Selected Issues for the Adolescent Athlete and the Team Physician: A Consensus Statement

Abstract

DEFINITION Team physicians may be called on to treat adolescent athletes, defined in this document as those in the 12- to 18-yr age range. Many are involved in school-based, intramural, or specialized sports participation and/or training, potentially resulting in injury and/or illness. Specialized treatments may be necessary due to growth and development of the adolescent. In addition, psychological factors are important factors in this age group and may play an important role in sports participation, emotional well being, and injury rehabilitation. Although many children younger than 12 yr are active in sports participation, their medical and musculoskeletal concerns are not included in the scope of this consensus statement. GOAL The goal of this document is to help the team physician improve the care of the adolescent athlete by understanding the medical, musculoskeletal, and psychological factors common in this age group. To accomplish this goal, the team physician should have knowledge of and be involved with: Musculoskeletal injuries of the adolescent athlete, specifically those to the shoulder, knee, elbow, and spine Medical conditions of the adolescent athlete, especially those pertaining to infectious diseases, concussion, and nutrition and supplementation Psychological issues related to sports specialization and overtraining SUMMARY This document provides an overview of selected medical issues that are important to team physicians who are responsible for the care and treatment of athletes. It is not intended as a standard of care and should not be interpreted as such. This document is only a guide and, as such, is of a general nature, consistent with the reasonable, objective practice of the healthcare profession. Adequate insurance should be in place to help protect the physician, the athlete, and the sponsoring organization. This statement was developed by a collaboration of six major professional associations concerned about clinical sports medicine issues; they have committed to forming an ongoing project-based alliance to bring together sports medicine organizations to best serve active people and athletes. The organizations are: American Academy of Family Physicians, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine. EXPERT PANEL Stanley A. Herring, M.D., Chair, Seattle, Washington John A. Bergfeld, M.D., Cleveland, Ohio David T. Bernhardt, M.D., Madison, Wisconsin Lori Boyajian-O'Neill, D.O., Kansas City, Missouri Andrew Gregory, M.D., Nashville, Tennessee Peter A. Indelicato, M.D., Gainesville, Florida Rebecca Jaffe, M.D., Wilmington, Delaware Susan M. Joy, M.D., Cleveland, Ohio W. Ben Kibler, M.D., Lexington, Kentucky Walter Lowe, M.D., Houston, Texas Margot Putukian, M.D., Princeton, New Jersey MUSCULOSKELETAL ISSUES The Adolescent Athlete's Shoulder Traumatic anterior shoulder instability Pathophysiology: Stability of the shoulder joint is from static (ligaments) and dynamic (muscular control) factors. Traumatic instability results from direct or indirect injury to the shoulder resulting in a subluxation/dislocation event. These injuries in the adolescent athlete are associated with a high rate of recurrence. The injury causing instability is either ligament tearing from bone or capsular injury. Dynamic muscular control is often lost with this injury and can magnify the instability. Bony injury to the glenoid and/or the humeral head may increase the severity of instability. Evaluation: History ○ The mechanism of injury may be a direct blow to the arm or an indirect injury from falling on outstretched arm. ○ Confirm the direction of subluxation/dislocation ○ Previous subluxation/dislocation episodes ○ Determine the method of reduction: spontaneous or the need for manual manipulation Determine the associated presence of symptoms and signs such as numbness and weakness Physical examination ○ Active range of motion (ROM) and strength ○ Provocative maneuvers for instability, such as apprehension and relocation ○ Neurological examination for axillary and musculocutaneous nerve injury Imaging ○ X-rays in two planes for physeal and other associated bony injuries ○ MRI with or without intra-articular contrast is the procedure of choice to better define the injury, but the indication and timing are controversial. Treatment: Initial treatment is reduction and immobilization. Early reduction on the field is desirable for pain relief and ease of reduction. Duration of immobilization and positioning in internal or external rotation is controversial. Operative versus nonoperative issues: ○ Early operative intervention with first time dislocation may be indicated. Timing of repair is controversial (immediate or at end of season). ○ Return to play (RTP) with nonoperative treatment requires resolution of pain, normal ROM and normal strength and strength balance, and resolution of neurological signs and symptoms. ○ Braces that limit ROM and rehabilitation may be helpful in allowing RTP for certain athletes, although recurrent instability may occur. Prevention: There are no specific programs proven to decrease the risk of first-time traumatic dislocations. Rehabilitation or bracing has not been proven to prevent recurrent dislocations. It is essential that the team physician: Recognize the high incidence of recurrence after initial traumatic subluxation/dislocation. Perform a history and a physical examination that can diagnose traumatic instability and associated injuries. Understand RTP issues with first-time traumatic dislocations of the shoulder. Understand initial treatment of traumatic subluxation/dislocation. It is desirable that the team physician: Be familiar with and perform reduction at the venue. Understand associated injuries such as bony Bankart and Hill-Sachs lesions and nerve injuries that may affect outcome of treatment. Understand primary factors responsible for shoulder stability. Work with the athletic care network to educate athletes, parents, and coaches regarding: ○ Risk of recurrent dislocation and the advantages and disadvantages of operative treatment at the time of first dislocation ○ Individual and sport-specific issues that may affect recurrent dislocation Nontraumatic shoulder injuries Pathophysiology: Sport-specific demands contribute to pathophysiology. Baseball data has shown: ○ Excessive throwing, measured by number of pitches per game or pitches per season, results in higher injury rates. ○ Better pitchers throw a higher number of pitches and have higher injury rates. ○ Year-round participation without rest results in higher injury rates. ○ Specialty pitches such as curve balls and sliders may play a role. Musculoskeletal deficits in ROM and strength balance occur early in intensively training adolescent athletes. This may result in biomechanical problems such as glenohumeral internal rotation deficit (GIRD), glenohumeral joint hyperangulation, and scapular dyskinesis (1,9). Epiphyseal changes may occur due to traction and rotational stresses. Alterations in these musculoskeletal and biomechanical factors may lead to a decline in performance or injury. Most injuries are the result of overuse and can be successfully treated with relative rest and rehabilitation. Other injuries such as labral tears, instability, and rotator cuff injuries may require surgical treatment. Other sports such as swimming, tennis, and have musculoskeletal and biomechanical but injury risk has not been as well Evaluation: History ○ history or other to and of ○ in the motion and in the shoulder pain occur ○ issues such as and in Physical examination ○ ROM specifically internal and external rotation ○ for labral and rotator cuff ○ for scapular motion and ○ factors related to and Imaging ○ X-rays in two planes to physeal changes of and ○ MRI with intra-articular contrast for labral and rotator cuff injuries Treatment: of sport-specific demands relative rest and biomechanical and musculoskeletal deficits rehabilitation and of labral and rotator cuff injuries that not to rehabilitation and may be for these are not to for training, or rehabilitation. Prevention: to overuse and of musculoskeletal and biomechanical factors has been to be the best Work with the athletic care network to educate athletes, parents, and coaches overuse and It is essential that the team physician: a history and physical examination for the Understand that these injuries are often a of overuse than an injury event. It is desirable that the team physician: Understand that the demands of or other and musculoskeletal and biomechanical factors can contribute to decline in performance or injury. Understand for age as a Understand that rest from and scapular and strength are the of treatment. Understand that labral lesions in this age group and should be Work with the athletic care network to educate athletes, parents, and coaches overuse and The Adolescent Athlete's pain and instability Pathophysiology: musculoskeletal, and psychological factors are associated with the of the pain is often The six major of symptoms are and is a of symptoms. The common of symptoms are or and These symptoms are in Traumatic instability may occur from an injury to the normal instability is associated with and and/or of the Evaluation: History ○ Determine was a specific injury. ○ is instability associated with the symptoms. ○ Determine and of the pain well ○ Recognize conditions may as pain ○ Determine a history of injury ○ Determine the presence of signs and symptoms. ○ factors Physical examination ○ Perform an examination of the to and stability. ○ the for and ○ for musculoskeletal and biomechanical balance, and Imaging ○ and with in at or of ○ may be in selected Treatment: Rehabilitation the primary treatment of symptoms ○ The major the and and treatments may and for pain and instability is not specific lesions are and need to be factors should be Prevention: with the proven of and Other may and and external rotator and control It is essential for the team physician a history and physical examination for the traumatic and of pain and instability. Understand that rehabilitation is the primary of treatment. It is desirable for the team physician Understand