Thank you everybody for joining us. That was a great last lecture. We appreciated Dr. Reitberg joining us. And thank you again for joining us today. We're excited to have Dr. Emily Krauss from Stanford. Again, we've kind of gone through the goals, but housekeeping wise, we are going to keep everybody video and audio muted. Again, my name is Sterling Herring. I'm a PGY3 at Vanderbilt. So if you click on your participants list and scroll up near the top, you should see my name up there. If you have any questions, feel free to shoot them to me via chat over the course of the lecture, and then I can present it for you at appropriate times. Again, any general questions, there's an email address there. You can track us down on Twitter. So without further ado, we're excited to have Dr. Emily Krauss with us. Thank you very much for joining us, Dr. Krauss. Thank you for having me. This is my first virtual lecture didactic series with this large of participants following. So that's awesome. Quick question. Am I okay sharing my screen now? Yes, absolutely. So you should be able to share your screen and kind of take it away from me. Okay. Any rules that you guys have as far as should I be looking for chat questions or are we going to just wait until the end for Q&A? However you want to do it. So people will either, I can keep an eye on the chat box and kind of ask them as they come up. You can pause in the middle or you can just set it aside for the end and we can ask questions then. All right. And do we have a hard stop at, I guess, 2pm or what's that? Whatever the next hour is where you are. To me, it's one o'clock. It's 12.03 right now. So we have about just under an hour. Great. I'm going to share my screen. Let's do this, wrong lecture, there we go, I know how much time I have, great, can you guys see that? Looks great. All right, awesome. Okay, so just going to move this here. Okay, so I'm just going to be able to speak to you on some topics that I feel pretty passionate about. So I'm Dr. Emily Kraus. I'm a sports physiatrist and I am working at Stanford Children's Orthopedics and Sports Medicine Center. Literally like five or ten minutes ago I had some of my staff actually drag this up so I was like I want a backdrop and so you can see where I'm working. If this starts to tip towards me please maybe like raise your hand or do something to alert me because I don't really want to do a talk on concussions if I can help it, especially sustained on myself. So I've been working at Stanford Children's Orthopedics and Sports Medicine Center for about three years. I would love to talk more about that but really the goal of today is to talk a bit about overuse injuries and sports specialization in the pediatric athlete. So a quick outline I'm going to talk about epidemiology and risk factors for overuse injury and then go into a little bit about types of overuse injuries. Apothecial injuries, growth plate injuries, and other pediatric injuries if we have time. Hopefully this is new information for you and there's not too much overlap with other lectures but please feel free to ask questions. I'll have Sterling kind of try and field those as best as possible and if maybe there's a kind of a stopping point in the middle to just kind of take a break and we can all come up for air and ask some questions I can field them then or just wait until the end. Hopefully I'll have some time at the end. All right so I'm just to give a little bit of some background on a day in my life. I feel like I have a dream job. I work in an academic setting. I get to work with young athletes and really I still work with adult athletes as well and I really kind of landed in this job during my sports medicine fellowship which was at Stanford and I also did my residency training at Stanford. So this is the clinic that I work in. I'm actually in clinic today for a couple of patients. It's in Sunnyvale. It has a motion analysis and sports performance lab in it so I do some sports biomechanics too. Happy to give a lecture on that at another time. I really think it's a fascinating topic and especially with our physiatry background I think it's we can really use our knowledge to really better understand function and how that relates to injury risk and injury prevention. I do some community outreach. That's a talk at a bike shop up in San Francisco looking at kind of maintaining bone health and for the for the cyclist which is a non-impact activity. I did some sideline coverage. This was primarily during fellowship. I did some sideline coverage for the football team but I still do some high school football sideline coverage. I still get a chance to do a lot of teaching and mentoring, give a lot of lectures like this and then I get to engage in some really cool research. I'm primarily related to bone health, female athletes, male athlete, triad related stuff that kind of the importance of nutrition interventions, hormonal imbalances. I do some studies on ultramarathoners. So kind of this wide array and it's really fun and keeps things interesting and here's a couple of just organizations that I serve on as well. So why study sports injuries? That's a really important question as well as why I understand sports injuries. So on a survey back in 2017 and 18 by the National Federation of State High School Associations, they identified 65 different sports and 13 adaptive sports for students with disabilities. This is continuing to increase every year. There are over 7 million total participants and a greater than 15,000 increase in female sports which is incredible but it also just emphasizes the importance of understanding how these athletes can participate in their sports as safely as possible. So back in 1972, the Title IX Educational Assistance Act was passed. This allowed institutions receiving federal aid stated that they must provide equal opportunity for women's and men's sport. This increased high school and female collegiate participation by over 600% especially in the high school age range. There was increase on almost 900 or over 900 percent. So why study sports injuries in young athletes? There has been just a trend for an increased duration and intensity of training. We are seeing earlier specialization and year-round training in the athlete. There are an increase in the difficulty of skills practiced and there's also more adventure and extreme sports which I think is pretty cool. One of the sports we cover here in the Bay Area is the NorCal Mountain Biking League. High school mountain bikers are going out and training through the fall and winter and then competing in the spring. They sustain all sorts of injuries from acute injuries, crashes to overuse injuries, knee pain, concussions. With those new sports, you need to really understand the risk profile with those potential injuries that can develop. Skateboarding, rock climbing, trick blading, which is like rollerblading. I was trying to find a really cool trick blading video but I couldn't get it all together for you guys. So next time. So a few just kind of statistical questions. How many high school athletes make it to any NCAA level in their sport? So this was back in 2016 and 17. There was a big study that kind of looked at these the breakdown and there were 4.3 million men and 3.4 3.0 million women who