m inimizing i njury r isk in y oung a thletes neeru jayanthi, m.d. emory university sports medicine...

MINIMIZING INJURY RISK IN YOUNG ATHLETES

Neeru Jayanthi, M.D.

Emory University Sports Medicine Center

President International Society for Tennis Medicine and Science

LOYOLA UNIVERSITY CHICAGO

EMORY SPORTS MEDICINE-ATLANTA

“EMORY TENNIS MEDICINE”

YOUTH SPORTS BACKGROUND

Overuse injuries in Young Athletes AMSSM Panel/Writing Group

Collaborative Research with Lurie Children’s (multiple grants)

Consultant (Unpaid): American Academy Pediatrics (AAP)

Council of Sports Medicine Fitness (COSMF)

Aspen Institute (Project Play) Mom’sTeam Institute WTA medical advisory board (Age

Eligibility Rule)

DISCLOSURE I have been flying around the country and

world for my work with WTA and the Society for Tennis and Medicine Science, and AMSSM and I have had to leave my pregnant wife at home Palm Springs, CA Miami, FL Rome, Italy Sioux Falls, South Dakota

DISCLOSURE (INCLUDE MILLAN PICTURE)

OBJECTIVES

To understand how to utilize the evidence to identify at risk training patterns in youth sports

To understand the potential successes and risks of sports specialized training

To understand how to counsel a young athlete on appropriate training recommendations that may reduce their risk of serious overuse injuries

COUNSELING?

USA TODAY-SAFE KIDS1.35 MILLION ER VISITS

Overuse injuries occur due to repetitive submaximal loading of the musculoskeletal system when rest is not adequate to allow for structural adaptation to take place.

BACKGROUND-OVERUSE INJURIES

American Medical Society of Sports Medicine (AMSSM)

Aspen Institute American Academy of Pediatrics (AAP) National Athletic Training Association (NATA) American College of Sports Medicine (ACSM) American Orthopaedic Society for Sports

Medicine (AOSSM) STOP campaign USA Youth Baseball Safe Kids Campaign Mom’s Team

“MESSAGING” OVERUSE INJURIES

WHAT HAPPENED TO YOUTH SPORTS?

FACES OF YOUTH SPORTS TODAY (INDIVIDUAL STORIES)

ORGANIZATIONAL AND COMMUNITY EFFORTS

Sports specific National Governing Bodies Youth sports leagues

DO WE PRACTICE WHAT WE PREACH?

INJURY MODEL

Injury Model

Predisposed Athlete

Susceptible Athlete

Injured Athlete

Intrinsic factors Extrinsic factors Inciting eventAge Demands of sport Acute injuryInflexibility Equipment Change in volumePrevious injury Conditions Change in mechanics

(Meeuwisse 1994)

SPECTRUM OF INJURY

Full Participation• Optimum performance

Performance affected• Biomechanical problem• Training load

Time Loss Injury• Training errors• Low/Intermediate risk injuries

High Risk InjuryProlonged absence/surgeryLong-term implications

TOO MUCH

Picture: http://i257.photobucket.com/albums/hh207/doodmiguel/SumoWrestler.jpg

EVALUATE RISK There is not enough data correlating training and

risk of development of a higher risk overuse injuries

Volume Sports Specializatio

n

Age and Growth rate

Prior Injury

EXPOSURE RISK

RISK FACTORS FOR MEDICAL WITHDRAWALS IN USTA JUNIOR NATIONAL TENNIS TOURNAMENTS

AGE & MEDICAL WITHDRAWAL INCIDENCE (JAYANTHI N, O’BOYLE J)

7.4

11.7

20.622.7

0

4

8

12

16

20

24

Medical Withdrawal/ 1000 Match Exposures

12's 14's 16's 18'sAGE

QUANTIFYING INJURY RISK

LEVEL OF RISK

RISK OF ATHLETE RISK OF INJURY

SPORTS PARTICIPATION

HIGH HIGHLY SPECIALIZED HIGH VOLUME >16 hrs/wkHIGH COMPETITION>8 months/yearHRS/WK > AGETRAINING RATIO >2:1PRIOR INJURY (back)RAPID GROWTH

