Physical activity and sports/pediatric injury prevention

Muscle soreness

Prevention strategies: warm up the body with a mix of static and dynamic stretching that prepares muscles for activity. Holding the stretch for a timeframe (toe touches and stretches) are static and activities that allow the body to continue to move are dynamic (jumping jacks). Start with lighter weights and fewer repetitions when starting a new regimen.

Soreness should be minor, resulting from microscopic muscle or connective tissue damage; it is a normal result of muscles that are adapting to a new exercise program. Clinicians should explain this soreness ahead of time so that new exercises do not use this condition as an excuse to stop their fitness regimen.

Strains and sprains

Prevention Strategies: Participate in a preseason conditioning program. Tape site of the previous injury. Warm up body temperature before stretching. Maintain playing surfaces. Use proper footwear. Limit practice time.

Injuries are mostly related to pivoting sports, such as basketball, football, and volleyball. Knee braces should not replace adequate conditioning specific to the sport. Use only after a formal diagnosis and management plan is in place following consultation with a provider or athletic trainer; braces should only one aspect of acute or overuse injury treatment.

Fractures

Prevention strategies: Do strength-conditioning exercises. Use proper techniques. Take safety precautions. Use protective gear that fits well, such as wrist guards.

Most common fractures are of the elbow and femur. Depending on the age of the child, the growth plate may be open, which places the child at risk of injury to the growth plate and subsequent abnormal healing limitations to the fracture bone growth. Most fractures heal appropriately, with proper casting and observation since the bone is still remodeling.

Stress fractures

Prevention strategies: Use soft running and playing surfaces. Use proper footgear. Do strengthening exercises. Stop activity when pain occurs.

Occur after the repetitive force is placed on the musculoskeletal system without adequate time for healing to occur between activities. children are at an increased risk because of weaker osteochondral junctions, decreased bone mineralization, thinner cortices, and variations in hormone levels.

Lacerations, contusions, abrasions

Prevention strategies: protective equipment is essential

Injuries are mostly related to baseball (contusion/abrasion), soccer, cycling, and ice hockey (lacerations)

Anterior leg pain syndrome or medial tibial stress syndrome (shin splints)

Prevention strategies: confirm proper body mechanics for the activity being performed. Do not increase the duration, frequency, or intensity of an activity too quickly. Promote bone strength and density by including enough calcium and vitamin D in the diet. Use a soft playing surface. Use proper footwear. When a shin splint is present, take adequate time to rest and heal or the athlete will risk progression to a stress fracture.

Improper body mechanics can increase the risk of injury. Do not increase the duration, frequency, or intensity of an activity too quickly. During rest periods, the athlete can cross-train with nonimpact activities such as biking, swimming, and weights.

Plantar fasciitis

Prevention strategies: Use proper footwear (cushioned with fitted heel counters or lifts). Stretch calf and achilles tendon. Do ice and massage after the event. Correct biomechanical errors. Limit hills and speed work; increase soft-surface running.

When present, avoid activities such as running, jumping, or long periods of standing. Roll a tennis ball in the arch of the foot to increase circulation and improve healing.

Blisters

Prevention strategies: Wear socks. Wear properly fitted shoes. Use powder, petroleum jelly, an an antifriction product (highly recommended), or second skin on at-risk or reddened area(s).

Head and neck injuries

Prevention strategies: have appropriate supervision and coaching that teaches proper skills, such as tackling. Adhere to the safety rules of the game. Strengthen neck muscles. Use appropriate equipment: helmets and face and mouth gear. Follow concussion guidelines for RTP after injury.

Greatest risk for these injuries are from cycling, diving, equestrian sports, football, gymnastics, ice hockey, wrestling, trampolines, football, rugby, and cheerleading. Risks increase with age.

Eye trauma

Prevention strategies: although not required for most sports leagues, parents and coaches should mandate that children wear safety glasses or goggles when they play.

Protective eyewear is made of ultra-strong plycarbonate that is 10 times more impact resistant and does not decrease the vision for the athlete.

All-terrain vehicles (ATVs)

Loss of control; No one < 16 years should drive or ride on ATVs. Those > 16 years should take a hands-on training course offered by certified instructors. Wear protective clothing (boots, goggles, helmet, long pants, and reflective outerwear). Have flags, reflectors, and lights on ATVs. Never carry passengers. Never ride on public or paved roads or at night.

