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Current Trends
in Youth Sports Injuries
Jeff G. Konin, PhD, ATC, PT
Associate Professor & Vice Chair
Objectives of This Course
1. Identify the epidemiology of injuries
sustained by children playing sports
2. Discuss practical injury prevention
programs for simple implementation
3. Identify trends in the use of protective
youth sports equipment
4. Discuss the impact emergency planning
has on reducing catastrophic youth
sports injuries
Konin Copyright 2009
Epidemiology of Youth Sports Injuries:
Startling Statistics!
• Approximately 20 percent of children and
adolescents participating in sports
activities are injured each year, and one in
four injuries is considered serious.
• Children and adolescents who are just
beginning a sport or activity are at greater
risk for injury.
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National Center for
Sports Safety
& Safe Kids USA
National surveillance for sports injuries among US high school
student-athletes, 2003 youth risk behavior survey
Hootman, JAT 2006*
• N = 15,214, in 2003 (athletes = 53.7%)
• High risk dieting behaviors were
associated with greater injury rates –
fasting, dieting, vomiting
• Also tobacco, alcohol, psychological
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Slowly Creeping Up…………..
• 1.5 million injuries a year
with BMX bikes
• 2.6 million injuries a year
• Over 3 million injuries per
year in-line skating
• 65 thousand injuries per
year horseback riding
• Nearly 68 thousand kids
were treated last year for
trampoline injuries
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Who Manages Youth Injuries?
• Parents
• Coaches
• Friends
Physical Therapists
Athletic Trainers
Physical Educators
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What role does obesity play in
today’s youth sport’s injuries?
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Be careful with BMI – people can over or under react!
Here are some celebrities and athletes that the
government has deemed "overweight":
Michael Jordan: 6'6": 216 lbs: 25
Bobby Labonte: 5'9": 170 lbs: 25
Karl Malone: 6'9": 259 lbs: 28
Yao Ming: 7'6": 310 lbs: 27
Brad Pitt: 6'0": 203 lbs: 28
Keanu Reeves: 6'1": 223 lbs: 29
Cal Ripken: 6'4": 210 lbs: 27
Nykesha Sales: 6'0": 184 lbs: 25
Will Smith: 6'2": 210 lbs: 27
Bruce Willis: 6'0": 200 lbs: 29
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Sports Psychology
in Children’s Sports
The mind of
a child is
by the
parent and
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Abrams, Center for Sports Parenting 2005
“70 percent of kids drop out of sports by age 13, and the
main reason is pressure from parents and coaches.”
Bob Bigelow, one of the authors of ``Just Let the Kids Play,'' believes
the odds of winning a scholarship are even more remote than many other
experts say, estimating that just 1 in 300 high school senior athletes will
get a fabled “full ride.''
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Unrealistic expectations of parents
In Northern California today:
> There are about 2,000 club soccer teams
> There is a decline in the number of multi-sport athletes as kids
specialize in one sport to maximize their scholarship chances.
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• The Northeastern
University Center for
the Study of Sport in
Society found that, of
black teens, 66
percent believe they
will ultimately play pro
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Behavioral Response Of Injury
The Injury Itself
• The stressor, loss of self-control
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Behavioral Response to Injury
Emotional Responses
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Educate The Athlete…
and the parent!
• First – assess parental knowledge in
general and current disposition
• Explain facts about the injury
• Realistic expectations of recovery
• Importance of psychological skills as a
part of the rehabilitation process
• Allow athlete to educate you
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Case Study
• How would you counsel a 12 year old
child and parents referred to you with
OSD and wanting to return to playing
• Topics might include: learning what the MD
told them, their goals, their realisms, their
timeline, what they googled, child’s interests,
compliance, motivation, past experiences
Konin Copyright 2009
Protective Equipment:
Rules, benefits, considerations & knowledge
Purposes of Protective Equipment
1. Dispose & absorb forces
2. Limit anatomical movement
3. Support joint structures
4. Support musculotendinous
5. Enhance proprioceptive
6. Secure protective pads
Source: JG Konin et al, in The Athlete’s Shoulder, 2nd Ed, 2009
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Protective Equipment Guide
• Does the equipment protect the
area of concern appropriately?
• Can the athlete perform the
skills required for his/her sport
and position while wearing the
• Will the device maintain proper
anatomical alignment?
• Is the device potentially
hazardous or injurious to other
• Is the device legal by the rules
and regulations of the sport?
