Dr. Sarah Gubara (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Sara Gubara. And today, I'm joined by Dr. Greg Canty, Medical Director of the Sports Medicine Center at Children's Mercy Kansas City.

Today, we're exploring sports injuries. Dr. Canty, thank you so much for taking the time to join us.

Dr. Greg Canty: Thanks for having me, Dr. Gubara. Looking forward to the conversation.

Host: I'm excited. So, let's get into sports injuries that many may overlook. What are some of the most common sports injuries you see that are frequently missed or mistaken for a minor issue?

Dr. Greg Canty: Well, I would say probably one of the more frequent injuries we see with the start of school sports are really knee injuries. And knee injuries come in many different flavors. Some of the ones that I think folks should be particularly aware of or to think about are those kind of maybe X-ray-negative knee injuries where someone maybe has an injury. Sometimes the X-ray can be falsely reassuring, and it's kind of diagnosed as just a sprain.

But I would tell folks to be aware of any knee injury, even if it's X-ray negative, if it's accompanied by swelling in a young athlete. And that could be a lot of swelling or can sometimes be a small amount of swelling. But I think you have to have a little proceed with caution if there's swelling involved

Host: That makes sense. Are there other specific symptoms or red flags that should prompt a primary care provider to refer an athlete sooner than taking a wait-and-see approach?

Dr. Greg Canty: If we go back to kind of the knee injury question, I tell folks that if you've got swelling involved with an acute knee injury in a young athlete, it's often one of three things. It could be a patella dislocation, which are quite common. And by the time they present to healthcare providers, sometimes the patella's relocated and the X-ray looks normal.

And the other thing we frequently see in young adolescent athletes are ACL tears and ACL ruptures. They can present with sometimes a large amount of swelling, what I call kind of the big fat swollen knee, or they can sometimes have a smaller amount of swelling. So, we think you have to be concerned about that.

And then, occasionally fractures. When you involve the growth plates around the knee, there can be fractures and injuries that are not readily obvious on plain film X-rays. And so, I keep those in mind because I think I see those that are missed when they show up a week or two afterwards, and they've been immobilized. And sometimes that's really a delay in diagnosis and treatment for those young athletes. Along with that, you'll occasionally have some meniscus injuries that can present. Particularly, they'll have pain and tenderness along the joint line.

You asked a little bit about specific symptoms or red flags. I think for those it's really that inability to weight bear. We talk a lot to residents or learners who want to hear more about sports medicine in our clinic. Limping counts as weight bearing. But if someone cannot really weight bear or even put any weight on or a limp on it, I think that needs to be seen on an urgent basis.

Host: That makes sense. So, you mentioned growth plates. Growth plates can make pediatric sports injuries so different from adult injuries. What are some growth plate injuries that referring providers should be especially aware of?

Dr. Greg Canty: Probably two come to mind, and particularly those adolescent athletes. You know, in the world of pediatrics, we take care of an interesting age frame. You take care of young athletes. And then, by the time they're 17 or 18, they're practically many times adult anatomically-wise. But in those transitional phases of kind of the pre-teens and teen years, you oftentimes will see the growth plate or what we call the apophysis lead to very unique injury patterns.

There's a couple I think about that come to mind. One is what are called pelvic avulsion fractures, which are avulsion fractures along the pelvis where the large muscle groups from the lower extremity will attach. Those are oftentimes injured when you think of activities such as running and sprinting in a sport. Those are oftentimes kind of explosive type injuries, and you get these large muscle groups as they're developing, but they still attach to a rather immature piece of the skeleton along the pelvis, and it will actually just pull that small piece of bone or cartilage cap off.

And so, I think when you're dealing with young athletes in that kind of, we'll say 13, 14 to 17 type age range, it can happen a little bit outside of that, but it gives you a general framework. If you see those and they have a sudden explosive type injury, you have to have a really high suspicion of an avulsion fracture. Those can sometimes even be difficult to see on X-rays. So, have a high likelihood of suspicion. They'll oftentimes be mistaken for just a muscle strain.

The others are transitional fractures we see around the ankle. I see a lot of ankle fractures and injuries that will present and be presumed to be an ankle sprain. There are things called a Tillaux fracture or what's called a Salter-Harris III fracture of the ankle that's very unique to that adolescent age group, and those will oftentimes be missed on X-ray and on exam.

And so, if you have someone with a large amount of swelling, again, just like the knee, and really an inability to weight bear, be very suspicious. Take a close look at those X-rays or speak with your radiologist about those to really take a look and make sure there's no evidence of a growth plate fracture involved with those. Those are probably two of the more commons we see that are very unique to that age category.

Host: Overuse injuries are becoming so much more common as youth athletes specialize in a single sport. Dr. Canty, what should providers watch for during evaluation?

Dr. Greg Canty: As we see the increase in early sports specialization, we've talked a lot about that in the world of pediatric sports medicine, that we're not always the biggest fans of sports specialization, because we really want people to develop a broad range of skills that we think will help them and really give them more opportunities as they go into adolescence to kind of sample. So, I'm a big fan of sports sampling when they're younger. But we know that folks will oftentimes be drawn to one particular sport. And if they do do early sports specialization, I think you have to have an increased awareness of these overuse injuries. You have to look for those subtle yellow flags even more than someone who's playing a multitude of sports, because it's oftentimes the same motion over and over and over. And that repetition in a young growing skeleton just puts you at risk for injury.

