The Pediatric Athlete
Mininder Kocher, Rachael Tucker, and Patrick Siparsky
In This Chapter
Epidemiology Exercise physiology
Psychosocial aspects of sports participation Nutrition
Performance enhancing substances Arthroscopy
Over the past 30 years, there has been a significant increase in the number of children and adolescents participating in physical activity and team sports, with the largest increase among adolescent females.1 The overall trend has seen a shift from the largely unstructured, unsupervised "free play" of the early 20th century to the evolution of organized and highly structured youth sports activities.2 It is estimated that at present as many as 30 million children and adolescents participate in organized sport in the United States. In 1995, reports indicated that 15 million 5- to 14-year-olds played baseball in the United States.3 The Youth Risk Behavior Survey (YRBS) was a large population-based study performed throughout the 1990s enabling accurate assessment of the emerging trends in youth sports participation. Results from the 1997 survey reported that 62% of U.S. high school students participated in one or more sports teams, with the majority playing in a combination of both school and nonschool teams.4
The YRBS study highlighted a number of significant demographic differences when results were compared for age, gender, and ethnicity. Although the number of women participating in sports teams has increased fivefold over the past 30 years, a disparity continues to exist between genders according to the 1997 YRBS study.1 While almost 70% of male high school students participate in sports, only 53% of similarly aged females exhibit the same level of sporting interest.1,4 This gender disparity was even more dramatic among ethnic minorities, with only 40% of Hispanic and African-American females participating compared to 62% and 71% of males, respectively.4
Furthermore, progression into adolescence was also associated with a reduction in the involvement of both males and females in vigorous sporting activities.1,4 For males, there was a reduction in vigorous exercise participation from 81% in grade 9 to only 67% by grade 12.1 Vigorous exercise was defined as activity causing shortness of breath, lasting at least 20 minutes, 3 days per week.1 As expected, this trend was even greater in females with 61% of female ninth graders participating in vigorous exercise compared to only 41% by 12th grade.1
The growth and increasing popularity of school and community youth sports programs has become an integral part of American youth culture that has the potential to benefit the long-term physical and psychosocial health of those children and adolescents who participate.4
Increased youth participation in sports and physical activities has resulted in an increase in sports-related injuries secondary to trauma and overuse.2 The annual rate of sports injuries within the United States is estimated at approximately three million, with as many as 70% of those resulting from youth sports activ-ities.3 The financial costs of managing these injuries in 1996 was well in excess of $1 billion.3
Pediatric sports injuries are often unique not only in terms of the underlying pathology but also the challenges in managing these injuries. Many patients participate in multiple teams during a given season; the rest periods between seasons are short, if not nonexistent, and there is increasing demand for sporting success from parents, schools, and sporting establishments.5
Pediatric sports injuries can be classified according to the age of the athlete, the type of injury, and the sport/activity responsible for an injury.6 From an epidemiology standpoint, these classifications assist in the identification of potential risk factors for injury and the implementation of prevention strategies and rehabilitation plans that are appropriate for the age of the patient and the sport they play.
Several studies have identified a correlation between increased risk of sports-related injury and increased age of the pediatric athlete.6 A number of explanations to explain these findings have
• Serious injuries are being seen with increased frequency in the pediatric athlete.
• The pediatric athlete differs from the adult athlete biologically, physiologically, and psychologically.
• Injury patterns in the pediatric athlete are age dependent and sport specific.
• Injury types include acute traumatic injuries and chronic overuse injuries.
• This chapter provides overviews of general issues of pediatric sports injury epidemiology, endurance training, flexibility, strength training, thermoregulation, psychology, nutrition, and performance-enhancing agents. In addition, common pediatric sports injuries are addressed by anatomic region.
been postulated. These include greater opportunity for injury in the adolescent athlete due to longer game times and more frequent and intense practices.6 The provision of medical assistance at many high school and college games allows for greater reporting of injuries.6 It appears that anatomic factors such as the increased size of the athletes and the resultant increased force and speed of collisions play an insignificant role, as the same trend was noted for both contact and noncontact sports.6
Sports injuries can be broadly divided into acute traumatic and overuse type injuries according to their pathophysiology.6 Whereas many acute traumatic injuries are the result of random events, overuse injuries are often the result of entrenched training errors and therefore have greater potential for prevention.6 The difficulty lies in identifying these overuse injuries as initially they are only subtly disabling when compared to an immediate fall to the ground after a sprain.
