Intensive training in young athletes.

An increasing number of children take part in organized sporting activities, undergoing intensive training and high level competition from an early age. Although intensive training in children may foster health benefits, many are injured as a result of training, often quite seriously. This paper reviews some of the areas of research dealing with intensively trained young athletes, and focuses on physical, cardiovascular and muscular effects, sports injuries and psychological effects of intensive training. It is concluded that measures should be taken to modify present training and competition schemes to avoid the deleterious effects of intensive physical activity on these children.     

Apophyseal damage in adolescent athlete

The increasing demands on the adolescent athlete in high performance sports puts high biomechanical stress on the growing structures of the active and passive locomotor system. The "growing factor" itself increases stretching forces on tendon insertions, which are often overloaded when a physical demanding sport is performed additionally. The apophysis is an ossification nucleus near the tendon insertion, which appears before the growing age resumes and these apophysis finally fuses with the adjacent bone. The tensile forces from vigorous sports activity leads to a chronic or acute avulsion of the ossifying tendon insertion. The radiological appearance of this apophyseal damage with ossification and osteolytic processes is sometimes difficult with respect to differential diagnoses. Apophyseal impairment is associated with pain, tenderness to palpation and decreased muscle function. If it is not diagnosed and treated properly it can lead to end of career in many adolescent athletes.     

Overview of injuries in the young athlete

It is estimated that 30 million children in the US participate in organised sports programmes. As more and more children participate in sports and recreational activities, there has been an increase in acute and overuse injuries. Emergency department visits are highest among the school-age to young adult population. Over one-third of school-age children will sustain an injury severe enough to be treated by a doctor or nurse. The yearly costs have been estimated to be as high as 1.8 billion US dollars. There are physical and physiological differences between children and adults that may cause children to be more vulnerable to injury. Factors that contribute to this difference in vulnerability include: children have a larger surface area to mass ratio, children have larger heads proportionately, children may be too small for protective equipment, growing cartilage may be more vulnerable to stresses and children may not have the complex motor skills needed for certain sports until after puberty. The most commonly injured areas of the body include the ankle and knee followed by the hand, wrist, elbow, shin and calf, head, neck and clavicle. Contusions and strains are the most common injuries sustained by young athletes. In early adolescence, apophysitis or strains at the apophyses are common. The most common sites are at the knee (Osgood-Schlatter disease), at the heel (Sever's disease) and at the elbow (Little League Elbow). Non-traumatic knee pain is one of the most common complaints in the young athlete. Patellar Femoral Pain Syndrome (PFPS) has a constellation of causes that include overuse, poor tracking of the patellar, malalignment problems of the legs and foot problems, such as pes planus. In the child, hip pathology can present as knee pain so a careful hip exam is important in the child presenting with an insidious onset of knee pain. Other common injuries in young athletes discussed include anterior cruciate ligament injuries, ankle sprains and ankle fractures. Prevention of sports and recreation-related injuries is the ideal. There are six potential ways to prevent injuries in general: (i) the pre-season physical examination; (ii) medical coverage at sporting events; (iii) proper coaching; (iv) adequate hydration; (v) proper officiating; and (vi) proper equipment and field/surface playing conditions.     

Musculoskeletal injuries in the pediatric and adolescent athlete

There are approximately 35 million children participating in organized sports in the United States. With this increasing participation, we have seen an overall increase in sportsrelated injuries in young athletes over the past 20 years. Young athletes suffer both acute and chronic, or overuse, injuries. They are susceptible to many of the same injuries as their adult counterparts, but due to the effects of growth on the musculoskeletal system, they are at risk for injuries to the growth plate, apophysis, and joint surface. Common acute and overuse injuries seen in young athletes are discussed here.     

Specific injuries induced by the practice of trampoline, tumbling and acrobatic gymnastics

Purpose

The recreational and competitive practice of acrobatic sports, that is, trampoline, tumbling and acrobatic gymnastics (ACRO), is growing rapidly around the world. Many studies described the injuries affecting young artistic gymnasts, but only few concerned acrobatic sports.

