m inimizing i njury r isk in y oung a thletes neeru jayanthi, m.d. emory university sports medicine...
TRANSCRIPT
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MINIMIZING INJURY RISK IN YOUNG ATHLETES
Neeru Jayanthi, M.D.
Emory University Sports Medicine Center
President International Society for Tennis Medicine and Science
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LOYOLA UNIVERSITY CHICAGO
EMORY SPORTS MEDICINE-ATLANTA
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“EMORY TENNIS MEDICINE”
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YOUTH SPORTS BACKGROUND
Overuse injuries in Young Athletes AMSSM Panel/Writing Group
Collaborative Research with Lurie Children’s (multiple grants)
Consultant (Unpaid): American Academy Pediatrics (AAP)
Council of Sports Medicine Fitness (COSMF)
Aspen Institute (Project Play) Mom’sTeam Institute WTA medical advisory board (Age
Eligibility Rule)
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DISCLOSURE I have been flying around the country and
world for my work with WTA and the Society for Tennis and Medicine Science, and AMSSM and I have had to leave my pregnant wife at home Palm Springs, CA Miami, FL Rome, Italy Sioux Falls, South Dakota
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DISCLOSURE (INCLUDE MILLAN PICTURE)
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OBJECTIVES
To understand how to utilize the evidence to identify at risk training patterns in youth sports
To understand the potential successes and risks of sports specialized training
To understand how to counsel a young athlete on appropriate training recommendations that may reduce their risk of serious overuse injuries
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COUNSELING?
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USA TODAY-SAFE KIDS1.35 MILLION ER VISITS
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Overuse injuries occur due to repetitive submaximal loading of the musculoskeletal system when rest is not adequate to allow for structural adaptation to take place.
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BACKGROUND-OVERUSE INJURIES
American Medical Society of Sports Medicine (AMSSM)
Aspen Institute American Academy of Pediatrics (AAP) National Athletic Training Association (NATA) American College of Sports Medicine (ACSM) American Orthopaedic Society for Sports
Medicine (AOSSM) STOP campaign USA Youth Baseball Safe Kids Campaign Mom’s Team
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“MESSAGING” OVERUSE INJURIES
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WHAT HAPPENED TO YOUTH SPORTS?
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FACES OF YOUTH SPORTS TODAY (INDIVIDUAL STORIES)
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ORGANIZATIONAL AND COMMUNITY EFFORTS
Sports specific National Governing Bodies Youth sports leagues
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DO WE PRACTICE WHAT WE PREACH?
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INJURY MODEL
Injury Model
Predisposed Athlete
Susceptible Athlete
Injured Athlete
Intrinsic factors Extrinsic factors Inciting eventAge Demands of sport Acute injuryInflexibility Equipment Change in volumePrevious injury Conditions Change in mechanics
(Meeuwisse 1994)
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SPECTRUM OF INJURY
Full Participation• Optimum performance
Performance affected• Biomechanical problem• Training load
Time Loss Injury• Training errors• Low/Intermediate risk injuries
High Risk InjuryProlonged absence/surgeryLong-term implications
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TOO MUCH
Picture: http://i257.photobucket.com/albums/hh207/doodmiguel/SumoWrestler.jpg
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EVALUATE RISK There is not enough data correlating training and
risk of development of a higher risk overuse injuries
Volume Sports Specializatio
n
Age and Growth rate
Prior Injury
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EXPOSURE RISK
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RISK FACTORS FOR MEDICAL WITHDRAWALS IN USTA JUNIOR NATIONAL TENNIS TOURNAMENTS
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AGE & MEDICAL WITHDRAWAL INCIDENCE (JAYANTHI N, O’BOYLE J)
7.4
11.7
20.622.7
0
4
8
12
16
20
24
Medical Withdrawal/ 1000 Match Exposures
12's 14's 16's 18'sAGE
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QUANTIFYING INJURY RISK
LEVEL OF RISK
RISK OF ATHLETE RISK OF INJURY
SPORTS PARTICIPATION
HIGH HIGHLY SPECIALIZED HIGH VOLUME >16 hrs/wkHIGH COMPETITION>8 months/yearHRS/WK > AGETRAINING RATIO >2:1PRIOR INJURY (back)RAPID GROWTH
SPONDYLOLYSISSTRESS FRACTURESGROWTH PLATEOCD
RESTRICT
INTERMEDIATE
MOD SPECIALIZEINTERMEDIATE GROWTHINTERMED VOL. <16 hrs/wk6-8 months/yearHRS/WK = AGETRAINING RATIO 2:1
APOPHYSITISAPOPHYSEAL AVULSIONSINSTABILITY
TEMPORARY RESTRICTIONS OR REDUCE
LOW MULTIPLE SPORTSRECREATIONALLOW VOLUME STATIC GROWTHTRAINiNG RATIO 1:1<6 months/year
PATELLOFEMORAL MUSCLE STRAINTENDONITIS
MINIMAL RESTRICTIONS, AS TOLERATED
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SPECTRUM OF RISK
Where on the spectrum is your athlete?
