There are ∼3 million annual injuries incurred during sports participation among children and adolescents in the United States, with injury defined as one that causes time lost from sports participation. Pediatricians need to have the skills to diagnose, manage, and/or triage these injuries. Training in management of musculoskeletal injuries is not integrated into the pediatric curriculum as systematically as it should be, according to surveys of recent pediatric graduates.
Injury rates have been reduced because of changes in the sport environment through increased safety regulation. The preseason examination is an opportunity to diagnose and rehabilitate old injuries and thereby prevent reinjury. However, effective prevention occurs only when the patient history is accurate and appropriate diagnoses and rehabilitation programs are initiated by the physician performing the preseason examination.
For the individual patient with a musculoskeletal injury, there are four phases of rehabilitation: 1) limiting additional injury and controlling pain and swelling; 2) improving strength and flexibility of the injured structures; 3) progressive improvement in strength, flexibility, proprioception, and endurance of the injured structures until near-normal function is achieved; and 4) returning to the sport gradually through functional rehabilitation.
Finally, injury in sports also includes psychological injury. Young athletes should play sports for enjoyment, to improve self-esteem, and to improve athletic skills. If these are not priorities in youth sports, then participation in sports potentially is harmful by decreasing self-esteem, diminishing athletic skills, and discouraging additional participation in sports. Pediatricians should be aware of potential psychological issues and provide guidance to address them.
Pediatricians should be involved in providing medical care for children and adolescents when these patients are injured in sports participation. The overall goal of this article is to increase the competency of pediatricians in sports medicine care, specifically prevention of sports-related injuries. A framework for approaching sports injury prevention is provided. Specific objectives are: 1) to review the epidemiology of sports injuries in children, adolescents, and young adults in the United States; 2) to review injury prevention by removing environmental risks of injury; 3) to review injury prevention for individuals; 4) to review the principles of rehabilitation and their implementation in primary care; and 5) to review the psychosocial aspects of sports and injuries and consider whether children/adolescents should participate while in pain and whether we push children/adolescents too hard in sports in the United States.
ROLE OF THE PEDIATRICIAN
In 1979, 5% of sprained ankles and 11% of other ill-defined sprains in children ≤14 years of age were treated by pediatricians.1 Alumni from a pediatric residency program who trained in the 1980s listed sports medicine/orthopedics as second among areas of being least comfortable.2 In 1994, a national survey of pediatric chief residents indicated that 90% felt comfortable managing an ankle sprain, yet only 26% of their programs had a sports medicine elective and only 55% offered clinical experience in managing musculoskeletal injuries.3
In addition, the majority of the chief residents would refer calcaneal apophysitis and patellofemoral pain, two common and uncomplicated conditions in children and adolescents, which could be, with appropriate training, cared for by pediatricians. In summary, for >2 decades it has been documented that pediatricians have had little training in caring for routine musculoskeletal injuries. In the managed care environment, this may place pediatricians at a competitive financial disadvantage. By referring to a specialist, the patient and family are inconvenienced. If they are not referred and the injury not rehabilitated properly, a poor standard of care results, and the risk of reinjury is increased.4-6 The time is now to require training in musculoskeletal injury management during pediatric residency and to encourage practicing pediatricians to improve their skills in sports medicine.
EPIDEMIOLOGY OF SPORTS INJURIES
Approximately 30 million children and adolescents participate in organized sports in the United States. Twenty-five percent to 30% of sports injuries occur in youth involved in organized sports, another 40% occur in youth playing unorganized sports. There are ∼3 million injuries annually, when injury is defined as time lost from the sport. Approximately 770 000 of these organized sports injuries require physician visits and 45 000 to 90 000 require hospitalization.7 The estimated cost (direct and indirect) in 1996 dollars was $1.3 billion for the evaluation and acute management of these patients, assuming a conservative 6% annual increase in the medical costs for patients when the study was done in 1982.
