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Participation in competitive athletics is a very beneficial endeavor and can be an important outlet for young athletes to help them develop important life skills that are applicable both on and off the fields, and courts. In the pursuit of winning and producing the next star athlete these benefits can be transcended and unfortunately lead to significant injury. Injuries are not always preventable, however, there are several guidelines and practices that can be implemented to try and reduce the chances that these will occur.
Proper conditioning including core strengthening,stretching, and maintenance of a normal range of motion are important to the overall health of the athlete and forms the basis for injury prevention. Learning proper body mechanics specific to the sport you are training for in conjunction with core conditioning is essential to utilize proper muscle groups and to minimize injuries. Participation in general health and core conditioning can help avoid fatigue, particularly late in games, which can commonly lead to a loss of proper mechanics. The loss of proper mechanics leads to improper loading of the shoulder and elbow and can lead to increased stresses on ligaments, growth plates and tendons. There can be increased stress on knee and ankle joints. This increased stresses on the body can lead to injuries.
Sports competition is an important part of many young people’s lives, it is important to encourage participation while attempting to prevent injuries.
By Richard A. Zell, M.D.
The Achilles tendon is the largest and strongest tendon in the body. The Achilles tendon is formed from the confluence of the Soleus and the Gastrocnemius and inserts on the calcaneus over a broad area (2x2cm). The Achilles tendon plays a vital role in gait and running. As people are more active in the summer months overuse disorders of the foot and ankle become more prevalent. Many of these conditions involve the Achilles tendon.
In children, inflammation of the Calcaneal Apophysis or Severs disease is a common cause of posterior heel pain. This condition often affects active children (soccer players, etc.) in their high growth years. The condition is characterized by pain over the Achilles tendon insertion on the calcaneus. The condition is often bilateral. Symptoms are exacerbated by running and other sports. Achilles tendon stretching is the most important component of treatment. A lift in the shoe can sometimes be helpful. For recalcitrant cases a course of physical therapy and splinting are necessary. Severs Disease (as with Osgood Schlatter Disease in the knee) is self-limited and resolves as growth is completed.
Achilles tendon problems are also common in the adult population. There are different stages of Achilles tendonitis. Initially, there is an inflammation of the peritenon or lining of the Achilles tendon. Later stages involve inflammation and degeneration of the tendon tissue. The area most vulnerable is the avascular zone located 2-6cm proximal to the calcaneus. This condition affects active individuals involved in running and jumping such as tennis players and joggers. Achilles tendonitis is associated with: overuse syndromes, foot deformities (such as flatfoot or pes cavus), training errors, poor footwear or underlying inflammatory arthropathy. Patients report posterior heel pain , start up pain (increased pain as they start to walk) and difficulty playing sports. Physical exam demonstrates: tenderness, decreased ankle motion, increased temperature, edema and thickening of the tendon. Radiographs can demonstrate calcification within the tendon and possibly cortical erosion (in patients with inflammatory arthropathy.) An MRI can demonstrate partial tears of the tendon and tendonosis.
Most cases of Achilles tendonitis are successfully managed non-surgically. The initial and most important treatment of Achilles tendonitis is heel cord stretching. A tight heel cord compromises the normal mechanics of the foot. Heel cord stretching exercises are straight-forward (patients are given a hand-out or attend one visit of physical therapy) and should be performed several times per day. Heel lifts, shoewear modifications and orthotics (especially in patients who pronate) can be helpful. Brief courses of NSAIDS are occasionally used. With continued symptoms, a patient is referred to physical therapy for a program of modalities (ultrasound, etc.) and more intensive stretching. Dorsiflexion braces used at night are also quite helpful. Some patients require a period of immobilization in a cast or removable boot. Steroid injections are not used in the area of the Achilles tendon given the high risk of tendon rupture. Surgery is rarely needed but if necessary consists of debridement of the Achilles tendon sheath and tendon. At times, the Achilles tendon has such degenerative disease that tendon transfers are required to replace the diseased Achilles tendon.
Posterior heel pain can also be caused by inflammation of the Achilles tendon insertion. These patients have similar symptoms and limitations to patients with Achilles tendonitis. Physical exam demonstrates tenderness in the region of the Achilles tendon insertion. The calcaneus is often more prominent in the area of the Achilles tendon insertion (a condition termed Haglunds Deformity.) There can also be calcification in the area of the Achilles tendon insertion. Most often non-surgical treatment is successful. For continued symptoms, surgery is required to remove the prominent calcaneus that impinges on the Achilles tendon. Achilles tendon ruptures are common injuries in the summer months. Ruptures are most common in males (5:1 male to female ratio) and occur in middle-aged and older adults. Achilles tendon ruptures are common in weekend warriors who stress their deconditioned gastroc-soleus muscles in activities such as tennis or basketball. An Achilles tendon rupture can also occur after jumping from a height or a fall. Other factors that predispose an individual to Achilles tendon rupture include: preexisting Achilles tendonitis , systemic inflammatory arthritis, endocrine dysfunction (renal failure, hyperthyroidism), infection and use of fluoroquinolone antiobiotics or steroids.
Most patients report a “pop” after a misstep, jump or push off. Patients often state that they feel as if they were kicked in their calf. Most patients (but not all) report difficulty ambulating and feelings of weakness. Physical exam demonstrates: ecchymosis, swelling and a palpable gap at the rupture site (usually 2-6 cm from the calcaneus. The Thompson test (squeeze the calf to elicit plantarflexion of the foot) is the classic test to determine the integrity of the Achilles tendon. Radiographs are obtained to assure that there is no bony avulsion associated with the tear. An MRI can be obtained when the diagnosis is not clear.
Management of Achilles tendon ruptures include: casting/bracing or operative repair. Casting avoids the risks of surgery (infection, wound healing problems) but has a risk of re-rupture. At times the tendon heals in an elongated position with resultant decrease in strength. Surgical treatment is favored in younger and active patients. With current surgical techniques patients are allowed to weight bear within two weeks of surgery in a brace. The results of operative repair are good and allow the individual to return to sports.
© 2008 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author
Athletic Injuries of the Shoulder and Elbow in the Young Adult
By Derek S. Shia, M.D.
