Surmounting Setback Through Strength

Surmounting Setback Through Strength

Published in Rite Up, 2023 – Issue 2. 
 
Running intensely down the long runway, Lawrence launched into a roundoff, followed by five no-handed back handsprings and then a back handspring into a double pike. Landing sharply on the mat with all of the pressure on her ankles, she fell to the ground. “I was in terrible pain, and I just remember paramedics coming over,” says 16-year-old Lawrence, of Richardson. That day in June of 2022, Lawrence broke both of her ankles at the USA Gymnastics® Championships in the trampoline and tumbling event in Des Moines, Iowa. “I was really scared that I wouldn’t be able to tumble anymore,” she says.

A girl doing a handstand in front of a sign that says gymnastics

An elite power tumbler, Lawrence has been a gymnast since she was 5. “I would flip all around the house,” Lawrence says. “I’d flip off the couch, make up routines on my bed and outside with my friends at recess. I’ve always had a passion for it.”
 
After a trip to the emergency room in Des Moines, Lawrence and her family decided to wait until they got back to Dallas to have surgery. “It was the longest car ride ever,” says Hollis, Lawrence’s mother, “but I knew the wonderful reputation of Scottish Rite for Children because I used to work there as a physical therapist, and I had heard that Dr. Ellis was the person we needed to see.”

A few days later, Lawrence found herself in the care of pediatric orthopedic sports medicine surgeon and medical director of clinical research Henry B. Ellis, M.D., and a multidisciplinary team of experts at the Scottish Rite for Children Orthopedic and Sports Medicine Center in Frisco. After having surgery on both ankles, Lawrence underwent a treatment plan that included having splints on both legs and then successively wearing casts, boots and braces before she could walk without aid. For many weeks, she was in a wheelchair until she could use crutches. “The lack of things I could do made me feel pretty hopeless,” Lawrence says. “I stayed in bed all day. I couldn’t do anything on my own, even go to the bathroom or take a shower.”

During her visits at Scottish Rite, Lawrence received a continuum of care in body, mind and spirit, including support from physician assistant Ben Johnson, P.A.-C., A.T.C., pediatric nurse practitioner Heather Barnes, D.N.P., child life specialist Marissa Willis, CCLS, and pediatric psychologist Emily Stapleton, Psy.D. “Dr. Stapleton talked to me every visit about how I was feeling mentally, which I didn’t take into consideration before the injury,” Lawrence says. “I thought I’d just be lying in bed, and then I’d get up and be fine, but it was a lot harder than I expected mentally. She really helped me discover things that I like to do besides tumbling, like reading and doing crafts.”

Hollis says that for her as a parent, Scottish Rite for Children means trust. “I totally and completely trust the doctors, nurses, support staff and therapists,” Hollis says. “Once we were in the hands of Scottish Rite, I knew Lawrence would be okay.”

A woman stands in front of a green wall with her arms crossed

After a few months, Lawrence started walking and began the recovery process. “I was so excited to get strong, work out and do normal things that I took for granted like walking with my friends,” Lawrence says. “It might take a village to get elite athletes back after a bad injury,” Dr. Ellis says, “but the truth is that it takes a special patient with resilience, strength — both mental and physical — and perseverance.”
 
Today, Lawrence is back in the gym taking power tumbling classes and learning a new specialization called acrobatics and tumbling, a sport that combines gymnastics and the athletic aspects of competitive cheerleading. She takes private lessons from Hope Bravo, the 2019 U.S. tumbling bronze medalist who also competed in the Acrobatics and Tumbling program at Baylor® University. Lawrence says that Baylor’s program is the best, and she aspires to join the team when she graduates from high school. “

The care I received at Scottish Rite was amazing,” Lawrence says. “Though the injury set me back and that was really difficult, I’m glad I am where I am now because I didn’t think that would be possible. I love what I’m doing now. I have new goals, and I’m happier than I’ve ever been.”
 
Read the full issue.

The Growing Athlete’s Hip: How to Prevent Problems Today and Tomorrow

The Growing Athlete’s Hip: How to Prevent Problems Today and Tomorrow

Download a PDF of this summary.