Which sports are associated with the highest injury rate? Football has the highest injury rate among high school athletes, followed by wrestling.8 Gymnastics, basketball, baseball and softball, track and field, and cross-country have lower rates of injury, and the percent of athletes injured annually in these sports ranges from 7% to 46%.9 For most high school and college sports in which males and females participate, the injury rate for males and females are similar.8,9 However, knee injury rates are higher in female athletes compared with male athletes at the college level.10 Fatalities are rare in sports participation. Mueller reported 160 nontraumatic deaths in high school and college athletes in the United States between 1983 and 1993.11 The majority of these were cardiac deaths, with a minority attributable to heat-related injuries. There were 53 traumatic deaths from 1982 to 1992 in football, the majority of these being attributable to head/neck trauma. This number decreased steadily between the 1970s and 1990s, with no traumatic deaths among youth playing football reported in 1990.
INJURY PREVENTION: SUCCESSFUL INJURY REDUCTION THROUGH REMOVING ENVIRONMENTAL RISKS TO INJURY
Interventions have been successful in reducing sports injury rates by changing the sports environment through effective safety regulations. Consider the following three examples:
The incidence of catastrophic neck injuries in high school and college football decreased significantly after the rule forbidding spear-tackling began to be enforced in 1976.11
Garrick reported a 50% reduction in the overall injury rate in female high school gymnasts after the trampoline was removed from competition.8
Ankle and lower leg injuries were reduced with the introduction of breakaway bases in softball.12
These interventions were designed to prevent injuries recognized in descriptive studies identifying injury rates and potential mechanisms of injury. These intervention studies provide models for future research into sports injury prevention.
Successful intervention to prevent sports injuries, however, often is a difficult, complicated process requiring an understanding of the factors involved in injuries; epidemiology; the design, implementation, and monitoring of the effects of interventions; and the social context of trying to prevent serious injury. One current example of the difficulty in trying to prevent sports injury, in consideration of these issues, is the proposed use of the reduced injury factor (RIF) ball in baseball, instead of a traditional hardball, to reduce death caused by ball impact to the chest wall, an injury referred to as commotio cordis. In 1995, 15 million 5- to 14-year-olds played baseball in the United States. There were 167 000 emergency room visits by these players, 47 900 of which were for ball impact injuries. From 1973 to 1995, there were 68 deaths from ball impact injuries, leading the United States Product Safety Commission to recommend using the RIF ball as an attempt to reduce the mortality associated with ball impact.13 However, this recommendation is not without controversy, because the mechanism of death in commotio cordis is postulated to be a ventricular arrhythmia after a blow to the chest during a vulnerable moment in the cardiac cycle, and therefore, potentially not preventable by a change in the type of ball used.14 The RIF ball is softer than the traditional hardball and is designed to diffuse the point of impact at the chest wall.15 One report suggested the RIF ball actually increased the potential risk of injury.16 There already has been one reported death attributable to chest trauma with a RIF ball (Barry Goldberg, personal communication). Widespread implementation of the RIF ball has not occurred, although it is being considered in response to pressure to do something to prevent these deaths. Death in baseball attributable to commotio cordis is rare, with approximately three to five occurrences per year. Measuring the effect of the RIF ball on mortality rates may be practically impossible.
POTENTIAL MECHANISMS FOR REDUCING INJURIES IN ALL YOUTH SPORTS BY CHANGING THE SPORTS ENVIRONMENT
There are mechanisms to potentially reduce sports injuries by examining the athlete, the sports environment, and how sports are conducted. These factors include: 1) the preseason examination, 2) medical coverage at sporting events; 3) proper coaching, 4) adequate hydration, 5) proper officiating, and 6) proper equipment and field/surface playing conditions. Each is discussed below.
Preseason Medical Evaluation
Two of the goals of preseason medical evaluation are: 1) to identify conditions that could be worsened by sports participation, and 2) to identify musculoskeletal problems that can be rehabilitated before returning to sports.
