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Concussion&Sports Injuries in School-aged Athletes

Online Health Chat with Paul M. Saluan, MD and Adam Lake, MEd, ATC, CSCS

September 19, 2012

Introduction

Cleveland_Clinic_Host: Children between the ages of 5 to 14 years old account for nearly 40 percent of all sports-related injuries treated in hospital emergency departments. When your child breaks an arm or leg, you know the emergency room will assess the injury and help arrange the orthopaedic care needed. But other injuries, like a concussion, may have more subtle symptoms. As a parent, it’s not always easy to determine when to seek help—or what type of doctor to call. This discussion will provide information on these key points as well as provide tips on how school-aged athletes can help prevent and recover from injury.

Injuries associated with participation in sports and recreational activities account for 21 percent of all traumatic brain injuries among children in the United States. Certified Athletic Trainer Adam Lake will discuss the signs and symptoms of concussions, what treatment options are available and how long the athlete should remain on the sidelines.

Immature bones, insufficient rest after an injury, and poor training or conditioning contribute to overuse injuries in many student athletes. In fact, overuse injury, is responsible for nearly half of all sports injuries to middle- and high-school students.

For More Information

On Cleveland Clinic
Cleveland Clinic’s Center for Sports Health brings together top orthopaedic surgeons, primary care sports medicine physicians, physical therapists, athletic trainers, nutritionists, radiologists and exercise physiologists to keep athletes in the game.

Our experts treat athletes in all sports and at all ages and skill levels. As our patient, you have access to the same specialists who treat Cleveland's professional sports teams. Our comprehensive services include rehabilitation, athletic training, performance, imaging, nutrition, and evaluation and management for sports-related concussions.

In  Cleveland Clinic’s Concussion Center, the Center for Sports Health offers concussion evaluations and management, through a collaborative effort between Primary Care Sports Medicine and the Neurologic Institute and is dedicated to evaluating and managing concussed athletes using a comprehensive, multidisciplinary approach.

Our team is made up of primary care sports medicine physicians, neurologists, neurosurgeons, neuropsychologists, certified athletic trainers, vestibular therapists, radiologists, neuro ophthalmologists, and researchers, all dedicated to getting the athlete back to play, safely.

On Your Health MyChart®: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: mychartsupport@ccf.org
A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult


For Appointments

To make an appointment with Paul Saluan, MD, or any of the other specialists in the Center for Sports Health or the Center for Pediatric Orthopaedic Surgery at Cleveland Clinic, please call 216.444.2606 or toll free at 866.275.7496. You can also visit us online at http://my.clevelandclinic.org/childrens-hospital/specialties-services/departments-centers/orthopaedic.aspx .


About the Speakers

Paul M. Saluan, MD, holds joint appointments in the Center for Sports Health and the Center for Pediatric Orthopaedic Surgery within the Orthopaedic and Rheumatologic Institute at Cleveland Clinic. He specializes in pediatric and adolescent sports medicine and arthroscopic surgery and in pediatric orthopaedic surgery. He is certified in orthopaedic surgery by the American Board of Orthopaedic Surgery.

Dr. Saluan is the developer and director of the Orthopaedic Arthroscopy Skills Lab Curriculum. He is also a contributor to a pediatric outcomes instrument that is being developed to assist in pediatric injury/disease-specific outcomes research. He has won several awards for his working including the Pinnacle Performance Center Award for Clinical Excellence in Sports Medicine.

Adam Lake, MEd, ATC, CSCS, is a certified athletic trainer for Cleveland Clinic Sports Health. He is a nationally certified by the board of certification and licensed by the Ohio Occupational Therapy, Physical Therapy, and Athletic Trainers Board. He is also a certified strength and conditioning specialist through the National Strength and Conditioning Association. He is actively involved in the concussion management program and several other concussion-related research projects.


Let’s Chat About Concussion and Sports Injuries in School-aged Athletes

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialists Dr. Paul Saluan and expert Adam Lake. We are thrilled to have them here today for Concussions and Sports Injuries in School-aged Athletes.


Baseline Testing

mollylucas: We live in eastern Pennsylvania. How do we find a certified location for our middle school-aged son to get a baseline test done?
Adam_Lake_MEd_ATC: I would recommend contacting the school district or local health system to see if they have the ability to conduct a baseline assessment. The baseline assessment, which is generally done via the Internet,  usually requires an access code, so that it is stored in  a  database and can be accessed in the future.

Nreynolds: Thank you Adam. However, in my area the only baseline assessment that is being done are for high school students with the use of the ImPACT® web program which is not geared for younger children.
Adam_Lake_MEd_ATC: The ImPACT®database should have normative data for athletes that are middle school aged as well.

mollylucas: Adam, what is your input for having baseline testing done for middle school age children playing football?
Adam_Lake_MEd_ATC: Baseline testing is valuable in middle school athletes. If there is a baseline test done, that gives one the ability to have a direct comparison to any post-injury evaluation.