Motorcycles, motor scooters, mopeds, minibikes, minicycles, trail bikes

Collisions: inability to accelerate when mixing with other traffic; inadequate brakes; Wear a helmet at all times. Teenage motocyclists should receive at least 30 hours of professional instruction, including 10 hours of driving in moderate to heavy traffic. Discourage motorcycles for youth transportation. Off-road vehicles should not be used on the street.

Riding lawnmowers

Collisions or falling off when a passenger or operating; playing in the vicinity of an operating. Be at least 16 years old and take an take an ATV course prior to operating riding mowers.

Snowmobiles

Collisions, rollovers (teenage boys and young males account for 75% of all collisions). The AAP recommends that no one under the age of 16 years should operate. The minimum age to operate a snowmobile varies by state. All youth should obtain a state-certified safety certificate. Adequate instruction/supervision by an adult is paramount. Do not travel alone. Wear protective clothing (boots, goggles, helmet, insulated outwear, and reflective clothing). Travel only on designated trails, and avoid roads, railroads, waterways, and pedestrians.

Personal watercraft (PWC; jet skis/water scooters)

Collisions, turnovers, ejections (some models can carry up to three passengers and reach speeds up to 60 mph). No one < 16 years should operate a PWC. Wear a US Coast Guard-approved floatation device. Do not jump waves. Complete a safe boater course that includes instruction on personal watercraft (jet skis). Do not operate a PWC if under the influence of alcohol. Never operate in swimming areas or after sunset.

Golf carts

Collision, loss of control, turnovers; restrict drivers to those > 16 years. Limit the number of riders. Drive only at safe speeds; wear seatbelts; use helmets; Limit use to designated areas.

Community/school playgrounds

Falls, collisions; Equipment and surfaces should be regularly inspected (including sharp protrusions, detached matting, exposed concrete footings, and tripping hazards) and maintained by schools and cities; all equipment should meet US Consumer Product Safety Commission guidelines. Maintain good sight line for supervision of the child.

Roller sports (skateboards, scooters)

Falls, collisions (boys injured more than girls); wear a helmet and other protective gear (wrist guards, elbow, and knee pads). Do not ride in or near traffic; utilize and promote skateboarding parks. Check the skating area for holes, bumps, and rocks; do not ride on uneven surfaces. Limit skateboarding to day light hours. Children < 5 years should not use skateboards; 5 to 10 year olds should be under an adult’s supervision.

Swimming

Drowning (due to drain entrapment/entaglement; lack of swimming skills; inadequate supervision; lack of CPR training); Home pools should have pool alarms, fences, and covers. All children should get swimming lessons and demonstrate proficiency. Non swimmers require constant “arms-length” and “touch supervision”. Never swim alone or in the dark.

Trampoline

Falls; doing acrobatic maneuvers; colliding with others using the trampoline; The AAP does not recommend trampolines for home use. If there is a trampoline at home, general recommendations: adult supervision at all times. Prohibit ladders, install netting and monitor the condition of the trampoline and parts. Prohibit somersaulting, multiple jumpers, and jumping onto a trampoline from a higher surface. Check homeowner insurance for coverage of trampoline related injuries.

Winter sports (skiing, snowboarding)

Falls, collisions; Dress warmly (insulated outerwear, hat, gloves, slip resistant snow boots); wear safety goggles when skiing, snowboarding, or snowmobiling. Wear sunscreen. Wear special helmets made for skiers, snowboarders, and snowmobilers. When ice skating or sledding, wear a multisport of bicycle helmet if a ski helmet is unavailable. Use proper equipment, wear knee and elbow pads when ice skating and wrist guards when snowboarding.

Bicycle riding

Always wear a bicycle helmet when riding a bicycle. Wear fluorescent clothing that can increase the rider’s visibility. Do not allow the child to ride at dusk or after dark. Use lighting on the bike and/or the bicyclist including front white lights, and rear red lights. Follow the rules of the road.

Anticipatory guidance for sports

Pre-participation physical exam, before starting any sport, ensure the child undergoes a physical exam. Teach the importance of a proper warm-up before and a cool-down after. Emphasize proper technique. Ensure the child has appropriate and proper fitting equipment. Incorporate age-appropriate strength training and flexibility exercises to build strength. Listen to the body and avoid overtraining.

