The Pediatric Athlete

The Pediatric Athlete

Mininder S. Kocher, MD, MPH

Theodore J. Ganley, MD1

Michael T. Busch, MD1



Pediatric Sports Medicine

Pediatric sports medicine is an emerging subspecialty that is a hot field! It is hot in orthopaedic surgery, with new subspecialty organizations such as PRISM (Pediatric Research in Sports Medicine) and study groups such as ROCK (osteochondritis dissecans), PLUTO (pediatric ACL), and JUPITER (patellofemoral instability). Pediatric sports medicine sessions are now regular occurrences in orthopaedic meetings, including AAOS, POSNA, AOSSM, IPOS, AAP, and AANA. Most children’s hospitals have established sports medicine programs. Orthopaedic trainees interested in pediatric sports medicine are often pursuing dual fellowship training in both pediatric orthopaedics and sports medicine, or they are pursuing a single fellowship that has a large pediatric sports medicine component. A recent review of 14,636 pediatric sports medicine cases submitted by candidates for Part II certification by the American Board of Orthopedic Surgeons from 2004 to 2014 showed a large increase in the number of cases performed by dual pediatric and sports medicine fellows from 2.1% to 21.4% over a 10-year period.1

Pediatric sports medicine is also a hot field for patients and families. More than 30 million children and adolescents are participating in youth sports in the United States. With increased participation in competitive sports at a young age come increasing rates of injury. More than 3.5 million children 14 years old and younger receive treatment annually for youth sports injuries. Children 5 to 14 years old account for 40% of sports-related injuries in emergency rooms. Recent trend in youth sports includes professionalization, early sports specialization, and increasing rates of burnout and dropout. Youth sports has become a big business, estimated as a $17 billion market. Young athletes are specializing in a single sport year-round at early ages.2,3 With increasing competition, pressure, and specialization come increasing rates of burnout. Almost 45% of children aged 6 to 12 played a team sport regularly in 2008, and now only 37% do. And 70% of adolescents are dropping out of sports by age 13. These children and adolescents leaving youth sports may forgo the health and psychosocial benefits of being physically active.

Trouble comes in many forms when caring for the young athlete. Although the conditions are not as grave as tumors, serious infections, and trauma, the acute and overuse injuries that affect the young, active child are very common. Sports medicine, like much of pediatric orthopaedics, is the treatment of low-energy trauma or repetitive microtrauma. Demographic evaluations now show that although the total number of children involved in organized sports decreases as the children get older, the intensity of the competition, and training for that competition, increases—and with it, many injuries.4

Sources of trouble caring for the pediatric athlete are both clinical and psychosocial. The orthopaedic surgeon will have frequent contact with the overzealous sports parents. Managing these interactions is a key to staying out of trouble. NEWSFLASH! These families often have heavily invested both financially and psychosocially in their child’s sports. Often, the parents are living vicariously through the child’s athletic accomplishments or projecting their athletic insecurities on the child (Fig. 14-1). Other times, parents are simply doing what they think is best for their children, and the whole family structure is focused around the children’s sports activities. Parents may have dreams of their child becoming a professional athlete or getting an athletic scholarship to college, even though the odds of this are exceedingly unlikely. Or parents may simply want their child to excel in one dimension, be popular and respected, or get special consideration
for college admission. Just as treating any child with a medical condition, when treating the child athlete, you must consider the whole family. Beware the “crazy sports parents.” These are parents, who have overly invested in the kid’s sports: devastated at injury, pushing to get them back as soon as possible, and always telling you how great an athlete the child is. These crazy sports parents may require an approach that focuses on putting the injury in perspective and the long-term health of the child. And they may require a clinic visit that lasts longer than 15 minutes.

Figure 14-1 The overbearing sports parents.