•Diversified•Low volumesLow
•More specialized
•Moderate volumes
Int.•Highly specialized
•High volumes
High
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SPECIFIC ADVISE TO REDUCE RISK?
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PREVENTION
Are overuse injuries more preventable? Volume related Sports specialization (young athletes) Age related Sports specificity Biomechanical load Prior injury Sports specialization TRACK research (interventional counseling)
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NCAA DATA
A more recent NCAA study describes 30% to be overuse and 70% to be acute/traumatic. Football was 8 times more likely to be acute Females twice as likely to be overuse
Yang et al 2012
Sampling problem of the 16 sports (biased towards more traumatic sports)
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BONE STRESS INJURIES
29% of track and field athletes had MRI documented bone stress injury over 5 years
10.8% of all female athletes (mean age 18) had bone stress injuries Significantly increases with FAT risk factors
Nattiv, UCLA
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HIGH SCHOOL DATA
RESULTS: A total of 2834 overuse injuries were reported
during 18 889 141 athletic exposures (15.0 per 100 000 athletic exposures).
Girls had greater rates of overuse injury (18.8) than boys (12.6)
Overuse injuries represented 7.7% of all injuries,
The most frequent site of injury was the lower leg (21.8%).
Injuries most frequently resulted in time loss of less than 1 week (50.0%), with only 7.6% resulting in time loss greater than 3 weeks.
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AMSSM POSITION STATEMENT Approximately 49-53% of injuries in
young athletes are overuse rather then acute.
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2133 charts retrospectively reviewed 53% overuse Female >male (overuse) Female 3 x more PFPS Female 90% hip/thigh overuse Males more contact/collision sports
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YOUNG FEMALE ATHLETESS
Patellofemoral pain Point prevalence 16.3/100 young female athletes
Young female athletes more likely to develop patellofemoral pain if specialized Myer et al.
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SPORTS SPECIALIZED TRAINING
What information would we provide non medical sports community to change this “perceived succcess by specialization”? Do we have evidence about
successes and risks?
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TIGER WOODS
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Study Sport(s) Athletes Evidence for (+): Study conclusions
Begin intense training before
age 12Specialize
before age 12
Begin intense training after
age 12
Diversify early, specialize after
age 12
Hume 199426Rhythmic gymnastics 106 across all levels + +
Amount of gymnastic training during development is related to level of attainment. All gymnasts participated in other sports, with no difference between elites and sub-elites. Enjoyment of gymnastics was strong predictor of attainment.
Law 200731Rhythmic gymnastics
6 elite 6 sub-elite + +
Elites and sub-elites began intense training at similar ages, but elites were involved in fewer other activities from age 4-16, and accumulated more hours training by age 16.
Helsen 199823Men’s' soccer, Men’s' field hockey
33 international 39 national 52 provincial +
Soccer began practicing at age 5, field hockey at age 9. Hours spent in practice were similar among levels until age 12. After age 12, international players spent more time in practice than national players, and national players spent more than provincial players.
