Price Transparency
With Her Knees Back in Sync, Abbee’s Ready to Take It From the Top!

With Her Knees Back in Sync, Abbee’s Ready to Take It From the Top!

by | Aug 18, 2022 | Sports Medicine

A woman in a green jumpsuit is dancing on a stage .

Abbee, age 16 of Denton, isn’t like most kids her age. She attends a unique online school just so that she can devote as much time as possible to her true passion – dancing. She is dedicated, spending more than 40 hours a week practicing her dance, earning an invitation to participate in an exclusive pre-professional program at The Joffrey Ballet School.

Abbee dances all day, every day and is determined to pursue a career as a professional dancer. “I knew from a young age that this is what I wanted to do forever,” she says. When Abbee began noticing that her knees were “buckling” while she was dancing, she knew something was wrong. “It would happen while I was dancing, and it would take me out of dance for a few days until the pain went away,” Abbee says. “Eventually, it was happening so often that we decided it was time to see a doctor.”

Abbee visited our Sports Medicine clinic in Frisco to see Jane S. Chung, M.D., pediatric sports medicine physician for Scottish Rite for Children who has a passion for caring for female athletes and dancers. After discussing her history, performing a physical exam and reviewing X-rays and an MRI, Dr. Chung explained that Abbee’s kneecaps sit higher than normal. This position of the kneecap is referred to as patella alta and it can cause patellar instability or patellar subluxation, which is a partial dislocation of her kneecap. Chung reviewed the treatment options, ranging from physical therapy (PT) to surgery. As many patients do, Abbee chose a nonoperative approach first. She began PT to strengthen the muscles in her knees right away, working with physical therapist Jessica Dabis, P.T., D.P.T., O.C.S., to complete exercises to reduce the frequency and hopefully prevent dislocations. After completing PT, Abbee returned to her rigorous dance schedule, and she noticed that her knees felt much stronger.

Abbee visited with pediatric sports medicine surgeon Philip L. Wilson, M.D., and pediatric orthopedic nurse practitioner Chuck Wyatt, M.S., CPNP, RNFA,  who described the procedure and recovery and put her at ease. In November 2021, Wilson reconstructed the torn MPFL, which also corrected her patella alta. This procedure should prevent the instability episodes in this knee. Abbee began PT with Jessica Dabis at Scottish Rite again to rehab her left knee following surgery, working to get back to dancing

Soon after her surgery, Wyatt and Wilson determined that Abbee’s right knee also had a torn MPFL. Abbee knew this meant she would likely need another surgery, but she wasn’t worried. “I was already going to be out for this entire dance season, why not just get them both done and be completely healthy?” Abbee says. She continued PT of her left knee while preparing for surgery for her right knee, just 59 days after her first surgery. After surgery, Abbee was extremely diligent about her rehabilitation, following every instruction.

A woman in a green leotard is standing on one leg on a stage .

She continued PT through July 2022, strengthening the muscles in her knees and following her therapist’s prescribed dance-specific rehabilitation progression. This included a step-by-step return to dance skills and movements, building up from modified to full-out participation. She’s now back to doing what she loves most, dancing, and is so thankful for the team at Scottish Rite for helping her get where she needs to be. 

“Having two back-to-back knee surgeries before the age of 16 is never something I imagined for myself,” Abbee says. “But now I am so extremely proud of myself for making that difficult decision because now I can go back into dance confidently knowing that my knees will be better. I won’t have that fear that my knees will partially dislocate. This entire experience at Scottish Rite has truly changed my life for the better, and I couldn’t have asked for a better team and medical care.”

WE ENJOY HEARING ABOUT OUR CURRENT AND FORMER PATIENTS’ SUCCESS STORIES. TELL US ABOUT YOUR MVP. 

Overcoming Gymnast’s Wrist – A Tale of a Gymnast Named Delaney

Overcoming Gymnast’s Wrist – A Tale of a Gymnast Named Delaney

by | Jun 28, 2022 | Sports Medicine

Delaney, 12 of Lewisville, has been tumbling and flipping her whole life, well almost. Starting around 18 months old, this level 7 gymnast practices 20 hours per week. She is so happy to be back in her normal rhythm after a season of modified training because of a wrist injury. Delaney credits her occupational therapist, Lindsey Williams, O.T.R., C.H.T., with helping her focus on new goals to work toward while she was getting better.