Athletic injuries involving the shoulder and elbow are common problems and range in severity from simple overuse and muscle strains that may require only conservative measures including icing and rest, to fractures and ligament ruptures that can require surgery. As competitive participation in sports continues to be a very important part of life, injuries as a result of repetitive trauma continue to be commonplace. While the shoulder and elbow are separate joints, within the mechanics of throwing and other athletic endeavors these two joints are closely related and pathology in one or the other can affect normal kinematics and result in injury. It is important to recognize overuse injuries early in order to avoid permanent problems.
Participation in competitive athletics is a very beneficial endeavor and can be an important outlet for young athletes to help them develop important life skills that are applicable both on and off the field. In the pursuit of winning and producing the next star athlete these benefits can be transcended and unfortunately lead to significant injury. Injuries are not always preventable, however, there are several guidelines and practices that can be implemented to try and reduce the chances that these will occur.
Proper conditioning including core strengthening and stretching are important to overall health of the athlete and forms the basis for injury prevention. Participation in general health and core conditioning can help avoid fatigue, particularly late in games, which can commonly lead to a loss of proper mechanics. The loss of proper mechanics leads to improper loading of the shoulder and elbow and can lead to increased stresses on ligaments, growth plates and tendons. This increased stress can lead to injuries. Learning proper throwing mechanics is extremely important which in conjunction with core conditioning involves improving arm and body position in order to utilize large muscle groups to minimize injuries.
Maintenance of a normal range of motion in athletes through stretching is important particularly of the shoulder. The loss of shoulder motion can lead to abnormal shoulder kinematics and can result is both shoulder and elbow injuries. One particular abnormality that is often seen in throwing athletes is the loss of internal rotation with the shoulder in 90 degrees of abduction. This is a result of compensatory tightness of the posterior capsule of the shoulder and leads to GIRD (Glenohumeral Internal Rotation Deficit). A side to side difference in the range of motion of the shoulder in throwing athletes is very common but as that difference increases above 20 degrees it is considered pathologic. This capsular tightness can lead to internal impingement of the shoulder that over time can develop into rotator cuff and labral tears in the shoulder, as well as injuries around the elbow. Stretching the posterior capsule through several exercises can help to prevent injuries throughout the season. Several studies involving professional athletes from tennis and baseball have demonstrated the importance of these stretches in preventing injuries over the course of the season. Two common stretches that are utilized include the sleeper stretch and the cross arm stretch.
The sleeper stretch is performed lying on the patients affected side. The affected arm is brought into 90 degrees of abduction and the arm is stretched in internal rotation. The point of the stretch is to feel the stretch in the posterior aspect of the shoulder, not in the front. The stretch should be performed slowly and should not be painful. The second stretch is performed with the arm adducted across the body. Pressure is applied with the opposite arm on the upper arm. It is important to perform these exercises multiple times per day to achieve maximal effects.
In addition to stretching exercises it is important to keep the rotator cuff musculature in shape through preventive strengthening. Unlike strengthening exercises involving large muscle groups such as the deltoid, pectoralis major, and biceps which can require heavy weights, rotator cuff strengthening usually requires 2-5 lb weights or resistance bands. The rotator cuff is often ignored during weight training for sports and its health and strength is integral for optimal shoulder function. A rotator cuff strengthening program should be incorporated into all conditioning programs but particularly for throwing athletes, swimmers, and overhead athletes.
Pitch counts and types of pitches are important for all pitchers but particularly for younger patients who are skeletally immature (e.g. still growing). In these patients the bones involving the shoulder and elbow joints are not fully mature and are at a higher risk for serious injury than fully grown patients. For this reason it is important to restrict players from throwing certain pitches depending on their age. In addition it is important to take pitch counts into account, depending on the players age pitch counts should be accurately recorded and not exceeded. The little league association in conjuction with orthopedic surgeons have published guidelines regarding pitch types and pitch counts and rest intervals. These guidelines have been published for the protection of the players and are used to ensure that they can avoid overuse injuries. Often athletes can play for multiple teams, select teams, all-stars etc. It is important that information about pitch counts and days of rest are shared between different coaches. Even if an athlete is “needed” for a big game or help with a double header it is important to think about the best interest of the athletes arm, even in professional sports pitchers require rest between starts. The implementation by little league of these rules in 2007 have lead to a significant reduction in injuries and a decrease in the numbers of Tommy John Surgeries performed (reconstruction of the ulnar collateral ligament of the elbow).
Pitchers league age 14 and under must adhere to the following rest requirements:
If a player pitches 66 or more pitches in a day, four (4) calendar days of rest must be observed.
If a player pitches 51 - 65 pitches in a day, three (3) calendar days of rest must be observed.
If a player pitches 36 - 50 pitches in a day, two (2) calendar days of rest must be observed.
If a player pitches 21 - 35 pitches in a day, one (1) calendar day of rest must be observed.
If a player pitches 1-20 pitches in a day, no (0) calendar day of rest is required.
Pitchers league age 15-18 must adhere to the following rest requirements:
If a player pitches 76 or more pitches in a day, four (4) calendar days of rest must be observed.
If a player pitches 61 - 75 pitches in a day, three (3) calendar days of rest must be observed.
If a player pitches 46 - 60 pitches in a day, two (2) calendar days of rest must be observed.
If a player pitches 31 -45 pitches in a day, one (1) calendar day of rest must be observed.
If a player pitches 1-30 pitches in a day, no (0) calendar day of rest is required.
Several things are important to watch out for in any throwing athlete including loss of velocity or loss of control. Other signs of fatigue include the loss of proper throwing technique or increasing time between pitches. If these signs are observed then increased rest for the player is required. The loss of range of motion of the elbow with inability to completely extend or flex the elbow is important to watch out for and usually represents underlying pathology in the elbow. Any pain that the player is having while throwing requires immediate cessation of throwing and evaluation by a sports medicine physician.
A thorough history is vitally important including the type of sport the player is engaged in. If the patient is a baseball player it is important to find out the patients position, how many games are played each week, as well as pitch types. It is important to determine when the pain started, was it an acute event with one pitch or hit or has it been gradually worsening. When is the pain occurring: constant, with the early cocking phase of throwing, follow through etc. Are there mechanical symptoms: catching, clicking locking, instability.
Radiographic evaluation of the shoulder and elbow is important part of the initial evaluation of an injury and can demonstrate open growth plates, possible stress fractures, and signs of osteochondral lesions. Many times depending on the symptoms of the patient or due to failure of nonoperative treatment an MRI is ordered. MRI’s can add a lot of information regarding the soft tissue component of an injury. The addition of intra-articular contrast can also be beneficial particularly for detection of labral pathology around the shoulder and ligament pathology around the elbow.
