Physical therapist Tuan Mai, PT, DPT, discusses the lifelong benefits conferred by regular physical activity and the incidence of injuries among young athletes, detailing risk factors and how they can be addressed. Focusing on conditions commonly seen in pediatric primary care, he explains that rest alone won’t get most hurt kids back to their former performance levels and describes how the right rehab – such as the multidisciplinary approach offered at UCSF – can support children’s healing and future well-being. Bonus: Hear about FIFA's injury prevention program for soccer players, shown to reduce the risk of ACL damage.
Thanks for having me again. Um, like I, uh, my name is Tuan Mai. I'm the clinic manager for sports medicine and physical therapy. And we have locations in Oakland, Walnut Creek, and San Ramon. And today I'm presenting on sports medicine in the primary care setting. So we're gonna introduce the topic, talk a little bit about sports specialization, uh, common injuries in youth sports, some of the benefits of physical therapy, and talk about how um we uh take referrals for physical therapy. So our mission at the hospital and at our clinic is to inspire hope and promote healing, and we do that through long-term athletic development. So we promote physical development to prevent injuries and enhance fitness behaviors that can be retained later in life. Uh, just a quick introduction. So for the, um, from the National Center for Health Statistics, um, there's about 54% of children 6 to 17 participated in sports in 2020. You can see it's pretty evenly uh divided between, uh, boys and girls, um, and then, uh, age groups and amongst, uh, race and race and ethnicity as well. So for uh injury rates, this is from the NCHS uh uh interview survey from 2011 to 2014, um, that there's 8.6 million sports and recreation-related injury episodes per year. Um, and 65% of those Involve uh persons aged 5 to 24. So in our sports medicine center, we see uh patients uh in that age range and 41, over 41% involve sprains and strains. So some of our um Acute injuries and overuse type injuries. The highest rate observed is among children aged 10 to 14 years of age, and uh we see that in our clinics as well because uh many of our patients are, are in that age range. So the question is, how do we prevent all these sports injuries that we, that we see, um, and I'm gonna tell you there's one. Perfect thing that will stop all of these sports injuries, and that is to never play sports. However, the US Department of Health and Human Services physical activity guidelines recommend youth aged 6 to 17 need at least 60 minutes of moderate to vigorous activity daily. That includes physical education at school and sports activities, individual team, or just getting out there and running around and playing. Uh, the immediate benefits for, um, For youth is to reduce anxiety, blood pressure, improve quality of sleep, and insulin sensitivity, and then the long-term benefits for youth are, uh, that they improve cognition, bone health, fitness, and heart health, and it also reduces the risk of depression. So you can see there's lots of benefits to youth sports, uh, you know, the physical and psychological health, social well-being, academic performance, and health behaviors, um. I know when I was younger, I didn't play uh youth sports, um. Organized youth sports and um and my wife did and she's always talking about how she's much better at time management with her academic performance um because there's only so many hours in the day and these uh patients that play or youth that play sports have to really prioritize when they're gonna do their homework, when they're gonna eat, when they're gonna sleep, so that they can um go to practice and play in uh in these different uh sports. So the issue in youth sports is that um the physical demands are greater than the physical durability of these youth, and then sports specialization is also another issue. So sports specialization is defined as playing a single sport for 8 or more months per year at the exclusion of other sports. And youth who specialize are more than 1/3, so about 37% more likely to suffer an injury than those who sample sports, which means that they are trying different sports. Uh, sports sampling is associated with a decreased risk of sports injuries, um, and, uh, youth athletes would definitely benefit from, um, participating in sports sampling, so doing a lot of different sports activities. Uh, this is a, a fun graphic. Um, this is the football recruits for Ohio State, and you can see that, um, most of them were multi-sport athletes in high school, only a few specialized in football. And then we also have to look at the odds ratio versus exposure, and you can see that when you get up to 16 hours per week, that there's a much higher risk of injury. Um, and We, you know, the caveat is that there is some degree of sports specialization that's necessary to attain kind of these elite levels of, of, uh, sports, but for most sports this intense training, uh, with exclusion of others should be delayed until adolescence. To optimize um their suc the patient or the youth success while minimizing risk and of injury and psychological stress. So, um, many of our patients uh who come in with injuries, they Once they're kind