Sample questions to ask and examination maneuvers to perform during the preseason examination have been published.17 An important objective in goal 1 is to identify athletes at risk for sudden cardiac death. However, cardiac conditions placing athletes at risk of sudden death are rare, and the preparticipation examination is of limited value in identifying these abnormalities.18 An estimated 200 000 athletes would have to be screened, using the evaluation described below, to prevent one cardiac death in sports. For the individual patient, however, a history of syncope, presyncope, palpitations, and/or anginal pain with exercise, especially coupled with a family history of premature cardiac death with exercise, requires evaluation before clearance to participate in sports is granted. This evaluation includes electrocardiography, echocardiography, stress test, and ambulatory 24-hour electrocardiography.19 Goal 2 of the preseason medical evaluation represents the higher yield in reducing additional injury. Evidence that rehabilitation of injuries leads to injury reduction will be discussed below (see “Injury Prevention in the Individual Patient”).
Medical Coverage at Sporting Events
Medical coverage at athletic events is desirable and required in many settings. However, by itself, medical coverage at sporting events has not been demonstrated to reduce injuries. Appropriate coverage at games provides the opportunity for prompt diagnosis, treatment, and, if appropriate, immediate rehabilitation. Prompt treatment can reduce swelling, and appropriate bracing and/or restricting the athlete from additional participation may prevent worsening of the injury. Starting rehabilitation exercises on the day of the injury can slow disuse atrophy and the extent of the injury, and the rehabilitation period can be impacted favorably. This requires physicians to have training in on-the-field management, which is not available in many pediatric residency programs. Tracking and rehabilitating injuries until they are fully recovered is as important as providing medical coverage at sporting events. Team physicians play a vital role in the diagnosis and treatment of these injuries, yet the provision of medical care along the continuum of preseason examinations, game coverage, and follow-up is inconsistent or lacking.20 The pediatrician who desires to become more involved has at least two mechanisms: 1) volunteering to attend sporting events with an experienced sports medicine physician, and 2) attending continuing medical education activities. In the latter category, the American Academy of Pediatrics and the Society for Adolescent Medicine (816–224–8010; home page:http://cortex.uchc.edu/sam/) annual meetings include sports medicine sessions. For a more intense experience, the American College of Sports Medicine offers team physician courses (317/637–9200; home page:http://www.acsm.org/sportsmed).
Coaches play key roles in injury reduction, as demonstrated by the trend of fewer catastrophic neck injuries that occurred in football from 1972 to 1990. This reduction in injury was associated with coaches teaching players not to spear-tackle and referees enforcing penalties for spear-tackling.11 Coaching style influences the motivation, self-esteem, and fun experienced by youth in sports.21 Poor social support, poor social skills, and negative life events are correlated with sports injuries.22Coaches may influence these variables and, in doing so, may influence injury rates favorably. Coaches also may be able to prevent injuries by providing an appropriate progression in sports participation in which young athletes are not asked to perform skills without mastering the requisite techniques. Injury rates increase with increased skill of play.23,24 Young athletes should progress in intensity and difficulty of sport as they are capable. Advancing too quickly may increase the risk of injury. For example, a player who is not comfortable catching a ball thrown hard from a short distance should not play first base where he may be hit by a ball thrown by a teammate. This player might be better at another position until he masters catching balls thrown hard from short distances. Lack of training and poor physical fitness are risk factors for injury in new military recruits (median age, 19 years) undergoing basic training.25 For them the rate of exercise progression is too rapid, given their level of fitness, and overuse injuries result, including stress fractures of the tibia and metatarsals. The pediatrician can serve as an advocate for injury prevention by serving on sports boards to promote adequate training for coaches.
The rate of heat-related injuries may be reduced by developing strategies to ensure proper hydration and cooling. Risk factors for heat-related illness include increased body weight and poor conditioning before entering into a rigorous training program.26 Physicians should advise athletes, parents, and coaches of these risk factors. Those players starting summer football practice, for instance, should be allowed to work gradually into condition and should be allowed full access to fluid replacement.
Regarding the fluid to be consumed during exercise, assuming the exercise is <1 hour and the child/adolescent is euvolemic, there is no benefit to drinks containing sodium and chloride and/or 6% carbohydrate solutions, compared with water, when measuring electrolyte balance, thermoregulation response, or aerobic response in 9- to 12-year-olds exercising in the heat.27
Although recommended for activities >1 hour, the effectiveness of carbohydrate–electrolyte solutions has yet to be demonstrated when children drink ad libitum and do not remain euvolemic. A key characteristic of the fluid is that it should be palatable because that encourages consumption.