Source: JG Konin et al, in The Athlete’s Shoulder, 2nd Ed, 2009
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Commotio Cordis: Incidence by Sport
Blunt trauma during 20mSec window, VFib
15% survive commotio cordis events
4% 2%
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Ice Hockey
Commotio Cordis
Optimal Management
• Chest protectors, softer balls, etc have all
been proposed
• Consensus is be prepared with an AED!
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Mouth Guards
• Stock, mouth formed,
and custom-fitted
• Required for lacrosse,
ice hockey, football,
field hockey
• Recommended for
basketball & soccer
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Concussions in Children
Konin Copyright 2009
Mechanisms of Injury
• Concussion
– Acceleration-deceleration forces result in
shearing forces which distort the vascular and
neutral elements of the brain – chemical
• Cumulative effect!!!!!!!!!!!!!
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S & S of Concussion
Physical Symptoms
Vision difficulty
Balance Difficulties
Light sensitivity
Emotionality Symptoms
Sleep disturbances
Memory loss
Attention disorder
Reasoning difficulty
Konin Copyright 2009
Post-concussion Syndrome
• Vary in symptoms & length of presence
• Always have medical professional assess
and determine safety for clearance
• Do not go by athlete comments alone
• Beware of physician shopping
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Various Scales Used to Grade Concussions
Grade 1 (mild)
Transient symptoms; no
LOC; symptoms and mental
status abnormalities resolve
within minutes
Grade 2
Transient symptoms; no
LOC; symptoms and mental
status abnormalities last
longer than minutes
Grade 3 (severe)
People working with younger (pediatric)
athletes should be aware that recovery
may take longer than in older athletes.
Additionally, these younger athletes are
maturing at a relatively fast rate and will
likely require more frequent updates of
baseline measures compared with older
Source: JAT 2004 Position Statement
Konin Copyright 2009
Because damage to the maturing brain of
a young athlete can be catastrophic (ie,
almost all reported cases of secondimpact syndrome are in young athletes),
athletes under age 18 years should be
managed more conservatively, using
stricter RTP guidelines than those used to
manage concussion in the more mature
Source: JAT 2004 Position Statement
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F/U Guidelines
• Avoid meds – only acetaminophen from MD
• Avoid ingesting alcohol, illicit drugs, or other substances
• Instructed to rest, but complete bed rest is not
• Eat a well-balanced diet that is nutritious in both quality
and quantity
• An athlete should be awakened during the night to check
on deteriorating signs and symptoms only if he or she
experienced LOC, had prolonged periods of amnesia, or
was still experiencing significant symptoms at bedtime
Source: JAT 2004 Position Statement
Konin Copyright 2009
Recovery patterns of athletes reporting posttraumatic headache
following sports-related concussion
Register et al, JAT 2006*
• Prospective randomized experimental study
• 375 concussed high school and collegiate athletes average
age 16.65 +/- 1.87
• Self-reported graded symptom checklist (GSC)
• Days 1,3, & 7 post injury data collection
• Conclusion: young athletes reporting PTH following a
concussion endorse a higher number of symptoms and
demonstrate decreases in neurocognitive performance
when compared to those not reporting PTH
• Thus, headache is a sign of incomplete recovery
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Concussion Gender Differences in Youth
Divine et al 2007 MSSE*
• Female athletes have higher severity o
symptoms and longer recovery rates
• This was only seen when comparing nonhelmeted athletes
• Unsure of reasons why
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Concussion Management
What would you say
is the most practical
and affordable
method of decisionmaking following a
concussion for those
settings without large
budgets and
personnel resources?
Konin Copyright 2009
Younger Athletes Slower to Recover
from Concussions, Studies Show
posted 02/02/09 5:45 pm
ROCKVILLE, Md. - Every year more
than 300,000 people report getting
concussions from sports. But experts
say millions more likely go
And while we see professional
athletes like Super Bowl quarterback
Ben Roethlisberger bounce back, for
kids and teenagers it can be a long
road to recovery.
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Rotator Cuff and Periscapular Muscle Strength in
Adolescent Male Baseball Players
Kelp-Lenane et al. JOSPT 2008*
• Assessed strength relationship for 55 11-15 y/o
male baseball pitchers – Tanner 2 or 3, pitching
for 2 years, no pain
• PS muscles were significantly weaker than RC
muscles in dominant and non-dominant of all
• Strength differences do not appear to be a result
of pitching – are we doing the right thing in
Rotator Cuff and Periscapular Muscle Strength in Adolescent Male Baseball Players
Kelp-Lenane et al. JOSPT 2008*
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Shoulder Injuries
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AC Joint Sprain
• Downward force on the
acromion process
• Must be strong enough to
displace AC ligament
• With excessive force, can
eventually displace CC
ligaments (Conoid &
• Debate as to the exact
grading criteria, not important
– functional limitations are!