Sports competition is an important part of many young people’s lives, it is important to encourage participation while attempting to prevent injuries. Through appropriate training, stretching and mechanics as well as following pitching guidelines many injuries can be effectively avoided.
By Alan M. Reznik, M.D., MBA
There is a lot of excitement about “evidence-based” medicine these days. It is as if clinical research was absent in the past. We all know medicine is not the “Wild West” as some would portray it. Just the same, it is often helpful to point out new data that will be helpful in guiding treatment options and revisit good old data to stay the course. To that end, this is aimed at updating you on some of the recent evidence that may have sparked some discussion and may help you talk to your patients. In practice now for almost 25 years, adding a seasoned understanding to this data may also be helpful to you in your daily practice. The most important “take away message” here is that the data needs to be applicable (to the patient in front of you today) in order to make sense. There is so much on the web that confuses our patients. They just don’t know what applies to them. It is our unique responsibility to help them understand the subtle differences that is the essence of clinical acumen.
A general word or two about rotator cuff repairs: It is clear now that arthroscopic repair is the standard for almost all tears. It is also clear that tears come in many sizes and shapes. Most recent evidence-based article was in JBJS in Jan of 2014 issue (A Prospective Randomized Trial of Immobilization Compared with early motion By Jay D Keener, et al. JBJS 2014;96:11-19) talks about early rehab for tears (small to medium in size). It showed that early (protected) motion in a guided rehab program (as in our office) offers better function at 3 months of prolonged immobilization even though there is no statistical difference at 24 months in the two groups. In 114 of the 124 patients seen at 30 month follow up 92% of the tears were healed. In practice, the better three-month results mean an earlier return to light selected work (heavy laborers and workman’s comp are separate issues) and hence for my average patient the early motion program a real advantage. Here as in other studies a “no significant difference” in final outcomes is not necessarily the full story. Larger or very large tears present a different set of issues, don’t heal as well and present a real challenge when addressed later in their course. A new acute traumatic large tear is always best treated earlier than later.
After much discussion over the past three decades about the best way to treat clavicle fractures, a study published in the Sept. 4 issue of the Journal of Bone & Joint Surgery compared nonsurgical treatment, open reduction and plate fixation for midshaft displaced clavicle fractures. As reported in a prior newsletter, in a good evidence-based article by: C.M. Robinson, FRCSEd(Tr&Orth); et al.: Open Reduction and Plate Fixation versus Non-operative Treatment for Displaced Midshaft Clavicular Fractures: A Multicenter, Randomized, Controlled Trial: J Bone Joint Surg Am, 2013 Sep 04;95(17):1576-1584 goes a long way to answer this question.
According to the results of this study, improved outcomes and reduced rate of nonunion after acute displaced, midshaft clavicle fractures was associated with internal fixation using plates. It is important to note that after excluding nonunions from analysis, the authors found no significant differences in DASH or Constant scores at any time point during the study period. The implication of this finding was nonunion (the failure of healing) was the prime driver of the poor outcomes and 16 times more likely in the nonrepaired group. The results for displaced mid shaft fractures are therefore improved when the bone is fixed with a plate (preferably earlier, within two weeks of the injury) and the complications of a non-union can be avoided.
Also in the January issue of JBJS there is a comprehensive review of AC joint separations. (Xinning, Li, et al JBJS 2014; 96:73-84. This is more commonly known to most of us and our athletic patients as a “shoulder separation.” Usually it happens after a fall onto the outer edge of the shoulder as opposed to a “shoulder dislocation” (the ball is knocked out of the socket) usually after a forceful external rotation of the arm in an overhead position. For shoulder separations, in most cases, we see the deformity at the end of the collarbone. In higher-grade injuries the tip of the collarbone can “tent” the skin. There are many types of separations. They are most commonly graded one through six. Lower grades, grades one and two, minimally displaced and not tenting the skin, can be treated non-operatively and if there are symptoms at a later date they can be addressed nicely arthroscopically. Grade three is more displaced and controversial. Operative verses nonoperative treatment (with accepting a visible deformity) becomes a personal decision made with the patient after the risks and benefits are reviewed. Grade four, five and six are more significantly displaced (4-posterior,5-superior and 6-inferior, under the acromion) all need operative repair. There are many treatments and the method of ligament reconstruction recommended includes 5 key features, a method of repair and reconstruction of the torn ligaments incorporated in my practice over 10 years ago, and they are best depicted on my patient education pages on our website under my tab: http://www.togct.com/downloads/reznik/ AC_Joint_Reconstruction.pdf
Shirvinda Wijesekera, M.D.
We have all heard of cases of terrible back pain or sciatica. Some of these ailments can be related to a common injury to the intervertebral disc. The human intervertebral disc is a structure that lies between the vertebral bodies. It functions as a shock absorber to cushion the forces we all experience throughout the course of the day. When this disc becomes injured it can lead to a common scenario described by many names: herniated disc, slipped disc, ruptured disc, or sciatica.
The human disc has an outer layer of tough fibrous bands, much like those of a steel belted tire. These rings of tissue reinforce a soft center, the nucleus pulposis, which works as the force absorbing center. When the disc is injured the tough rings can tear, allowing the soft nucleus to extrude through the tear.
There are many grades or severities to these types of tears. On occasion this can lead to a mild bulge in the disc. At other times a complete tear can create a channel, through which the soft nucleus can travel into the spinal canal. These two components, the torn outer layer of the disc and the encroachment into the spinal canal leads to the common symptoms of back pain and sciatica. In those patients in whom the soft nucleus travels into the spinal canal and impacts upon one of the spinal nerves, sciatica predominates. Those patients with less impact on the spinal nerves often experience more back pain.
The diagnosis of a herniated disc can often be suspected from a simple description of a patients symptoms and a physical examination. An MRI scan can often provide radiographic evidence to support your doctors’ suspicion of a herniated disc. Once your doctor has made the diagnosis a variety of treatment options are available to you.
Many conservative options exist, including observation, medications, and physical therapy. The vast majority, more than 80% of those with a herniated disc will have their symptoms abate with these conservative measures. Most of those patients will have their symptoms considerably improve within 3 months or less.
