Hi, everyone. I'm Dr. Mary Dubon, and I'm really excited to talk to you today with my lovely co-presenters and co-session director about the topic of clinical pearls of pediatric sports medicine. So again, I'm Dr. Mary Dubon. I'm a pediatric rehabilitation medicine and pediatric sports medicine physician through Boston Children's Hospital, Spalding Rehabilitation Hospital, and Harvard Medical School. I'm joined today by my co-session director, Dr. Jonathan Napolitano through Nationwide Children's Hospital and the Ohio State University College of Medicine, and he is a pediatric sports medicine physician with many interests in leadership sports medicine and ultrasound. And we have some excellent faculty with us as well, including Dr. Aaron Carlin, who is the original pediatric rehabilitation medicine and pediatric sports medicine physician. He's at Aschner Clinic Medical Center and has many leadership roles within his department. Prebak is in Seattle at Seattle Children's Hospital and University of Washington Medical Center. He is a sports medicine physician with many interests and much experience across the board of sports medicine, but does have a special interest in pediatric sports medicine, which he practices at Seattle Children's. We have Dr. Stephanie Tao, who's another one of our pediatric rehabilitation medicine and pediatric sports medicine physicians, and she is at University of Texas Southwestern Medical Center. So without further ado, I want to just talk a little bit about what we think about clinical pearls of pediatric sports medicine and why we're thinking that this session is really important for us to be talking about. You know, we know that there's going to be a wide variety of folks that are listening in today, hopefully people with different backgrounds, people who might be pediatric sports medicine physicians also, some folks that might be pediatric rehabilitation medicine physicians who might want to learn a little bit more about sports medicine, and some folks that might be adult trained sports medicine physicians who want to learn a little bit more about pediatric sports medicine as they may occasionally have some folks who are pediatric or adolescent patients coming into their clinic. We do know that pathology is different in pediatric populations, so in kids and adolescents, because of their growing, we see things that are just different and treatments are different than what we see in adults as well. And so what's bread and butter for us may look like zebras to the average physiatrist, so we want to just give a little primer today on all of those topics, and obviously in the course of this hour, we're not going to be able to give you everything about pediatric sports medicine, but we hope to give hopefully a helpful overview. This year, we decided to do it based on sports topics. Last year, we gave our first round of this, and we kind of spoke through some of the hot topics in pediatric sports medicine and those high yield topics that we wanted people to walk away from our lecture learning. And so this year, we decided to go a little bit of a different route and looking at really common sports and a different diversity of sports too. So we're looking at things like football, which is, you know, one of the most common sports that we see across the United States. And it's obviously a contact sport. We're looking at things like baseball and softball, which are overhead athlete sports, which have some pretty significant considerations when you're thinking about youth. Swimming, diving, synchronized swimming, kind of grouping those together is also common sports for youth and high school-aged individuals. And so we wanted to include them as well. If you look here, this is data from the National Federation of State High School Association. And so they're looking at national representative sample across the country and trying to estimate numbers of individuals who are participating in high school sports across the country. And so you see that some of the sports that I just mentioned have pretty high numbers of participants. Gymnastics and dance look artificially low, but those numbers are actually pretty inaccurate because most people who are participating in athletics or dance are not participating through their state high school, but they're participating in local dance studios and in local gyms. And so we wanted to also include those sports and athletic endeavors because we wanted to include some performing arts medicine and the performing art athletics in the discussion as well, because it's common and also because there's different considerations to apply within your pediatric sports medicine practice. So without further ado, I want to pass it along to my co-session director, Dr. Jonathan Napolitano, to talk about how sports might be a little bit different this year because of the COVID-19 pandemic. All right. Thank you all for joining us. As Mary had mentioned, we want to talk about sports specific, but before we can get into sports specific pathology, we need to talk about that's something that's affecting all of our participation across the country. So when we put this program together and submitted our proposal last year in 2019, COVID-19 was not on our minds, but now we can't get it off of ours. So that has a role in each of your clinical practices, but also on the sidelines in the fields as well. As you can see from these headlines, there's a lot of back and forth. Are there going to be sports? Are there not? For those of you who don't have sports as a big percentage of your practice, you may be thinking, well, how does this affect my team getting back on the field? Other people may be thinking, I can't believe we are playing sports or even talking about sports with a pandemic going on. The reason why this is a challenge is because there's a lot of risks and benefits to be considered here when we discuss, are we moving forward? Are we participating in sports? There are certain risks out there, but then there are also benefits that need to be weighed as well. Over the next couple of slides, I hope to walk you through that process and realize why these decisions are so difficult. First of all, at the time of this recording and this presentation at the end of October, we had over 800, I'm sorry, 8.6 million total cases of COVID-19 in this country responsible for over 224,000 deaths. Out of those cases, 6.5 million of them have age data reported along with them. And we learned from that, that over 466,000 cases are in the 5 to 17-year-old age group. That makes up a good 7.2% of national cases, which is not a small number. However, what we do know is that this is a overall milder disease in adolescents. And therefore, it is fortunately only responsible for 66 deaths, yet those are 66 deaths that need to be considered moving forward. These data may be smaller than we may accept or expect because this data, as I said, is through October when a lot of these schools have begun virtually. So why does that matter? Last spring, when this pandemic began to spread across our country, governors and governments across the country began to mandate that schools be closed. During this process, the thought behind it was that even though the disease may be milder in children, spreading this disease can largely affect our country as a whole. And so therefore, if we think about less exposure is less cases, are we talking about greater exposure when we're putting people out on the field? The isolation from COVID-19 in adolescents being home from school has had a resounding effect on mental health in these adolescents. So 30% of children who are isolated or quarantined during this pandemic have reported signs of PTSD or met criteria rather of PTSD include increased depression, increased anxiety, disrupted sleep all throughout this pandemic. Those are some of the reasons that the AAP overall recommends when safe to do so that we should encourage return to the classroom. The benefits that they cite are better academic instruction, better social and emotional development, and also as an effort to combat some of these mental health considerations with social isolation and other mental health problems. This systematic review from 2013 reports that sports in general can be a excellent escape and help a lot of these social and psychological benefits of sports. They aggregated over 30 articles and looked at over 29 total categories of the benefits of sports. This included overall mental well-being, decreased depressive symptoms among numerous others. But we know that the only benefits of sports are not just the social and therefore in this country with increased virtual classrooms and sedentary lifestyle, we are already combating a youth obesity epidemic. So it's important to review that epidemic in light of our current pandemic and encouraging activity. Additionally, the effect of this isolation is not across the country and with all socioeconomic classes. The role of sports in underserved areas has a certain role of stability, discipline, and mentorship, keeping kids out of trouble and in other words off the streets. In the same demographic, there's a lot of opportunities of sports that leads to overall escape from some of these other underserved environments and the opportunity for higher education as over 180,000 athletic scholarships are offered to Division I and Division II athletes to participate in youth sports. So those are some of the benefits, but there's a number of risks as well. As I said, overall, there's a milder disease in children. However, we have seen risks of severe disease. Myocarditis is sequela of both severe and asymptomatic cases of COVID-19. Out of the Ohio State University, they conducted a study that reported out of athletes with positive COVID-19 testing, they reported over 15% of those athletes had cardiac MRI evidence of myocarditis. And now that's a very high sensitivity test and the clinical significance of that positivity is debated hotly in trying to figure out how do we best treat these athletes. However, when we look at this distribution of sudden cardiac death in athletes, prior to COVID-19, myocarditis was already the third leading cardiac death in youth athletes. And therefore, if we have all of these other hundreds of thousands of athletes who are positive, and if we're looking at 15% of that, this could be a very big health crisis. So it's that reason that a number of organizations, including cardiologists and pediatricians across the country, have tried to outline a protocol for figuring out how do we get kids safely back active. This is one of those such algorithms put out by JAMA Cardiology earlier this year, looking at asymptomatic and symptomatic cases. While they did not go so far as to recommend cardiac MRI for everyone, they did recommend screening those with symptoms with both high sensitivity troponins, echocardiograms, EKGs, and additional testing as deemed necessary by your