It is important that an injury be viewed in context of the sport in which it occurred as an injury that may be functionally disabling for one sport may have no relevance in another sport.6 Furthermore, it is important that physicians recognize that time lost from sports participation is often more of a concern to athletes and their coaches than the nature of the injury itself.6 These perceived differences in injury severity will inevitably impact management programs.
Among school athletes, football has the highest rate of injury, with wrestling not far behind.3 The rate of injury in both males and females at high school and college level are comparable with the exception of knee injuries, which are slightly greater in females at a college level.7 Fortunately, fatal sports injuries are rare. A study conducted by Mueller et al8 reported 160 non-traumatic deaths in high school and college athletes in the United States between 1983 and 1993, with the primary cause being cardiac death and only a small number of heat-related injuries. They also reported 53 traumatic deaths from 1982 to 1992 in football resulting primarily from head and neck trauma.8
The increased popularity of endurance sports such as swimming, running, rowing, and cycling among children and adolescents has heightened awareness of aerobic training as a means of maximizing performance.9,10 The beneficial effect of aerobic training in adults is now well established, with increases in maximal oxygen uptake (VO2max) of up to 15% to 20% reported in the literature.10 The ability to enhance the aerobic capacity of children and adolescents through endurance training remains controversial, however, as many of the studies to date have been methodically flawed and largely neglected adolescents.9-11
While there are several physiologic parameters by which to measure aerobic fitness, maximal oxygen uptake (VO2max) is the most commonly used in studies involving adult endurance.9,10 The usefulness of this parameter in children was questioned as the majority of children fail to ever reach the plateau consistent with maximal oxygen uptake.9,10 As a result, VO2max has been replaced with peak VO2 in pediatric endurance studies, which instead measure the highest VO2 level achieved before the point of voluntary exhaustion.9,10
Despite the traditional view that prepubescent children are incapable of improving their aerobic capacity through endurance training, evidence is now emerging in the literature to the con-trary.9,10 A review of the 22 studies by Baquet et al9 demonstrated that a 5% to 6% increase in peak VO2 among both children and adolescents is possible with appropriate aerobic training.9 The ability to achieve these increases is influenced by several factors including baseline peak VO2 levels, program design, maturity level, and genetics.9,10
The role of pubertal status on a child's ability to enhance aerobic capacity through endurance training remains unclear due to a lack of quality longitudinal data.9,10 Early research indicated that for the same relative training intensity, greater gains in peak VO2 were demonstrated for circumpubertal relative to prepubertal subjects.9,10 Two theories have been used to explain this. First, a so-called maturational threshold below which training-induced adaptations in aerobic fitness were physiologically limited and, second, the greater level of habitual activity among children maintained their VO2 closer of its maximum potential making additional increases in peak VO2 more difficult to achieve.9,10 Though limited, evidence is slowly emerging to contradict these theories as we gain a better understanding of the role of genetic, environmental, and endocrine influences.9-11 High-quality longitudinal studies that document not only chronologic age but also maturity status are essential.10
Designing a program that incorporates appropriate levels of training duration, frequency, and intensity is essential to achieving the desired increase in aerobic capacity.9-11 The literature review of Baquet et al9 found that three to four sessions per week, lasting 30 to 60 minutes were optimal. Interestingly, no clear relationship was found between the length of training program and peak VO2 improvement.9 Training intensity is generally defined in terms of the percentage of maximal heart rate (% HRmax).9,10 Several studies have confirmed that a heart rate that exceeds 80% of maximum is required to obtain significant increases in peak VO2.9
Comparison between continuous and interval training and their effect on peak VO2 is limited to prepubertal children.9,11 Nine of the 16 studies reviewed by Baquet et al9 demonstrated a significant increase in peak VO2 after continuous training. However, only 3 of the 16 studies showed improvement when the heart rate was less than or equal to 80% of the maximum.9 The implementation of continuous training among children poses difficulties with regards to compliance and motivation.11 Interval training is not only easier to put into practice but has more consistently positive results. Programs that combine continuous and intermittent exercises make results difficult to interpret.9
The increasingly competitive nature of sports has resulted in a reluctance by athletes to take adequate breaks from training and performing.12 The damaging effects of prolonged endurance training on skeletal muscle and function are well documented in the literature as is the huge capacity that human skeletal muscle has for repair and adaptation, given adequate recovery time.12 A study by Grobler et al12 demonstrated that although minor exercise-induced muscle damage is a precursor for adaptation, the reparative capacity of skeletal muscle is limited and the cumulative effects of repetitive trauma and injury to skeletal muscle may lead to reduced performance, especially in long distance runners. Further research is needed to investigate the limits of skeletal muscle regenerative capacity after chronic injury.12