of away from their parents, they talk about kind of being burned out on certain sports or I don't want to go back to a certain sport, and so there's some relationships there between kind of the psychological stress burnout of the sport and doing too much and then the the injuries. So what can we do? There's 3 things that I think we can do. We can increase the physical durability of the patients. We can decrease the physical demands, and then we can encourage sports sampling. So sports sampling has a twofold effect. It leads to an increased fundamental motor skills, which leads to less injury. And then there's also less single action repetitive motions, for instance, if you're talking about baseball, then. Um, the pitcher that continues to throw over and over and over again with those same types of motions and get that overuse type of injury. Um, and then, uh, moving on to some common injuries in youth sports, you probably, um, have seen many of these in your practices, but we'll review some apophyseal type injuries, muscle strains, knee pain, ACL type injuries, ankle sprains, and concussions. So for these youth athletes, we really think about the bones, um, they're skeleton immature, so the bones are gonna be weaker than than the surrounding muscles and tendons, so, um. That's always kind of in the back of your mind is Is the injury. You know, dealing with the bones and does that need, you know, further medical management. So this is uh just a sampling of the apophyseal injuries that um that we see in many of our patients um around the hip, you get the uh ASIS and AIS, the ischial tuberosities, um, you get the medial epicondyle epicondyle in the elbow, um, you also get Osgood Schlatter's, um, sending Larsson Johansson. Uh, in the knee and then Seever's disease or calcaneal pophysitis in the uh. In the, in the heel. So these are You know, we consider them kind of something like growing pains, um, especially with like a fevers or Najge schlatters, um, they're probably not going to Um Like tear anything, it's, it's, it's pretty unlikely, but what's gonna happen is that they're just gonna have a lot of pain, um, they're gonna limit their function. Versus if you get uh patients with uh kind of like uh your baseball players with uh a medial epicondyle injury, then you're gonna see, um, again, uh, that's like where you have to really shut them down because um you're looking at uh the widening of the growth plate right there and, and, uh, that causing a lot of uh problems moving forward. Um, muscle strain wise, if you look at professional soccer players, 31% of all injuries are, um, muscle type strains, and most of the muscle strains are affecting the, uh, lower extremity muscle groups, so the groin, the hip or hip abductor, the hamstrings, the rectus femoris, or the calf. Um, and if you have a previous history of an injury to one of those muscle groups, it's a very, um, important, uh, risk factor for future injury of that same muscle group. So, um, when, when you have your patients come in and they have start getting muscle strains in the hamstring or the calf or the or the quads, then you're looking at their risk factors increase, um, over the, um, even after they return and and if they've healed. So we always want to look at how they You know why they had that injury to begin with and what we can do to to work on that in physical therapy to address the risk factors. Uh, muscle strength is known to decrease with age. We generally don't see that with our, you know, current patients, so, um. But sometimes those older players are more likely to sustain hamstring or kind of calf muscle injuries. With knee pain, there's just so many structures in the knee and so many possibilities for uh injury to the knee. So you have your patellar femoral stress syndrome which um as an overuse injury, uh, we see quite a lot in our clinics, um, against Bajgu Schlaughters and sending Larsson Johansson, you have patellar tendonitis, IT band syndrome, bursitis, uh, fat pad impingement. And then some more traumatic things like patellar subluxation or dislocation. And then the worst, you know, ones are the ACL and MCL, PCL tears, meniscus tears, um, OCD lesions, um, and then, uh, some other growth plate type injuries. So for patello femoral stress syndrome, um, so you get uh pain around the patella or tendon, um, uh, or the uh patella resulting uh from physical and biomechanical changes in the joint. Um And Pretty much it's kind of like a multifactorial. Issue. A lot of these patients are again doing the same sport and repetitive injury, repetitive movements over and over. They might just be playing only field sports, so they're running all the time. They have practice. They have multiple teams that they're playing on playing soccer. They might play on a club team. They might play on their school sports team, so you're going to get a lot of overuse and overload. Muscular dysfunction is an issue where um we talk a lot about like kind of the butt and the gut, so uh how strong your glutes are, um, and how strong your core is to kind of take some of the pressure off of the quad and the, and the tendons around the um patellar. Patella in order to um Kind of support those that area so that it's not taking so much of the load. And then biomechanical problems we see a lot of