Hodges 199625 Wrestling21 elite
21 club-level +
Elite wrestlers spent more time training after age 16 compared to club-level wrestlers. However, since all subjects began intense training at 13.2 + 0.6 yrs, comparison to early intense training (before age 12) not possible.
Soberlak 200344 Men’s' ice hockey 4 elite + +Elite players intensified their deliberate hockey training in late adolescence and played other sports during developmental years
Carlson 198813Men's and women's tennis
10 elite 10 near-elite + + Elite players began intense training and specialized later (after age 13-15) than near-elites (age 11).
Lidor 200232Various men’s' and women’s' sports
63 elite 78 near-elite + +
Elite more likely than near-elite athletes to begin intense training after age 12 and to have played >1 sport during developmental years.
Gullich 200622 Olympic sports
1558 German athletes from Olympic
promotion programs + +Elite athletes began intense training and competition in their sport later than near-elites (11.4 yrs vs 10.2yrs and 13.1 vs 12.0). More elites participated in >1 sport from age 11 than near-elites (64% vs 50%).
Moesch et al. 201139
Sports measured in cms, gms or secs*
148 elite 95 near-elite +
Elite athletes began intense training at a later age compared to near-elites. Near-elites accumulated more hours of training by age 9, 12 and 15 than elites, while elites accumulated more training by age 21 than near-elites.
Baker et al. 20035
Men's and women's field hockey, Men's basketball, Women's netball
15 elite 13 near-elite + +
Elites accumulated more hours of sport-specific practice from age 12 years onwards. However, all subjects began intense training at about age 12, so unable to compare to an early intense training group. Elites had broader range of sports experiences throughout their careers compared to near-elites.
Barynina 19926Men's and women's swimming
Elite Russian swimmers (number not reported) +
Swimmers who began specializing before 11 yrs of age spent less time on national team and retired earlier than later specializers.
Wall 200747 Boys' ice hockey
Parents of 8 minor league players (mean
age 13.9 yrs) and 4 ex-minor league players (mean age 14.5 yrs) +
Dropouts began off-ice training earlier than non-dropouts (11.75 vs 13.8 yrs of age) and spent more hours in off-ice training (107 vs 6.8 per year). Both groups participated in a similar number of other sports (4.75) from 6-13 yrs of age.
*Canoeing/kayak, cycling, orienteering, rowing, sailing, skiing, swimming, track and field, triathalon, weightlifting
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IS 12 THE MAGIC NUMBER?
Higher proportion of injuries in those who quit all other sports before 12
Jayanthi et al.
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WHO SPECIALIZES?
High level goals College? Professional?
Specialized training in higher median incomes >70,000 dollars and with
private insurance Jayanthi et al.
Technical, individual sports
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NCAA STUDIES
Di-Fiori, et al.296 student athletes vs 164 studentsSimilar age of specialization (14-17 y/o)Parent or sibling in competitive sports (p<0.001)Unpublished
Malina et al.376 Div 1 Female athletes17% specialized (highest rates in individual sports)
Jayanthi, et al.318 student athletesMany chose their Univ sport as main sport in elem schoolMany played multiple sports in high school without year round trainingUnpublished
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“TRAINING AND SPORTS SPECIALIZATION RISKS IN JUNIOR ELITE TENNIS PLAYERS,” JAYANTHI, DECHERT, LUKE ET AL.
<10 11 12 13 14 15 16 17 180%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
58%63% 61%
55%
71%
84%79%
88%
95%
Age
Per
cen
t S
pec
iali
zin
g
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“TRAINING AND SPORTS SPECIALIZATION RISKS IN JUNIOR ELITE TENNIS PLAYERS,” JAYANTHI, DECHERT, LUKE ET AL.
• Relationship to injury
• If player specialized, 1.5 x more likely to have reported an injury (p<0.05)
• We do not know true specialization risks in all sports
• Can we separate sports specialization from the volume of training?