After a teammate and her mom described the gymnast’s wrist pain and treatment plan, Delaney and her mom took their advice to see someone at Scottish Rite for Children about her similar complaints. Pediatric sports medicine physician Jane S. Chung, M.D., confirmed that Delaney also had gymnast’s wrist, an overuse injury, in one hand and was showing signs of it developing on the other. The treatment plan started with immobilization, a cast on one arm and a removable splint on the other, and a new approach to training while protecting her wrists. Delaney was committed to this plan. At one point, Delaney even opted to extend her time in the cast just to be sure she didn’t go back too soon. “I wanted to be sure my wrist was ready, so I listened to Lindsey and kept working on my other goals like stretching for splits.”

“We were very concerned when we learned this could affect her growth. She had only complained of pain for a couple of weeks, we are glad that we received the advice to get it checked out.” Delaney’s mom recalls their initial surprise and hopes others will learn to watch out for signs of gymnast’s wrist.

Delaney, and sometimes her brother Luke, have enjoyed the activities that Lindsey has given her to increase the use and strength in her hand, wrist and arm. Delaney and her mom appreciate that Lindsey can talk-the-talk. Her mom says, “she knows gymnastics lingo, and she knows the demands of the sport.” Lindsey worked her magic with Delaney, getting to know her as an individual, looking for her motivations and challenging her to find ways to keep moving forward even when she was ordered to “rest.”

Lindsey says, “I’m excited to see Delaney ready to graduate from occupational therapy and return to her sport. I love my job and seeing kids getting to do what they love makes me love it even more.”

WE ENJOY HEARING ABOUT OUR CURRENT AND FORMER PATIENTS’ SUCCESS STORIES. TELL US ABOUT YOUR MVP.

Learn about overuse injuries in gymnasts wrist.

Unique Considerations for Female Athletes

Unique Considerations for Female Athletes

by | Jun 13, 2022 | Sports Medicine

These are highlights from a lecture provided as part of, Coffee, Kids and Sports Medicine, a monthly lecture series for medical professionals. Using example cases and detailed visuals, sports medicine physician Jane S. Chung, M.D., discussed the evaluation and treatment of the female athlete.

Watch recording.

Download PDF.

What are the unique benefits for girls participating in sports?
Known benefits of physical activity include cardiovascular fitness, cognitive function, strength and many more. Female athletes have also shown to have these benefits:

  • Higher self-esteem
  • Better grades
  • Higher graduation rates
  • Lower rates of teen pregnancy
  • Lower rates of smoking and drug use
  • Lower rates of depression and anxiety
  • As much as 30% greater bone mineral density than nonathlete counterparts

What are some sport-related physiological and anatomical characteristics of females compared to males?

  • Higher percent body fat (average 26% vs. 14%)
  • Less lean muscle mass
  • More oxygen consumption with weightbearing exercise
  • Total cross-sectional area of muscle (60% vs. 80%)
  • Smaller heart and faster heart rate
  • Smaller thorax and lungs
  • Lower blood volume and VO2 max
  • Fewer red blood cells and 10% less hemoglobin

What has changed in the definition of the female athlete triad?
Female athlete triad was a medical condition initially described as involving these three components: osteoporosis, amenorrhea and eating disorder. Now, the updated definition recognizes that the central cause of female athlete triad is due to low energy availability with the three components being interrelated and each lying on a spectrum.

Spectra of the Female Athlete Triad

  • Low energy availability
  • Impaired bone health
  • Menstrual dysfunction

Triad occurs when energy intake does not adequately compensate for exercise related energy expenditure. This is referred to as under-fueling which then can adversely affects reproductive, bone and possibly cardiovascular health.

What are Risk Factors for the Athlete Triad?

  • Sports that emphasize aesthetics and leanness such as dance, cheerleading, figure skating, gymnastics, long- and middle-distance running, pole vaulting, cycling, wrestling, light-weight rowing (coxswain) and horse jockeying.
  • Early age of sport specialization
  • Family dysfunction, abuse, dieting, stressors from family/coaches

What is Energy Availability?
Amount of dietary energy left to support other physiologic functions after subtracting energy used in exercise.