cardiologist. Regardless of what that initial evaluation is, there's an agreement that return to sport after a COVID-19 positivity needs to be monitored and treated with care. This infographic was put out by the British Journal of Sports Medicine earlier this year as well, and really mirrored the return to activity similar to a return to play that we are all familiar with in that and after concussion. So this six-step protocol walks athletes through a program to slowly increase their maximum heart rate, their time of activity to observe for symptoms prior to returning back to activity. So as we move forward back to our scheduled programming of sports-specific diagnoses and treatments in the pediatric athlete, I'm going to talk to you today briefly about the youth throwers. So baseball mainly is the topic here. I have no relevant disclosures to this presentation, though I am a contributing author for up to date. What I'm going to talk about in this section of the presentation are shoulder injuries specifically. So I'll talk about general considerations, little league shoulder, and shoulder dislocations, how these syndromes are different in the pediatric versus adult population, and then we'll transition to elbow conditions as well. So different from the lower extremity where the majority of limb length and growth comes at the center of the limb at the knee, the upper limb, the majority of the growth comes at both the proximal and distal ends. So the humerus or the shoulder joint, the proximal humerus, is responsible for up to 40% of the upper limb length. And therefore, we know that fiseal injuries to these growth plates can impair ultimate limb length and growth. So therefore, we have a condition called proximal humeral epiphyseal lysis, commonly known as little league shoulder. This is a syndrome as a result from shear and stretch injury to the epiphysis. It comes by a combination of repetitive rotational and distraction forces that lead to microtrauma. This rotation force comes at that late cocking stage of external rotation, rapidly accelerating, causing this traction at the visus. The other forces there are distraction because proximal to the visus, your rotator cuff muscles is holding the humeral head stable while momentum in the ball and the leverage of the arm is rotating forward in that acceleration phase. We know that this visus closes between 18 and 21 years old. So that's a big risk of injury. We most commonly see this in 11 to 16 year olds. Overall shoulder pain in the little league baseball player is reported between 13 and 16% in various studies. Out of those patients, about a third of them show radiographic findings, little league shoulder. This breaks down to roughly 5% of all little league participants will have an incidence of little league shoulder. It's important in this audience that we talk about here that little league shoulder is far, far more common in our patients than any sign of rotator cuff injury or tears. And that's important to look at in our population. So that's what it is. How do we diagnose it? How do we treat it? First of all, always history and physical is most common. It gives you the clue of where you're going. Look, typically this begins as an insidious onset, worse with pitching, and then becomes prohibitive, meaning that every time we're throwing, it causes more and more pain. Initial workup would include x-rays. I recommend that these x-rays are done with an AP view of the shoulder in both internal and external rotation, as you see in the images here, where you can see this asymmetric widening of the visus. So the proximal medial portion of the visus here shows normal alignment, where out laterally on the top view shows some widening of that visus. That's a little bit less appreciated on that internal rotation beneath it, but you can still see asymmetry. An exam can be very wide ranging. It can be a completely benign exam, but only reporting pain with throwing, versus a very hand positive exam. Any type of shoulder motion you're putting someone through can recreate the pain. That's all different based on the time of presentation. Typically, the most consistent finding is tender to palpation directly over the physis, which would be deep within the deltoid. The most common exam finding that I find positive, again based on our known cause of this rotational forces, is pain with resisted internal and external rotation of the humerus. So how do we treat it? It's a combination of three different treatment strategies. No one more important than the next. Absolutely, number one becomes rest from throwing. Continuing to throw with this equals continued damage to that physis and can risk growth arrest. But I recommend that at that time of diagnosis, we already start rehab and therapy. Because of that treatment needs to focus away from the shoulder, but as a youth athlete is developing, they're normally underdeveloped in their core and hip control, which leads to overthrowing with the arm, increasing the forces here. So spending your beginning course of your rehab focused on lower body conditioning and then eventually progressing to scapular postural strengthening and finally into throwing mechanics. This picture here is the typical athlete that I see in clinic who's hunched over on my exam table texting while I'm talking to them about why the anterior shoulder hurts here. So clearly an imbalance as we're all comfortable and familiar with. But the third aspect of this treatment policy is counseling. Counseling involves the risk of overuse injuries in sports and the risk of sports specialization. I use this as an opportunity to talk about diversifying and taking specific time off from individual sports. The next thing I want to talk about is shoulder dislocations. Again, different in the adult versus the pediatric populations. Young patients have a very high risk rate of recurrence of shoulder dislocations. Those that are less than 20 years old have as high as 95% recurrence rate, especially those that are involved in high activity and collision sports. The pathology worsens with each recurrent dislocation resulting in soft tissue or bony Bankart lesions to the glenoid cavity, increased humeral head deformity of Hill Sachs lesion, and eventual bone loss and capsule deformation. Therefore, surgical stabilization is less likely to be successful with recurrent episodes because of that bone loss at the glenoid. Overall, with recurrent dislocations, you have seen increased arthritis as well with as much as 40% arthritis seen in recurrent dislocators compared to 18% in a single episode. Operative stabilization is therefore recommended quite early and therefore my treatment algorithm, which we'll outline on the next slides, really does not treat a dislocation lightly. 60 to 80% relative risk reduction in recurrent instability after a primary surgical intervention. This really looks at a traumatic shoulder dislocation. We're not talking about those hypermobile patients who have party tricks to move their shoulders around, but we're talking about a single event. I use my age differentiated as 14 years of age or younger. If those are younger, if we have a primary dislocation, they do very well post rehab. However, if that becomes recurrent, I will further evaluate them. However, if we're over the age of 14, I already start arthrogramming. So after any initial shoulder dislocation, I will obtain an arthrogram to look at this. If there is any signs of bony or soft tissue Bankart lesion that goes directly to surgery. But other than that, we look at the time of their injury. If this is mid season, I will attempt to do a short course of rehab for two to three weeks to see how we can improve. But if they fail rehab or if they have early recurrence, they go directly to surgery. It's important to have a surgical colleague who is both conservative, but also understands the risk here of this population. Other extremities or other joints injured in throwers commonly is the elbow. Pediatric elbow x-rays can be very intimidating to those not familiar with looking at them because of these various ossification centers. You have six different ossification centers within the elbow which have different times at which they first appear and different times at which they fuse. This is important to know which may be a fracture or which may be just the normal variant of the ossification. Most commonly what we see is medial epicondyle apothecitis. This is not medial epicondylitis. This we call little Lee's elbow most commonly. This is a traction or stress injury to the apothecitis, very similar to Oshkidge-Slaughter disease at the knee. It's caused by a repetitive valgus load again in that acceleration and deceleration of your elbow. The ossification closure is as late as approximately 15 years, so this can happen throughout your little Lee career. Most common in those 11 to 16 years old. As I mentioned, this is a common thing that I see in clinic. It's more common than a UCL injury and far, far, far more common than medial epicondylitis in this age group. So how do we diagnose and treat it? First, we want to know the history. Is this acute? Did this happen at all one throw? Because then I'm clearly aware, concerned of an avulsion type fracture seen on the x-ray to the right. But otherwise, I'm progressing into x-rays to look at what type of asymmetry I may have, comparing side to side, or otherwise looking for detraction or widening of that hypothesis. My exam is most consistent with centered palpation over this area, pain with resisted wrist flexion, and a valgus load of the elbow. Treatment's the same as my shoulder rehab, where I'm starting with rest, but early rehab to focus on those lower extremity and core imbalances, but again, also counseling as well. As we continue the rest of our talks here today, I'm excited to introduce Dr. Brian Kravec from University of Washington. He's going to talk to us about the swimmers and slightly different overhead athletes and different upper extremity injuries. Thanks, Jonathan, and thank you for having me today to speak about the swimming athlete. As noted above, I serve several roles in regards to swimming, and I work at Seattle Children's University, Washington. I've also had the privilege of working with our U.S. national team and have traveled through them internationally. A lot of the swimmers I've met throughout the years started as youth athletes, so I'm going to try and take some of those pearls that I've learned and communicate them with you today. What we're going to do is we're going to focus on two specific areas. One, we're going to understand the shoulder, specifically some of the risk factors, what does the literature suggest, and then how that translates to the evaluation and treatment of these athletes. And then two, we're going to look at concussions. Now that may surprise you a little bit that we're going to focus on concussions, but we have developed some guidelines