October 2015 Bulletin

Overuse Injuries Among Young Athletes: A Q&A With Seattle Children’s Sports Medicine Specialists

Burton BulletinQuitiquit BulletinLockhart BulletinExperts from Seattle Children’s Sports Medicine Program, including Drs. Monique Burton, Celeste Quitiquit and John Lockhart, address questions about overuse injuries in young athletes.

Thank you to Dr. Wendy Sue Swanson, a pediatrician at The Everett Clinic in Mill Creek, a member of Seattle Children’s medical staff and executive director of Digital Health, and author of the Seattle Mama Doc blog, for submitting these questions.

What are the most common overuse injuries you see in school-age children and teens? Are there particular sports that primary care providers should screen for more judiciously?

One of the most common types of overuse injuries in children and teens is traction apophysitis – a condition caused by inflammation in the growth centers where tendons attach muscle to bone.

In the chain of muscle, tendon and bone, the weak spot is actually the bone, which is subject to chronic stresses from repetitive use and is susceptible to overuse injury. Common types of apophysitis include Sever’s (calcaneal apophysitis) in school-age children and Osgood-Schlatter’s (tibial tuberosity apophysitis) in teen athletes.

There are many other overuse injuries that occur throughout the body as well. Factors that increase the likelihood of suffering from these include balance between strength and flexibility, growth spurts, demanding schedules, early sports specialization and increase in competition level.

We recommend pediatricians screen all young athletes for overuse injuries, including traditional sports like soccer, but also activities like dance and martial arts. Depending on the patient’s physical activity, you may focus more closely on certain areas that are most vulnerable to overuse.

Adolescent female athletes should also be screened for menstrual irregularities as a predisposing factor to bone stress injuries and a warning sign of insufficient nutrition. This may also alert the provider to other underlying concerns like eating disorders.

Typical treatment for overuse injuries includes ice and elevation, and modification or avoidance of activities causing pain and rest. But those recommendations can be challenging for young athletes to accept. Are there any exceptions to these rules?

Often, overuse injuries will limit sports participation based on discomfort, but not all injuries have to limit participation entirely. For a young athlete who is passionate about their sport, it can be hard for them to avoid all participation.

In many cases we recommend “relative rest,” suggesting that patients avoid actions that cause pain or may worsen the injury, but remain active in other ways.

For example, patients with Osgood-Schlatter’s may still attend practices, as long as they avoid running and repetitive jumping that stresses their lower extremities. This allows them to work on their technique and perform alternative conditioning and core work while still allowing their injuries to heal.

Young athletes should never try to “push through” an injury. This will only cause further pain and damage, and may increase the amount of time they will be out of play.

Additionally, for some inflammatory or aggravating injuries – like an ankle sprain or overuse injuries – trials of anti-inflammatories can be recommended. These should not be used for more than 14 days in a row and should not be taken right before exercise, as they can mask injury symptoms.

Overall, it’s important to discuss appropriate activities and a rehabilitation plan with the child and their family so everyone is in agreement and understands the restrictions and plan for recovery.

When doing sports physicals for children and teens, what questions can illuminate risk for overuse injuries?

Sports physicals are a great opportunity for primary care physicians to connect with young athletes, especially adolescents who are often seen by healthcare providers less frequently.

Providers can assess a child’s risk of overuse injuries by asking several questions during their pre-participation sports physical examination:

  • Which sports and other physical activities do you participate in?
  • What time of the year do you participate in each activity?
  • Do any of your sports seasons overlap?
  • How many total hours per week do you participate in organized activities?
  • Are you experiencing any ongoing pain or discomfort?
  • Have you experienced discomfort while playing sports in recent months or past seasons?
  • For females, what was the age of your first period and how frequent are your menstrual cycles?

If there are any risk factors for injury, primary care providers may want to recommend physical therapy for their athletes prior to the start of the season to help decrease or prevent injury.

How can providers partner with parents to support young athletes to participate in sports in a healthy way?

Primary care providers can serve as a wonderful source of support for young athletes and their families. Office visits are a great opportunity to check in with the athletes and make sure they are enjoying their sports, screen for signs or symptoms of overuse and investigate cues for overtraining or burnout.

