Anthony Luke

Overuse Injuries and Burnout in Youth Sports: APositionStatementfromtheAmericanMedicalSocietyfor Sports Medicine

### Background Youth sport participation offers many benefits including the development of self-esteem, peer socialisation and general fitness. However, an emphasis on competitive success, often driven by goals of elite-level travel team selection, collegiate scholarships, Olympic and National team membership and even professional contracts, has seemingly become widespread. This has resulted in an increased pressure to begin high-intensity training at young ages. Such an excessive focus on early intensive training and competition at young ages rather than skill development can lead to overuse injury and burnout. ### Purpose To provide a systematic, evidenced-based review that will (1) assist clinicians in recognising young athletes at risk for overuse injuries and burnout; (2)delineate the risk factors and injuries that are unique to the skeletally immature young athlete; (3) describe specific high-risk overuse injuries that present management challenges and/or can lead to long-term health consequences; (4) summarise the risk factors and symptoms associated with burnout in young athletes; (5)provide recommendations on overuse injury prevention. ### Methodology Medical Subject Headings (MeSHs) and text words were searched on 26 March 2012 from MEDLINE, CINAHL and PsycINFO. The search yielded 953 unique articles. Additional articles were found using cross-referencing. The process was repeated on 10 July 2013 to review any new articles since the original search. Screening by the authors yielded a total of 208 relevant sources that were used for this article. Recommendations were classified using the Strength of Recommendation Taxonomy (SORT) grading system. ### Definition of overuse injury Overuse injuries occur due to repetitive submaximal loading of the musculoskeletal system when rest is not adequate to allow for structural adaptation to take place. Injury can involve the muscle-tendon unit, bone, bursa, neurovascular structures and the physis. Overuse injuries unique to young athletes include apophyseal injuries and physeal stress injuries. ### Epidemiology It is estimated that 27 million US youth between 6 and 18 years of age participate in …

T1rho, T2 and focal knee cartilage abnormalities in physically active and sedentary healthy subjects versus early OA patients—a 3.0-Tesla MRI study

Abstract(1) To assess the degree of focal cartilage abnormalities in physically active and sedentary healthy subjects as well as in patients with early osteoarthritis (OA). (2) To determine the diagnostic value of T2 and T1rho measurements in identifying asymptomatic physically active subjects with focal cartilage lesions. Thirteen asymptomatic physically active subjects, 7 asymptomatic sedentary subjects, and 17 patients with mild OA underwent 3.0-T MRI of the knee joint. T1rho and T2 values, cartilage volume and thickness, as well as the WORMS scores were obtained. Nine out of 13 active healthy subjects had focal cartilage abnormalities. T1rho and T2 values in active subjects with and without focal cartilage abnormalities differed significantly (p < 0.05). T1rho and T2 values were significantly higher (p < 0.05) in early OA patients compared to healthy subjects. T1rho measurements were superior to T2 in differentiating OA patients from healthy subjects, yet T1rho was moderately age-dependent. (1) Active subjects showed a high prevalence of focal cartilage abnormalities and (2) active subjects with and without focal cartilage abnormalities had different T1rho and T2 composition of cartilage. Thus, T1rho and T2 could be a parameter suited to identify active healthy subjects at higher risk for developing cartilage pathology.

