One of the most prominent trends in caring for the pediatric athlete is the significant increase in patient volume. An ever-increasing number of children are participating in organized sports, outside of school. This is accompanied by a decrease in physical activity at school due to cuts in time and funds from physical education, arts, and recess (National Research Council 2013). As such, organized sport is often the primary mode that children in our nation use to get their physical activity. The number of young athletes participating in organized sport increased from 32.8 million in 1997 to 44 million in 2008; 66 % of these children are boys and 34 % girls (National Council of Youth Sports 2008). Children, particularly girls, are starting to participate in organized sports at younger ages (National Council of Youth Sports 2008). Many of these kids remain involved in organized sport throughout childhood and eventually transition to higher level athletics. Participation in high school sports increased for the 24th consecutive year, passing the 7.7 million athlete mark for the first time ever in the 2012–2013 year (National Federation of State High School Associations 2012–2013). The top sports for boys are football, track and field, basketball, baseball, and soccer, while for girls they are track and field, basketball, volleyball, soccer, and softball (National Federation of State High School Associations 2012–2013). Each of these activities is accompanied with its own array of common injuries. The rise in pediatric patient volume is likely not only due to an increase in participation but also in part due to an increase in the amount of activity for the most involved athletes. Many youth activities, up to 75 %, are offered year-round (National Council of Youth Sports 2008). Concomitantly, many youngsters now participate in more than one activity and in multiple seasons. These multisport athletes have an inherently higher injury risk when their increased exposure is coupled with the lack of an “off-season.” With an ever-increasing number of children participating in organized sport, the physician needs to be equipped to handle the growing child athlete population.

While there are certainly risks associated with participating in sports, the benefits of doing so cannot be understated. Being physically active positively influences a child’s health, their performance as a student, and their emotional and social development.

In terms of health, participating in sports and remaining active provides a multitude of benefits, at the core of which is maintaining a healthy weight and avoiding childhood obesity, which is on the rise in the United States. Currently, 17 % of children and adolescents 2–19 years of age are obese, and of particular concern is the one-third of low-income children 2–4 years of age that are either overweight or obese (Ogden et al. 2010; Centers for Disease Control and Prevention 2012). Maintaining a healthy weight through activity avoids the increased general health risks of heart disease, high blood pressure, high cholesterol, and diabetes, in addition to the orthopedic risks of Blount’s disease, slipped capital femoral epiphysis, and fracture. The physical activity and exercise provided by regular sports may help to mitigate this epidemic. For example, the surge in female sports participation following the passage of Title IX has been correlated with a decrease in body mass index in adolescent females, improving their overall health (Kaestner and Xu 2007).

Activity and sport also provides health benefits specific to the growing female athlete that should be noted, in particular the benefits to bone health. Improvement in bone mass, bone mineral density, and bone mineral composition has been well documented in females who participate in high-impact sports, such as gymnastics, soccer, and basketball (Maïmoun et al. 2013). Bone mass is particularly improved by participating in these higher impact activities near puberty, especially earlier in puberty (Tenforde and Fredericson 2011). In fact, a direct relationship in which an increased frequency of weight-bearing activity is directly related to bone mineral density has been established by meta-analytic methods (Ishikawa et al. 2013).

Moreover, the benefits of early athletic participation continue into adulthood in many different areas. Higher levels of cardiorespiratory fitness as a youngster have been demonstrated to be associated with persistently better cardiovascular health as an adult. Similarly, having a healthy body composition in childhood is correlated to better adult cardiovascular health and a lower risk of death (Ruiz et al. 2009), and aerobic physical activity reduces the risk of premature mortality among US adults (Zhao et al. 2013). Also, increased physical activity is positively associated with health-related quality of life (Klavestrand and Vingård 2009). The establishment of fitness and healthy practices early in life are likely to have lifelong benefits for the pediatric athlete. Thus, it is critical to encourage ongoing activity and, when able, return an injured child to sports participation. These healthy, active individuals will be better prepared to become healthy active adults and remain fit for a lifetime.

