Cynthia J. Stein

Modifiable risk factors for cancer

Over 6 million people around the world die from cancer each year. Modifiable risk factors have been linked to a wide range of malignancies, including cancers of the oropharynx, oesophagus, larynx, lung, kidney, bladder, pancreas, skin, stomach, ovary, breast, cervix, uterus, prostate, and colon. Research indicates that over half of all cancers in developed countries could be prevented if we implemented population-wide measures to promote the following behaviours: reduce tobacco use, increase physical activity, control weight, improve diet, limit alcohol, utilise safer sex practices, get routine cancer screening tests, and avoid excess sun exposure.

Pediatric sports injuries: A comparison of males versus females

Background: There is still much that we do not know about differences in sports injuries between young male and female athletes and the factors that may increase the risk for injuries in this regard. Purpose: To describe and compare differences between males and females in pediatric sports-related injuries. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A retrospective chart review was performed using a 5% random sampling (N = 2133) of medical records of children aged 5 to 17 years seen over 10 years in a sports medicine clinic at a large academic pediatric hospital. Information was collected and analyzed on age, sex, height, weight, injury type (overuse vs acute/traumatic), location of injury, and sports involvement. Results: Overall, female athletes had a higher percentage of overuse injuries (62.5%) compared with traumatic injuries (37.5%); the opposite was seen in male athletes (41.9% vs 58.2%, respectively; P < .001). Looking at specific areas of injury, female athletes sustained more injuries to the lower extremity (65.8%) and spine (11.3%) as compared with male athletes (53.7% and 8.2%, respectively). Male patients had a greater percentage of injuries to the upper extremity (29.8%) as compared with female patients (15.1%). The type of hip/pelvis injuries differed greatly by sex, with females sustaining more overuse (90.9%) and soft tissue injuries (75.3%) versus males, who suffered injuries that tended to be traumatic (58.3%) and bony (55.6%) in nature. Males were more likely than females to participate in team and contact/collision sports. The percentage of females with patellofemoral knee pain was approximately 3 times greater than that of males (14.3% vs 4.0%, respectively; P < .001). Males were twice as likely as females to be diagnosed with osteochondritis dissecans (8.6% vs 4.3%, respectively; P < .001) and fractures (19.5% vs 8.2%, respectively; P < .001). The percentage of males and females who sustained an anterior cruciate ligament injury was almost equal (10.0% and 8.9%, respectively; P = .369). Conclusion: Sports injuries in young males and females differed by injury type, diagnosis, and body area. These results may be related to the referral patterns unique to the division of the hospital, including a high number of female dancers. Further investigation is required to better understand the injury risk in pediatric male and female athletes.

Overuse injuries in youth sports.

Abstract Although youth sports participation is beneficial on many levels, it is also associated with an increased risk of injury. Risk factors for injury in children and adolescents include the presence of growth cartilage, existence of muscle imbalance, and pressure to compete despite pain and fatigue. Overuse injuries, such as patellofemoral pain, Osgood-Schlatter disease, calcaneal apophysitis, Little League elbow, Little League shoulder, spondylolysis, and osteochondritis dissecans, are common injuries in organized sports. However, proper education, supervision, and training can help reduce the risk of these injuries and facilitate early intervention.

Anterior Cruciate Ligament Injuries in Pediatric Athletes Presenting to Sports Medicine Clinic A Comparison of Males and Females Through Growth and Development