through USA Swimming, and I've been fortunate enough to sit on the task force for that, to provide a sport-specific return to swimming concussion program that should help you when you're taking care of these athletes. Okay, so let's get started. So, you know, swimming is a really interesting sport, right? We have different strokes that we perform, whether that's fly, back, crawl, freestyle, or breaststroke itself. And we know for elite athletes, they spend a lot of time in the pool. It's estimated that elite swimming athletes will swim 60 to 80 kilometers per week, going over 30,000 different strokes throughout that time. And then take an age group athlete who's someone who swims at a specific age for a club, and they're still swimming a mile or two per session. My son swims, and you know, that means he might be swimming up to 12 miles a week going through his swimming training. And what we know is that the shoulder is one of the most common areas that gets injured. That's followed by the lower extremity, and specifically the knee, as well as the lumbar spine. Now, what does the data show us in regards to swimming injuries? Well, this is where we got some work to do here. There's a variety of studies that will look at this in regards to either age groups, high school swimmers, collegiate swimmers, or even master swimmers. What we know is for these age group swimmers, and here you could see them broken up by specific ages in relation to this, a lot of this is self-reported. So people will ask, how many people say they've had a shoulder injury? And the metrics vary here for these age group swimmers. So much lower in here, you could see it's in some of them in the range of 20% as well. There is some database in high school databases which show that the percentage of individuals have a report a higher incident in high school, as well as in the collegiate athlete. And interestingly, in swimming, a lot of the Division I collegiate athletes are actually our national team members. When you look at these studies as a whole, we at least get some sense of how this relates to athlete exposure. And the age group swimmers were lacking that data, but here you can see the data from the high school and collegiate athletes. You can see how from relatively there's an increase as one gets more involved in swimming. So what are the risk factors for swimming? So we have the data, we know shoulder is one of the top areas as well. What are the risk factors that we can identify that then help us shape how we evaluate our athletes and how we treat our athletes as well? And this chart pretty much summarizes this and it was a great systematic review done by Hill in 2015. And it was really looking at what are what are what is the good studies show? And and the first answer is that we need to do more studies, right? As you can see here, there isn't high level evidence for anything that we found at this standpoint to suggest one specific thing. But there is some data to suggest there's some things we can look at. As I alluded to in the last slide, competition level, so the the the level for which one is competing may play a role. So those those high school compared to collegiate athletes convert to elite athletes, it's those older more experienced athletes that may be at a future risk for injury. Now whether that relates because they've been spending a lot more time swimming compared to the younger athlete, that needs to be sort of determined. But it does seem like it's the longer you get in your career, the more likely you are to experience a shoulder injury. We know that there's some data that has to do with the range of motion in regards to internal and external rotation, specifically that if there's a bit of a loss of internal rotation compared to external rotation, we're going to get some of that tightness in the posterior capsule and that can cause an imbalance of the shoulder itself leading to injury as well. We know laxity or instability can play a role. Now laxity can be an advantage in swimming. A backstroker is able to catch more water there, but if you get instability in that shoulder, that can potentially lead to pain. And we know that if you have a prior injury of injury to the shoulder itself, that that may be a predictor and that can be helpful when we're doing our prepartation physicals. Interestingly, a bunch of other factors on the right have low level evidence. In rehab, we spend a lot of time talking about the scapular and scapular dyskinesis. I do think those are important, but if you sort of pool the data together, the studies would suggest perhaps they're not as much predictive of someone who's going to get shoulder injury. And one of the things I tend to focus on, and if you have an understanding of swimming, is technique and technical errors. Now this slide summarizes some of the easy questions you can ask about, and nowadays people have videos that they'll bring in regards to how they're swimming. On the bottom left you can see the obvious posture. You know, swimming is a horizontal sport, right, and it requires a balance from the fingertips to the toes and engagement of the core to keep us level. That's how you're going to be the most efficient moving through the water. So if somebody swims like this person on the bottom, their legs are sinking, they have poor kicking, that can lead to stress to the shoulder and overuse type of injuries. On the right you can see an example of someone who is crossing midline or crossover. They're kind of adducting too far, they're arching their spine towards the left, and that can put pressure on the shoulder joint itself. On the top left you'll see someone who's extending their arm too far down, they're trying to catch water in the middle, and that often leads to movement of the shoulder joint forward, which can cause injury. And then I have an example of someone here, it's backstroke, who the check mark is in an ideal position of where your hand is to catch the water, where if someone's extending the shoulder too much, going too low, they can get into trouble. So let's go through a couple of videos just to illustrate this point. And on this first slide that's coming up, here's someone who has a nice stroke. I want you to notice how their their arms coming forward, coming outward, they're grabbing the water. If we can get that to circle back again and repeat, you can see how they, again, they catch the water, they come through their elbows towards the side, they're propelling themselves forward, they have nice rotation in regards to their shoulders and how they're moving. They have good head position when they're breathing. This is a great example of some form we want to see. Now let's take this next person. You can already see how they're flatter, their arm is coming forward, they're crossing over right there. This is someone who may potentially run into more trouble in regards to their swimming technique compared to the person we saw on the first slide. Here's an example of this backstroker. Again, we're going to cycle through this one more time and you can see how there's arms out, they're rotating, they're keeping their heads still and steady as they're going through. They're catching that water and they're propelling themselves as forward as possible. As opposed to this individual who's trying to move fast, but you can see how wide their arm is coming out. Really not good rotation in regards to the shoulder joints itself. This might be someone, again, who might be at risk for shoulder injuries. If you have this data in these videos, you can have a conversation about that. Okay, so that's some things we ask about. How does that translate to how we evaluate these athletes? Well, again, swimming is unique in the sense that it's a horizontal position relative to other sports where we tend to be more vertical. Playing football and soccer, gymnastics, we're flipping around all over the place. We want to work from the fingertips all the way down to the toes when we're thinking about an evaluation of these athletes. As we work ourselves down, you're going to work from the head. You're going to think about the neck. Is there hypertonicity of certain areas? A lot of swimmers will breathe to one specific side, so they might have a hypertonicity in the upper trap or the sternoclavicular mastoid where they're turning their head more, and that may lead to some asymmetry. They may have some weakness or inhibition of the lower trap area, the serratus, some of the scapular stabilizers, as well as the obliques and the glutes that might lead to sinking of the lower body, putting more pressure on the shoulder itself. And that's why, although the studies may show little evidence, we're going to evaluate these individuals, look at neck range of motion, look at the shoulder, look at scapular dyskinesis, especially if it's on the side that's injured. Maybe do a scapular assist test, like in the lower middle section there, see if that alleviates some of that pain. And don't forget about the core as well as the lower extremity. I love to put people in this this quadruped position and have them lift the arm and the leg. You can get a good sense of flexibility. Was that arm, shoulder, hips, leg alignment straight, or is it off? You can get a good sense of balance. A lot of people will be wobbling around over here. And a pearl to the patient, right, you then link it back to, look, hey, when you swim in the water, you're in this horizontal position. Think about if you don't have that stability, how that translates to what you're doing over and over and over again within the water. And then we're going to craft our program based on these findings here. And our rehabilitation, you know, is going to incorporate some of the important things of the kinetic chain from the hand all the way down towards the spine. If you think about it, when your arm goes in the water, you're finding the optimal position where that hand and forearm and all that is going to grab the water. It's almost like a more closed kinetic chain type of movement there. So doing some of these exercises for scapular stabilization in the shoulder with the ball really facilitates some of that as well. We're going to make sure, like on the right, we're working on our spine, our core stabilizations. One of the things I like to ask kids is like, how much do you like kicking? Are you a good kicker? Because kids who seem to get into trouble often will say, I don't really like kicking, you know, I don't go as fast. I go back roads sometimes. It's just, they're not as good at that, which tells me about their core. We need to work on that as well as some of their hip strength and ankle flexibility. One other key thing, and that's unique to to swimming, is the concept of postural restoration and breathing, right? So buoyancy comes into play. How you breathe, where you hold that in your lungs or lower your diaphragm plays an important role in the plane that you're on as you're