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Sports Injuries You May Overlook · Pediatrics in Practice: A CME Podcast

• 0:03
  Dr. Sarah Gubara (Host):
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  Welcome to Pediatrics in Practice, a CME podcast.
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  I'm Dr.
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  Sara Gubara.
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  And today, I'm joined by Dr.
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  Greg Canty, Medical Director of the Sports Medicine Center at
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  Children's Mercy Kansas City.
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  Today, we're exploring sports injuries.
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  Dr.
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  Canty, thank you so much for taking the time to join us.
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  Dr. Greg Canty:
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  Thanks for having me, Dr.
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  Gubara.
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  Looking forward to the conversation.
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  Host: I'm excited.
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  So, let's get into sports injuries that many may overlook.
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  What are some of the most common sports injuries you see that are frequently
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  missed or mistaken for a minor issue?
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  Dr. Greg Canty:
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  Well, I would say probably one of the more frequent injuries we see with the start
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  of school sports are really knee injuries.
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  And knee injuries come in many different flavors.
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  Some of the ones that I think folks should be particularly aware of or
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  to think about are those kind of maybe X-ray-negative knee injuries
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  where someone maybe has an injury.
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  Sometimes the X-ray can be falsely reassuring, and it's kind
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  of diagnosed as just a sprain.
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  But I would tell folks to be aware of any knee injury, even if it's
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  X-ray negative, if it's accompanied by swelling in a young athlete.
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  And that could be a lot of swelling or can sometimes be a small amount of swelling.
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  But I think you have to have a little proceed with caution
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  if there's swelling involved
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  Host: That makes sense.
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  Are there other specific symptoms or red flags that should prompt a primary
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  care provider to refer an athlete sooner than taking a wait-and-see approach?
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  Dr. Greg Canty:
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  If we go back to kind of the knee injury question, I tell folks that if
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  you've got swelling involved with an acute knee injury in a young athlete,
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  it's often one of three things.
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  It could be a patella dislocation, which are quite common.
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  And by the time they present to healthcare providers, sometimes the patella's
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  relocated and the X-ray looks normal.
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  And the other thing we frequently see in young adolescent athletes
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  are ACL tears and ACL ruptures.
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  They can present with sometimes a large amount of swelling, what I
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  call kind of the big fat swollen knee, or they can sometimes have
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  a smaller amount of swelling.
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  So, we think you have to be concerned about that.
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  And then, occasionally fractures.
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  When you involve the growth plates around the knee, there can be
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  fractures and injuries that are not readily obvious on plain film X-rays.
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  And so, I keep those in mind because I think I see those that are missed
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  when they show up a week or two afterwards, and they've been immobilized.
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  And sometimes that's really a delay in diagnosis and treatment
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  for those young athletes.
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  Along with that, you'll occasionally have some meniscus injuries that can present.
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  Particularly, they'll have pain and tenderness along the joint line.
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  You asked a little bit about specific symptoms or red flags.
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  I think for those it's really that inability to weight bear.
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  We talk a lot to residents or learners who want to hear more
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  about sports medicine in our clinic.
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  Limping counts as weight bearing.
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  But if someone cannot really weight bear or even put any weight on or
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  a limp on it, I think that needs to be seen on an urgent basis.
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  Host: That makes sense.
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  So, you mentioned growth plates.
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  Growth plates can make pediatric sports injuries so different from adult injuries.
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  What are some growth plate injuries that referring providers
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  should be especially aware of?
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  Dr. Greg Canty:
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  Probably two come to mind, and particularly those adolescent athletes.
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  You know, in the world of pediatrics, we take care of an interesting age frame.
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  You take care of young athletes.
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  And then, by the time they're 17 or 18, they're practically many
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  times adult anatomically-wise.
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  But in those transitional phases of kind of the pre-teens and teen years,
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  you oftentimes will see the growth plate or what we call the apophysis
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  lead to very unique injury patterns.
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  There's a couple I think about that come to mind.
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  One is what are called pelvic avulsion fractures, which are
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  avulsion fractures along the pelvis where the large muscle groups from
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  the lower extremity will attach.
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  Those are oftentimes injured when you think of activities such as
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  running and sprinting in a sport.