Thirty percent of soccer injuries in men's soccer have been attributed to foul play.28 There was a reduction in catastrophic neck injuries in football between 1970 and 1990, not only because spear-tackling was recognized as contributing to the mechanism of injury, but officials began to penalize players for doing it. Proper officiating might play a significant role in injury reduction among youth participating in sports.
Proper Equipment/Field Conditions
Often taken for granted, field conditions can represent a risk of injury for the young athlete. Between 1979 and 1992, 15 reported deaths occurred in 3- to 22-year-olds in soccer because of movable soccer goals being tipped over and crushing a player.11Anchoring the goals will reduce this risk. Field maintenance, including elimination of holes and sharp objects on the field and removal of chairs, bags, and other objects from the immediate perimeter of the field, will eliminate potential sources of injury. Proper safety equipment also plays a role in injury prevention. Traumatic leg injuries occur more often in soccer players with inadequate or no shin guards.4 Mouth guards worn during sports participation can reduce dental injuries.29 Mouth guards are not worn routinely by athletes in any sport except football.30Pediatricians should consider advising the use of mouth guards in sports where there is potential for dental trauma, including soccer, basketball, and baseball. As noted in above, pediatricians can advocate for injury prevention by being a member of the sports board and promoting maintenance of proper equipment and optimal field conditions.
INJURY PREVENTION IN THE INDIVIDUAL PATIENT
To this point, much of what has been discussed has been from a public health perspective and has focused on changing the sports environment as a method to decrease injury rates. What can be done to influence the injury rate for the individual patient? Adult soccer players who fully rehabilitate their injuries will have reduced injury rates after returning to soccer.4 Previous injuries are a risk factor for subsequent injury.31 Unrehabilitated injuries, manifested as persistent symptoms and reduced strength, flexibility, proprioception, and/or endurance of the involved extremity, are risk factors for additional injury. Two examples that illustrate this are that 1) traditionally, primary anterior shoulder dislocations in adolescents were felt to be best treated surgically because the injury recurrence rate was reported as 50% to 90%. Aronen reported that after a primary anterior shoulder dislocation, 75% of midshipmen at the Naval Academy, with a mean age of 19 years, returned to full sports participation after a 3-month rehabilitation program;6 and 2) that Keller et al introduced an injury prevention program into a men's senior division soccer league, resulting in a 75% reduction in injury incidence and an 80% reduction in medical costs of caring for soccer injuries.5Specifically, warm up and cool down periods were implemented using proprioceptive facilitation techniques. All players had to wear shin guards that protected the proximal tibia and malleoli during all practices and games. During winter training, all players wore ribbed, all-terrain soled shoes. All players with a history of ankle instability taped ankles before practices and games. Return to play was allowed only when at least 90% strength and range of motion of the injured structure was achieved. Players with anterior cruciate ligament laxity were excluded from play.
REHABILITATION OF MUSCULOSKELETAL INJURIES
What should the pediatrician prescribe for physical therapy for rehabilitation of musculoskeletal injuries? The pediatrician might consider creating new or using existing educational materials to instruct patients in these phases of rehabilitation.32,33 There are four rehabilitation phases:
Phase 1, limit additional injury and control pain and swelling.
Phase 2, improve strength and flexibility (range of motion) of the injured structures.
Phase 3, progressively improve strength, flexibility, proprioception, and endurance training until near-normal function is attained.
Phase 4, return to exercise and sports symptom-free.
PHASE 1: LIMIT ADDITIONAL INJURY AND CONTROL PAIN AND SWELLING
The methods to carry out Phase 1 are represented by the RICE mnemonic: rest, ice, compression, and elevation.
Rest is best called relative rest. The athlete can do whatever he wants as long as it does not hurt during or within 24 hours of an activity. For example, if a patient sprains her ankle and cannot bear weight on it comfortably, she needs to be on crutches, even if only for 24 hours. Most often, crutches and/or bracing require a longer time. The criteria to remove the crutch/brace is the ability to go without it and remain pain-free. “No pain—no gain” is a counterproductive philosophy when applied to the rehabilitation of injuries. Patients need to understand proper crutch use before leaving the clinic, because other injuries can result from stair-walking or improper use.