Extremes of joint and ligament laxity have important implications for the pediatric athlete due to the increased risk of both acute traumatic and overuse type sporting injuries in addition to a number of degenerative orthopedic conditions, many of which have long-term implications for sports participation and performance.13
Childhood is associated with a gradual reduction in flexibility with the greatest loss occurring around puberty as a result of a growth-induced muscle-tendon imbalance.14 This loss of flexibility is less pronounced in females.14 Excessive tightness during this time of rapid growth is thought to play a major role in both acute and overuse type injuries affecting, in particular, the lower back, pelvis, and knee.13 Slight improvements in flexibility are observed after the pubertal growth spurt in both males and females through early adulthood at which point it plateaus and then starts to decline once again.14
While only 4% to 7% of the general population meet all criteria for generalized ligament laxity, evaluation of flexibility still remains an essential component of the clinical assessment of a young athlete as it enables identification of those individuals at increased risk in addition to providing invaluable information for injury prevention and rehabilitation programs.13,15 Studies performed by Marshall and his colleagues in 1980 demonstrated that increased flexibility was associated with a greater risk of sports-related injuries, particularly in those requiring rapid change of direction or acceleration.13
Although several instrumented tests are available to test the flexibility of individual joints, it is the use of simple screening tests such as the modified Marshall test devised in 1978 that are more commonly used as a routine part of the clinical assessment of the young athlete.13 By measuring thumb to forearm apposition, the modified Marshall test can quickly identify extremes of flexibility that warrant further, more in-depth investigation and assessment relevant to their given sporting interest.13
Traditionally, strength training was discouraged among the pedi-atric population due to the perceived risk of growth disturbances and other injuries.16 Research over the past 20 years, however, has demonstrated that not only can strength training be a safe and effective component of any comprehensive fitness program, but it can also provide clear health benefits to the pediatric age group.16,17 These benefits include improved athletic performance as a result of increased coordination, muscle strength, and power in addition to enhancement of long-term health due to increased cardiorespiratory fitness, reduced risk of injury, improved bone mineral density, and blood lipid profile.16-18
Research shows that expertly tailored strength training programs in children and adolescents are associated with increased muscle strength and performance advantages in sports such as football and weight lifting.18 Increases in strength of 50% to 65% above baseline have been reported in the prepubescent athlete over a 2- to 3-month training period.19 Interestingly, in the preadolescent child, however, this increased strength occurs in the absence of muscle hypertrophy, highlighting the role of neu-rogenic adaptation as the likely cause. Neurogenic adaptation refers to the recruitment of increased motor neurons that can fire with each muscle contraction.18 Moreover, the loss of benefits after the program is discontinued for 6 weeks provides further evidence in support of this hypothesis.16 In contrast, strength training during and after puberty is further enhanced by the hormonally induced increase in muscle growth that occurs in both males and females.18
Although the risk of injury associated with strength training is real, research shows that it is no greater than in any other sport when adult supervision is available to ensure that proper technique and safety precautions are taken.16,18 Data obtained by the National Electronic Injury Surveillance System between
1991 and 1996 estimated that strength training was responsible for more than 20,000 injuries annually in the under 21-year-old age group.20 The usefulness of these results is limited, however, by the lack of distinction between competitive and recreational injuries or comment regarding the quality of the equipment being used or the presence of adult supervision.18 Of note, 40% to 70% of those injuries were attributable to muscle strains, primarily within the lumbar area.18 Case reports indicate that children and adolescents participating in strength training are at increased risk of specific lumbar injuries including herniated intervertebral disks, paraspinous muscle sprains, spondylolisthe-sis, and pars interarticularis stress fractures.16
Heat-related illnesses are preventable.21 However, heat stroke remains the third most common cause of exercise-related death among high school athletes in the United States, after head injuries and cardiac disorders.22
There are several physiologic characteristics unique to the pediatric population that contribute to the thermoregulatory disadvantage that they face in extreme climatic conditions including increased surface area-to-body mass ratio, reduced sweating capacity, greater generation of metabolic heat per mass unit, and a slower rate of heat acclimatization.21,23 A large surface area-to-mass ratio is advantageous in mild to moderate climates due to the increased convective surface that it provides.22 In hot humid weather, however, this provides a larger area for heat influx, thereby raising the core temperature and increasing the risk of heat-induced illnesses.22 Conversely, in cold climates, enhanced metabolic heat production and cutaneous vasoconstriction are often insufficient to overcome the heat lost from their vast surface area, particularly in cold water.24