participated in high school sports. However, 94% did not make it to the NCAA level. So there was a tweet that went out this morning about learning how you can be the next LeBron James as opposed to a resident and I hate to break it to you but it's probably not going to happen. So keep your day job, keep going to these lectures and getting the appropriate training. Unfortunately, only five to six percent of athletes make it to the NCAA and that kind of breaks down based on D1, D2, D3. What about professional stardom? As you can imagine, that is even a lower percentage with about 0.04% of high school athletes drafted into the pros. And I can't tell you how many athletes and their parents who come in and they have these big aspirations for how they're going to kind of go to that next level. And I really think part of our job as clinicians is to kind of adjust those expectations and kind of create this kind of reframe an athlete's approach to their sport. I mean it doesn't have to be just always fun and always games and everybody wins type philosophy but I think there needs to be kind of a shift in that focus and that can affect how they cope with an injury as well as how they handle their training and maybe take a healthier approach to their training and a healthier approach to exercise. So just another look at some more statistics. Unfortunately, as many as 70% of athletes discontinue playing organized sports by the age of 13. Questions of possible burnout and other kind of overturning pieces, injuries. And then at least 50% of athletic injuries are related to overuse. 60 million children and adolescents between 6 and 18 years of age are involved in organized sports. And 3.5 million children are injured annually playing sports or participating in recreational activities. So there is a demand for the pediatric sports medicine physician. You know sometimes I explain to people what I do for my job they're like that many kids are getting hurt and the answer is yes. And I'll kind of talk a little bit about why that is and the types of injuries that I see. So I'm just to go through a few more definitions. Sport specialization is defined as intensive year-round training in a single sport at the exclusion of other sports. A study on over 3,000 athletes found that current high school athletes specialize an average of two years earlier than current collegiate and professional athletes. Another survey found that greater than one-third were classified as highly specialized in a single sport. So a few more definitions. Early specialization is defined as a high volume of deliberate practice with a low amount of deliberate play in a single sport with a focus on performance as early as age 6 or 7. Early sampling is defined as involvement in various sports with a focus on deliberate play. I love using the words deliberate practice and deliberate play in my clinic. I talk a lot about even sampling or kind of experimenting with other sports. I think a lot of athletes and have this almost perfectionistic approach to sometimes to sports that they have to be on the varsity team or on the top top league. And it really is just I'm trying new sports and if they take this mindset that maybe that other sports could could really contribute and enhance their ability to perform in their the sport that they love, that sometimes it's a little bit of a carrot for them. But it can be a challenging to educate and shift that that mindset. A little discussion on performance. A survey of 148 elites and nearly Danish athletes found that the elite group specialized three and a half years later and spent fewer hours participating in that main sport during early adolescence compared with the near elite group. There's a really good book that I read by David Epstein called Range and it talks all about kind of trying to be a generalist in a highly specialized field. If you have some free time, which you may right now, it's a pretty good book and it's a I think it's a good audible too. So I listen to a lot of audiobooks on commutes and long drives. A study on NCAA D1 athletes found that 70% did not specialize in their sport until at least age 12. 88 had participated in more than one sports and athletes who engaged in sport-specific training at a younger age had shorter athletic careers. I know there's this idea of kind of this Tiger Woods philosophy of 10,000 hours like putting more hours really leads to a better performance down the road but really that increased injury risk is there too and there's just a lot of other there are a lot of ways to approach to physical activity in a healthier way. So let's talk about injury risk. So sport specialization was significantly associated with onset of all injuries including serious overuse and knee injuries in a kind of retrospective study on both tennis players as well as I'm just all all athletes. Athletes who participated in organized sports compared with free time in a ratio of greater than two to one had an increased risk of overuse injury and then young athletes who participated in more hours of organized sports per week than their age in years had an increased risk of an overuse injury. So that's a rule that has been kind of continued to be implemented and recommended and hopefully I'll get to my final side side with some of those take-home points as far as using that age and it's a kind of it's an easy to digest recommendation for the for parents to kind of walk away with and they can remember that like oh this kid's 12 shouldn't be training more than 12 hours per per week. So an audit of injuries in six English pro soccer academies in six English pro soccer academies about 600 elite soccer athletes aged 11 to 18 were prospectively monitored. They found that the greatest time loss for injury was in that youth 14 to 15 age range right there. Highest rates of severe injury is from the new 15 age range. The thought is or philosophy is that it's this greatest increase in stature, leg length, and body mass during that 14 to 15 age range which I'll kind of dive into a little bit as far as the why. So I'm talking about risk factors for overuse injury so we can kind of break them into an intrinsic and extrinsic risk factors. Actually I just want to make sure I see the chat function so good okay. I'm following along. Oh good good good okay and let's see if I can get rid of it now. I'm assuming you didn't see that. All right we're back in business. So risk factors so broken down into extrinsic intrinsic and extrinsic risk factors. As you can imagine as a lot of risk factors kind of the main risk is on prior injury but I mean you have to factor in a lot of other factors especially in the adolescent athletes specifically as it relates to growth. So a lot of these athletes they're having their peak growth spurts around that 14-15. I'm usually I'm kind of a little bit younger in the female athletes and a little bit older in the male athletes and during that peak growth spurt time there can be that elevated injury risk as muscles are lengthening, bones are catching up. With that increase in bone lengthening there can be areas of vulnerability and kind of more kind of hypo dense regions which can put an athlete at risk of injury in those areas. So there's that. There's susceptibility of growth cartilage to repetitive stress. So the whole