Ice is an effective therapeutic modality for controlling pain and swelling after an injury. Patients need specific instructions in the use of ice: it should be placed in a plastic bag and applied directly to the skin continuously for 20 minutes. Prolonged icing (>20 minutes, although the duration depends on the site) can result in peripheral nerve cryoinjury manifested as palsy. Crushed ice is ideal because it conforms to many joint surfaces. Advise patients to be aware that commercial, synthetic products with a freezing point below 0°C can result in a skin burn, even when used for as brief a period as 20 minutes. For the first 48 hours, advise patients to ice three to four times a day, and then at least once per day as long as swelling and/or pain is present.
Compression needs to be tight enough to promote reabsorption of edema at the injury site but not so tight as to impede venous return distal to the compression. Compression can be applied as a tubular stockinette or any elastic bandage and should be applied adequately distal and proximal to the injured structure. For example, after acute internal derangement of the knee (ie, anterior cruciate ligament sprain or meniscal tear), the compression wrap should be applied from midcalf to midthigh. This can be accomplished by applying the compressive wrap sufficiently distal and proximal to the knee and not just over the knee. Otherwise, if the wrap is applied only at the knee, as the patient stays upright for longer periods of time, dependent ecchymoses and swelling distal to the wrap may result. This complication can be avoided with proper compression and elevation.
Patients may not elevate an injured extremity unless instructed to do so. Some will elevate an injured extremity for 1 or 2 days, but not when they return to school or work and are upright all day. By the end of the day, the swelling may have returned. Elevating the leg as much as possible during the day is advisable.
Analgesia is important as a short-term treatment because pain will result in guarding and disuse, which, over days to weeks, results in inflexibility, atrophy, and loss of endurance. This results in additional compromise of the ability to stabilize the injured structures. A treatment plan to specifically address flexibility, strength, endurance, and proprioception should be developed in conjunction with a physical therapist or athletic trainer. While the injury is being rehabilitated, the noninjured structures and cardiovascular fitness need to be maintained. Therefore, patients should be encouraged from the first day of therapy to maintain their cardiovascular fitness as well as to exercise other noninjured structures, always following the relative rest guideline. Cardiovascular fitness can be maintained by swimming, cycling, water-jogging, or any other aerobic activity. Weight training is encouraged for the uninjured extremities or for the injured extremity as long as it is pain-free. Finally, to avoid the isolation from the team/sport that some athletes experience after an injury, athletes should be encouraged to go to practice and games and remain as much a part of the team as possible. Reactions to injury include anger, sadness, and guilt, especially if the athlete has been training for months or years to attain a certain level of competition and is then excluded by injury. Being apart from the team can worsen these feelings. It is helpful when coaches and physicians support the continued involvement of injured players in team activities so that the athlete's transition back to sports after an injury is easier.
PHASE 2: IMPROVE STRENGTH AND FLEXIBILITY/RANGE OF MOTION
This phase must be conducted with a physical therapist or athletic trainer with sports medicine experience. For most injuries, the patient can maintain the strength of muscles by starting isometric exercises, pain-free, as soon as possible after the injury. Isometric contractions are characterized by muscle contraction without joint movement. The cardinal principle in all phases of rehabilitation is relative rest, as noted above.
Analgesia should be continued for 7 to 10 days. Ice should be continued as long as swelling and/or pain are present.
PHASE 3: PROGRESSION OF STRENGTH, FLEXIBILITY, ENDURANCE, AND PROPRIOCEPTION TO NEAR-NORMAL LEVELS
Under the guidance of a physical therapist or athletic trainer, the patient who is rehabilitating successfully will report improved range of motion, strength, and endurance, and fewer symptoms of inflammation and instability. If the patient is not improving, several possibilities exist—the diagnosis is incorrect, the therapy is inappropriate, or the patient is being noncompliant with the rehabilitation plan. The pediatrician should consider consultation if the diagnosis is uncertain. Regarding correct performance of the rehabilitation, have the patient demonstrate the exercises with the therapist or trainer to be certain he/she is doing them correctly.