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SPORTS PHYSICALS(UNINJURED)
SPORTS INJURY(INJURED)
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AMSSM FOUNDATION GRANTS
AMSSM (American Medical Society for Sports Medicine) (two time recipient)
Foundation Grant to continue this study in Collaboration with Lurie Children’s Memorial Hospital, Chicago, IL
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LONGITIDUNAL COMPONENT
PHASE 1: Ht/wt
UNINJURED
INJURED
PHASE 2: 2-3 year longitudinal phase
UNINJURED
INJURED
UNINJURED
INJURED
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DEFINING SPORTS SPECIALIZATION
Intense Year Round Training in a Single Sport at the exclusion of other sports
Jayanthi et al., DiFiori et al.
Year round training/competition
> 8 months) Choose a main sport Quit all other sports
to focus on one sport
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RATES AND DEGREES OF SPECIALIZATION
38%
34%Jayanthi, et al.
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SPORTS SPECIALIZATION RATES
baseball
basketball
cheerleading
cross country
dance
diving
football
gymnastics
lacrosse
soccer
softball
swimming
tennis
track & field
volleyball
wrestling
Highly specialized
15.42%
20.51%
28.30%
27.62%
25%
38.46%
12.32%
32.97%
26%
26.56%
22.89%
21.50%
47.95%
21.84%
24.18%
12.20%
baseball
basketball
cheerleading
cross country
dance
diving
football
gymnastics
lacrosse
soccer
softball
swimming
tennis
track & field
volleyball
wrestling
Low specialization
50.25%
47.34%
41.51%
43.81%
34.72%
30.77%
50.74%
21.98%
42%
39.06%
45.78%
45.79%
20.55%
44.83%
43.79%
48.78%F
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RESULTS/STATISTICS
1191 athletes (Male 50.7%) Total of 1880 evaluations (35% are
follow up) Baseline
Uninjured 360 (30.1%) Injured 837 (69.9%)
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INJURY TYPE Injury type:
Overuse: 564 injuries (66.4%)
Serious overuse (139/564) or (24.6%)
Traumatic: 286 (33.6%)
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CLINICAL DIAGNOSIS
Injury causes/type (Clinical diagnoses) (confirmed
through EMR) Acute Overuse Serious Overuse
Stress fractures Spondylolysis/Stress Fracture OCD Elbow ucl, etc.
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INJURY LOCATIONS
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APOPHYSITIS/AI (96 CASES)O Growth rates higher
O Training volumes similar
O Developmental issue
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SERIOUS OVERUSE INJURY RISK
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DEGREE OF SPECIALIZATION
Overuse and Serious Overuse injuries more likely with increased specialization
Acute injuries less likely with increased specialization
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TRAINING RULES
Age vs hours Train less hours week
then your age i.e. if 12 year old, train
less then 12 hours week (all physical activity, or just your sport)
16 year old….<16
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SPORTS TRAINING RATIO
Do not exceed 2:1 ratio of organized sports to free play 12 year old
<12 hours/week total <8 hours/week organized sports >4 hours/week free play
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AGE OF SPECIALIZATION
Higher proportion of injured athletes who specialized <12 years old vs > 12 years old
Higher proportion of serious overuse injuries in athletes who specialized <12 years old vs >12 years old.
