Overdoing it

10/19/2009

In today’s age of sports specialization, heavy practice schedules and year-round training, a disturbing number of young athletes are having their seasons chopped short – and their long-term health jeopardized – by overuse injuries.

As more and more youngsters are forced to visit doctor’s offices for everything from bone fractures and Little League elbow to shin splints and damaged knees, the alarm is being sounded loud and clear by sports medicine professionals that too much of the same activity can do more harm than good.

Overuse injuries are sabotaging what should be a fun and rewarding experience for millions of young athletes. These children, who are breaking down due to the constant stress being placed on their young and developing bodies, often face the unenviable prospect of long and sometimes painful rehabilitations, and even surgery, to repair the damage.

“What people need to know is that children are not young adults when it comes to their bodies and sports,” says Dr. John DiFiori, professor and chief of the Division of Sports Medicine at UCLA and team physician for the UCLA Department of Intercollegiate Athletics. “We see a variety of different types of problems in our offices involving tissue, muscles and bones.”

Overuse injuries have emerged as a disturbing trend fueled by several factors: Kids specializing in one sport before puberty; parents blinded by the pursuit of athletic scholarships pushing their children beyond what is acceptable; youngsters participating on travel teams or playing on multiple teams during the same season; negligent coaches pushing youngsters beyond what is acceptable just to win another game; and young athletes simply not giving their bodies any rest between seasons.

“Overuse injuries are extremely common in youth sports,” says Dr. Johnny Benjamin, chairman of the Department of Orthopedic Surgery at the Indian River Medical Center in Vero Beach, Fla. “The dynamics of youth sports have changed over the years. No longer does a talented athlete play all sports and move from one sport to another as the seasons change. Now these child athletes are forced to specialize in a single sport year round and they participate on multiple teams in multiple leagues, many times simultaneously.”
 
VIEW FROM THE SIDELINES
 
The American Academy of Pediatrics estimates that more than 30 million children and teens participate in organized sports each year. Of those, approximately 3.5 million seek treatment for overuse injuries and chronic fatigue from overtraining.

While specific data doesn’t exist regarding the number of overuse injuries occurring in youth sports, there is little debate among the sports medicine community that they are on the rise.

“We do know that there are approximately 30 million children involved in some form of youth sports,” says DiFiori. “We also know more and more of these kids are participating on nearly a year-round basis and in some cases, without question, more of them are participating in a single sport at a young age. In the past some might play a particular sport in the fall and something different in the winter, but now some kids are participating in the same activity in different forms year round. We know the kinds of things that will contribute to the development of overuse injuries and we’re seeing them in our office, no question about that.”

Since the advent of organized youth sports, sitting on the bench while teammates played has never been a lot of fun for children. Yet nowadays, that is where many youngsters find themselves when their bodies simply aren’t developed enough to withstand the wear and tear of a heavy load of games, practices, specialty camps and the never-ending training sessions that they go through.

“The dramatic rise in overuse injuries among children is particularly heartbreaking considering what the doctors told me: That overuse injuries are preventable,” says Regan McMahon, a San Francisco Chronicle reporter who spoke with countless experts in the field while authoring her book Revolution in the Bleachers. “The only conclusion to draw from this is that kids are being hurt unnecessarily. It’s ironic that sports, an endeavor meant to be, at its core, healthy exercise, is in fact hurtful to kids if they are training too hard and constantly.”

The Tommy John ligament surgery, an elbow procedure named after the former Los Angeles Dodgers pitcher who was the first to have it done, used to be performed on pitchers in their 20s – but not any longer. Since the pitching motion is an unnatural one – and with a child throwing too many of them coupled with inadequate rest – it’s not uncommon for kids who haven’t even reached their teenage years to have this surgery done to repair their arms.

Dr. James Andrews, the nationally renowned orthopedic surgeon, says that he is seeing four times as many overuse injuries in youth sports than just five years ago, and that more kids are having surgery for chronic sports injuries, too.

Dr. John Moor, the orthopedic surgeon for the Cincinnati Reds, told the Sarasota Herald-Tribune: “Unless we do things differently, we’re giving these kids life-altering injuries. We’re taking away their ability, as they become adults, to really enjoy the full extent and range of their bodies.”
 
 
RAISING AWARENESS
 
Sometimes overuse injuries can be attributed to parents and coaches putting pressure on the child to excel simply to attain athletic glory, regardless of the health risks.
“Parents, coaches and the commercialization of athletics in general are unfortunately the culprits,” Benjamin says. “The potential perfect storm occurs when a demanding parent, with possibly unrealized personal aspirations, an aggressive coach with their sights set on advancing to the next level and pay for play models – such as traveling teams, sports academies, personal position coaches and clinics – meet.”