growth plate consideration which I'll get into in a little bit more detail. Adolescent growth spurts as I had mentioned. The previous level of conditioning. A lot of these kids are coming from summer of hanging out being sometimes doing a lot of video games sometimes I'm kind of at the pool and relaxing or not really in intense training and then they go straight into preseason training in August. That can be a really big acute increase in load and volume. And you kind of want to factor in that acute to chronic workload ratio and how that relates to injury risk as well. And I unfortunately won't get into that in too much detail but there's a lot of debate as far as kind of how that approach has changed and how that philosophy has changed over the last couple of years. Different anatomic factors as far as leg length discrepancy, pes planus, pes cadus, different kind of anatomic alignments as far as like cue angles and that kind of hip to knee ratio and that angle and alignment. There has been some okay research on the role of that as a risk factor. On biomechanics, so you think about how an athlete runs, how they land, how they jump, that's going to put them at different risk for specific injuries, particularly the ACL, the telephemeral pain, ankle sprains if they don't have good proprioception or put an ankle strain. Menstrual dysfunction, I don't get into too much detail about the female athlete triad and male triad equivalent, relative energy deficiency in sport, all that's going to factor in as far as risk profile especially as it relates to bone health. Then all the other psychological and developmental factors as far as stress levels. There's a lot of really good research out on sleep and the role of sleep in recovery. Nutrition goes into that as well and then so many other stressors with these kids as they're in getting into that especially that junior year when they're looking at colleges or thinking about if they do have up the potential of being recruited, they might be recruited that year. That stressor is going to put a whole another layer of pressure on their their ability to train and perform and their injury risk. So other extrinsic risk factors, I talked a little bit about training and workload, training and competition schedules as far as if there are, are these athletes over training? Are they going to too many games, too many matches per season and how long is that season? Is it year-round? Especially in the Bay Area, I mean one of the benefits of the Bay Area, it's gorgeous all year round, but one of the downsides is it's gorgeous all year round and it's really hard to kind of pump the brakes and take a proper offseason. That's really of all ages. Environments, I mean good weather and also really, really bad weather, kind of training in the cold, the rain, the humidity and things that could really, temperature regulation is going to be different in the youth athlete. And then psychological factors, really thinking about the pressure that an athlete sustains from or experiences from their, their peers, as well as maybe their parents, maybe their coaches, maybe the parent was involved in that same sport and so there is this maybe expectation that maybe isn't really communicated, but those are questions that you can sometimes tease out in the clinic visit and I think it's a really important piece. Sometimes you realize that this kid, this teenager who's doing gymnastics all year round and many, many hours per day doesn't really like to do gymnastics and maybe they just like to dance and you start to tap into that, those types of questions and all of a sudden there's almost this like Eureka moment where the, with the kid where they're like, oh I don't have to do this sport, I can maybe play these other, do these other activities and it's a nice breakthrough moment. even with the parent and the child. So looking at overall epidemiology of overuse injuries. So High School Rio is a type of as injury surveillance system. There's a couple of other ones out there if you are on a little bit more research minded. This is Alison Schroeder, who I don't know if she is on this lecture, but she, I know her fairly well. And this is a really good article looking at high school injuries. And they found based on a survey of, or study on over six years, almost 3,000 overuse injuries and greater than 18 million athlete exposures. Some of the most interesting takeaways is the overused injuries affected females more than males, and those injuries usually occurred earlier in their high school career. Question of theories of neuromuscular and biomechanical changes during that time, various lower extremity flexibility and strength and other hormonal changes, as I touched on earlier, the sports that were most often affected were track and field, field hockey and lacrosse, and lower leg overuse injuries were most common. So why increased risk? So we kind of talked about this previously, but year-round exposure to a single sport. First study was on youth baseball pitchers and found the greatest risk for shoulder and elbow surgery in those pitched greater than eight months per year. There's question of maybe introducing technical skills too early, such as the kick serve and tennis or this higher pitching volume with or poor pitching mechanics in baseball. I mentioned overscheduling and competition and then just psychological burnout as well. So I think it's important to remember that children are not miniature adults. I really liked this cartoon. There's a lot of growth and maturation taking place with these ages and rates of maximal growth spurt. And unfortunately, they're not cookie cutter and they are very different depending on gender, race. There's a lot of, there's a genetic piece to that. And so you can't, every kid who walks, every 12 year old who walks into my clinic room is very different as far as their emotional interaction, how they handle their injury, if their parents try to talk over them. I mean, there's a lot of different dynamics that you have to factor in. And take each one individually. You need to think about the growth plates, which I'll talk about in a little bit. And then I don't talk about concussions, but even just concussion presentation is very different than in an adult. As I said, highly variable and different in maturation as well. So I'm talking a little bit about the musculoskeletal chain in adolescence. So often the ligaments, tendons and muscles are the strongest links. And the growth cartilage, epiphysis, which is adjacent either to an apophysis or an epiphysis, which I'll define, is the weakest link. This isn't always the case. I do see ACL tears or ligament sprains. I do see tendon injuries and strains and tendonitis, but less often than I see growth plate related, especially in those kind of repetitive, kind of into that over-training, over-specialization age group. So we're all on the same page, growth plate defined, multiple different physes that we're gonna talk about. The epiphysis is the end of the long bone. The diaphysis is the shaft of the bone. The metaphysis is that flare of the bone. The physis is the high-length cartilage growth plates, and it's responsible for that longitudinal growth of the bone. And the apophysis, there you go. The apophysis is the growing center, which grows upon the