SPONDYLOLYSISSTRESS FRACTURESGROWTH PLATEOCD

RESTRICT

INTERMEDIATE

MOD SPECIALIZEINTERMEDIATE GROWTHINTERMED VOL. <16 hrs/wk6-8 months/yearHRS/WK = AGETRAINING RATIO 2:1

APOPHYSITISAPOPHYSEAL AVULSIONSINSTABILITY

TEMPORARY RESTRICTIONS OR REDUCE

LOW MULTIPLE SPORTSRECREATIONALLOW VOLUME STATIC GROWTHTRAINiNG RATIO 1:1<6 months/year

PATELLOFEMORAL MUSCLE STRAINTENDONITIS

MINIMAL RESTRICTIONS, AS TOLERATED

SPECTRUM OF RISK

Where on the spectrum is your athlete?

•Diversified•Low volumesLow

•More specialized

•Moderate volumes

Int.•Highly specialized

•High volumes

High

SPECIFIC ADVISE TO REDUCE RISK?

PREVENTION

Are overuse injuries more preventable? Volume related Sports specialization (young athletes) Age related Sports specificity Biomechanical load Prior injury Sports specialization TRACK research (interventional counseling)

NCAA DATA

A more recent NCAA study describes 30% to be overuse and 70% to be acute/traumatic. Football was 8 times more likely to be acute Females twice as likely to be overuse

Yang et al 2012

Sampling problem of the 16 sports (biased towards more traumatic sports)

BONE STRESS INJURIES

29% of track and field athletes had MRI documented bone stress injury over 5 years

10.8% of all female athletes (mean age 18) had bone stress injuries Significantly increases with FAT risk factors

Nattiv, UCLA

HIGH SCHOOL DATA

RESULTS: A total of 2834 overuse injuries were reported

during 18 889 141 athletic exposures (15.0 per 100 000 athletic exposures).

Girls had greater rates of overuse injury (18.8) than boys (12.6)

Overuse injuries represented 7.7% of all injuries,

The most frequent site of injury was the lower leg (21.8%).

Injuries most frequently resulted in time loss of less than 1 week (50.0%), with only 7.6% resulting in time loss greater than 3 weeks.

AMSSM POSITION STATEMENT Approximately 49-53% of injuries in

young athletes are overuse rather then acute.

2133 charts retrospectively reviewed 53% overuse Female >male (overuse) Female 3 x more PFPS Female 90% hip/thigh overuse Males more contact/collision sports

YOUNG FEMALE ATHLETESS

Patellofemoral pain Point prevalence 16.3/100 young female athletes

Young female athletes more likely to develop patellofemoral pain if specialized Myer et al.

SPORTS SPECIALIZED TRAINING

What information would we provide non medical sports community to change this “perceived succcess by specialization”? Do we have evidence about

successes and risks?

TIGER WOODS

Study Sport(s) Athletes Evidence for (+): Study conclusions

Begin intense training before

age 12Specialize

before age 12

Begin intense training after

age 12

Diversify early, specialize after

age 12

Hume 199426Rhythmic gymnastics 106 across all levels + +

Amount of gymnastic training during development is related to level of attainment. All gymnasts participated in other sports, with no difference between elites and sub-elites. Enjoyment of gymnastics was strong predictor of attainment.

Law 200731Rhythmic gymnastics

6 elite 6 sub-elite + +

Elites and sub-elites began intense training at similar ages, but elites were involved in fewer other activities from age 4-16, and accumulated more hours training by age 16.

Helsen 199823Men’s' soccer, Men’s' field hockey

33 international 39 national 52 provincial +

Soccer began practicing at age 5, field hockey at age 9. Hours spent in practice were similar among levels until age 12. After age 12, international players spent more time in practice than national players, and national players spent more than provincial players.