Most parents want to support their child’s areas of interests and goals. At times this enthusiasm can lead to missed cues, such as a decline in athletic performance, which may suggest the child is no longer enjoying the activity. Often, talking with the patient alone can give the provider insight into a potentially difficult situation where parental, coach or other pressures are affecting an athlete.

Finally, providers should partner with parents and encourage them to engage the young athlete in multiple sports and physical activities rather than single sports specialization. This prevents a child from overusing the same muscle groups to perform the same sport-specific skills. It has not been shown that early specification leads to more elite performance in most sports. In fact, there is evidence in the collegiate population that more Division 1 athletes tend to specialize later than their non-athlete cohorts.

How can providers help prevent burnout in young athletes?

Factors that may lead to burnout include high training demands, frequent intense competition, negative performance criticism and little personal control for the athlete. Warning signs may include frequent visits for minor complaints or injuries, lack of expected improvement from an injury, fatigue, change in mood, etc.

To prevent burnout and overuse injuries, the American Academy of Pediatrics recommends children and adolescents have at least one day of rest each week to allow for both physical and psychological rest and recovery.

Additionally, all athletes need to take breaks from their sports to rest physically and mentally. Young athletes should spend about two months a year refraining from playing sports. This does not have to occur consecutively, and athletes can spend that time playing a different sport or activity that stresses the body in a different way.

Sometimes we have to remind our patients and ourselves that sports should be fun! If it is no longer enjoyable, taking an extended break or switching sports may be in order.

What Every Pediatrician Should Know About Pedophiles

Jenny BulletinSexual abuse is not a topic routinely discussed at well-child checkups, yet it affects more children than frequented subjects like influenza or sudden infant death syndrome (SIDS). According to the American Academy of Pediatrics, 25% of girls and 10% of boys experience unwanted sexual contact during childhood or adolescence.

“Sexual abuse is an under-recognized problem,” says Dr. Carole Jenny, medical director for Seattle Children’s Protection Program, a pediatrician and former member of an FBI task force targeting pedophiles. “But it’s a significant public health concern. Children who are sexually abused experience long-term consequences including chronic health conditions, mental illnesses and shorter lifespans.”

Pediatricians can play a significant role in identifying or preventing sexual abuse, Jenny says.

“Pediatricians should consider teaching children and adolescents about bodies and personal safety as a part of well-child care,” she notes. “They should encourage parents to take their child’s safety seriously, especially if he or she ever complains of unwanted sexual contact. The worst psychological trauma occurs when a child reports abuse but no one believes them. It’s devastating.”

Thankfully, research suggests children who receive timely, appropriate treatment for sexual abuse can live happy, healthy lives.

“When victims are carefully evaluated and quickly referred for specialized treatment, the outcomes are very positive,” Jenny says. “But pediatricians have to know the warning signs to watch for.”

Jenny offers the following information to help those working in pediatric healthcare identify sexual abuse of a child.

Factors that put children at greater risk for sexual abuse:

  • Developmental delays
  • Low self-esteem
  • Absent parents, neglect
  • Single-parent families
  • Parents who have a history of abuse

Warning signs of abuse:

  • Child has inexplicable physical complaints like headaches, stomachaches or genital complaints
  • Child overreacts to a question about someone touching them
  • Child suddenly seems more aware of, and preoccupied with, sexual conduct, words and parts of the body
  • Child has unreasonable anxiety over a doctor’s physical examination
  • Child appears fearful, frequently crying and clinging to parent(s)

Questions to ask parents if you suspect abuse:

  • Has the child regressed to bedwetting or soiling underwear?
  • Have the child’s eating habits changed?
  • Has the child recently become withdrawn or more aggressive toward their peers?
  • Does the child act out in school? How are they performing academically?
  • Is the child suddenly avoiding normal family intimacy?
  • Is the child afraid of a particular person or place and being left alone with that individual?
  • Has the child seemed unusually interested in sex or tried to get other children to perform sexual acts?

If you suspect a child is being abused, contact the Department of Social and Health Services/Child Protection Services. To find treatment for a patient who has been sexually assaulted, contact Seattle Children’s Protection Program or the Harborview Center for Sexual Assault and Traumatic Stress.

Information on sexual abuse for patients and families is available through the American Academy of Pediatrics. Families seeking support are encouraged to contact the King County Sexual Assault Resource Center.