Concussion Diagnosis and Prognosis

Soccermomma: I'm concerned about head injury from heading a soccer ball. My son complains often after a game that he has a bad headache? He's 16 years old, and plays high school soccer.
Dr__Saluan: Your son should be evaluated by a concussion specialist to address these recurrent headaches. Do not continue playing with the headaches.

tnuccio: Does having a bad concussion make you more prone to getting them again? And, how long does it take to heal from a concussion fully?
Dr__Saluan: Yes, having concussions does make you more prone to future concussions. The time to take to heal from a concussion is highly variable and individual.

sballard: What are the signs that we should look for?
Adam_Lake_MEd_ATC: There is a concussion guide on our website:  clevelandclinic.org/concussion

The initial signs you or the coach may observe include  a dazed or stunned appearance, confusion or clumsiness, seeming 'out of it', slow responses to questions, personality or behavior changes, loss of consciousness—even if temporary, forgetting plays or assignments, and forgetting play prior to or after a 'hit'.

sballard: Are there any specific signs that we should be looking for?
Adam_Lake_MEd_ATC: As in the previous answer, symptoms that may be reported by the athlete are headaches, nausea, balance problems, double or blurry vision, sensitivity to light or noise, fatigue or drowsiness, change in sleep patterns, trouble comprehending, concentrating and /or paying attention, depression, irritability, nervousness or sadness, or feeling 'just not right' or being in a 'fog',

thumper_1: With head injuries during sporting events, can you provide basic exam tests a lay person (such as a parent) can do, and the best triage advice based on the results (when to go to the ER [emergency room], when to go to urgent care, when to let them keep playing, etc.)?
Adam_Lake_MEd_ATC: We like to say ' when in doubt, sit them out.' Worsening symptoms, such as drowsiness and difficulty staying awake, inability to recognize people or places, slurred speech, repeat vomiting, and any unusual behavior changes should be recognized and the athlete taken to the emergency room for evaluation.

thumper: Is there a higher correlation between postconcussive syndrome (PCS) and multiple sclerosis or Parkinson’s disease?
Dr__Saluan: Anecdotally, if you look at Muhammad Ali and his lifetime exposure to concussion and head injury, and the eventual development of Parkinson's disease, it is worrisome to say the least.

However, we don't have any real scientific evidence at this time to show that concussions lead to Parkinson's disease or multiple sclerosis.

show_me: Do symptoms of a concussion show up immediately, or could there be a delay appearing for several days? Can you have a concussion with no symptoms?
Adam_Lake_MEd_ATC: Concussion symptoms can occur immediately, but can also be delayed and occur within 24 to 48 hours.

Concussion Treatment

sballard: My 11-year-old son took a hard blow and woke up with a nosebleed. I took him to the hospital and they did a CT scan and blood work, and everything was normal. However, my son said that he felt like he needed to throw up, so they said he had a concussion. How long should he stay out from football?
Adam_Lake_MEd_ATC: He should also be evaluated by a sports medicine physician that specializes in concussion management to have a complete evaluation. There are several other tests that should be done that are not routinely done in an emergency room. Once he has been evaluated and is symptom-free, he should follow a graded return-to-play program. The length of this program will depend on his specific case.

Graded Return-to-Play Post-injury

Nreynolds: For children with concussions younger then high school age, for example between the ages of 8 and 12 years old, how do you know when it is safe for them to return to contact sports?
Adam_Lake_MEd_ATC: It is important for all athletes to be completely recovered from a concussion before they return to sports. It is important that they are evaluated by a physician who is experienced in concussion management, and that they follow a graded return-to-play progression. Younger athletes often require more time to recover. They are often treated more conservatively and require a longer return-to-play progression.

Nreynolds: Can you please explain what a graded return-to-play progression is?
Adam_Lake_MEd_ATC: A graded return is a gradual increase in exercise level until a full return to sports. It is important that this program is monitored by a medical professional. We use a six-step program: 1. rest, 2. light aerobic exercise, 3. moderate intensity exercise, 4. higher intensity exercise and participation in non-contact drills,5. participation in practice, and 6. return to game play.

Impact Sport Diagnosis and Prognosis

Shakerchamber_1: When will Cleveland Clinic consider mini-clinics in schools where impact sports are played? How can we make that happen?
Adam_Lake_MEd_ATC: We have information for parents and athletes available on the Cleveland Clinic Concussion Center website clevelandclinic.org/concussion and are looking into providing educational sessions for parents and athletes.

Shakerchamber_1: What is the long-term effect on children from football impact over middle school and high school ages as it relates to their ability to learn?
Adam_Lake_MEd_ATC: The long term effects from football impact are unclear. It is important that all athletes experiencing any symptoms of concussion be seen by a physician.

Other Sports Injury Prevention

dfoote: What is your opinion of children with seizure disorders participating in football, soccer, etc.?
Dr__Saluan: As long as there is medical control of their seizures and they have been cleared by their pediatrician, then they should be able to play without increased risk.

barry: My daughter is the only pitcher on her high school softball team. She works with her trainer to get heat before games and ice after, but she plays in every season (including winter). I’m scared she could do serious damage to her shoulder. Do you think this is a real concern? I’ve been told that the fast pitch motion is the natural motion of the arm, so there’s nothing to worry about, but I’m still worried about the long-term effects.
Dr__Saluan: I think there is a concern for overuse creating a problem for your daughter’s shoulder. Softball players don't get the same types of injuries that baseball players do, but they can still get significant issues related to joints breaking down over time.