Sweat glands play a central role in the pediatric athlete's ability to thermoregulate. By 3 years of age, the number of sweat glands that a person will have is fixed.22 Despite having a greater density of sweat glands per skin area than adults, the sweating capacity in children is restricted due to a lower sweating rate and a higher sweating threshold.25 As a result, their ability to dissipate body heat by evaporation is reduced until the transition is made to an adult sweating pattern in late puberty.21,23
The reluctance of children to drink during prolonged exercise further exacerbates this thermoregulatory disadvantage.26 The American Academy of Pediatrics recommends prehydration in addition to enforced periodic drinking during the course of prolonged exercise.21 Although water is readily available, flavored drinks are often easier for children to tolerate.21 Moreover, as the risk of dehydration is even greater in children with certain diseases or conditions such as cystic fibrosis, diabetes, and anorexia, the need for optimal fluid intake during exercise is essential.21
PSYCHOSOCIAL ASPECTS OF SPORTS PARTICIPATION
Participation in sports activity is associated with a large number of health benefits that can influence both physical and psychosocial well-being. The social interaction associated with sports participation is instrumental in a child's psychosocial development including character development, self-discipline, emotion control, cooperation, empathy of others, and leadership skills.25 The acquisition of new skills aids in building confidence and self-esteem.25 It also allows children to experiment with success and failure in a low-risk environment.27
The YRBS study mentioned earlier in this chapter was a nationally representative study conducted throughout the 1990s by the Centers for Disease Control and Prevention. It evaluated the new trends in sports participation with particular focus on its effect on health behaviors.4 It found a strong positive trend between sports participation and several types of positive health behaviors in both white males and females, including consumption of fruit and vegetables as part of a healthy diet as well as reduced levels of smoking or illegal drug use and a reduced risk of suicide.4 This trend was not found among ethnic minorities, and, in fact, among Hispanics and African Americans, the risk of negative health behaviors actually increased with sports participation.4
Knowledge of cognitive and motor developmental milestones as well as the factors that motivate children and adolescents to participate in sports is essential when designing sports activities that are both rewarding and beneficial.24,27 Motor development is a sequential process like any other developmental milestone, and the rate of progression varies between children.28 Participation in most sports require fundamental motor skills including kicking, throwing, running, jumping, and catching.28 Most children will acquire these skills through informal play, but mastery often requires more formal instruction and repetition.28 Although this process of acquisition and mastery can potentially be accelerated through intensive instruction and practice, research shows that it rarely speeds up motor development or leads to enhanced athletic performance.28
The principle motivating factors for young children to participate in sports activities are fun and enjoyment.25 For an activity to be viewed as enjoyable, there must be a certain level of excitement but ultimately a sense of personal achievement associated with the improvement or mastery of specific skills.25 We must acknowledge that although virtually all children have the ability to acquire new motor skills, the ease of acquisition and degree of mastery may vary among children.27 Research has shown that children who feel less competent with one particular skill will be less likely to continue with that sport in the long term.27 Therefore, it is important that young children are exposed to a range of sports that challenge and enable them to acquire a variety of fundamental motor skills.27
Progression into adolescence is not only associated with a number of physical changes resulting from the pubertal growth spurt but also a shift in the motivational factors influencing sports participation.25,27,29 Cognitive and motor development is now sufficient to allow the incorporation of strategy into sports such as football or basketball.28 The need for fun and excitement is overtaken by social factors such as interaction with friends and physical appearance, although mastery of skills still remains important.25,28 Differing rates of progression through puberty can result in inequality within and between genders.28 Those who experience earlier growth spurts may be temporarily taller, heavier, and stronger, which often leads to unrealistic expectations due to the erroneous conclusion that they are destined to become better athletes than their less mature peers.28
The level of adult involvement has increased significantly with the evolution of organized sports. Although the traditional role of supervisor still exists, the nature of adult involvement in youth sports has also evolved. An increased level of sophistication has developed due to the advent of specialized coaches, sports psychologists, nutritionists, and so on, all of which undoubtedly have an impact on the psychosocial development of the young athlete.