Organized sport and activity also provide benefits in terms of a child’s psychological health. With respect to mood, physical activity and sports participation have been associated with a lower incidence of depression in the pediatric population (Singh et al. 2008). Regular physical activity is both protective against depression and effective in minimizing the symptoms of depression in athletes who already suffer from it (Brown et al. 2013). Moreover, high-level physical activity has been associated with improved self-esteem scores (Strauss et al. 2001).

Further evidence exists that the benefits of organized sport are not only physical in nature but permeate into other areas of childhood. Being a part of a sports team is in many ways an educational experience allowing them to work on their social skills and problem-solving skills, teaching teamwork, sportsmanship, and hard work. In terms of academics, studies have shown that youngsters participating in organized sport have higher grade point averages, better school attendance, lower dropout rates, and fewer discipline problems (National Federation of State High School Associations 2013; United States Department of Education 2002). According to the National Federation of State High School Associations (NFHS) report titled “The Case for High School Activities,” students who do not participate in after-school extracurricular activities, including athletics, are 49 % more likely to use drugs and 37 % more likely to become teenage parents than those who spend 1–4 h/week participating in these activities (National Federation of State High School Associations 2013; United States Department of Education 2002). Moreover, the effect of organized sport and physical activity has proven to be beneficial academically for historically underserved youth populations. It has been shown that “middle-school kids in inner-city neighborhoods who play organized team sports have a higher sense of self-worth and better social skills than their less athletic peers” (National Federation of State High School Associations 2013).

Children who play sports build self-discipline, increase self-confidence, create goals for the future, and develop skills to handle competitive situations. These are skills that will serve these individuals both on and off the competition field and may contribute to long-term successes. In fact, participation in athletic activities at a young age is also a predictor of later success in college and in one’s career. Participation in extracurricular activities provides students from all socioeconomic statuses, ethnic backgrounds, and academic standings measurable gains in college admission test scores (Everson and Millsap 2005). While sports participation has been associated with higher levels of alcohol consumption, it is significantly correlated with lower rates of both cigarette and illegal drug use (Lisha and Sussman 2010). 18- to 25-year-olds who had been involved in high school athletics were more likely to participate in volunteer work and to vote. These individuals were also more likely than their nonparticipant counterparts to feel comfortable with public speaking (National Federation of State High School Associations 2013). These athletes are better equipped to face the challenges of adulthood.

The benefits of sports participation for the physically and/or cognitively challenged child and adolescent athlete have also been documented. As of 2010, it has been estimated that greater than three million individuals who are differently abled participate in sports in the United States and many more likely do so recreationally (Patel and Greydanus 2010). There are distinct advantages to sports participation for young people with physical or cognitive challenges. These include, but are not limited to, positive social experiences, psychological development, moral development, increased independence, improved coping abilities, teamwork skills, competitiveness, and enhanced self-confidence. It is clear that recreational and sports activities provide a wide array of opportunities and benefits, physical and otherwise, for a broad range of children, and as such sports-related activities are a critical aspect of youth development.

Unfortunately, despite the many benefits of youth sports participation, there still remains a risk of injury that cannot be overlooked. The rise in sports participation increases the exposure of children to both the benefits and the risks of athletics. The impact of injury in young athletes is larger than most people conceive, both in the immediate setting and in the long term, as possibly lifelong consequences may result. Sports injuries can be severe and a small segment even catastrophic. One epidemiologic study concluded that of severe sports injuries, one in four required surgery, while more than half of these injuries resulted in medical disqualification for an entire season (Darrow et al. 2009). While only 0.3 % resulted in career-long medical disqualification, the number is still clinically relevant in the context of the vast number of youth sports injuries each year.

Young athletes have growing and developing skeletons that are vulnerable to the stresses of injury and excessive activity. This is an important consideration as injuries in childhood can affect the future health and activity levels of athletes. Injury in childhood can lead, in some cases, to disturbed physeal growth, either due to acute injury or by repeated excessive stress placed on the physis (Maffulli et al. 2010). Epidemiologically, just under half of acute growth plate injuries were sports related, and of those, almost 15 % have been shown to be associated with growth disturbance (Caine et al. 2006a). Growth disturbances range from those that are not clinically relevant to those that may have far-reaching implications and need to be monitored until maturity is reached.

