Age Related Issues in Sports Medicine

 

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Pediatric Sport Epidemiology


Millions of children and adolescents participate in school related and non-school related sports activities each year [1]. In United States high school sports alone, there are approximately two million injuries that occur each year [1]. To re-iterate the point that pediatric sports injuries are common, one study reported that one in five pediatric emergency room visits was due to a sports injury [1]. Furthermore, at primary care clinics, sports injuries are reported to be the main reason for a pediatric visit [1].


Age and gender play a significant role in pediatric sports epidemiology. According to one study completed by the Centers for Disease Control and Prevention (CDC), the highest rates for pediatric sports injuries occur with males and in the 10-14 year old age group [1]. For males, sports injuries tend to occur more during team sport activity [2]. For females, more overuse injuries tend to occur in sports [2]. Females are also most likely to have ACL injuries, especially in basketball and soccer [1]. Age and skeletal immaturity are major factors in sports injuries with children due to physeal plates. Up to 10% of injuries in children playing sports include physeal damage [1]. In adolescence, increased growth rate can contribute to physeal and general bone weakness and decreased muscular flexibility, contributing to higher incidence of bone fractures [3]. Individuals who have completed puberty are more likely to have sprains and strains [1]. It is interesting to note that injuries in the 5-12 year old age group are likely to be more traumatic in nature [4]. This group also tends to have more fractures and injuries to the upper extremities [4]. Individuals in the 13-17 year old age group tend to have more injuries of the pelvis, spine, and chest [4].


Pediatric Sport Injuries as related to Gender

Males Females
More injuries occur during team sports More overuse injuries
Highest rate of injuries in 10-14 year old age group More ACL injuries
Most injuries occur in football Most injuries occur in soccer


Most Frequent Types of Injuries based on Age Group 

5-12 year olds Traumatic injuries, Upper Extremity Injuries and Fractures
13-17 year olds Pelvis, Spine, and Chest Injuries
Post-Puberty Sprains and Strains 


In pediatric sports, the types of injuries that occur vary widely. Lower extremity injuries are the most common overall [1]. The most common upper extremity injuries are fractures [1]. The hand is the most common fracture site in pediatric sports [1]. Elbow injuries account for approximately 5% of pediatric sports injuries [1]. Beyond orthopedic injuries, heat stroke and dehydration can be the cause of major injuries, especially in football [1]. With pediatric head and face injuries, approximately 1/3 of them involve dental damage [1]. Neurological injuries are also of significance in pediatric sports epidemiology, in which approximately 20% of head injuries in the United States occur during sport [1]. Spinal cord injuries commonly occur during sport, especially in football and cheerleading [1]. Cardiovascular injuries are an additional very serious type of pediatric sports injury, including sudden cardiac deaths [1]. Common causes of sudden cardiac death in the pediatric population include hypertrophic cardiomyopathy and anomalous coronary arteries [1]. Rarer causes are commotio cordis and Brugada syndrome, where ventricular fibrillation is likely to occur [1].


Type of sport also significantly affects the epidemiology of pediatric sports injury. For males, most injuries occur in football, and for females most injuries occur in soccer [3]. Softball and basketball are also sports in which a high number of female athletes get injured [3]. Most foot and toe injuries occur in taekwondo [1]. Most ankle injuries occur in volleyball, track and field, basketball, soccer, cheer, and lacrosse [1]. Most upper extremity injuries occur in throwing sports or in activities where one must catch themselves, such as judo, gymnastics, baseball, and snowboarding [1]. Facial injuries often occur in martial arts and in hockey [1]. Cervical and spinal injuries occur most frequently in contact sports like wrestling and football [1].


Body Part Injuries as related to Type of Sport

Foot/Toes Taekwondo
Ankle  Volleyball, Track and Field, Basketball, Soccer, Cheer, Lacrosse
Upper Extremity Throwing sports, Sports involving catching self, Gymnastics, Snowboarding, Judo
Facial Martial arts, Hockey
Cervical/Spinal Contact sports, wrestling, football


For more information, a helpful resource can be found in the book, Injury in Pediatric and Adolescent Sports: Epidemiology, Treatment, and Prevention.

Pediatric Sport Concussion

Sports concussion in pediatrics occur at an alarming rate in the U.S., Especially in boys sports such as football. A recent study showed that the incidence rate for concussions across 12 high school sports as .24 per 1000.[5] Boys’ sports accounted for 75% of all concussions. Boys football had an incidence rate of .60 while the second highest was girls soccer at .35. Lincoln, Caswell, Almquist, Dunn, Norris & Hinton also showed that concussion rates increased 4.2 fold over the 11-year period that their study took place, indicating that concussion occurrence is increasing.[5]

While the incidence rate may seem low at .24 per 1000, many concussions go unreported or unrecognized. According to one study, only 47.3% of concussions sustained by high school football players were reported.[6] The top reasons for not reporting concussions were, "Not thinking the injury was serious (66.4%), motivation to not be withheld from competition (66.4%), and lack of awareness of possible concussion (36.1%)."[7]

Experiencing a concussion makes one three times more likely to experience a subsequent concussion in the same season.[8] Athletes that experience concussions that result in a loss of consciousness are four times more likely to sustain another concussion that involves loss of consciousness.[8] For athletes who had sustained three or more prior concussions, 54% played football and 18% were soccer players. Players that experienced a concussion were much more likely to have an initial on the field loss of consciousness, anterograde amnesia, confusion and subsequent concussion while only 5% of athletes who had their first concussion lost consciousness.[9] In addition, athletes that have had three or more concussions are 6.7 times more likely to experience loss of consciousness.

