Ask the Expert: Dr. Daniel Green, Orthopedic Surgeon, Answers Your Questions About Pediatric Sports Medicine

by Dr. Daniel Green
Green

Q1. What are your thoughts on kids specializing in one sport at an early age and how much more at risk are they for repetitive use injuries from the demands of one sport – especially when they are one-sided sports?
We certainly think there’s an increase of overuse in children who play the same sport all year round. There’s anecdotal evidence to support this too. Some of the major league baseball scouts have noticed that children are less likely to make it to the majors if they are from a warm climate where they are able to pitch all year round. It seems that when the pitchers from the North and Northeast make it to the majors, their elbows and shoulders hold up better. Additionally, we’re noticing overuse injuries such as stress fractures and spondylolysis in runners who run year-round and tennis players who play all year. In general, we think that cross-training or doing more than one different sport has some protective and beneficial advantage to kids.

Q2. My daughter plays on the varsity soccer team at her high school and practices four hours a day, five days a week. A couple of her teammates have suffered ACL tears. I thought this was something only pros had to worry about. What are the dangers and implications of tearing an ACL at such a young age?
Any high end athletes –especially in sports like soccer, lacrosse or football – are susceptible to having their anterior cruciate ligament tear (versus a kid who does not get off the couch). We believe that female athletes have a higher rate of ACL injuries in sports like basketball and soccer. This doesn’t mean that we’re asking young athletes to avoid the sports they love, but we are trying to focus on ACL prevention programs, like our ACL Injury Prevention Program here at HSS. It has been proven that young athletes who participate in simple exercise programs designed to promote flexibility, build agility and strengthen the core develop skills and techniques that have been proven to reduce ACL tears. A lot of our athletes end up having an injury like an ACL tear because they try to compete in their sport too soon after recovering from an injury. If one part of your body has not recovered from injury – be it your legs, hips, back or anything else—it often means you cannot fully protect yourself and leaves you more vulnerable to injury.

Q3. My son suffered a tri-plane ankle fracture playing football earlier this year. The doctor said we could opt for surgery or try a more conservative approach. We chose the conservative approach. What’s the risk that there might be damage to his growth plate?
Most patients with tri-plane fractures have a crack that goes into their ankle joint and also in a different plane through their growth plate. Most of these fractures require surgery because more than one or two millimeters of gap at the fracture site can lead to arthritis in the ankle. We usually get a CAT scan or MRI to document the exact size amount of fracture displacement. For anything that has any significant displacement, we recommend surgery. The good news is that while tri-plane fractures only occur while a child is growing, they happen when the growth-plate is starting to close, so this fracture typically never leads to a long-term growth plate or leg length issues.

Q4. My eight-year-old is a competitive dancer and recently developed Achilles Tendonitis. Should I be concerned that she developed a sports-related injury at such a young age?
It’s unusual for an 8-year-old to develop Achilles Tendonitis, but there is a common type of heel pain found in pre-adolescent children that mimics Achilles Tendonitis. It’s called Severs Disease. This growing pain occurs as the Achilles inserts itself into the growth plate of the heel bone. During this stage, the growth plate of the heel bone can have pain and swelling in active children. It’s annoying but generally resolves itself over time with stretching exercises and symptomatic treatment like rest, an ice pack and over the counter anti-inflammatory medication. It is best to consult with your treating physician on the proper course of treatment

Q5. My son fractured his wrist playing ice hockey last season. He was treated by an orthopedist at our local hospital, and it seems like his bone healed correctly, but I’m worried that will happen again. How likely is it for him to break another bone and is there anything we can do to decrease the likelihood that another injury will happen?
Refractures of the arm in pediatric orthopedic patients can happen. The most common of refractures occur after the forearm has been broken in the middle of the forearm between the wrist and elbow. While this type of fracture might appear healed in an x-ray two months after the injury occurred and the cast is removed, there’s still at least a 5 percent chance that the arm could re-break within two years. The good news is that the most common wrist fracture is an injury to the distal radius (near the wrist), and those are very rare to refracture. Once a child’s x-rays show healing and the fracture is no longer tender, there can be a slow resumption of sports.
Remember, many children are also not getting enough vitamin D and calcium in their diets, which are both important for bone health. Children should be getting three portions of calcium-rich food per day. For example, three 8-oz. cups of milk meet the RDA for calcium. They should also have nearly 1,000 units of vitamin D per day, though this essential nutrient isn’t in most foods. Children can satisfy the daily need for vitamin D by spending time in the sun, drinking fortified milk or taking a supplement. We have observed that many young athletes who experience a refracture also have low levels of vitamin D.