In the smaller subset of patients that do not improve with conservative care or have worsening neurological examination, surgical treatment is often possible. These microsurgical techniques can result in patients going home with a minimal scar, and a rapid recovery. The techniques that past generations have had to endure have changed. New techniques, have led to better outcomes with much less morbidity. Ultimately, your doctor can provide you with a treatment regimen to return you to a normal life.
© 2008 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author
By Alan M. Reznik, M.D., MBA
ACL injuries in women jumped into the spotlight in 1999 when WNBA star Rebecca Lobo blew out her knee. The truth is she was only one of many knee injuries in professional, college, high school and recreational sports. Now, these injuries are adding up, and 1.4 million women have torn their “A-C-L,” that’s Anterior Cruciate Ligament, in the last ten years. That’s twice as many women than the decade before. So, we must ask ourselves: Why is this happening? What do we know about this problem? Lastly, what can the female athlete do to prevent being part of the newest and largest epidemic in sports?
One fact is clear; women have entered competitive sports in the last two decades. Each year, there are more girls playing sports in high school, college level sports, and professional level teams than the year before. The standard of play at all levels has gone up. For these reasons alone, the number of total knee injuries should have increased. Yet, when counted, the number of torn knee ligaments is far greater than expected. It seems the risk of this type of injury far surpasses the number of women playing hard. In fact, the NCAA found female athletes were six times more likely to tear their ACL than the male athletes each hour of play. This finding translated to nearly 2,200 high-level female college athletes being sidelined per year. So, the answers to the mystery have to be more complex.
It turns out that ACL tears occur in differing age groups in women and men. In females, ACL tears start around age 14. The number peaks near age 18 and then the occurence decreases dramatically. In males, it starts at age 16, peaks near 20 and continues to be an issue until the age of 40. The younger onset in women may be due to an earlier maturity. We know the quality of bone and its stiffness changes when you stop growing, making the bone less forgiving and the ligament more susceptible. The age-related drop off in women may, in part, be due to bearing children, since most competitive sports have to pause during pregnancy.
Women are anatomically different than men. They have wider pelvises and legs that are, on average, tend to “bow outward “ (valgus alignment) versus “bowing in” (varus alignment) in men. The roof of the center of the knee, the femoral notch, is narrower in women than men placing more strain on the ACL with knee extension. Female hormones are also felt to cause increased joint laxity of the so called, “secondary restraints” of the knee; those ligaments that also guide knee motion along with the ACL are less taunt putting more stress on the ACL. The early age of maturity, leg alignment, tighter space around the ACL, and the hormone-related looseness of the knee are all considered important reasons for an increase injury rate in women athletes over their male counterparts.
Women’s and men’s muscles react in differing ways in sports. Video tapes of high school athletes during competition have taught us that men and women have their own ways of jumping and landing. Women tend to bend their knees less, landing with their knees straighter, and they use their quadriceps muscles to a greater extent than their hamstrings. This causes them to be more flatfooted when they land. This lack of muscle balance causes increased strain on the ACL particularly at the end of a quick move. Adding the muscle pattern difference to the anatomic factors does explain why many of the injuries occur as non-contact events.
Since the anatomic factors are given, the only way to decrease the risk is to improve the athlete's muscle balance and landing style. From the video tape studies, we know practicing two-legged landing has the potential to reduce the risk for female athletes when working on keeping the knees more bent when jumping, when landing on the balls of the feet while using their hamstrings (back of thigh) and glutei (buttock) muscles to protect the knee. In fact, studies have shown that preseason and in-season balance and jumping programs does provide some protection although, not all authors agree on by how much. Once the ACL is torn, many athletes lose knee stability with jumping, twisting and pivoting motions. Rehab can help and muscles compensate for some of the loss but they cannot replace the mechanical protection the normal ACL gives in high level sports. The result is often recurrent injury that leads to tearing of the meniscal cartialge. Damage to the cartilage can be the start of arthritis and is associated with the knee locking or getting stuck in one place. With repetitive injury, the knee can even become completely locked and the player cannot extend the knee or even walk on it. To avoid long term problems, most athletes opt to have the ligament reconstructed. With modern techniques, this can be done arthroscopically through a fiber optic telescope. A graft replaces the torn ACL and this is all done through small incisions with a video camera and special instruments designed for this type of surgery. With modern, high-tech, techniques the procedure can be done as an outpatient. After surgery the patient is in a brace to protect the graft.
Rehab can start in the first few days of post-op and many patients can be completely free of crutches within two weeks. The majority of players can start a sport specific training program within three to six months and can return to competitive sports at the completion of the program. Remembering, as always, return to full sports varies pending the extent of the original injury, the exact surgery required for that injury, the type of sport played and the athletes own rate of recovery.
© 2008 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author
Sherri L. O’Connor, PA-C
A “stinger” is a nerve injury commonly associated with contact sports. In the Fall, we see a lot of these injuries, which typically occur during football season. Most of the time, an athlete may return to play. To understand how a “stinger” develops, let’s talk about the basic structure of the anatomy in the upper areas of the body.
A “stinger” involves the brachial plexus and potential nerve injury that supplies the arm. The brachial plexus involves the nerves that exit off of the neck. The nerves then run down the arm to the hand and supply the motor and sensory to the arm.
When an impact injury occurs that could possibly cause an overstretch of the nerve from the neck or head, the player then feels immediate burning pain associated with the nerve being overstretched. This often feels like an electric shock into the arm that descends down into the hand.
A player should be assessed by a doctor for potential injury to the neck and nerve roots. Usually, the symptoms will resolve and the player is allowed to participate further. Occasionally, if symptoms persist, a more extensive evaluation is needed in an office setting. This includes symptoms of neck pain, weakness into the arm greater than several days or a player with a history of “stingers.”
Post treatment can consist of restriction of play, protective gear, Tylenol or Advil medications, and physical therapy. Further testing such as an MRI, a nerve conduction study (EMG) would be obtained if symptoms persist. More than 90% of affected individuals will have resolution of symptoms within days.
Play It Safe!
