Pediatric Sports Medicine Injuries: Lower Extremity Tal Lassiter, MD,MHA Director, Bassett Shoulder and Sports Medicine Research Institute Disclaimer I have no financial conflicts or interests to disclose. Outline 1. Who we are and what we do 2. STOP Sports Injuries Program 3. Two specific pediatric athletic injuries ACL tears in Children Hip labral injuries • • • • • • Academic All-American Gymnast at Cornell AOA Brody School of Medicine Orthopaedics and Sports Medicine at Duke University Best Clinical Science paper from AOSSM AOSSM, AANA member New England Shoulder and Elbow Society          UNC undergrad Harvard MD Duke Surgery/Ortho ECU Sports fellowship/team doc Bern, Switzerland AO fellowship Sports CAQ UNC MHA Associate Professor, Duke Orthopaedics AOSSM, AANA, NESES Why?! Bassett Healthcare is a rural academic medical center committed to providing excellence in healthcare services, educating physicians and other healthcare professionals and pursuing health research. Shoulder and Sports Medicine Research Institute Activities • • • • • • • Research and Teaching Baseball Hall of Fame NY State High School Baseball Outcomes: Shoulder, Knee, Hip Colleges: Hartwick, SUNY Oneonta Fellowship Education: CME, Medical Students Sports Trauma and Overuse Prevention The Problem • 30 million children participate in organized sports (Source: Safe Kids USA) • Participation in high school athletics is increasing, with more than 7.3 million high school students participating annually (Source: National Federation of State High School Associations) • High school athletics account for more than 2 million injuries annually, including o 500,000 doctor visits o 30,000 hospitalizations (Source: Centers for Disease Control) The Problem • Young athletes are specializing in sports (and positions) at an earlier age, with more than 3.5 million children under the age of 14 treated annually for sports injuries. (Source: Safe Kids USA) • Immature bones, insufficient rest after injury, poor training and conditioning contribute to overuse injuries. • Overuse injuries account for half of all sports injuries in middle school and high school. (Source: Safe Kids USA) The Lasting Problem A child’s history of injury is….. 1. A risk factor for future injury during both their youth and adulthood 1. A contributor to long term degenerative diseases, such as osteoarthritis. The Lasting Problem – Part 2 70% of kids participating in sports drop out by the age of 13 because of • Adults • Coaches • Parents These children lose the benefits of exercise, teamwork and healthy competition! What is Overuse? Overuse is considered excessive and repeated use that results in injury to the bones, muscles or tendons involved in the action. Why are Injuries on the rise? • • • • • Immature bones Insufficient rest after an injury Poor training or conditioning Specialization in just one sport Year-round participation What Can We Do to Prevent Overuse and Trauma Injuries? • • • • • • Promote injury prevention on multiple levels, including: Learning about the STOP Sports Injuries campaign and visiting www.STOPSportsInjuries.org for resources Take the Pledge on the website to prevent injuries Holding ongoing discussions about the importance of rest with athletes Mandating pre-season physicals Enforcing warm-up and cool down routines Encouraging proper strength training routines What Can We Do to Prevent Overuse and Trauma Injuries? Additional tips: o Drink enough water based on activity and temperature levels o Educate athletes on proper nutrition for performance o Supervise equipment maintenance o Encourage kids to speak with an athletic trainer, coach or physician if they are having any pain. Additional Prevention Strategies Work with local athletic governing bodies to mandate pitch counts and limit number of matches or tournaments played. More Prevention Strategies • Encourage participation for fun and limit emphasis on winning • Discourage early specialization • Treat symptoms of problems/injury EARLY Proper Technique is Key • Provide proper instruction on throwing mechanics Discourage the teaching of curve balls until high school (puberty) o Ban the radar gun in youth sports o Mandate a 3 month “rest-period” each year for throwing athletes o Organizational Partners for STOP Sports Injuries Campaign Sports Medicine Organizations • American Orthopaedic Society for Sports Medicine • National Athletic Trainers’ Association • American Medical Society for Sports Medicine • American Academy of Orthopaedic Surgeons • American Academy of Pediatrics -Sports Physical Therapy Section