Regardless, the young athlete themselves is often also very invested in their sport. Often their identity and peer group is tied to their sports. Their psychosocial functioning is closely associated with their identity as an athlete. When injured, they may lose this identity and experience psychosocial stress. They may become distraught or cry when you diagnose them with an anterior cruciate ligament (ACL) tear. As pediatric orthopaedic surgeons who have treated patients with osteosarcoma, cerebral palsy, myelodysplasia, or skeletal dysplasia, it can be hard for us to appreciate the impact that a sports injury can have on a young athlete and their family. Although it may seem minor compared to children with
more severe conditions, we still must realize how real and devastating the news is to them. When giving bad sports injury news such as a torn ACL, it can often be helpful to pause and let the family digest the diagnosis and circle back to them in clinic to discuss treatment and outcome since they may be in “shock” from the initial diagnosis with poor retention of information thereafter. Sometimes, even scheduling another clinic visit later in the week can be helpful. Tell the family that you appreciate what bad news this is for them, but let them know that this is a common injury and emphasize the good prognosis in terms of return to sports. There will be time later in the treatment pathway to lay crepe with discussions of reinjury, graft failure, complications, and long-term arthritis.

Watch for the young athlete who is not coping well from their injury. Initially, many patients and families go through the Kubler-Ross stages of denial, anger, bargaining, depression, and acceptance. However, some patients may experience a true adjustment disorder or major depression that they are unable to cope with. Having had a handful of high-level youth athletes who committed suicide or attempted suicide at some point after their sports injuries, I think it is very important to be proactive and vigilant regarding depression. I let patients know that this injury can have a large psychosocial impact on them. I suggest they talk about how they are feeling, stay connected with their team, redirect their athleticism and training to physical therapy (PT), and focus on the goal of returning to sports. It can be helpful to talk to friends or teammates who have recovered from a similar injury. While it is normal to feel bummed out from being out of sports, if they are having difficulty coping or feeling depressed, then they should seek help. It can be hard to talk to their parents, or teammates, in the limited time we have in the clinic about these issues. We work closely with sports psychologists within our sports medicine program and sports psychologists in the community. Working with a “sports” psychologist has less of a stigma than working with other mental health professionals.

Also be alert for the child athlete who is looking to you or their injury to rescue them from overbearing athletic expectations. They may have played a sport for a long time, but now it is no longer fun or they are not as good as they were. An injury is a “safe” way to drop the sport. This is could be a swimmer with shoulder pain, a gymnast with back pain, or a dancer with patellofemoral pain. They may not be getting better with regular treatment and have negative imaging examinations. Be wary of a pain syndrome, such as chronic regional pain syndrome (CRPS). In fact, many cases of CRPS are diagnosed in the sports medicine clinic.5 But sometimes these are patients trying to leave their sport. Telling them that they need a break from their sport or redirecting to another sport may come as a relief to the athlete and gradual acceptance by the parents. Unfortunately, the higher the level of the athlete, the more difficult such issues are to sort out.

Staying Out of Trouble as a Team Physician

Many sports medicine surgeons and physicians are team physicians. Being a team physician can be an incredible fun and rewarding experience. It can also be a source of stress, pressure, and time sink. I am a team physician for two local high schools, supervise coverage at the Boston Public Schools, am head team physician at a Division 3 college, am the orthopaedic consultant for a Division 1 college, and also cover a number of other events such as the Boston Ballet, the Boston Marathon, USA Track & Field, and the US Ski Team. Being on the sideline at a high school football game, the wings at a ballet performance, or the finish at a ski race allows you to appreciate the athlete in their native environment. It also gives
you a sense of the demands on the athlete and injury mechanisms. Working with athletic trainers at the high school or college level as a well-functioning team is essential. Respect the trainer’s experience and judgment. Let them run out onto the field first and call you over when they need you. Don’t assert your medical credentials as they often know the athlete better than you and may have seen more of a certain injury than you! NEWSFLASH! Being a team physician takes time and energy. The commitment is commensurate with the level of sport. Being a professional team physician sounds glamorous but can be completely time consuming and stressful. As pediatric orthopaedic surgeons, we have unique expertise as high school team physicians and in youth sports leagues. Also look for undercovered sports such as gymnastics, figure skating, running, and dance. These sports may greatly appreciate the attention and can become very devoted to your practice.