swimming through the water there. So anyone who's involved with swimming know about drills that have to do with breath control. Well, some of your rehabilitation, and I encourage you to find a therapist who can work on this, is making sure we get good engagement in regards to that breathing pattern and how we're engaging the diaphragm, any asymmetry, that breathing, because that maintenance of that core is so critical to swimming. And swimming's a sport where people will lose gold medals by 0.01 seconds or may win eight or more of them by 0.01 seconds. So it's an important thing. And then we're going to think about our complementary component, you know, cupping was a big deal a few years ago. Dry needling is a big thing now that that some of these athletes will be asking about. Just think about those things in regards to soft tissue management as well. There's also some sports specific things you can do with your physical therapist. And here I've outlined a few things in regards to freestyle on the left and backstroke on the right. And we're going to look at a couple videos in a sec. One of the things, as you can see in the top left, push off. When you come to the wall and then you push off, you want to be in a very streamlined position. So you can simulate some training of that on the balance ball, similar on the left for backstroke. On the lower left, you can see some ways you can get creative with trying to work on core stability as well as some resistance in regards to the freestyle stroke. And on the right, you'll see that for backstroke. It's really sort of illustrated here. So here we have push off, he's coming off the wall, he's kind of oscillating back and forth, simulate some of the dolphin kicking that you first do. Really working on core stability as well. And then on the next one, here's an example. And this is extremely hard, but just trying to work with some pulleys to work on just some of those biomechanics. Now, you don't want to overload the system too much, but this is a great example of some creative ways you can rehabilitate someone. And then last but not least, we're not just going to throw those kids or athletes back to the water. We're going to think about their training and what hurts and modify that. We're going to give them periods of rest. And we're also going to remember, and here's a pearl, think about the equipment athletes use to get back. So here you have an outline of the various different equipment, including whether it's kickboards, pull buoys, fins, and some of the indications for that, and some of the contraindications. You know, kickboard, if your arm is getting impinged and you're in one position, you may irritate the shoulder as much. Using a pull buoy really, you know, takes the legs out of this, causing you to use more of the shoulder, and that may lead to some pain. Whereas, as opposed to perhaps using zoomers or fins, may be more beneficial to the shoulder because it gives a little bit of a rest. And obviously paddles are something else you have to sort of think about in regards to putting stress to the shoulder. All right, let's move on to concussions here. So I can give you great examples internationally of trying to manage concussions in an important way. As was previously noted, you know, we're aware of the symptoms related to concussion, and the literature does suggest that concussions can occur in swimming, although it's less likely. What we don't know is on these age group groupers. Age groupers tend to swim in club teams, and there's not a great database for that, so we need to figure that out more. As part of USA Swimming, I've been fortunate enough to sit on a task force where we decided to take the Berlin concussion symptoms, which actually used to have a phase for swimming. They took it out for some reason, the last reiteration of it, and adapted that to swimming. Because swimming is unique. Again, we're in a different postural position. Every time someone swims, they're in essence doing a flip turn, and they have to dive in the water. And there's some things to think about when an athlete is experiencing concussions, and especially with the vestibular component to this. So similar to the Berlin guidelines for general concussion, here's a sport-specific guideline that breaks it up into very similar stages. So we kept it like that so you're familiar with it. Again, these are guidelines, and so you have to adapt this as you need. But similar to the regular Berlin concussion, you are going to, you know, go from one stage, wait 24 hours, if there's no symptoms, advance to the next. Obviously, you want to make sure that someone is okay with activities of daily living, not having significant symptoms, and has come off medicines or anything to manage your pain symptoms before you start a return to swimming program. But once we get past that first stage, we can move on. So stage two here, light aerobic exercise. So for this, this might be where you have an opportunity for someone to swim with a kickboard. They're keeping their head steady. They're not exerting themselves too much. Maybe they even need fins. You could add in, you know, the heart rate and a percentage of their maximal heart rate to make sure they're doing a light aerobic kind of training program without taxing themselves. Sometimes you have to work on land-based exercises, and that's where stationary bike or elliptical could come in. But the kickboard's a first good, nice way to integrate in some type of exercise program. And if they're okay with that, then we're going to increase the intensity, right? So here we are. Now we're going to add in, for freestyle, you can add in snorkel. Snorkel's a great way to keep the head steady while allowing one to go through simulating more of an exertion in regards to the swimming, specifically freestyle itself. We could layer in things like breaststroke, freestyle, as opposed to flying back. Fly has more of an undulation, and that may not be tolerated as well. Back, the hardest thing with back is just that you might not know where you're heading, and if you get disoriented, you can crash into another individual. So we're going to be careful with that. We're going to eliminate flip turns and work on open turns, so that way you're touching and going, so that we're not having the vestibular spinning issue. And we're going to increase the maximal percentage of heart rate so that we can tax the system a little bit more. And somebody can deal with or tolerate that. Then we're moving on to, in essence, non-contact drills, which is really just advancing the interval training for swimming and the stress to the system, allowing them to go through, still trying to eliminate flip turns, and definitely no diving or starts at this time, but increasing the stress for heart rate. And then eventually we're going to get to the point where we are going to integrate in flip turns, make sure they're not dizzy with that, and then add in starts as well. And so we're increasing the amount of time that individual is in the water. And after successfully, in essence, getting back to a full practice, including all the flip turns and such, then we can return that individual to competition. And so here's a nice summary of the basic guidelines to the right, and a reference for you that you can utilize and show to your parents while you're taking care and getting those athletes to return to swimming. So with that, some take-home points here. Swimming, swimmer's shoulder, right, variable injury rates based on the level of evidence. Do a nice, good functional assessment of those individuals, knowing that we still need to do some better research in regards to true risk factors, but we've identified a few in regards to level of competition, some of the things to look at in regards to range of motion and strength from head to toe as well. And know that the majority of these injuries actually do get better with the time. For concussions, you know, want to recognize it does happen, and when it does, now you're empowered to have a concussion return to swimming protocol, very sports specific, that should help our athletes return in a safe way and as quickly as possible. Okay, with that, so thank you very much for having the opportunity to do that. I've had a chance to give you some references there, and really excited to answer any questions anyone else may have in regards to swimming. Hi everyone, so in this session, we will talk about pediatric sports medicine updates as it pertains to youth American football. I have no disclosures relevant to this presentation. As an outline of today's presentation, we will go over a general overview of youth football, including common injuries. We will focus on stingers and concussions and the most recent evidence and medical discussion surrounding these injuries. Then we will discuss some ethical considerations in youth football and the end, at the end of the presentation with a summary of take-home points. American football is one of the most popular sports for youth athletes. Concerns about the number of head and neck injuries have led athletes to stop playing football, leaving concerns for many about the future of football. Moreover, much of the media over the past few years have focused on chronic traumatic encephalopathy, raising concerns in the general public that many concussions lead to CTE. There is a wide array of different injuries seen in football in football players. The most commonly injured areas in football at all ages are the knee, ankle, hand, and back. The head and neck range from 5% to 13% of injuries. The overall incidence and severity of injuries in younger football players are lower than those in older players. However, injury epidemiology data is limited for younger players compared to high school, collegiate, and professional levels. The risk of catastrophic injuries to the head and neck in football is low and comparable to the risk in gymnastics and lower than the risk in ice hockey. In addition, the risk appears lower for youth players than for high school players and lower for high school players than for college players. Stingers, also known as burners or traumatic upper trunk brachial plexopathies are common injuries seen in football. In a study of American football players across high school, collegiate, and professional levels, 50.3% of all players reported a stinger in their career. The incidence is unclear in younger athletes and even in the population in which the incidence has been reported, stingers are historically underreported. However, even though stingers are quite common, management is not clearly defined with some recommendations debated by the experts. For the scope of this talk, I'll do a brief overview of stingers with a focus on discussing management recommendations based on expert opinion. Stingers result from injury to either the cervical nerve root or the brachial plexus. Typically, a player will experience immediate sharp burning