Methods

During a 5-year period, 357 traumatic events were collected in young acrobats practicing trampoline, tumbling or ACRO. Accident characteristics, level of expertise and training, injury location (upper limb, spine and lower limb), type of tissue injured (bone, cartilage, muscle, ligament and tendon) and provoking factors (intrinsic/behavioural and extrinsic) were investigated.

Results

Acrobats of national and international levels were mostly injured. Injuries occurring in acrobatic sports concerned predominantly the lower limbs and concerned in this body part mainly damages to ligaments. Forearm and knee injuries were preferentially related to trampoline. Ankle injuries were preferentially related to tumbling. Wrist injuries were preferentially related to ACRO. Upper limb bone damage and upper limb tendon damage were preferentially related to trampoline and ACRO, respectively. Intrinsic/behavioural factors were the main injury determinant in the three acrobatic sports.

Conclusions

The main injuries in acrobatic sports (i.e. lower limbs) are similar to those observed in artistic gymnastics. Specific injuries may result from falls and incomplete and/or erroneous figure’s landing and may also depend to the type of the landing surface.

Level of evidence

II.     

Acute hand injuries in athletes

Hand and wrist injuries in athletes are common, representing between 3 and 25% of all sports injuries. As many as a quarter of all sports injuries involve the hand or wrist. We review the recent literature regarding acute hand injuries in athletes based on the structures involved – bone, muscle/tendon, ligament, and neurovascular – including diagnosis and pathophysiology of these injuries, focusing on athlete-specific facets of treatment, and when available, opinions on return to play.     

Etiology and pathophysiology of tendon ruptures in sports

Of all spontaneous tendon ruptures, complete Achilles tendon tears are most closely associated with sports activities (1–3). Schönbauer (3) reported that 75% of all ruptures of the Achilles tendon are related to sports. In Plecko & Passl (2) the number was 60%. In our material of 430 cases, the number of sports-related Achilles ruptures was very similar (62%), while only 2% of ruptures of other tendons were sports-related (P<0.001) (1). Also, the majority of Achilles reruptures occurred in sports. The ruptures occurred most often in soccer (34%), track and field (16%) and basketball (14%). The distribution of Achilles ruptures according to different sports varies considerably from country to country, according to the national sport traditions. For example, in northern and middle Europe, soccer, tennis, track and field, indoor ball games, downhill skiing, and gymnastics are the most common; and in North America, football, basketball, baseball, tennis and downhill skiing dominate the statistics (1, 2, 4). In sports, some Achilles ruptures are not spontaneous or degeneration-induced but may occur as a consequence of the remarkably high forces that are involved in the performance (2). Ruptures in the high jump or triple jump are good examples. In such cases, failure in the neuromuscular protective mechanisms due to fatigue or disturbed co-ordination can frequently be found. The spontaneous complete rupture of the supraspinatus tendon of the rotator cuff does not occur very frequently in sports. Those sports that include high-energy throwing movements, such as American and Finnish baseball, American football, rugby and discus and javelin throwing, may, however, produce this injury. Partial tears and inflammations of the rotator cuff complex are much more frequent in throwing sports. The complete rupture of the proximal long head of the biceps brachii tendon is rare among competitive and recreational athletes. In our material, under 2% of these ruptures were associated with sports activities (5). The rupture (avulsion) of the distal tendon of the biceps muscle is rare. In sports, gymnastics, body building and weight lifting have been said to be able to produce this injury (6). In general, complete ruptures of the quadriceps tendon and the patellar tendon occur most often in older individuals. In our study, the mean age of these patients was 65 years (5). However, these injuries do also occur in younger age groups, especially in athletes. In athletes, the rupture most frequently occurs in high-power sports events, such as high jump, basketball and weight lifting, at the age of 15-30 years. A chronic patellar apicitis (jumper's knee) may predispose rupture of the tendon (7). As is the case with the rotator cuff complex, overuse inflammation and partial tears of the quadriceps and patellar tendons are one of the most characteristic athletic injuries. Complete spontaneous ruptures of other tendons in sports are rare, although the literature does provide case studies from almost every tendon the human body possesses (8–18).     