In this program, our pediatric orthopedic and sports medicine experts described how the skeletal development of the hip is affected by repetitive and extreme movements inherent to athletic activity. The changes, in some cases, can be permanent. Keep reading to learn what we know about preventing irreversible changes and treating symptoms of these sport-related hip conditions.

Apophysitis and Apophyseal Fractures in the Hip and Pelvis

Apophysis is a normal bony outgrowth that arises from secondary ossification centers. The bone fragment will ultimately fuse with the primary bone. The apophysis contributes more to the shape of a bone than the longitudinal growth. Until the ossification center fuses, also referred to as the point at which the “growth plate closes,” the tendon or ligament attached to the apophysis can pull and cause pain in the soft cartilage in the apophysis.

Hip and pelvic apophyses that are vulnerable to acute or overuse injuries are located at the ischial tuberosity, the iliac crest, the anterior superior iliac spine (ASIS) and anterior inferior iliac spine (AIIS). An apophyseal avulsion fracture. An anterior-posterior view of the pelvis is helpful when evaluating complaints in the pelvis so contralateral comparison can be made.
Risk factors for injury includes:

  • Tight muscles and muscle groups
  • Early in the sports season
    • Change in activity from sedentary to active
    • Sudden increase in intensity or duration of training or competition
  • Ignoring activity-related pain
  • Minimal recovery from workouts
    • Year-round training
    • Lack of cross-training
    • Overtraining

Treatment for these conditions is most often nonoperative and is centered around protecting the area involved. Rest, protected weight-bearing, gentle passive ROM and gradual return to play are necessary elements of the plan. Healing and symptom resolution may take 12 weeks or more and radiographic healing is not required prior to returning to sports.

Internal and External Snapping Hip

Athletes may report “popping” in the hip.

If you can see it, it’s likely coxa sultans externus, external snapping hip. This is a condition of the iliotibial band popping over the greater trochanter on the lateral side of the femur. Runners may complain of this when running or walking, and they may describe that it “pops in and out.”

If you can hear it, it’s likely coxa sultans internus, internal snapping hip. This occurs when the iliopsoas muscle, deep in the groin, causes painful popping. This condition is often seen in dancers and tumblers. Treatment includes hip flexor stretching and activity modification.

Femoroacetabular Impingement (FAI)

An overuse injury seen in adolescent and young adult athletes in the hip can be caused by changes in the shape of the femoral head-neck junction (Cam-type) or the acetabulum (Pincer-type). These changes can cause pinching and tearing of the labrum, the soft tissue surrounding the acetabulum that acts to deepen the socket. Early injury from impingement can cause premature hip arthritis. Therefore, this condition is continuing to get more attention with the goal to prevent deformity and consequences.

How does a Cam-type deformity develop?
The femoral head collides prematurely with the acetabulum. The impact causes a change in the shape of the head from being spherical to being more “cam” shaped, or oblong. These may develop secondary to another medical condition in the developing hip, such as:

  1. Slipped capital femoral epiphysis (SCFE) is seen in approximately one in 10,000 may occur and result in avascular necrosis of the femoral head.
  2. Perthes disease – rare condition affecting blood flow in the hip and causes deformity.
  3. Trauma or fracture

In athletes, there is not a primary condition like those listed above. Therefore, idiopathic Cam deformities have been identified in teenage athletes who participate in soccer and other sports. Younger players studied do not show this condition, so the window of opportunity and the exacerbating activity are being studied more closely. Shearing forces may be occurring at the physis to protect the bone, but ultimately may be causing changes in the growth plate and therefore the shape of the femoral head.

Can this be prevented?

Early conversations are looking at the parallel occurrence in the shoulder and elbow in baseball players. Evaluation of the dosage of activity, such as pitch counts in baseball, have been implemented to preserve the anatomy and improve performance in elite athletes. For now, working on proper mechanics and activity modification in adolescence may be our best tools to prevent this deformity.