Adults are vital for the enforcement of rules and the creation of a safe, controlled environment in which to impart their knowledge and assist children and adolescents in the acquisition of new skills and development of appropriate attitudes toward sports.27,28 Their involvement in sports activities can also have a detrimental impact on psychosocial development through the expression of negative and unsportsman-like behavior, negative reinforcement, and the enforcement of demands and expectations that exceed the child's abilities.25,27
In the early years of life, parental influence is instrumental in the development of lifelong core values and attitudes.25 By 12 years of age, a child's attitudes toward winning are already well established and often directly reflect the values held by their parents.25 These values and attitudes are often acquired through observation of parental behavior, and although extreme parental behavior is rare, the use of negative comments or reinforcements were negative, of which the majority were corrective in nature.25 Variation was found between sporting codes with the greatest incidence among soccer and rugby players.25 Children of relaxed and supportive parents who positively reinforce their child's performance are not only more self-confident but are more likely to be successful athletes.25,27
As the child progresses to adolescence, the role of parents starts to diminish as the role of the coach increases.25 Coaches, through their provision of feedback and reinforcement, have a great impact on the confidence and self-perception of the young athlete.25
The increasingly competitive nature of sports has led to a shift in goals that are largely adult oriented and focused on winning at any cost.3 Competitive behaviors start to emerge at 3 to 4 years of age, and the potential exists to either enhance or exploit this trait through the use of sports.25 The danger arises when the demands and expectations placed on young athletes by their parents or coaches exceed their abilities.25 This can result in the development of unhealthy competitive behavior with serious antisocial interpersonal consequences or even problems such as burnout and chronic stress.25
The nutritional concerns of the pediatric athlete are complex and unique from those of their adult counterparts as it involves the interaction between normal growth and development and the optimization of athletic performance.30,31
During the 1980s, there was an erroneous belief that leanness correlated with enhanced athletic performance as a result of studies that demonstrated a positive correlation between running performance and percentage of body fat.32 Not only is there a lack of scientific evidence to prove that reducing weight alone will improve athletic performance, but, in fact, deliberate caloric restriction in children and adolescents is likely to have detrimental implications, not only for their athletic performance but also their growth and development and general health.32 Unfortunately, these erroneous beliefs are perpetuated today by coaches with little or usually no training in athlete nutrition.32 In the case of school-based coaches, their employment is often dependent on the success of their teams and controlling an athlete's weight is often the easiest parameter by which a coach can try and ensure athletic success.32 In fact, by reducing the dietary fat contribution, it is possible that essential sources of protein, as well as minerals and vitamins such as calcium, magnesium iron, zinc, and B12 and other fat-soluble vitamins, which are critical for growth, may be also eliminated from the diet.31 Diet should play an integral role in any comprehensive training program with specific attention to energy requirement including appropriate combinations of protein, carbohydrates, fat, vitamins, and minerals.31 These requirements are often subject to large interindividual variation, not only between sporting codes but often within a given sport.31
Results from the YRBS study in the 1990s confirmed that children and adolescents involved in regular sporting activities not only maintain healthier diets consisting of greater amounts of fruit and vegetables but are often less concerned with caloric intake and energy balance.33 For young athletes, the energy requirements must be sufficient to ensure normal growth and development but must also provide the additional calories to account for physical training.31 The recommendations for estimated energy requirements in young athletes set by the Food and Nutrition Board are based on age, height, weight, and physical activity classification.31
Protein is an essential part of a young athlete's diet as it is required to build amino acids necessary for the growth and development of lean body mass and healthy bones but also as a alternative source of energy to carbohydrates.31 There is a lack of research regarding the recommended daily protein intake for young athletes.31 For adults, 12% to 15% of their dietary energy should come from protein; however, in children, the demands are greater, especially when involved in competitive, intensive training during periods of rapid growth.31
Research shows that children and adolescents up to the age of 13 to 15 years have restricted glycolytic capacity, which questions the role of high carbohydrate diets.31 Regardless, nutritionists recommend that at least 50% of a young athlete's diet consist of carbohydrate due to the importance of this energy source during high-intensity training.32 There remains a significant amount of research needed with regards to optimal nutrition of the pediatric athlete for enhancing performance and maximizing recovery.