mother bone. So just a nice color-coded breakdown there. So usually the articular cartilage is considered the growing bone, that's thicker, more plastic. That remodeling potential is really high in the young athlete. The vulnerability really takes place at the epiphyseal plate, so that growth plate, especially with different shear forces that are taking place. The apophysis, so that insertion of the tendon onto the mother bone, is where there's a lot of traction, especially with muscular contraction. So considering the quad muscle and how that patellar tendon attaches to the tibia, and that tibial tubercle. There's a lot of traction with running, with kicking, with jumping. There's a lot of elasticity and resiliency of the metaphysis of long bones. So you actually see, often, incomplete fractures in this age group, with the green stick or other incompletes, like buccal fractures. One thing that I do get to see pretty regularly in my clinic are fractures managed non-operatively. And I see a lot of buccal fractures, which is just an incomplete fracture on one side. The good news is kids heal all the time. Our kids heal a lot better, and they really, that particular fracture is pretty easy to heal in a short amount of time. So I'm going into more definitions for you all, specifically as it relates to the apophysis. So it's also considered the traction apophysis. It's located at the site of major muscle tendons, one here, one there, and it's subject to tensile forces. So an apophysitis is an overused condition causing pain, inflammation, microtrauma to these insertions. This is different than kind of an apophysis kind of at the end of the long bone that is really important to kind of continue that longitudinal growth. Okay, so general considerations if you want to think about in your history and exam, usually the pain is of insidious onset as opposed to sudden onset. If there is sudden onset pain in an area of a growth plate, you want to think about a possible abulsion. So an actual, where that growth plate is actually a bulge off of the long bone. There's usually focal tenderness. Often there's quite a bit of soft tissue swelling in that area, especially, I will speak about Oshkosh ladders, I've seen some pretty swollen tibial tubercles in some jumpers and basketball players. Imaging is often not necessary. And I kind of put a little asterisk here because that's some consideration, especially in the pediatric population. You're thinking about overall how much radiation and trying to be really judicious with your imaging. And so I don't do kind of pre x-rays before I see them in clinic. I see them in clinic and then decide whether an image is absolutely necessary. That's even sometimes with fracture follow-ups too. If I can avoid, if the kid is fully functioning, full range of motion, completely pain-free and I'm about to jump off the walls, then we may not need x-rays. So really be thinking about that. I mean, with any medical decision, you should be thinking about the costs and the benefits of it. And especially in the pediatric population, there's another layer of risk that you wanna think about. And parents are usually like really on it too. And they're questioning most images. And so you really need a good explanation for why you are ordering what you're ordering. You may see, if you do get an x-ray, especially if you're concerned about an avulsion, you may see irregularity, sometimes fragmentation of the apotheosis with soft tissue swelling. It's pretty important to compare. If you're really concerned about some fragmentation, sometimes that's a normal variant. And so sometimes you have to kind of take that into account that that might just be their normal anatomy and they'll be completely fine and that will fuse with time. Treatment relative rest is usually the name of the game. Activity modification, sometimes complete rest. And I'm really using pain as guide. I also put an asterisk there because sometimes kids have a hard time really gauging, is this pain too much pain? So sometimes you have to give pretty concrete parameters as opposed to just say, let the pain guide you. So some more research on bicep injuries comprise about 15 to 30% of all skeletal injuries in children treated in EDs. One to 30% of pediatric sports injuries. There's a lot of wide range because sometimes they're not properly diagnosed in the ED. And so you just kind of get a big range of numbers there. They can be traumatic. They can be overuse or stress-related. I'm gonna talk about the stress-related overuse ones now. Traumatic is most commonly seen in football. Unfortunately, I chose not to include Salter-Harris fractures as part of this lecture series. I'm happy to come back and give a little short 15 minute or 30 minute lecture in the future if that's of interest. I know we don't probably get as much of that type of education in lectures and didactics just because of all the other things that you're trying to learn in your residency. So the whole thought process as far as the mechanism of overuse or stress-related bicep injuries start with repetitive loading that leads to alterations in the blood supply specifically of the metathesis. This leads to interference with mineralization of those hypertrophied chondrocytes. And then there's hypertrophic zone continues to widen leading to disruption of that growth plate, sometimes separation and often pain. So I wanna jump into some cases. So I have a 12 year old male pitcher who presents to your clinic with right shoulder pain. He reports several months of, oops, several months of worsening diffused shoulder pain with a recent increase in throwing activity. His exam, he's got anterolateral proximal humeral tenderness. He has pain and weakness with resisted shoulder internal and external rotation and AV duction. Really, I think just to kind of explain this pain and weakness is probably more pain-related weakness as opposed to frank weakness to kind of narrow your differential. And there's maybe some question of glenohumeral internal rotation deficit. Based on this and based on this concern for maybe a growth plate injury to an region of the upper humerus, you get an X-ray and you see some widening of this proximal humerus. So I don't think I've ever seen something so nice and easily separated like that, but usually you can see some sclerosis or disruption of the proximal humerus. And that is an area of growth plate. So this is considered little league shoulder, but I wanted to take a quick TV timeout and we're gonna try this, probably chat function. Name this physical exam. You can chat it out too, but whatever's easier. All right, somebody wants to put it in the chat. We have an apprehension test. Yes, woo-hoo. All right, yeah, Anton and Captain Mills and Shobain. And what about, this one's a little tougher. So imagine this kid, I wish I could do this on myself. So it's not going down, it's going forward and backward. And this is the same, he's just doing it in a supine function on the first one. Yeah, George, nice work. Yeah, I think they also can call it the fedora test too. So this is a load and shift. So imagine that he is pushing forward and backward. You could also think about this like a sulcus test too, but he's looking for anterior and posterior glenohumeral joint instability, which often we see. I