1. 16th FINA World Sports Medicine Congress MANCHESTER 2008 “CHILDREN IN AQUATIC SPORT: a shared clinical responsibility” David Gerrard FACSP Dunedin School of Medicine University of Otago NEW ZEALAND David Gerrard FACSP Dunedin School of Medicine University of Otago NEW ZEALAND

2. OVERVIEWOVERVIEW EXERCISE AND HEALTH ETHICAL DUTY OF CARE TRAINING OVERLOAD GENERAL MEDICAL PROBLEMS MUSCULOSKELETAL DEVELOPMENT ORTHOPAEDIC INJURY EXERCISE AND HEALTH ETHICAL DUTY OF CARE TRAINING OVERLOAD GENERAL MEDICAL PROBLEMS MUSCULOSKELETAL DEVELOPMENT ORTHOPAEDIC INJURY

3. EXERCISE & HEALTH Active lifestyle for children Neuro/musculo/skeletal development Socialisation Skill acquisition Diseases of “stasis” Childhood obesity Type 2 diabetes Legacy in adulthood… Active lifestyle for children Neuro/musculo/skeletal development Socialisation Skill acquisition Diseases of “stasis” Childhood obesity Type 2 diabetes Legacy in adulthood…

4. AQUATIC SPORT CHILDHOOD DEVELOPMENT COORDINATION RESPIRATORY BENEFITS “NON-ASTHMAGENIC” NON-WEIGHT BEARING STRENGTH WATER SAFETY CHILDHOOD DEVELOPMENT COORDINATION RESPIRATORY BENEFITS “NON-ASTHMAGENIC” NON-WEIGHT BEARING STRENGTH WATER SAFETY

5. TRAINING & HEALTH TRAINING & HEALTH OVERTRAINING“STALENESS” FAILING ADAPTATION OVERLOAD OVERTRAINING SYNDROME OVERTRAINING“STALENESS” FAILING ADAPTATION OVERLOAD OVERTRAINING SYNDROME

6. Overreaching, Overtraining,Overexertion: EFFECTS ON PHYSICAL PERFORMANCE

7. “MALADAPTATION”“MALADAPTATION” Exertion : overexertion Reaching : overreaching Training : overtraining Load : overload Work : overwork Use : overuse Exertion : overexertion Reaching : overreaching Training : overtraining Load : overload Work : overwork Use : overuse

8. Pressures on Children in Sport Social Physical Emotional Social Physical Emotional

9. A DUTY OF CARE BIOETHICAL GUIDELINES COMMON PRINCIPLES INFORMED CONSENT AUTONOMYNON-MALIFICENCECOACH/PARENT/PHYSICIANADMINSTRATOR BIOETHICAL GUIDELINES COMMON PRINCIPLES INFORMED CONSENT AUTONOMYNON-MALIFICENCECOACH/PARENT/PHYSICIANADMINSTRATOR

10. RECOMMENDATIONRECOMMENDATION “That the rights of the young swimmer ought to recognise age, competence and sex.”

11. RECOMMENDATIONRECOMMENDATION “That those responsible for the care of the young swimmer respect professional boundaries.”

12. EXISTING ETHICAL CODES

13. OVERVIEWOVERVIEW “That special consideration be given to the social, emotional and physical pressures on children engaged in aquatic sport.”

14. GENERAL MEDICAL ISSUES GENERAL MEDICAL ISSUES CHRONIC VIRAL INFECTION The EARS NOSE & THROAT ASTHMA The SKIN CHRONIC FATIGUE ANAEMIA USE OF MEDICATION CHRONIC VIRAL INFECTION The EARS NOSE & THROAT ASTHMA The SKIN CHRONIC FATIGUE ANAEMIA USE OF MEDICATION

15. “INAPROPRIATE LETHARGY” “INAPROPRIATE LETHARGY” Diagnosis of exclusion in young athlete: Infectious (viral) Pyschological (psycho-social) MetabolicNutritional Diagnosis of exclusion in young athlete: Infectious (viral) Pyschological (psycho-social) MetabolicNutritional