Unpublished, Jayanthi et al. 2015
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SOCIOECONOMIC FACTORS FOR SPORTS SPECIALIZATION AND INJURY IN YOUNG ATHLETES: A CLINICAL STUDY
Daniel B. Holt, B.S.1, Neeru Jayanthi, M.D.1, Alex Austin, M.D.2, Pasulka Jacqueline, B.A.3, Cynthia LaBella, M.D.3 and Lara Dugas, Ph.D.1,
1. Loyola University Chicago – Stritch School of Medicine, Maywood, IL
2. Cook County-Loyola-Provident Family Medicine Residency Program, Chicago, IL
3. Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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SOCIOECONOMIC STATUS AND SPORTS PARTICIPATION
Low SES Schools Middle SES Schools
High SES Schools0
5
10
15
20
25
30
35
40
Perc
ent
of
Stu
dents
Pla
yin
g
Sport
s
Low SES Schools Middle SES Schools
High SES Schools0
5
10
15
20
25
30
35
40
Perc
ent
of
Stu
dents
Pla
yin
g
Sport
s
Low SES Schools Middle SES Schools
High SES Schools0
5
10
15
20
25
30
35
40
Perc
ent
of
Stu
dents
Pla
yin
g
Sport
s
Low SES Schools Middle SES Schools
High SES Schools0
5
10
15
20
25
30
35
40
Perc
ent
of
Stu
dents
Pla
yin
g
Sport
s
(Colabianchi N, Johnston L, and O’Malley PM, 2012)
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SPECIFIC OBJECTIVE To determine whether the following factors are
associated with a risk of serious overuse injury in a diverse clinical population of young athletes. Insurance status Financial class
Median Income Race
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METHODS Design:
Clinical Cohort Study Population:
Multi-Center (Loyola - Chicago and Lurie Children’s) Sports Medicine and Primary Care Clinics
7-18 year-old young athletes
Injured and Uninjured
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METHODS Demographic information was collected and analyzed:
Public Assistance vs. Private Insurance Public Assistance <
$31,716/year Low, Medium, High
Socioeconomic Status Divided into tertiles based
on median household income by zip code
US Census Bureau: 2007-2011 American Community Survey
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RESULTS Athletes included in study = 1,121
94% of young athletes who initially completed the survey were included
Public Assistance = 19% 33% in Low, Medium, and High SES tertiles
$111,499, $71,440, and $48,895
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RESULTS
Free Play Organized Sports0
2
4
6
8
10
12
7.13
10.35
5.23
10.69
6.00
10.00
5.53
10.55
5.25
11.27
Type of Play vs. SES and Insurance
Public AssistancePrivate InsuranceLow SESMedium SESHigh SES
Hou
rs/W
eek
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RESULTS
Public Assis-tance
Private Insurance
Low SES Medium SES
High SES0.00
0.50
1.00
1.50
2.00
2.50
1.45
2.04
1.671.91
2.15
Sports Training Ratio
Org
an
ized
Pla
y:F
ree P
lay
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RESULTS
Public Assis-tance
Private Insurance
Low SES Medium SES
High SES
7.8
8.9
7.68.6
9.7
Months/year competing Main Sport
Mon
ths/y
ear
com
peti
ng
main
sp
ort
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RESULTS
Spec
ializ
atio
n Rat
e
Serio
us O
veru
se In
jury
0.00
15.00
30.00
45.00
18.1811.11
30.22
16.9918.37
7.84
24.0019.78
41.81
19.86
Effect of SES and Insurance on Spe-cialization Rate and Serious Overuse
Injury
Public AssistancePrivate InsuranceLow SESMedium SESHigh SES
Rate
(%
)
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CONCLUSIONS Young athletes on public assistance may be
protected from serious overuse injury due to: A greater amount of free play and lower sports
training ratio
Young athletes on public assistance and of lower socioeconomic status may be protected from serious overuse injury due: Lower sports specialization rates
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SPORTS SPECIALIZED TRAINING: 2+ YEAR FOLLOW UP: PRELIMINARY RESULTS
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RE-INJURY, REPEAT INJURYGOOD NEWS!! GREAT FOR BUSINESS!!
Re-injury Repeat Injuries
Total Injuries
Responses
6 month 60 38 110 256
12 month 34 27 72 160
18 month 28 31 59 120
24 month 22 15 40 83
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REINJURY
Recurrence: Any type of injury following a previous injury.
Repeat: Same type of injury
45% recurrent/repeat injuries
Jayanthi et al. 2+ year follow up
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HOW DO WE MINIMIZE INJURY RISK?
