1. Current Trends in Youth Sports Injuries
Jeff G. Konin, PhD, ATC, PT
Associate Professor & Vice Chair

2. Objectives of This Course
Identify the epidemiology of injuries sustained by children playing sports
Discuss practical injury prevention programs for simple implementation
Identify trends in the use of protective youth sports equipment
Discuss the impact emergency planning has on reducing catastrophic youth sports injuries
Konin Copyright 2009

3. National Center for Sports Safety & Safe Kids USA
Epidemiology of Youth Sports Injuries:
Startling Statistics!
Approximately 20 percent of children and adolescents participating in sports activities are injured each year, and one in four injuries is considered serious.
Children and adolescents who are just beginning a sport or activity are at greater risk for injury.
National Center for Sports Safety & Safe Kids USA
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4. Activity No. of Injuries on 1000s(%)
Rank
5 to 14 years of age
12 to 24 years of age
25 to 44 years of age
>45 years of age 1
Pedal cycling 332 (13.9)
Basketball 440 (20.9)
Basketball 256 (14.7)
Exercising/track 133 (24.1) 2
Basketball 261 (11.0)
Football 28 (13.7)
Pedal Cycling 204 (11.7)
Recreation sport 112 (20.3) 3
Football 243 (10.2)
Exercising/track 172 (8.2)
Exercising/track 198 (11.4)
Water sport 44 (7.9) 4
Playground equipment 219 (9.2)
Soccer 145 (6.9)
Baseball/
softball 182 (10.4)
Skating/skateboarding 29 (5.2) 5
Baseball/softball 185 (7.8)
Recreational sport 102 (4.9)
Recreational sport 146 (8.4)
Pedal cycling 27 (4.9)
Remainder
1,114 (48.0)
958 (45.5)
754 (43.3)
208 (37.6)
Total
2,384 (100.0)
2,104 (100.0)
1,740 (100.0)
553 (100.0)
National health survey 1999
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5. Also tobacco, alcohol, psychological distress
National surveillance for sports injuries among US high school student-athletes, 2003 youth risk behavior survey Hootman, JAT 2006*
N = 15,214, in 2003 (athletes = 53.7%)
High risk dieting behaviors were associated with greater injury rates – fasting, dieting, vomiting
Also tobacco, alcohol, psychological distress
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6. Slowly Creeping Up…………..
1.5 million injuries a year with BMX bikes
2.6 million injuries a year skateboarding
Over 3 million injuries per year in-line skating
65 thousand injuries per year horseback riding
Nearly 68 thousand kids were treated last year for trampoline injuries
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7. Who Manages Youth Injuries?
Parents
Coaches
Friends
Physicians
Physical Therapists
Athletic Trainers
Physical Educators
Others
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8. What role does obesity play in today’s youth sport’s injuries?
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9. Be careful with BMI – people can over or under react!
Here are some celebrities and athletes that the government has deemed "overweight":
Michael Jordan: 6'6": 216 lbs: 25 Bobby Labonte: 5'9": 170 lbs: 25 Karl Malone: 6'9": 259 lbs: 28 Yao Ming: 7'6": 310 lbs: 27 Brad Pitt: 6'0": 203 lbs: 28 Keanu Reeves: 6'1": 223 lbs: 29 Cal Ripken: 6'4": 210 lbs: 27 Nykesha Sales: 6'0": 184 lbs: 25 Will Smith: 6'2": 210 lbs: 27 Bruce Willis: 6'0": 200 lbs: 29
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10. Sports Psychology in Children’s Sports
The mind of a child is highly influenced by the parent and coach!
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11. Abrams, Center for Sports Parenting 2005 “70 percent of kids drop out of sports by age 13, and the main reason is pressure from parents and coaches.”
Bob Bigelow, one of the authors of ``Just Let the Kids Play,'' believes the odds of winning a scholarship are even more remote than many other experts say, estimating that just 1 in 300 high school senior athletes will get a fabled “full ride.''