Being a capable team physician requires a knowledge base beyond pediatric orthopedics and sports surgery. ORTHOPAEDICS 101: A good team physician has an understanding of concussion, heat-related illness, dehydration, the female athlete, infectious diseases, nutrition, the adaptive athlete, and sports psychology. Look for this in your fellowship training. After training, look to acquire or maintain these skills through team physician courses or becoming involved in organizations such as ACSM and AMSSM.

Remember that youth sports has become a big industry. As a result, you will be faced with questions regarding nutritional supplements, performance enhancement, strength and conditioning training, and specialized equipment. Children don’t need extra nutrients to perform athletically. Supplemental vitamins and minerals for the pediatric athletic are usually expensive and unnecessary. Performance-enhancing substances are a major source of trouble for young athletes.6,7 Chances are very good that if you care for many young athletes, you care for a population that is taking a performance-enhancing substance.6 It has been estimated that 10% to 20% of adolescent athletes (depending on the sport) use some kind of performance-enhancing substance. Although anabolic steroids are the most risky and have received the most attention, creatine, diuretics, amphetamines, and other stimulants can also be problematic.

Children and adolescents are at risk for heat injury and dehydration just as pro athletes are, maybe more so. Children are less efficient at regulating heat because they perspire less when they are hot. Children also make more metabolic heat per body mass than do adults. As a team doctor, you must be proactive in preventing heat injury. You can recommend and enforce a policy that includes mandatory periodic water drinking, cancellation or modification of practice in unsafe weather, and the discouragement of weight loss through water loss (e.g., wrestlers). Helmets should be removed when children are not in contact situations, so heat loss can occur through the head. Daily weights may be done before and after practice to monitor fluid loss.

Sometimes as a team doctor you have to speak up for young athletes who are put in dangerous situations due to limited budgets. You should also insist on proper fitting equipment that is in good repair. Sports equipment and playing fields should be age and size appropriate. Have discussions with the coaches and trainers regarding injury prevention and proper warm-up. Although coaches are loath to give up practice time, emphasizing performance benefits and keeping players on the field can be a convincing argument for warm-up. The medical team should practice simulated cervical spine injury protocols using a backboard and collar. Equipment to remove the facemask of helmets should be readily accessible. Protocols to access emergency medical services (EMS) should be reviewed.

Recent news headlines have exposed team physicians who have sexually assaulted young athletes. Being a team physician means that you are in a position of trust and a position of power. Respecting the moral and ethical obligations of this position is essential. Team physicians should not put themselves in a position where they could be compromised or accused of inappropriate behavior. Examining the athlete should be done with appropriate clothing and ideally with others observing.

Sports Injuries

Many of the acute injuries that occur to the pediatric athlete are fractures covered elsewhere in this text. This section emphasizes the most commonly encountered pediatric athletic injuries, with the focus on staying out of trouble as you help these young athletes return to sports.


Typical shoulder injuries in young athletes include sternoclavicular (SC) joint injuries, clavicle fractures, acromioclavicular (AC) joint injury, glenohumeral instability, and little league shoulder.

Sternoclavicular Joint Injury

SC joint injuries, although still uncommon, are being seen with increased frequency. Posterior SC joint injuries are usually traumatic resulting from a direct blow to the medial clavicle.8 There is deformity and pain at the SC joint. There may be hoarseness, difficulty swallowing, or vascular insult from posterior displacement of the medial clavicle toward the important mediastinal structures of the esophagus, trachea, and large vessels (Fig. 14-2A). Staying out of trouble with SC joint injuries includes not missing the diagnosis. These injuries are notoriously difficult to view on plain X-ray, including the serendipity view. Three-dimensional imaging (CT or MRI) is required to make the diagnosis and to characterize the injury (Fig. 14-2B). Although traditional teaching is that these injuries are usually medial clavicle physeal fractures since the medial clavicle physis closes late, a recent study showed that nearly half of these injuries in adolescents are true joint dislocations.9 Treatment should be urgent and in the operating room with vascular/cardiac surgery backup. Rare cases have been reported of serious blood loss from reduction of a posterior SC joint dislocation. Stay out of trouble and inform your vascular surgeons. Don’t do this case at the surgery center! Closed reduction has been described with abduction of the shoulder in the horizontal plane with a beanbag between the shoulder blades and percutaneous reduction with a towel clamp. Because closed or percutaneous reduction may redislocate or is often unsuccessful, I tend to operate on posterior SC joint dislocations. This involves open reduction, repairing the intra-articular disk if torn, repairing the periosteal
tube, and stabilizing the medial clavicle and sternum with heavy suture. Ligament reconstruction is not typically needed.