pain that radiates down one arm and may be associated with weakness, paresthesias, and numbness. The pain usually resolves in seconds to minutes. Motor strength usually normalizes within 24 hours, but in more severe cases, a variable degree of weakness in the muscles innervated by the upper trunk of the brachial plexus may last longer. The C5 and C6 nerve roots are the most commonly affected, but any nerve root can be involved and the mechanism of injury in patient's anatomy can affect the injury. There are three proposed mechanisms of injury. First, brachial plexus stretch or traction, which typically results from lateral neck and shoulder depression. Another mechanism is nerve root compression in the neuroforamina, which typically occurs when the neck is in hyperextension and it's lateral-lateral neck flexion, similar to the Sperling test maneuver, or injury from direct blow to the brachial plexus, which tends to occur at Erb's point where the brachial plexus is superficial and vulnerable. Brachial plexus stretch is a more common mechanism in youth athletes in particular. Stingers can further be classified into three groups based on the type of nerve injury as described by Seidon and Sunderland, the Seidon and Sunderland classification system as seen here. Routine imaging is not needed for an isolated stinger that resolves rapidly without residual symptoms. Further diagnostic workup is warranted when there are persistent symptoms, neurologic deficits, or recurrent stingers. Timing of imaging is controversial and unique to each patient's scenario. Your leading differential diagnosis list will guide which imaging to perform, which could include cervical spine x-rays, MRI, CT, CT-SPECT, or other imaging studies. Most stingers do not require EMG. However, EMG can be useful in the setting of persistent neurologic symptoms to further investigate the etiology, but also to prognosticate recovery. Determination of return to play is multifactorial and should not be based solely on the presence or absence of improvement on serial EMGs. Initial treatment typically includes rest. Below is a table from Ahern et al's recent publication in 2019, which describes management based on the grade of injury. Physical therapy plays a significant role in athletes with persistent stinger-related symptoms or chronic stinger syndrome and early progressive resistance exercises. Return to play after sustaining a stinger and return to play is based on expert opinion guidelines, but standardized criteria have not been uniformly accepted by the medical community. In general, in order to return to play, the athlete needs to have adequate time to heal from the injury, complete resolution of all symptoms, full pain-free range of motion, normal strength, and the ability to perform sport-specific skills without symptoms. Most athletes experience quick and complete resolution of symptoms, and so they may return to play immediately. However, if an athlete does not experience complete resolution of symptoms, they should be held from the current game and re-evaluated at the end of the game. Symptoms persisting beyond this point warrant full neurologic workup with imaging. Specific return to play guidelines should be based on frequency of stingers, symptoms, neurologic deficits, and any abnormalities on diagnostic studies. However, there is some discrepancy between expert opinions. For example, guidelines from Cantu et al. in 2013 suggest that an athlete may return to play if they have had less than three stingers in less than 24 hours, as long as there is a full cervical range of motion on their exam, normal neurologic exam, no neurologic symptoms, including no sensory or motor changes, and no clinical signs of fracture or cervical spine instability. Meanwhile, guidelines from Standart and Herring in 2009 suggest that if there has been a second stinger, even if they're asymptomatic in the same season, removal from the current game is recommended. Guidelines from Weinstein in 1998 recommend the use of both clinical and electrodiagnostic studies to aid in return to play. After a stinger, individuals who have weakness persisting beyond two weeks should obtain electrodiagnostic evaluation. There are also no formal guidelines for when to disqualify an athlete from play, but general consensus is that the following items are contraindications for contact and collision sports. Lastly, regarding prevention of stingers, the main focus has been on proper tackling technique and conditioning and strengthening. However, there may be also a role for protective equipment. Below on the left is a Bullock collar, a Cowboy collar in the middle, and a Kerr collar on the right. Cervical collars are intended to decrease the risk of injury by decreasing cervical extension and lateral flexion. Research led by Rausen et al, studying these three types of collars and test dummies, revealed that Kerr collars minimize head acceleration and forced transmission through the neck the most. However, cervical collars also come with their own risks. Restricting cervical spine range of motion may affect the player's performance on the field. Some collars may limit cervical spine extension and place the athlete's cervical spine in a more flexed position, potentially increasing the risk of severe cervical spine injury or concussion by not being able to achieve proper tackling form with the head up. Conditioning and strengthening programs focus on neck and core musculature have also been proposed to decrease the incidence and recurrence of stingers, but have not been validated in the literature systematically. Now, let's briefly talk about concussion. For the scope of this presentation, I will focus on highlights specific to youth football. Within the past five years, multiple consensus or position statements have come out of multiple national or international organizations, such as the AMSSM and the AAP. If you have not reviewed these statements, I would strongly encourage you to review these for the latest updates regarding concussion. Because of a larger number of participants in youth and high school sports, concussions in the pediatric and adolescent age groups account for the majority of sport-related concussions. When compiling large epidemiologic studies, American tackle football continues to be the high school sport with the highest risk of concussion. Recent research has shown that in middle school, tackle football also has the highest concussion rate. One study demonstrated that youth tackle football players aged eight to 12 years old have concussion rates higher than in high school athletes, with a nearly two and a half times higher concussion risk in 11 to 12-year-olds when compared to eight to 10-year-olds. The majority of concussions occur from tackling or being tackled, with head-to-head contact being one of the leading causes of concussion in youth football players. Studies in older athletes in high school show more impacts in games than contact practices and more in contact than non-contact practices. In 2015, the AAP published this policy statement on youth tackle football. They discussed many things, including concerns regarding cumulative and catastrophic head and neck injuries. They also cited the most recent literature regarding head and neck injury types of incidents, noting that much data is lacking in the youth football population. A good portion of the statement also discusses injury prevention strategies. Decreasing contact practices has been proposed as a method for decreasing injury risk, especially concussions, because even though games have a higher incidence of concussion, there are more practices and thus more exposure through practices. However, others argue that the risk of concussion is higher in games than practices, and so this change may not decrease concussion incidence. In addition, by decreasing time practicing proper tackling technique, there is concern that there would be an increase of impacts and concussion risk during games given lack of training. Therefore, if contact practices are to be reduced to decrease overall head impact exposures, the AAP recommends extra emphasis placed on teaching appropriate tackling technique to avoid increased risk during games. Delaying tackling until a certain age has also been proposed, given the brain is in rapid periods of development in younger years. However, there is concern that athletes wouldn't learn skills required for tackling until they're older, when they are bigger, faster, stronger, more coordinated, and capable of delivering more forceful blows, which could increase injury risk. Thus, more data is needed in this area. Teaching proper heads up tackling technique was also emphasized in the AAP statement, as well as enforcing rule changes. While spear tackling, which is associated with catastrophic injuries of the head and neck, was banned in 1976, enforcement of this ban could still be improved. The AAP statement also discussed the current evidence in protective equipment and recognized that the introduction and updating of helmet designs has played a large role in reducing head injuries, particularly catastrophic head injuries and brain injury-related fatalities. But the role of helmets and specific designs is still unclear in concussion prevention. Neck strengthening was also discussed with preliminary evidence that neck strengthening may have a role in concussion prevention by decreasing the neck fatigue and increasing the effective mass of the head that then causes an external force to have a decreased acceleration effect on the head. The AAP statement on tackling youth football quickly gained a lot of controversy, highlighted in an AAP perspectives piece published in 2019. In this perspectives article, the authors expand on published criticisms of the AAP policy, particularly its reliance on informed consent as a justification for youth participation in tackle football. Summarized in the statement, participants in football must decide whether potential health risks of injury are outweighed by the recreational benefits associated with proper tackling. They noted that if participants are to provide morally and legally meaningful consent to assume the risks of tackle football, they need information on which to base that decision. The article also pointed out that a verbal or written agreement to participate in tackle football provides no evidence of whether the player or parent has sufficient understanding to support a conclusion that the decision is in fact informed. The authors also argue that since AAP's policy statement uses terms such as unclear or limited more than 40 times, that the evidence supporting their recommendations is inadequate to allow for an informed discussion or decision. The perspective article also notes that the AAP needs to clarify whether parents and players must both consent and if so, at what age levels. The age at which a player is able to provide meaningful consent or assent is