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12. Unrealistic expectations of parents
In Northern California today:
> There are about 2,000 club soccer teams
> There is a decline in the number of multi-sport athletes as kids specialize in one sport to maximize their scholarship chances.
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13. Cold Hard Facts
The Northeastern University Center for the Study of Sport in Society found that, of black teens, 66 percent believe they will ultimately play pro ball.
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14. Behavioral Response Of Injury The Injury Itself
The stressor, loss of self-control
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15. Behavioral Response to Injury Emotional Responses
Denial
Anger
Frustration
Bargaining
Depression
Acceptance
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16. Educate The Athlete… and the parent!
First – assess parental knowledge in general and current disposition
Explain facts about the injury
Realistic expectations of recovery
Importance of psychological skills as a part of the rehabilitation process
Allow athlete to educate you
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17. Case Study
How would you counsel a 12 year old child and parents referred to you with OSD and wanting to return to playing basketball?
Topics might include: learning what the MD told them, their goals, their realisms, their timeline, what they googled, child’s interests, compliance, motivation, past experiences
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18. Protective Equipment:
Rules, benefits, considerations & knowledge

19. Purposes of Protective Equipment
1. Dispose & absorb forces
2. Limit anatomical movement
3. Support joint structures
4. Support musculotendinous structures
5. Enhance proprioceptive feedback
6. Secure protective pads
Source: JG Konin et al, in The Athlete’s Shoulder, 2nd Ed, 2009
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20. Protective Equipment Guide
Does the equipment protect the area of concern appropriately?
Can the athlete perform the skills required for his/her sport and position while wearing the device?
Will the device maintain proper anatomical alignment?
Is the device potentially hazardous or injurious to other participants?
Is the device legal by the rules and regulations of the sport?
Source: JG Konin et al, in The Athlete’s Shoulder, 2nd Ed, 2009
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21. Commotio Cordis: Incidence by Sport
Blunt trauma during 20mSec window, VFib
15% survive commotio cordis events
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22. Commotio Cordis Optimal Management
Chest protectors, softer balls, etc have all been proposed
Consensus is be prepared with an AED!
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23. Mouth Guards Stock, mouth formed, and custom-fitted
Required for lacrosse, ice hockey, football, field hockey
Recommended for basketball & soccer
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24. Concussions in Children
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25. Mechanisms of Injury Concussion Cumulative effect!!!!!!!!!!!!!
Acceleration-deceleration forces result in shearing forces which distort the vascular and neutral elements of the brain – chemical cascade
Cumulative effect!!!!!!!!!!!!!
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26. S & S of Concussion Physical Symptoms Headache Vision difficulty
Nausea
Dizziness
Balance Difficulties
Light sensitivity
Fatigue
Emotionality Symptoms
Irritability
Sadness
Nervousness
Sleep disturbances
Cognitive
Memory loss
Attention disorder
Reasoning difficulty
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27. Post-concussion Syndrome (PCS)
Vary in symptoms & length of presence
Always have medical professional assess and determine safety for clearance
Do not go by athlete comments alone
Beware of physician shopping
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28. Various Scales Used to Grade Concussions
Grade 1 (mild)
Transient symptoms; no LOC; symptoms and mental status abnormalities resolve within minutes
Grade 2 (moderate)
Transient symptoms; no LOC; symptoms and mental status abnormalities last longer than minutes
Grade 3 (severe)
Any LOC

29. Source: JAT 2004 Position Statement
People working with younger (pediatric) athletes should be aware that recovery may take longer than in older athletes. Additionally, these younger athletes are maturing at a relatively fast rate and will likely require more frequent updates of baseline measures compared with older athletes.
Source: JAT 2004 Position Statement
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30. Source: JAT 2004 Position Statement
Because damage to the maturing brain of a young athlete can be catastrophic (ie, almost all reported cases of second-impact syndrome are in young athletes), athletes under age 18 years should be managed more conservatively, using stricter RTP guidelines than those used to manage concussion in the more mature athlete.
