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Hip Injuries in Young Athletes

Hip Injuries in Young Athletes

by | Mar 31, 2021 | Sports Medicine

Pediatric orthopedic surgeon and associate director of clinical research, Henry B. Ellis, M.D., presented this as part of Coffee, Kids and Sports Medicine education series.

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Ellis provided a detailed discussion of the history and physical exam of young athletes with hip complaints to distinguish between common and less common hip conditions. Young athletes require a different approach than an adult athlete. Numerous conditions present more often, or only, in a younger patient compared to an adult. These include slipped capital femoral epiphysis (SCFE), adolescent hip dysplasia, epiphyseal dysplasia, apophysitis, stress fractures and more.

The ball and socket joint allows motion in all planes. For some young athletes, the soft tissue is particularly flexible which can increase the risk for injuries. A review of the anterior-posterior (AP) pelvis X-ray in a growing child provides an excellent overview of the pertinent anatomy in the growing pelvis and hips. There are physes, growth centers, that are present early and active through adolescence. Pelvis and hip growth centers include:

  • Acetabular physis (triradiate cartilage)
  • Proximal femoral physis
  • Greater trochanter apophysis
  • Ischial tuberosity
  • Anterior superior iliac spine

Five Key Tips for Evaluating the Youth Athlete’s Hip

  • History can help focus the exam.
  • Always examine both sides.
  • Adequately expose the area of interest while maintaining modesty.
  • Look beyond the hip.
  • Consider chaperone or an assistant in the room with hip exam.

Ellis says his detailed hip exam will last about 15-20 minutes. To provide an overview, he demonstrated a “three-minute hip exam” before he provided a detailed explanation of each step discussing associated conditions with each step.

Tests for recognizing signs of concerning conditions: 

  • Passive hip flexion that causes obligate (automatic) external rotation is indicative of SCFE and requires a prompt referral to minimize sequelae.
  • Dial test/passive circumduction with the hip joint relaxed. The provocation of pain indicates intra-articular problems such as synovitis or infection.
  • Hip flexion (90+ degrees) with adduction and internal rotation that causes pain is a sensitive screening tool for labral pathology.
  • Hip apprehension sign is positive when hip abduction and external rotation in side-lying causes apprehension and indicates a need for additional assessment for hip dysplasia.

In conclusion, Ellis provided some take-home messages for the audience.

  • A good clinical exam will often lead you to the diagnosis.
  • AP and frog pelvis X-ray is appropriate to evaluate for hip problems.
  • 80% of hip injuries are soft tissue strains that can be treated with rest, early range of motion and gradual return to sports when pain improves.
  • Some hip conditions require a MR arthrogram, so avoid an MRI of the hip until evaluated by a specialist, unless a stress fracture or other concerning diagnosis is suspected.

Ellis never disappoints an audience. As the first event after a break from our livestream events, we received these wonderful comments from attendees:

  • “So great to be here again!”
  • “Thank you for a well put together and thorough presentation. Also, I appreciate the handouts.”

Check out our latest on-demand lectures available for medical professionals.

Recognizing Athletes With Disordered Eating

Recognizing Athletes With Disordered Eating

by | Mar 29, 2021 | Sports Medicine

A pediatric sports medicine physician and member of the Female and Male Athlete Triad Coalition, Jane S. Chung, M.D., shares the latest in energy availability and the consequences of under fueling for young athletes.

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Sports can place high demands on growing bodies and athletes need their medical team to identify signs of unintentional or intentional disordered eating.

The traditional model of female athlete triad has evolved in recent years and now acknowledges that males also experience the triad. Osteoporosis, amenorrhea and eating disorders are pathologies that can occur at the extreme end, but the triad is now thought to be in a spectrum of optimal health to disease. In this model, the three components of bone density, menstrual function and energy availability are connected to each other. With this new approach, signs and symptoms are being identified earlier and even prevented.

