Melanie Cole, MS (Host): Welcome to Long Live Childhood, a pediatric health and wellness podcast presented by Children's Health of Orange County. Together, we can keep kids happy and healthy. I'm Melanie Cole. And joining me today is Dr. John Schlechter. He's a board-certified fellowship-trained pediatric orthopedic surgeon, specializing in sports medicine and arthroscopy for children and adolescents. And he's also the Director of the Sports Medicine Program with Children's Health of Orange County, and he's here to talk to us today about sports injuries and treating and hopefully preventing your child's sports injury.

Melanie Cole, MS: Dr. Schlechter, thank you so much for joining us today. I'd like you to start by telling us about the most common sports injuries that you see in our young athletes. Tell us a little bit about some of those and the prevalence of these kinds of injuries.

Dr John Schlechter: Well, thank you, Melanie. Thank you for having me. I greatly appreciate the opportunity. Sports here in Orange County keep me quite busy, especially soccer and football to name two. Knee injuries is usually my focus in the office and probably one of the most frequent things I see in the young athlete.

Melanie Cole, MS: So then, tell us a little bit about some of the factors, because you see obviously football and soccer, and we know about ACL tears in girls, pretty common in soccer. So, tell us a little bit about some of the factors, whether we're talking about throwing injuries in baseball players, you know, football contact. What are you seeing and what are some of the reasons you're seeing these?

Dr John Schlechter: Yeah, it usually runs the gamut, meaning that depending on age, first decade of life, second decade of life, the injury patterns are definitely different as well as the sport that the child engages in. A lot of injuries can come from overuse, like you had mentioned about the throwing injuries. Those technically tend to be from repetitive throwing more so than a one-time traumatic event, where the football and maybe the soccer knee injury tends to be from the unfortunate twist or cut that leads to a knee injury or a tackle or a direct contact or a blow to the knee that could end up injuring the child or adolescent athlete.

Melanie Cole, MS: So before we get into the specifics of some of these injuries, Dr. Schlechter, you just mentioned overuse. So, this is a big issue that we've seen in the youth sports arena. Can you speak to parents just about that for a minute? I have a gymnast son, and I had to convince him during his high school gymnastics years to not work out all year round, to do other things. Can you speak about cross training and training errors that you see that cause some of these overuse injuries?

Dr John Schlechter: So early specialization in sport, I would imagine, comes from a good place. You want to excel at one certain thing and, you know, practice makes perfect. However, there's an issue when too much of a good thing is not a good thing anymore, and I think that's what we're seeing in the overuse arena more so than anything else. We're right in the middle of the NBA playoff season right now. And the Los Angeles Lakers are in the playoffs, whether you're a fan or not of LeBron James, but he has coined the term load management and has been known to sit out a game during the regular season, even if he's perfectly healthy, just to rest and avoid that overuse scenario. And that's something that I try to highlight in the office. And whether or not the child plays through pain, where I think a lot of them are out there on the field, trying to push through an injury is probably not the safest thing for them to be doing when their body's trying to give them a message to slow down and maybe rest a bit.

Melanie Cole, MS: It's really important and such good advice. Now as we're talking about that, we think of equipment. And many parents are under the guise that, you know, the helmets, knee pads, wrist pads, whatever it is, is going to completely protect their children. Tell us a little bit about the equipment today. And is it giving our children the protection we hope it does?

Dr John Schlechter: I'm going to highlight the throwing athlete. There's been studies on using braces during throwing to help limit the load on the elbow. We're embarking on a study currently, a prospective study, comparing braces on the throwing athlete, and this is children age eight to 12, so definitely the younger athlete versus a bucket. So if you want to talk about a specialized piece of equipment, maybe the bucket you would pick up at a hardware store like the Home Depot versus no protection at all, to try to decrease the amount of throws on the young elbow. Growth plates are susceptible to injury, so trying to limit the load on them is useful. In football, a knee brace can sometimes be protective. We know that in offensive linemen, like in the collegiate age. So if a child's playing offensive line, because of the other bodies close to them during a tackle football game, falling onto a knee brace can help in that scenario.