Partial Tears of the Anterior Cruciate Ligament in Children and Adolescents

Background: The functional outcome after partial anterior cruciate ligament tears in children and adolescents treated without reconstruction has not been established. Hypothesis: Nonreconstructive management of partial anterior cruciate ligament tears can be effective in certain pediatric patients. Study Design: Prospective cohort study. Methods: We studied 45 skeletally mature and immature patients 17 years of age or less who had an acute hemarthrosis, magnetic resonance imaging signal changes, grade A or B Lachman and pivot shift result, and an arthroscopically documented partial anterior cruciate ligament tears. All patients were treated without reconstruction, underwent a structured rehabilitation program, and were followed up for a minimum of 2 years. Results: Fourteen patients (31%) underwent subsequent reconstruction. Significant associations with subsequent reconstruction included tears that were greater than 50%, predominantly posterolateral tears, a grade B pivot shift test result, and older chronologic and skeletal age. Among patients who did not require reconstruction, those with tears that were greater than 50% or predominantly posterolateral had significantly lower Lysholm, satisfaction, and Cincinnati Knee Scale scores. Conclusions: Nonreconstructive management is recommended for partial anterior cruciate ligament tears in children and adolescents 14 years of skeletal age or younger with normal or near-normal Lachman and pivot shift results. Reconstruction is recommended in older athletes or in those with greater than 50% or predominantly posterolateral tears.

Meniscal Measurements of T1ρ and T2 at MR Imaging in Healthy Subjects and Patients with Osteoarthritis

PURPOSE To prospectively evaluate differences in T1(rho) (T1 relaxation time in the rotating frame) and T2 values in the meniscus at magnetic resonance (MR) imaging in both patients with varying degrees of osteoarthritis (OA) and healthy control subjects. MATERIALS AND METHODS The study was institutional review board approved and HIPAA compliant. Written informed consent was obtained from all subjects. T1(rho) and T2 measurements were performed at 3.0-T MR imaging in 60 subjects deemed to be healthy (n = 23; mean age, 34.1 years +/- 10.0 [standard deviation]; age range, 23-59 years), having mild OA (n = 27; mean age, 52.5 years +/- 10.9; age range, 32-69 years), or having severe OA (n = 10; mean age, 61.6 years +/- 11.6; age range, 50-86 years). Semiautomatic segmentation was performed to generate T1(rho) and T2 maps of the menisci. Clinical findings were assessed by using Western Ontario and McMaster Osteoarthritis (WOMAC) questionnaires. Differences in T1(rho) and T2 values between the three subject groups were calculated by using two-tailed t tests (with P < .05 indicating significance), and receiver operating characteristic analyses were performed. Correlations of meniscal T1(rho) and T2 values with age, cartilage-derived T1(rho) and T2 parameters, and WOMAC scores were calculated. RESULTS Significant differences between the three subject groups were found: Mean T1(rho) values were 14.7 msec +/- 5.5, 16.1 msec +/- 6.6, and 19.3 msec +/- 7.6 for the healthy, mild OA, and severe OA groups, respectively. Mean T2 values were 11.4 msec +/- 3.9, 13.5 msec +/- 4.7, and 16.6 msec +/- 8.2 for the healthy, mild OA, and severe OA groups, respectively. Correlations of meniscal T1(rho) and T2 values with subject age (R(2) = 0.18, for correlation with T2 only), cartilage-derived parameters (R(2) = 0.14-0.29), and WOMAC scores (R(2) = 0.11-0.45) were significant. CONCLUSION Meniscal T1(rho) and T2 values correlate with clinical findings of OA and can be used to differentiate healthy subjects from patients with mild or severe OA.

Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine.

• Youth sport participation offers many benefits including the development of self-esteem, peer socialization, and general fitness. • However, an emphasis on competitive success, often driven by goals of elite-level travel team selection, collegiate scholarships, Olympic and National team membership, and even professional contracts, has seemingly become widespread. • This has resulted in increased pressure to begin highintensity training at young ages. • Such an excessive focus on early intensive training and competition at young ages rather than skill development can lead to overuse injury and burnout.

Sports-related Injuries in Youth Athletes: Is Overscheduling a Risk Factor?

