With youth participation in sports continually increasing, rehabilitation and injury prevention awareness is more important than ever

Participation of children and adolescents in sports has been estimated at 30 million participants, according to the National Institutes of Health.¹ As sports participation increases, sports injuries have also increased. Approximately 5% of school children are "seriously injured during physical education every year."² Statistics reveal that from 1997 to 1998, sports-related injuries accounted for more than one-fifth of the visits to emergency departments by persons ages 5 to 24.³ Sports injuries to young people now exceed infectious diseases.⁴

Sports injuries fall into two classifications acute traumatic and overuse. The mechanism involved in acute traumatic is generally a single blow or twist acted upon the body, with the resulting injury being a strain, sprain, or fracture. Damore⁵ and Burt and Overpeck³ agree that sprains and fractures were the most common types of injuries they encountered in their research. In the overuse category, repetitive training or microtrauma can produce chronic inflammation or stress fracture.

Low Back Pain
Low back pain in young athletes ranks high for most sports, especially in gymnastics, figure skating, and dance. Repetitive flexion, extension, and rotational movements correlate with increased incidents of low back pain.⁶ Understanding the difference between adult and pediatric types of low back injuries is important (Table 1).⁷ Chiropractors should also know the differences in presentation of possible spondylolysis versus lumbosacral strain symptoms. Though each case is unique, certain generalities are present (Table 2).⁸

Physically active young people who present with symptoms of spondylolysis and a history of repetitive hyperflexion, hyperextension, and rotational activities should receive anteroposterior, lateral, and oblique lumbar radiographs. Where a complete fracture is suspected, a single-photon emission computerized tomography may reveal a developing stress fracture before it is evident on plain films. Early conservative intervention and treatment can result in complete healing of the pars interarticularis defect. The longer a pars defect persists, the more likely it will progress to an outright fracture.

Specific rehabilitative exercises must be part of conservative management. Special attention should be placed on strengthening and balancing the relationship of the abdominal and back extensor muscles. Two particularly effective back exercises are forward flexion and back extensors. If there is anterior pelvic rotation noted during the evaluation, left and right lumbar rotational exercises should be included to strengthen and balance the internal and external obliques.

Lower Extremity Injuries
The pediatric athlete with open physeal plates is more susceptible to growth plate injuries and avulsion fractures, rather than the ligament and muscle-tendon injuries that often occur in adults.⁹ Bony contours are not as well defined in children due to incomplete ossification, therefore the chiropractor must look for certain types of injuries based on the history and physical findings because radiographic signs may be difficult or impossible to see.¹⁰

In a survey of older, more elite young athletes, Hutchison¹¹ reported on injuries that required physical or medical assistance for participants at the United States Tennis Association National Boys’ Tennis Championships from 1986–1988, and from 1990–1992. During the 6-year period, a total of 304 athletes (21.1%) sustained new or recurrent injuries that required evaluation by the health care team. The analysis of injuries showed a higher rate of lower extremity injuries than upper. When evaluated by anatomic regions, back injuries were most common, followed by thigh, shoulder, and ankle injuries, respectively. When evaluated by injury type, strains and sprains were the most common (71% of all injuries), with fractures and dislocations being rare (1.3% of all injuries). The lower extremity provided the majority of sprain-type injuries, with 87.5% of ligament sprains coming from the knee and ankle.¹¹

In the case of the knee, differential diagnosis of children’s knee injuries includes not only the typical adult injuries to bone, ligament, and cartilage, but also growth plate injuries.10 Anterior cruciate ligament (ACL) injuries in skeletally immature adolescents are being diagnosed and reported with increasing frequency.¹²

As a major weightbearing joint, normal hip function is fundamental to successful sports participation. Hip injuries are not responsible for a large percentage of sports-related injuries, and the young child rarely sustains a significant hip injury.¹³ However, the chiropractor must keep in mind that the immature skeleton of the adolescent is relatively injury prone, and the demands of sports often exceed the capacity of the growing musculoskeletal system.

As with low back pain, many lower extremity injuries can be treated using specific rehabilitative exercises as part of a conservative management regimen, such as joint specific linear as well as rotational exercises, which provide for stabilization and prevention. The use of surgical-tubing equipment is effective in cases of strain and to enhance joint stability.

An often overlooked component of many low back and lower extremity sports injuries is pronation, a pedal imbalance that causes an anterior shift in weightbearing. This shift can have negative effects on the entire kinetic chain.

About the Author
Kim D. Christensen, DC, CCSP, DACRB, is codirector of the SportsMedicine & Rehab Clinics of Washington, and current president of the American Chiropractic Association Rehab Council. He can be reached at Chiropractic Rehabilitation Associates, 18604 NW 64th Ave, Ridgefield, WA 98642 or via email: kimdchris tensen@hotmail.com. 

References
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