive systems as the mechanoreceptors that dictate the athlete's position sense are slow adapting and may not have yet changed the afferent input from the body to the brain.8
The conflict between the new position and the old position's proprioception makes for an unbalanced and dyscoordinated athlete who requires specific treatment to re-educate that same position sense and the angle-specific muscle performance.
More Variables Involved
In addition to recognizing the need for treating the patient's proprioceptive deficits and muscle-performance impairments, treating the pediatric athlete requires the knowledge that children have more variable movement patterns and thus require closer supervision than adult patients. The athlete will need to have frequent instructions in clear, short, specific demonstrations.
Children are neurodevelopmentally less likely to adhere to assigned home exercise programs because they lack the ability to inductively reason, meaning they cannot apply the general principles that you have told them to their specific situation.9 So the instructions to them should be given in the exact context that you expect them to apply the information. The clinician should show the young athlete what is meant literally and have the patient perform the skill with verbal, tactile and demonstrative feedback from the clinician.
The more intensive instruction that must be provided to young athletes to ensure a good-quality motor performance will pay dividends when the athlete is transitioned from rehabilitative injury care to a return-to-play regimen. Consider the prevalence of pediatric sports injury and the unacceptably high re-injury rate when establishing return-to-play criteria for your athletes.10,11 In the absence of clear, compelling data for precisely what criteria are to be used, we must proceed with best practices.
Our best practices are formed by the functional use of peer-reviewed science and our professional experience, which lead us to form a constellation of meaning about readiness to play by gathering data points like the athletes' lower-extremity functional scale score, the patients' subjective report, the physical exam findings, strength values obtained with dynamometry, and functional testing like the square hop test or 6-meter cross-over hop test.12,13
If the overall impression of the data is that the patient is improved but elements still exist that demonstrate incomplete return of muscle performance, such as abnormally early fatigue, abnormal peak torque values, or abnormal angle of peak torque generation, interventions can then be put in place to address those findings prior to clearing the athlete to play.
An example recently seen at the author's institution is that of a young swimmer and water polo player who was treated for symptomatic multi-directional instability of the shoulder. Upon completion of his episode of physical therapy care, his reassessment demonstrated good recovery as measured by hand-held dynamometry strength ratings and high upper-extremity functional scale scores.
The patient subjectively reported that the shoulder was performing at his premorbid level but upon testing with isokinetic dynamometry at higher speeds, a deficit in the amount of peak torque was seen. This lack of ability to generate symmetrical shoulder rotation peak torque values at a speed more closely approximating those seen in the context of sport indicated to the supervising clinician that if left uncorrected, the patient might be at risk for future injury.
The clinician then added a speed-specific correction to the athlete's independent shoulder exercise program. This extra step in caring for pediatric athletes may decrease the likelihood that the patients will re-admit to your service and will spare them the time loss, frustration and pain of an injury that could have been prevented.14
Treatment of youth sports injuries continues to improve, though there exists a wide disparity in the methodology and rationale for delivery of care and national practice standards have not yet been fully established. Recent editions of peer-reviewed journals and scientific conferences are adding a focus on pediatric sports medicine to their content.
As the fountain of knowledge in pediatric sports medicine increases, developments toward consensus can be undertaken. At this time, managing the pediatric athlete is complex and best-practice treatment regimens that are based on available sport science, an understanding of pediatric neurodevelopment and the specific demands of the child's sport, may serve the individual clinician in forming care models for this special population.
References are available online at www.advanceweb.com/PT
Gabriel Brooks is an advanced clinical specialist in physical medicine and rehabilitation in the Adolescent and Sports Medicine department at Texas Children's Hospital, Houston.