Considerations and Components of a Hip Injury Prevention Program

Factors that must be considered to prevent hip injuries in adolescent athletes include:

  • Open growth plates
  • Peak height velocity (PHV)
  • High volume of training particularly with loading in rotational and axial movements
  • Sport-specific end range of motion demands
  • Explosive and eccentric demands

Modifiable factors may include:

  • Muscle imbalances
  • Muscle weakness
  • Inflexibility
  • Poor technique
  • Sport-acquired deficiencies
  • Joint instability
  • Overtraining

Five Domains of Injury Prevention Strategies of the Hip

  1. Training Load Management
    Higher incidence of athletic hip pain found with athletes who specialize in a single sport before high school and participate in regular training at earlier ages and four times per week before the age of 12. Recommendations include sampling a variety of sports rather than specializing, monitoring workload, neuromuscular training programs and taking rest breaks from sport (two to three nonconsecutive months/year).
  2. Hip Mobility During Rapid Growth
    Through stretching, dynamic warm-up and eccentric training, hip tissues can stay flexible. Progression of eccentric training can improve the length-tension curve to improve performance and resist injuries.
  3. Motor Control and Stability
    Hypermobility and poor motor control need to be addressed with strategies that improve core stability and teach foundational movement patterns for sport-related movements, such as jumping and landing.
  4. Strength to Improve Imbalances & Specificity
    Once mobility and control are addressed, strengthening can occur. Eccentric adductor & abductor strength can be improved by combining activities, such as the Copenhagen plank and a Nordic Hamstring exercise. Looking for sport-specific strengthening tasks.
  5. Sport-Specific Movement Mechanics
    The culmination of these strategies is executing the sport-specific movement patterns with all of the fundamental movement competence and technical accuracy to ensure safety. Whether the sport demands jumping and landing on a court, changing direction at high speeds on the ice or holding extreme postures on a balance beam, the steps follow a standard pattern.

Implementing Hip Injury Prevention Programs

With confidence that many of these elements are modifiable due to neural plasticity of youth athletes before and during growth, making an effort to prevent injuries is appropriate. Research will continue to define the right and wrong approaches; however, we have some tips that are generally accepted. To avoid detraining, it is recommended to perform activities two to three times per week, approximately 20 min duration, up to 60 min for at least six weeks. It is important to implement it prior to the beginning of a season. Qualified instructors and supervision for continued implementation of the proper techniques are crucial elements of a safe and successful program.

Learn more about hip health in dancers.

This is a summary of a presentation in a monthly series for medical professionals called Coffee, Kids and Sports Medicine. Through events like these, Scottish Rite for Children experts share their experience and knowledge with others to ensure young and growing athletes are getting the best care in every environment.

Orthopedic Sports Medicine Fellowship – Vacancy

Orthopedic Sports Medicine Fellowship – Vacancy

The Scottish Rite for Children and UT Southwestern Medical Center (UTSW) Sports Medicine Fellowship is a new 12-month ACGME accredited fellowship program with an emphasis on pediatric sports medicine. Led by Philip L. Wilson, M.D., and Henry B. Ellis, M.D., this fellowship is an extraordinary clinical training program that allows physicians to master the skills needed to manage the full gamut of sport-related injuries in adults and pediatric patients including conditions such as osteochondritis dissecans (OCD), discoid meniscus, shoulder instability, femoroacetabular impingement (FAI) and a variety of anterior cruciate ligament (ACL) reconstruction options from a physeal-sparing to a traditional ACL with or without a lateral extra-articular tenodesis (LET). The fellowship will include exposure to fracture management that is common in athletes as well as osteotomies when indicated in athletes. 

The Sports Medicine program at Scottish Rite and UTSW participates in high level research as well as exposure to several multicenter study groups. The fellowship will also include experiences with quality improvement as this institution hosts a multicenter quality improvement initiative called SCORE – Sports Cohort Outcomes REgistry.

The one-year fellowship program is available to a postgraduate surgeon who has completed an orthopedic residency, but it may also be ideal for a surgeon who has just completed a fellowship who would like more exposure to pediatric sports medicine conditions and treatment. This fellowship is perfect for a PGY4 who is interested in sports medicine and may have been overlooked or gone unmatched. A PGY5 who is interested in a second fellowship is also an ideal candidate. 

Training Start: Clinical position to begin in August 2024 

Accredited Positions: 1 

How to Apply: Please send your contact information, CV and other supporting documents to orthosports.fellowship@tsrh.org. We would like to fill the position as soon as possible.