By Alan M. Reznik, MD, MBA
In the U.S. alone there are over three quarter million ER visits each year by children under the age of 15. A major cause of this is the alarming rate of injury during sports. The “Play It Safe” program was created by the American Academy of Orthopedic Surgeons (AAOS to increase awareness and to reduce injury to children during these sporting activities. Many studies show that the majority of injuries occur in unorganized or casual sports, like pick-up games of basketball, baseball and football. Still significant, organized league sports make up about one third of the injuries. Reducing the risk of both injury rates is a goal of the “Play it Safe” campaign. There are four topics that require special attention when it comes to children and sports:
1) Young athletes are not just small adults
2) Growing children's injuries create special concerns
3) Diagnosis and treatment offered to children
Children are growing all the time. This gives them some special advantages over adults. To start, their bones have a little more spring and bend before they break. They are typically lower to the ground and have lower body weights, making most minor falls of little consequence. At the same time, they tend to be less prepared for injury and their sense of danger is far less than an adult’s. Children also grow at differing rates at different times during development. A sudden growth spurt or a change in limb length can create the gawky behavior that makes some children seem accident-prone. These factors alone help explain some of the injuries prevalent in child athletes.
Sports injuries I’ve seen in children vary from a child simply exceeding his or her physical limitations to an accident occurring during an unsupervised activity in an unsafe environment. Adults have to be aware of their own children’s limits. Some 14 year olds are fully-grown, while others are not. I often hear stories of children in an agebased league playing against kids who weigh 50 to 100 pounds more. Many coaches and parents take performance at very young ages to an extreme, and lying about a child’s age or weight for an unfair advantage is simply wrong. Worse yet, studies have shown that in the late 1990’s, up to 500,000 young athletes were using black market steroids to increase muscle mass. The risks of these drugs are widely known, serious for children, and potentially life threatening. These “performance enhancing” products should be completely avoided. Sports for children should always be fun, not unhealthy or dangerous.
The bones in children grow in specialized areas near each joint called growth plates. These areas are softer than calcified bone in the middle of the limbs and therefore are more susceptible to injury. When an injury to a growth plate occurs, future growth and alignment of the limb is at risk if it is not treated properly.
Growing children’s bones can buckle and bend without breaking all the way. This creates fractures in the middle of the bone, which are often known as “green stick” fractures since they resemble what happens when you try to break a growing tree branch. These green stick fractures break, deform and stay deformed even though part of the bone (branch) is still intact. These “incomplete” fractures or breaks also require special attention. Both growth plate and green stick fractures affect bone growth. The growing child can remodel broken bones and overcome minor disturbances in growth. The child’s age, the fracture location, the bone’s angulation ( amount of bend) and the fragment’s displacement (separation) are important factors in determining how well a fracture will heal without orthopedic intervention. When it is clear that a deformity will result, prompt treatment is necessary.
Occasionally, because the growth plates are not calcified, a diagnosis can be much more difficult to make. The cartilage and growth plates cannot be seen directly on normal xrays. In these cases, a precise history of the injury ( force involved, position of the limb, direction of impact and anatomic location of the injury) helps in making a correct diagnosis. Many times, there is no substitute for an examination by experienced hands because findings on an x-ray are often only seen once the healing process is well underway. Sometimes a missed diagnosis becomes a missed opportunity for a simpler treatment.
In children, some injuries can be treated with a sling, splint or cast while others require perfect reduction to realign the growth plate or the joint space. The goal of all treatment should be to use the least invasive method to allow a child’s bones to heal with the lowest risk of deformity and to future growth.
Young athletes should be encouraged to play in organized or supervised sports. They should have training or specific stretching and exercise programs to prepare them for the sport. The sport itself with or without preparation should not be their only exercise. A child’s coach and parents should take into account the child’s age, height and weight before matching them in ageonly based sports. Parents should be sure the coaches have appropriate training and qualifications to coach their children. The children must have access to a safe playing area and appropriate well maintained equipment. Field conditions, weather conditions and available supervision should always be a factor when deciding to have a competition. In hot weather parents should be sure the children are well hydrated and beware of the risks of hyperthermia on very hot and humid days.
Children should warm up and stretch for sports. They should drink plenty of fluids. They should have appropriate fitting equipment. They should tell the supervising adult when they are hurt instead of trying to play through painful injuries. Safety rules for growing athletes, such as pitch counts, should be strictly followed, and children should not be played in multiple leagues in the same sport in the same season to “get around” these rules no matter how great the parents think they are. The rules are designed to protect growing children from injury; ignoring the rules will risk serious growth injury and only shorten their playing careers. Children should never be given “performance enhancing”drugs or supplements.
Protective gear is also important and sports specific. Helmets for biking, skiing, and roller-skating are no longer optional. Mouth guards, shin guards and plastic face guards have helped to reduce injuries and should be used. Elbow pads and wrist protectors should be worn for inline skating, even on pathways designed for skating. Binding releases for ski’s should be calibrated to the child’s skill level, height, and weight each season.
The AAOS promotes the idea that “youth sports should always be fun. The ‘winning at all costs’ attitude of coaches, parents, professional athletes and peers can lead to injury.” Remember, having unrealistic expectations can lead a child to continue play despite warning signs of injury. This puts a child at increased risk. Lastly, the AAOS reminds us, “Coaches and parents can prevent injuries by fostering an atmosphere of healthy competition that emphasizes self-reliance, confidence, cooperation and a positive self-image.”
(c)2009 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author
Proper Warm Up and Stretching Before Exercise for the Young
By Michael DeChello, MS, PT
It is necessary to warm up the body before beginning your exercise program or sport event to prepare the body for increasing levels of stress. A proper warm up will increase your ability to perform exercises correctly and reduce the risk of injury. It is important to learn how to properly and effectively warm up at an early age. This sets the stage for the young athlete as the intensity of exercise and the level of competition increases as young athletes grow. Failing to warm up is a mistake many exercise enthusiasts make. There’s and old saying, “If you don’t have time to warm up than you don’t have time to exercise.”
General warm up is divisible into two basic groups; general and specific. General warm up involves exercising the major muscle groups of the body with minimal or no load. Examples: jogging, stationary bike, jumping jacks. Warm up should be intense enough to increase the body core temperature and cause perspiration but not fatigue. A proper warm up will improve exercise performance by: increasing rate and strength of contractions, increase work capacity, increase cardiovascular and respiratory efficiency, and reduce the risk of injury by increasing muscle elasticity and joint range of motion. Following a general warm up program, a light stretching program should be performed.
Stretching should be done after a warm up because of the increased tissue temperature will make the stretching both safer and more effective.
A specific warm up should relate to activities specific to the exercise being performed. This can be accomplished by performing the exercise movement or sportspecific movement with little or no weights or at slower speeds. This helps to ensure proper form and technique.