Source: JAT 2004 Position Statement
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31. Source: JAT 2004 Position Statement
F/U Guidelines
Avoid meds – only acetaminophen from MD
Avoid ingesting alcohol, illicit drugs, or other substances
Instructed to rest, but complete bed rest is not recommended
Eat a well-balanced diet that is nutritious in both quality and quantity
An athlete should be awakened during the night to check on deteriorating signs and symptoms only if he or she experienced LOC, had prolonged periods of amnesia, or was still experiencing significant symptoms at bedtime
Source: JAT 2004 Position Statement
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32. Prospective randomized experimental study
Recovery patterns of athletes reporting posttraumatic headache following sports-related concussion Register et al, JAT 2006*
Prospective randomized experimental study
375 concussed high school and collegiate athletes average age /- 1.87
Self-reported graded symptom checklist (GSC)
Days 1,3, & 7 post injury data collection
Conclusion: young athletes reporting PTH following a concussion endorse a higher number of symptoms and demonstrate decreases in neurocognitive performance when compared to those not reporting PTH
Thus, headache is a sign of incomplete recovery
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33. Concussion Gender Differences in Youth Divine et al 2007 MSSE*
Female athletes have higher severity o symptoms and longer recovery rates
This was only seen when comparing non-helmeted athletes
Unsure of reasons why
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34. Concussion Management
What would you say is the most practical and affordable method of decision-making following a concussion for those settings without large budgets and personnel resources?
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35. Younger Athletes Slower to Recover from Concussions, Studies Show
posted 02/02/09 5:45 pm
                            
ROCKVILLE, Md. - Every year more than 300,000 people report getting concussions from sports. But experts say millions more likely go undiagnosed. And while we see professional athletes like Super Bowl quarterback Ben Roethlisberger bounce back, for kids and teenagers it can be a long road to recovery.
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36. Rotator Cuff and Periscapular Muscle Strength in Adolescent Male Baseball Players Kelp-Lenane et al. JOSPT 2008*
Assessed strength relationship for y/o male baseball pitchers – Tanner 2 or 3, pitching for 2 years, no pain
PS muscles were significantly weaker than RC muscles in dominant and non-dominant of all subjects
Strength differences do not appear to be a result of pitching – are we doing the right thing in rehab?
Rotator Cuff and Periscapular Muscle Strength in Adolescent Male Baseball Players Kelp-Lenane et al. JOSPT 2008*
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37. Shoulder Injuries
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38. AC Joint Sprain Downward force on the acromion process
Must be strong enough to displace AC ligament
With excessive force, can eventually displace CC ligaments (Conoid & Trapezoid)
Debate as to the exact grading criteria, not important – functional limitations are!
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39. Acromioclavicular Joint Disorder
X-rays to determine grade
G I-II sling, pain relief 5-7 days
G III non-op unless cosmetic concerns -Weightlifters
-Bathing suit appearance
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40. Surrounding awareness
Rationale:
Acute comfort
Surrounding awareness
Theoretically approximates a joint that will not heal on its own – therefore it provides comfort with partial tears
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41. Clinical Pathway for AC Sprain
Control pain, usually minimal inflammation
Avoid distraction activity
Progress with functional exercises as tolerated
Expect pain for a long time!
Resultant instability not common regardless of profession/career/sport
Bottom Line: Let pain & function dictate:
don’t “over treat” or “over advise”
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42. Will shoulder braces work? Functional?
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43. Elbow Injuries
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44. Little League Elbow Medial epicondylitis and adolescents
8-10 y/o ~ bone weakest component
15-18 y/o ~ muscle/tendon/tissue weakest component
Mid 20s and up ~ muscle and/or ligament weakest component
Age tells you what structure is involved
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45. What is your comfort level in advising with respect to preventing throwing injuries for little league baseball pitchers?