For more information about the Orthopedic Sports Medicine Fellowship, please visit the Fellowships & Graduate Programs page on our website.

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Healio Orthopedics Today: MPFL Reconstruction

Healio Orthopedics Today: MPFL Reconstruction

Patellar instability most commonly affects skeletally immature pediatric patients with open growth plates and medial patellofemoral ligament reconstruction should be the primary treatment for first-time patellar instability in skeletally immature patients, despite historical use of the adductor sling technique.

Medical Director of Clinical Research Henry B. Ellis, M.D., recently discussed MPFL reconstruction for first-time patellar instability with Orthopedics Today. 

Watch the full segment

Healio Orthopedics Today: Arthroscopic Meniscus Repair

Healio Orthopedics Today: Arthroscopic Meniscus Repair

In a prospective multicenter study, Medical Director of Clinical Research Henry B. Ellis, M.D., and colleagues used the Clavien-Dindo classification system to identify complications among more than 2,000 arthroscopic meniscus repairs in pediatric patients. Presented at the 2023 Arthroscopy Association of North America Annual Meeting, research showed that pediatric patients with an isolated meniscus repair had a complication rate of 14.25% and the team found no statistical cause for the failed meniscal repairs. Read the full article on Healio Orthopedics Today
Less Common Sports Continue to Grow in Popularity

Less Common Sports Continue to Grow in Popularity

About two-thirds of kids who come to see us for sport-related injuries play at least one of these five popular sports: soccer, football, basketball, baseball and volleyball. However, young athletes sustain injuries in many other sports and activities.

Download the PDF

The goal of the program is to inform health care professionals who work with young athletes about current concepts and the latest evidence on sport-specific injuries, providing care, returning to sports and preventing injuries. In part two of this program, Jacob C. Jones, M.D., RMSK, provided epidemiology, common injury patterns and recommendations for preventing injuries in softball, tennis, martial arts, rugby, fencing and track & field. This program was presented as a part of a monthly series for medical professionals called Coffee, Kids and Sports Medicine.

Pediatric sports medicine research has been supporting multisport athletes for various reasons including, but not limited to, the benefits that come from the varied skill development and training patterns and demands. Physical literacy is a term that describes how comfortable an individual is with various physical skills. With this in mind, we encourage kids and athletes to test out different sports and activities at varying levels of competitions. Injury risk can be managed in all activities, and knowing what injuries occur in which sports will help with that.

Softball
Softball injuries occur most commonly in the shoulder of pitchers. Much like baseball, repetitive motion, particularly on the growing joint and bones can cause an overuse injury. Because of the style of pitching, the adolescent elbow in softball is at a much lower risk of injury compared to baseball where the elbow accounts for half of injuries in pitchers. The mechanism of shoulder injury is also different in softball, and therefore, it is not diagnosed as Little Leaguer’s shoulder, which is commonly diagnosed in young baseball pitchers. Additionally, the softball pitcher experiences pain much earlier in the season, typically within the first six weeks. Other common injuries among high school softball players include ankle sprains and concussions.

Advice from an Expert – Softball
Katie Holehouse, P.T., D.P.T., CSCS, played softball as a child and earned a scholarship to play at George Mason University. One of her first jobs was as an assistant softball coach in a high school. She has three tips to avoid softball overuse injuries.

  1. Young athletes should take breaks from softball throughout the year.
  2. An appropriate warm-up should include total body movements of all joints – not just the arm.
  3. Strength and conditioning of upper and lower body during off-season can decrease injury risk.

Tennis
Tennis is a combination of quick movements and direction changes with the feet and repetitive, forceful movements with the arm(s). Since the game is not timed, fatigue also contributes to performance and injury risk in tennis.

Repetitive external rotation in shoulder and overextension in spine are the most common causes of injuries. The knee is another joint that is often injured in young tennis players. Joints like the elbow and knee in skeletally immature players will present with conditions that are very different from adults in this sport. For example, tennis elbow, a condition affecting the tendons around the elbow, is much less likely young tennis players than other conditions.