And I'm not necessarily a concussion expert, but helmets are important. They're important on bicycles and we're seeing a lot of electric scooters now and electric bicycles in Orange County. And to be riding one of those at 30 miles an hour without a helmet is definitely not in your best interest and not a good way to make friends with a neurosurgeon. And the tackle football helmet, also important. But we know even with a helmet, you still can have a shift in the brain within the skull that can lead to an Injury even with the best helmet on. So, being safe, watching your surroundings, especially when you're on an e-bicycle or e-scooter. And definitely following the laws of the road, super important.

Melanie Cole, MS: That's great advice. Now, let's talk about the difference between a sprain, a strain, a fracture, the things that we're seeing. Parents don't know what these are. Tell us a little bit about the differences and which one of those requires us to either go to the ER or urgent care, or our local orthopedic clinic and get an x-ray.

Dr John Schlechter: I think that's a great question, Melanie. So technically, a sprain is an injury to a ligament. One of the most common we see is in the ankle. Sprains usually come in different degrees. To make it simple, we'll say grade 1, grade 2 and grade 3. Grade 1, just maybe a little stretch; grade 2, the partial tearing of the ligament; and grade 3 can be a complete tear of the ligament. So technically, an ACL tear is a sprain, and a complete ACL tear would be a grade 3 or complete tear of that ligament. Now, some ligaments, depending on where they are in the body, can lead to more issues, instability and dysfunction. And then, those symptoms usually prompt a visit with a physician and then the physician can best decide via history and physical examination and imaging studies what the degree of the injury is and what the treatment to be rendered may need to be. So when in doubt, I think seeking the skills and services of a sports medicine-trained physician is probably always in the athlete's best interest.

In regards to a strain, those tend to be more of the muscle unit. Again, most strains can be rehabilitated with home remedies of rest, ice, heat, stretching, knee sleeves or thigh sleeves, compression, and then a slow return to sports. Typically for return to sport and adequate rest, what I usually tell families in the office is for however long it takes for the pain or dysfunction to go away. And this is, again, let's say for an injury that is not too severe. Usually, I'll have them double that amount of time and then return at 50% intensity. So, let's say it takes two weeks for the symptoms to subside, you would rest four weeks. And then, if you play four hours a week, you would go back and play two hours a week.

And then lastly, a fracture is a break in the bone. It can be, again, different grades. So, a bad bone contusion in technical terms can be a microtrabecular fracture of the bone. And in layman's terms, I usually explain that as, if you look at like a sponge and there's a crack within the sponge, but the sponge overall is intact, that's kind of that bone bruise or that deep bone bruise. So, that could be a fracture. There could be non-displaced fractures. Some of the most common are in the wrists. In the growing child, you can have a growth plate fracture that's non-displaced that can almost mimic a wrist sprain or strain. And then of course, the complete fracture where the bone is unfortunately in half and can be displaced and needs to be reset or sometimes needs to undergo surgery for best outcome.

Melanie Cole, MS: Well, thank you for that comprehensive explanation. Listeners, you can just rewind and listen to that part again. So, what does swelling in a joint mean?

Dr John Schlechter: Again, there's a spectrum that can be present with swelling. It could be rather benign from maybe just overuse. It could represent an inflammatory condition such as an arthritis. It can represent an infection, Lyme disease. So, you know, we're not in an area necessarily where Lyme disease is common here in Southern California, but people do travel. So, swelling in the joint could represent an infection and it could represent an injury such as a ligament tear or a meniscal tear if it follows a trauma. Cartilage damage does occur with overuse over time in children. So if there's pain associated with swelling, that's probably a little worse than just pain alone. And if you're shopping in the produce aisle and your swelling looks like something bigger than a lime or lemon or starts skating to that grapefruit size, that's something I would definitely seek evaluation for.

Melanie Cole, MS: So as we're talking about treatments, we're going to start with just the home treatments, that first-line treatment that parents, coaches should really know about. And you mentioned RICE, you mentioned, rest, ice, heat, bracing. Are you a heat guy? An ice person? What do we do if there's a muscle injury and our kids come home, they've got a sore shoulder, wrist, elbow, knees, whatever it is? Are we using heat? Are we using cold?

Dr John Schlechter: I think there's some controversy regarding that.

Melanie Cole, MS: Yes, there is.