To test for concussion in athletes a provider can use a form called the Acute Concussion Evaluation (ACE). This form has sections that look for loss of consciousness, amnesia, seizures, cognition, sleep and other important factors to keep track of when an athlete experiences a concussion.[10] The ACE provides instructions and a follow up action plan if an athlete does experience a concussion. A link to the ACE form is as follows, http://www.cdc.gov/headsup/pdfs/providers/ace-a.pdf.

The decision to take the athlete out of the game or to sideline the athlete for multiple games is an important decision to make. The athlete’s health and safety is the most important aspect to take into account. Loss of consciousness and amnesia are both indicators to withhold the athlete from play for the remainder of the game and the rest of the day.[11] The safest approach to allow an athlete to return to play is to allow a seven-day symptom free period before allowing them to return to play. If the athlete has had three mild concussions or more in one season, that athlete should be sidelined for the remainder of the season. In addition, if the athlete has post-concussion symptoms for more than three months, a full neuropsychological evaluation should be administered.[11] It is also worth noting that pediatrics are more at risk for impaired healing and a conservative method should be taken when considering whether or not to withhold the athlete.[11]

Metabolic Changes Over the Lifespan

Infancy to young adulthood

Various metabolic changes occur over an individual’s lifetime. According to Armstrong, Barker, and McManus, one important metabolic change includes the size of muscle fibers.[12] As an individual ages from infancy to becoming a young adult, muscle fiber size increase by twenty times.[12] Type one muscle fibers decrease, glycogen stores increase, and phosphocreatine increases with this particular aging process.[12] Oxidative enzymes are higher in children while anaerobic enzymes are higher in adults.[12] Blood lactate levels and glycogen depletion rates also increase with age.[12] Generally, children depend more on oxidative metabolism for intense exercise activities, rather than anaerobic, as compared to young adults.[12] Children also tend to recover more quickly from intense exercise activities.[12] Mitochondrial activity and function is generally higher in children and young adults, and insulin and glucose levels are generally lower, as compared to older adults.[13] Thermoregulation continues to change up through puberty and resting metabolism decreases significantly between childhood and adulthood.[14]


Middle-age to late adulthood

As one ages, they begin to lose muscle mass and the metabolism decreases in activity. Around the third decade, muscle density, and bone mass begin to decrease.[15] This decrease continues to take place as we advance into older age eventually leading to sarcopenia and osteoporosis. Body fat is also redistributed inward and it can begin to infiltrate muscle and organs, especially if a person is sedentary.[15] Osteoporosis especially begins in post-menopausal in the fifth decade.[16] Osteoporosis can lead to decreased bone mass, which increases the risk for bone fractures, death, and disability.[17] Sarcopenia is the loss of muscle tissue and is a normal part of the aging process. Muscle strength in the back, legs and arms can decrease by as much as 30-40% by the age of 80.[17] In a test of knee extensor and knee flexor strength in older adults aged 65-75, they found that both extensors and flexors showed a 2.5% reduction in strength per year.[18] Normal aging losses coupled with a sedentary lifestyle can hasten the speed at which sarcopenia and slowed metabolism take effect.[16] ACSM suggests that exercise and proper nutrition are both effective methods for slowing the process of sarcopenia and maintaining adequate bone mass.[16]

Total Joint Replacements and Sport

There are approximately 500,000 total joint replacements performed each year around the world, and approximately 300,000 of those are total knee replacement performed in the United States. (Vagel, Carotenuto, & Levine, 2011). Typically, total joint replacements (TJR) are performed to relieve pain and restore the quality of life for the individual receiving the TJR. Many of these individuals receiving a TJR participated in sporting activities prior to surgery; currently it is unclear whether it is safe for these individuals to continue to participate in sports postoperatively. Carotenuto et al. (2011), found that the current research has conflicting evidence regarding participation in sports following a TJR. The concern that high impact sports will increase the need for revision due to joint loosening or wear of joint components leads many surgeons to list sporting activities as a precaution postoperatively.
According to Golant, Christoforou, Slover, and Zuckerman (2010), postoperative participation in sporting events is beneficial to the patients overall health. An active lifestyle increases an individual’s muscular strength, endurance, proprioception, cardiovascular health, balance, and coordination, decreasing the likelihood for injury and falls. Golant el al. (2010), found that patients with a TJR also benefit from physical activity, but the level of activity is controversial. Some studies promote the participation of high impact sports while others refute high impact sport participation due to the risk of revision.
Though high impact sports for patients following a TJR are controversial, most studies have found that low impact sports are recommended. Sports like walking, water aerobics, cycling, swimming, and cross-country skiing are healthy and recommended by most surgeons. Golant et al. (2010) noted that low impact sports have been found to decrease the risk for revision due to loosening when compared to more sedentary patients. Chatterji, Ashworth, Lewis, and Dobson (2004) found an increase in low impact sports participation with patients who received a total hip arthroplasty. Regardless of the level of impact a patient wishes to participate following a TJR, it is recommended the patient discusses the sport with their surgeon prior to surgery to allow the surgeon to determine the appropriate approach and type of implant to accommodate the forces imposed by the sport.