Background: Limited data exist regarding the effect of the growth process on anterior cruciate ligament (ACL) injury risk in male versus female children. Hypothesis: The proportion of ACL injuries/sports injuries presenting to clinic will vary by age, sex, and body mass index (BMI). Study Design: Cross-sectional epidemiologic study. Level of Evidence: Level 3. Methods: The study group consisted of a randomly selected 5% probability sample of all children 5 to 17 years of age presenting to a sports medicine clinic from January 1, 2000 to December 31, 2009; 2133 charts were reviewed. Data collected included demographics, height and weight, injury mechanism, diagnosis, treatment, previous injury, and organized sports. Results: A total of 206 ACL tears were analyzed (104 girls, 102 boys). Girls were slightly older than boys (15.1 ± 1.7 vs 14.3 ± 2.1 years; P < 0.01). Male-female comparison of ACL injury/total injury by age revealed that girls had a steeper increase by age than boys. Among 5- to 12-year-olds, boys had a higher ACL injury/total injury ratio than girls (all P < 0.01). Children 13 to 17 years of age showed no significant difference for sex in ACL injury/total injury ratio. As age advanced, the proportion of ACL injuries/total injuries increased for both girls (P < 0.01) and boys (P = 0.04). BMI was independently associated with an ACL injury (P < 0.01). Conclusion: The proportion of ACL injuries/total injuries was similar for boys and girls aged 13 to 17 years. Girls showed a significantly steeper increase in ACL injury proportion versus boys through puberty. Clinical Relevance: This study will increase clinician awareness of ACL injury occurrence in young male and female athletes 5 to 12 years of age. Injury prevention efforts should target young girls before the onset of puberty and before injury occurs.

Costs of Obesity

The majority of the U.S. adult population is now overweight or obese (Flegal, Carroll et al. 2002; Hedley, Ogden, et al. 2004), and as the number of overweight children and adults continues to grow, we can expect to see a corresponding increase in obesity-related disease; even small changes in weight across a population can translate into large shifts in disease prevalence and a tremendous public health impact. Excess weight causes many negative health consequences (U.S. Department of Health and Human Services 2001), including cardiovascular disease (Rimm, Stampfer et al. 1995), type 2 diabetes(Chan, Rimm et al. 1994), cancer (Huang, Hankinson et al. 1997), and premature death (Hu, Willett et al. 2004). Overweight and obesity exacerbate conditions such as hypertension, high cholesterol, and osteoarthritis (National Heart Lung and Blood Institute 1998). Excess weight is also associated with an increased risk of sleep apnea, asthma (U.S. Department of Health and Human Services 2001) cataracts (Hiller, Podgor et al. 1998; Schaumberg, Glynn et al. 2000; Weintraub, Willett et al. 2002), benign prostatic hypertrophy (Giovannucci, Rimm et al. 1994) gallstones (Field, Coakley et al. 2001), menstrual irregularities, infertility (RichEdwards, Goldman et al. 1994) and pregnancy complications (U.S. Department of Health and Human Services 2001). Furthermore, health risks do not occur only in those individuals classified as overweight and obese; for some conditions, increase in risk is seen even at the upper end of the normal range of body mass index (Field, Coakley et al. 2001). In addition to the vast number of obesity related diseases seen in adults, weight-related conditions, such as type 2 diabetes, are being seen more commonly at younger ages, even in pediatric and adolescent populations Chapter 4

Musculoskeletal Conditions in a Pediatric Population with Ehlers-Danlos Syndrome.

Objective To describe musculoskeletal conditions in children with Ehlers‐Danlos syndrome (EDS). Study design A retrospective medical record review was performed, which evaluated 205 patients with EDS (ages 6‐19 years) seen in sports medicine or orthopedic clinic at a large pediatric hospital over a 5‐year period. Results Female (n = 147) and male (n = 57) patients were identified (mean age 12.7 years). The most common EDS subtype (55.6%) was hypermobility type. Patients had between 1 and 69 visits (median 4), and 764 diagnoses were recorded, most commonly laxity/instability, pain, subluxation, and scoliosis/spinal asymmetry. Nearly one‐half of patients (46.8%) received a general diagnosis of pain because no more specific cause was identified, in addition to 8.3% who were diagnosed with chronic pain syndrome. The most common sites of presenting issue were knee (43.4%), back (32.2%), and shoulder (31.2%). Over three‐fourths (77.1%) of patients had imaging. Most (88.1%) were prescribed physical therapy and/or other conservative measures, such as rest (40.5%), orthotics (35.6%), and medication (32.2%). Surgery was recommended to 28.8% of the study population. Conclusions Many pediatric and adolescent patients with EDS experience joint pain, instability, and scoliosis, along with other musculoskeletal issues. Despite extensive workup, the etiology of pain may not be identified. Large numbers of office visits, imaging studies, treatment prescriptions, and specialist referrals indicate considerable use of medical resources and highlight a great need for injury prevention and additional study.