Figure 14-2 Axial (A) and sagittal (B) CT scans showing posterior displacement of the right SC joint with impingement on the mediastinal structures. Stay out of trouble by recognizing that this is an injury requiring urgent management. Posterior displacement can result in difficulty breathing, difficulty swallowing, or injury to the major mediastinal vessels.

Anterior SC joint injuries are different than posterior SC joint. Although some are traumatic, many are atraumatic and associated with ligamentous laxity. Some cases are asymptomatic: they have a pop that is not painful, have full motion, and have full function. These can be observed. Cases that are symptomatic will require surgery: open reduction and ligamentous reconstruction. I usually use allograft gracilis tendon through drill holes in the medial clavicle and sternum weaved in a figure-of-8 fashion (Fig. 14-3). Stay out of trouble by drilling carefully in the mediastinum. Chucking up the drill so it can only extend a few millimeters from the tissue protector and connecting the drill holes with an angled curette saves some angst.

Clavicle Fracture

Clavicle fractures are common in sports. Special considerations in athletes include time to return to play and shoulder function. Open reduction internal fixation (ORIF) of displaced clavicle fractures has gained enthusiasm in adolescents extrapolating from treatment trends in adults (Fig. 14-4). However, recent studies have shown similar results in terms of function with nonoperative treatment. Children and younger adolescents have greater remodeling potential. Some sports
parents may push surgical treatment for a sooner return to play. However, in contact sports this may be 6 to 12 weeks with surgery compared with 12 to 16 weeks with nonoperative treatment. Avoid trouble by adopting a shared decision-making approach erring toward nonoperative treatment.

Figure 14-3 A: Open reduction of the SC joint, with forceps on the intra-articular disk. B: Allograft tendon weave through drill holes in the medial clavicle and sternum. C: Completed repair. Stay out of trouble by alerting your thoracic surgery colleagues that you will be operating on the SC joint and need thoracic backup. Don’t be the cavalier surgeon who attempts this procedure at an outpatient surgery center!

Figure 14-4 Displaced clavicle fracture in an adolescent athlete. What would you do? Stay out of trouble by not being dogmatic; not all displaced clavicle fractures in an adolescent need surgery and not all fractures can be managed nonoperatively. This is a great opportunity for shared decision-making with the family and patient.

Acromioclavicular Joint Injuries

Most AC joint injuries in children and adolescents are sprains without substantial displacement (types 1-3) that are treated nonoperatively. Even displaced AC joint injuries (types 4 and 5) in children and early adolescents may be treated nonoperatively. Unlike in adults, the ligaments are rarely disrupted. Instead, the periosteum remains attached to the intact ligaments, allowing excellent healing—sometimes so abundant that the callus is mistaken for a tumor (Fig. 14-5). Avoid trouble by simply watching these injuries recover in most children.

Figure 14-5 This distal clavicle physeal fracture had so much associated bony callus that it presented as a concern for a shoulder tumor. (Courtesy of C. Stanitski, MD.)