musculoskeletal and biomechanical factors symptoms. Understand and Understand the role of factors in the development and of Work with the athletic care network to educate athletes, parents, and coaches the development and of pain and instability. ligament Pathophysiology: The mechanism of injury in the is the as in with have a higher incidence of injury than their injuries in this may be spine bony as well as ligament injury has been in to of children with The presence of growth requires in treatment of injuries. Evaluation: History ○ the mechanism of injury. is or injury with a and to Physical examination ○ is to the ○ for other associated injury, instability, and injury. Imaging ○ and with in at or of ○ MRI is helpful in the of the injury as well as associated injuries such as and Treatment: Initial treatment and of especially and spine need for surgical of injuries in with growth has results as in is and bracing provides or no rehabilitation and RTP are the as Prevention: a sport-specific with these that have been to have in specific ○ control and balance, and ○ training to and sport-specific athletic programs ○ Risk ○ care of and of bracing has been to injury It is essential that the team physician: Understand the history and mechanism of injury. Perform a Understand the of the knee, especially in the adolescent. spine It is desirable that the team physician: Recognize risk of injury in adolescent and risk reduction the athletic care Understand that surgical for in the Understand the associated injuries that may or result from instability. Pathophysiology: is an potentially of bone resulting in and with or without and instability. with an and an have a for of with an have a The presence of symptoms such as or may Evaluation: History ○ is and ○ the presence of symptoms. Physical examination ○ There are no specific physical examination for although pain may be with and external rotation and of may be ○ for an Imaging ○ and with in at or of ○ MRI provides and and and Treatment: factors guide treatment and of the growth and and and stability. of with lesions and growth is with rest from should be in with lesions and in those growth symptoms nonoperative It is essential that the team physician: Be to diagnose It is desirable that the team physician: Understand the history and factors of in the Understand nonoperative and operative treatments of Work with the athletic care network to educate athletes, parents, and coaches The Adolescent Pathophysiology: with ○ the ○ in the ○ on These can from shoulder or arm and a number of Evaluation: History ○ Determine versus injury, of pain, and decline in ○ injuries in the ○ by number of pitches per game or pitches per Physical examination ○ Perform examination to of manual and nerve ○ to scapular motion and and Imaging ○ X-rays in two planes and with growth ○ MRI with intra-articular contrast is to better define injury, and and Treatment: Most injuries are the result of overuse and can be successfully treated with relative and of demands need for injuries that need for may ligament injury to treatment or lesions with symptoms. Prevention: to overuse and of musculoskeletal and biomechanical factors has been to be the best of per game and per and of pitches in Work with the athletic care network to educate athletes, parents, and coaches overuse and It is essential that the team physician: a history and physical Understand that the demands of can contribute to injuries to the and rest from is a of treatment. It is desirable that the team physician: Understand for age as a and of and of pitches Understand that factors can the injuries and musculoskeletal and biomechanical that lead to injury. Understand rehabilitation and scapular and strength are treatment Work with the athletic care network to educate athletes, parents, and coaches overuse and The Adolescent Athlete's higher of pain in than in higher of on and in than in ○ have a higher incidence of of to to to in the general may be higher in specific not risk for pain in specific in of pain is to musculoskeletal, and There may be an and/or other emotional problems and pain in should a factors and history of with a physical examination with neurological There are no primary conditions is the in adolescent to a sports medicine with The is to a the at the Sports that with rotation are associated with the of but can occur in The from to is with of is often the adolescent growth and without symptoms. Evaluation: with pain of or is by and better with rest and may have been for There are no on physical Imaging ○ is a ○ and of the spine can not improve and ○ of on or ○ can as to the of bony in active ○ MRI is not as as bone with for of early or Treatment: have been to best treatment a of is is controversial. of outcome have results RTP and bony Most with or without of bony Bony is a goal or are intervention is for a of or or with Prevention: and of training and participation in sports that and rotation and early to spine pain in adolescent may be are in occur at and Most in are than and is not as common as in symptoms or are common with and/or in with Evaluation: There are no