On physical examination, assuming surgery has not taken place, ligament healing will be manifested by minimal laxity with provocative testing but not a gross instability and little, if any, pain. Palpation of the ligament will be pain-free. If not, the ligament is not healed enough to begin functional rehabilitation. Muscle tendon unit healing will be manifested as no pain with resisted range of motion and no tenderness to palpation. Once 80% to 90% of strength and flexibility has been achieved, then functional rehabilitation can begin. It is important that the patient understand the difference between rehabilitation of strength, flexibility, endurance and proprioception, and functional rehabilitation. The former four components are prerequisites to testing the injured structures under controlled conditions (ie, functional rehabilitation) before returning to sports participation, where uncontrolled, high-intensity activity will occur.
PHASE 4: RETURN TO SPORTS
Full flexibility, strength, and proprioception are prerequisites for, but not synonymous with, full return to sports. Athletes need to return to sports in a stepwise manner after restoration of strength, flexibility, and endurance using functional rehabilitation. The functional rehabilitation should be sport-specific. For example, a soccer player with a medial collateral ligament sprain would need to progress through walking, jogging, sprinting, and then sprinting with sharp turns before return to soccer without restrictions. This progression may take days to weeks. A pitcher with a shoulder injury might start to throw lightly and progress in intensity over 7 to 14 days, increasing the number of pitches and intensity every 2 to 3 days, assuming no pain occurs. If pain occurs, the athlete should rest for 2 to 3 days, then return at a lower level of intensity and start to progress again, as tolerated. An example of functional rehabilitation on athletes with an acute lower extremity injury is shown in the Table .34 This protocol has a 2-week time line, which can be slower or faster depending on the injury. By the time they reach 20 minutes of jogging, most athletes are ready to start more aggressive functional rehabilitation, including sprinting, cutting, and jumping. This rehabilitation program is an example of a specific rehabilitation program that pediatricians can prescribe. Patients given vague guidelines may exceed what they are capable of and risk reinjury.
PLAYING WITH PAIN: ARE WE PUSHING OUR CHILDREN TOO HARD?
The cardinal principle in rehabilitation is relative rest—do not exercise or participate in sports if it is painful. Why do athletes return to sport with pain and incomplete rehabilitation? Several explanations are possible.
Inadequate rehabilitation can be attributable to lack of physician or therapist expertise or patient noncompliance with the rehabilitation program or both. Time must be spent with the patient to discuss the nature of the injury and the specifics of rehabilitation exercises. Handouts with written instructions accompanied by drawings demonstrating the exercises are helpful.
Pressure to compete from the athlete himself/herself, peers, parents, or coaches may occur. When the pressure to compete and win is paramount, young athletes play sports with pain and risk reinjury.
Particular sports may encourage participation while in pain. Sports characterized by repetitive practice of the same technique are likely to result in injury, if the athlete practices enough to be good at the sport. For example, patellar tendinitis is commonplace in experienced weight-lifters. Accomplished ballet dancers have chronic foot, ankle, leg, and back injuries. These sports stress certain muscle/tendon units and joints repetitively, and overuse injuries often result.
Athletes may be influenced by the significance of the competition. Those who have been training for an important competition, such as playing against a traditional rival or playing for a league, regional, or national title, will attempt to participate before rehabilitation is complete. This was demonstrated at the 1996 Olympic women's team gymnastics finals by Kerri Strug. When athletes, parents, and coaches extrapolate such dramatic, heroic experiences to a local gymnastic meet, then injuries among youth athletes are more likely to occur. The role of the pediatrician includes helping parents, athletes, and coaches understand the natural history of the injury if rehabilitated properly and possible sequelae if the athlete performs with pain. When the athlete's health is at risk, the physician should state clear recommendations regarding exercise and competition. If competition is contraindicated, the physician should advise against participation. If it is not clear whether an athlete should compete, the physician's role is to provide guidelines, not absolute dictums, for return to competition. Attention has been drawn to the training of young female gymnasts and figure skaters.