Related Organizations • Youth Sports Leagues Little League • • Professional leagues Medical Institutions Cleveland Clinic • Safe Kids USA STOP Sports Injuries Council of Champions (Continued) Joe Gibbs Ian Lawson Founder, Golf Channel President, DePuy Mitek Eric Heiden, MD Dennis Lewin Chairman, Board of Directors , Little League Baseball International Olympic Speed Skater and Orthopaedic Surgeon Jay R. Hoffman President, NSCA Bo Jackson Professional Multi-Sport Athlete James Justice Owner, Greenbriar Resort Stephen Keener President & CEO, Little League Howie Long Former NFL Player, NFL Sportscaster, Fox Network Renaldo Nehimiah Director, Track & Field Worldwide Teri McCambridge, MD Chairperson, AAP Council on Sports Medicine and Fitness Renaldo Nehimiah STOP Sports Injuries Council of Champions (Continued) Jack Nicklaus Golden Bear Enterprises/Professional Golfer Mitchell Stoller President and CEO, SAFE Kids Worldwide Jim Wilson Jerry Pate Former, Professional Golfer Rick Peterson Milwaukee Brewers Pitching Coach Christie Rampone WNT U.S. Soccer John Smoltz MLB Pitcher Bart Starr Former Green Bay Packer Quarterback Chairman, Jim Wilson & Assoc. Campaign focuses on 12 Sports • • • • • • • • • • • • Baseball Swimming Football Basketball Cheerleading Tennis Dancing Gymnastics Soccer Running Volleyball Softball Educational Content • Sports tips o Sport specific information • Video podcasts • Specific educational tool kits focused on various audiences o Parents o Athletes o Coaches o Healthcare providers Other Resources • • • • • www.STOPSportsInjuries.org www.orthoinfo.org www.nata.org www.sportsmed.org www.SAFEKids.org Let’s Work Together to STOP Sports Injuries And Keep Kids in the Game for Life! www.STOPSportsInjuries.org ACL Injuries ACL Tear Diagnosis • • • • • • • • Plant and change of direction Non-contact > contact injuries Unable to continue play Swollen (bloody effusion) “Knee dislocated” 95% by history Lachman’s test MRI diagnosis commonly MRI Bone bruises ACL Injury Epidemic, Early Specialization, YearYear-Round Play May Be LinkedLinked- AAOS 2009 Dogma Dogma: Facts: Don’t repair ACLs in kids Pediatric ACL tears should be reconstructed Concern = Growth Plate Injury • Mainly an issue for < 12 yo • Tanner stages 1-2 J Bone Joint Surg Br. 2002 Jan;84(1):38-41. The natural history and treatment of rupture of the anterior cruciate ligament in children and adolescents. A prospective review. Aichroth PM, Patel DV, Zorrilla P. • • 60 patients 23 patients who were treated conservatively revealed that the natural history of the injury resulted in severe instability and poor function of the knee Non-surgical treatment has bad results Arthroscopy. 2002 Nov-Dec;18(9):955-9. Associated injuries in pediatric and adolescent anterior cruciate ligament tears: does a delay in treatment increase the risk of meniscal tear? Millett PJ, Willis AA, Warren RF. Delay in surgical treatment was associated with a higher incidence of medial meniscal tears Meniscal tears lead to DJD Pediatr Orthop. 1997 Jul-Aug;17(4):505-11. Anterior cruciate ligament tears in children: an analysis of operative versus nonoperative treatment. Pressman AE, Letts RM, Jarvis JG • Ages 5-14 yo • Complete tear of the anterior cruciate ligament was best managed by intraarticular surgical reconstruction Non-surgical treatment of ACL tears has bad results J Pediatr Orthop. 2002 Jul-Aug;22(4):452-7. Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and The ACL Study Group • 15 reported cases of growth disturbance • 8 cases of distal femoral valgus deformity with arrest of the lateral distal femoral physis, • 3 cases of tibial recurvatum with arrest of the tibial tubercle apophysis, • 2 cases of genu valgum without arrest • 2 cases of leg length discrepancy ACL surgery in children has had bad results Physeal Sparing Soft Tissue ACL Reconstruction Hip Arthroscopy 1. Labral Repairs 2. FAI (Femoral-acetabular Impingement) Symptoms • • • • Groin pain Antalgia Catching, locking Difficulty sitting with hips flexed, getting out of a car • May masquerade as back or pelvic pain Signs and Symptoms • The “C” sign Impingement Test FABER Test Which athletes may need hip arthroscopy? Hip Labral Tears Femoral-acetabular Impingement FAI • Alpha angle • CAM lesion 3 Imaging Studies 1. AP Pelvis 2. Lateral View of hip (Dunn) 3. MRA of the affected hip (10-15 cc contrast) w/1.5 Tesla MRI AP Pelvis CAM PINCER Lat Hip MRA Arthroscopy Questions Pediatric Sports Medicine Injuries: Lower Extremity Tal Lassiter, MD,MHA Director, Bassett Shoulder and Sports Medicine Research Institute