signs and symptoms for in can with with and but can be with MRI examination is the of choice for The on MRI examination should with physical examination Treatment: in adolescent are The history of is manual and There is of of these can be as care for with In this they should be is for pain, and/or or Prevention: and rehabilitation general and as well as may improve performance and may have in from is a of the spine that and and in It is a The has not been It may be in and may be with is anterior of at in and the presence of These can affect the and/or Evaluation: for pain, and for and head The is is not neurological symptoms or signs are Treatment: The history is not well and symptoms often at the time of Sports participation is as is on the of symptoms and the of ○ than relative of and and may be ○ of to bracing should be ○ than surgical should be bracing may not be It is essential that the team physician: Understand pain is associated with a specific Understand are signs that to an Recognize as the of pain in the adolescent treatment. It is desirable that the team Understand the for and of Recognize pain can have physical and psychological a treatment for Work with the athletic care network to educate athletes, parents, and coaches pain, and ISSUES The Adolescent and is by the is and can occur of the by of symptoms of is and is the common of Other symptoms may and can and is necessary treatment is is and the physical examination is in Evaluation: an and relative with a high of is on for with a high rate in the first of the illness. of a for should be in certain In the of by is should be Treatment: is a that is is controversial and without proven such as has not been to severity or of symptoms. is treated with other than is is in the presence of or may result in and/or and/or and traumatic can occur in of Although and are in than physical without and their role in and RTP is Prevention: and can be by such as and of related to ○ Although may occur with are ○ There is a of RTP ○ clinical symptoms have to after is sports It is essential that the team physician The of is on clinical and is that may affect to to and In of is clinical symptoms have to after is sports It is desirable that the team physician: Understand that specific may to and and Work with the athletic care network to educate athletes, parents, and coaches and treatment. Other and is a of the common that not to the to is in the athletic Many are and with and as or are to and may a of and Evaluation: and of Determine of Treatment: and should be and provides treatment in of should be to help direct specific treatment. treatment ○ Initial treatment is on ○ is defined by ○ treatment is controversial. should not be ○ to ○ of on growth and is a for in adolescent athletes. with active lesions should not be to these are a is not should be is and specific are The a of of RTP for sports for are and infectious Prevention: and with and after and of and of and with a standard of and of the is controversial. Work with the athletic care network to lesions and early especially with primary by in of to by is on an Risk of recurrence to such as and Evaluation: Recognize is ○ of choice is in ○ for presence of to Treatment: the first of primary with should be treated and not to for a of Prevention: treatment for with a history of or an has of an the not with active lesions to It is essential for the team physician Recognize and of to treatment. Recognize to treatment and to decrease of the of sports about these infectious It is desirable for the team physician Understand as to and for sports for and other to help prevent Although is not by this are other that may be Work with the athletic care network to educate athletes, parents, and coaches the of infectious in The Adolescent and is a of the the only is of with a of is in and but can occur in Pathophysiology: ○ and ○ and ○ and in Evaluation: for symptoms of and/or with to occur after Determine history or history of or Physical is normal may be symptoms of are of should be to the may and be ○ of with with Treatment: are the of choice for and are ○ protect from symptoms for at ○ are with of ○ of either or may these to treat and Adequate may a in athletes, symptoms for of the adolescent athlete, the and the specific have the of Prevention: treatment. with It is essential that the team physician: Recognize and be to treat on the It is desirable that the team physician: Understand the of Understand for athletes. Recognize and be to educate athlete as to this and treatment Work with the athletic care network athletes, parents, and coaches on the and of The Adolescent and and The adolescent ○ of at for 12- to ○ of problems ○ in in sports Evaluation: and training ○ Determine and ○ for medical ○ for medical and and in sports should have of and In be at for in sports should be for the athlete Treatment: Determine is and/or a goal for should no than of their per nutrition and and other the athlete, and as the athlete at risk of the intervention Prevention: to in primary and of should be in early for issues specific to athletes. Work with the athletic care network to educate