Objective:To examine the association between “overscheduling” and sports-related overuse and acute injuries in young athletes and to identify other potential contributing factors to create a working definition for “overscheduling injury.” Design:Survey. Setting:Six university-based sports medicine clinics in North America. Participants:Athletes aged 6 to 18 years (13.8 ± 2.6) and their parents and pediatric sports medicine-trained physicians. Interventions:Questionnaires developed from literature review and expert consensus to investigate overscheduling and sports-related injuries were completed over a 3-month period. Main Outcome Measures:Physicians clinical diagnosis and injury categorization: acute not fatigue related (AI), overuse not fatigue related (OI), acute fatigue related (AFI), or overuse fatigue related (OFI). Results:Overall, 360 questionnaires were completed (84% response rate). Overuse not fatigue-related injuries were encountered most often (44.7%), compared with AI (41.9%) and OFI (9.7%). Number of practices within 48 hours before injury was higher (1.7 ± 1.5) for athletes with OI versus those with AI (1.3 ± 1.4; P = 0.025). Athlete or parent perception of excessive play/training without adequate rest in the days before the injury was related to overuse (P = 0.016) and fatigue-related injuries (P = 0.010). Fatigue-related injuries were related to sleeping ≤6 hours the night before the injury (P = 0.028). Conclusions:When scheduling youth sporting events, potential activity volume and intensity over any 48-hour period, recovery time between all training and competition bouts, and potential between-day sleep time (≥ 7 hours) should be considered to optimize safety. An overscheduling injury can be defined as an injury related to excessive planned physical activity without adequate time for rest and recovery, including between training sessions/competitions and consecutive days.

High-Field Magnetic Resonance Imaging Assessment of Articular Cartilage Before and After Marathon Running: Does Long-Distance Running Lead to Cartilage Damage?

Background There is continuing controversy whether long-distance running results in irreversible articular cartilage damage. New quantitative magnetic resonance imaging (MRI) techniques used at 3.0 T have been developed including T1rho (T1ρ) and T2 relaxation time measurements that detect early cartilage proteoglycan and collagen breakdown. Hypothesis Marathon runners will demonstrate T1ρ and T2 changes in articular cartilage on MRI after a marathon, which are not seen in nonrunners. These changes are reversible. Study Design Cohort study; Level of evidence, 2. Methods Ten asymptomatic marathon runners had 3-T knee MRI scans 2 weeks before, within 48 hours after, and 10 to 12 weeks after running a marathon. The T1ρ and T2 MRI sequences in runners were compared with those of 10 age- and gender-matched controls who had MRI performed at baseline and 10 to 12 weeks. Results Runners did not demonstrate any gross morphologic MRI changes after running a marathon. Postmarathon studies, however, revealed significantly higher T2 and T1ρ values in all articular cartilage areas of the knee (P < .01) except the lateral compartment. The T2 values recovered to baseline except in the medial femoral condyle after 3 months. Average T1ρ values increased after the marathon from 37.0 to 38.9 (P < .001) and remained increased at 3 months. Conclusion Runners showed elevated T1ρ and T2 values after a marathon, suggesting biochemical changes in articular cartilage, T1ρ values remain elevated after 3 months of reduced activity. The patellofemoral joint and medial compartment of the knee show the highest signal changes, suggesting they are at higher risk for degeneration.

T1ρ Imaging Demonstrates Early Changes in the Lateral Patella in Patients With Patellofemoral Pain and Maltracking

Background: Patellofemoral pain (PFP) is a common condition and often presents without evidence of arthritis on radiographs. Magnetic resonance imaging (MRI) has shown good correlation between T1ρ and T2 relaxation times and changes in the cartilage matrix, but as of yet, there are limited data in the literature utilizing these modalities to evaluate the patellofemoral joint. Hypothesis: Patients with PFP and patellar tilt will show longer T1ρ relaxation times in the lateral facets of their patella but no difference in T2 values. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 20 patients aged 18 to 45 years with anterior knee pain, patellar tilt, and no evidence of osteoarthritis were identified and consented to undergo MRI including axial T1ρ and T2 relaxation time mapping sequences. Knee cartilage was segmented on spoiled gradient recalled acquisition in steady state (SPGR) images using a spline-based algorithm. These results were then compared with those of 10 age-matched controls. Results: The mean T1ρ values of the lateral facets were significantly elevated in patients with PFP compared with controls (46.33 ± 4.92 ms vs 42.32 ± 3.67 ms, respectively; P = .031), while no significant difference was observed in the medial facets (42.20 ± 5.55 ms vs 41.42 ± 4.09 ms, respectively; P = .69). Significantly higher mean T1ρ values were noted in the lateral facets of the patients with PFP (46.33 ms) compared with the medial facets (42.20 ms) (P = .0001), while no significant differences in T1ρ values were observed between the medial and lateral facets of the controls (P = .502). No significant differences were noted in T2 relaxation times. A high correlation was noted between the mean T1ρ values of the whole patella of patients with PFP and the degree of patellar tilt (r = 0.72). Conclusion: There were significantly higher T1ρ values in the lateral facets of patients with PFP and patellar tilt that were not seen in control patients. These higher values approach the numbers seen in patients with early osteoarthritis.