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Acromioclavicular Joint Disorder
• X-rays to determine
• G I-II sling, pain relief
5-7 days
• G III non-op unless
cosmetic concerns
-Bathing suit appearance
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• Acute comfort
• Surrounding awareness
•Theoretically approximates
a joint that will not heal on
its own – therefore it
provides comfort with partial
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Clinical Pathway for AC Sprain
Control pain, usually minimal inflammation
Avoid distraction activity
Progress with functional exercises as tolerated
Expect pain for a long time!
Resultant instability not common regardless of
Bottom Line: Let pain & function dictate:
don’t “over treat” or “over advise”
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Will shoulder braces work? Functional?
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Elbow Injuries
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Little League Elbow
• Medial epicondylitis and
– 8-10 y/o ~ bone weakest
– 15-18 y/o ~
muscle/tendon/tissue weakest
– Mid 20s and up ~ muscle and/or
ligament weakest component
• Age tells you what structure is
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What is your comfort level in advising with respect
to preventing throwing injuries for little league
baseball pitchers?
9-10 years
11-12 years
13-14 years
Pitches per
Pitches per
Pitches per
Pitches per
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Preventing Injuries in Throwers with the Core and Hips
LE Flexibility (Used as part of an overall warm-up)
Ipsilateral hip extension
Hip IR/ER (Lack of IR will force truck to open early and increase stress on medial
Elbow and /or anterior shoulder)
Core Training for Throwers
Abdominal Bracing /Drawing in maneuver
Prone Cobra Progression
LE Balance/Proprioception*
Standing Pulls - ant/post/lat pull (Weak gluts cause the hip to drop leading to drop of shoulder)
LE Functional Strength Training**
Wind-Up/Lunge with twist
Lunge with twist
Step-Ups with twist
*Functional exercise that is multiplanar, incorporates the lumbo-pelvic-hip core
complex and can be challenged with proprioceptive input from unstable surfaces,
eyes closed, etc
** Lunge strength will help deceleration injuries to the shoulder
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Serape Effect
Konin et al ATT 2003
Deficits in measurable active
& passive hip extension,
active hip flexion with pain
(Kouvalchouk Rev Chir Orthop 1998)
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Epicondylitis Considerations
 Strings too loose
 Grip too large
 Poor technique
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Wrist Ligament Sprains
“It is only a sprain”
Avoid Grip Strength Activity!
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Jersey Finger
Pulling against fixed object
Lifting with tips of finger
Crush Injury
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Mallet Finger
* Usually a result of
blunt trauma
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Muscle Strains
Quadriceps & Hamstring Update
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Treatment of Hamstring Strains
• THE RISK FACTORS: Muscle weakness,
decrease muscle flexibility, lack of proper warmup, fatigue, improper flexor/extensor strength
ratio, increasing age, menstrual disturbances,
previous injury
• Can we prevent ALL of these?
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To Stretch Or Not To Stretch
• Systematic search - 293
articles, of which 14 used
a control group.
• Five suggested
prevention, six suggested
no difference but three
suggested increased
injury. The positive
studies had warm-up as a
Shrier I, Clin J Sports Med 1999, EBSM 2002
Konin Copyright 2009
Wenos & Konin
J Strength Cond Res. 2004
• Controlled warm-up intensity enhances hip
range of motion.
• In a field setting, it is estimated that a warm-up
of 70% of HRR would duplicate the muscle
readiness equivalent to an RER of 1.00 before
PNF stretching.
• Equivalent to 4 minutes of a light aerobic activity
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The Impact of Stretching on Sports Injury
• Stretching before or after exercise is not associated with
a reduction in total injuries
• Produces small, statistically non-significant reductions in
muscle soreness
• 5th day post injury tendon exhibits weakest tensile
strength (right about the time one starts to “feel better”),
then progressively gets stronger each day
Thacker et al, Med Sci Sports Exer 2004, Herbert & Gabriel, BMJ 2002
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The Child’s Knee
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Ligament Injuries - ACL
•  200,000 new ACL injuries
per year
• History
– Majority are non-contact injury
with knee in extension (70%)
– Hemarthrosis within a few
– Audible pop in 50%
– More common in females risk is at least 5X higher
among women than men and
the gender difference is even
higher at the elite levels
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Factors associated with anterior cruciate
ligament injury history in female athletes
Increased generalized laxity
Decreased ITB flexibility
Previous ankle injury
Menstrual cycle changes
A decreased protective role of dynamic knee stabilizers (quadriceps
and hamstrings)
A diminished ability to resist anterior shear with muscle contraction.
