Treating children can be a fun, challenging and very important part of your practice. Many factors, including psychosocial, physical and emotional differences, come into play when treating pediatric patients. Most of us can identify with the differences as we have experienced them ourselves as young patients.
Active children may be participating in recreational activities, competitive sports, club sports, dance and fun activities. The sports pyramid model shows a very diverse group of performers with broad participation (see photo at right). Many of us would call this a broken model due to the narrow early focus on performers at the expense of broad participation. Outlying areas of the pyramid would include youth with disabilities, average or above-average athletic ability, over-served athletes with burnout and injuries, low-income children, late bloomers, and clinically obese or overweight individuals.
Encouraging kids to be active and exercise is an important element of every office visit with your young patients and parents. Activity needs to be fun and part of a kid’s everyday lifestyle. There is a trend of kids leaving organized youth sports. This may be due to a variety of reasons: the child is not having fun, parental influence, coaching, and peers dropping out of sports. Children are specializing in a specific sport at an early age, which can lead to early burnout, overuse injury and a lack of experiencing different individual and team activities. Recreational activities with their family and friends provide children with a well-rounded lifestyle and healthy lifelong habits. We also see the tremendous influence that parents and coaches have in young athletes with the belief that this exceptional child will be an elite, professional athlete someday.
Approaching Pediatric Patients With The ‘Five C’s’
Basic approaches to treatment of pediatric patients outline what I call the “five Cs”:
Conservative measures. These include PRICE or protection, restricted activity, ice, compression and elevation.
Cross-training program. Kids need to keep active, make it fun and have attainable goals.
Control. Protect and support the area of injury, but allow some functional activity/range of motion (ROM).
Compassion. Have empathy and understanding. Children have many outside pressures from parents, peers and coaches as well as a wide range of social, psychological and physical components.
Compliance. Establish goals and objectives that are specific and attainable. It is important that the parents/family and coach understand their role in ensuring that the child is adherent with respective treatment plan.
These five Cs really involve treating kids as conservatively as possible, understanding their needs and goals, biomechanical issues, and any special attention or adherence issues. Obviously, the parents will most likely have a major role in the treatment plan as well as patient adherence. There is often a special doctor-patient relationship, family influence and level of understanding that all play important roles in treatment of injury.
A Closer Look At Common Sports Injuries And Contributing Factors
Here are common injuries in youth sports, most of which are overuse injuries, which I commonly refer to as the “top 10.”
• Inversion ankle sprains
• Turf toe/soccer toe
• Calcaneal apophysitis
• Plantar fasciitis
• Achilles tendonitis
• Medial tibial stress syndrome
• Patellofemoral pain syndrome
• Stress fractures
• Iliotibial band syndrome
• Posterior tibial tendonitis
Contributing factors to injuries include training errors, muscle dysfunction (strength and flexibility), footwear, training surfaces, biomechanical factors and psychosocial factors. Obviously, podiatry focuses on biomechanics and footwear as important factors in the treatment of overuse type injuries. Using the two-pronged approach to treatment will help greatly to speed the healing and recovery phases following an injury. Treating the cause is the most challenging aspect of injury recovery and prevention. Rehabilitation and understanding biomechanical factors are keys to a complete recovery. Surgical treatment is often the last resort. When discussing the treatment plan with the child and parents, it is important to “under-promise and over-deliver.” The length of recovery and return to activity will depend on many factors including the motivation, support and fitness and conditioning of the patient.
Cross-training is of major importance in keeping the child motivated and conditioned. When it comes to recovering from an injury, one may incorporate swimming, biking, weight training and activity modification that is not painful. Bracing, taping and footwear all play important roles in the recovery process.
Biomechanical considerations include foot type, gait evaluation, specific sport activities, history and type of injuries in the past, and the shoes the patient use for the given activity. In the more chronic type of injuries, orthotic use needs to be controlled and protective in nature, and specific to the type of activities. A child’s foot is changing rapidly with growth and development. Abnormal foot position can lead to adaptations and eventual complications. The goal is to alleviate or minimize any structural disorders leading to abnormal compensations in the feet, and protect the foot during the period in which other forms of treatment are occurring.
Physical therapy and rehabilitation is another important area of treatment. Children are more susceptible to re-injury and a longer recovery period if they are not fully rehabilitated. Some of the challenges that children have with rehabilitation include shorter attention spans, feeling invulnerable, thinking that rehab is not important and a desire to avoid being perceived as different. The reasons to rehabilitate are to prevent recurrent or related injury, and regain full strength, power and endurance, flexibility, coordination, and full performance capability. The main principles of youth rehabilitation are to keep it short, simple, fun and motivate children to improve performance.
A Guide To Rehabilitation Phases And Return To Sport/Activity
Phase 1 of rehabilitation is controlling pain and swelling. This happens via the aforementioned PRICE principle. Phase 2 consists of therapeutic exercise. Phase 3 is early return to activity and continuing therapeutic exercise. Phase 4 is return to activity.
Specific principles for youth rehabilitation include: a defined period of time to meet goals; short exercise bouts; a small number of exercises; an integrated program with a schedule; built-in incentives; and evidence of progress. Considerations should include flexibility, strength training, activity instructions and criteria for modification or restricted activity.
There are a variety of considerations with return to activity guidelines. Injured areas should be healed to meet demand. Strength and endurance levels should be near normal. Muscle flexibility and ROM should be normal. Children should have functional tests for proprioception and coordination. Cardiorespiratory fitness level should be restored for play. In recreational sports, it is important to phase in playing time gradually as tolerated to help monitor progress after returning from an injury. The longer the child has been recovering, the more gradual the playing time should increase. The coach must understand the return to activity plan for the child. Communication is the key.
There are many special considerations, challenges, trends and contributing factors to injury prevention and treatment in young athletes and children. There are tremendous psychosocial and physical differences in children as well as the added challenge of influences from parents, coaches and teammates affecting motivation, adherence and rehabilitation. It is always better to under-promise and over-deliver with regard to a timeline of recovery and return to play prediction. It is extremely important to ensure there is a full recovery and restoration of performance capability in addition to prevention of further injury. Always remember that children have a special doctor-patient relationship that can be very rewarding. The child’s sports experience should be a fun, safe and a positive experience to help lead to an active adult lifestyle for health and fitness.
Dr. Dutra is an Assistant Professor in the Department of Applied Biomechanics at California School of Podiatric Medicine at Samuel Merritt University. He is a Past President and Fellow of the American Academy of Podiatric Sports Medicine, and a Fellow of the American College of Sports Medicine. Dr. Dutra is a Podiatric Consultant for Intercollegiate Athletics at the University of California at Berkeley. He is the Clinical Director of the Healthy Athlete Fit Feet Program with the Special Olympics of Northern California.