complicated. At all levels, there are a good percentage of players who choose to hide or underreport concussion symptoms at a greater personal risk. They suggest that stronger language like brain injury or damage instead of concussion be used to clarify the acute symptoms are reflective of a brain injury which needs to be taken seriously. The authors also suggest that the AAP statement provide a model consent form. Here is a Pop Warner's intent to inform document which is a prime example of the inadequacy of the informing process for players and the families. It doesn't mention specifics about risks and does not even mention concussion. Furthermore, it implies football has the same risks for injury as cheerleading or dance by lumping them together into one form when we know the injury risks for each of those sports is quite different. The authors also argue that AAP's assertion that consent is sufficient to justify participation in youth tackle football appears to be inconsistent with AAP policy statements on at least five other sports and activities. For example, when comparing football to hockey, the AAP statement acknowledges that rates of injury and concussion are lower in hockey than in football yet the AAP recommends banning body checking for all players under the age of 15 and encourages physicians to advocate for expansion of non-checking programs in hockey. However, they have not made a similar recommendation about blocking and tackling in football and it is unclear why as these would carry similar risks. The respective article also notes that the AAP statement implies that the benefits of tackle football can outweigh the risks but provides little supporting discussion on the unique benefits of tackle football compared to other activities outweighing the risks of youth football. Lastly, the authors criticize that the AAP policy statement on youth tackle football needs to provide guidance about whether pediatricians should use directive counseling in advising parents and children in their decision on whether to play tackle football and how to do so. Also in 2019, Dr. Cynthia Labella published a commentary through the AAP on youth tackle football. She highlights a study by Christman et al in 2019 that showed that parents perceive concussion rates in tackle football to be substantially higher than they actually are. Furthermore, concussion risk in tackle football is lowest when players are less than 12 or 13 years old before pubertal growth spurt begins. As bodies get larger and faster, collisions occur with greater force. And the parents... So she concludes that the parents' misperception is likely due to exposure to biased media headlines and stories of former players rather than those from published scientific data. Labella also discusses that we still do not have enough data to understand the long-term effects of concussion, especially in youth athletes, and that the studies that have been sensationalized by the media have many limitations, including participation selection bias, recall bias, limited study designs that didn't gather data from adequate comparison groups or gather certain historical data such as previous concussion history. Moreover, these studies were performed on individuals who played football in a different era with different roles. And Labella argues that it is difficult to apply the findings of these studies to the current generation of youth football athletes. She points out that the rules will continue to evolve, and therefore, as physicians, we need to help families interpret the research data and fill in gaps missing from headlines. In summary, youth tackle football has higher risk for acute and overuse injuries compared to other sports, return to play guidelines for stingers, burners, or controversial and based on expert opinion guidelines. Further concussion research specific to youth athletes is needed to guide recommendations. Parent and child perception of youth football participation risks may be different from reality of risks, but much more research is needed to understand these risks. And the decision for a youth athlete to participate in American football is complex and an individualized discussion. Here is a list of references for this presentation. If you have any questions, please email me at stephanie.tau at utsouthblaston.edu. Thank you, and now on to the awesome Dr. Aaron Carlin, who will present on youth gymnastics. Welcome all virtual 2020 AAPMNR Annual Assembly attendees. My name is Aaron Carlin. I'm gonna be talking to you about common injuries and prevention strategies, and what I feel to be the most challenging sport on the planet, youth gymnastics. So just a little bit of background. First of all, there's five competitive gymnastics forms to be aware of. We're gonna focus on artistic gymnastics, which is what most of us think of when we think of Olympic gymnastics. And this is Simone Biles on balance beam. And unless you've been living under a rock, you know who she is. There's also rhythmic gymnastics and others that are out there. With women's gymnastics, there are four events. Men's gymnastics, six that I have listed. The overlap between the two are floor exercise and vault. One of the things that's unique about artistic gymnastics or gymnastics in general is the fact that for success, you need to be able to combine proprioceptive control or what's called air awareness or body awareness with a significant amount of strength to tolerate impact loading through the joints, torsional forces through the joints, as well as the dynamic dismounts. In addition, significant flexibility, especially in the lumbar spine, but taking all of those physical attributes and then adding in the grace and artistry of presentation for the judges is something very unique to gymnastics. Gymnastics starts very early for those, a lot out there like my own family. Classes, mommy and me classes are starting before the age of two. Competitive training for the majority is prepubescent, peaking in teen years, but that means that you have a long period of participation in competition with open physis, which adds to additional risks of injury. Of course, gymnastics is year round training. And with that comes a large amount of repetitive, high impact and torsional forces to the upper and lower extremities. These prolonged practice times as you move along in your career. There's recreational gymnastics, of course, which is just a few hours a week. But then when you move into competition, moving from Excel or in the junior Olympic level, which you can see here with my daughter and her team, they're practicing 20 to 22 hours a week. And then you move up to the Olympic level and we're getting 30, 40 hours a week or more, almost practicing every day. With that are increased exposure hours to injury and injury rates, as you can see, are gonna increase as you would expect. So sprains and strains are gonna be the most common. In females, the lower extremity is the most common site for injury. For males, the upper extremity is gonna be most common. Highest risk skills that are gonna cause injury are gonna be your handsprings and your flips and tucks, which is accounting for about 50% of all injuries, primarily due to the significant amount of momentum, angular velocity and kinetic energy inherent to those maneuvers. Floor exercise, as you can see here from this gymnast at Auburn, is the most common event causing injury. She unfortunately broke both her tibia and fibula, not just that right leg, but her left leg as well. And it also hits home the idea that in competition, there's more than a 10-time increase in these types of injuries. The wrist is the first area that we're gonna talk about. This is the most commonly injured upper extremity joint in female gymnasts. High forces, up to 16 times body weight during impact on vault and other activities such as floor. The gross majority of gymnasts are gonna report some type of wrist pain throughout their career. Soft mats, because that leads to wrist hyperextension. Twisting elements and growth spurts when there's fissile weakness are gonna increase risk. Common injuries about the wrist I have listed here, we're gonna focus on the top two because they're not common to other sports. We're gonna talk about gymnast wrist and grip lock. So gymnast wrist, many of us have heard of, is that stress injury to the distal radial fissus. It's caused by repetitive compression and sheer forces on that extended wrist. The distal radius, as you know, takes about 80% of that axial load with weight bearing. These kids tend to present with chronic wrist pain with no definite trauma history. They'll have tenderness to palpation, swelling over the site and some grip weakness. X-rays might show widening of the distal fissus. Treatment is generally gonna be removal from weight bearing through the upper extremities and removal from gymnastics, rice principles. Sometimes we'll be putting these kids in casts if they can't be trusted to stay away from gym, which is unfortunately not uncommon. And then graduated return to play. Proper technique and equipment as well as use of wrist guards lowers risk. And we've seen a decreased rate of these injuries with the newer wider vault. Grip lock occurs on the uneven bars, high bar and still rings. You can see in the picture on the top, this is associated with circling skills, things like giants, clear hips, dislocates, inlocates on rings. The athlete's leather grip folds up on itself and actually locks up. So the hand stays in place while the entire body continues to go around in a circular rotatory fashion. Tends to result in both arm radius and ulnar fractures. Key to keep in mind is that if you're at an event when this happens and they are still suspended from the bars, which does happen not infrequently, you need to stabilize those fractures before removal. Proper fitting of grips is key for prevention. The elbow, we certainly see injuries because of the repetitive impact loading and hyperextension, such as what's occurring with this gentleman on still rings. I've listed some of the more common injuries. We're gonna focus on osteochondritis dissecans of the capitellum. Why? Well, because this is seen almost exclusively in youth gymnasts and youth baseball players. So important for this population. due to the high impact on that extended elbow in a valgus position, that shear and compression force at the capitellum causing injury. Early diagnosis is extremely important, um, because of the risk of progression to loose bodies. Um, it tends to be an insidious onset, lateral and posterior lateral pain. X-rays might show, um, lucency or what you see here, or it might show lucency that you see here on the X-ray, sometimes loose body, and oftentimes they'll have range of motion loss with, with, uh, elbow extension. Uh, treatment of course is going to be rest from gymnastics, time away, uh, and loose body removal if necessary. The shoulder is one of the most