Relationship between knee kinetics during jumping tasks and knee articular cartilage MRI T1rho and T2 relaxation times

BACKGROUND Articular cartilage of young healthy individuals is dynamic and responsive to loading behaviors. The purpose of this study was to evaluate the relationship of cartilage T(1ρ) and T(2) relaxation times with loading kinetics during jumping tasks in healthy young individuals. METHODS Fourteen healthy subjects underwent: 1) motion analysis while performing a unilateral hopping task and bilateral drop jumping task; and 2) quantitative imaging using a 3 Tesla MRI for T(1ρ) and T(2) relaxation time analysis. Three dimensional net joint moments and angular impulse was calculated using standard inverse dynamics equations. Average T(1ρ) and T(2) relaxation times and medial-lateral ratios for each were calculated. Multiple regression was used to identify predictors of cartilage relaxation times. FINDINGS Average knee flexion moment during hopping was observed to best predict overall T(1ρ) (R(2)=.185) and T(2) (R(2)=.154) values. Peak knee adduction moment during a drop jump was the best predictor of the T(1ρ) medial-lateral ratio (R(2)=.220). The T(2) medial-lateral ratio was best predicted by average internal rotation moment during the drop jump (R(2)=.174). INTERPRETATION These data suggest that loads across the knee may affect the biochemistry of the cartilage. In young healthy individuals, higher flexion moments were associated with decreased T(1ρ) and T(2) values, suggesting a potentially beneficial effect. The medial-to-lateral ratio of T(1ρ) and T(2) times appears to be related to the frontal and transverse plane joint mechanics. These data offer promising findings of potentially modifiable parameters associated with cartilage composition.

Heat injury prevention practices in high school football.

Objective:To survey high school American football programs regarding current prevention measures for reducing heat injuries during the football season. Design:Web-based survey of 27 questions based on consensus statement guidelines by the American College of Sports Medicine on reducing heat injury risk in youth football. Setting:National (United States) and community-based. Participants:High school programs receiving survey distribution from their state athletic association and the National Federation of State High School Associations. Main Outcome Measures:Responses (percentage and incidence) to questions on preseason acclimatization procedures, practice modification protocols, preparticipation risk factors, hydration management strategies, rest period strategies, heat injury education and policies, and preparation for heat-related emergency care. Results:A total of 540 high school football programs from 26 states completed the survey. The reported number of preseason heat injuries per program (1.38 ± 2.08) was greater (P < 0.001) compared to during the regular season (0.98 ± 1.84). Programs modified equipment configurations during preseason (no helmets or pads, 31.3%; just helmets, 57.0%; helmets and shoulder pads only, 33.5%) or altered the practice schedule when there was excessive heat. Hydration management, education, and preparation for dealing with an acute heat injury varied among programs. Conclusions:Greater implementation of effective prevention measures to reduce the incidence of heat-related injury and death in high school American football is needed. Strategies should focus on modifying practices appropriately on a day-to-day basis to minimize heat strain and optimize hydration, identifying and educating at-risk individuals during the preparticipation period, and developing an emergency action plan for effectively managing heat injuries.