A cool down period is also important following an exercise program. This gives the body a period of time to adjust to recovery. A cool down period assists: muscular relaxation, removal of waste products, reduces muscle soreness and allows the cardiovascular system to adjust to normal levels.
There are misconceptions regarding weight training for strength and flexibility: increasing your strength does not limit your flexibility, increasing your flexibility does not limit your strength gains and increasing muscular size does not cause lack of flexibility. Exercises must be performed through the entire range of motion. There should be emphasis on lowering or lengthening the muscle as well as lifting or shortening the muscle. Muscle groups on both sides of the joint should be worked equally to avoid a overpowering of one muscle group. Example: Push/pull or bicep curls and triceps extension.
Proper preparation for your workout or sports events, good technique and form, and cool down will ensure you to have a safe, effective and productive workout.
(c) 2009 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author
“It Hurts When I Run”
By Michael DeChello, MS, PT
I see it every year around the time the frost leaves and the signs of spring are evident. The same pattern starts to emerge. Patients start showing up with pains that are all too common. “I have pain in my heel, my knee hurts or my hip hurts. “ This is usually about the time when the serious runner is starting to feel the effects of their training to prepare for a competitive running event. Weather it is a seasoned marathon runner trying put another completed marathon under their belt or the beginner who wants to do their first New Haven Road Race. They have been training for several months and progressing their training regime and as the event get closer the symptoms start to intensify until it effects their training and usually leads to necessary rest causing them to drop out of the event or wait until the next one.
Running for many is an important part of their lives, it helps define who they are and often is carried out like an obsession. We have known for a long time the positive physical health benefits of running and equally as important the psychological well being from running. However, there are intrinsic and extrinsic risk factors that can lead to the development of symptoms progressing to injury. The reduction of these risk factors can ward off some of the common injuries associates with running.
Considering the biomechanics of running, a factor that is often forgotten is that running is a one legged sport. The runner is only on one foot and leg at a time. This occurrence leads to significantly higher forces on the weight bearing extremity. These high forces combined with the degree of repetition when running and underlying risk factors can increase the likelihood of an injury. Some of the extrinsic factors that need evaluation are, but not limited to, footwear, running surface and training schedules. Intrinsic factors that need to be examined and many times more difficult to control are as follows; increased inward angle at the knee, weak or inefficient medial quadriceps muscle, hyper mobility of the patella, ligamentous laxity, abnormal joint mobility, abnormal pronation of the foot, other lower extremity malalignment and weak hip musculature to name the most common. Identifying these risk factors by someone trained to do so can make appropriate recommendations to correct as much as possible.
The top five injuries associated with running due to intrinsic and extrinsic factors are; patellofemoral pain/ iliotibial band syndrome, achilles tendonitis, stress fractures, medial tibial stress syndrome (shin splints) and plantar fascitis. The following is a brief overview of the cause and treatment of each. This should not be taken as a way to diagnose or a comprehensive treatment plan and continued plan should be evaluated by your doctor.
The patellofemoral complex is comprised of multiple structures that stabilize the patellofemoral joint, the joint between the patella and femur. The quadriceps act as active stabilizers, the ligaments and retinaculum acts as passive stabilizers and the joint surfaces act as static stabilizers. An imbalance between any of these structures causes the tracking of the patella on the femur to be abnormal causing excessive stress on one of the structures leading to pain and dysfunction. A carefully designed lower extremity strengthening and stretching program is very important. Correcting any malalignments in the foot and knee via an custom orthotic for the shoe is necessary. Hip abductor weakness has recently been found to be associated with patellofemoral pain and should be addressed. Core strengthening exercises are also recommended for stabilization of the spine which allows for more efficient movement of the extremities.
The iliotibial band is an extension of the tensor fascia lata muscle in the hip as a thickening of the fascia of the upper leg. The ITB fans out distally to insert on the lateral aspect of the patella and lateral retinaculum of the knee. Functionally it helps with abduction at the hip. Keeping in mind again that running is a one legged exercise and when the weight bearing limb hits the ground the hip musculature has to be strong enough to maintain a level pelvis. If not and the hip drops it causes excessive strain and pulling on the ITB which increases the stretch tension relationship. This leads to increase in compression forces on the lateral aspect of the knee. Specific stretching and strengthening exercises of hips and ITB will help better stabilize the hip during running reducing the compression forces.
The achilles tendon is the continuation of the gastrocsoleus complex of muscles and inserts on the calcaneous or heel. The gastrocsoleus originates above the knee making it a multi joint mover. It has a direct impact on the knee, ankle and subtalar joint in the foot. Recently the term tendonopathy has become the lump-all category for tendon pathology. This term includes early stage tendonitis, paratendonitis and later stage chronic tendonitis. Chronic tendon pain usually does not have inflammatory changes in the affected tendon, but rather degenerative changes. Achilles tendon disorders are divided into three zones: 1) non-insertional 2) tendon insertion and 3) at the muscle tendon interface or junction which is more proximal. The approach to treatment is conservative initially with rest to decrease the strain on the tendon. In some cases a walking boot may be required. The use of modalities such as ultrasound, electric stimulation, cross friction massage, heel lifts and ice may be helpful. After pain is reduced, a gradual return to activities while monitoring symptoms is necessary, progressing to strengthening exercises. In some cases custom fit orthotics may be helpful as a prevention option.
The term shin splints is gradually being used less because of the generality of the term. More recently the term medial tibial stress syndrome is coming into use. This term is appropriate to use in the absence of stress fracture or compartment syndrome. Medial tibial stress syndrome includes periostitis, traction peristalgia, tendonopathy and fatigue failure of the connective tissue connecting muscle to bone. Medial tibial stress syndrome occurs at the posteriomedial aspect of the tibia. There is usually no pain at rest and a palpable tenderness. Pain is usually brought on by exercise and can be sharp or dull in nature. Pronation or the lack of control at the midstance phase of running is usually associated with MTSS. Treatment approach includes rest as the most important. Training alterations needs to be considered. Biomechanical evaluation should be performed, and shoe and custom orthotics may be indicated to control pronation. Calf stretching and core strengthening should be included in a comprehensive exercise program. Alternative low impact exercise should be given during the rest period to help maintain overall cardiovascular conditioning. Gradual return to activity and incrementally building up distance and intensity should facilitate a smooth return to normal exercise.