Hodges 199625 Wrestling21 elite

21 club-level +

Elite wrestlers spent more time training after age 16 compared to club-level wrestlers. However, since all subjects began intense training at 13.2 + 0.6 yrs, comparison to early intense training (before age 12) not possible.

Soberlak 200344 Men’s' ice hockey 4 elite + +Elite players intensified their deliberate hockey training in late adolescence and played other sports during developmental years

Carlson 198813Men's and women's tennis

10 elite 10 near-elite + + Elite players began intense training and specialized later (after age 13-15) than near-elites (age 11).

Lidor 200232Various men’s' and women’s' sports

63 elite 78 near-elite + +

Elite more likely than near-elite athletes to begin intense training after age 12 and to have played >1 sport during developmental years.

Gullich 200622 Olympic sports

1558 German athletes from Olympic

promotion programs + +Elite athletes began intense training and competition in their sport later than near-elites (11.4 yrs vs 10.2yrs and 13.1 vs 12.0). More elites participated in >1 sport from age 11 than near-elites (64% vs 50%).

Moesch et al. 201139

Sports measured in cms, gms or secs*

148 elite 95 near-elite +

Elite athletes began intense training at a later age compared to near-elites. Near-elites accumulated more hours of training by age 9, 12 and 15 than elites, while elites accumulated more training by age 21 than near-elites.

Baker et al. 20035

Men's and women's field hockey, Men's basketball, Women's netball

15 elite 13 near-elite + +

Elites accumulated more hours of sport-specific practice from age 12 years onwards. However, all subjects began intense training at about age 12, so unable to compare to an early intense training group. Elites had broader range of sports experiences throughout their careers compared to near-elites.

Barynina 19926Men's and women's swimming

Elite Russian swimmers (number not reported) +

Swimmers who began specializing before 11 yrs of age spent less time on national team and retired earlier than later specializers.

Wall 200747 Boys' ice hockey

Parents of 8 minor league players (mean

age 13.9 yrs) and 4 ex-minor league players (mean age 14.5 yrs) +

Dropouts began off-ice training earlier than non-dropouts (11.75 vs 13.8 yrs of age) and spent more hours in off-ice training (107 vs 6.8 per year). Both groups participated in a similar number of other sports (4.75) from 6-13 yrs of age.

*Canoeing/kayak, cycling, orienteering, rowing, sailing, skiing, swimming, track and field, triathalon, weightlifting

IS 12 THE MAGIC NUMBER?

Higher proportion of injuries in those who quit all other sports before 12

Jayanthi et al.

WHO SPECIALIZES?

High level goals College? Professional?

Specialized training in higher median incomes >70,000 dollars and with

private insurance Jayanthi et al.

Technical, individual sports

NCAA STUDIES

Di-Fiori, et al.296 student athletes vs 164 studentsSimilar age of specialization (14-17 y/o)Parent or sibling in competitive sports (p<0.001)Unpublished

Malina et al.376 Div 1 Female athletes17% specialized (highest rates in individual sports)

Jayanthi, et al.318 student athletesMany chose their Univ sport as main sport in elem schoolMany played multiple sports in high school without year round trainingUnpublished

“TRAINING AND SPORTS SPECIALIZATION RISKS IN JUNIOR ELITE TENNIS PLAYERS,” JAYANTHI, DECHERT, LUKE ET AL.

<10 11 12 13 14 15 16 17 180%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

58%63% 61%

55%

71%

84%79%

88%

95%

Age

Per

cen

t S

pec

iali

zin

g

“TRAINING AND SPORTS SPECIALIZATION RISKS IN JUNIOR ELITE TENNIS PLAYERS,” JAYANTHI, DECHERT, LUKE ET AL.

• Relationship to injury

• If player specialized, 1.5 x more likely to have reported an injury (p<0.05)

• We do not know true specialization risks in all sports

• Can we separate sports specialization from the volume of training?