don't think, another consideration you actually wanna think about in the physical exam is like ligamentous laxity and hypermobility. So kind of doing the Baton test and looking for those Baton signs is really important too, especially if they kind of complain of some instability. So to talk about the Little League shoulder, which is specifically as it relates to the proximal humeral physis. So usually the proximal humerus physis closes in girls by the age of 14 to 16 and in boys by 16 to 21 years of age. They, the mechanism with that increased external rotation and shear stress arising from that motion causes adaptive changes to the proximal humeral epithesis that can lead to kind of chronic pain and separation of that area. It's often seen with this glenohumeral internal rotation deficit. So you can see some excessive external rotation, some lack of internal rotation. Usually that is asymmetric. We often see some side to side variation as far as that rotation, but you're really wanting to make sure that that, especially that whole arc or that circle doesn't get reduced. Cause that can lead, as you can imagine, some compensation in their pitching biomechanics, which then translates to other areas that aren't related to pitching and just overall lack of range of motion, especially in the teenage age range is no bueno for down the road. So thoughts on treatment and return to play. Usually the management is rest of approximately three months. I really, I get, I'm pretty leery about providing any type of timeframe just because of how variable it is from depending on the athlete, as well as depending on how diligent the athlete is with their level of rest. Always referring these guys to physical therapy. I feel like kind of speaking to the, preaching to the choir here, the importance of really good physical therapy, especially like PE sports, PT is really important. And if you do go into a practice, you find yourself seeing a lot of younger athletes, make sure that you have a physical therapist that can work, that knows how to work with a young athlete and how those different motivators are different, but also that they're not afraid to work with the young athlete. There's a lot that you can do. There's a lot of strength work that you can do. And you just need to make sure that you have that kind of a good rapport and dynamic with that PT. When an athlete is completely pain-free, you can consider getting them back into the game, but really having them switch positions to something that's gonna require less throwing, like for space. Sport specifics, like an interval throwing program is key, long toss program for position players, additional mound interval throwing. Here's a nice example of pitch counts by the AOSSM, American Orthopedic Society for Sports Medicine. One study did find that pitchers who threw more than 100 innings per season had a 3.5 times higher rate of injury than those who did not. So I know another baseball example, but an important one and one that we often see. So 12-year-old right-handed boy presents your clinic with medial elbow pain. He thinks he wants to go pro, parents are gung-ho, he's on multiple teams. He stated that the right medial elbow pain began mid-season. He says it's worse with kind of late acceleration, part of his unpitching, which I'll get into a little bit more. Overall noted a decrease in pitch velocity and just overall distance. He often pitches double headers, he's unsure of pitch counts. Also throwing this in, because I did have this in my clinic, he likes to play catch with his dad, throw the football around in addition to all the activities that he does, because he just likes to do that and it's good bonding with his dad. And he would play baseball 11 months out of the year. So lots of risk factors hopefully lighting up in your head. So your astute physical exam, you find tenderness to palpation along the medial epicondyle with a little bit of swelling even. He has an increased valgus carrying angle on that right side. No evidence of flexion contracture yet. No laxity at valgus stress at 30 degrees. Negative milking maneuver, which is right there. And negative tonels at the elbow as well. One small extra exam maneuver that I do is I actually have them kind of go through that range of motion and then I give them a little bit of resistance. So it's kind of like a milking maneuver, but I kind of try and take them through that throwing motion a little bit more. And sometimes I can get a positive test on that that I wouldn't through a milking maneuver. And it's just kind of the way that that load and that torque is on the elbow. So you get an x-ray due to suspicion for a possible non-displaced or partially displaced medial epicondyle avulsion fracture, loose bodies, osteochondritis desiccans, which unfortunately I don't get into in this talk, or actual ligament calcification. So just a couple of different examples of some things that you may see. This is one where sometimes I will get a contralateral film just to see if there is some very similar kind of abnormalities as far as fragmentation. But if there's swelling and tenderness and then there's fragmentation at the epiphysis, you want to be thinking about that that's a kind of epiphyseolysis of the medial epicondyle. And I'll get into that a little bit more. A couple of slides. And then you can see some actual separation at the growth plate there. So this gives me anxiety, trying to figure out ossification centers of the elbow. It's probably one of the bigger challenges is interpreting elbow x-rays in a pediatric athlete or a pediatric patient. Sometimes I will see elbow fractures or supracondylar fractures, and I always kind of have to pull up and it varies depending on the age. As you can see, this is when ossification centers develop. What is not here is when they fuse. And the last ossification center to usually fuse is that medial epicondyle. So it's going to continue to put that athlete at risk of kind of avulsion or separation. Another thing, actually, I'll see, I might actually talk about it. So to kind of look at the anatomy, yes. So the ulnar collateral ligament, as you probably remember, has three different bundles. So the anterior bundle is usually the one that's most vulnerable to injury, but I don't think I've seen, no, I don't think I've seen a UCL tear in this population yet. So that's not, like I said earlier, that's not the weakest link. It's the insertion of that ligament and that musculature to the medial epicondyle. So that's where you're going to see the weakest link is that growth plate. So we see these in repetitive overhead throwing athletes, a lot of torque of that throwing motion. There's tensile and shear stress at the elbow leading to this repetitive trauma and hypertrophic zone, as I had mentioned earlier, and again, common in baseball pitchers. But I've seen this in a squash athlete who is probably like 10 years old. So it's related to just the training and the volume that the athlete is experiencing and is their body developing rapidly? So another question that's really important to ask is whether they had a recent growth spurt and you often play a little detective work and you'll see that within the last six months, they've had a rapid growth spurt. So you can imagine that those muscles are even tighter