To Brace or Not to Brace? And Other Bracing FAQ’s in Pediatric Sports Medicine

To Brace or Not to Brace? And Other Bracing FAQ’s in Pediatric Sports Medicine

by | Apr 21, 2021 | Sports Medicine

The opinions about bracing joints to address or prevent injuries in youth sports are constantly evolving. The objective comparison of one brace to the next is challenging because of the many variables associated with the conversation. Age, type of brace, joint flexibility, sport, level of competition and many other factors come into play. Additionally, there are hundreds of braces on the market that promise to protect a joint or offer relief from an injury.

What is an orthotic?
An orthotic is the medical term for braces and splints that provide support or protection to muscles, joints or bones. Our sports medicine team provides splints and braces after an injury when appropriate. Athletic trainer Josh Stevens, A.T.C., L.A.T., says, “Most sport-related injuries do not need a cast, but braces offer immobilization and provide protection of the joint while it is healing.” Since braces are removable, they have a lower risk of complications than a cast and can be an appropriate treatment for a fracture.

Braces and orthotics range from off-the-shelf, or ready to wear, to custom designed and fabricated for a single patient. We asked Scottish Rite orthotist, Kelsey Thompson, C.P.O., to respond to common questions from patients. 

Off-the-Shelf
Some braces are easily found online and in sporting goods stores and pharmacies. These offer a range of benefits. These may include compression to reduce swelling in a new injury or stability to prevent movement in a specific direction. These do not require the orthotist to participate in selection, fit or adjustments.

Should I wear an ankle brace to play basketball?
There’s not one answer for everyone. There isn’t evidence to show that an ankle brace is going to prevent an injury. For athletes that have ankle injuries or ankle instability frequently, a comfortable, well-fitting brace or properly applied ankle tape may be helpful.

What is a patellar tendon strap?
In older teens, a condition called patellar tendonitis may cause pain in the front of the knee. The strap is placed across the middle of the patellar tendon, the short, tight band between the patella (kneecap) and the lower leg bone. The pressure on the middle of the tendon changes the intensity and direction of the tension (stretching) that causes the pain with movement.

Semi-Custom Braces and Orthotics
In some cases, an orthotist may be involved in measurement, selection or modifications to these braces. 

Are all shoe inserts the same?
Shoe inserts are often recommended to help reduce foot pain from flat feet or high arches. The purpose of a shoe insert, also called a foot orthosis, is to provide stability to a flexible foot or support to a rigid (inflexible) foot. Since every foot is unique, an athlete may try several inserts before finding one that works.

Proper foot positioning will help an athlete by providing a solid foundation for movement. The foot is considered the beginning of the kinetic chain, a series of mobile and stable joints and muscles working together to produce movement and control. An orthotist evaluates the mobility and function of the foot and ankle to design a custom foot orthotic when off-the-shelf options do not provide the support needed.

Why do some football players wear a knee brace?
You might notice that football linemen often wear a brace on each knee. These hinged braces have been shown to protect the knee joint from stresses to a ligament on the inside of the knee, the medial collateral ligament. This ligament may not withstand the forces of tackles in these strong, and typically, larger players. These braces are made in many sizes and require a good fit and proper application to be effective.

Custom Braces
An orthotist participates in the measurement and recommendation for these devices. Some are even fabricated from raw materials for the patient in our orthotics and prosthetics lab.

After an anterior cruciate ligament (ACL) reconstruction, will I have to wear a brace to play sports?
Every case is unique. Some athletes do need a custom or semi-custom functional knee brace to return to contact or sports that require a lot of change in direction. Our physical therapy team provides functional and sport-specific rehabilitation to enhance intrinsic protection (muscle and nerve control and power inside the body) to reduce dependence or eliminate the need for an external brace. Depending on the patient’s maturity and extent of injury determines how long the brace needs to be worn. The goal of the brace is to prevent re-injury to the ligament that was surgically repaired.

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Are there injuries that require long-term permanent custom braces?
Yes, in cases like Scottish Rite MVP Kalen, a significant joint injury can cause nerve damage. When a nerve is no longer able to “talk to” a muscle, the muscle will no longer do its job. For Kalen, a traumatic knee injury left him unable to lift his foot putting him at risk of tripping when walking, running and playing football. The orthotist fabricated an ankle foot orthosis (AFO) that fit inside his normal shoes and could also be worn with his custom knee brace. The AFO was flexible enough to allow running but prevented the footdrop that might cause tripping.

What advice do you have for young athletes?
If I had to pick one piece of advice, I would remind them that flexibility and stretching are so important. Here at our Frisco campus, we see a lot of patients with flat feet or low back pain and most of them would benefit from regular stretching to increase their flexibility. Look for sports and activities that promote flexibility. Choose a supportive shoe with an off-the-shelf insole is also a great option to add to prevent unwanted aches, pains and injuries. Kids grow very quickly and without proper stretching, they can get tight. Encourage them to actively stretch or even try sitting on the floor with their legs straight when playing a video game.

