Feature
Working with the Teenaged Athlete
A conversation with Joel Boyd, M.D.
By virtue of being a sports medicine doctor, you specialize in teenagers,” says Joel Boyd, M.D., an orthopedic surgeon who practices at TRIA Orthopaedic Center in Bloomington. That’s because they’re the largest group playing sports, he explains.
Boyd thinks sports medicine has a number of parallels with pediatrics. For one thing, physicians in both specialties tend to follow patients over years. “If you see a kid at age 5 or 6 or 7 years for a wrist fracture, and they play hockey or another sport, more than likely, you’re going to be seeing that kid for most of their other bumps, bruises, sprains, and strains,” he says.
But Boyd says sports medicine physicians bring a unique perspective when treating injured teens. “We’re trained to understand the normal progression of injuries and when it may be safe for an athlete to return to play,” he says. “It’s not that primary care physicians don’t know, it’s just that they don’t spend a lot of time figuring out when the athlete can come back safely.”
Boyd, who supervises TRIA’s sports medicine fellowship and works for a number of professional and school teams, recently spoke with Minnesota Medicine about sports medicine and the special concerns of teenaged athletes.
Q.What are the injuries that most often bring teens to a sports medicine physician?
Concussion, ACL injuries, and shoulder injuries. Ankle sprains or strains—those kind of things—would more often be seen in an urgent care or primary care setting.
Q.Is the concussion rate in teens higher than it used to be?
I think it’s recognized as a problem now rather than that it’s a new problem. People are starting to realize that a concussion could have long-term consequences. We tend to see concussions most often in collision sports such as football and hockey, and the rates are fairly high in soccer.
Q. Are teens more prone to concussion than adults?
We don’t have data that suggest that teenagers are more susceptible to concussion; but most experts now concur that suffering a concussion at a younger age is serious. I don’t think we know that a second concussion is more dangerous than the first, but most would agree that having multiple concussions is a problem. And some think it might be easier to get a second concussion.
Q. How do sports medicine physicians approach concussion?
While other physicians might deal with concussion in the exam room, we deal with concussion on the sidelines. If you’re a team physician, you have to have a good protocol for assessing whether an athlete is concussed or not. And then you have to stick to that protocol. Once it’s been determined that a player has a concussion, then you have to have another protocol for return to play.
It’s easy to say that a player who has had a concussion should be out the rest of the game. In reality, it’s hard to put that into practice because one person’s little head bump is another person’s big concussion. In addition, symptoms can occur immediately or be delayed. Sometimes someone will say they have a dull headache that just won’t go away. It’s not like your leg doesn’t work and you have a lot of pain.
Q. Can you describe what happens on the sidelines when you’re concerned that a player has a concussion?
You try to talk to the kid, even though he may not want to talk to you. They are aware that this could be the end of the night for them, and they don’t want to stop playing. So you try to get information by asking questions like, Where are you? What quarter is it? What’s the score? If they’re not talking, you don’t know if they’re upset or confused. In those cases, we’ll ask the athletic trainer to be on hand because he or she knows the athlete better. Often, the student will open up a little more in their presence. Then you try to assess their memory about what happened. You also might ask them to remember three things or count backwards in serial sevens. And you might have them close their eyes and walk backwards. Concussed athletes have a hard time maintaining their balance doing this. All these things are part of standard sideline protocols.
Q. What should primary care providers know about treating concussion in teens?
Primary care physicians should be aware of the initial presentation, signs, and symptoms of concussion and when to hold an athlete from further competition. If they have a special interest in concussion and have a return-to-play protocol (which may include computer testing, a physical exertion test, and practice monitoring), then they can evaluate for return to play. If not, the athlete should be referred to a musculoskeletal specialist or neurologist who has these protocols.
Several bodies including the Centers for Disease Control and Prevention, the Academy of Sports Medicine, and the American Academy of Orthopedic Surgeons have developed guidelines for evaluating athletes for concussion. Many sports organizations—from professional to amateur to high school—continue to struggle with which evaluation process to use; but there are common signs and symptoms that not only primary care physicians, but also parents, coaches, and athletes themselves, should recognize. These include headache, balance problems, dizziness, fatigue, sleep issues, irritability, emotional changes, difficulty concentrating, and vision changes.