The use of performance-enhancing substances among children and adolescents is increasing as a result of media exposure, the availability of so-called natural supplements, the absence of formal drug testing in schools, and the increasingly competitive nature of youth sports.30,34 Pediatric athletes are at high risk due to increased susceptibility to societal pressures at a time when they are often dealing with complex developmental and psychosocial changes.
The term ergogenic is derived from the Greek "to make work" and refers to the inherent ability of many substances to enhance athletic power and/or endurance.34 In many cases, the ergogenic effects of a substance are actually secondary to their intended use.34 It is therefore essential that physicians dealing with athletes, especially those competing in high-level sports, have a working knowledge of substances that contain ergogenic properties, as inappropriate prescribing/counseling may result in an athlete's disqualification from a competition.35
Although a wide range of performance-enhancing substances are available in the United States, anabolic-androgenic steroids are by far the most publicized and intensely studied. Anabolic-androgenic steroids are synthetic analogues of the male hormone testosterone, and their use in the pediatric athlete for both performance and physique enhancement has been documented in the medical literature for well over 20 years.34 The use of androgenic steroids is widespread, with an estimated 4% to 12% of male adolescents and 0.5% to 2% of female adolescents using anabolic-androgenic steroids in the 1990s despite being banned by almost every major athletic governing body.35
As the name suggests, anabolic-androgenic steroids have both masculinizing and tissue-building effects, such that when used in conjunction with adequate strength training and proper diet, they have the ability to increase muscle size and strength, enabling high-intensity workouts and possibly even a reduced recovery time after workouts.34 As a result, it tends to be strength athletes (e.g., weight lifters, throwers, and football players) and those participating in sports such as swimming and running that require frequent, high-intensity workouts, who are attracted to the substance.35
Research demonstrated a significant correlation between the use of anabolic-androgenic steroids in adolescents and the abuse of other common drugs such as alcohol, tobacco, cannabis, and opioids.35
Although the perceived performance-enhancing benefits appear high, the side effects of using anabolic-androgenic steroids are extensive and often irreversible.34 In addition to personality changes and psychological problems that are associated with steroid use, premature closure of epiphyseal plates with subsequent linear growth arrest, irreversible alopecia, gynaeco-mastia, acne, and irreversible masculinization of secondary sexual characteristics in females are just a few of the more dramatic and often psychologically devastating side effects of anabolic-androgenic steroids.34
Drug testing is both time-consuming and expensive, making the widespread testing of young athletes virtually impossible.26 Despite this, many schools and youth organizations have implemented voluntary drug testing, which has a dual benefit of identifying and providing assistance for athletes with abuse problems as well as reducing the peer pressure to use drugs.24
With the introduction of the Dietary Supplement Health and Education Act in 1994, the role of the U.S. Food and Drug Administration in regulating "natural supplements" was elimi-nated.12 Since that time, "natural agents" such as creatinine, androstenedione, and DHEA have been widely accessible via health stores and the Internet.12 This accessibility results in an erroneous perception that these substances are "safe" even though the absence of regulatory control eliminates any legal requirement of manufacturers to declare all active ingredients and potential interactions and fully test their products for short-and long-term effects.24
The use of performance-enhancing drugs among athletes of any age is unethical, unhealthy, and potentially life threatening.26 As physicians, we have a responsibility to acquire and impart factual knowledge to young athletes contemplating the use of these substances. Although the effectiveness of using scare tactics that emphasize the negative effects of substance use has been questioned, there is a clear role for positive counseling with regards to healthy alternatives such as strength training and con-
ditioning, nutrition, and skill acquisition through coaching and camps.26