Dr John Schlechter: So, I usually go with whatever feels best. Ice, I guess the theory in my mind is to decrease blood flow to a region. Heat to increase blood flow. If you're of the heat mindset, then maybe increasing blood flow will help flush out inflammation. If you are the ice person, maybe decreasing blood flow will cause less inflammation. I don't think we know for sure. Muscle stim units too are also popular, but I think the idea of stimulating the muscle with an electrical stimulus is also to increase blood flow to a region. So, I usually go with whatever feels best, being a patient myself and having gone to a physical therapist, typically you heat first, do the soft tissue mobilization, the massage, some exercise, and then ice after. So, it seems to work for me and I think that's my approach, personally.

Melanie Cole, MS: It is. What really feels best is what's so important. One of the big issues in sports injury is return to play, Dr. Schlechter. So, how do we know? I mean, when in doubt, sit it out, right? And we just mentioned concussion briefly. But when it's another kind of. Injury, a musculoskeletal injury, when do we know our kids are safe to get back in the game?

Dr John Schlechter: I think that we touched on it a little bit with the however long it takes for your symptoms to subside, double it and then return out to 50% intensity. I think that's a good rule of thumb. I think when in doubt, sit it out. I am a big fan of physical therapy and engaging our physical therapy colleagues, also our athletic training colleagues. So from injury on the field to back to competition, there's a gap in between those two. And I think in that gap, functional testing, dynamic testing, seeing what the athlete looks like on a practice field or in a physical therapy office or in a training facility and seeing how they do with stress prior to getting back on the field is usually the safest. If you can't perform in a physical therapy center or in a practice field, then you're probably not going to do so well in a game. And when there's competition and an opponent, especially in a contact sport, I think that athlete's at risk.

Melanie Cole, MS: Well then, you know, we're just getting such great information, Dr. Schlechter. It's so important for parents to hear. As we get ready to wrap up, you're offering your best advice here. As a pediatric orthopedic surgeon, I'd like you to speak to parents and coaches and the athletes themselves, because certainly the most important part of sports injuries is prevention. So, I'd like you to speak about what you want parents and coaches to know. If an athlete gets hurt in the field, what would you like them to do first? And then, give us your best advice on prevention, because that's really what it's all about.

Dr John Schlechter: An ounce of prevention is worth a pound of cure. I think Ben Franklin might have said that one. So, there's definitely truth in that. I think LeBron James again and load management comes up. So, I think just sometimes saying no to an event is super important. Listen to your body. And if you're just not feeling, happy and healthy and like you're in your best condition, yes, sometimes it's important as an athlete to push through that. And I think, you know, as a good coach, the coach tries to have the athlete do that. But there are times where you're just going to have to say no. There's such pressure on children and young athletes to perform to try to get to that next level. There's feeder teams that children have to perform one prior to making a high school team. So, there's those pressures. There's the pressure of scholarship. But I think managing the pressure is also super important. So, I think everything in moderation, including moderation is important. And sometimes you do have to push it, but I think listening to your body is super important.

And also, taking that time off. We like to say three months off a year, whether it needs to be three months in a row or just three months spread out over 12. I think that's a good rule of thumb. And during those three months, maybe cross train or seek out the advice of a strength and conditioning coach who understands children is super important and the developing, growing skeleton to try to hone in on skills that maybe it can prevent injury. So for anterior cruciate ligament tears, there are prevention programs out there that athletes can learn during the off season and use for warmup prior to competition. And when there's an injury on the field, withdrawing from that competition is probably safest and then seeking out the specialization of somebody who really understands children at a children's center is probably the best bet. And urgent cares, although they're very useful and they're handy in the community, sometimes they don't have the level of expertise that is present at a pediatric-centric institution.

Melanie Cole, MS: What a great point and such informative episode this was, Dr. Schlechter. Thank you so much for joining us today. And for more pediatric health and wellness tips, you can visit choc.org. It's that simple. Thank you so much for listening to Long Live Childhood, a pediatric health and wellness podcast, presented by Children's Health of Orange County. Together, we are keeping kids happy and healthy. And please, parents, remember to share on your social channels as we're all learning from the experts at CHOC together. I'm Melanie Cole. Thanks so much for joining us today.