SPORTS PHYSICALS(UNINJURED)

SPORTS INJURY(INJURED)

AMSSM FOUNDATION GRANTS

AMSSM (American Medical Society for Sports Medicine) (two time recipient)

Foundation Grant to continue this study in Collaboration with Lurie Children’s Memorial Hospital, Chicago, IL

LONGITIDUNAL COMPONENT

PHASE 1: Ht/wt

UNINJURED

INJURED

PHASE 2: 2-3 year longitudinal phase

UNINJURED

INJURED

UNINJURED

INJURED

DEFINING SPORTS SPECIALIZATION

Intense Year Round Training in a Single Sport at the exclusion of other sports

Jayanthi et al., DiFiori et al.

Year round training/competition

> 8 months) Choose a main sport Quit all other sports

to focus on one sport

RATES AND DEGREES OF SPECIALIZATION

38%

34%Jayanthi, et al.

SPORTS SPECIALIZATION RATES  

baseball

basketball

cheerleading

cross country

dance

diving

football

gymnastics

lacrosse

soccer

softball

swimming

tennis

track & field

volleyball

wrestling

Highly specialized

15.42%

20.51%

28.30%

27.62%

25%

38.46%

12.32%

32.97%

26%

26.56%

22.89%

21.50%

47.95%

21.84%

24.18%

12.20%

baseball

basketball

cheerleading

cross country

dance

diving

football

gymnastics

lacrosse

soccer

softball

swimming

tennis

track & field

volleyball

wrestling

Low specialization

50.25%

47.34%

41.51%

43.81%

34.72%

30.77%

50.74%

21.98%

42%

39.06%

45.78%

45.79%

20.55%

44.83%

43.79%

48.78%F

RESULTS/STATISTICS

1191 athletes (Male 50.7%) Total of 1880 evaluations (35% are

follow up) Baseline

Uninjured 360 (30.1%) Injured 837 (69.9%)

INJURY TYPE Injury type:

Overuse: 564 injuries (66.4%)

Serious overuse (139/564) or (24.6%)

Traumatic: 286 (33.6%)

CLINICAL DIAGNOSIS

Injury causes/type (Clinical diagnoses) (confirmed

through EMR) Acute Overuse Serious Overuse

Stress fractures Spondylolysis/Stress Fracture OCD Elbow ucl, etc.

INJURY LOCATIONS

APOPHYSITIS/AI (96 CASES)O Growth rates higher

O Training volumes similar

O Developmental issue

SERIOUS OVERUSE INJURY RISK

DEGREE OF SPECIALIZATION

Overuse and Serious Overuse injuries more likely with increased specialization

Acute injuries less likely with increased specialization

TRAINING RULES

Age vs hours Train less hours week

then your age i.e. if 12 year old, train

less then 12 hours week (all physical activity, or just your sport)

16 year old….<16

SPORTS TRAINING RATIO

Do not exceed 2:1 ratio of organized sports to free play 12 year old

<12 hours/week total <8 hours/week organized sports >4 hours/week free play

AGE OF SPECIALIZATION

Higher proportion of injured athletes who specialized <12 years old vs > 12 years old

Higher proportion of serious overuse injuries in athletes who specialized <12 years old vs >12 years old.

Unpublished, Jayanthi et al. 2015

SOCIOECONOMIC FACTORS FOR SPORTS SPECIALIZATION AND INJURY IN YOUNG ATHLETES: A CLINICAL STUDY

Daniel B. Holt, B.S.1, Neeru Jayanthi, M.D.1, Alex Austin, M.D.2, Pasulka Jacqueline, B.A.3, Cynthia LaBella, M.D.3 and Lara Dugas, Ph.D.1,