athletes, parents, and coaches issues at the time of the physical examination and other who related to strength and who related to and Evaluation: and training Determine and by history for for performance Treatment: Determine is and/or a goal for should no than of their per nutrition and and Prevention: and Work with the athletic care network to educate athletes, parents, and coaches issues at the time of the and other in adolescent ○ is at and is higher in than in ○ in this age group and and other ○ of and ○ than of in high ○ who are to ○ The common of are and supplementation may be for at risk for and athletes. Evaluation: about of and other ○ risk adolescent is other ○ a to about sports participation and and from indirect to direct for in athletes. Treatment: for performance in adolescent athletes. for performance training, and sports the of and about and issues related to play and supplementation for athletes. Work with the athletic care network to educate athletes, parents, and coaches at the time of the and other Prevention: supplementation in athletes. on the risk of should be early in sports Work with the athletic care network to educate athletes, parents, and coaches at the time of the and other It is essential that the team physician: the athlete and related to nutrition and Understand that has that may affect physical and normal growth and Be of the athlete It is desirable that the team physician: and performance and ○ the of and ○ nutrition and related to strength training for the athlete who strength and ○ related to and for ○ Understand related to ○ Understand the of on normal growth and ○ Understand the on the timing of on The Adolescent and and specialization is a in the adolescent. The of data is and a is the scope of this the team physician, the are There has been an increase in the number of surgical and medical problems in the adolescent athlete the Many overuse injuries can be related to an increase in the or of practice and game participation in the adolescent. Adolescent have the for overtraining as their but may not be as to they are for number of pitches per per and are for for the of in other sports are in and early sports specialization with to the risk of overuse injuries. and are important in overuse injury. to are of or of 12 training and in sports or should be The of an increase in and of training and on the of the adolescent is of training can be in for It is essential that the team physician The of overtraining on the adolescent The adolescent and their as to It is desirable that the team physician: Understand the role of rest and in overuse injury. Understand the role of psychological as a to injury although the issues athletes, parents, and coaches the of rest and the for in in the Adolescent This issues to the adolescent and related to concussion, to traumatic injury can be defined as and neurological after a direct or indirect blow to the head or The is often and symptoms clinical symptoms a than injury, and as such, are The clinical symptoms that occur may or may not of is is common in and has been to for of injuries in high is the common for Pathophysiology: history of in is not well The deficits and problems are to those in require a to and for their to to normal than and professional athletes. has only been in younger than yr in of may be a after on the to or and Evaluation: the adolescent athlete in the as other Recognize the and signs and symptoms of and problems may with and and is as a clinical and provides objective of may be resolution of symptoms. is normal changes in with growth and be with to be in place for and may occur. with be for or need to be Return to (RTP) ○ in allowing the adolescent athlete to ○ The athlete be at rest and with to ○ RTP in the adolescent should not be with initial symptoms and of Other risk factors such as younger age and history be ○ The of is to athlete of ○ symptoms ○ a of other factors RTP age of athlete, history and severity of in and injury, and ○ a of ○ the athlete to they with sport-specific without risk for practice with risk for practice with risk for and ○ may be and understanding to help guide RTP Prevention: ○ can prevent these should be well and for the ○ and not and potentially risk for ○ decrease risk for and injury, but their role in is ○ important intervention in as well as other injuries. Although may for is It is essential that the team physician: the athlete, and signs of with for not with signs of symptoms of to to Understand that the the adolescent and are not Understand that the adolescent requires a time to than the in on an It is desirable that the team physician: a and medical for the and of that is with athletic parents, and athletes. This is especially important in no medical are at or with other of the athletic care network the and RTP for the Work with the athletic care network to educate athletes, parents, and coaches regarding: ○ The of and these injuries are in the younger athlete ○ The risk of head injury, injury, and risk of injury ○ or other and

The authors' abstract, as published at the source. Medicine & Science in Sports & Exercise, 2008 · DOI ↗