They tend to get tendonitis problems from this pitching motion that is unique to softball (biceps). The common approach is to give her some rest over a period of eight to 10 weeks to allow her shoulder to settle down.

jlocke: Is it true that by wearing a mouth guard your risk of getting a concussion is lower? I’ve heard that and I think my daughter, who plays soccer, should wear one out of precaution? Do you agree?
Adam_Lake_MEd_ATC: There is no scientific evidence that supports wearing a mouth guard will reduce the risk of concussion. However, it is not a bad idea and will protect her teeth at the very least.

sight_unseen: My son’s baseball coach told him that if he starts weightlifting now (he’s 12 years old) it will help to prevent injuries as he gets older. Is that true? How young is too young to start weigh lifting? How might that effect his growth and performance as he ages?
Dr__Saluan: Weightlifting in this age group, the 10- to 14-year-old group, should consist of resistance training using bands, push-ups, and the child's own body weight. Free weights and weight machines are generally not a good idea for younger people in this age group. Their growth plates are still fairly wide open, which creates a weak link in the bone where the stress will go when lifting heavier weights.

mnewman: My boys are 6- and 7- years old, and would like to get involved in sports. In your opinion, what is the safest sport for children? I would like them to be involved in a team sport, as I think that would be a better experience for them than an individual sport.
Dr__Saluan: The safest sports for young individuals are sports that are played in moderation with no or minimal contact. High contact sports such as football, hockey and lacrosse are associated with higher levels of injury. Different types of injuries are associated with different sports.

Track and field, cross country and swimming are associated less with traumatic injuries and more with overuse injuries. They are usually less severe than contact sports, and generally less likely to need surgery to correct.

In general, make sure your children are in good physical condition and get appropriate amounts of rest. Also, check on the coach's credentials and track record to make sure no patterns of injury are noted.

Soccermomma: Regarding soccer conditioning, during endurance training, the children are running concrete staircases, but many are having knee discomfort and spasms. Does the impact on the concrete cause injury?
Dr__Saluan: This is considered a training error, when multiple athletes experience similar problems due to the training atmosphere. I would avoid hard surfaces as a routine.

the_man: I've read various reports. Does stretching really help prevent sports-related injuries?
Dr__Saluan: Warming up, which is what we call dynamic stretching (stretching with activity, such as jogging, hopping, lunges and jumps) help warm the muscles and tendons.

Knee Treatment

dipper: Two weeks ago my son was playing basketball and felt a pop in his knee. I took him to the doctor, and they said he had a torn ACL. However,  the doctor said he could continue to walk on it until we could schedule time for surgery at his winter break. He’s not playing basketball anymore, but is still walking on it. Is that OK or normal?
Dr__Saluan: ACL injuries cause instability of the knee, which can then cause meniscal and cartilage injury. The ACL is something we have the ability to reconstruct effectively. Meniscal and cartilage injuries are more difficult to deal with and can cause lifelong issues.

Children with ACL injuries should be fixed sooner rather than later because of the risk of further injury in the interim. Even if they are not involved in sports, they could still get further damage prior to ACL reconstruction if delayed too long.

If your child has swelling and/or giving way of the knee, get him taken care of sooner than winter break. Good luck, and if I can be of any further assistance, please let me know

Groin Pull Treatment

thumper_1: What is the best treatment for a groin pull?
Dr__Saluan: Ice, rest and avoid overstretching. Once the initial pain dies down, then a slow functional return to sports is the right way to go. Functional return means stretching through a normal arc of motion using muscles that are already warmed up. The old approach of stretching a cold muscle is not helpful.

Sports Psychology

thumper: For high potential athletes, is a sports psychologist beneficial in helping with handling issues of pressure? What are the key qualities to look for when selecting a good sports psychologist?
Dr__Saluan: I think sports psychology is an emerging field in all levels of sports that is of high value. For instance, visualization and imagery help higher level athletes perform even better if done routinely. This approach can be fine tuned with a sports psychologist.

Also, when an athlete is injured, they tend to become a bit nervous about an ultimate return to sports. For instance, children with ACL (anterior cruciate ligament) injuries may become nervous about re-injury, and ultimately have this affect their return to sports. A sports psychologist can have a huge impact with these issues. We will be using their services more and more.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialists Paul M. Saluan, MD and expert Adam Lake, is now over. Thank you, Dr. Saluan and Adam for taking the time to answer our questions today about Sports Injuries in School-Aged Athletes.

Dr__Saluan: Thanks for the opportunity to answer these great questions. If I can be of any further assistance, please feel free to come in for an appointment with me to discuss Pediatric and Adolescent Sports Medicine issues. (can we add his number?)  877.440 TEAM (8326)

Adam_Lake_MEd_ATC: Thank you for your time, Have a nice afternoon. For more information on concussion you can visit: clevelandclinic.org/concussion


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