Some examples we'll talk about a little bit, it can happen in any sport, but we'll talk about gymnastics a little bit because there's probably two that many people can kind of visualize. Really gymnast wrist is one that comes to mind a lot. Gymnasts are frequently walking on their hands over and over again. We also think about gymnasts, cheerleaders, football players, pretty much any athlete that does a lot of repetitive back extension. We see stress fractures called a spondylolysis frequently that are mistaken for just mechanical back pain. It turns out to be something much more. The classic Little League elbow throwers in that early adolescent age group that's throwing repetitively over and over develop irritation along that medial epicondyle. We'll see a lot of our overhead athletes that do things. We'll say this time of the year we see a lot of swimmers, but it occurs in volleyball players, any overhead throwers will get a lot of impingement and shoulder pain.

And I think you just have to be aware of pain that's lasting more than a couple of weeks in single sport athletes in particular. And so, probably any athlete, a decent rule of thumb, but really if you're a single sport athlete, you're having a joint pain or some type of musculoskeletal condition that's not improving over about two weeks, I think that needs to be checked out. The more attention you pay to that early, probably the better outcome, the quicker outcome you get. And sometimes with these overuse injuries, X-rays can be not as helpful as we want them to be. So, you really have to have a high index of suspicion. And so again, if you're having pain lasting more than two weeks, or the young athlete at two weeks or so is still not wanting to participate or having some change of their participation and training plan, that's worthy of getting checked out, because it may really help you in the long run.

Another thing I talk to a lot of folks when you talk about overuse injuries, I think of it as an overuse injury, but really kind of burnout in young athletes. We see young athletes that do single sport specialization. I think we have to think about those that are sometimes getting burnout. They need some time away from sport. They need some time to think about and focus on themselves. I tell people you got to have to have your own self-identity outside of sport too.

I think sometimes emphasizing that when you see symptoms of burnout in young athletes where they're playing too many games, too many practices, start to have joint aches and pains, I think it's always a subtle conversation to have with families and young athletes because they get pressure from both internal pressure themselves. They're putting on to get better and striving to get better at the sports. You also get a lot of external pressure from both coaches and parents. Even if it's not intentional, they feel that pressure and they know how much time, energy and, frankly, finances that people spend on youth sports today, and they'll internalize that pressure and it can lead to some burnout. And I think thinking about that as an overuse injury is also something that healthcare providers should be aware of.

Host: Dr. Canty, what's one sports injury or condition that you wish more referring providers had on their radar, and why does early diagnosis matter?

Dr. Greg Canty: I think if we think about one condition that I really would like referring providers to have on their radar, that's bone stress injuries. In particular, we'll see a lot of things that get labeled as shin splints, and shin splints clearly happen. We talk about pain there along that medial tibial stress, but the thing we see a lot of as it progresses is really stress fractures. The most common's going to be there along the tibia, the fibula in the lower leg, but you can have those elsewhere.

And I think oftentimes thinking about stress injuries of the bone really helps you think more globally about a patient. And so, I think if you have an athlete that comes in that's complaining of pain, I want them to have on their radar, things that may contribute to the conversation, the risk of bone stress injuries, things like what's this young athlete's training plan? Have they had a recent marked increase in their training load? Do they get enough recovery time? Do they get days off? Do they get good sleep at night? What about their nutritional status? Do they get enough calories? Do they get the right kind of calories? And oftentimes, in young female athletes will use menses as a marker to figure out if they're having irregular menses after having established a regular pattern, that could also suggest they're at higher risk of having a bone stress injury.

And so, we'll see those frequently, athletes will get diagnosed with shin splints. They'll try to push through for weeks, if not months, and that gradually gets worse and worse and worse. So, I think whenever you have a hint or a suspicion of shin splints or maybe a stress fracture, taking a step back and thinking not just about where does it hurt, is it point tender, but also asking those questions globally about their health can be really helpful and help you get on the right page right away and help them really get a quicker recovery and back to sport, back to activity sooner.

And it also helps by having that conversation help athletes start to think about. I'll sometimes say that diagnosing a stress fracture sometimes is easy. It's helping young athletes understand why they got that stress fracture and what we can do to prevent the next one that really can sometimes be more challenging.

But I think we see a lot of those. And if referring providers had that in mind, I think they can maybe pick up a few of those even earlier and be a help to their patients. And so, I tell folks, if you think about that, a young athlete's having point tenderness, difficulty doing things like a single leg hop or jumping on one leg, you should get those taken care of and maybe referred over a little bit more quickly.

Host: Thank you, Dr. Canty, for walking us through sports injuries that may be overlooked as well as your recommendations. You've been a fantastic advocate for youth sports and health and wellness. I'm grateful to have the time to talk to you.

Dr. Greg Canty: I really appreciate the opportunity, and I hope our conversation's helpful for the healthcare providers out there.

Host: Absolutely. And as a reminder to our audience, claim your CME credits after listening to this fascinating episode today. You can do so by visiting cmkc.link/cmepodcast, and then click the Claim CME button. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm Dr. Sarah Gubara. And this has been Pediatrics in Practice, a CME podcast.