The long-term effects of childhood injury have perhaps been best documented in youth athletes with meniscus and ACL injuries. Sustaining a significant injury as a child can be a considerable burden to the athlete as he or she becomes a young adult. As adult athletes, those with a history of ACL injuries retire from sports at an increased rate and have an increased risk of osteoarthritis relative to those who do not have a history of an ACL tear (Maffulli et al. 2010; Lohmander et al. 2004, 2007). Moreover, a recent meta-analysis has demonstrated that, compared to those with early surgical stabilization, pediatric patients undergoing nonoperative or delayed surgical treatment for ACL tears saw increased joint instability, a decreased rate of return to full activities, and a 12 times higher rate of meniscal injury (Ramski et al. 2013). The vision of providing a stable knee, therefore, is to prevent these very early degenerative knee conditions. Given the correlation between youth sports injuries and future quality of life concerns, it is clear that sports injury prevention, both primary and secondary, is one of the most important principles in the care of the pediatric athlete (Caine and Golightly 2011).

Once incurred, the effect of these injuries on the parents and families of these athletes is also not negligible. There is significant cost, both monetary and psychological, to the injured athlete and his or her family. An epidemiologic study (Caine et al. 2006b) of high school athlete injuries estimated the average total cost of sports injuries, accounting for clinic and emergency department visits, surgery, and hospital admissions. While most of the injuries assessed were not in and of themselves severe, given the huge number of children participating in sports and the commonness of these injuries, the total economic burden they pose to society and the health-care system is immense. Four sports, baseball, basketball, football, and soccer, had total annual medical costs of over $100,000,000 each. Basketball and football injury-related medical costs were at the top of the group, each with over $400,000,000 in cost each year. Indirect costs are also substantial. Basketball and football had estimated work loss costs of over $1 billion each, with other sports such as baseball, gymnastics, horseback riding, skiing, soccer, softball, and wrestling each totaling over $100 million in work loss costs. The enormity of these costs is clear, and as such, increased surveillance, improved treatment, and more rigorous preventative measures are imperative.

Recent estimates reveal that US high school athletes sustain an estimated 2,000,000 injuries per year (Gottschalk and Andrish 2011). Prepubescent athletes are at risk for different injuries than the adult population, particularly given their relative physeal weakness, which predisposes them to growth plate injuries. Upper extremity injuries are also exceedingly common in pediatric sports. Injuries to the elbow, forearm, and wrist make up about 25 % of sports injuries in this age group (Magra et al. 2007). With respect to upper extremity specifically, injury is particularly common in overhead sports. More than two million children participate in baseball each year, and elbow and shoulder injuries are extremely common in this and other throwing sports.

While organized sport is a risk factor for injury, the pediatric athlete can take many forms. Many children participate in recreational activities or sustain sports-type injuries while participating in nonformal, non-team activities such as backyard play, trampolines, monkey bars, moon bouncers, etc. The burden of these injuries is also important when considering the overall health of a child.

Between 2002 and 2006, there were an estimated 4.61 million emergency department visits for recreational injuries from bicycles/tricycles, scooters, playground equipment, swimming/water activities, skiing/snowboarding, trampolines, and skating in children in the United States (Parkin and Howard 2008). This exemplifies the significant health burden to the youth population that these activities, while not organized sports, still pose. There are temporal variations in these activities, and thus there are also temporal variations in their related injuries. Snow activity-related injuries peak in late January. Other activities lead to more late spring and summer injuries, with trampoline and scooter injuries peaking nationwide in June and cycling and water activity injuries in July. Skating and playground injuries had more than one peak season, with each activity seeing injury peaks in both April and September, months where most children are in school, and yet the weather is still mild enough in most of the country to allow for significant outdoor activity participation (Loder and Abrams 2011).

Playground equipment is responsible for a significant injury burden in children in the United States. A retrospective analysis (Vollman et al. 2009) revealed that over a 10-year period, there were about 2,136,800 playground injuries to children 18 years of age and under. The most frequently documented mechanisms of playground equipment injury were falls, while the most common injury type for which a patient seeks out emergency room medical care is a fracture. The most commonly implicated play apparatuses were climbers followed by swings and then slides. Approximately 59,800 children (3 %) required admission to the hospital for treatment of a playground equipment-related injury, over 90 % of these injuries being fractures, averaging approximately 6,000 children annually.