The use of arthroscopy in the pediatric and adolescent population has dramatically expanded over the past decade as a result of increased youth participation in sports and the subsequent rise in sports-related injuries.5 With the advent of smaller, more sophisticated arthroscopic instruments over the past decade, the major obstacle to its application in children was overcome.5 In fact, Gross36 noted that, after extensive experience, despite the difference in joint size, basic techniques of arthroscopy are largely the same in both children and adults. At present, arthroscopy is indicated in the management of severe shoulder, elbow, wrist, hip, knee, and ankle injuries in the pediatric pop-ulation.5 Advantages to arthroscopy in this population include reduced postoperative morbidity, smaller incisions, more rapid return to activities, decreased inflammatory response, and improved visualization of joint structures.5
Shoulder injuries in the pediatric athlete include acute fractures, overuse injuries such as little league shoulder (Fig. 9-1), and shoulder instability (Fig. 9-2). Most major shoulder injuries requiring arthroscopy are related to instability and can be divided into two descriptive groups: traumatic anterior instability and multidirectional instability.5,29-42
The incidence of elbow injuries continues to increase as a result of the growing popularity of youth sports. Many of the elbow injuries are repetitive, overuse type injuries, such as osteo-chondritis dissecans, which is prevalent in baseball, racket sports, and gymnastics.43 In fact, the little league elbow is now an accepted term for a common overuse injury in young throwing athletes, with etiologies including fragmented medial epi-condyle (Fig. 9-3), osteochondritis dissecans (Figs. 9-4 and 9-5), ulnar hypertrophy, and medial epicondylitis.42-45
Figure 9-1 Little league shoulder. Widening of the proximal humeral physis associated with repetitive overuse.
Figure 9-2 Traumatic anterior shoulder instability. A, Bankart lesion. B, Repair of Bankart lesion.
Figure 9-2 Traumatic anterior shoulder instability. A, Bankart lesion. B, Repair of Bankart lesion.
Wrist arthroscopy is not a commonly practiced treatment modality among pediatric and adolescent patients because many injuries achieve successful healing nonoperatively and also because of the restricted size of the joint space.45 Kocher et al46 note an increasing incidence of repetitive use type injuries such as triangular fibrocartilage injuries (Fig. 9-6) and believe arthroscopy is indicated for debridement or determination of the extent of ligamentous injury in those patients failing nonoperative therapies.47
Although hip arthroscopy is a commonly used diagnostic and treatment modality for hip pathologies in the adult population, its application in the pediatric population is only beginning to increase. Indications in the pediatric population include isolated labral tears (Fig. 9-7), loose bodies, chondral injuries, and internal derangement associated with Perthes disease and epiphyseal dysplasias.48-52 The risk of complications, although small, does exist; they include pudendal nerve irritation and recurrent injury.5
Currently, the largest application of arthroscopy in the pedi-atric and adolescent population is in the treatment of knee
Figure 9-4 Sagittal magnetic resonance imaging of the elbow demonstrating chondral defect of the capitellum associated with osteochondritis dissecans.
Figure 9-6 Ulnar styloid fracture (A) associated with a triangular fibrocartilage complex tear (B).
Figure 9-6 Ulnar styloid fracture (A) associated with a triangular fibrocartilage complex tear (B).
pathology and is directly attributable to increased athletic CONCLUSIONS activity.37 Key indications for knee arthroscopy include osteo chondritis dissecans (Figs. 9-8 and 9-9) discoid meniscus, tibial spine fractures (Figs. 9-10 and 9-11) and partial and complete anterior cruciate ligament tears.53-62
At present, the use of ankle arthroscopy in the pediatric population is restricted to a small number of conditions including osteochondritis dissecans, loose body removal, and triplane fracture repair due to technical challenges resulting from the size of the joint and the risk of neurovascular damage.36,63-66
Pediatric sports injuries are being seen with increased frequency. Just as the child is not a "little adult," the pediatric athlete is not a "little adult athlete." An understanding of the unique considerations of the pediatric athlete with respect to epidemiology, endurance, flexibility, strength, thermoregulation, psychology, and nutrition is important background knowledge. Recognition of common injury patterns of the shoulder, elbow, wrist, hip, knee, and ankle is essential to effective management.
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