Cardiovascular screening personal history

Chest pain/discomfort/tightness/pressure related to exertion. Unexplained syncope/near-syncope (judged not to be of neurocardiogenic [vasovagal] origin; of particular concern whne occurs during or after exertion). Excessive exertional and unexplained dyspnea/fatigue or palpitations associated with exercise. Prior recognition of a heart murmur. Elevated systemic blood pressure. Prior restriction from participation in sports. Prior testing for the heart, ordered by a physician.

Cardiovascular screening family history

Premature death (sudden and unexpected, or otherwise) before age 50 years attributable to heart disease in one or more relatives. Disability from heart disease in a close relative < 50 years. Hypertropic or dilated cardiomyopathy, long QT syndrome, or other ion channelopathies, Marfan syndrome, or clinically significant arrhythmias; specific knowledge of certain cardiac conditions in family members.

Cardiovascular screening physical examination

Heart murmur (likely to be organic and unlikely to be innocent) auscultation should be with the patient in both supine and standing positions (or with Valsalva maneuver), specifically to identify murmurs of dynamic left ventricular outflow tract obstruction. Femoral pulses to exclude aortic coarctation. Physical stigmata of Marfan syndrome. Brachial artery blood pressure (sitting position); preferably taken from both arms.

Sport physical examination: height and weight, BMI

Establish a baseline and monitor for eating disorders, steroid abuse, and obesity

Sport physical examination: Blood pressure, pulse

Assess in the context of the participant’s age, height and sex

Sport physical examination: general appearance

Excessive height and excessive long-bone growth (arachnodactyly, arm span greater than height, pectus excavatum) are suggestive of Marfan syndrome.

Sport physical examination: eyes

Important to detect vision defects; one of the eyes should have greater than 20/40 corrected vision. Lens subluxations, severe myopia, retinal detachments, and strabismus are associated with Marfan syndrome. Document an isometropia; the absence of one eye can limit sports choices.

Sport physical examination: cardiovascular

Increased intensity and displacement at PMI suggest hypertrophy and CHF, respectively; murmur that intensifies with standing or Valsalva maneuver suggests hypertrophic cardiomyopathy; simultaneous delay between femoral and radial pulses or femoral pulse diminishment suggests aortic coarctation.

Sport physical examination: Respiratory

Observe for accessory muscle use or prolonged expiration and auscultate for wheezing. EIB requires exercise testing for diagnosis.

Sport physical examination: abdominal

Assess for masses, tenderness, or organomegaly (especially liver, spleen, and kidneys). In females, assess for any pain, or enlargement over the hypogastric area or pelvis that might suggest pregnancy or gynecologic problem; proceed with further workup as indicated.

Sport physical examination: genitourinary

Hernias and varicoceles do not usually preclude sports participation. Check for single, undescended testicles, and/or masses.

Sport physical examination: musculoskeletal

Use of the 90-s orthopedic examination. Consider supplemental shoulder, knee, and ankle examinations as indicated specifically to the chosen sport’s injury-prone areas.

Sport physical examination: skin

Evidence of molluscum contagiosum, herpes simplex, impetigo, or lesions suggestive of MRSA, tinea corporis, or scabies would temporarily prohibit participation in sports where direct skin-to-skin competitor contact occurs (wrestling, martial arts)

Sport physical examination: neurologic

Gross motor assessment with attention to equality of strength, especially with a history of recurrent stingers/burners, and head injury. Usually sufficiently assessed during the 90-second musculoskeletal examination.

S/S mild head injury

raised, swollen area from a bump or a bruise. Small, superficial (shallow) cut in the scalp. Headache. Sensitivity to noise and light. Irritability. Confusion. Lightheadedness and/or dizziness. Problems with balance.

S/S red flags for moderate to severe traumatic brain injury (TBI)

loss of consciousness for longer than a few minutes, persistent headache or wrosening headache, repeated vomiting or nausea, slurred speech, and numbness or weakness in the arms and legs. Other concerning signs are convulsions or seizures, unusual behavior, inability to recognize people or places, and inability to be awakened. Additionally, clear fluids draining from the nose or ears are a serious sign.