Advice from an Expert – Tennis
Orthopedic surgeon and avid tennis player, John E. Arvesen, M.D., is a three-time Texas High School State Champion and two-time Big 12 Champion at Baylor University. Arvesen offers these tips for preventing injuries in young tennis players:

  1. Dynamic warm-up is key for injury prevention.
  2. Many injuries come from faulty mechanics.
  3. “Throwers Ten” is a good supplement to the serve.
  4. Remember good hydration, especially in the summer.

Martial Arts
All of the different forms of martial arts help young athletes build strength, improve balance and increase flexibility. Additionally, they contribute to improvements in cognitive function, self-esteem, self-respect and self-awareness.
The varying styles contribute to differences in injury risk across the different forms. Some like tae kwon do and grappling may have a higher risk of contact injuries from engaging and striking with the hands, body and feet. In competitions, the head and pelvis are most frequently injured. Contusions and bloody noses are the most common injuries. Weapons may increase the risk of injuries. Meditative forms of martial arts, such as tai chi, have lower risk of contact injuries and offer safety in slow, controlled movement patterns.

Advice from the Experts – Nose Bleeds
Our athletic trainer team boasts more than 50 years of experience in sideline care of young athletes. Their top tip for managing epistaxis (a bloody nose) in martial arts and other sports is “Don’t tilt the head back!” This may lead to swallowing or vomiting of blood. Have gloves, gauze and Vaseline® on hand when the risk for this injury is high. Cutting tampons or purchasing commercially available cotton nose plugs help to slow the hemorrhage.

Rugby
Some sources suggest rugby is the ninth most popular sport in the world. The rules for youth differ from those of adults. Rugby injuries most commonly occur during a match with more than three-quarters of injuries occur during tackling. Proper tackling form is key to help avoid injury. Rugby injuries affect teenage girls most often. The style of play puts the head at the greatest risk of injury and football-like helmets are not used. The lack of protective equipment also contributes to joint and bone injuries, such as fractures, in the clavicles, hands and extremities.

Advice from an Expert – Head to the Hip
Fracture clinic nurse practitioner Ray Kleposki, M.S.N., CPNP, a former rugby player and currently a youth rugby coach, has 20 years of experience in the sport. His advice is to learn proper tackling form, which differs from football — head to the side hip. He advises that learning and following the rules prevents both injuries and penalties.

Rib injuries may not be common in youth sports, but the consequences of misdiagnosis and treatment can be high. Rib fractures are less common in kids compared to adults; however, kids with rib fractures have higher rates of hemothorax/pneumothorax, spleen and liver injury.
Rib injuries with these signs and symptoms warrant further medical evaluation:

  • Cardiac involvement
  • Abdominal injury
  • Trouble breathing, painful breathing and/or coughing
  • Dysphagia
  • Hoarse voice

Fencing
Fencing is a combat sport that is growing in popularity that involves sword fighting. With proper training and equipment, young athletes safely participate in fencing which has three different disciplines:

  • Foil
  • Epée
  • Saber

A competitive fencer typically focuses on one of these disciplines. Each discipline has different weapons, targets and rules. Saber athletes have the highest injury rate with injuries in the knee, thigh and ankle. Anecdotally this occurs more in the lead leg. Other injuries common to other sports may also occur including acute sprains and strains and chronic complaints in the leg are consistent with patellofemoral syndrome. Unique to fencing, puncture injuries are generally prevented with proper equipment.

Track & Field
The variety of events in track & field expose athletes to acute and chronic, or overuse, injuries. The array of injury patterns differs based on the demands of the event. Running, sprinting, jumping, throwing and combination of these requires each event to be considered separately when it comes to injury incidence and risk.

A recent study evaluated youth hurdlers and found the most commonly injured body parts were the ankle, knee and wrist. The injury types that most often cause a hurdler to present to an emergency department are fractures, joint sprains and contusions.

Learn more in an article “Age and Sex Comparisons in Pediatric Track and Field Hurdle Injuries Seen in Emergency Departments of the U.S. Sports,“ recently published in Sports, an international peer-reviewed journal. This article is a review of data from a registry called the National Electronic Injury Surveillance System. Dr. Jones and his peers in the Pediatric Research in Sports Medicine Society studied this information to describe a population that had not been done before. This kind of work helps providers in caring for and helping to prevent injuries in specific populations.