Spinal injuries and conditions in young athletes

Anatomy and Development of the Young Spine.- The Young Athletes Spinal Mechanics.- Acute Thoracic and Lumbar Injuries.- Acute Cervical Spine Injuries.- Concussion in Youth Sports.- Adolescent Overuse Spine Injuries.- Throwing Sports and Injuries Involving the Young Athletes Spine.- Spinal Injuries in Collision/Heavy Contact Sports.- Spine Injuries in the Aesthetic Athlete.- Swimming and the Spine.- Spinal Injuries in Combat Sports.- Principles of Rehabilitation in the Young Athlete.- Congenital Spine Malformations and Sports Implications.- The Young Athlete with Down Syndrome.- Spinal Deformity: Presentation, Treatment, and Return to Sport.- Intrinsic Spinal Cord Abnormalities in Sport.- Metabolic Spinal Disorders in the Young Athlete.- Infectious and Inflammatory Diseases Affecting the Young Athletes Spine.- Spine Tumors in the Young Athlete.- Return to Play after Spinal Surgery.- Adaptive Sport.- The Spine in Skeletal Dysplasia.

Body Mass Index and Menstrual Patterns in Dancers

Questionnaires were distributed to investigate body mass index (BMI) and menstrual patterns in female dancers aged 12 to 17 years. The study cohort consisted of 105 dancers, mean age 14.8 ± 1.1 years, and mean BMI 19.5 ± 2.3 kg/m2. In all, 92% were healthy weight for height. First menses age ranged from 10 to 15 years (mean 12.9 ± 1.1 years). A total of 44% reported irregular menses; of those, 14% described irregularity as “every other month,” 37% as “every 3 months,” and 49% as “skips a month occasionally.” A total of 36% of the dancers stop getting their menses during times of increased activity/dance, and 30% have gone >3 months at any time without getting their menses. A significant negative correlation between BMI and age of first menses was found with lower BMI associated with increased age of first menses (linear regression, β = -0.49, P = .021). This study supports an association between BMI and age of menarche among young female dancers. Given bone health reliance on hormonal milieu in female dancers, future research is warranted.

Concussion in Youth Sports

Concussion is a type of traumatic brain injury caused by rotational acceleration of the brain following a direct trauma to the head or a force transmitted to the head after injury to the trunk or spine. Concussion results in disturbance of normal brain function, often causing symptoms such headache, dizziness, nausea, and problems with memory, concentration, balance, and sleep. Physical and cognitive rest are the foundations of concussion management, and for most athletes, symptoms resolve within a few days to weeks. Unfortunately, some athletes have prolonged symptoms and may require additional treatments such as physical therapy, medications, and psychological support. There are no proven methods to consistently reduce the risk of concussion. Treatment protocols continue to evolve as our understanding of concussion increases.

Knee injury patterns in young Irish dancers

OBJECTIVE To characterize knee injury patterns in Irish dancers. METHODS A retrospective chart review was performed for Irish dancers under age 19 who presented with knee injuries to the sports medicine or orthopedic clinic from January 1, 2000 to December 31, 2010. Data were collected on all knee injuries partially or directly related to Irish dance. Injury was defined as dance-related pain or damage to the structures in the knee that resulted in evaluation in the clinic. Survey data were collected to determine the number of different schools/studios represented by the dancers in the study. RESULTS Sixty-seven Irish dancers with 86 knee injuries were evaluated. Half (50.7%) of these patients received more than one diagnosis during these visits. Overuse injuries accounted for 90.7% of knee injuries. Time to presentation ranged from less than 1 week to over 1 year. There was a significant difference in time to presentation, with traumatic injuries being evaluated sooner than overuse injuries. The most common diagnoses, accounting for 53.5% of injuries, were patellar tracking disorders, including patellofemoral syndrome, hypermobile patella, and patellar subluxation. CONCLUSION In Irish dance overuse injuries represent the great majority of knee injuries, and patellofemoral tracking disorders are the most common diagnosis. For many dancers, there is often a delay of weeks to months between the onset of symptoms and evaluation in clinic. Prevention programs could potentially eliminate a large portion of knee pain experienced by young Irish dancers.