Prevent overuse injuries in child athletes: Info for family physicians

Shifts in American culture have led to a rise in sports-related overuse injuries in children, says Robert Gotlin, DO.

“Certainly, parents want to raise their kids to be healthy and happy,” says Dr. Gotlin, the director of orthopedic and sports rehabilitation at Mount Sinai-Beth Israel Medical Center in Manhattan. “But the culture has changed to add in the need to be the best athlete in town as well.”

Some parents seek to live vicariously through their children, notes Dr. Gotlin, while others see athletic prowess as a ticket to a scholarship or even a professional career.

“The reality is that very few kids get to that level, no matter how good they are,” he says. “But parents still push and think that they can be in that 1%.”

Organizations such as the American Academy of Pediatrics and the American Medical Society for Sports Medicine have attested to the rise in children playing sports and sports-related overuse injuries in kids.

In his 25 years of practicing sports medicine, Dr. Gotlin has noticed that kids coming in with overuse injuries are getting younger all the time. He used to mainly see teenagers with these injuries, but he now treats children as young as 9 years old, and he says children as young as 3 are presenting with overuse injuries from specializing in one sport too soon.

Nearly half of American children who play sports train and compete in a single sport year-round, a recent AOA survey of more than 1,000 parents revealed. Released in October, the survey also found that one-quarter of child athletes had had an overuse injury, according to their parents. Consistent with Dr. Gotlin’s observations, parents reported that their children begin focusing on a single sport around age 8, though some children begin doing this at age 3. Soccer, basketball and baseball or softball are the most popular year-round sports for kids, the survey found.

Primary care physicians and pediatricians are often the first point of contact for a child with an overuse injury. The DO spoke with several sports medicine physicians who offered advice on treating these children, including what to watch for, how to counsel parents and when to refer patients to a specialist.

‘People need rest’

To prevent injury before it happens, primary care physicians and pediatricians can ask their patients what physical activities they engage in and watch for signs that a child has lost interest in playing a sport, Dr. Gotlin suggests.

“Kids will say they have a stomachache, which is made up in their head because they don’t want to play,” he says. “And they claim fatigue. They give hints that they’ve had enough, but unfortunately, their parents and coaches often say, ‘Oh come on, suck it up, you can do it.’ ”

Most physicians and parents miss these early signs that a child is being overworked, notes Dr. Gotlin, who says that children lacking desire to play are most vulnerable to injury because they are easily distracted and less vigilant.

When talking with parents, Dr. Gotlin recommends acknowledging the benefits of sports while noting the necessity of rest.

“Organized sports build character, discipline and confidence,” he says. “There are many good things about being on a team, but when the child loses control and it becomes more of a coach or a parent guiding the activity, then we have problems.”

To avoid overuse injuries, child athletes should take at least a day off per week and a month off per year, says Patrick F. Leary, DO.

“People need rest,” says Dr. Leary, the director of sports medicine at the Lake Erie College of Osteopathic Medicine in Erie, Pennsylvania. “And certainly, children with open growth plates need to have rest because they are more susceptible to injury.”

Children should not be encouraged to focus on one sport, Dr. Gotlin says. If the child is only interested in playing one sport, he or she should take at least one season off every year.

When he talks to overzealous parents, Dr. Gotlin says he comes to the table armed with facts. Parents sometimes need to see hard evidence that overuse injuries are real injuries and not just perceived, he says.

Primary care physicians can cite data from the AOA survey and can also use information from the American Medical Society for Sports Medicine’s recent position statement on overuse injuries in youth sports. Studies estimate roughly half of all sports injuries are due to overuse, elite soccer players younger than age 14 are more prone to overuse injuries than older players, and high school athletes playing sports year-round report 42% more overuse injuries than those playing seasonally, according to the statement.

David Carfagno, DO, recommends meeting with the parents separately from the child.

“Have a mini-parent conference,” says Dr. Carfagno, the owner and medical director of the Scottsdale Sports Medicine Institute in Arizona. “I’ll say ‘Hey, why don’t you take your kid out for a few weeks. It will help not only orthopedically, but also mentally. It will give him or her a chance to just be a kid.’ I’ve had great success with that.”

Dr. Carfagno also gives parents follow-up calls to remind them of his recommendations.

“With a phone call, you get parents outside of the realm of the doctor’s office,” he says. “The exam room can be intense because you are giving parents a lot of very powerful, volatile information that could determine their kid’s activity level over the next three to 12 months.”

Caution parents on the dangers of burnout, suggests Dr. Leary, who is also the president of the American Osteopathic Academy of Sports Medicine.

“If you have your kids excelling at age 10 and 12, they may suffer from burnout at age 16, 17, 18 when we really want them participating in sports so that they’re not getting into the other negative things that teenagers can get into,” he advises parents.

Pushy parents are often themselves pushed by coaches, Dr. Carfagno notes, and he suggests speaking to the coach directly if possible, which physicians who are established community leaders can do easily.

“I would urge primary care physicians to be present in their communities,” he says. “Don’t just be an isolated physician in your clinic waiting for athletes to come to you. Get out there and establish your competency.”

Physicians can get to know coaches through volunteering at their children’s schools and participating in other community service activities, Dr. Carfagno says.

When to refer

Primary care physicians treating children with overuse injuries also must know when to refer these patients to a sports medicine physician. Dr. Carfagno suggests referral if the physician is uncomfortable treating orthopedics or if preliminary treatment doesn’t heal the injury.

“If you have tried a conservative route with a basic injury for the first two to four weeks and it’s not better, then you can send the patient over,” he says. “This applies to knee, shoulder or elbow pain or a strain or tendonitis, among other injuries.

“It’s amazing how many physicians just send the patient over right away. Primary care physicians should have the autonomy to try treating the injury and working with the patient first.”

Referring patients to physical therapy is also an option, particularly if they have soft-tissue injuries or tendonitis, Dr. Carfagno notes.

Referral is also a good idea when parents are stubborn or resistant to pull an injured child off of a sport for a season, Dr. Leary notes.

“Sometimes parents need to hear it from somebody else,” he says. “It happens to me, too. Sometimes I need to send patients to another physician, my partner or maybe an orthopedic surgeon, so they get the same statement again.”