Sidelined: Experts discuss sports injuries in our children

Recently, Central Penn Parent brought together experts for a panel discussion about the rise in the number and severity of youth sports injuries, including concussions and ACL tears. They also shared perspectives on treatment and prevention. The discussion has been edited for space; click here for the full transcript.

 Corey Higgins, physical therapist and center manager, Drayer Physical Therapy
Jayson R. Loeffert, D.O., primary care sports medicine, Penn State Hershey Medical Group.
Ellen M. Deibert, MD, FAHA, neurologist, WellSpan Neurology
Meagan Fernandez, DO, pediatric orthopaedic surgeon, Geisinger Holy Spirit Orthopaedics
Jim Launer, chief athletic officer, Spooky Nook Sports
Dr. Bernard Lewin, chief medical officer, Aetna Better Health and Aetna Better Health Kids in Pennsylvania
Leslie Penkunas, editor, Central Penn Parent

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Leslie Penkunas: Kids have always gotten injured playing sports. Have injuries changed in the past decade or so?

Meagan Fernandez, D.O.: They have increased tremendously. With single-sport specialization at these tremendously young ages, they’re getting adult complete tears, mid‑substance tears of their ACL, which we didn’t used to see. I had a 6 year old last week with an ACL tear.

Penkunas: What’s the most common sports injury?

Jayson R. Loeffert, D.O.: Muscle injuries, tendon injuries, nothing that requires surgery. But a lot of this, like Meagan alluded to, is this overuse injury where they’re not getting a chance to rest. They’re using their body in a way that they’re not really designed to and it’s causing them to break down and eventual injury.

Bernard Lewin, M.D.: Number one is there are many more girls participating in sports than there used to be. Anatomically, they’re different from boys on average.

Dr. Fernandez: Right. And the hormonal component as they get to puberty.

Dr. Lewin: Exactly right. And so what we’re seeing is more participation by young women.  We’re seeing a different level of coaching where there is pressure to perform at a higher level.

I think that that’s leading to greater efforts and greater strains and greater use or perhaps overuse of structures that may not be ready developmentally at an earlier age.

Dr. Fernandez: As they subspecialize into single sports, the specialization is at a younger and younger age.

Dr. Loeffert: I think an important definition is that the sport specialization is defined as participating in one sport greater than eight months of the year at the exclusion of [participation in] other sports.

Dr. Fernandez: [You] shouldn’t participate in more hours than your age. So if you have a 14 year old, they shouldn’t be doing more than 14 hours [per week]. Not only that, not all injuries are the same. In my experience in general, the gymnasts are the worst. They spend five hours [a day] in the gym… It’s just brutal for their bodies at such a young age.

Dr. Lewin: Any time you’re doing a repetitive activity over and over and over that involves the same muscles, joints and bones, you’re going to stress those muscles, joints, and bones inordinately. And for girls’ soccer, for example, that sudden change in direction and cleats on the ground that rotate your knee, it’s a repetitive injury which relates to the ACL injuries.

Penkunas: Are there specific challenges in treating a pediatric ACL?

Dr. Fernandez: Yes, because they’re still growing. Their anatomy is different and they have growth plates, which is the biggest issue. There was a time 30 years ago when we said, we can’t do anything because of your growth plate. We’ll brace you and [you] don’t do anything… Now we do special ways of avoiding [irreparable damage]. And then they rehab afterwards.

Corey Higgins: It’s almost harder to hold someone back than to motivate someone, especially when they’re already motivated. So it’s a lot of education, a lot of doing what’s safe. You’re going to have to make sure that you’re listening to the protocol, you’re listening to the doctor.

Dr. Fernandez: Six months seems like an eternity.

Higgins: It’s brutal. But the goal is that we just keep planning. This is what we’re going to do next week. And these are the steps we have to take to get back to here. Understanding how important it really is, if they try that.

Penkunas: How long does it typically take in physical therapy for a 10 year old to recover from an ACL tear?

Higgins: I’ve seen anywhere between six to nine months to return to a sport fully. That being said, function stuff usually is six to 10 weeks in.

Dr. Lewin: Why are these kids doing these extraordinary activities? And as a parent, your job is to make sure that they aren’t injuring themselves, and get them to adult life. When I see people who have had serious injuries — and I don’t see anything but the serious injuries; I see fractures and cruciate ligament tears and labral tears and rotator cuff tears and the things that are serious — I get pushback from the parents often that [the child] can’t be out of this sport for four months, because they’re trying to get a position on some travel team or want to be seen at a scouting event.

Higgins: Absolutely.

Dr. Fernandez: The vast majority of it is parent pressure. There is no literature to support that having your kid work out with their pitching coach and that exponential amount of time [result in sports scholarships]. In fact, the statistics go in the other direction. The studies say it’s the three-sport athletes who aren’t subspecializing at that younger age who are going on to play collegiate professional sports.

Dr. Loeffert: There is literature that says just 2 percent of athletes will actually get a scholarship.

Dr. Fernandez: If they specialize, the literature says there is a higher risk they are burning out.

Penkunas: It seems that kids have to pick their sport so early and that’s just the way it is. Kids are being asked at 7 or 8, what’s your sport?