Glenohumeral Instability

Shoulder instability is seen frequently in adolescent athletes and can be classified as anterior instability, multidirectional instability (MDI), and posterior instability.10 Anterior instability is usually traumatic and often results in anteroinferior capsulolabral disruption (Bankart lesion). The risk of recurrent dislocation is high in patients 18 years of age and younger, probably over 70%. Fixing the first-time dislocator versus fixing the recurrent dislocator is controversial. A one-size-fits-all approach does not work. I find an MRI helpful to delineate the extent of injury. In the acute setting, an MRI arthrogram is not necessary due to the arthrogram effect of the hemarthrosis. If there is a more extensive labral tear, ALPSA (anterior labral periosteal sleeve avulsion) lesion, HAGL (humeral avulsion of the glenohumeral ligament) lesion, or loose body, then surgery may be indicated initially. I find, however, that most patients can be managed nonoperatively and have surgery if they dislocate again. If the shoulder has dislocated two or three times, the patient and family usually appreciate that the shoulder is dysfunctional preoperatively. If you operate on a first-time dislocator, the shoulder was “normal” to the family before you operated. Stay out of trouble by adopting a shared decision-making process in these cases. Some families are risk averse and want to avoid surgery. Others are more averse to recurrent instability that may take the athlete out of sports and want to have it fixed initially. Also, the timing of the season may impact decision-making. A patient with a dislocated shoulder in the beginning or middle of the football season can often return to sports and have it fixed at the end of the season. I usually do an arthroscopic labral repair and capsulorrhaphy (Fig. 14-6). Open stabilization may be indicated for instability after prior arthroscopic surgery. However, open surgery has potential complications of subscapularis rup ture or losing external rotation. Latarjet coracoid transfer has become very popular in adults and is being performed more frequently in adolescents. Indications for Latarjet include glenoid bone loss, large engaging Hill-Sachs lesion, and “off track” lesions. However, the Latarjet procedure is a larger operation than arthroscopic stabilization and has substantial risks such as nerve injury, nonunion, and stiffness.

MDI is very different from anterior instability. The direction of instability is usually posteriorly and inferiorly. The pathology is usually capsular laxity, not
a labral tear. The typical patient is a ligamentously lax adolescent female. Look for Ehlers-Danlos syndrome and refer to genetics if appropriate. Do a Beighton score. Staying out of trouble means the initial treatment should be PT. Identify shoulder therapists who like to work with these patients as both physical and mental therapist. The shoulder PT for MDI should address strengthening, scapular mechanics, scapular winging, shoulder posture, snapping scapula, and pain control. Beware of the voluntary dislocator with psychiatric overlay. Although I try to avoid surgery in MDI patients, some patients fail PT and have instability that impairs activities of daily living (ADLs). In these patients, shoulder stabilization can be performed by arthroscopic capsulorrhaphy or open capsular shift. I favor open inferior capsular shift in patients with Ehlers-Danlos syndrome or generalized ligamentous laxity as it reduces capsular volume to a greater extent than arthroscopic capsulorrhaphy.11 Be careful of operating in overhead athletes with MDI such as swimmers, throwers, and gymnasts. If their symptoms are with sports but not ADLs, then they may have difficulty returning to sports because of loss of motion and they may be unhappy. If they are having difficulty with ADLs, then I think surgery is reasonable, and I tell them that return to sports is possible but not assured.

Figure 14-6 Arthroscopic anterior labral repair and capsulorrhaphy for recurrent anterior traumatic instability. Anteroinferior labral tear without glenoid bone loss is the most common pathology in recurrent anterior traumatic instability in adolescents. Stay out of trouble by not going overboard with shoulder instability treatment in the adolescent; Latarjet, remplissage, or allograft ligament reconstruction is rarely indicated.

Little League Shoulder

Little league shoulder is widening of the proximal humeral physis from repetitive rotational stress. This is often a cause of chronic shoulder pain in younger pitchers, whereas internal impingement is often the cause of chronic shoulder pain in older adolescent pitchers. Interestingly, proximal humeral physeal changes and acquired increased humeral retroversion is an adaptive change in pitchers to allow for the increased external rotation of the throwing arm seen in adult pitchers. The diagnosis can be made from history, physical examination, and comparison X-rays showing increased widening of the involved arm (Fig. 14-7). The treatment is nonoperative with activity restriction, PT, and pitching mechanics. Stay out of trouble by giving the family a realistic expectation for return to throwing at 4 months instead of 3 to 6 weeks.12 Emphasize PT and pitching mechanics to avoid recurrence. Try to find a biomotion lab that does pitching mechanics, physical therapists who like pitchers, and pitching coaches who understand pitching mechanics and injury.