The triad was known to be caused by the interrelationship of eating, hormone balance and bone health. Sadly, the condition was associated with “eating disorders” and assumptions were made that athletes may be intentionally causing these problems. Though this is still the case in some sports where figure and appearance are highly valued, the newer model of the triad is designed to address all types of “disordered eating.” This can include restrictive eating by “picky eaters” or simply those athletes who are too busy to consume adequate calories.

Energy availability is a more relevant term that accounts for the needs of the individual athlete, the sport and the training schedule. An athlete must fuel, or eat, according to these aspects. When the intake meets the demand, the energy balance is neutral. With a neutral energy balance, the young athlete can stay healthy and build strength, grow taller, compete at his or her optimal performance and minimize unwanted weight gain or loss. With a more sport and performance- centric conversation, athletes may be more willing to discuss their eating habits.

Here are some questions to ask your patients and some thoughts on how to respond to their answers:

ASK YES NO
Do you eat three meals a day plus snacks? Great, be sure to include three food groups in each meal and two food groups in each snack. Eating throughout the day and prior to activity is the best way to ensure your body gets the energy it needs and uses all of the nutrients the right way. Fueling with protein post work-out, practices/games is important to help with muscle healing and recovery.
Do you adjust your eating quality and quantity based on your training schedule? Good. Do you have someone to talk to about how you make those choices? Your body has different energy needs based on the activity you are doing. Begin to pay attention to feeling full or tired during activity to know if you need to adjust your plan.
Do you eat a rainbow of foods on every plate? Great. Eating a variety of foods ensures you get the nutrients you need for your bones to grow, and for your body to become faster and stronger with your training. Without variety in your foods, you may be missing important nutrients that strengthen and help your bones grow.
Do you have a daily goal of water intake? Is your daily goal close to ?? oz.? [calculate ½ body weight in kg] Be sure to choose water and start working toward a daily goal.

Chung participates in national study groups on the subject and has other clinical and research interests including:

  • Stress fractures and other consequences of under fueling for sports
  • Sleep in young athletes
  • Concussion recovery

Check out our latest resources for medical professionals. 

Keeping Up with the Count: When Has She Rehearsed Enough?

Keeping Up with the Count: When Has She Rehearsed Enough?

by | Mar 4, 2021 | Sports Medicine

In youth sports, this message is clear – excessive training puts an athlete at risk for injury. Young dancers may or may not be comfortable comparing their training to that of other “athletes,” but the concern for their safety is similar. Scottish Rite for Children physical therapist, Julia Buckelew, P.T., D.P.T., O.C.S., works with many dancers in our sports medicine practice and hopes to reach others with this message.

Overtraining occurs when there is a high intensity or a high volume of training and performance declines. Overtraining is often associated with overuse injuries and burnout when the dancer no longer enjoys the activity. The year-round nature of dancing creates a culture and environment that, without deliberate efforts to avoid, lead to these conditions. Company auditions, numerous classes, rigorous pre-show rehearsals and summer intensives can run-down a dancer.

What are signs of overtraining?

  • General fatigue felt throughout the day despite amount of sleep.
  • Extended time needed to recover from post-exercise soreness.
  • Reduced performance/technical skill despite normal or increased training hours.
  • Difficulty concentrating.
  • Increased risk of injury.

How can a dancer avoid overtraining?

  • Shift attention to the quality of training over the quantity of training.
  • Apply common time management techniques to plan rest and cross training.
  • Implement training periodization by recognizing performance cycles.
  • Learn about sleep hygiene to improve sleep quality.
  • Learn the value of mental imagery for rehearsal to allow the body to rest.
  • Increase self-awareness about beliefs and behaviors that motivate.

Thoughts on Perfectionistic Dancers
Scottish Rite pediatric psychologist Emily Stapleton, Psy.D., says, “Perfectionistic dancers tend to be ambitious, determined and driven for success in their performance. Unfortunately, these traits that make them successful also increase their likelihood of overtraining.”

These athletes tend to focus on results and have potentially harmful motivations including:

  • Desire to avoid making mistakes.
  • Fear of failure.
  • Fear of negative evaluation by others.
  • Meeting parent or coach’s expectations.