The charge that these athletes are being injured psychologically has been made in the lay and professional literature.35,36 One report suggests that height velocity is reduced in highly trained gymnasts, yet this study has recruitment bias that limits its value.37 Overtraining of female athletes may include weight loss complicated by development of eating disorders, amenorrhea, and osteopenia.38,39Undoubtedly, overtraining can result in injury. The role of the physician is to recognize the nutritional, musculoskeletal, and psychological signs of overtraining in young athletes and initiate an appropriate diagnostic evaluation and treatment plan. The nutritional signs of overtraining occur when energy expenditure exceeds intake over time. This can occur in any sport in which the early energy expenditure is significant, such as swimming, and is not compensated for by calorie intake. A principal nutritional manifestation is weight loss or failure to gain weight. Other nutritional manifestations overlap with psychological signs of overtraining. These include fatigue, poor performance, reduced attention span, and irritability, and have been related to reduced muscle glycogen levels.40-42 The athlete may complain of feeling “washed out,” “sluggish,” or “stale,” or report persistent muscle soreness that is inconsistent with the physical examination and/or a reduced sense of well-being. The pediatrician should rule out organic disease as a cause of these complaints, such as anemia, infection, or hypothyroidism, and consider overtraining as the etiology when the evaluation proves inconclusive. If organic etiologies are discovered, they should be treated. If the fatigue and staleness are attributable to overtraining, the physician should develop a plan with input from a dietitian for increased carbohydrate intake and reduced training. Coaches may not understand the need for reduced training, creating a dilemma for the athlete. The pediatrician can advocate for the athlete by discussing it with the athlete, family, and coach. The treatment plan may require temporary curtailment or withdrawal from training with the goal of returning to training with potential for enhanced performance. Coaches, unfortunately, may react to this recommendation by demoting the athlete permanently or advising termination from the team, which is inappropriate.
The psychological stress in youth sports can come from many sources.21,43 When the stress and demands of the sport exceed the young athlete's abilities, then sports is no longer fun. Frustration and decreased self-esteem can result. The combination of psychological coping skills, lack of social support, and negative life events are correlated with sports injuries.21
The personal meaning of the sport to the youth and her/his family needs to be explored. Some families build their lives around their children/adolescents sports, and when the youth does not win, it is interpreted as a family catastrophe. This is counter to the philosophy of sports as a fun, self-esteem-building endeavor and predisposes the youth to injury and reduced self-esteem. These athletes will present to physicians with injuries or clinical signs of stress that the physician can recognize and begin to discuss with the athlete, parents, and coaches.
In summary, youth sports are part of American culture and involve millions of children and adolescents. They provide opportunities for socialization and developing coping strategies to deal with challenges and adversity. Unfortunately, three million injuries in children and adolescents occur annually in organized sports in the United States. Pediatricians must be better trained in recognition and treatment of existing injuries and preventing additional injuries. Preseason evaluation is a method of detecting and the opportunity to rehabilitate old injuries. The tracking of injuries is an important role of the sports medicine team, of which the team physician is a vital part. Other strategies to potentially prevent injuries include education about heat-related injuries, medical coverage at sporting events, coaching education, good officiating, and proper equipment. In general, young athletes should not participate if in pain. Finally, excessive pressure to perform well in sports, coupled with poor psychological coping skills and lack of social support, is associated with injury in sports, not to mention stress on the athlete. The pediatrician may be presented with any of these problems. The challenge is to get young athletes back to sports activities for enjoyment, with no increased risk of injury.
Dr Hergenroeder was supported in part by the Maternal and Child Health Bureau, Leadership Education in Adolescent Health Training Grant 1-MCJ-489501-01-0.
- Received July 25, 1997.
- Accepted October 17, 1997.
Reprint requests to (A.C.H.) Adolescent Medicine and Sports Medicine Section, Texas Children's Hospital, 6621 Fannin, 3-3340, Houston, TX 77030-2399.
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- Copyright © 1998 American Academy of Pediatrics