Plantar fascitis is the most common cause of heel pain. The plantar fascia is the thick tough connective tissue which runs from the heel to the base of the toes. The condition develops when this tissue becomes inflamed specifically where it attaches at the heel. The progressive pull of the tissue results in painful covering of the bone and the tissue itself. Over time this can cause micro tearing of the tissue. The tissue attempts to heal forming small areas of scar tissue. Each time the tissue is stretched it results in further tearing. This effect can lead to a chronic condition. The most common compliant is burning, stabbing or aching pain in the heel. Most often the symptoms are described by pain with the first few steps in the morning and/or after sitting for any length of time upon standing. The most commons causes of plantar fascitis are tight calf muscles and biomechanical abnormalities such as flat feet or high arches. As we age the resiliency of the tissue lessens making us more prone to this problem. Traditional physical therapy and conservative measures in most cases can help reduce the symptoms. These measures include modalities like ultrasound, electric stimulation, deep friction massage, stretching and iontophoresis. Anti inflammatory medication and local cortisone steroid injections may also be helpful. Controlling the symptoms is important however, addressing the underlining problem is the key to long term success. Proper stretching to maintain the flexibility of the tissue is vital and correcting the biomechanical abnormalities is also necessary. This can be achieved with proper fitting custom orthotics.
© 2010 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author
Derek S. Shia, M.D.
Traumatic shoulder dislocations are the most commonly occurring large joint dislocations. As a group, these occur most commonly in young males and is especially common in contact sports such as football, wrestling, hockey and lacrosse. The shoulder is a complex joint composed of the ball, humeral head, and the socket, glenoid. The glenoid has a very shallow concavity unlike other joints, such as the hip, which allows the shoulder to have a tremendous range of motion allowing the arm to be successfully positioned in space. The downside to this freedom of motion is an increased risk of instability.
The shoulder can dislocate in any direction, but the most common is an anterior dislocation. Anterior dislocations occur in 97% of cases. The second most commonly occurring direction is a posterior dislocation. Anterior dislocation usually occurs with a posterior directed force on the arm when the shoulder is in an abducted and externally rotated position, similar to the position of the arm when cocking back to throw a ball. For this reason, many overhead athletes may be prone to continued instability despite non-operative management. Posterior dislocations on the other hand, occur with a force directed on the arm when it is flexed and adducted as if trying to scratch your opposite shoulder.
The shoulder has both static and dynamic restraints that combine to keep the shoulder in a reduced position. The static restraints when an injury occurs cannot be altered without surgery and include the labrum, glenoid, and ligaments. The dynamic stabilizers of the shoulder include the rotator cuff and the scapular stabilizer muscles. When there is an injury to the static restraints of the shoulder the dynamic stabilizers can be utilized to try and overcome the static restraint limitations to provide a stable shoulder. The use of physical therapy can help optimize the dynamic stabilizers and is the foundation of non operative management surrounding shoulder dislocations.
The acute management of a shoulder dislocation requires prompt recognition of the problem followed by appropriate treatment which results in reduction of the joint. Many times this can occur on the playing field with the assistance of a trained professional. Many techniques have been described to achieve this and patients typically feel significant relief after the reduction has been successfully performed. Delayed reduction can lead to significant problems including nerve and vessel injury so prompt reduction of the shoulder is recommended as soon as a trained professional can be located.
After reduction has been obtained, it is important to obtain radiographs (xrays) of the shoulder. There are two important reasons that x-rays need to be obtained: 1. It is important to objectively determine whether the shoulder has been relocated and is in the correct position. 2. It is vitally important to determine whether a fracture has occurred to either the humeral head or glenoid. Fractures of either bone can significantly affect the treatment options and whether surgery will be necessary.
Dislocations that occur during an athlete’s season can often be temporized with the ability to return to the field in a relatively short period of time if no fracture or tendon injury is present. Depending on the athletes sport a brace is sometimes recommended to prevent further instability events.
The difficulty of these braces is that they are typically bulky and do not allow abduction and external rotation. For an overhead athlete such as a quarterback these braces cannot be worn due to the position necessary to throw a ball. Non-operative management of athletes that are in season typically involves a short period of immobilization for 7-10 days combined with physical therapy. Return to play can be instituted after obtaining pain-free range of motion with no objective or subjective feelings of instability.
The risk of recurrent dislocation is related to several factors including age, activity level, and contact sports. In patients under the age of 20 there is a >90% chance of recurrent instability. Recurrence rates in patient over the age of 30 falls significantly and is a little less than 30%.
Recurrent instability, ie. multiple dislocations, of the shoulder is typically an indication for surgical intervention. The typical injury of the shoulder is a Bankart lesion, which occurs in over 95% of shoulder dislocations, and is a result of a tear of the anterior inferior labrum of the glenoid. Other types of injuries also commonly occur around the shoulder such as rotator cuff tears but usually happen in patients over the age of 45 years. In the vast majority of the cases, surgery can be performed arthroscopically to address the pathology in the shoulder.
This is usually performed with three small incisions about 1 cm in length. Immobilization is required over the first month. Physical therapy is started after surgery and is usually continued for 4 months after surgery and return to play can typically be achieved in 6-9 months.
Alan M. Reznik, M.D., M.B.A.
Each year we turn to sports and athletic activity to help our children learn the value of teamwork, avoid the perils of too many video games and prevent childhood obesity. Yet we must also balance those goals against expectations of super athletic ability and the risks of multiple sport injuries. Too often I see children in my office that are pushed to their limit, poorly coached or enrolled in multiple leagues with the unfounded idea that more is better. I have personally witnessed a father/coach stop counting pitches when his child was nearing the pitch count limit for his league as his child faced a tough inning in a close game. We all would hope that the health and well being of our young athletes is the number one goal for all involved in youth sports. But we seem to know intuitively this is just not the case.
It is imperative to warm up properly. Avoid playing when you are tired or hurt. Field and weather conditions are also important when “playing safe.” When I was an orthopaedic resident, we often discussed the importance of the “wet-bulb” temperature. That is the temperature and humidity combination that prevents normal sweating. The lack of ability to sweat can be a major cause of heat stroke and has been responsible for a number of well-publicized high school athlete deaths. This is something every coach should know before summer football practice starts and another reason why heavy equipment cannot be worn on many hot and humid summer preseason practice days. Good hydration is essential in the hot weather.
In an article in USA Today, Michelle Healy questioned the safety of youth sports and the qualifications of those responsible for our children, based on survey data from the new non-profit group Safe Kids World Wide.