9-10 years
11-12 years
13-14 years
Pitches per game 50 75
Pitches per week
100
125
Pitches per season
1000
Pitches per year
2000
3000
Proof??????????
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46. Preventing Injuries in Throwers with the Core and Hips
LE Flexibility (Used as part of an overall warm-up)
Ipsilateral hip extension
Hip IR/ER (Lack of IR will force truck to open early and increase stress on medial
Elbow and /or anterior shoulder)
Core Training for Throwers
Abdominal Bracing /Drawing in maneuver
Prone Cobra Progression
LE Balance/Proprioception*
Standing Pulls - ant/post/lat pull (Weak gluts cause the hip to drop leading to drop of shoulder)
LE Functional Strength Training**
Wind-Up/Lunge with twist
Lunge with twist
Step-Ups with twist
*Functional exercise that is multiplanar, incorporates the lumbo-pelvic-hip core
complex and can be challenged with proprioceptive input from unstable surfaces,
eyes closed, etc
** Lunge strength will help deceleration injuries to the shoulder
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47. Serape Effect
Konin et al ATT 2003
Deficits in measurable active & passive hip extension, active hip flexion with pain (Kouvalchouk Rev Chir Orthop 1998)
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48. Epicondylitis Considerations
Strings too loose
Grip too large
Poor technique
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49. Wrist Ligament Sprains
“It is only a sprain”
Avoid Grip Strength Activity!
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50. Jersey Finger Pulling against fixed object Lifting with tips of finger
Laceration
Crush Injury
Amputation
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51. Mallet Finger
* Usually a result of blunt trauma
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52. Muscle Strains Quadriceps & Hamstring Update
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53. Treatment of Hamstring Strains
THE RISK FACTORS: Muscle weakness, decrease muscle flexibility, lack of proper warm-up, fatigue, improper flexor/extensor strength ratio, increasing age, menstrual disturbances, previous injury
Can we prevent ALL of these?
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54. To Stretch Or Not To Stretch
Systematic search articles, of which 14 used a control group.
Five suggested prevention, six suggested no difference but three suggested increased injury. The positive studies had warm-up as a co-intervention.
Shrier I, Clin J Sports Med 1999, EBSM 2002
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55. Wenos & Konin J Strength Cond Res. 2004
Controlled warm-up intensity enhances hip range of motion.
In a field setting, it is estimated that a warm-up of 70% of HRR would duplicate the muscle readiness equivalent to an RER of 1.00 before PNF stretching.
Equivalent to 4 minutes of a light aerobic activity
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56. The Impact of Stretching on Sports Injury
Stretching before or after exercise is not associated with a reduction in total injuries
Produces small, statistically non-significant reductions in muscle soreness
5th day post injury tendon exhibits weakest tensile strength (right about the time one starts to “feel better”), then progressively gets stronger each day
Thacker et al, Med Sci Sports Exer 2004, Herbert & Gabriel, BMJ 2002
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57. The Child’s Knee
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58. Ligament Injuries - ACL
 200,000 new ACL injuries per year
History
Majority are non-contact injury with knee in extension (70%)
Hemarthrosis within a few hours
Audible pop in 50%
More common in females - risk is at least 5X higher among women than men and the gender difference is even higher at the elite levels
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59. Kramer et al JAT 2006, Lie et al 1997, Smith et al 1993
Factors associated with anterior cruciate ligament injury history in female athletes
Increased generalized laxity
Decreased ITB flexibility
Previous ankle injury
Menstrual cycle changes
A decreased protective role of dynamic knee stabilizers (quadriceps and hamstrings)
A diminished ability to resist anterior shear with muscle contraction.