Heat related illness

Children are primarily at a higher risk of severe hyperthermia in extreme conditions. External factors such as high heat stress; high humidity that reduces the efficacy of sweating in releasing body heat; air velocity or lack of air movement; solar radiation and individual exercise intensity can further increase risk. Helping the student athlete acclimate to the heat in a structured manner, ensuring adequate hydration, recommending loose-fitting and light-colored clothing, and decreasing or avoiding exercise during extreme temperatures.

Dehydration

When the intra and extracellular compartments are in balance, the body maintains blood volume through regulation by the kidneys, hormones (antidiuretic hormone and aldosterone), and solutes such as sodium, potassium, proteins, and glucose. The intake of water and electrolytes maintains hydration and regulates the fluid shifts between the intracellular and extracellular compartments. As athletes exert energy, their active muscles generate heat, which raises their core temperature. The body responds by dissipating heat through circulation (warm blood sent to the skin; flushed face), evaporation (sweating), and hormonal adjustment (adjusting to the loss of electrolytes and water through sweat). The amount of fluid lost can vary based on the intensity and time engaged in an activity, the temperature, humidity, the individual’s loss of water due to sweat, and wearing of additional clothes or equipment such as a uniform or pads. The coaching staff should play a role in educating, monitoring, and supporting the athlete’s ability to maintain hydration and should be proactive in providing drink breaks, having water bottles accessible, and reminding players to drink.

Cardiac screening and risk

The ultimate goal for the healthcare provider performing the PPE is to recognize athletes who are at risk of significant morbidity or mortality from preexisting cardiac conditions that may or may not be diagnosed. A key takeaway is that the athlete’s health and safety are the priority when determining eligibility to participate and personal motivation or interest in the sport on behalf of the athlete should not be a deciding factor. The ability to auscultate an organic murmur or detect warning signs (history of chest pain, excessive exertional dyspnea, or syncope) or a positive family history of sudden death due to an unknown cause or heart disease can raise suspicion, and further testing is required to properly clear and athlete for participation. 12-lead ECG or echocardiogram.

Acute infectious mononucleosis

Viral illness caused by the Epstein-Barr virus. Splenic rupture can occur spontaneously, but the risk of rupture increases when participating in a contact or collision sport or a sport in which there is an increase in intraabdominal pressure (rowing and weightlifting that require Valsalva maneuvers); the risk is at its highest within the first 3 weeks. Athlete should avoid exertion for the first 2 to 3 weeks after the onset of symptoms, when the spleen is more likely to enlarge. At 3 weeks after symptom onset, if afebrile and symptom free, the athlete may return to light non-contact physical activities.

Head injury and concussion

Less emphasis is now placed on the loss of consciousness, posttraumatic amnesia, and retrograde amnesia as ways to diagnose and classify the severity of the concussion, as these only appear in a minority of injured athletes. Both physical and cognitive rest is recommended after the diagnosis of a concussion. The athlete should rest for 24 to 48 hours, then slowly and progressively become more active and begin progression through the return to sport strategy steps.

Return to learn and play

1. Symptom limited activity: daily activities that do not provoke symptoms, high school-aged and younger youth should not return to sports until they have successfully returned to academics

2. Light aerobic exercise: walking or stationary cycling at a slow to medium pace; no resistance training.

3. Sport-specific exercise: running or skating drills, no head impact activities

4. Noncontact training drills: harder training drills (passing drills); may start progressive resistance training.

5. Full-contact practice: following medical clearance, participate in normal training activities.

6. Return to play: normal game play

Female athlete triad

Perform a complete history that includes a physical, daily nutrition intake, exercise, and menstrual function. Menstrual history should document any history of abnormal menses in the previous 12 months. Assess for low body mass index, orthostatic hypotension, bradycardia, signs of an eating disorder, (parotid gland swelling, callus of proximal interphalangeal joint, cold/discolored hands or feet, lanugo).

Screen for all elements of the triad at the PPE and at annual physicals.

If one component of the triad exists, screen for others.

If an eating disorder is suspected, refer the athlete to a nutrition professional and a mental health professional for screening/treatment if indicated.

Consider the use of DEXA, bioelectrical impedance, water or air displacement plethysmography, and or skin fold measures to document fat free mass.

Diagnosis of amenorrhea: screen for other causes. Obtain an ultrasound if signs of PCOS are present (acne, hirsutism)

Screen for bone mineral density after a stress of low-impact fracture, 6 months of amenorrhea or oligomenorrhea, or as part of assessment for disordered eating pattern.