1. Loyola University Chicago – Stritch School of Medicine, Maywood, IL

2. Cook County-Loyola-Provident Family Medicine Residency Program, Chicago, IL

3. Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL

SOCIOECONOMIC STATUS AND SPORTS PARTICIPATION

Low SES Schools Middle SES Schools

High SES Schools0

5

10

15

20

25

30

35

40

Perc

ent

of

Stu

dents

Pla

yin

g

Sport

s

Low SES Schools Middle SES Schools

High SES Schools0

5

10

15

20

25

30

35

40

Perc

ent

of

Stu

dents

Pla

yin

g

Sport

s

Low SES Schools Middle SES Schools

High SES Schools0

5

10

15

20

25

30

35

40

Perc

ent

of

Stu

dents

Pla

yin

g

Sport

s

Low SES Schools Middle SES Schools

High SES Schools0

5

10

15

20

25

30

35

40

Perc

ent

of

Stu

dents

Pla

yin

g

Sport

s

(Colabianchi N, Johnston L, and O’Malley PM, 2012)

SPECIFIC OBJECTIVE To determine whether the following factors are

associated with a risk of serious overuse injury in a diverse clinical population of young athletes. Insurance status Financial class

Median Income Race

METHODS Design:

Clinical Cohort Study Population:

Multi-Center (Loyola - Chicago and Lurie Children’s) Sports Medicine and Primary Care Clinics

7-18 year-old young athletes

Injured and Uninjured

METHODS Demographic information was collected and analyzed:

Public Assistance vs. Private Insurance Public Assistance <

$31,716/year Low, Medium, High

Socioeconomic Status Divided into tertiles based

on median household income by zip code

US Census Bureau: 2007-2011 American Community Survey

RESULTS Athletes included in study = 1,121

94% of young athletes who initially completed the survey were included

Public Assistance = 19% 33% in Low, Medium, and High SES tertiles

$111,499, $71,440, and $48,895

RESULTS

Free Play Organized Sports0

2

4

6

8

10

12

7.13

10.35

5.23

10.69

6.00

10.00

5.53

10.55

5.25

11.27

Type of Play vs. SES and Insurance

Public AssistancePrivate InsuranceLow SESMedium SESHigh SES

Hou

rs/W

eek

RESULTS

Public Assis-tance

Private Insurance

Low SES Medium SES

High SES0.00

0.50

1.00

1.50

2.00

2.50

1.45

2.04

1.671.91

2.15

Sports Training Ratio

Org

an

ized

Pla

y:F

ree P

lay

RESULTS

Public Assis-tance

Private Insurance

Low SES Medium SES

High SES

7.8

8.9

7.68.6

9.7

Months/year competing Main Sport

Mon

ths/y

ear

com

peti

ng

main

sp

ort

RESULTS

Spec

ializ

atio

n Rat

e

Serio

us O

veru

se In

jury

0.00

15.00

30.00

45.00

18.1811.11

30.22

16.9918.37

7.84

24.0019.78

41.81

19.86

Effect of SES and Insurance on Spe-cialization Rate and Serious Overuse

Injury

Public AssistancePrivate InsuranceLow SESMedium SESHigh SES

Rate

(%

)

CONCLUSIONS Young athletes on public assistance may be

protected from serious overuse injury due to: A greater amount of free play and lower sports

training ratio

Young athletes on public assistance and of lower socioeconomic status may be protected from serious overuse injury due: Lower sports specialization rates

SPORTS SPECIALIZED TRAINING: 2+ YEAR FOLLOW UP: PRELIMINARY RESULTS

RE-INJURY, REPEAT INJURYGOOD NEWS!! GREAT FOR BUSINESS!!

  Re-injury Repeat Injuries

Total Injuries

Responses

6 month 60 38 110 256

12 month 34 27 72 160

18 month 28 31 59 120

24 month 22 15 40 83

REINJURY

Recurrence: Any type of injury following a previous injury.

Repeat: Same type of injury

45% recurrent/repeat injuries

Jayanthi et al. 2+ year follow up

HOW DO WE MINIMIZE INJURY RISK?

