Young Athletes and Rehabilitative Therapy

During the past half-century, the number of young people involved in organized athletic programs has increased dramatically. At the beginning of this decade, at least 30 million children were estimated to be participating in soccer, football, swimming, gymnastics, hockey and figure skating, as well as baseball.¹ Not surprisingly, as participation increases, so do injuries. It has been reported that sports injuries to young people now exceed infectious diseases.²

Classification of Injuries

There are two classifications of sports injuries: acute traumatic and overuse. The mechanism involved in acute traumatic injury is generally a single blow or twist acted upon the body, with the resulting injury being a strain, sprain or fracture. In the overuse category, repetitive training or microtrauma can produce chronic inflammation or stress fracture.

Low Back Pain

Low back pain in young athletes ranks high in all sports, especially in gymnastics, figure skating and dance. Repetitive flexion, extension and or rotational movements correlate with increased incidents of low back pain.³

It is important to know the difference between types of low back injuries in adults and children (see Table 1).⁴ It is also important to be aware of the differences in presentation of possible spondylolysis versus lumbosacral strain symptoms. Though each case is unique, certain generalities may be observed (see Table 2).⁵

Young athletes who present with spondylolysis symptoms and a history of repetitive hyperflexion, hyperextension and rotational activities should receive anteroposterior, lateral and oblique lumbar radiographs. In cases where a complete fracture is suspected, single-photon emission computerized tomography may reveal a developing stress fracture before it is evident on plain films. Early conservative intervention and treatment can result in complete healing of the pars interarticularis defect. The longer a pars defect persists, the more likely it is to progress to an outright fracture.

Specific rehabilitative exercises must be a part of conservative management. Special attention should be placed on strengthening and balancing the relationship of the abdominal and back extensor muscles. Two back exercises that are particularly effective are forward flexion and back extensors. If there is anterior pelvic rotation noted during the evaluation, left and right lumbar rotational exercises should be included to strengthen and balance the internal and external obliques.

Lower Extremity Injuries

The pediatric athlete with open physeal plates is more susceptible to growth plate injuries and avulsion fractures rather than the ligament and muscle-tendon injuries that most often occur in adults.⁶ Bony contours are not as well defined in children due to incomplete ossification. The chiropractor must look for certain types of injuries based on the history and physical findings, because radiographic signs may be difficult or impossible to see.⁷

In a survey of older, more elite young athletes, Hutchison et al. reported on injuries that required physical or medical assistance for participants at the United States Tennis Association National Boys' Tennis Championships from 1986-1988 and from 1990-1992. Over the six-year period, a total of 304 athletes (21.1%) sustained new or recurrent injuries that required evaluation by the healthcare team. The analysis of injuries showed a higher rate of lower extremity injuries than upper. When evaluated by anatomic regions, back injuries were most common, followed by thigh, shoulder and ankle injuries, respectively. When evaluated by injury type, strains and sprains were most common (71% of all injuries), with fractures and dislocations being rare (1.3% of all injuries). The lower extremity provided the majority of sprain-type injuries, with 87.5% of ligament sprains coming from the knee and ankle.⁸

In the case of the knee, differential diagnosis of children's knee injuries includes not only the typical adult injuries to bone, ligament and cartilage, but also growth plate injuries.⁷ Anterior cruciate ligament (ACL) injuries in skeletally immature adolescents are being diagnosed and reported with increasing frequency.⁹

As a major weight-bearing joint, normal hip function is fundamental to successful sports participation. Hip injuries are not responsible for a large percentage of sports-related injuries, and the young child rarely sustains a significant hip injury.¹⁰ However, the chiropractor must keep in mind that the immature skeleton of the adolescent is relatively injury prone, and the demands of sports often exceed the capacity of the growing musculoskeletal system.

As with low back pain, many lower extremity injuries can be treated using specific rehabilitative exercises as part of a conservative management regimen. The use of surgical tubing equipment is very effective in cases of strain and to enhance joint stability.

Postural Support

An often overlooked component of many low back and lower extremity sports injuries is pronation, a pedal imbalance which causes an anterior shift in weightbearing. This shift can have negative effects on the entire kinetic chain. Custom orthotics help support young athletes when they are wearing street or athletic shoes. If they participate in bare feet, such as in gymnastics, a simple taping to support the medial arch will be of benefit.

References

1. National Institute of Health. Conference on Sports Injuries in Youth: Surveillance Strategies: Proceedings: April 8-9, 1991. Bethesda, MD: National Institute of Health Publication 93-3444.
2. Pipe A. Consternation midst perspiration: sports medicine and children. Presented at the annual meeting of the Canadian Orthopaedic Association. Winnipeg, Manitoba: June 14, 1993.
3. Harvey J, Tanner S. Low back pain in young athletes: a practical approach. Sports Med 1991;12:394-406.
4. Micheli L, Wood R. Back pain in young athletes, significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med 1995;149:15-17.
5. Conner S. Sports-related back injuries. Rehab Management 1994;7(5):53-57, 136.
6. Best TM. Muscle-tendon injuries in young athletes. Clin Sports Med 1995;14(3):669-686
7. Smith AD, Tao SS. Knee injuries in young athletes. Clin Sports Med 1995;14(3):629-650.
8. Hutchison MR, Laprade RF, Burnett QM 2nd, Moss R, Terpstra J. Injury surveillance at the USTA Boys' Tennis Championships: a 6-yr study. Med Sci Sports Exerc 1995;27(6):826-830.
9. McCarroll JR, Shelbourne KD, Patel DV. Anterior cruciate ligament injuries in young athletes. Recommendations for treatment and rehabilitation. Sports Med 1995;20(2):117-127.
10. Boyd KT, Peirce NS, Batt ME. Common hip injuries in sport. Sports Med 1997;24(4):273-288.