Preventable injuries appear to be booming in children's sports. Although no Canadian figures are available, in the U.S. 3 million sports injuries are now seen annually in hospital emergency rooms and 5 million in doctor's offices, Dr. Ross Outerbridge, a pediatric orthopedic surgeon told SportMedBC. Dr. Jack Taunton of UBC's Allan McGavin Sports Medicine Centre agrees: "We are seeing more kids participating in sports now than in the past and the demands and expectations on them are higher." Sports injuries generally fall into two categories: overuse and traumatic injuries.

Overuse Injuries:
The following are key reasons for overuse injuries, says Taunton:

Training errors: These are caused by "doing too much too soon," says Taunton. "We know that children are not little adults." Parents and coaches need to understand that, "as children go through growth spurts, the bone gets longer, but it takes a while for that muscle-tendon unit to achieve the same length." The resulting muscle tightness is classically seen in the quadriceps, leading to Osgood-Schlatter disease, in 12 – 14 year old girls, and 13 – 15 year old boys. Another example is Sever's disease, the "adolescent equivalent of Achilles tendon problems," says Taunton. This was the commonest injury in a study of 100 provincial and national level gymnasts, he carried out with Dr. Susan Mackie, a gymnastics coach and family physician.

Multiple sport training: "When you see kids growing up, you see them playing soccer and basketball with the demands of a jumping sport and a running sport. If you are doing two sports at a high level, individuals with inflexibility or inadequate strength start running into problems," says Taunton. The different playing surfaces – the more forgiving soccer field versus the hard basketball court – create " a whole different adaptation the body has to make. Add that to alignment issues, such as whether the child is flat-footed or has pronated or supinated feet and that child (10-12 year old girls, 11-13 year old boys) will get heel pain on soccer pitches or basketball courts. That's a really common problem," says Taunton.

Year-round training: "If it is periodized and if the child takes breaks, year-round training can be acceptable with appropriate cross-training," says Taunton. "If they train for 3 or 4 weeks, then get a week off, or if they get in the pool and cross-train."

Technique: "Technique in so many sports is critical," says Taunton. Swimmers, for example, frequently get rotator cuff syndrome or whipkicker's knee, from a large volume of swimming combined with poor technique

Early Specialization: "If a child does one activity exclusively, they don't have the opportunity to develop other skills or other muscles in a balanced fashion," says Taunton. "Sports like dance and gymnastics are very good at a young age for developing body awareness and proprioception," he says. However, as with other single sports, when they become intensely competitive, many athletes " will quit and say ' now what do I do?' He recommends specializing in sports such as soccer, basketball and field hockey at 15-16. However, sports such as gymnastics or figure skating demand a singular commitment at a much younger age, creating potential problems ranging from eating disorders to serious growth-related injuries. The drive is to keep these athletes artificially small and thin. If you happen to have gone through a growth spurt and are much taller, you can't do the moves that give the highest scoring," says Taunton. He has seen an increasing number of gymnasts in recent years with osteochondritis dissecans in the elbows and knees. Studies have shown that some gymnasts' wrists stop growing, resulting in premature arthritis, which is directly related to the number of hours spent training.

"If you had individuals with closed growth plates, we wouldn't see some of these really concerning injuries which are related to overuse in a skeleton which is still growing. There, you lose the blood supply to the cartilage, you get a loose body and then you are set up for arthritis."

Safety equipment is critical, especially in high-speed sports, says Taunton, and parents should not skimp on quality. That means properly fitting helmets for snow sports, cycling, rollerblading and hockey. Hockey players should also wear high quality shinguards, shoulder pads and other protective gear. Skates should not be handed down from older siblings. Athletic footwear is now designed to accommodate flat, pronated or high arched feet.

Coaches: Coaches need to understand the implications of growth in training, says Taunton. For instance, he has seen children running up and down bleachers in practices, which can predispose them to Osgood-Schlatter disease. Rest is another important concept for coaches: " they have to understand that rest is just as important as a day of throwing the baseball," he says. "Violence, especially in hockey, needs to be curbed," says Taunton, pointing out the risk of concussions when smaller players are overpowered by larger ones.

INJURY PREVENTION

So how can injuries be prevented? Taunton says the number one risk for running injuries, for example, is a previous injury that has not been properly rehabilitated. He recommends the following:

• Trained team personnel: Every team should have someone trained in sports first-aid.
• Flexibility and strengthening training: Taunton notes that gymnastics coaches, for example, are now carrying out more flexibility and strengthening training than in the past.
• Medical examination before starting a sport: Certain children should undergo a medical examination prior to participating in sport, says Taunton. These include children with the following:
• Congenital abnormalities such as fused neck vertebrae, a single kidney or testicle or poor eyesight in one eye.
• Flat-footed athletes.
• Overweight children who are at risk for heat-related illnesses, high blood pressure and Type 2 diabetes.
• Asthmatics: These children may have problems in dry, cold conditions.
• Children with a history of cardio-respiratory conditions such as a heart murmur, several fractures or alignment problems.
• Marfan's syndrome: Tall, thin, loose-jointed athletes with long fingers may have this hereditary connective tissue condition, which can cause dislocated kneecaps, shoulders, or lens, but more seriously, an aortic rupture, causing sudden death. When Taunton worked with the Vancouver Grizzlies basketball team, he had all of the players screened for this condition.

Tips for dealing with injuries

• X-rays are useless for many injuries: bone scans are necessary for potential stress fractures.
• MRI's are necessary for investigating ligament injuries. These can generally be obtained within 24 hours for serious injuries and within 4 weeks for more minor injuries, says Taunton
• Injuries resulting in pain at night, back pain lasting more than 2-3 weeks or pain on hopping should receive immediate attention from a sports medicine professional
• Catastrophic injuries, such as unstable neck injury or a slipped hip growth plate, should be seen immediately by a physician.

Rehabilitation and return to play

Rehabilitation can be extensive and athletes and their parents need to know that shortcutting treatment can result in arthritis.

• What should parents watch for in their child athletes?
• A decreased desire to play sport.
• Stressed immune system: frequent respiratory infections or mononucleosis.
• Dropping weight.
• Irritability, sleep or bowel problems.
• Iron deficiency anemia: This is very common in rapidly growing adolescents parents should have the child's ferritin level checked.
• Diet is important: Ensure the child is taking sufficient calcium.

Parents should find a good physiotherapist or conditioning coach, who understands the nature of children's growth and its potential problems, says Taunton. Psychological demands: Parents need to accept that very few pitchers in little league baseball make it to the professional leagues and the same applies to other sports. " We have seen parents who have quit their jobs and moved, "to accommodate their child's elite-level training," says Taunton. "The child is an age-class wonder but can't handle the psyche of it all.

Heather Kent is a Vancouver freelance medical writer. She is a regular contributor to the Canadian Medical Association Journal and numerous other North American health and medical publications.

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