common, or is the most common area of injury in men's gymnastics primarily because of that increased stress in the men's events such as still rings, high bar, parallel bars, and the pommel horse. There's a significant amount of glenohumeral mobility that's needed to be successful on those events, uh, and amount of strength. So there's a significant, so that results in a lot of torsional force through the shoulders that can result in some of the common injuries that I have here. Let's go. Let's go. This video. Come on. Let's land it. Come on. Video of my son and you can see him as he's working around a significant amount of torsional movement. Come on. Let's land it. Come on. Come on. There you go. He dislocates, leading to a double back, which he landed. In terms of the spine, um, certainly we're all familiar with mechanical low back pain, and that's quite common in this population, spondylolisis, spondylolisthesis as well. Just always need to be aware of that with extension-based, uh, back pain. There, gymnasts is certainly at highest risk in many sports because of repetitive hyperextension inflection, axial loading, and twisting going through, uh, the spine. For example, this, this athlete coming down in his swing on rings is having six to nine times of his body weight going through his low back, uh, when he comes through in his full swing. Um, spondylolisis, of course, is that stress fracture of the lumbar pars interarticularis. The events that you're going to see this, or the movements that you're going to see this most commonly, uh, uh, caused by are going to be your back and front walkovers, your back and front handsprings, and then your chenko vault, which is coming off of the springboard to a round off and then to a back tuck. Um, almost 20% of artistic gymnasts have had this documented. Um, so quite, quite important to be aware of with any kind of extension-based low back pain, positive stork test, and tenderness on exam. Um, x-rays can show the fracture, the oblique, of course. Bone scans with SPECT, CAT scan, MRIs are also used and can aid with treatment and return to play decisions. Um, treatment, of course, whether we're talking about bracing or not bracing is controversial and that we'll save that for another time. Um, the main idea here though is prevention. Abdominal stabilization, antilordotic strengthening, landing mechanics, which we're going to touch on in our next couple of slides, and then reduction in the hyperextension-based skills frequent. So the key thing here with knee is not to go over Osgood-Schlatt or patella femoral pain, which we're all familiar with, but just to identify that the knee is the second most commonly injured body part. Why? Because of landing. If you look at the top row, this is how gymnasts used to be taught to land. Knees together, straight spine, head right over their buttocks and their heels. Now it's a squat landing, the chest is forward, the head is over the knees and the ankles. So that's changed and that's something that you want to be able to communicate with your athletes. The lower leg, ankle, and foot is the most commonly injured, uh, area in all of gymnastics, specifically the ankle. Of course, lateral ankle sprains are going to predominate. We'll touch real quickly on Taylor osteochondritis dissecans and Sievers disease because they're quite more specific to this, or at least Taylor osteochondritis dissecans is to this population. Why? Taylor OCD occurs to repetitive landing short, which you saw with that gymnast who broke both her tibia and fibula previously. They're going to, that's hyperdorsiflexion. They tend to have anterior ankle pain with weight-bearing tenderness in that area as well. So the history might show that lucency or loose body over the talus. Treatment is going to be rest, reduced weight bearing, walking boot, and possibly crutches, going to PT to strengthen your ankle stabilizers, and then a graduated return to play. The main idea with Sievers disease is not to talk about its management, but more about activity modification. This is analogous to Osgood-Schlatter at the knee, but at the calcaneus, use of cheetah pads at practice or using the gym pit. The foam pit for landing is key. That way they can continue with their routines on bars and beam and rings, et cetera. Concussion in gymnastics is not that common, it's infrequent, but the idea to bring it up here is that return to play poses some significant challenges for the practitioner. We need to be keeping in mind that these athletes are going back to the sport that requires significant quick reaction time, visual tracking, that body or air awareness, exertional tolerance, and also inversion, flipping, and twisting tolerance. Neck strengthening, proper landing, and falling, especially, technique are key. The return to play is very different than going back to contact or collision sports in that it has to take all that into account. We're going to move initially from just stretching at the gym to limited inversion, no twisting or flipping, to beam and floor walkthroughs, moving then to inversion and basic tumbling, then to strength training, but still holding off on twisting, but we're adding an individual skill progression, going further in individual skill progression, and then starting our twisting maneuvers, adding then full strength training and skill work, putting sequences together and partial routines, and then finally full routines and full practice. Very different and very specific to gymnastics, and this is put out by USAG. The last thing we're going to talk about is the female athlete triad, not to really go through the triad, but more just to say be on the lookout, especially in sports like gymnastics where the concept oftentimes is thinner is better, and there might be an ideal body. The idea here, of course, is that any patient gymnast who comes into my office with a stress fracture in the lower extremity is getting a full dietary and menstrual history workup to look for any signs of the female athlete triad. Of course, the first part is disordered eating, not an eating disorder, but disordered eating. Diet restriction can also be evidenced with excessive exercise or energy purging. That then can lead to the amenorrhea, which the shutting down of the endocrine axis in the reproductive system because of the reduction in caloric intake. There's a higher risk of a rate of delayed menarche in female athletes versus non-athletes. The calcium per day needs, the calcium needs to be added to their diet. OCPs can be utilized to resume menses, but are going to have a minimal effect on bone mineral density, and then finally leading to osteoporosis because of the reduced estrogen level from the amenorrhea. This completely offsets, unfortunately, the benefits on bone mineral density from their impact and strength training workouts through gymnastics, leading to premature bone loss, inadequate bone formation, and then they're going to be at risk for those stress fractures that we were talking about. With that, I will say thank you very much, kudos, and another shameless plug for my children, the remarkable gymnast, and I'm now going to introduce the esteemed Mary Dubon, who is going to talk to us about dance medicine. Thank you. Hi. Thanks so much, Dr. Carlin, for that introduction, and thanks for everyone who's been listening and with all this information that we've been providing to you guys. This will be our last topic, so thanks for hanging in there with us as we talk about so much within the field of pediatric sports medicine. Today, I'm going to be talking a little bit about dance, which is a topic near and dear to my heart as a dance medicine physician and performing arts medicine physician. Maybe this is true, maybe this isn't true, but it seems like if you look in the literature when people are thinking about dance or dance medicine, this is what they're thinking about. It's almost, in some ways, a category of its own rather than being a sport like football or swimming or softball. It's a category that includes so many different types of styles, and so I think the biggest thing that I want to emphasize is really to not put everybody in dance in the same box and to realize that some of these art forms are contact collision, so there's actually something called contact improv. I think some contact activity is very important because if an individual comes to your clinic and they had a concussion from something outside of dance or inside of dance and you're trying to clear them back to dance, I think a lot of providers think of dance as a non-contact activity, and so they're not necessarily looking at it the same as they would be getting back to other contact sports, but you do have to make sure that you understand when somebody's saying dance what they're referring to. For some people, it might be multiple of the forms that are on this slide, and for some people, it may just be one, so I think that it's really important to get a good history when talking about that. We actually see different injury patterns in different forms of dance as well. On this slide, you'll see breakdancing, and in a lot of the other art forms, you're going to see more lower extremity injuries, whereas in breakdancing, you might see neck injuries and upper extremity injuries, and so it's really important for us to kind of differentiate. I will also put this as a plug as we have a lot more in the literature about ballet than we do about the other different types of art forms, and so there's some interest also in Irish dance, and so we have some information on Irish dance, but really from a pediatric and adolescent sports medicine standpoint, we really need a lot more data in all of the areas, but particularly in the non-ballet areas to give us a little bit more information about taking care of this population. So I wanted to put a plug out to the Journal of PM&R, so the Purple Journal actually had a great article that was put out by Dr. Yin et al a few years ago, and that article actually is a pretty good overview of some epidemiology within dance, and so looking specifically at, you know, a pediatric sports medicine practice and thinking about the different types of injuries that we see in pediatric dancers, and they looked at really the younger, the adolescent type dancers, and so their mean age was age 14, and so things that they saw, a really common thing that they see that I would agree I see a lot in my clinic is patellofemoral pain. Now, again, in ballet dancers, I think we think about it a lot, but we see it in other dancers too, but one of the things that I think is really important if you are taking care of a dancer with patellofemoral pain is to look at alignment. So when I see dancers in clinic, I'll actually have them do things like be in first position where their hips are externally rotated, so their feet, their heels are together, and their toes are pointing away from each other, and a lot of dancers