Learn more more about pediatric sports medicine.

Stress Fractures: How Nutrition Plays a Role

Stress Fractures: How Nutrition Plays a Role

by | Apr 12, 2021 | Sports Medicine

Many athletes with injuries seem to have overlapping nutritional concerns. In particular, gymnasts, dancers, soccer players, cross country runners and track & field athletes are being treated for stress fractures. For some, it’s a second or third stress fracture within a year. These reoccurring stress fractures often are a sign of under-fueling in the young athlete. This is when they are not consuming the optimal caloric intake for the energy they are burning with exercise and sport.

A handful of the female athletes also report that in the midst of their intense training and competition schedule they have stopped having regular periods. This is a concern for young females. Loss of the menstrual cycle is a sign that the athlete has an energy deficit where she expends more calories than she is eating and drinking. This can lead to hormonal, growth and development complications that can be long-lasting and needs to be addressed as soon as possible. Not only does this have general health implications, but it can set the athlete up for overuse related injuries, decreased performance and even time loss from sports.

Female Athlete Triad
Though they rarely occur together, these inter-related conditions: 1) low energy availability, 2) bone loss and 3) menstrual irregularities are called female athlete triad. Low energy availability, or not having enough calories to carry out the demands of the athlete’s sport is the main cause of this. Here are common questions addressed in a nutrition consultation for a young athlete experiencing these and other medical conditions:

  • Are they skipping any meals?
  • Are they getting 3 out of the 5 food groups at each meal?
  • How much water/fluid are they drinking?
  • Are they getting adequate calcium and vitamin D for their age?
  • Are they getting enough protein for their weight, sport and age?
  • Are they spacing this protein out adequately throughout the day?
  • Do they appear to be getting adequate calories for their growth and sports needs?

Customized Plan
Nutrition counseling is an important role in recovery and injury prevention, especially when athletes have had injuries that are linked to energy deficiencies. Young athletes should learn to fuel their bodies for sports and activities so that they are performing at their best and avoid preventable injuries.

  • Identifying fueling ways to increase calories or other nutrients needed.
  • Discussing pre- and post-exercise snack and meal planning.
  • Planning ways to optimize fluid intake.
  • Providing education on specific topics based on the athlete’s needs and goals. This might include supplements, hydration or specific nutritional deficiencies.

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Find more resources on sports nutrition for young athletes.

Fueling for Home Runs: Nutrition Tips for Young Baseball Players

Fueling for Home Runs: Nutrition Tips for Young Baseball Players

by | Apr 9, 2021 | Sports Medicine

While baseball may not be considered an endurance sport or immediately thought of as a power sport, it still demands a level of energy and strength for successful catches, pitches, hits and runs. Additionally, baseball requires concentration, fine motor skills and coordination for sometimes hours on end. For these reasons, nutrition is very important for the young baseball player. Being adequately fueled and well hydrated prior to game time will give the young baseball player sustained energy, strength and focus for top health and performance. 

Certified sports dietitian, Taylor Morrison, M.S., R.D., CSSD, L.D., says, “Young baseball players tend to be very focused on skills practice and miss the opportunity to improve their game by properly fueling and hydrating.” She encourages parents to support young athletes by learning sport-specific tips and providing appropriate food choices to help the athlete meet nutrition goals. 

Tips for Supporting Your Young Athlete
Here are five things you can do for your baseball player to ensure sustained energy, focus and coordination on the field.

1. Emphasize the importance of good hydration each day, every day. Make sure your athlete is drinking water during and after a game as well. 
2. Provide a balanced meal three to four hours before the game. This meal should consist of:

  • Quality carbohydrates such as whole grain bread, pasta, rice, oatmeal, fresh fruit, starchy vegetables, low-fat dairy.
  • Lean protein such as chicken or turkey breast, fish, lean ground beef, low-fat dairy.
  • Healthy fat such as nuts or nut butters, olive oil, avocados, seeds (including chia & flax seeds).
    • Example: Turkey sandwich on whole wheat bread with lettuce, tomato and avocado + fresh fruit cup + glass of low-fat milk.

3. Offer a snack one to two hours before the game.

  • A pre-game snack should focus on easily-digested carbohydrates. Limit protein, fat and fiber, which take longer for the body to digest and may affect performance during the game.
  • Examples: Fresh fruit, dried fruit, pretzels, applesauce, low-fiber cereal, low-fiber granola bar, white bread or white pasta.
  • For those athletes who experience pre-game jitters and stomach discomfort, a liquid source of carbohydrates like a small serving of a sports drink may be tolerated better right before a game.

4. A sports drink may supply the athlete with additional easy-to-digest carbohydrates if energy levels start to dip during a game.

5. Don’t forget recovery. A good recovery meal contains carbohydrates, protein, healthy fat and fluid. Together, these nutrients replenish depleted energy stores (carbohydrates), repair muscle, help fight inflammation and rehydrate the body.

Learn more about nutrition and hydration for young athletes.

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.