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  Those are oftentimes kind of explosive type injuries, and you get these large
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  muscle groups as they're developing, but they still attach to a rather immature
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  piece of the skeleton along the pelvis, and it will actually just pull that
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  small piece of bone or cartilage cap off.
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  And so, I think when you're dealing with young athletes in that kind of, we'll
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  say 13, 14 to 17 type age range, it can happen a little bit outside of that,
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  but it gives you a general framework.
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  If you see those and they have a sudden explosive type injury,
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  you have to have a really high suspicion of an avulsion fracture.
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  Those can sometimes even be difficult to see on X-rays.
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  So, have a high likelihood of suspicion.
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  They'll oftentimes be mistaken for just a muscle strain.
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  The others are transitional fractures we see around the ankle.
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  I see a lot of ankle fractures and injuries that will present and be
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  presumed to be an ankle sprain.
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  There are things called a Tillaux fracture or what's called a Salter-Harris
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  III fracture of the ankle that's very unique to that adolescent age
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  group, and those will oftentimes be missed on X-ray and on exam.
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  And so, if you have someone with a large amount of swelling, again, just
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  like the knee, and really an inability to weight bear, be very suspicious.
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  Take a close look at those X-rays or speak with your radiologist about
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  those to really take a look and make sure there's no evidence of a growth
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  plate fracture involved with those.
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  Those are probably two of the more commons we see that are
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  very unique to that age category.
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  Host: Overuse injuries are becoming so much more common as youth athletes
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  specialize in a single sport.
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  Dr.
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  Canty, what should providers watch for during evaluation?
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  Dr. Greg Canty:
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  As we see the increase in early sports specialization, we've talked a lot about
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  that in the world of pediatric sports medicine, that we're not always the
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  biggest fans of sports specialization, because we really want people to
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  develop a broad range of skills that we think will help them and really
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  give them more opportunities as they go into adolescence to kind of sample.
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  So, I'm a big fan of sports sampling when they're younger.
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  But we know that folks will oftentimes be drawn to one particular sport.
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  And if they do do early sports specialization, I think you have
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  to have an increased awareness of these overuse injuries.
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  You have to look for those subtle yellow flags even more than someone
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  who's playing a multitude of sports, because it's oftentimes the same
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  motion over and over and over.
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  And that repetition in a young growing skeleton just puts you at risk for injury.
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  Some examples we'll talk about a little bit, it can happen in any sport, but
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  we'll talk about gymnastics a little bit because there's probably two that
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  many people can kind of visualize.
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  Really gymnast wrist is one that comes to mind a lot.
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  Gymnasts are frequently walking on their hands over and over again.
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  We also think about gymnasts, cheerleaders, football players,
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  pretty much any athlete that does a lot of repetitive back extension.
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  We see stress fractures called a spondylolysis frequently that are
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  mistaken for just mechanical back pain.
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  It turns out to be something much more.
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  The classic Little League elbow throwers in that early adolescent age
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  group that's throwing repetitively over and over develop irritation
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  along that medial epicondyle.
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  We'll see a lot of our overhead athletes that do things.
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  We'll say this time of the year we see a lot of swimmers, but it
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  occurs in volleyball players, any overhead throwers will get a lot
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  of impingement and shoulder pain.
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  And I think you just have to be aware of pain that's lasting more
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  than a couple of weeks in single sport athletes in particular.
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  And so, probably any athlete, a decent rule of thumb, but really if
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  you're a single sport athlete, you're having a joint pain or some type of
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  musculoskeletal condition that's not improving over about two weeks, I
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  think that needs to be checked out.
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  The more attention you pay to that early, probably the better outcome,
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  the quicker outcome you get.
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  And sometimes with these overuse injuries, X-rays can be not as
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  helpful as we want them to be.
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  So, you really have to have a high index of suspicion.
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  And so again, if you're having pain lasting more than two weeks, or the
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  young athlete at two weeks or so is still not wanting to participate or
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  having some change of their participation and training plan, that's worthy of
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  getting checked out, because it may really help you in the long run.
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  Another thing I talk to a lot of folks when you talk about overuse injuries,
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  I think of it as an overuse injury, but really kind of burnout in young athletes.
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  We see young athletes that do single sport specialization.
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  I think we have to think about those that are sometimes getting burnout.