Medial Epicondyle Fracture

Medial epicondyle fractures can occur in throwing or upper extremity weight-bearing athletes such as gymnasts. In throwers, there may be an antecedent history of medial elbow pain before the acute fracture. Whereas there is controversy regarding operative versus nonoperative treatment of displaced medial epicondyle fractures in a typical pediatric patient, I would recommend surgical fixation for the high-demand elbow athlete such as a baseball or softball thrower, or a gymnast (Fig. 14-8). ORTHOPAEDICS 101: The humeral origin of the UCL originates from the medial epicondyle, so the medial epicondyle must be important. Acute fixation followed by early mobilization typically leads to good results. If treated nonoperatively, this can lead to symptomatic nonunion with pain, valgus instability, and ulnar neuropathy. Fixing an established medial epicondyle nonunion is challenging in terms of scar, protecting the ulnar nerve, and mobilizing the fragment back to its base.13 Thus, staying out of trouble with this fracture in the athlete involves ORIF to avoid symptomatic nonunion.

Figure 14-7 Humeral epiphysiolysis in a 13-year-old pitcher. Mom said that her son was so good that she had him pitching in three different leagues. A, B: Views of the right proximal humerus at presentation. He had significant shoulder pain. There is widening of the physis consistent with proximal humeral epiphysiolysis. C: This lateral image of the proximal humerus after 6 months of rest shows that the physeal appearance has returned to normal.

Figure 14-8 Medial epicondyle displaced fracture in adolescent athlete treated with ORIF (open reduction internal fixation). The management of displaced isolated medial epicondyle fractures is controversial—surgical versus nonsurgical. However, this indication is not. Medial epicondyle fractures associated with elbow dislocation or entrapped within the joint should be fixed!

Little League Elbow

Little league elbow describes injuries about the pediatric throwing elbow related to repetitive valgus loading.14 These injuries include medial injuries from repetitive distraction (medial epicondyle apophysitis), lateral injuries from repetitive compression (OCD [osteochondritis dissecans] of the capitellum), and posterior injuries from repetitive shear (olecranon apophysitis).

Figure 14-9 Sagittal MRI showing loose body associated with OCD of the capitellum. Should you do a simple procedure (scope, removal loose body, microfracture) or a complex procedure (OATS): the decision should be driven by patient factors (upper extremity athlete such as gymnast or baseball pitcher) and lesion factors (large lesions, poor underlying bone, cystic changes in the bone, uncontained lesions without a shoulder).

Medial epicondyle apophysitis is characterized by medial elbow pain, tenderness at the medial epicondyle, and widening of the apophysis on X-ray. Treatment is nonoperative and similar to little league shoulder: stop throwing, PT, pitching mechanics. Staying out of trouble is setting reasonable expectations regarding returning to throwing, usually in 6 to 8 weeks. If the child throws through medial elbow pain, they can sustain a medial epicondyle avulsion fracture (see above). This warning usually gets the families’ attention and facilitates compliance.

OCD of the Capitellum

Repetitive compressive loading of the capitellum can lead to OCD in throwers and gymnasts. OCD involves fragmentation of the subchondral bone with articular cartilage and can lead to instability and a loose fragment (Fig. 14-9). OCD can be suspected on X-rays and MRI is useful for staging the lesion. If detected early with intact articular cartilage, OCD can be treated nonoperatively with cessation of sports. Approximately 40% of lesions will heal in the elbow, which is lower than the knee (60%).15 Lesions that do not heal can be treated with arthroscopic drilling. Later-stage lesions are treated with either fragment removal and microfracture or cartilage resurfacing with OATS (osteochondral autograft transfer system) plugs from the knee. This can be done through a direct anconeus splitting approach in hyperflexion. High-demand athletes such as pitchers and high-level gymnasts may have better results with OATS. Staying out of trouble in OCD of the capitellum means trying to detect the lesions early where treatment is simpler.

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Jan 30, 2021 | Posted by in ORTHOPEDIC | Comments Off on The Pediatric Athlete
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