Dr. Daniel Green is a pediatric orthopedic surgeon at Hospital for Special Surgery and director of the Pediatric Sports Program for the Division of Pediatric Orthopaedic Surgery. He specializes in pediatric knee surgery, scoliosis and trauma.

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The information provided in this blog by HSS and our affiliated physicians is for general informational and educational purposes, and should not be considered medical advice for any individual problem you may have. This information is not a substitute for the professional judgment of a qualified health care provider who is familiar with the unique facts about your condition and medical history. You should always consult your health care provider prior to starting any new treatment, or terminating or changing any ongoing treatment. Every post on this blog is the opinion of the author and may not reflect the official position of HSS. Please contact us if we can be helpful in answering any questions or to arrange for a visit or consult.

Comments

Heather says:

Hello! My daughter is a champion level Irish dancer. Irish dance is comparable to ballet and tap as far as activity level, but includes hitting the floor very hard with their feet over and over. with shoes with very hard soles. Her teachers would like her to take two 3 hour classes a week. Right now she takes a 1 1/2 hour class and a 2 hour class each week. The day after the 2 hour dance she has a lot of muscle pain. I am worried that two 3 hour classes is too much. I am worried about her developing bones. Older students in her school have broken feet before, but I am more worried about things like shin splints and stress fractures. She loves dance, but it is not worth risking her future health to be a little better right now. Please let me know what you think the risks are.

Thanks!

HSS on the Move says:

Hi Heather, Thanks for reaching out. We’re sorry to hear your daughter is having pain. Pediatric orthopedic surgeon Dr. Daniel Green says, “There are no hard and fast rules about how many hours a week of Irish dancing is too much. But the fact that she is having pain is concerning. We have seen many Irish dancers with stress fractures of their feet and ankles, so if the discomfort is significant she should be evaluated. Younger kids definitely benefit from a day off when performing activities at a high level. Remember a healthy diet including vitamin D and calcium is important. Dancers also need to remember to stretch their Achilles” tendon.” It is best to consult with your physician with any questions or concerns.

Mete Dikengil says:

My son is is 17 yrs. old and has been playing competitive soccer since age 12 without much rest. between his club team and high school team he was playing every season. He developed pain last yr.which gradually increased in his right knee and now he can no longer play going into his senior year in HS. MRI shows OCD of the medial chondyle (2 to 3 cm). Since his growth plate had not yet closed the advise was rest which he did for 3 mos.. Unfortunately the first scrimage back he came out due to knee pain. Next year he is college bound and is interested in playing college ball. Any advise?

HSS on the Move says:

Hi Mete, thanks for reaching out with your question. Dr. Daniel Green, pediatric orthopedic surgeon, says, “This is a complicated question; many patients with osteochondritis dissecans need more than 3 months of rest, also unstable cases require surgery (about 10%). In general, we also recommend surgery for cases that are symptomatic despite 6 months of rest. You should discuss with your treating physician who could best advise.”

Ray Huggins says:

Dear Doc:

i have an 11 year old daughter who fell down about 7 weeks ago. She stayed home that evening and the next morning she could not walk. i took her to the hospital emergency room and they did an Xray we were told that she has inflammation in the hip an was given an antibiotics to take for one week. after she returned to her followup and then an ultrasound was done. when she did the ultrasound on the second visit it was then we were told that she has a torn tendon in the left hip. she was advised to go to physiotherapy which has been going on 4 to 5 times a week and still no progress she complain of terrible pain and cannot walk to this day without Crutches. I am of the view that something more is wrong with her hip I am also noticing the way she is standing up now i see that her right hip is protruding and she upward where as the left is low. help i need advise. i am located on the island of Antigua and i feel that my daughters condition is a little more that just an xray and an ultrasound.