These tendencies can cause significant frustration, low self-esteem and self-doubt when they are not meeting their expectations or the expectations of others (e.g., parent, coach). This leads to the drive to learn new moves, perfect a routine and difficulty taking a break from training. Since they feel training is never complete, they self-select into an inappropriately high-training load. The cumulative effects of endless run-throughs, long hours of rehearsal and impact and stresses from repetitive movements may lead to injuries, exhaustion and reduced quality in performance. 

Stapleton says, “Research has shown that when these athletes direct their perfectionistic behaviors toward progress-oriented goals, rather than focusing solely on results or performance, some of the risks of overtraining are mitigated.” Athletes can do this by implementing cognitive-behavioral strategies including:

  • Appropriate goal setting.
  • Redefining their definition of success in sport.
  • Using positive self-talk.

Emily Stapleton, Psy.D., and Julia Buckelew, P.T., D.P.T., O.C.S., contribute to the article series, Keeping Up with the Count. A collection of tips and information for dancers from a multidisciplinary dance medicine team. They recognize the needs for these highly specialized athletes and aim to help reduce the risk of injuries in this population.

Apophysitis of the Hip or Pelvis

Apophysitis of the Hip or Pelvis

by | Mar 1, 2021 | Sports Medicine

The professionalization of youth sports has led to an epidemic of overtraining. With that comes an increase in injuries caused by overuse. Unlike injuries from overuse in adults, like carpal tunnel syndrome, pediatric overuse injuries occur at areas of the bones called growth centers. These areas are vulnerable to injuries. Pediatric orthopedic surgeon Henry B. Ellis, M.D., says, “Rest and activity modification is crucial for these conditions.”
With an interest in studying and treating conditions in the hip in athletes, Ellis informs families that other treatments are unlikely to work if the aggravating activity continues. He encourages athletes to listen to their bodies and learn to properly stretch and to speak up if there is activity-related pain.

What is apophysitis of the hip or pelvis? 

Tenderness in specific bony areas of the hip and pelvis is called apophysitis. This typically occurs in adolescents ages 10- 19 who have “tight” hip and thigh muscles.

What causes apophysitis in hip or pelvis?

Muscles of the hip attach on the pelvis and upper leg bones. In growing children, several tendons attach to apophyses (growth plates). On the pelvis, these include the iliac crest apophysis and the ischial tuberosity apophysis and on the hip, the greater trochanter apophysis. These areas are made up of soft cells called cartilage. These weaker cells are at a higher risk of injury.

The most common cause of the pain is repeated pulling of the tendons on the apophysis causes apophysitis (painful inflammation). This commonly occurs during periods of rapid growth or increased activity. Overuse in these areas occur in activities such as dance, gymnastics and those that include running and sprinting.

What are the symptoms of apophysitis?

Apophysitis causes pain or tenderness at the muscle attachment that worsens with activities such as sports or running. Some experience swelling, others feel or hear a pop or snap.

How is it diagnosed?

A thorough history and physical examination are used to diagnose apophysitis. In some cases, X-rays may be ordered to evaluate the growth plate and rule out other issues.

How is it treated?

This is a self-limiting condition where rest is recommended, but kids may participate in activities that do not cause painful symptoms. Treatment includes modifying activities and providing comfort as needed. Learning to properly stretch and strengthen the muscles attached to the apophysis will reduce the tension.

A gradual return to sports is recommended when pain is improved. Symptoms will resolve with completion of growth in this area. In time, stronger bone cells replace the soft cartilage cells, but pain may come and go for months to years. If symptoms persist and cannot be managed with rest, it is important to see a medical provider with experience treating growth plate conditions in young athletes. Physical therapy may be recommended.

Physical therapy for apophysitis

Since the condition requires rest and removal of aggravating factors, more exercise is not an appropriate solution. After a formal evaluation, a physical therapist will provide a custom exercise plan to promote improvements in lengthening of tight muscles and tissues, strengthening of weak muscles and alignment of the body during movement and functional tasks. In many cases, core conditioning, strengthening of the abdominals and other trunk muscles, is a foundational component of treatment.

How can apophysitis of the hip/pelvis be prevented?