patients that come in, we see they're moving poorly, so their knees are collapsing in their arches are collapsing in, it's causing their knees to kind of touch or kiss each other when they're squatting, and that usually is pretty common in the patients we see when we ask them to do a squat or to do a single leg squat where their knee is just caving in. And that puts a lot of stress on the medial side of the knee and then over time, you know, it doesn't happen once or twice, it's, it's the repetitive motion every time you run, you're doing a little bit of a single leg squat and um each time that joint is going in, it's pulling the kneecaps kind of pulling out and you can um cause a lot of irritation that way. Uh, ACL injuries, the incidence is about 68 per 100,000 person years, that's, um, all inclusive of, uh, children and adults, um, but there is an increasing incidence in pediatric patients, and the incidence we're seeing is, um, high in high school. Uh, for risk factors, they've done many studies and, um, for adolescent females, they're somewhere between a 3 and 6 times higher. Um, rate of ACL injury than males. Again, risk factors include previous injuries to that area, um, and then the, uh, where we talk about kind of like the neuromuscular system and how ligament dominance, quad dominance, or leg dominance is causing, um, The uh the need to not move in the correct way, so. With when we think about running or any of the field sports are absorbing a lot of ground reaction forces during these sports maneuvers, except with and with cutting and um ligament dominance is where you see, again, the knee caving in. Uh, quad dominance is where you see the, um, the quad is much stronger than the hamstrings, and, uh, some of our clearing tests are to compare the quadriceps to the hamstrings to see that the ratio isn't, uh, out of, uh, you know, unbalanced. And then leg dominance is we're looking at um imbalance between strength and joints in either the right or the left leg, um, and females athletes have been reported to generate lower hamstring torques in the non-dominant uh leg. So again, if you have that lower hamstring strength or torque, then you're causing, um, you're again more quad dominant, and that can be a risk factor for ACL injuries. So, um, some of the, some of the things we use is there's a fantastic ACL injury prevention program. It's been validated. Um, it's called the FIFA 11 plus, so it has running and agility, it has strength, it has plyometrics, it has balance, it has landing techniques. So it's, uh, the study showed that there's about a 30% reduction in the injury risk using this FIFA 11 plus. Now, in the, um, This is, uh, you know, obviously with FIFA you're looking at like a soccer type of program, but they did this study with the FIFA 11 Plus with basketball players, and the injury rates also decreased for basketball players as well. So you can think about using the FIFA 11 Plus for any jumping, running, landing, cutting type of type of sports. Um, and then if you look at the, the study, the FIFA 11+ kids program reduced the overall injury rate in children playing soccer, um, much more than just your usual warm up and Warm up is kind of a loose term because it's hard to know each team kind of does things differently depending on the coaches and the parents involved, but a lot of times you'll see kids run up and down a couple of times and do some leg kicks and then they're like, OK, we're warmed up and ready to play if they even do that. So the injury rate for those that Did just the regular warm-up was 0.85 injuries per 1000 exposure hours versus for the FIFA 11 plus it was only 0.43, so kind of cut the injury risk in half. Uh, ankle sprains is a common one you probably see in your clinics. Um, the incidence is almost 4 per 1000 participants. Again, risk factor is previous injury, and then, uh, the previous injury, you're actually at a risk of 5 times higher to injure that same ankle. Um. Shoes with aerosols tend to be an issue in the heels, where they're 4.3 times more likely to injure their ankle compared to if they didn't have those aerosols in the shoes. Um, and then if they aren't stretching, so, um, if their calves are tight, then you're looking at 2.6 times more likely uh injury and then partial sway, so you're looking at balancing, um, if they have high sway or poor balance, then they're 7 times as likely to have an ankle sprain. Uh, and then we talked about concussions. What's a concussion? Well, there's 3 conditions. Um, that, uh, must occur. And that's a biomechanical force that acts on the brain, so it's caused by a bump, blow or jolt to the head, and the head doesn't have to be directly hit for it to be injured. So you're talking about whiplash type injuries or even blast type injuries, uh, rapid acceleration and deceleration causing the brain to move violently inside the skull. And then a temporary disruption of normal neurological function, creating chemical changes in the brain. Uh, and unfortunately for youth, those, um, who are 13 years of age or less, um, they are likely to have an extended recovery timeline. Uh, they have a different physiological response, um. As a result of the concussion. And even athletes, when they say that they've recovered within minutes, show abnormalities on cognitive tests 36 hours