Management of anterior cruciate ligament injuries in skeletally immature adolescents

Anterior cruciate ligament (ACL) injuries in skeletally immature adolescents are bein diagnosed and reported with increasing frequency. Nonoperative management of midsubstance ACL injuries in adolescent athletes frequently results in a high incidence of giving-way episodes, recurrent meniscal tears, and early onset of osteoarthritis. An intraarticular ACL reconstruction (using the central 10-mm patellar tendon graft) in young athletes approaching skeletal maturity provides predictable excellent knee stability, and the athletes are able to return to competitive sports with a decreased risk of recurrent meniscal and/or chondral injury. Guidelines for the management of ACL injuries in skeletally immature adolescents are presented.     

Training issues in elite young athletes

Over the past decade, there has been a surge in the number of sports opportunities available to young athletes. Although physicians, parents, and coaches should promote healthy activity and participation, intense training at a young age can predispose exuberant young athletes to certain difficulties. Elite young athletes are at risk for overuse and growth plate injuries in certain sports. Intense training combined with inadequate nutrition may cause growth delay in elite young athletes, but this delay does not appear to affect permanent adult height. Weight training, when done properly, is safe and effective for prepubescent and pubescent athletes. Awareness of neurobehavioral development can help guide the process for appropriate sports participation. Young athletes should be closely monitored for signs of excessive physical and emotional stress so that sports participation can be fun and rewarding.     

Evaluation of overuse injuries in children and adolescents

With the increasingly competitive nature of many youth sports and with single-sport specialization occurring at young ages, overuse injuries are common among young athletes. Several growth-related factors contribute to the development of overuse injuries in children and adolescents, including the susceptibility of growth cartilage to injury and the adolescent growth spurt. This article will discuss these unique factors and provide an overview of the diagnosis and treatment of overuse injuries in this age group. Specific measures aimed at preventing overuse injuries in young athletes also will be presented.     

Potential risk of rerupture in primary achilles tendon repair in athletes younger than 30 years of age

BACKGROUND: Complete Achilles tendon ruptures are found more often in athletes who participate in sports involving explosive acceleration or maximal effort. In most studies, the consensus for athletes is surgery. This form of treatment has been shown to exhibit the best functional performance with a lower rerupture rate. HYPOTHESIS: Achilles tendon ruptures in a young population (<30 years) have a higher rerupture rate than similar injuries in an older age group (31-50 years), in which the injury is more common. STUDY DESIGN: Cohort study; Level of evidence, 4. METHODS: Retrospective study was carried out by chart review. Magnetic resonance images were obtained comparing appearance of repair in young and old patients at 8 to 12 weeks after operation. RESULTS: There were a total of 4 reruptures in the 89 Achilles tendon repairs. This was an overall rerupture rate of 4.5%, which was consistent with the literature. When the reruptures were critically analyzed, it was noted that the 4 reruptures of the repaired tendon occurred in a young population. Of the 89, there was a subgroup of athletes (n=24) who were 30 years of age or younger at the time of injury. The incidence of rerupture for these individuals was 16.6%. In the remaining athletes (n=65) older than 30 years, the incidence of rerupture was zero. There were no significant differences (P < or =.05) in all parameters measured (average days in a boot, average days to active range of motion, average time to full weight-bearing, average days to bike or use a stair climbing machine, average return to sports) between age groups except in the time from injury to surgery (7.1 days, for athletes < or =30 years vs 2.65 days for athletes >31 years). CONCLUSIONS: The results of Achilles tendon repair with an early weightbearing and an early range of motion rehabilitation program are good. However, caution may need to be taken in the younger athlete (< or =30 years) during rehabilitation. CLINICAL RELEVANCE: Although the authors recommend aggressive rehabilitation for Achilles tendon repairs, caution should be observed in the younger athlete.     