Sport Training in Senior Athletes

[19] 


With the realization that those over 80 are the fastest growing age group of the entire population, it is important that this segment of people understand the health benefits of exercise. Yes, there are some undeniable and inevitable changes that come along with aging; however, evidence shows that the benefits of physical activity and training in the senior population continue to grow. These benefits include fewer falls with injury, improved muscular strength and endurance, a decreased incidence of coronary artery disease, and a lower risk of cardiovascular related mortality (Franklin, Fern, & Voytas, 2004). Senior athletes can enjoy participating in a variety of athletic or sport related activities including swimming, running marathons, golfing, playing basketball, lifting weights, cycling, tennis, etc. Based on the activity the senior athlete is training for, the training regimen should be specifically designed to produce both metabolic and physiologic adaptations aimed to improve his or her athletic performance. The American College of Sports Medicine (ACSM) recommends the following training guidelines for senior athletes:
1. Train 3-5 days per week
2. 55%-65% to 90% of maximum heart rate or 40%-50% to 85% of maximum oxygen uptake reserve
3. 20 to 60 minutes of continuous or intermittent aerobic activity
4. Any activity that engages the large muscle groups like walking, jogging, running, cycling, rowing, stair climbing, etc.
5. Perform resistance training: one set of 10-15 repetitions for major muscle groups two to three days per week
6. Perform flexibility training: stretch major muscle groups at least four times each for a minimum of two to three days per week
Even at advanced ages, it is apparent that with the implementation of regular sports training, performance levels can be maintained.

[20]

[21]

Recent Related Research (from Pubmed)

Older adults are the least physically active age group and account for the highest amount of medical cost (Nelson, Rejeski, Blair, Duncan, & Judge, 2007), which led to many studies to determine an appropriate level of exercise for adults to maintain a healthy lifestyle. The American College of Sports Medicine (ACSM, 2015) has established a guideline for a recommended level of activity for the healthy adult. The current recommendations are as follows:

Cardiorespiratory moderate intensity ≥ 30min a day 5 days a week
Vigorous exercise ≥ 20min a day 3 days a week

Resistance Exercise each major muscle group 2-3 days a week

Flexibility Exercise Maintain Joint Range of Motion 2 days a week

Neuromotor for balance, agility, & coordination 2-3 days a week
Exercise

Individuals who currently have a more sedentary lifestyle are encouraged to gradually increase the amount and level of activity to decrease the potential for overuse injury and to provide for a more enjoyable exercise experience. Nelson et al. (2007) recommends that older adults create a plan for physical activity. The plan should “reduce sedentary behavior”, “increase moderate levels of activity”, and “take a gradual step approach”(p. 1101). Research has shown physical activity to increase an individual’s overall health, decrease medical costs, and provide psychological benefits for all age groups, which has led to campaigns that encourage daily physical activity.


Resisted Sled Sprint Training vs. Non-resisted Training

In many sports, sprinting is a key to optimal performance. For this reason, Petrakos, Morin, and Egan (2015) compared the effects of resisted sled sprint training to those of non-resisted sprint training on athletes. Resisted sled sprint (RSS) training involves multiple straight-line sprints while pulling a sled, which is loaded with additional weight that is attached to the athlete by a waist harness. The authors hypothesized that RSS could provide effective benefits when performed alone or in combination with traditional or non-resisted sprint training in force production, strength, and power while sprinting. The authors found that when the RSS load was 12% to 43% of the athlete’s body mass, improvement was noted in sprint performance for trained individuals. When the load was lighter than 12%, the authors concluded that there was no benefit to RSS when compared to non-resisted sprint training. A combination of RSS and non-resisted sprint training or plyometric training may also provide benefits in improving overall sprinting acceleration when compared to non-resisted sprint training alone (Petrakos, Morin, & Egan, 2015).

References

  1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 Gottschalk A, Andrish J. Epidemiology of sports injury in pediatric athletes. Sports medicine and arthroscopy review 2011; 19(1), 2-6. http://journals.lww.com/sportsmedarthro/Abstract/2011/03000/Epidemiology_of_Sports_Injury_in_Pediatric.2.aspx (accessed 18 Nov 2015).
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