The AAOS first launched the “play it safe” program in 1995, and in 2013 launched an educational web site, http://www.stopsportsinjuries.org as a learning resource.
A health and happy youth athlete must be our first goal. Once achieved, a lifetime of sports accomplishments should be waiting for them.
Dr. Alan M. Reznik, M.D.
From my experience there are several concerns that should not be ignored.
The simplest and most straight forward is any injury causing a deformity. If the finger, wrist, elbow, shoulder, knee, foot, just does not look “right,” it needs attention. Deformity often means a fracture or a dislocation. Most are medically urgent, if not emergent. It sometimes surprises me when I see people weeks later with a deformed finger that has been fractured, bent and now healing that way. Even worse, they often come to the office with a knee injury, when I also notice a crooked finger. When they ask about it, they only then admit to the injury.
In the knee...one should not ignore any injury that causes almost immediate swelling and or significant bruising. Bleeding into or around the knee is a major cause of rapid swelling and can mean a
significant ligament tear or a fracture in the joint. If this is associated with an inability to move the knee or bear weight, a good examination (preferably by an orthopedic surgeon) and an xray is best.
Another common injury is an Achilles tendon rupture. Often a tennis player will go to the net and stop short and then feel like someone kicked them in the back of the ankle.
A basketball player will swear someone stepped on the back of their leg. The pain and shock wave from the tendon giving out is distinct. Swelling and inability to push off or toe walk is a big tip off. These need to be repaired.
The most serious can be head and neck injury. Concussions have gotten a lot of press of late. The NFL has just agreed to a 3/4 of a billion dollar settlement for long term results of head injuries. Any significant headache after a hit in sport or fall needs evaluation at the side lines, and if there are any doubts, removal from play. Loss of consciousness, even for a few seconds, changes in mental status, inability to answer simple questions, or amnesia are signs of risk for significant injury. These signs require a mandatory stop of play and frequent reevaluations shortly after (see guidelines for concussion later in article.
Once cannot forget the tragic death of the actress, Natasha Richardson, at age 45 while skiing. Bleeding inside her skull was not discovered and her “feeling fine” delayed getting her appropriate evaluations soon after the injury.
Neck injuries are equally dangerous. Any neck injury with associated neurologic changes, loss of movement, weakness in any limb, or loss of sensation after an injury must be sent to the ER after appropriate immobilization by a qualified person. Do not sit a player up after a neck injury to see if they are OK. It may risk injury and it’s not a good idea.
The most deceptive injury is something known as compartment syndrome . It is usually associated with an injury to the forearm or lower leg(it is very rare in the thigh) and its most common finding is crescendo pain. That is pain that seems out of proportion to the injury and it continues to increase with time. It occurs because each of the muscle groups in the lower leg and forearm are wrapped in neat compartments covered by a layer of lining tissue known as fascia. When an injury occurs the blood flows into the area and swelling causes increasing pressure in the compartment. The blood gets trapped in the compartment and the circulation is eventually cut off by the high pressure. The muscle loses its blood supply and can be lost permanently if the compartment is not surgically released in time.
I found this guide for concussions for your reference.
Main Category: Sports Medicine / Fitness
Also Included In: Neurology / Neuroscience
Last Updated: 10 Jun 2013
Original Date: 19 Mar 2013
The American Academy of Neurology has released its guideline for evaluating and managing athletes with concussion. The AAN says that over one million sportsmen and sportswomen in the USA experience a concussion annually. This is the first concussion update in 15 years.
According to the AAN (American Academy of Neurology), which published the new guideline in Neurology (March 18th, 2013 issue), Americans now have an objective, evidence-based review of the literature by a committee of experts from various fields.
The Academy added that its guideline has been endorsed by a wide range of sports, medical and patient groups, including: The National Association of Emergency Medical Service Physicians, the Neurocritical Care Society, the American Football Coaches Association, the National Football League Players Association, the Child Neurology Society, the National Academy of Neuropsychology, the National Association of School Psychologists, and the National Athletic Trainers Association.
Co-lead guideline author, Christopher C. Giza, MD, with the David Geffen School of Medicine and Mattel Children's Hospital at UCLA, explained that it is imperative that any athlete who is suspected of experiencing concussion be removed from play straight away.
Dr. Giza said:
“We've moved away from the concussion grading systems we first established in 1997 and are now recommending concussion and return to play be assessed in each athlete individually. There is no set timeline for safe return to play."
The author panel included a broad range of expertise, the AAN informed. They spent "thousands of work hours" locating and examining scientific studies. They excluded studies that did not provide compelling evidence to make recommendations, such as expert opinions or anecdotal accounts. Each study was independently analyzed and graded by two or more authors.
The AAN emphasized that "Concussion is a clinical diagnosis. Symptom checklists, the Standardized Assessment of Concussion (SAC), neuropsychological testing (paper-and-pencil and computerized) and the Balance Error Scoring System may be helpful tools in diagnosing and managing concussions but should not be used alone for making a diagnosis."
What are the signs and symptoms of concussion?
Loss of consciousness, or a “blackout” occurs in less than 10% of concussion, a reason why these injuries are often misdiagnosed.
Jeffrey S. Kutcher, MD, with the University of Michigan Medical School in Ann Arbor and a member of the AAN, said:
"If in doubt, sit it out. Being seen by a trained professional is extremely important after a concussion. If headaches or other symptoms return with the start of exercise, stop the activity and consult a doctor. You only get one brain; treat it well."
Should there be absolute rest after a concussion? - the guideline states that there is insufficient compelling evidence to support absolute rest after concussion, but the athlete should be immediately removed from play.
Part of concussion management may include activities known not to worsen symptoms and which are not linked to a risk of repeat concussion.
Sports Concussion Tool Kit - American Academy of Neurology
The AAN has also launched an app called "Concussion Quick Check" which is available for iPad, Android, IOS (Apple) and some other mobile devices. It is aimed at helping coaches, trainers, parents and other athletes rapidly decide whether somebody is experiencing concussion and needs to see a doctor.
A team of investigators from the Toronto University explained that kids take longer to recover from second or third concussions, compared to those with a first concussion. Their findings were published in the journal Pedatrics (June 2013 issue).
Sources quoted: The American Academy of Neurology, and Medical News Today.
© 2013 The Orthopaedic Group, LLC Not to be reproduced without the express permission of the author