Energy availability is described using a spectrum:

  • Optimal energy availability
  • Reduced energy availability
    • Unintentional: inadequate dietary intake and/or excessive exercise
    • Intentional: disordered eating behaviors
  • Low energy availability
    • Eating Disorder: clinical mental disorder defined by DSM-V
    • Disordered Eating: various abnormal eating behaviors including restrictive eating, fasting, frequently skipped meals, diet pills, laxatives, diuretics, enemas, overeating and binging and purging

How much dietary intake is normal?
Optimal energy availability is 45 kcal/kg fat free mass per day. This is known to support physically active women. Anything less than 30 kcal/kg fat free mass per day contributes to negative metabolic, reproductive and bone health related changes are seen below this level.

  • An athlete’s weight should be >90% of expected body weight.
  • Low BMI is a strong predictor of low bone mineral density and stress fractures.

What are normal and abnormal menstrual cycles?
Also called eumenorrhea, the typical cycle occurs every 28 days and lasts about 7 days. In cases where the cycle occurs less frequently, specifically more than 35 days apart, it is called oligomenorrhea. The absence of the cycle, amenorrhea, may be primary or secondary. In cases of low energy availability, the absence is further defined as functional hypothalamic amenorrhea.

How are estrogen and progesterone associated with musculoskeletal health? 

Beyond the reproductive cycle, these hormones are also important in bone health.

  • Stimulates osteoblasts
  • Inhibits osteoclasts
  • Muscle activation
  • Ligament and tendon stiffness
  • Suppresses hormones that cause articular cartilage breakdown

What is peak bone mass and what can positively influence it in female athletes?
Peak bone mass is a measure of bone mineral density that is used to assess bone health and risk for injury such as fracture, stress fracture and osteoporosis later in life. Ninety percent of peak bone mass is obtained by age 18 in females and age 20 in males. In young adults, bone mineral density 10% higher than the mean may reduce risk of fractures as well as delay the onset osteoporosis as much as 13 years. Therefore, attention to bone mass during childhood and adolescence is of utmost importance.

Genetics is the main determinant of peak bone mass. The following items also impact peak bone mass:

  • Mechanical forces
  • Gender
  • Hormones
  • Nutrition
  • Physical activity or other outside risk factors.

Early puberty is the most crucial time to positively influence peak bone mass with weightbearing sports and high-impact exercises. Studies have found that participation in sports can increase bone mass by as much as 10%.

What problems occur from low energy availability?
Several systems are affected, and the consequences compound in a cascade. Here are some key messages to keep in mind.

Bone Health

  • A reduction in bone formation caused by suppression in hormones is possible.
  • Low bone mineral density is known to increase the risk of stress fractures.
  • Changes from low bone mineral density may be irreversible.
  • DXA scans are recommended based on the presence of specific high and or moderate risk factors.

Reproductive System

  • Functional hypothalamic amenorrhea is a diagnosis of exclusion.
  • Other causes of abnormal menstrual cycles should be considered.
  • Young athletes believe it is a normal response to training, but it is not.

Tip for young athletes: encourage females to be prepared for their period with supplies (feminine hygiene products, clean clothes, plastic bag) and to monitor their menstrual cycle to adjust training as needed.

Cardiovascular Health

Studies have shown that history of prolonged irregular menstrual cycles may negatively affect cardiovascular health and has shown possible association with:

  • Coronary artery disease
  • Endothelial dysfunction
  • Unfavorable lipid profiles and increased LDL

Performance

  • Triad may reduce performance and training responses, delay or extend healing and cause fatigue.

What is Relative Energy Deficiency in Sports?
Also referred to as RED-S, this is an evolution of the concept recognizing impaired physiological functioning caused by relative energy deficiency. This includes but is not limited to impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis and cardiovascular health.

How is male athlete triad different than female athlete triad?

Reproductive suppression is seen in males in these forms:

  • Low testosterone (T)
  • Oligospermia
  • Decreased libido

When is screening for triad or RED-S most appropriate? 
Well visits such as during a pre-participation physical evaluation (PPE) or the yearly check-up and any time an athlete presents for a recurrent injury, bone stress injury or other illness. To diagnose the condition, only one of the three components must be present. Evaluate further with any positive finding.