16. CHRONIC VIRAL INFECTION CHRONIC VIRAL INFECTION Eg. Infectious mononucleosis EBV (Epstein-Barr) Undulating clinical course Chronic fatigue/mood change Serological markers ConvalescenceTherapy Clear guidelines to coach/parents Eg. Infectious mononucleosis EBV (Epstein-Barr) Undulating clinical course Chronic fatigue/mood change Serological markers ConvalescenceTherapy Clear guidelines to coach/parents

17. ANAEMIA ANAEMIA Typically females Dietary intake of Fe Lethargy & pallor Serological markers of iron deficiency “Informed” therapy Sound nutritional advice Typically females Dietary intake of Fe Lethargy & pallor Serological markers of iron deficiency “Informed” therapy Sound nutritional advice

18. Paediatric sports trauma “ The immature musculoskeletal system is vulnerable to excessive physical loading and repetitious overuse …”

19. “ Avoid doing too much,too soon, too fast,too often - before it ’ s too late. ” N. Mafulli MD.

20. MUSCULOSKELETAL DEVELOPMENT Bone and soft tissue Asynchronous growth Sites of active growth Potential for stress Overuse trauma Bone and soft tissue Asynchronous growth Sites of active growth Potential for stress Overuse trauma

21. BONE AND SOFT TISSUE Essential stimuli Weight-bearing & NWB A menu of skills Repetitive stressors Essential stimuli Weight-bearing & NWB A menu of skills Repetitive stressors

22. ACTIVE GROWTH SITES Epiphyseal plates Articular cartilage Apophyses Vulnerability to overuse Epiphyseal plates Articular cartilage Apophyses Vulnerability to overuse

23. OVERUSE INJURIES in SWIMMING

24. The SHOULDER in SWIMMING Glenohumeral articulation Multiaxial Functional stability Overuse potential Rotator cuff Impingement Glenohumeral articulation Multiaxial Functional stability Overuse potential Rotator cuff Impingement

25. ROTATOR CUFF “SWIMMER’S SHOULDER”

26. Mechanism of pathology Subacromial impingement Stroke mechanics Muscle “imbalance” Early recognition Mechanism of pathology Subacromial impingement Stroke mechanics Muscle “imbalance” Early recognition

27. LOW BACK PAIN Repetitive hyperextension Focal pain Exclude bone fatigue Gymnastics, dance, volleyball,tennis, cricket fast bowling, butterfly swimming Repetitive hyperextension Focal pain Exclude bone fatigue Gymnastics, dance, volleyball,tennis, cricket fast bowling, butterfly swimming

28. “ BREASTROKER ’ S KNEE ” Medial knee pain Focal site Diagnosis of exclusion Mechanism of “ kick ” Valgus stress Torque “ Egg-Beater ” kick Water polo & synchro Medial knee pain Focal site Diagnosis of exclusion Mechanism of “ kick ” Valgus stress Torque “ Egg-Beater ” kick Water polo & synchro

29. “ BREASTROKER ’ S KNEE ” “ Pes anserinus ” Insertions of: Sartorius Gracilis Semitendinosis Focal area Proximal tibia “ Pes anserinus ” Insertions of: Sartorius Gracilis Semitendinosis Focal area Proximal tibia

30. PRINCIPLES of MANAGEMENT 1.PREVENTION Coaches must recognise the risk for specific injuries in aquatic sport. 1.PREVENTION Coaches must recognise the risk for specific injuries in aquatic sport.

31. PRINCIPLES of MANAGEMENT 2. AWARENESS The unique characteristics of the immature musculoskeletal system & response to the biomechanical stress of aquatic sport. 2. AWARENESS The unique characteristics of the immature musculoskeletal system & response to the biomechanical stress of aquatic sport.

32. PRINCIPLES of MANAGEMENT 3. DIAGNOSIS Emphasis on the accurate diagnosis of musculoskeletal injuries in children. 3. DIAGNOSIS Emphasis on the accurate diagnosis of musculoskeletal injuries in children.

33. SUMMARYSUMMARY The wellbeing of the child athlete must never be compromised by inappropriate sports participation or training. The wellbeing of the child athlete must never be compromised by inappropriate sports participation or training.

34. CHILDRENCHILDREN A precious resource…