later, and there's no evidence that a young athlete recovers same day. So signs and symptoms of a concussion, you have physical, you have the sleep, you have the cognitive, and you have the emotional aspects, and you can have combinations or all of the above. Signs and symptoms of a concussion from the physical standpoint, you have headaches, fuzzy or blurry vision, visual processing or tracking dysfunctions, nausea or vomiting, dizziness, sensitivity to noise or light, balance dysfunctions, vestibular dysfunctions, or just feeling kind of tired and lethargic. Some patients will sleep more than usual and others will sleep less than usual, so it's really kind of dependent on their previous um experience uh or their previous sleep patterns, and then they also have difficulty falling asleep or staying asleep. From an emotional standpoint, you have increased irritability, nervousness or anxious sadness, and overall more emotional. Again, that's gonna be something that. Um, the parents and the coaches might have a better idea if, if a, a patient is, um, exhibiting any of these signs. From a cognitive standpoint, they have difficulty thinking clearly. Uh, days are feeling out of it, they feel slowed down, uh, they have difficulty concentrating or difficulty remembering new information. From a management standpoint, uh, the brain is in this kind of energy crisis or acute metabolic crisis, and there has to be an acute care plan and um healthcare provider instructions. Uh, in the past, we talked about cocoon therapy where they would be where they, it was the recommendation that they would go, you know, lay in a dark room and Everything is quiet and they just sleep all the time and the newer studies have shown that it might do more harm than good. Once symptoms are manageable, we wanna allow for a slow introduction to the mental, physical, and social activities. So um we're always thinking about uh following a return to learn protocol, um, and then, um. It's not necessary that they are asymptomatic before they begin gradual return to activities. Again, it should be under the guidance of a healthcare professional, um, but, you know, again, prior to returning to sports, there should be a return to learn. Um, post-concussion management, um, this is just general guidelines, making sure your child gets rest. You wanna allow for, for naps or rest breaks, uh, you wanna limit physical activity as well as any kind of thinking and concentration activity. So, you know, homework, uh, any kind of jobs, class workload, um, doesn't mean you can't do any of these things, but, but you try to limit it, uh, initially, uh, lots of fluids and healthy foods. Um, and then as symptoms decrease, you're gonna return gradually to daily activities. If the symptoms worsen, then you might have to reduce a little bit again and then try again a, a different day. Um, and it's normal for the child to feel frustrated and sad when they don't feel right and can't be active. With return to school, they might need extra help with schoolwork, um, accommodations can be lifted as they improve, and you wanna inform. The school staff, so teachers, nurses, psychologists, About uh injury and symptoms and then The the school personnel should watch out for for any of these things, any increasing symptoms or changes that um they hadn't seen before. From a return to play guideline, um, the, the really important thing is you must have written, uh, physician, whether it's an MD or a DO clearance to be in and progress through the fault, the stages. So, um, there's, you can, as you can see there's uh. That's all the stages right here. And so it's the guidelines, so limiting physical activity, starting aerobic activity, then doing a little bit more um with some resistance training, strenuous activity, non-contact training, limited contract practice, full contact, and then um and then return to play. So, um, and each time you have to go through all of the stages, um, but it's gonna take a minimum of 6 days to get through stage 1 and 2. From a concussion recovery timeline, if the child is evaluated within one week of an injury by a concussion specialist, it can decrease the number of days that they're gonna be out, um. Versus a child that doesn't see somebody, a concussion specialist. So we're still working education for, for everybody, right, the children, the teammates, the coaches, the families, um, to make sure that they're seeking evaluations for concussions. Um, I know some of that is, you know, with the, with California state laws regarding concussions, um, you know, they, they, they start getting savvy to, oh, I know if I report the symptoms or I have a concussion that's diagnosed that I'm going to be out at least 7 days, and that's Um, that's kind of where our challenge is, is, is to make sure that, that we're identifying, uh, these patients that, that have a concussion. So our concussion program, uh, we look at a multidisciplinary approach. I know Doctor Hadamia did an update on concussions, uh, last month, but, uh, we do have our primary care sports medicine. Um, we have, uh, neuropsych, athletic training is, you know, on the field with some of the, uh, local high school teams, and then our physical therapy, uh, department also, uh, works on, uh, patients with concussion and getting them, uh, back