Trampolines and moon bounce injuries are most common in younger children, with the average age being 8–9 years (Briskin and LaBotz 2012). Moon bounce injuries show similar patterns to those sustained on trampolines, both with increased injury risk when more than one child is present. In trampolines, injuries to the lower extremity are slightly more common than the upper extremity, but upper extremity injuries are more likely to be fractures. The most common trampoline injury that requires emergency room attention is a fracture. However, physicians must also be vigilant for more rare injuries that are fairly unique to trampoline usage, including atlantoaxial subluxation and sternal injuries/dislocations (Briskin and LaBotz 2012). On moon bounces, supracondylar humerus fractures are the most common injury (Lovejoy et al. 2012). Again, the lower extremity is injured slightly more frequently than the upper extremity (Thompson et al. 2012).

Skiing and snowboarding commonly present with head, knee, and wrist injuries, with wrist injuries being even more common in snowboarders. In these snow sports, injuries are associated with lower skill levels as well as poor-fitting and rented equipment. Skateboarders also see a significant injury burden, and the number of skateboard-related injuries has been on the rise. It has increased from 70,350 in 2000 to 108,510 in 2011 (Thompson et al. 2012). Most of these patients are male, and fractures are common in this population, particularly upper extremity wrist and forearm fractures sustained during falls (Lovejoy et al. 2012).

ATV and motocross sports are also of unique concern, as these tend to be associated with a very high-energy mechanism of injury, due to the higher speed collisions associated with these motorized sports. These activities have high rates of head, spinal, and extremity injuries, all of which may have substantial long-term consequences (Larson and McIntosh 2012). Significant increases in ATV-related injury numbers in recent years have been seen. Head injuries are common and are the leading cause of mortality in ATV accidents. Extremity injuries are most frequent and cause significant morbidity (Lovejoy et al. 2012).

Specific sports predispose athletes to a unique set of injuries. It is important for the treating physician to appreciate the relative risks of different injuries based on participation in a wide variety of sports and activities.

The literature suggests that, for boys, the highest overall rates of injury per a set number of hours occur in ice hockey, rugby, and soccer. Older boys appear to have a higher incidence of injury than younger boys in football, rugby, and soccer. For girls, soccer, basketball, and gymnastics have been shown to have the highest injury rates per 1,000 exposure hours (Caine et al. 2006b, 2008). Most of these sports involve a significant amount of player-on-player contact, as well as cutting, pivoting, and jumping, all well-established injury mechanisms. Per each athlete exposure, high rates of injury are also seen in baseball and softball, as well as cross-country running (in both sexes), presumably given a high rate of overuse in these activities.

Knowing the particular risks of each sport can be an important part of the discussion when selecting a sport for a particular child or when discussing switching activities after a particular injury has been sustained. Certain sports place specific joints and structures at very high risk, such as soccer and football do with their high rate of knee injuries. A pediatric sports injury incidence review (Caine et al. 2006b) found the most common body part injured in basketball to be the ankle/foot followed by the knee, in skiing to be the knee/lower leg, in snowboarding to be the wrist/forearm followed by the knee, in gymnastics to be the ankle followed by the knee, in soccer to be the knee followed by the ankle, and in tennis to be lower extremity (ankle) followed by upper extremity.

A recent epidemiologic study of knee injuries in US high school athletes (Rechel et al. 2011) showed that from 2005/2006 to 2010/2011, there was an overall rate of 2.98 knee injuries per 10,000 exposures. The most commonly involved structure was the medial collateral ligament, followed by the patella/patellar tendon, anterior cruciate ligament, meniscus, lateral collateral ligament, and posterior cruciate ligament. Football had the highest knee injury rate (6.29 per 10,000 athlete exposures) followed by girls’ soccer (4.53 per 10,000 athlete exposures) and girls’ gymnastics (4.23 per 10,000 athlete exposures). On the other hand, girls’ volleyball and softball had the lowest injury incidences. Swimming is also known to have a virtually nonexistent risk of ACL tear. For patients at high risk of ACL tears or those with concerns about re-tears who are not committed to a particular sport, knowing and discussing these lower risk activities can be very useful in determining which course of action and which sports may be most appropriate for a child moving forward.