Providers can also watch Jenny’s April 2015 Grand Rounds presentation, What Every Pediatrician Should Know About Pedophiles, for CME credit.

Seattle Children's Provides Influenza Vaccinations to Patients and Household Contacts

Seattle Children’s is providing influenza vaccinations to inpatients, outpatients and their household contacts. All inpatients, except hematology/oncology patients, will be screened for eligibility. Outpatients will be offered the vaccination when they come to Seattle Children’s for clinic visits. Seattle Children’s will also offer the vaccination to Emergency Department (ED) patients.

Seattle Children’s bills the insurance of patients and siblings under age 21 for their vaccinations, but provides vaccinations free of charge to adults age 21 years and older who live with a patient. All vaccinations given to children are documented in the Child Profile Immunization Registry.

Children’s efforts to vaccinate patients are in accordance with recommendations from the Centers for Disease Control and Prevention to increase access to the vaccine in healthcare settings.

For questions about flu vaccinations at Seattle Children’s, email Dr. Matthew Kronman, infectious diseases specialist.

Upcoming CME for October 2015

Everett CME: A PCP Approach on Muscle Weakness and Motor Delay

  • Presented by Christian Ionita, MD
  • Thursday, Oct. 15 from 6:30 to 7:30 p.m.
  • Location: Snohomish County PUD Training Center, 2320 California Ave., Everett, WA
  • Free Category 2 CME credit
  • Light dinner will be served.
  • RSVP to Emily Rice by email or at 206-422-5668.

Grand Rounds for October 2015 (CME Credit Available)

Upcoming Grand Rounds

  • Oct. 8: Managing Adolescent Obesity/Overweight: What Works
  • Oct. 15: Dramatic Healing: How Dramatic Play and Storytelling Can Play a Part in Achieving Overall Health
  • Oct. 22: Errors in Medical Decision-Making: Is It the System or the Thinking That We Need to Attack?
  • Oct. 29: Medical Quality Assurance Commission (MQAC): Protecting the Public
  • Nov. 5: So You Want to Do Global Health? What Does That Mean; What Might That Look Like?
  • Nov. 12: Pain and Health Outcomes After Surgery
  • See all upcoming grand rounds.

Watch Past Grand Rounds Online

  • Personalizing Treatment for Children with Neuroblastoma: An Old Paradigm with New Tools
  • The Crisis of Connection and Its Consequences on Our Health
  • Drop Your Assumptions and Pick Up the Evidence: Strategies to Address Vaccine Hesitancy
  • Managing Transitioning Adolescents With Chronic Disease to Adult Care: What Works
  • Managing Transition of Childhood Disease to Adulthood: CHD and Beyond
  • See all online grand rounds.

For Provider Grand Rounds information, visit our website.

New Medical Staff and Allied Health Professionals, October 2015

Medical Staff

  • Colleen Annesley, MD, Seattle Children's, Cancer and Blood Disorders Center
  • Zeenia Billimoria, MD, University of Washington, Neonatology
  • Christopher Chambers, MD, Harborview Medical Center, Ophthalmology
  • Ashley Eggers, MD, Seattle Children's, Anesthesiology and Pain Medicine
  • Margot Gottschalk, MD, Seattle Children's, Emergency Medicine
  • Siri Kanmanthreddy, MD, Seattle Children's, Anesthesiology and Pain Medicine
  • Anjana Lal, MD, Seattle Children's, Anesthesiology and Pain Medicine
  • Kimberly McDermott, MD, Neighborcare – Columbia City, Pediatrics
  • Virginia Dawn Muench, MD, Bainbridge Pediatrics, PLLC, Pediatrics
  • Catherine Otten, MD, Seattle Children's, Neurology
  • Faith Ross, MD, Seattle Children's, Anesthesiology and Pain Medicine
  • Julie Tea, MD, Seattle Children's, Hospital Medicine
  • Deborah Woolard, MD, Seattle Children's, Emergency Medicine

Allied Health Professionals

  • Judy DeBoer, ARNP, Seattle Children's, Otolaryngology
  • Rachel Ghosh, ARNP, Seattle Children's, Gastroenterology and Hepatology
  • Dianna Soelberg, CRNA, Seattle Children's, Anesthesiology and Pain Medicine