than they normally are and they're attaching to that elbow. Kind of going into more risk factors, age greater than 80 pitches per game, as I think I mentioned, more than eight months of competitive pitching, faster speeds, to continue to pitching despite fatigue or pain. And then this is kind of the breakdown of the most at risk of athletes. And I've seen this in catchers and more in pitchers, but I also have seen them in catchers as well. So five stages of pitching, you guys, this is a good, actually, this is a good boards question for just PM&R, I feel like I maybe saw this in my boards or at least in the practice questions. Which stages of pitching are at the highest risk? Jacked, go. Waking people up. We've got an early acceleration from Jose. Yeah, all right. Got it, late cocking, early acceleration. So kind of going into the treatment rest, at least four to six weeks, big asterisk here. I usually, I think I would addend that to be longer than four to six weeks. I would say several months. And usually this is a combination of physical therapy. So I'm really a shutdown for four to six weeks, but that doesn't mean four to six weeks of back green light, go back into sport. Four to six weeks and then starting to do a gradual throwing progression. So really looking at elbow range of motion and strengthening of the flexor pronator musculature is kind of the basic PT, but really we're thinking about optimizing core, lower body trunk strength and thinking about pitching mechanics too. And that neuromuscular piece is really essential. All of my pitchers go through a return to throw program that can last several months. Sometimes they will have occasional flare ups and then I just back it off or maybe shut them down for a little bit longer. This is really important for them to take care of because the risk is that they go back too soon. They could potentially evulse. They could have a much bigger injury. Surgery usually, if failed non-operative approach, at least giving it six months, there's a really displaced avulsion fracture or, of course, of older athletes with MRI findings of a UCL tear. So that's a bigger separation there. So kind of going into some more prevention strategies, Pitch Smart is a program through the MLB on the website and they have really good, they break it down by age. I'm not going to go through all of this with you but that's a great resource. There's a lot of good resources out there for youth sports, specialization, and injury prevention depending on the sport. Curveball. So what about these pitching guidelines? Are they adequate? So one study looking at MRIs and physical exam and symptoms over a season and they performed pre and post assessments. They had 100% compliance with pitching guidelines. Still, you don't know what those kids are potentially doing at home. There were 48% that had a documented MRI abnormality, 32% saw worsening of preseason MRI or developed a new abnormality. The factor most associated with an abnormal MRI was year-round play. So really kind of cutting down, reinforcing the offseason, bring back the offseason, and also thinking about, you know, what is normal on an MRI? Are we going to see some type of lighting up? Our MRIs are getting more sensitive but what's, like, where is the threshold for us to shut down? And I think it's probably some kind of gray transition zone. So you just really want to try and be on that lower end of the zone. Some lighting up is probably okay as far as lighting up, as far as edema, but if you're starting to see separation, chronic changes, sclerosis, some more long-term or chronic changes, then that's of concern. All right, shifting gears, I see a lot of gymnasts, dancers of all sorts in my in my clinic. I'm ballet and they're usually high-level, very intense, very fit, but also very prone to injury. So a 14-year-old female gymnast presents to your clinic with right wrist pain. She says it's more of an aching in quality, dorsally located, usually associated with floor exercise, balance beam. She is fumilar. She just switched to a different gym. The gym increased its intensity as far as hours. She's trying to get to the next level in her kind of competitiveness and the skill set. And so she's trying, she's really trying to advance, advance her skills and kind of build up her technique. So we'll make sure and flag that and get back to those questions. So gymnast wrist or distal radial fascial stress injury affects up to 25% of non-elite gymnasts. Age range around 10 to 14, depending on where they are in their puberty and kind of growth, late closure. Often see, the report is this, or thought theory behind it, is this repetitive axial loading and hyperextension of the wrist, especially if there's some range of motion limitations other places. This repetitive stress causes inflammation and growth plate of distal radius and can lead to premature closure of the distal radial fascia, which is what you really want to avoid and kind of a scary, scary consequence. So here are some nice examples of some abnormal x-rays and imaging. So on exam, you can see tenderness over the dorsal radial region, limited range of motion. It can be a little bit more diffuse. Sometimes it's not even at, sometimes it's a little more into the hand, sometimes it's more into the wrist, but you want to be thinking about distal radius fascial or gymnast wrist definitely in those situations. So on imaging, you can see the widening of the distal radial fascia. You can actually see a positive ulnar variance, which means that there's probably premature closure of the distal radius, which is going to lead to range of motion limitations and potentially arthritis type issues down the road. So you really want to try and pick that up. I mean, oftentimes they're not presenting to your clinic until later on at that stage. So you really want to try and educate your gyms and your coaches as much as you can and your pediatricians. So on treatment, often stopping all weight-bearing exercises for a minimum of six weeks. Usually it's more than this. Serial radiographs to make sure that there is improvement in those, that sclerosis and widening. Return to play once range of motion, I'm sorry, once pain is resolved in full range of motion. Surgery, if you see earlier, biseal bridging. I think I have a picture of that. Yeah, so you can see biseal bridging there. Really reducing high impact and stress loads during growth spurts. Wrist guards are important and oftentimes they are using like tiger paws in the gym, which you want to be asking about what type of wrist guards, what they're using. There is a really good article that I do not have on here about return to sport progression in gymnastics and kind of depending on the type of injury. They really outline things. I'm not a gymnast, so I don't know all this specific, the appropriateness of different progression and kind of knowing all the lingo. And so that kind of helps alleviate some of those kind of disconnects as far as what techniques they should be doing, what skills they should be doing and should not be doing. Kind of going through, I have about 10 slides left. I want to make sure and give you guys some time for questions too. 13 year old soccer player with acute anterior hip pain after kicking a ball in a game. He has pain with active hip