  • Apophysitis of the hip/pelvis may be difficult to prevent.
  • Proper warm-up and stretching exercises will reduce the stress on the apophysis.
  • Limit or vary physical activities to avoid overtraining and overuse.
  • Rest when sore or having pain.

Watch Ellis describe this condition in a series for pediatricians and primary care providers on our YouTube playlist for medical professionals.

More Than Checking the Box: Effective Pre-Participation Physical Evaluations Help Young Athletes

More Than Checking the Box: Effective Pre-Participation Physical Evaluations Help Young Athletes

by | Feb 26, 2021 | Sports Medicine

Often buried in a long to-do list, the sports pre-participation evaluation (PPE) is something that deserves our full attention. The intent of the annual, required physical is to address concerns before they are a surprise in an athletic environment. Some screening is designed to pick up more concerning issues than others, but an effective evaluation has the potential to protect a young athlete’s playing time and set them up for optimal performance.

Sports medicine physician Jacob C. Jones, M.D., RMSK, says, “It’s really not meant to be about the permission to participate, it’s meant to reduce the risk of emergencies. When implemented properly, the PPE is effective at identifying the most critical issues.” Jones describes the value of the PPE that helps the athlete on and off the field.

Annual Visit with the Primary Care Provider
Some young athletes may only see their primary care provider for this required activity. This gives the provider an opportunity to address issues beyond safe sports participation, such as developmental and mental health screening, wellness guidance, and education on age-specific topics like menstruation and substance abuse.

Awareness of Family Medical History
A family history of cardiac issues, diabetes, sickle cell trait and other conditions may not be discussed in families if not prompted by a screening tool like the PPE. Improved awareness of family history can help individuals and families make positive changes to reduce the risks of modifiable conditions. Learn how to discuss your family’s medical history before a PPE. 

Reduced Time Out of Sport for Injuries
The musculoskeletal screening portion of the PPE is a quick assessment of the strength and function of the trunk, arms, and legs. Any complaints of pain, especially activity-related pain, should be addressed before the season begins. Many conditions, especially overuse injuries, will have better outcomes if they are recognized and treated early. Proper counseling for injury management and tailored rest will reduce the risk of these problems. Learn more about common overuse injuries.

General Wellness Education
Athletes are at a high risk of missing the mark with nutrition, either due to unrealistic goals for aesthetic sports such as dancing or gymnastics or unintentionally not meeting their nutritional needs for training and competition. The PPE looks for patterns of injuries or other signs that an athlete may be underfueling. Learn more about underfueling.

Learn more about pediatric sports medicine.

Wellness in Youth Sports: Tips for Parents and Coaches of Young Athletes

Wellness in Youth Sports: Tips for Parents and Coaches of Young Athletes

by | Feb 18, 2021 | Sports Medicine

In a medical education series, Jane S. Chung, M.D., and Taylor Morrison, M.S., R.D., CSSD, L.D., informed pediatric health care providers about the role of wellness in recovery and injury prevention. Health care providers are not the only ones to influence young athletes and their choices to prepare for and recover from sports. Tips for Parents and Coaches
  • Teach your athlete to listen to his or her body. Hunger, pain and fatigue are signs that the body is not prepared to tolerate training.
  • Encourage proper fueling for the activity. Consider the duration and intensity of the activity and give specific suggestions to meet appropriate pre-event nutrition needs.
  • Support proper hydration throughout the day, not just around activity.
  • Use positive language when talking about food and sport-specific bodyweight goals.
  • Speak up when performance declines. Talk to the athlete about sleep, eating habits and stress management so you can act quickly when you are concerned.
  • Listen without judgment.
More Tips for Coaches
  • Choose appropriate training load, intensity and duration. The physical and psychosocial demands of training need to be enough for growth and improvement, but not so much that it causes injuries or illness.
  • Integrate recovery into your schedule of training. Cross training and in-season rest days can support better performance and reduce time on the bench.
  • Learn, model and actively teach athletes positive coping skills to manage stress.
Learn more about training load, recovery and young athlete wellness in the summary of Chung and Morrison’s latest lecture.