Q. Let’s talk about ACL injuries. Why are they prevalent in teens?
Teenagers tend to present with ACL injuries because they participate in many of the stop/start/pivot sports such as football, soccer, and basketball, where athletes change direction or decelerate quickly on a sticky or unforgiving surface. ACL injuries tend to be more common in these sports as compared with a sport like hockey. They also can occur when a player is hit by another player.
Females seem to have a higher incidence rate of ACL injuries than males. An NCAA study showed a five-times-greater risk for ACL injuries in Division I women basketball players as compared with men. We see similar trends in high school athletes. Although research has not turned up one particular reason why female athletes seem to be at greater risk for ACL injuries than male athletes, there are several potentially interesting associations. One may be a lower extremity muscle imbalance between the quadriceps and hamstrings. Lack of core strength may be another. Programs are currently being designed to look at these factors in terms of injury prevention.
Q. How should primary care physicians manage patients with knee injuries?
A good clinical exam is the first step. The physician needs to examine the knee visually to see if there’s swelling and decreased range of motion. A standard X-ray series should be ordered to rule out acute problems that need immediate attention such as a fracture.
If the knee is locked or if there are other red flags such as instability, immediate referral to an orthopedic surgeon is in order. Otherwise, referral can be made after initial management that includes rest, ice, compression, elevation, and use of a knee immobilizer and crutches along with early physical therapy.
Q. What is the general recommendation regarding surgery in teens?
Most young athletes should have their ACLs reconstructed. Whether an adult gets an ACL reconstructed depends on his or her activity level and the types of activities in which they’re involved. But most young people are involved in a lot of activities and have no idea what type of job they’re going to have in the future. They might be a SWAT team member or in the military. They might be jumping from airplanes. Most young people need to have a stable joint going forward. In most cases, they can expect to return to play their sport in six months to a year after surgery.
Q. Why are teens prone to shoulder injuries?
Because they tend to participate in more throwing and contact sports and because they have more flexible joints. Although dislocations and recurrent subluxations tend to occur in athletes who play collision and throwing sports, a range of subtle shoulder instability problems can occur in athletes who participate in noncontact sports such as swimming, tennis, volleyball, and gymnastics.
Q. What’s the first step in diagnosing a shoulder injury?
To evaluate a dislocation, a physician needs to X-ray three views of the shoulder: AP, Y view, and axillary view; an MRI can help them evaluate soft-tissue injuries.
A primary care provider can provide initial treatment and management of these injuries if he or she is knowledgeable about reduction techniques. Initial acute management of a dislocation includes closed reduction followed by rest, ice, compression, and elevation with a sling or immobilizer. Referral to a musculoskeletal consultant following initial conservative management is often appropriate.
If the physician is not knowledgeable in reduction techniques or if the reduction attempt fails, he or she should make an immediate referral to the nearest emergency department or to a musculoskeletal specialist. The treating physician should also refer to a specialist if the injury is not acute but is a recurrence of a dislocation or if the athlete has feelings of instability, numbness, or tingling in the affected upper extremity. A referral should also be made if the joint is locked.
Q. How much do pediatricians and family physicians need to know about sports medicine?
They need to be familiar enough with the types of injuries athletes get and when symptoms are worrisome that they can make appropriate referrals. I’d recommend they have a relationship with several orthopedic and sports medicine specialists.
Q. Do we take sports injuries in teens more seriously today than we used to?
I think we do to some degree. And I think that’s because we recognize the long-term consequences of them and because kids are involved in so many sports activities. Also, these days there’s a lot more intensity around athletics for young people. In the old days—I consider myself part of the old days—you played outside, you played every sport a little. If you got hurt, your parents might say, Well don’t play that or Put something on it until it gets better. Now, both the parents and the teens expect to see someone who will diagnose the problem and help them get better. MM
Carmen Peota, managing editor of Minnesota Medicine, and Megan Reams, manager of clinical outcomes, research, and education at TRIA Orthopaedic Center, conducted this interview.