flexion now. Tenderness at the inferior to the anterior inferior iliac spine. He got x-rays, showed this positive arrow sign. Treatment options, anti-inflammatories, sometimes crutches and surgery if minimal displacement. So question for the group, if somebody can quickly tell me which muscles attached to the AIIS. Yes, good job George. Rectus femoris. So this is an avulsion, kind of partially displaced avulsion fracture of the insertion of the rectus femoris at the AIIS. Avulsion fractures of the hip and pelvis. Depending on the time of year, I will see probably three or four of them in a season. You can see, I really like this picture because it has a nice breakdown of all the muscle insertions at the different growth plates. I've seen ischial tuberosity, hamstring avulsion. Again, you really want to be thinking about this. If there is that pain, I wouldn't just kind of chalk it up to a hip flexor strain. I would think about avulsion fractures and probably try at least to get an AP pelvis in this situation. So age range is usually around 13 to 15 years of age before that secondary, before the fusion of these ossification centers. Oftentimes you can see on plain films, you just have to be looking for it. So usually treatment is rest and immobilization. I have yet to send any of these for surgery, thankfully, but usually the thought is displacement of greater than 15. Sometimes they'll even be a little bit more, even greater, they'll allow more greater distance just because these athletes, pediatric athletes, and with their growing bone and development, they heal really well. So just for the sake of time, I'll just do one more because this is one that you'll see a lot. So Otgut-Schlatter syndrome, Otgut-Schlatter disease. So this is an apophysitis of the tibial tubercle. Usually see them in age 12 to 15, sometimes older, jumpers, basketball players, runners, all athletes. Usually it's the beginning of the fall season, sometimes just PE will flare these knees up, and I can see really a lot of swelling in that area. Usually present, athlete presents pain with jumping, squatting, going upstairs, can be bilateral, usually see an enlarged tibial tubercle, pain on resistive knee extension. Make sure you have them, try at least to activate knee extension so you know that there isn't a full, it isn't a full avulsion. You can see that just mechanism of that ossification center there, and here is a typical x-ray that I see. So there's the apophysis that is yet to fuse, that's pretty normal. Sometimes you'll even see some soft tissue swelling, which you can see there, but what you don't want to see is a lot of separation here, or anything that's kind of more extending into, kind of further into that growth plate, because then you do worry about the risk of possible avulsion down the road with like one wrong step. So again, also another example, imaging, sometimes you can get away with just an x-ray lateral. Usually I'll get an AP lab though, just to make sure that there's nothing else that could be missing. Some other things on your differential that you really don't want to miss, I may just do sending Larsen-Johansson just because it relates to osculator so much. Treatment is usually just activity modification. Sometimes I'll allow the athlete to play, but just really scale back or dial back on their jumping and specific tasks that are really flaring them up. Sometimes I'll do patellar strapping and different braces, but not always. Oftentimes these kids are weak in the hips and glutes, and so I get them into some physical therapy, either formally or providing just some basic exercises to start, and they usually do really well. And that is an osteochondroma. Okay, one more. Sending Larsen-Johansson, this is at located an apophysitis of the inferior pole of the patella, so it's a different location. Usually praying localized to the lower pole, and sometimes they're swelling, not always swelling. Imaging, you can do an ultrasound. So here is a tibial tubercle, tibial tuberosity patella, and there is kind of the area of the inflammation, and that's extra little ossification center there. Usually you'll see a nice clean patellar tendon and maybe some mild swelling, but usually not a significant amount of tendinosis, usually not at all. So treatment is very similar as far as activity modification, similar to Oshkosh ladders. So for the sake of time, I'm going to just skip these last two and finish on these two slides as far as youth sports specialization and safety recommendations. I think really a big takeaway, and I know this is really small, but this is from at your own risk.org. I believe this is NATA, National Athletic Trainers Association, put this together. I'm really encouraging delay in specialization of a single sport as long as possible. Having athletes play on one team at a time, surprising how often they are not, really playing that same sport less than eight months out of a year, with no more hours per week than age in years, two days of rest per week, really can't emphasize sleep enough, and then a rest and recovery time organized with some sport participation, time from organized sport participation. So really dedicated recovery and respect that. So let's go to Q&A. All right, I think we have a handful of questions here. I know I personally am still processing this, that I'm not going to be the next LeBron. That was kind of cold. I'm having a bit of a crisis now. So one question here, one of the ways that children differ from adults is their primary locus of influence. So this is kind of a question for me that I think might be relevant. So adult athletes can primarily have an internal motivation, but children can have like an internal or an external pressure, you know? So any tips on bedside approach to preventing overuse injuries when a parent is the one that's pushing the training regimen? Yeah, so I think I really try to, and this is a challenge as far as kind of bedside approach, to speak to the athlete. And you'll have the parent try and speak over, and that's usually for me kind of a red flag, to kind of get to the motivation. So you kind of start to ask the why. So what do you enjoy about your sport? How long have you been playing the sport? And you can usually get gauge if the athlete, like why their participation in the sport is related to because they think it's fun versus some other other reason. And if that is the case, I think then I kind of step back and do this like a bigger education on kind of simplifying some of the things that I had spoken about earlier, including overall just risk. And usually when I when I use the word burnout and injury risk and the injury risk with early specialization and high intense volume or training, usually the parents start to get more concerned and sometimes it starts to click and process. So it's really kind of finding what their, even what the parents motivator is. I mean if they want their kids to be a lifelong athlete, which could be in a very competitive sense or not, they need to make the changes now. And sometimes that's enough for them to listen to the rest and activity modifications and some of the guidance that this provides. And sometimes I do refer them to certain websites that can go into greater detail specifically about their their sports, like even just giving