A smaller ACL than men
A narrower intercondylar notch than men
Wider Q-angle
Wider hips/pelvis
Increased foot pronation
Kramer et al JAT 2006, Lie et al 1997, Smith et al 1993
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Neuromuscular Training
May Assist in Preventing ACL Injuries
• 3/6 studies reduced ACL injury in females
• Question of consistencies, cost & time of implementation,
compliance issues
• Some evidence that proprioceptive and balance exercises
improve outcomes in individuals with ACL-deficient knees
• Improvements in joint position sense, muscle strength,
perceived knee joint function, and hop testing were reported
post intervention
• No adverse effects with intervention
• Too few studies to safely confirm
Hewett et al, AM J Sports Med, 2005 Cooper et al, Res Sports Med 2005, Engebretson and Bahr BJSM 2005, Hammill et al JAT 2006
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ACL Injuries in Children
ACL deficiency in the skeletally immature has
resulted in a high incidence of secondary
meniscal injuries, degenerative joint disease,
and symptomatic instability in both sports and
daily activities.
Skeletally immature athletes are in fact much less
likely to limit their activities and adapt to ACL
insufficiency than skeletally mature counterparts.
Graf et al 1992, Mizuta et al
1995, McCarroll et al 1994
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ACL Prevention Programs
 PEP Program
 Dr Mandelbaum et al. Santa Monica
 No cost
 SportsmetricsTM
 Dr. Noyes et al Cincinnati Sports Medicine
 Fees & certification
 The 11
 Developed by FIFA F-MARC (Medical Research Centre)
 No cost
Konin Copyright 2009
ACL Prevention Program
• We use PEP (Prevent Injury Enhance Performance)
• Highly specific 15-minute training session that replaces/compliments
the traditional warm-up 2-3x weekly
• The Goals of the Program are to:
1) Avoid vulnerable positions
2) Increase flexibility
3) Increase strength
4) Include plyometric exercises into the training program
5) Increase proprioception though agilities
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What About Knee Braces?
Appear to play a role – may
always be in question
The “Breaking Point”
Pietrosimone et al JAT 2006, Naiibi & Albright Am J Sports Med 2005, McDevitt et al Am J Sports Med 2004
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How Common are Ankle Injuries?
Most common sports injury
85% of ankle injuries are sprains
85% of sprains involve lateral ligaments
20% - 40% lead to chronic symptoms
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What Do You Need To Know
About Ankle Sprains?
Most common risk is previous ankle sprain
Supervised rehabilitation with proprioception intervention reduce risks of
Balance training improves sensorimotor control in athletes with previous
Effect seems to be limited to those with previous injury, where postural
control, position sense and postural reflexes are reduced
Appropriately applied brace or tape does not hinder performance
Taping or bracing can reduce incidence for recurrence of ankle sprains in
athletes with previous ankle problems
Unclear if high top shoes reduce the risk of injury
Thacker et al, AM J Sports Med 1999, Bahr R. EBSM 2002
Konin Copyright 2009
High Ankle Sprain
• Tib-Fib Sprain (anterior/posterior)
• Mechanism of injury is fixation and rotation
• Treatment is difficult due to lack of good support
for this area internally & externally
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Managing The High Ankle Sprain
Be patient!
Tell the athlete to be patient!
Tell the parents to be patient!
Tell the coach to be patient!
Konin Copyright 2009
Failing to Plan = Planning to Fail
• Emergency Action Planning
• Build from existing templates & models
• Follow nationally and regionally accepted
standards of policies & procedures
• Identify key steps – don’t guess
– What key components should be included?
– Who are the stake holders?
– What expenses might exist?
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Field Safety
• Uneven playing surfaces
• Surfaces with greater than normal friction, ie old
hardwood courts
• Slippery playing surfaces, fields with puddles
• Improper illuminated lighting for night events
• Irrigation systems not completely buried
• Baseball dugouts without proper protection from hit balls
• Fences and that surround fields with protruding parts
• Goalposts and other fixed apparatus that are not
properly protected with padding
Konin Copyright 2009