Cumulative incidence of shoulder region tendon injuries in male former elite athletes

Some types of sports are thought to include a high risk for shoulder region tendon injuries but little data exist on long-term cumulative incidence of these injuries. The aim of our study was to investigate shoulder region tendon injuries diagnosed by physicians in former elite male athletes participating in sports including maximal overhead manoeuvres (overhead athletes) and also other athletes before the age of 45 years and within the subjects' lifetime, compared to control subjects. A postal questionnaire was sent in 2002 to male former elite athletes (n=785; mean age 68 years when responding to the questionnaire; overhead athletes n=111, others n=674) and control subjects (n=416; mean age 67 years). Overhead athletes had a higher risk for shoulder region tendinopathy before the age of 45 (adjusted odds ratio (OR) 4.1, 95% confidence interval (CI) 2.0-8.4, p<0.001) and within lifetime (OR 1.8, 95% CI 1.1-3.0, p=0.027) compared to control subjects. Compared to controls the risk for tendon rupture before the age of 45 (adjusted OR 4.4, 95% CI 1.3-14.8, p=0.016) and within lifetime (OR 2.0, 95% CI 1.0-6.9, p=0.041) was also high in overhead athletes. There was no difference in the risks of shoulder region tendon injuries between the other athletes and the control subjects. Our data indicate that shoulder region injuries are common in athletes participating in sports including maximal overhead manoeuvres and the long-term consequences of these injuries for athletes' daily life and functional ability should be determined.     

Use of prescription drugs in athletes

Although athletes are young and generally healthy, they use a variety of non-doping classified medicines to treat injuries, cure illnesses and obtain a competitive edge. Athletes and sports medicine physicians try to optimize the treatment of symptoms related to extreme training during an elite athlete's active career. According to several studies, the use of antiasthmatic medication is more frequent among elite athletes than in the general population. The type of training and the kind of sport influence the prevalence of asthma. Asthma is most common among those competing in endurance events, such as cycling, swimming, cross-country skiing and long-distance running. Recent studies show that athletes use also NSAIDs and oral antibacterials more commonly than age-matched controls, especially athletes competing in speed and power sports. Inappropriately high doses and concomitant use of several different NSAIDs has been observed. All medicines have adverse effects that may have deleterious effects on elite athletes' performance. Thus, any unnecessary medication use should be minimized in elite athletes. Inhaled beta(2)-agonists may cause tachycardia and muscle tremor, which are especially harmful in events requiring accuracy and a steady hand. In experimental animal models of acute injury, especially selective cyclo-oxygenase-2 inhibitors have been shown to be detrimental to tissue-level repair. They have been shown to impair mechanical strength return following acute injury to bone, ligament and tendon. This may have clinical implications for future injury susceptibility. However, it should be noted that the current animal studies have limited translation to the clinical setting. Adverse effects related to the CNS and gastrointestinal adverse reactions are commonly reported in connection with NSAID use also in elite athletes. In addition to the potential for adverse effects, recent studies have shown that NSAID use may negatively regulate muscle growth by inhibiting protein synthesis. Physicians and pharmacists taking care of athletes' medication need to be aware of the medicines that an athlete is taking and how those medicines interact with performance, exercise, environment and other medicines. Sport associations should repeatedly monitor not only the use of banned substances, but also the trends of use of legal medicines in athletes. Not only physicians and pharmacists, but also athletes and coaches should be better educated with respect to potential benefits and risks, and how each agent may affect an athlete's performance. The attitudes and beliefs leading to ample use of legal medicines in athletes is an interesting area of future research.     

Bone marrow changes in stress injuries

Stress injuries and associated bone marrow changes are a common finding in athletes of all levels. Magnetic resonance imaging (MRI) is the imaging modality of choice for detecting characterizing and staging these injuries. However, because bone marrow edema patterns may also be seen in asymptomatic athletes, it is imperative for the sports medicine physician and the radiologist to closely correlate the imaging findings with the clinical signs and symptoms to assess the clinical significance of the imaging findings. This article reviews the pathophysiology, MRI findings, and clinical implications of stress injuries in athletes.     