A smaller ACL than men
A narrower intercondylar notch than men
Wider Q-angle
Wider hips/pelvis
Increased foot pronation
Kramer et al JAT 2006, Lie et al 1997, Smith et al 1993
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60. Neuromuscular Training May Assist in Preventing ACL Injuries
3/6 studies reduced ACL injury in females
Question of consistencies, cost & time of implementation, compliance issues
Some evidence that proprioceptive and balance exercises improve outcomes in individuals with ACL-deficient knees
Improvements in joint position sense, muscle strength, perceived knee joint function, and hop testing were reported post intervention
No adverse effects with intervention
Too few studies to safely confirm
Hewett et al, AM J Sports Med, 2005 Cooper et al, Res Sports Med 2005, Engebretson and Bahr BJSM 2005, Hammill et al JAT 2006
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61. ACL Injuries in Children
ACL deficiency in the skeletally immature has resulted in a high incidence of secondary meniscal injuries, degenerative joint disease, and symptomatic instability in both sports and daily activities.
Skeletally immature athletes are in fact much less likely to limit their activities and adapt to ACL insufficiency than skeletally mature counterparts.
Graf et al 1992, Mizuta et al 1995, McCarroll et al 1994
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62. ACL Prevention Programs
PEP Program
Dr Mandelbaum et al. Santa Monica
aclprevent.com
No cost
SportsmetricsTM
Dr. Noyes et al Cincinnati Sports Medicine
sportsmetrics.net
Fees & certification
The 11
Developed by FIFA F-MARC (Medical Research Centre)
fifa.com/aboutfifa/developing/medical/the11/index.html
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63. ACL Prevention Program
We use PEP (Prevent Injury Enhance Performance)
Highly specific 15-minute training session that replaces/compliments the traditional warm-up 2-3x weekly
The Goals of the Program are to:
1) Avoid vulnerable positions 2) Increase flexibility 3) Increase strength 4) Include plyometric exercises into the training program 5) Increase proprioception though agilities
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64. Konin Copyright 2009

65. Appear to play a role – may always be in question
What About Knee Braces?
The “Breaking Point”
Appear to play a role – may always be in question
7mm
12mm
15mm
5mm
Pietrosimone et al JAT 2006, Naiibi & Albright Am J Sports Med 2005, McDevitt et al Am J Sports Med 2004
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66. How Common are Ankle Injuries?
Most common sports injury
85% of ankle injuries are sprains
85% of sprains involve lateral ligaments
20% - 40% lead to chronic symptoms
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67. What Do You Need To Know About Ankle Sprains?
Most common risk is previous ankle sprain
Supervised rehabilitation with proprioception intervention reduce risks of repeat
Balance training improves sensorimotor control in athletes with previous injury
Effect seems to be limited to those with previous injury, where postural control, position sense and postural reflexes are reduced
Appropriately applied brace or tape does not hinder performance
Taping or bracing can reduce incidence for recurrence of ankle sprains in athletes with previous ankle problems
Unclear if high top shoes reduce the risk of injury
Thacker et al, AM J Sports Med 1999, Bahr R. EBSM 2002
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68. High Ankle Sprain (SYNDESMOTIC)
Tib-Fib Sprain (anterior/posterior)
Mechanism of injury is fixation and rotation
Treatment is difficult due to lack of good support for this area internally & externally
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69. Managing The High Ankle Sprain
Be patient!
Tell the athlete to be patient!
Tell the parents to be patient!
Tell the coach to be patient!
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70. Failing to Plan = Planning to Fail
Emergency Action Planning
Build from existing templates & models
Follow nationally and regionally accepted standards of policies & procedures
Identify key steps – don’t guess
What key components should be included?
Who are the stake holders?
What expenses might exist?
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71. Field Safety Uneven playing surfaces
Surfaces with greater than normal friction, ie old hardwood courts
Slippery playing surfaces, fields with puddles
Improper illuminated lighting for night events
Irrigation systems not completely buried
Baseball dugouts without proper protection from hit balls
Fences and that surround fields with protruding parts
Goalposts and other fixed apparatus that are not properly protected with padding
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