What are appropriate screening questions?
The Female and Male Athlete Triad Coalition provides a list of 15 screening questions. These are consistent with the American Academy of Pediatrics 2019 Preparticipation Physical Evaluation recommendations and can help to guide further discussion and assessment.

  • Do you worry about your weight or body composition?
  • Do you limit or carefully control the foods that you eat?
  • Do you try to lose weight to meet weight or image/appearance requirements in your sport?
    • Does your weight affect the way you feel about yourself?
    • Do you worry that you have lost control over how much you eat?
    • Do you cause yourself to vomit or use diuretics or laxatives after you eat?
  • Do you currently or have you ever suffered from an eating disorder?
    • Do you ever eat in secret?
  • What age was your first menstrual period?
  • Do you have monthly menstrual cycles?
  • How many menstrual cycles have you had in the last year?
  • Have you ever had a stress fracture?

What are other risk factors of RED-S?

  • History of menstrual irregularities
  • History of stress fractures, family history of osteoporosis
  • Depression
  • Perfectionistic or obsessive personalities
  • Overtraining
  • Non-healing injuries
  • Inappropriate coaching
  • Early sports specialization

What are the treatment and recovery expectations for athletes with female athlete triad?
The primary goal is restoration and normalization of body weight, to restore menses and to improve bone health. Rest or modified training may be recommended depending on the risk of injury or presence of concerning symptoms. A collaborative treatment approach includes a physician with experience treating athletes with triad, a dietitian, a psychologist and sometimes other specialists. Treatment with a birth control pill may lead to the false belief that the natural process has been restored, however, these do not cause the return of normal menses.

Returning to sports should be considered using a cumulative risk assessment. Recovery occurs first with energy status, then menstrual status and then bone health. Earlier diagnosis reduces the length of recovery and hopefully prevents irreversible changes. Resumption of normal menses can sometimes take months or longer, reversal of low bone mineral density can sometimes take year or longer, and sometimes may be irreversible.

What are strategies to optimize bone health in young athletes?

  • Focus on risk factors to address biological risk factors for low bone mineral density
  • Ensure adequate calcium and vitamin D, nutrition and overall energy availability
  • Encourage adequate sleep as it may promote bone health
  • Appropriate loading activities during the “critical period” of youth (early puberty)

About the Speaker
Jane S. Chung, M.D., is a pediatric sports medicine physician at Scottish Rite for Children Orthopedics and Sports Medicine Center in Frisco, Texas. She is passionate about the health and safety of young athletes and cares for pediatric sport-related medical and musculoskeletal conditions. Chung loves to teach other provider, parents and athletes about the unique needs of female athletes during crucial growing years.

Spondylolysis: A Common Cause of Back Pain in Young Athletes

Spondylolysis: A Common Cause of Back Pain in Young Athletes

by | Dec 29, 2021 | Sports Medicine

Back pain is a common complaint in young athletes. Most often, it is caused by an overuse injury related to repetitive extension-based motions. Muscles may become fatigued and sore, and some may progress to injury to the structures of the spine itself. Stress placed on the vertebrae (the bones in the spine) due to repetitive movements related to sport participation can lead to a bone stress injury or stress fracture. This condition is called spondylolysis.

Sports medicine physician Jane S. Chung, M.D., says, “Athletes and parents should be aware of the symptoms of spondylolysis, as this is one of the most common causes of low back pain in adolescent athletes that we see in pediatric sports medicine.”

What sports are most likely to cause spondylolysis? 
Spondylolysis is often associated with sports that require repetitive back extension (arching of the back, or bending backwards), such as tumbling during gymnastics or cheer, blocking as a football lineman, dancing or serving in volleyball or tennis. Our experience has been that spondylolysis can occur in any sport, including baseball, soccer and others that are not thought of as involving excessive back extension.

Is this a condition diagnosed in children only?
There are different types of spondylolysis that occur in all ages, but it is more commonly diagnosed in adolescent athletes because of the extreme demands of physical activities and sports.

What symptoms are reported with this condition?
Back pain and stiffness during and after activity are most common.

How is it diagnosed?
A thorough history and physical exam will often provide information that raises the possibility of spondylolysis. The diagnosis is usually confirmed with imaging. Sometimes, if there is a complete fracture or crack in the bone, this can be seen on X-rays. More often, an MRI is helpful to identify stress injuries that may not be visible on X-rays.