them this type of handout too. Okay, that's very helpful. Thank you. So just kind of taking the long view. A couple of the questions from the chat over here. Pitch count versus innings. Any thought on that? Yeah, I think pitch count is easier because innings are going to be highly variable. So I think that's probably more easily studied too. So based on on the research that's out there, pitch counts has kind of been what people have relied on. What I was saying is sometimes what's not factored in is, okay, they did a great job, they're really religious with their pitch counts, but then they're doing other overhead throwing like throughout practice and all that adds up. So I'm really kind of factoring in all the other aspects of practice that could be also contributing to overall volume and accumulation of load. So it's all about load management and body development and making sure that the body has developed enough to handle the load that the body that you're subjecting that joint to. Okay, we're running up against the hour here, but we have a couple maybe we can do rapid-fire, is that all right? Yeah. All right, question about softball. Softball pitch counts, is there a standard? Is there no standard? Are there standards being developed? Yeah, that's a good question. I'll have to get back to you. I think it's probably more related to just no standard because not good enough research, but I think I agree with you that there should be some, there just needs to be more structure and guidelines, but like in gymnastics, in softball, and some of these other sports, whether it's even just even in running, like what, is it mileage, is it hours, is it a combination of those with these younger kids because especially some of these kids love to do their sport and they will go out there and play until the sun goes down, until they get like pulled back in, and we need to find ways to kind of channel that energy in a more positive way. So I agree with you. Oh, great. Age range of the majority of patients you see in your practice, do peds, sports meds, populations have a different need than adults, or is it, I know you said you kind of emphasized that kids are not just small adults, but kind of grand scale? Yeah, so I see age eight and up. I don't have an age cap, but I would say most of my age range is probably like 10 to 12 to 17, 18, and I do see some acute fractures, so kind of non-operative management of fractures and concussions to kind of fill in some of my clinic, and then I see overused injuries, a lot of kind of running related, and then I also do some sports biomechanics. I think depending on if you are in an area with a lot of high schools, and there is a dent, it's a population dense area, there is a high demand for that type of profession. I do see a lot of, sometimes peds, sports will do a combination of adults and peds, which is totally fine, especially in a smaller town. I think that would be more manageable and probably a more robust practice, and it's totally doable, especially if you think a small town, I mean you're kind of really targeting kind of all certain, all age groups, and it's kind of fun to have a family come in and you're just treated the mom for her knee pain and then you see the daughter for her ankle sprain. Yeah, no, that's great. This is a question I really like from Megan Caballero. This is a kind of systemic thinking, right? So you've got coaches that aren't necessarily in the room, in the clinic room with you, but they have a huge influence on, you know, things like overuse injuries and that sort of thing. How do you target these people? How do you educate these people? Yeah, so there is the Positive Coaching Alliance, which is pretty well known, at least in California, and I think a lot of the coaches are members of that. So, I mean, I agree with you. It's hard to target these coaches, these trainers, who are interacting and engaging with these athletes, and I don't really think it's their job to customize every training plan to an athlete's level of development, but I think it's important to make sure that we're all on the same page as far as, hey, you guys should be doing a dynamic warm-up, ideally FIFA 11 plus before soccer. Hey, you should be doing an active recovery. You need to think about pre- and post-race snacks. So there are some fundamental knowledge, and I think Positive Coaching Alliance, so kind of targeting certain organizations and coaching groups. Other ways is through, like within Stanford, we have the Young Athletes Academy, which primarily is related to relationships with different high schools, and so you have an athletic trainer at a high school, if you can push some good information or even give, I mean, this is a great example, like giving a webinar where all these coaches can log in and get some basic information. If I take this talk and, I mean, remove all the specific injuries and really just talk about the stats on injury risk and sports specialization, sometimes that piece can finally click because coaches are coming from a lot of different backgrounds. Some of them are parents. Some of them have been coaching for 20 plus years and they don't like change, so if you can say, if you can find the carrot or the incentive that keeps them under, helps them understand that this is going to help their athletes perform better and stay on the field, that can be incredibly helpful. Again, like the parents, the what's in it for me approach, I like it. Last question, pediatric athletes with asthma, any thoughts on that? Yeah, so oftentimes, I mean, I haven't seen a ton of, maybe it's just kind of the area that I'm in, or maybe they're seeing the Palm team. I think it's important that the pediatric athlete who comes in with asthma has a really good understanding of how to manage their asthma, that they're not overusing any of their inhalers, that they have the right dose, that they're always prepared, and that that's communicated to their coach, their athletic trainer, and so that there are no really scary episodes that happen on a field because there's a lack of education. So I think communication, education, and preparedness, and I think we can all talk about the importance of preparedness in this time of a pandemic, are probably the easiest ways to get started with that kid, but also understanding that that may evolve as they get older, and they may grow out of that level of severity of asthma, but it's a good question. Perfect, thank you so much. I think we're gonna wrap it up. Again, Dr. Krause, thank you so much for joining us, it's been fantastic. Thank you, thanks for this opportunity. No, absolutely, the pleasure was ours, fantastic lecture, and again, for anybody who is here, who wants to share this with their colleagues, or who maybe didn't get to see the whole thing, these are up on the website. You can watch them, the links are there at physiatry.org slash webinars. Again, there's Dr. Krause's Twitter handle, mine, and AAP. Again, thank you, Dr. Krause, we appreciate you taking the time. Thank you, have a great rest of your day, bye. Thanks, you too.

overuse injuries

pediatric athletes

Little League shoulder

gymnast wrist

Osgood-Schlatter syndrome

preventing overuse injuries

delaying specialization

injury prevention

personalized care

educating coaches and parents