HSS on the Move says:

Hi Ray, thank you for reaching out with your question. If you are interested in your daughter being treated at HSS, please call our Physician Referral Service at 877-606-1555.

Joanne says:

Hi I’ve had an anxious couple of months now my son had been complaining of knee pain for a couple of months to his dad. Then beginning of school summer holidays I picked my son u from soccer camp, where his words were mam my knee is really painful I think I need to see the doctor I’ve told dad.

(in 2010 Christmas, my son wasn’t well , high temperature then went to get him off settee and he was screaming with pain, he couldn’t walk on knee, he went for MRI then on his right knee, then said it was probable osteomyelitis, he was treat with penicillin for 2-3 years.) My son from 3 years old, it was recognised his immune system was uncompromised, had many bouts of pneumonia, scarlet fever, chicken pox numerous times, used to take low antibiotic over the winter months.

Anyway going back to August this year, I managed to get my son seen by gp that afternoon, who sent us to hospital, hospital said we can call dr’s in 48 hours for results, which I did and as my sons leg was getting worse, my gp sent us to RVI Newcastle as the xray showed exotosis on his femur. A doctor told us bone specialist at the time told us if it wasn’t cartiladge / ligaments it may be a tumour. We were discharged from hospital awaiting MRI. We have since been for results where we told they could offer a bone biopsy for my son, but because he looked well, they didn’t want to put him through it. I feel I wasn’t able to ask questions as my son was crying we are going back to see him next week, I really need advice on the questions I need to ask as if they say it again, what if it is bone cancer, should I be asking for them to do bone biopsy as I feel I need to know what they have seen on the xray ????

Thanks you soo much for your time, I really hope you can help a very anxious mum .

HSS on the Move says:

Hi Joanne, thank you for your inquiry. Dr. Emily Dodwell, Pediatric Orthopedic Surgeon, says: “Your son’s medical history sounds quite complicated. Probably the best way to ensure proper care for your son would be to have him seen by an orthopedic surgeon that could review his entire medical history and past laboratory and imaging results, and re-examine him. It would be important to bring in all of his records/consultation notes, past imaging and past lab results. It is of course difficult to give you appropriate advice without reviewing the full medical history and examining your son.” If you are interested in seeing a pediatric orthopedic surgeon at HSS, please contact us at 877-606-1555.

sagar says:

hi, my name is sagar and im 25 yrs old.from past 2 moths im having a pain in the knee.initially it started in the back of the knee.gradually spread to the front portion too.the pain is not concentrated and not regular.first i thought its joint and after that i found it in the back leg muscles also.recently i also found my backbone is paining when im bending forward.i consulted many docs but no use.i never had any injury.pls explain me what is the problem.

HSS on the Move says:

Hi Sagar, thank you for reaching out. Dr. Marci Goolsby, Sports Medicine Physician, says “Many things can cause pain in the knee, including the knee joint itself, muscles and tendons around the knee, and sometimes even pain from somewhere else called ‘referred pain’ such as pain seen in the leg from a pinched nerve in the back. I cannot explain your particular problem by your description alone but you may want to consult with a physician in-person.” If you are interested in care at HSS, please contact our Physician Referral Service at 877-606-1555 for assistance.

Parisa Elyasvandi says:

Hi, patient Parisa Elyasvandi 26 years old from Iran,
lost her left foot in a bus accident 4 years ago.
I can send the radiography ,It is difficult and painfool
to walk for her, want to know what can we do for her,
Thanks a lot, H.Elyasvandi hoelyas@yahoo.com

HSS on the Move says:

Hi Parisa, thank you for reaching out. We have sent your inquiry to the International Center at HSS and they shall be responding to you shortly.

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