What is the treatment for this condition?
Shane M. Miller, M.D., sports medicine physician, says, “With increased demands placed on young athletes including year-round sport participation and specializing in one sport, we are diagnosing this condition more frequently. When identified and treated early, athletes tend to miss less time from their sport, and have a greater success rate of returning to sports and continuing to play at a high level.”

Initial treatment often requires resting from any activity that causes or increases the pain, such as sports, running and lifting weights. In some cases, a brace is recommended to help with pain.

Physical therapy may also be recommended to help improve flexibility and core strength. Muscle imbalance caused by tight hamstrings and weak stomach muscles can be improved with appropriate exercises. Stronger muscles support the spine and help decrease the stress placed on the bones and discs.

Is surgery needed?
It is unlikely that surgery would be needed unless the spondylolysis progresses to a more severe condition called spondylolisthesis. Even with this progression, rest and bracing are often successful. Surgery may be necessary in cases if the non-surgical treatments do not work.

With increasing trends of single sport specialization and the pressure of performing year-round, this is a common injury we treat in our young athletes. Chung and Miller encourage athletes and parents to not ignore these symptoms and to seek further evaluation by a pediatric sports medicine specialist if they are concerned. Early detection and treatment lead to a greater chance of returning to same level of sport.

Learn more 

Young Athletes and Heel Pain

Young Athletes and Heel Pain

by | May 18, 2021 | Sports Medicine

Skeletally immature athletes, those that are still growing, have unique conditions that occur in the growth centers of the bones. Heel pain in adults is caused by different issues because their growth centers are closed. Sports medicine physician Jacob C. Jones, M.D., RMSK, says, “This is one of the most common conditions we see in the developing athlete. Though it is a condition that does not have lasting problems or require aggressive treatment, it can really disrupt an athlete’s training and competition. Following guidance for rest, cross-training, improving ankle mobility and delaying specialization can help to keep the heels game-ready.”

What are growth centers? 
The medical term for a growth center is a physis. The physis is an area of the bone that has soft tissue called cartilage that is later replaced by new bone cells. Some are areas where bone growth makes bones longer. Others, called apophyses, give the bones a unique shape. These growth centers are found in the elbow, pelvis, heel and other areas. The apophyses are attachment sites for tendons.

What growth center is in the heel?
The calcaneal apophysis is in the calcaneus (heel bone). The apophysis is the attachment site for the very strong tendon from the calf muscle, called the Achilles tendon.

What causes heel pain in the calcaneal apophysis?
Children become more committed to sports around 8-12 years old. With running, or repetitive jumping, the Achilles tendon pulls on the cartilage in the heel. This, accompanied by the impact on the ground with running and jumping, can lead to irritation in this area. Because this has a gradual onset, this is referred to as an overuse injury and is often referred to as Sever’s disease.

What is Sever’s Disease?
Sever’s disease, or calcaneal apophysitis, is a type of overuse injury and the most common cause of heel pain in active children ages 8-12. It is caused by repetitive movements, like running and jumping and may occur in only one or both sides. The pain is usually not related to a specific injury and comes on gradually.

What is the treatment for Sever’s disease?
Changing shoes or adding heel cups may be recommended to help with comfort during recovery. Simple ankle stretching exercises may also be helpful. Other treatments are available and should be considered on an individual basis, but rest is the most common prescription for this condition. Returning to a sport and other physical activity may gradually prevent recurrence. Pain may last months to years and may come back or worsen with increased sport or activity.

How long does Sever’s disease last?
Sever’s disease will resolve with completion of growth in this area. Because the growth plate is soft until it is closed, this problem can happen again in this age group. Pain in this area typically resolves by the mid-teenage years.

What factors may increase risk of initial or recurrent Sever’s Disease?

  • Playing sports on a hard surface or barefoot.
  • Footwear with poor cushioning, such as soccer cleats.
  • Year-round sports participation.
  • Sudden increase in training intensity.
  • Increase in duration or frequency of activity, such as tournaments and camps.
  • Tight Achilles tendon or calf muscle.

Learn more about Sever’s disease in this popular short lecture featuring sports medicine physician Jane S. Chung, M.D.