Other times, it can be the case of a self-driven youngster simply pushing himself to be the best he can be, unaware of the physical limitations of his young body. Clearly, a fine line exists between a child being dedicated to a sport and forcing themselves to do too much.

“As healthcare educators in sports medicine, we attempt to raise awareness constantly,” says Dr. Jeff Konin, executive director of the Sports Medicine & Athletic Related Trauma (SMART) Institute at the University of South Florida. “The attitude of ‘it won't happen to me’ is prevalent, and the drive to win and compete is contagious, many times being pushed by parents and coaches. Perhaps more public figures speaking out would help, but for them to do so potentially admits fault on their part or their medical team, thus you won't see this often. Perhaps technological education campaigns would be more effective than current print media, such as podcasts or injuries integrated into computer games.”

Some of the major players in youth sports are beginning to take significant steps to address the epidemic. Little League International recently modified its decades-old rules on pitching restrictions. Rather than placing a limit on the number of innings that a child can pitch per week, restrictions are now based on the number of pitches actually thrown. While the switch is definitely a step in the right direction, it does little to address the ones most in danger – youth athletes who play on multiple teams, year-round.

“Limiting pitch counts per game and week – versus previous rules of limiting innings thrown – has certainly assisted with the potential reduction of elbow and shoulder injuries, though no proof actually exists to date,” Konin says. “However, outside of a single league that a child plays in, these rules are extremely stretched. For example, no rules exist for limitations of throwing during practice, and no rule exists that limits a child to playing on one team, so many kids who take the sport seriously play in more than one league, where ‘inter-league monitoring’ does not exist.”
 
COACHING COUNTS
 
Modifying rules in youth sports, like pitching restrictions, will hopefully contribute to alleviating the problem of overuse injuries. But rather than relying on youth sports organizations like Little League to mandate change, coaches can do their part, too. By proactively preventing such unnecessary injuries by making sure that their players are receiving adequate rest, nutrition and are using proper form and technique, many problems can be avoided.

Sometimes, injuries thought to be related to overuse are actually the result of poor mechanics. Teaching young athletes the proper technique for a particular sports skill is not done solely to increase performance, but also to prevent injury. Overuse injuries can sometimes be prevented by using movements that are less taxing on specific body parts.

Although some experts often differentiate overuse-related injuries from injuries caused by improper form, using proper form can decrease the chances of an overuse injury occurring. That is why it is incumbent upon youth sports coaches to not only monitor how often their players are performing a particular skill, but also in what manner they are executing it.

“If mechanics are off, injury will likely occur and if injury occurs from normal biomechanics, then compensatory motions will lead to other injuries,” says Konin in reference to the human body’s natural inclination when injured to rely on non-injured body parts to compensate. For example, if a quarterback attempts to throw a ball while suffering from a leg injury, he will likely attempt to use more arm strength to compensate for the lack of leg strength – thus heightening the chance for an arm injury. Athletes at every level usually are not too anxious to come out of a game, which is why it is the coach’s responsibility to make sure that a child never plays through an injury.

“If you have weak stomach muscles you will overuse the arm,” says Michelle Cappello, sports medicine management coordinator for the Children's Hospital & Research Center in Oakland, Calif. “Sixty percent of the power when throwing comes from the torso and legs.”

Although all sports medicine experts agree that too much volume in any sport is never a good idea, many like Cappello also feel that a lot of today’s overuse injuries can still be prevented with the use of safe and proper techniques.

Cappello oversees the Sports Medicine Center for Young Athletes, a program designed to offer young athletes, coaches, administrators and parents a resource for sports injury care and prevention or, as she describes it, “wellness education.” The program addresses the problem of overuse injuries by proactively teaching proper technique and conditioning methods.

“We have an on-site lecture series for parents, coaches and athletes. We come in and talk about things like swimmers shoulder and ACL injury prevention,” she says. “We can treat these things, but 50 percent of sports-related injuries are completely preventable, although you can make an argument that 100 percent are preventable.”

Some of their seminars are centered on general sports movements, while others like “Tough Cuff” are designed to teach coaches and athletes proper strength and conditioning methods for the rotator cuff. They say that by training all muscle groups involved in the movement patterns of throwing an athlete can severely minimize the risk of injury.

While Cappello is confident that a significant portion of overuse injuries can be avoided with proper education on conditioning and technique, she still warns against overworking a child too much.

“The foundation that we build with these kids is really important with regard to how they perform movement,” she says. “If you can really get the techniques down correctly they’ll strengthen, but also, do they have enough rest built in? You have to look at the volume of exercise that these kids are doing. There is a point where too much volume is too much volume, but there are a lot of variables to it.”

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