Make Good Decisions Sports Medicine: The Time for Prevention is Now! Jordan D. Metzl, MD, FAAP Hospital for Special Surgery www.drjordanmetzl.com Role of health provider What is reasonable to expect? What patterns are we seeing? Graphic Representation of the Numbers of High School Athletes in the United States as Reported by the National Federation of State High School Associations, 1970-2012 Millions of athletes 8 7 6 5 4 3 2 1 0 1970 1980 1990 2000 2010 Girls Boys General Changes in the Youth Sports World Increasing competition Travel, select teams Increasing numbers of participants estimated 30 million under age 18 Injury frequency Calender Year When Youth Sport Becomes too Serious How To Ensure the Healthiest Sports Experience? Mind Competition Psychological Makeup Fun? Body Body Build/Sport Selection/Training Error? Injury Profile? Injury History 1
Are We Doing A Good Job Discouraging Young Athletes When Appropriate? (Athletic Darwinism) Charles Darwin Are Different Bodies Built for Different Sports? Sport Specialization Questions Is sport specialization dangerous? Is sport specialization a good idea? Who should specialize? When should they specialize? What factors should be considered when making a specialized young athlete? What Can Help You With These Answers? Your brain/common sense! Difficult issue to fully quantify Intensive Training and Sport Specialization in Young Athletes (AAP Position Statement, www.aap.org) AAP Sport Specialization in Young Athletes Those athletes who specialize after puberty tend to have a lessened injury rate and a more consistent performance record Children should participate in sport based on their ability and level of interest Early recognition and identification of risk factors of injury are essential Body composition, weight, and stature, sexual maturation and evidence of emotional stress should all be considered 2
Prevention of Common Sports Injuries in the Adolescent Athlete Concussion ACL Injury Throwing Injury (LLE) Stress Fracture Case History #1 16 year old soccer player Kicking soccer ball Feels pop in her knee Comes into office with swollen knee next day ACL Injury in the Adolescent Athlete Injury rate for ACL injury in female soccer players is roughly 20 injuries/1000 hours of formal soccer playing (Knee Surg Sports Traumatol Arthrosc. 2008 Feb;16(2):194-8. Epub 2007 Sep 26) Soccer Basketball Lacrosse Field Hockey Gymnastics Acute Traumatic Injury ACL Injury Video Knee Injuries - ACL Female ACL 3-4 times more common than males College, High School studies Recognizing injury Prevention www.aclprevent.com 3
ACL tears predictive of osteoarthritis development Male 1 and female 2 soccer players followed after ACL injury (12-14 years) ~75% of male patients and >80% of female patients showed radiographic changes Surgical repair made no difference to outcomes Young patient with old knee ~50% of patients with ACL/meniscal injury have arthritis 10 20 years after the diagnosis 3 Better to prevent than treat! 1 von Porat et al. Ann Rheum Dis 2004;63:269 273; 2 Lohmander et al. Arthritis Rheum 2004;50(10):3145 52; 3Lohmander et al. Am J Sports Med 2007:35(10):1756-69 Prevention of ACL injury Risk factors for ACL injury Muscular fatigue 1 Greater quadriceps vs hamstring muscle force causes greater anterior force 2 Training and strengthening reduce injury rates 3,4 Minimize quadriceps:hamstring strength imbalance Strengthen to decrease fatigue 1 Kernozek et al. Am J Sports Med. 2007:[Epub ahead of print] Yu et al. Br J Sports Med. 2007;41(Suppl 1):i47-51; 2 Mandelbaum et al. Am J Sports Med. 2005;33(7):1003-10; Myer et al. BMC Musculoskelet Disord. 2007;8:39 Does ACL Prevention Work? ACL Prevention: Before and After Program 8/7/10 10/29/10 How do Athletes Prevent Injury? Strength To Prevent Injury: Think Kinetic Chain 4
Kinetic Chain Needs Strength + Flexibility Athletes of All Ages Need Their Kinetic Chain to Work! Today Show on Youth Strength Training Resources to Encourage Youth Strength Training at Home Take Home Points: ACL Injury Prevention is key Identification of at risk athletes Development of prevention strategies AAP with DVD and Flashcard Set Aap.org/Amazon I-Tunes $3.99 Common Sports Injuries in the Adolescent Athlete ACL Injury Throwing Injury (LLE) Stress Fracture Case #2 13 year old pitcher 4 weeks of worsening shoulder/elbow pain Initially only with throwing hard Now pain with throwing softly 5
Longitudinal study of elbow and shoulder pain in youth baseball pitchers Lyman S. et al, Med. Sci. Sports Exerc., Vol. 33(11) Developmental Phases of Throwing The purpose of this study was to evaluate the frequency of elbow and shoulder complaints in young pitchers Prospective cohort study of 298 youth pitchers was conducted over two seasons. The frequency of elbow pain was 26%; that of shoulder pain, 32%. Risk factors for elbow pain were increased age, increased weight, decreased height, lifting weights during the season, playing baseball outside the league, decreased selfsatisfaction, arm fatigue during the game pitched, and throwing fewer than 300 or more than 600 pitches during the season. Risk factors for shoulder pain included decreased satisfaction, arm fatigue during the game pitched, throwing more than 75 pitches in a game, and throwing fewer than 300 pitches during the season. Facing target Push Facing target, Cocking, Toss Age 2 Developmental Phases of Throwing Developmental Phases of Throwing Age 4 Facing target, Ipsilateral step Perpendicular to target, Contralateral step Wind-up, Cocking, Contralateral step Body momentum, Follow-thru Age 6-9 Phases of Throwing A mature mechanic by age 10? Wind-up Cocking Acceleration Deceleration Follow- thru E.McFarland ACSM-kinematics Age 10 Division 1 collegiate athlete 6
Little League Shoulder: Mild Little League Shoulder: Moderate Little League Shoulder: Severe Proximal Humeral Physis Appears at 1 year of age Fuses between 15-19 years of age Accounts for 80% of humeral growth Adaptive remodeling increases external rotation, decreases internal rotation Treatment: LLS No throwing until pain free Xray for initial evaluation, possibly if concern for growth arrest Asses risk factors Modify throwing mechanic? 7
History Diagnosis Rest Mechanics Return to activity? Treatment - LLE Prevention Program for Throwers Warm-up 5-10 minutes Strength forearm upper arm shoulder core hips Pitch Counts Guidelines for maximum effort pitches 10 pitches per years of age per 7 day period. Age Target Maximum Effort Pitches (Greatest number of pitches allowed per game) 8 40-50 9-10 50-60 11-12 60-70 13-14 70-80 15-16 80-90 17-18 90-100 8
Guidelines for Appropriate Pitch Types Age Pitch Type 8 Fast ball 10 Change-up 14 Curve ball Stance Windup Cocking/acceleration Landing Follow through Biomechanics 15 Cut, Sink, or Rise (2 or 4 seam) HSS Thrower s Program Take Home Points Throwing Injury Play through the pain Recognition of previous injury patterns Prevention programs Strength Biomechanics 9