Dr. Fernandez: That is how they identify themselves. Then I come in and say you can’t do this for six weeks or whatever it is. One of my most uncomfortable conversations was with a gymnast. They get chronic stress fractures in their spine and things like that, and they have to sit out and it’s month and months and months.

Dr. Deibert: I do a lot of concussion work, how they work through it to get to the next step.

Penkunas: I’ve heard that the neck muscles make girls more susceptible to concussions because [females] don’t have the support.

Dr. Loeffert: The strength of the neck muscles and the way girls land in jumping.

Dr. Deibert: And the neck issue is what’s been thought to be related to why girls have taken longer to recover. The girls playing the sports are just as rough and just as aggressive and just as competitive as boys. But their training is night and day different. Boys are more inclined to do more upper body stuff than women are. Unless trained how to do that, the women don’t get the core training and the upper training that they really need to do.

Dr. Lewin: If you’re talking about concussions, especially in soccer interestingly, there is a lot of focus among boys and girls particularly at a young age as they’re running and looking at the ball and they’re not looking where they’re going. Force is mass times acceleration. If you weigh 80 pounds and you’re both running at the same speed, it doesn’t matter if you’re a boy or girl.

Dr. Deibert: My biggest issue with football is, particularly with the boys when they’re 11, 12, and 13, you can have a 90 pounder next to a 180 pounder. And it’s not weight adjusted like wrestling is. I feel like sports are way behind in changing the rules of the game.

Dr. Fernandez: In baseball they’ve implemented pitch counts. But then the kid plays in three leagues. They’ll do the pitch count for one game, one team. Even where there are regulations we, as a society, beat them.

Penkunas: Are the parents or the coaches — or a combination thereof —the main cause of preventable injuries?

Dr. Fernandez: Well, it’s everything. Youth sports are big business.

Jim Launer: Youth sports is our business. We don’t encourage same-sport specialization. Our longest academy season is seven months.   But part of what we do in our academy season is make it mandatory for the kids to be involved in a sports performance program. We’re teaching [a young athlete] how to back pedal, which you typically don’t see on the volleyball court, because we want to balance the body out. We want them to be a multi-sport athlete. Even if they are in our academy for seven months, we are encouraging the body to develop differently.
The other thing that we see with a lot of injuries with youth athletes is that they’re reaction based. They weren’t able to get out of the way or they didn’t see it coming. So we do a lot of reaction work with our athletes outside of the court or the field and we feel that that reduces their amount of injuries, because they just get out of the way faster.

Penkunas: What percentage of injuries that you all treat among your pediatric patients would you say are easily preventable?

Dr. Fernandez: That’s the majority of them.

Dr. Loeffert: So the literature says 50 percent is entirely preventable. It’s probably higher in what I see in my own population.

Dr. Fernandez: These sports performance programs, the literature strongly shows that they prevent injury while you’re doing them. There is one specifically for ACLs, a prevention program. They work.

Launer: That’s part of what we do in our academies is to put them in a program similar to that.  But half the time the kids don’t want to come. They don’t see the value in it. We’re saying, OK, we want them with a sports performance coach 30 minutes a week. That’s it. The point of this session is not to run them in the ground or train them like they’re professional level athletes. It is…to reduce the risk of injury.

Dr. Lewin: I think that one of the things we want to mention here as well is that the impact of an injury over a lifetime is greater the younger you sustain it.

Dr. Loeffert: An ACL tear isn’t just an ACL tear. An ACL tear puts you at a much higher risk of developing arthritis later and so there are some consequences that can carry on.

Dr. Fernandez: The second you tear it, that’s the case.

Dr. Lewin: We have a growing organ. You injure it, it grows abnormally. It never forms normally, and you’re going to carry that with you the rest of your life.

Dr. Deibert: I think the story with concussion is still being written when it comes to what’s cumulative and what isn’t at that age. We still don’t know what causes second impact syndrome in children.

Penkunas: What is second impact syndrome?

Dr. Deibert: Well, the brain likes to do funny things. [It] will swell if provoked in a way that it doesn’t like. [Second impact syndrome] is usually when an athlete suffers a concussion, is still symptomatic, and then returns back into a sport and sustains another injury, a blow to the body or the head. As a result, the brain has an inappropriate amount of swelling — suddenly — and also there can be hemorrhages related to that. Fifty percent of those athletes die. The other 50 percent are permanently brain injured.

Penkunas: There are obviously protocols within sports about how soon you can return to the field after concussion. I don’t know if it’s always followed.

Dr. Fernandez: The athletes learn [the protocol] and then they don’t tell you, so they can go back in. And the coaches, too, to some degree.

Dr. Deibert: Concussion is not a visible injury to a child or to their teammate. If you hurt your knee or you break your leg, you have a cast. Everybody goes, oh, no, this is terrible. But when a person suffers a head injury they don’t have the skill set psychologically to handle it. A lot of times it’s the teachers who don’t even believe them. Meanwhile the kid is still struggling with a lot of issues. They lose their friends. It is a very lonely injury.

Dr. Fernandez: They become isolated and the depression sets in. It’s vicious.