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EARLY RECOGNITIONEARLY INTERVENTION
Rehabilitative Training volumes/Cessation of sport Biomechanical flaws Identification of high risk overuse
injuries/imaging Late stage lesions
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LATE STAGE LESIONS
Pars Interarticularis 0% healing
OCD Fragmentation/instability
Apophysitis Late stage Chronic Ossicles
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SPORTS-RELATED LOW BACK PAIN Initial Plain xray 48.5% xray negative low
back problems were found to have spondylolysis
Physical exam not helpful
Kobayashi et al, AJSM 2012
MRI MRI with pars sequencing
(lumbar spine)
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PARS STRESS INJURIES Healing rates vary
considerably by stage of spondylolysis
Late stage spondylolysis may have close to 0% bony healing rates
Need early recognition (by patients/parents/coaches/ATPT) in addition to sports medicine physician
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REINJURY
Some successful programs to prevent primary injury ACL
Myer Silvers LaBella
The most success is in the previously injured (effect on risk reduction). Hamstring
Bahr
Serious overuse injuries?
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REHABILITATIVE DEFICITS
Young females with PFPS may predict future ACL risk
Myer et al.
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TRAINING RULES
Age vs hrs Sports training ratio Year round (8 months) Sports specialized training
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SPORTS SPECIFIC RECOMMENDATIONS
Pitch volumes Tennis tournament training guidelines
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SPORTS MEDICINE
If we really want to get more business, we should tell young athletes: Play more hours/week then age Play >2:1 sports training ratio Start specialization before the age of 12 Play an individual sport Be a female? Have a prior injury …we know you will probably need to see us!
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BIOMECHANICAL ASSESSMENTS Courtesy of
Sergio Gomez-Cuesta MSs (App Biomech)
Head of Physiotherapy and Biomechanical Analysis
LTA International High Performance Centre, Gosling Sports Park, UK
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TRAINING, RISK ASSESSMENT, AND COUNSELING IN KIDS (T.R.A.C.K)
May Lower Risk of Serious Overuse Injury By Being less specialized in sports Doing less hours of sports in a
week than your age Increasing Free Play so your Sports
Ratio is NOT >2:1.
Having at least 3 months off a year Having at least 1 day off a week
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ONGOING RESEARCHTRACK (Training Risk
Assessment and Counseling in Kids)
CONTROL N=252One time counseling and
serial risk assessment
INTERVENTION N=252
Serial counseling Risk Assessment
Risk Assessment
Risk Assessment
Risk AssessmentSPORT Counseling
Risk AssessmentSPORT Counseling
Risk AssessmentSPORT Counseling
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TENNIS What age did you start using the Kick
(topspin) serve? How many tournaments per month? How many matches in last 3 months? Any medical withdrawals in last 3 months?
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BASEBALL/SOFTBALL During last 3 months,
have you continued to throw or pitch with arm pain/fatigue during a practice, game or tournament?
How many pitches do you throw in a typical game?
How many months off from pitching?
At what age did you start throwing a breaking ball (curve or slider)?
http://photos2.demandstudios.com/dm-resize/photos.demandstudios.com%2F116%2F16%2Ffotolia_175752_XS.jpg?w=391&h=10000&keep_ratio=1
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BASKETBALL, FOOTBALL, HOCKEY, AND/OR SOCCER
During last 3 months, have you been involved in an ACL injury prevention program or training program aimed at injury prevention?
During the last 3 months, have you continued to play through a practice or competition after suffering a head injury and/or feeling symptoms of light-headedness, dizziness, and/or headaches?
Is your equipment checked by a qualified coach or athletic trainer before each season?
http://www.politicspa.com/wp-content/uploads/2011/08/peewee-football-300x239.jpg
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TRACK-PRELIMINARY DATA
Nearly 400 athletes (2 institutions): Intervention group: 27.7% injured Control group: 45% injured
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MESSAGING FOR OVERUSE INJURIES
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JUST DON’T OVER DO IT.
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Don’t give 110%...you can stop at 100!
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No! Actually, it is more likely from extrinsic modifiable causes such as excess training volume or sports specialization or neuromuscular training.
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THANK YOU!