Back pain in the pediatric and adolescent athlete

Clinicians taking care of athletes are likely to see many young patients complaining of back pain. The young athlete places significant repetitive stresses across the growing thoracolumbar spine, which can cause acute and overuse injuries that are unique to this age and patient population. Fortunately, by using a careful and systematic approach, with a sport-specific history, careful physical exam, and proper imaging, most problems can be properly identified. Although it is important to always remember that rare and more serious problems such as a neoplasm or infection maybe a source of pain in the athletic patient, most problems are benign and can be treated conservatively. Accurate diagnosis and management of back pain not only can prevent long-term deformity and disability, but it can also allow young athletes to return to doing what they love to do most: play sports.     

Characteristics of acute groin injuries in the adductor muscles: A detailed MRI study in athletes

Acute adductor injuries account for the majority of acute groin injuries; however, little is known about specific injury characteristics, which could be important for the understanding of etiology and management of these injuries. The study aim was to describe acute adductor injuries in athletes using magnetic resonance imaging (MRI ). Male athletes with acute groin pain and an MRI confirmed acute adductor muscle injury were prospectively included. MRI was performed within 7 days of injury using a standardized protocol and a reliable assessment approach. 156 athletes presented with acute groin pain of which 71 athletes were included, median age 27 years (range 18‐37). There were 46 isolated muscle injuries and 25 athletes with multiple adductor injuries. In total, 111 acute adductor muscle injuries were recorded; 62 adductor longus, 18 adductor brevis, 17 pectineus, 9 obturator externus, 4 gracilis, and 1 adductor magnus injury. Adductor longus injuries occurred at three main injury locations; proximal insertion (26%), intramuscular musculo‐tendinous junction (MTJ ) of the proximal tendon (26%) and the MTJ of the distal tendon (37%). Intramuscular tendon injury was seen in one case. At the proximal insertion, 12 of 16 injuries were complete avulsions. This study shows that acute adductor injuries generally occur in isolation from other muscle groups. Adductor longus is the most frequently injured muscle in isolation and in combination with other adductor muscle injuries. Three characteristic adductor longus injury locations were observed on MRI , with avulsion injuries accounting for three‐quarters of injuries at the proximal insertion, and intramuscular tendon injury was uncommon.     

Overuse injury and growing bones: the young athlete at risk.

Increasing numbers of children are becoming involved in competitive sport. International trends in pre-adolescent sports participation are mirrored in New Zealand, where promising young athletes are being exposed to high-intensity training from an earlier age. As a consequence, overuse injuries which were traditionally described in more mature athletes are now becoming recognized in pre-adolescents. The immature musculoskeletal system is less able to cope with repetitive biomechanical stress. Sites of overuse injury reflect the sites of rapid musculoskeletal development. It therefore behoves all medical practitioners, but particularly those in primary care, to be aware of the young athlete at risk. Inherent in the presentation of such musculoskeletal insult there often lurks an over-enthusiastic parent. We are all well reminded of the covert pressures adults may bring to bear upon children. Psychological, as well as physical injury often results.     

Imaging of sports injuries in children and adolescents

Sports injuries may be unique in childhood and adolescence due to the inherent weakness of the growing skeleton at specific sites, mainly the cartilaginous parts. Many injuries are predictable based on the known mechanism of injury encountered in certain sports. There are two distinct patterns of injury in sports; acute, and chronic or overuse. Imaging plays an important role in the diagnosis and management of these entities. Radiologists should be familiar with the advantages and limitations of the various imaging modalities when evaluating the injured young athlete. The present review focuses on the radiological findings and appropriate imaging approach in injuries that are typically or most commonly encountered in the skeletally immature athletes.     

The Special Olympics: An Injury Overview

In brief: The Special Olympics is a program of sports training and athletic competition for mentally retarded children and young adults. This article summarizes the injuries during the 1980 and 1981 New Jersey State Special Olympics. Eighty-seven of the 2,056 athletes as well as 47 spectators needed medical attention. There were only 58 athletic trauma injuries, and they were mild to moderate. Environmental factors were responsible for some heat cramps, fatigue, and sunburn. There were no seizures, medication problems, or difficulties related to the athletes' retardation. The injuries during the Special Olympics were similar in type and number to those in regular sports events. The results of this study show that it is safe for these athletes to participate in competitive sports.