EARLY RECOGNITIONEARLY INTERVENTION

Rehabilitative Training volumes/Cessation of sport Biomechanical flaws Identification of high risk overuse

injuries/imaging Late stage lesions

LATE STAGE LESIONS

Pars Interarticularis 0% healing

OCD Fragmentation/instability

Apophysitis Late stage Chronic Ossicles

SPORTS-RELATED LOW BACK PAIN Initial Plain xray 48.5% xray negative low

back problems were found to have spondylolysis

Physical exam not helpful

Kobayashi et al, AJSM 2012

MRI MRI with pars sequencing

(lumbar spine)

PARS STRESS INJURIES Healing rates vary

considerably by stage of spondylolysis

Late stage spondylolysis may have close to 0% bony healing rates

Need early recognition (by patients/parents/coaches/ATPT) in addition to sports medicine physician

REINJURY

Some successful programs to prevent primary injury ACL

Myer Silvers LaBella

The most success is in the previously injured (effect on risk reduction). Hamstring

Bahr

Serious overuse injuries?

REHABILITATIVE DEFICITS

Young females with PFPS may predict future ACL risk

Myer et al.

TRAINING RULES

Age vs hrs Sports training ratio Year round (8 months) Sports specialized training

SPORTS SPECIFIC RECOMMENDATIONS

Pitch volumes Tennis tournament training guidelines

SPORTS MEDICINE

If we really want to get more business, we should tell young athletes: Play more hours/week then age Play >2:1 sports training ratio Start specialization before the age of 12 Play an individual sport Be a female? Have a prior injury …we know you will probably need to see us!

BIOMECHANICAL ASSESSMENTS Courtesy of

Sergio Gomez-Cuesta MSs (App Biomech)

Head of Physiotherapy and Biomechanical Analysis

LTA International High Performance Centre, Gosling Sports Park, UK

TRAINING, RISK ASSESSMENT, AND COUNSELING IN KIDS (T.R.A.C.K)

May Lower Risk of Serious Overuse Injury By Being less specialized in sports Doing less hours of sports in a

week than your age Increasing Free Play so your Sports

Ratio is NOT >2:1.

Having at least 3 months off a year Having at least 1 day off a week

ONGOING RESEARCHTRACK (Training Risk

Assessment and Counseling in Kids)

CONTROL N=252One time counseling and

serial risk assessment

INTERVENTION N=252

Serial counseling Risk Assessment

Risk Assessment

Risk Assessment

Risk AssessmentSPORT Counseling

Risk AssessmentSPORT Counseling

Risk AssessmentSPORT Counseling

TENNIS What age did you start using the Kick

(topspin) serve? How many tournaments per month? How many matches in last 3 months? Any medical withdrawals in last 3 months?

BASEBALL/SOFTBALL During last 3 months,

have you continued to throw or pitch with arm pain/fatigue during a practice, game or tournament?

How many pitches do you throw in a typical game?

How many months off from pitching?

At what age did you start throwing a breaking ball (curve or slider)?

http://photos2.demandstudios.com/dm-resize/photos.demandstudios.com%2F116%2F16%2Ffotolia_175752_XS.jpg?w=391&h=10000&keep_ratio=1

BASKETBALL, FOOTBALL, HOCKEY, AND/OR SOCCER

During last 3 months, have you been involved in an ACL injury prevention program or training program aimed at injury prevention?

During the last 3 months, have you continued to play through a practice or competition after suffering a head injury and/or feeling symptoms of light-headedness, dizziness, and/or headaches?

Is your equipment checked by a qualified coach or athletic trainer before each season?

http://www.politicspa.com/wp-content/uploads/2011/08/peewee-football-300x239.jpg

TRACK-PRELIMINARY DATA

Nearly 400 athletes (2 institutions): Intervention group: 27.7% injured Control group: 45% injured

MESSAGING FOR OVERUSE INJURIES

JUST DON’T OVER DO IT.

Don’t give 110%...you can stop at 100!

No! Actually, it is more likely from extrinsic modifiable causes such as excess training volume or sports specialization or neuromuscular training.

THANK YOU!