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  They need some time away from sport.
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  They need some time to think about and focus on themselves.
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  I tell people you got to have to have your own self-identity outside of sport too.
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  I think sometimes emphasizing that when you see symptoms of burnout in
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  young athletes where they're playing too many games, too many practices,
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  start to have joint aches and pains, I think it's always a subtle conversation
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  to have with families and young athletes because they get pressure
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  from both internal pressure themselves.
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  They're putting on to get better and striving to get better at the sports.
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  You also get a lot of external pressure from both coaches and parents.
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  Even if it's not intentional, they feel that pressure and they know how much
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  time, energy and, frankly, finances that people spend on youth sports today,
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  and they'll internalize that pressure and it can lead to some burnout.
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  And I think thinking about that as an overuse injury is also something that
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  healthcare providers should be aware of.
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  Host: Dr.
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  Canty, what's one sports injury or condition that you wish more referring
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  providers had on their radar, and why does early diagnosis matter?
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  Dr. Greg Canty:
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  I think if we think about one condition that I really would like
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  referring providers to have on their radar, that's bone stress injuries.
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  In particular, we'll see a lot of things that get labeled as shin splints,
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  and shin splints clearly happen.
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  We talk about pain there along that medial tibial stress, but the thing
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  we see a lot of as it progresses is really stress fractures.
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  The most common's going to be there along the tibia, the fibula in the lower
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  leg, but you can have those elsewhere.
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  And I think oftentimes thinking about stress injuries of the bone really helps
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  you think more globally about a patient.
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  And so, I think if you have an athlete that comes in that's complaining of
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  pain, I want them to have on their radar, things that may contribute to
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  the conversation, the risk of bone stress injuries, things like what's
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  this young athlete's training plan?
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  Have they had a recent marked increase in their training load?
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  Do they get enough recovery time?
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  Do they get days off?
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  Do they get good sleep at night?
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  What about their nutritional status?
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  Do they get enough calories?
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  Do they get the right kind of calories?
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  And oftentimes, in young female athletes will use menses as a marker to figure out
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  if they're having irregular menses after having established a regular pattern,
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  that could also suggest they're at higher risk of having a bone stress injury.
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  And so, we'll see those frequently, athletes will get
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  diagnosed with shin splints.
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  They'll try to push through for weeks, if not months, and that gradually
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  gets worse and worse and worse.
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  So, I think whenever you have a hint or a suspicion of shin splints or maybe a
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  stress fracture, taking a step back and thinking not just about where does it
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  hurt, is it point tender, but also asking those questions globally about their
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  health can be really helpful and help you get on the right page right away and help
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  them really get a quicker recovery and back to sport, back to activity sooner.
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  And it also helps by having that conversation help
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  athletes start to think about.
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  I'll sometimes say that diagnosing a stress fracture sometimes is easy.
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  It's helping young athletes understand why they got that stress fracture and what
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  we can do to prevent the next one that really can sometimes be more challenging.
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  But I think we see a lot of those.
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  And if referring providers had that in mind, I think they can maybe
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  pick up a few of those even earlier and be a help to their patients.
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  And so, I tell folks, if you think about that, a young athlete's having point
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  tenderness, difficulty doing things like a single leg hop or jumping on one leg, you
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  should get those taken care of and maybe referred over a little bit more quickly.
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  Host: Thank you, Dr.
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  Canty, for walking us through sports injuries that may be overlooked
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  as well as your recommendations.
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  You've been a fantastic advocate for youth sports and health and wellness.
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  I'm grateful to have the time to talk to you.
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  Dr. Greg Canty:
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  I really appreciate the opportunity, and I hope our conversation's helpful
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  for the healthcare providers out there.
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  Host: Absolutely.
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  And as a reminder to our audience, claim your CME credits after listening
• 11:58
  to this fascinating episode today.
• 12:01
  You can do so by visiting cmkc.link/cmepodcast,
• 12:07
  and then click the Claim CME button.
• 12:09
  If you enjoyed this podcast, please share it on your social channels
• 12:13
  and check out the entire podcast library for topics of interest to you.
• 12:18
  I'm Dr.
• 12:18
  Sarah Gubara.
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  And this has been Pediatrics in Practice, a CME podcast.