The Young Athlete

Pediatric Sports Participation

During the past 30 years, the number of children and adolescents participating in physical activity and team sports has significantly increased, with the largest increase among female adolescents. The overall trend has shifted from the largely unstructured, unsupervised “free play” of the early 20th century to the evolution of organized and highly structured youth sports activities. It is estimated that currently up to 30 million children and adolescents participate in an organized sport in the United States. In 1995, reports indicated that 15 million 5- to 14-year-olds played baseball in the United States.

The Youth Risk Behavior Survey (YRBS) was a large population-based study performed throughout the 1990s that enabled accurate assessment of emerging trends in youth sports participation. Results from the 1997 survey indicated that 62% of US high school students participated in one or more sports teams, with the majority playing in a combination of both school and nonschool teams.

The YRBS study highlighted a number of significant demographic differences when results were compared for age, gender, and ethnicity. Although the number of girls participating in sports teams has increased fivefold during the past 30 years, a disparity continues to exist between genders according to the 1997 YRBS study. Although almost 70% of male high school students participate in sports, only 53% of similarly aged female high school students exhibit the same level of sporting interest. This gender disparity was even more dramatic among ethnic minorities, with only 40% of Hispanic and African-American girls participating compared with 62% and 71% for boys, respectively.

Furthermore, progression into adolescence was also associated with a reduction in the involvement of both boys and girls in vigorous sporting activities. In boys, participation in vigorous exercise (defined as activity causing shortness of breath, lasting at least 20 minutes, 3 days a week) reduced from 81% in grade 9 to only 67% by grade 12. As expected, this trend was even more pronounced in girls, with 61% of female ninth graders participating in vigorous exercise compared with only 41% by 12th grade.

The growth and increasing popularity of school and community youth sports programs have become an integral part of American youth culture and have the potential to enhance the long-term physical and psychosocial health of children and adolescents who participate in these programs.

Pediatric Sports Injury

Increased youth participation in sports and physical activities and specialization in particular sports (and positions) at an earlier age have resulted in an increase in sports-related injuries as a result of trauma and overuse. The annual incidence of sports injuries within the United States is estimated to be approximately 3 million, with up to 70% of those injuries resulting from youth sports activities. High school athletics account for more than 2 million injuries annually, including 500,000 doctor visits and 30,000 hospitalizations. More than 3.5 million children younger than the age of 14 years are treated annually for sports injuries. The financial costs of managing these injuries in 1996 was well in excess of $1 billion.

Pediatric sports injuries are often unique, not only in terms of the underlying pathologic findings but also with regard to the challenges in managing these injuries. Many patients participate in several teams during a given season, the rest periods between seasons are short if not nonexistent, and the demand for sporting success from parents, schools, and sporting establishments is increasing.

Pediatric sports injuries can be classified according to the age of the athlete, the type of injury, and the type of sport/activity being played when the injury occurred. From an epidemiologic standpoint, these classifications assist in identifying potential risk factors for injury and implementing prevention strategies and rehabilitation plans that are appropriate for the age of the patient and the sport being played.

Several studies have identified a correlation between an increased risk of sports-related injury and the increased age of the pediatric athlete. A number of explanations for these findings have been postulated, including a greater opportunity for injury in the adolescent athlete because of longer game times, along with more frequent and intense practices. The provision of medical assistance at many high school and college games allows increased reporting of injuries. It appears that anatomic factors, such as the increased size of the athletes and the resultant increased force and speed of collisions, play an insignificant role, because the same trend was noted for both contact and noncontact sports.

Sports injuries can be broadly divided into acute traumatic and overuse-type injuries according to their pathophysiologic characteristics. Although many acute traumatic injuries are the result of random events, overuse injuries are often the result of entrenched training errors and therefore have greater potential for prevention. The difficulty lies in identifying these overuse injuries because initially they can be only subtly disabling when compared with an immediate fall to the ground after a sprain, for example.

It is important that an injury be viewed in the context of the sport in which it occurred because an injury that may be functionally disabling for one sport may have no relevance in another sport. Furthermore, it is important for physicians to recognize that time lost from sports participation is often more of a concern to athletes, their families, and their coaches than the nature of the injury itself. These perceived differences in injury severity inevitably affect management programs.

Among school athletes, football has the highest rate of injury, with wrestling not far behind. The rate of injury in both males and females at the high school and college levels is comparable, with the exception of knee injuries, which occur at a slightly greater rate in females at the college level. Fortunately, fatal sports injuries are rare. Mueller and Cantu reported 160 nontraumatic deaths in high school and college athletes in the United States between 1983 and 1993, with the primary cause being heart related; only a small number of the injuries were heat related. These investigators also reported 53 traumatic deaths from 1982 to 1992 in football players, resulting primarily from head and neck trauma.

Youth Sports Injury Prevention

With recent evidence more firmly establishing the association between injury and specialization, the focus of many authors has shifted towards identification of factors reducing injury rates. For example, physicians, coaches, and parents have been targeted as critical figures in the encouragement of young athletes towards greater consideration of cross-training, engagement of multiple sports through the course of a given year, and longer periods of physical rest from specific activities. Not only will this provide for critical healing of tissues stressed by repetitive activities but also aids in the development of a greater diversity of motor skills. Periodic intervals of strength and conditioning, in place of active competition, and neuromuscular training programs are emphasized as important principles for injury prevention in the growing musculoskeletal system. For example, a number of different simple neuromuscular training programs, such as the FIFA-11 program an injury prevention program developed by a panel of international experts, with the support of the Federation Internationale de Football Association (FIFA), and other anterior cruciate ligament injury prevention programs, have been shown to decrease lower extremity injury rates and optimize performance. Continued study on the various factors that may decrease youth injury risks—from improved equipment to thoughtfully structured approaches to training—will be essential in keeping young athletes on the field and out of physicians’ offices. The STOP Sports Injuries program, a public outreach campaign sponsored by the American Orthopaedic Society for Sports Medicine (AOSSM) and designed to facilitate prevention of youth sports injuries, is emblematic of the larger transition from treatment towards avoidance of overuse-related conditions before they arise, many of which are highly preventable.