really want that 180 degrees, and so they'll really push into it, and they're really not using their hips as much as they should be, and so some of those dancers are actually, you know, using some tibial rotation too to get into that first position, and so then when they do things like plie, which is when you bend your knees down and then come back up, when they do those types of motions, which those motions are really important for landing mechanics, if you're turned out, quote unquote, your hips really allowing for, what's going to happen is your alignment and your mechanics are going to be really poor at your knee, and that's going to lead to things like patellofemoral pain syndrome. So that's a big thing that I'll look at is actually the patient's alignment when they're in clinic, so that's just a tip and a pearl to think about when you're looking at patients. You know, there's been other studies too that have shown things like ACL tears not as common in dancers, and that's a big reason that is because we think is because neuromuscularly they are training in how to land appropriately, and a lot of the movement, obviously there's improv, but a lot of the movement is planned movement versus in other sports and activities where things are not planned movement. So we do see a little bit different of injury patterns in different arenas. Other things that they saw during this study was that they saw some tendinitis, they saw lower extremity injuries, again, you know, this study was done in a clinic setting and included dancers, quote unquote, but we don't know how many break dancers include and how many ballet dancers include, and so those are some of the things that the literature needs to dive more into. Certainly, as Dr. Carlin pointed out, just like in gymnasts, we see PARs, stress reactions, spondylolisis quite frequently in dancers as well, so that's definitely something that they saw in this study and something to be mindful of as well, which brings me to my next slide of certainly you can see stress fracture, stress reactions of the feet, of the spine, as I mentioned, in dancers, and when you see that, definitely want to be thinking about all those things that Dr. Carlin just spoke to you guys about with the female athlete triad and that relative energy deficiency in sports, so you want to do a good dietary history, you want to do a good menstrual history in the females, but obviously, males can have relative energy deficiency in sport as well, and so I think that it's really important to be thinking about this, and again, there's such a stigma and such a thought, I think, you know, for years, people think dance and they think eating disorders, but as Dr. Carlin pointed out, it doesn't necessarily mean that somebody has an eating disorder, but there may just be, they're working out so constantly, hours upon hours a week, and maybe they don't actually know how to fuel themselves for all of what they're doing, so another topic that I wanted to make sure I covered, because if we're talking about kids and adolescents, man, if they're in ballet, they really cannot wait to get the pointe shoes on, right, and so that's something that, particularly for our female dancers, but for sure, there are male dancers that actually go on pointe as well. We think about pointe readiness. Now, traditionally, it's usually a dance teacher that'll tell people whether or not they're ready for pointe, but that practice kind of really varies throughout the country and throughout different studios, different, you know, companies and practices, and so there are definitely places where, you know, the dance teacher will send somebody to a physical therapist or a physical therapist will come evaluate, or they'll send them to a dance medicine physician, and so I definitely have had referrals before, where particularly the referrals I have gotten have been dance teachers that have been a little nervous that perhaps these individuals are not quite ready for pointe, and so they want to have a doctor officially evaluate them for this, so there's been many tests that have been out there in terms of assessing this, and bear with my little stick figure drawings here, but there's been a couple that I thought are worthwhile to point out. Pointe pencil test, I find helpful. It's easy to do. Essentially, you have the dancer lay down supine, and you have them pointe their toes in plantar flexion, and you're just going to put a pencil there, and just want to make sure that they have enough range of motion to be able to be up on their center when they are actually on pointe, so you want to make sure that pencil stays on there, doesn't roll off, and it's not that they're just curling their toes rather than using all of that range of motion that they have in their arch, in their foot, in their midfoot, in their toes altogether, but then there's, like I said, there's many tests that have been kind of studied, and there's a reference here at the bottom that does kind of demonstrate that three of the tests in particular were found to be most helpful when they looked at the different tests in the literature, and so one of them is the sauté test, and so this is basically, it's for those of you who are not dancers, basically what a sauté is, is you're going to be, usually you're going to be in a coupe, which is basically, you know, having your foot in a similar position as what's there, and you're just going to do single leg hops or single leg jumps there, and you want to make sure that the dancer is staying in the same spot, they're not jumping all over the place, and that they have some level of stability when they're doing that, so usually you'll have them do something like 16 of them to see what it looks like. You want to do it on both sides. The airplane test, I always use this test in clinic as well, and another one that's found to be helpful, so you have the dancer go into a flat back position with one leg extended behind them, arms out to the side like an airplane, and you're going to have them plié or bend their knee, bring their arms down towards each other, and then stand back up and bring their arms out back into that airplane position. You want to look for stability. That demonstrates a lot of strength and coordination within the core, within the glutes, within the quads as well, and you want to make sure that somebody seems stable when you're doing that, and I always do it on both sides, so that's a really good test to test for that overall strength that you really need for point. And the next one's a topple test. For those of you who know ballet, it's a single outside pirouette turn, and so for those of you who don't in that position, passe with your, um, with your toe at your knee, um, with your hip externally rotated, so you're kind of making a triangle there, um, and then you're going to turn towards your knee, do a single rotation, and land neatly. For those of you who know ballet, usually in a fourth position, um, and you want to just make sure that they're able to do that solidly without wobbling or falling forward or falling over on both sides. So I wanted to talk real quickly about some other considerations, and again, cannot speak about all of, um, pediatric dance medicine in, um, the limited time that we have, but just some pearls and things to think about. So, you know, I always talk to my patients about how, especially during growth and development, sometimes we find little extra bones that people have, um, that they didn't necessarily know about, and so one of them that we can find, and particularly in dancers and soccer players, we really don't go looking for it, or it doesn't wind up being symptomatic in other patients, is the osteogonum, and so you can see here that little extra bone, um, that we're seeing, um, at the edge of the tail is that, uh, you can imagine doesn't really bother somebody when they're walking around, but if you're going to go into that point position, so that pointed position of the foot, you can have posterior ankle impingement, where there's actually irritation and impingement that happens there, and oftentimes if you lay somebody down supine, especially if they have it asymmetrically, or they have it on one side and not the other, you have them point, and you feel that it's just limited and restricted on one side, and you'll actually see a different side to side oftentimes. So we'll get x-rays, and here, um, you can see this is actually me bringing my point shoes into work one day to get a good picture of what it's like to take an x-ray of somebody in the end point position, um, and you can actually do functional imaging with this with an x-ray actually in that position to see if you have that impingement, um, if it's actually functionally affecting somebody, right? So they could have that little extra piece of bone there, but does it actually cause any mechanical issues when they're actually, um, in point? So I do like to have somebody either do it on their point shoes, or they can just do it in regular, what we call releve, where they're not quite all the way on point, but what we call demi-point, um, and then the steator process is essentially very similar, except it's attached. It's not a separate little, as I'd say, tic-tac bone, um, like the osteogonim is. And my last little tidbit too is that, um, we have these other little extra bones that not everybody has. So sesamoid bones, um, you can certainly see, um, and dancers will come in, you know, the base of their first toe, they're going to have some discomfort there. It could be quite painful, difficult to walk on, and then you get x-rays and you see, ah, okay, right. They're tender to palpation right around the area of their sesamoid, and they do have sesamoids when you do x-rays. If you do an MRI, you'll often see edema and irritation there. You could actually get stress fractures, um, there as well. And oftentimes when they're injured, it's stress reactions that are happening there. So it's a bone stress injury, so you want to make sure that you're treating it as such. And some of the things that you can think about is actually having a little pad at the bottom of their foot that has a cutout right at the area of the sesamoids, um, at the base of their great toe there. Um, and we call that a dancer's pad for obvious reasons, and that could be really helpful. But sometimes these really can be very stubborn and can take quite a long period of time to feel better in terms of the discomfort. So those are my pearls for, for pediatric dance medicine. And I thank you so much for listening in and tuning in to all of our pearls for pediatric sports medicine. And I encourage you to give us some feedback of other things that you'd love for us to cover in future years. Thanks so much.

dance medicine

injury patterns

point readiness

common injuries

patellofemoral pain

tendinitis

stress fractures

ACL tears

alignment

core strength

point readiness tests

sesamoid injuries