towards activities. So we specialize in complex and multiple concussion patients and then guide them towards return to school and activity. Uh, from the standpoint of playing hurt versus playing injured, um, You know, things that hurt, you know, you have exhaustion, contusions, abrasions, blisters, some of those things that you can kind of play through, and then there's things that they should really take a, take. Some rest time and get medical treatment for things like fractures, muscle strains, joint sprains, concussions, and overuse injuries. Unfortunately, rest alone does not fix most sports injuries. Um, rest is great. Uh, we're, we're big proponents of rest or, or even what we call active rest where you're, you can do some other things and maybe leave the area that's injured alone, but You know, our advice is most athletes do need some form of rehab or physical therapy to get them back to their higher level of function and keep them in the game. Uh, from a, from a strengthening and power standpoint, children can definitely increase strength. It's very, it's not due to muscle hypertrophy as much, but it's, uh, due to, um, the neural adaptations, um, and their Becoming more efficient um with how they move. So a lot of times we see patients that come into physical therapy and we can get them. Moving correctly and then add some resistance to them, and they Instantly gain what we call strength, but it's really more of like a just uh getting more efficient motor unit um activation. We have our motion analysis lab, and In Walnut Creek and you can see, so we have uh 2D stud uh currently we have 2D studies and so we can see uh when patients are uh running um and then we also do a motion screen where we put the patient through um. Uh, a, a battery of tests for postoperative return to sport or, um, or in, in both, and non, non-operative return to sport where, um, we wanna make sure that they're moving properly and, and, uh, we have the video and, uh, photographic evidence of how they're moving. Um, and then we also do, um, Uh, like quad to hamstring strength ratios with our isokinetic machine to check for, uh, balance of the muscles. This is Steven. Thank you to Steven. Uh, from the standpoint of Something that that you can give. Uh, to your patients, um, sleep is, is a huge one. I know that's probably a challenge, um, but athletes that sleep less than 8 hours a night are 1.7 times more likely to have an injury versus those that sleep 8 or more hours. So, um, the study was in 2014, but a lot of information now on how, how important sleep is. I, I tell my kids all the time. Um, hey, you need to go to sleep. You wanna, you don't wanna get injured or, you know, when you're playing your sports. Uh, from the, from the benefits of physical therapy, um, our clinics are, uh, we gear the treatment towards healing of the initial injury as well as education and corrective exercise to limit the recurrence of the injury. Um, our sessions are one on one with a clinician, and all therapy is guided by the physical therapist. We also have physical therapist assistants. Um, our sessions are 45 minutes in length. And during an evaluation, we're looking at the whole athlete, um, so, uh, if you have a patient that comes in for knee pain, we're looking at their ankles and their hips and their core, um, and making sure that they uh move properly, uh, um, overall. Um, we really focus on our child and adolescent population. We do see patients 5 to 25, again, kind of the sweet spot is the uh 10 to um 18 year olds. Uh, we're in contact with our patients pretty much on a weekly basis. A lot of the patients get, uh, therapy, physical therapy every week, and we're able to observe their progress and compliance and then report that back to our, uh, referring providers. And we again we focus all of our knowledge and skill acquisition on this patient population and then we do our return to sport testing. We use our motion lab and other batteries of testing to ensure that the patient is ready to get back to sports and Full activities. From the referral standpoint, um, we, for the, for most patients, we do need a referral to request evaluate that requests evaluation and treatment for physical therapy. Uh, the referral should include a diagnosis and can also include activity precautions, uh, and, and specific, um, physical therapy, for instance, uh, concussion therapy, running evaluation, dance medicine, etc. and then also we, um. Mostly, most insurances require authorization, um, but again, only if it's needed for the patient's insurance. And then, uh, Children's Hospital Oakland has both physical therapy, so that's the um the outpatient physical therapy which tends to deal with the babies, non-athletes, um, any neurologic conditions, and um we're more of our orthopedic-based uh athletic population. And so if you clearly state sports medicine and physical therapy on your fax cover sheets and uh referrals, then. It'll get to us sooner and then we can take care of your patients uh much faster. Again, we have 3 locations. We have 1 at the Oakland campus which is in the main hospital. We have 1 in San Ramon, and then we also have a location in Walnut Creek. And this is our team of sports medicine clinicians, so, um, and all spread out and some are both Walnut Creek and San Ramon.