Dr. Deibert: I think that the fact that it’s invisible makes it very hard.

Dr. Fernandez: And they’re boys and their dad is a big football star.

Dr. Deibert: Right. Drink some water.

Dr. Lewin: Walk it off.

Dr. Fernandez: The pressure from the parents is one of the most vital aspects of these kids pushing themselves, playing through injury, not reporting their concussion.

Dr. Lewin: Children are extraordinarily good at getting nonverbal cues from their parents. I think that we, as parents, have to be aware of what might be our unconscious message, our unspoken message, and we have to examine our own motivations.

Launer: We learned early on at Spooky Nook that parents coaching their children wasn’t always leading to the greatest outcome. You kind of see the fun leave. They’re volunteering there selfishly in a way, because they had their own son or daughter in. Their motivation just seemed to be a little bit different.

Dr. Deibert: I think one of the hardest groups of patients is the driven kid, the A student. They are so demoralized from the injury, and it’s their very self that’s different. How they study, how they think, how efficient they are, and their schedules are so packed, and now all of a sudden everything just starts to fall apart and they weren’t counseled correctly from the very beginning and given some adjustments in their academics initially.

Dr. Lewin: If the brain swelling or the non-imaging, non-imageable, components of a concussion impact your emotion or your ability to learn or anything else, how much of that is your variability? Can you report it yourself? If I’m in a bad mood, I may not notice it until somebody says, boy, you seem to be in a bad mood today.

Dr. Loeffert: Concussions are not measurable on imaging. But parents will go into the ER looking for an image. If they don’t get one, they’re very frustrated, and it’s actually appropriate not to image for a routine concussion.

Dr. Lewin: I have been asked to look at scans of hundreds of people and children who have had concussions, and I’ve never seen anything abnormal on any of those scans.

Dr. Deibert: Neurologists have a set of red flags where we would want imaging up front. There are seizures on presentation — kids can seize when they get a concussion at the time of the hit. It’s generally benign, [but] we like to have imaging on those kids. Something you can measure on your exam we absolutely would want imaging from.

Dr. Fernandez: Parents demand imaging. I don’t see concussions, but I have parents demand imaging. I spend no less than 20 percent of my day explaining that there is no reason. Every time we x‑ray your child, that’s radiation.

Dr. Loeffert: If it’s going to change the care and affect the way they’re being treated, I think imaging makes a difference.

Penkunas: So any guidelines for parents on when they should take their child to a doctor for a suspected injury and when they should let their child resume play? Completely separate from concussions.

Dr. Fernandez: They shouldn’t be returning to play until they’re pain free and pain free for a period of time.

Penkunas: How about for the dedicated athletes who just want to get back to the field?

Dr. Fernandez: They lie and say they’re pain free.

Penkunas: Is there anything parents can do to make sure that doesn’t happen?

Higgins: When I see athletes like that, especially ones that want to get back, I do a lot of functional movement screening to see how they move functionally and do a lot of sport-specific testing as well if they’re coming to therapy at that point. We can measure that objectively saying here are your limitations, here is your impairment.

Dr. Lewin: I think that we, as professionals, see people for short periods of time and while a motivated kid may mask that pain, a good parent watching their child knows if they’re pain free or not.

Dr. Deibert: I think in the world of concussion, we have strict protocols. We do want the athlete checked out, because we don’t have an objective marker and the athlete needs to be followed. A very organized kid always has their knapsack ready for school. All of a sudden their stuff is all over the floor or they’re not keeping their stuff together. He was in football practice last week, something might be wrong here. Follow your instinct about it, because their behavior will be different.

Penkunas: If you had just one piece of advice to offer a young athlete just getting into sports — or perhaps the young athlete’s parents — what would it be?

Launer: Just having fun and understanding why you’re there. That period of sports and training is really what’s going to provide the foundation that you use the rest of your life for fitness. It’s so frustrating to me when I see a kid who is trained or coached to the point where they want to quit.

Dr. Fernandez: The younger the kid is who super subspecializes, the higher the burnout rate is. By 12 years old, they won’t want to play sports at all, because they burn out. I would say encourage multi-sport participation, discourage super subspecialization at young ages, and have fun.

Dr. Lewin: I think that ultimately what you want is to have your child be physically active and doing something they enjoy.

Dr. Deibert: I would tell them all of this. But also I think they need to be encouraged to report their injuries early. If there is something really bothering them, they need to tell an adult about it.

Dr. Loeffert: After the [U.S. Women’s team played in] 2016 World Cup… multiple players said what other sports they did besides soccer. Abby Wambach specifically talked about basketball and how she learned to jump to get the ball to get rebounds which helped her be a very tremendously successful heading forward in soccer. Morgan Ryan talked about track. It taught her how to run fast. There are different athletic avenues that you can take to get better.

Higgins: Just listen to your body. Your body is going to tell you everything you need to know.  And then also parents, just listen to your kids too. Sometimes, like with concussion or with injury, some of the little things are going to become more evident. The sooner it gets picked up, then the sooner they can [address it and] get back on the field instead of turning from acute to chronic pain.

Note: responses were edited for length. Click here for the full transcript.