Gymnastics

Gymnastics participants are beginning the sport at 5-6 yr of age and achieving the highest level of competition in the mid-teens, often retiring by age 20 yr. Boys tend to have more upper extremity injuries, and girls have more lower extremity injuries. In addition to mechanical or traumatic injuries, female gymnasts tend to have delayed menarche and can have hypothalamic amenorrhea or oligomenorrhea, associated with low body weight. The typical body habitus of the elite gymnast manifest as reduced weight for height, coupled with amenorrhea or oligomenorrhea, suggests that reduced bone density is a problem for female gymnasts. In most gymnasts, bone density tends to be high. It is speculated that this is secondary to the repetitive high-impact activities. In spite of this increased bone density, stress fractures are a significant problem. The short stature associated with male and female gymnasts is probably caused by selection bias and not the result of gymnastics training.

Common problems include acute traumatic injuries, such as an ankle sprain, and chronic overuse injuries, such as wrist and spine stress fractures. The incidence of injury increases with the level of skill and is greatest in the floor exercise. Wrist pain due to chronic upper extremity weight bearing can be caused by a distal radial stress Salter I fracture, which typically occurs on the radial dorsal aspect of the wrist and is worsened by passive extension and palpation. Other wrist injuries include triangular fibrocartilage complex tears, scaphoid fractures, dorsal ganglions, and carpal ligament injuries.

Treatment in almost all cases involves immobilization for some period, application of ice, and administration of analgesic drugs. If pain persists, the correct diagnosis can be made by MRI or arthroscopic examination to rule out intra-articular tears, loose bodies, or ligamentous instability. The pediatrician should have a low threshold for referral to a hand specialist in a wrist injury that is not improving with rest. Ligamentous laxity can predispose to elbow or shoulder dislocation and ankle sprains. Spine problems include spondylolysis (pars interarticularis stress fracture) and spondylolisthesis (Chapter 671.6) due to repetitive extension loading.

Swimming

Shoulder injury is the most common overuse injury of competitive swimmers. Swimmer’s shoulder is a combination of subacromial bursitis and rotator cuff tendinosis, usually of the supraspinatus, manifested as insidious shoulder pain. Pain, due to subacromial bursitis, may be produced by the Hawkin impingement test, in which pain is provoked by passively abducting the humerus to 90 degrees, forward flexing 30 degrees to the parasagittal plane, and then internally rotating the humerus. Supraspinatus tendinosis produces pain with active abduction with the arm in the same position as the Hawkin test, internally rotating the arms as if emptying a can, raising the arm against resistance. Pain and/or weakness indicates supraspinatus injury.

Treatment includes ice, modification of stroke technique, relative rest, and muscle strengthening of the rotator cuff and upper back muscles. Prevention includes avoiding rapid increases in training load, proper technique, and strengthening exercises.

Baseball

Throwing injuries of the elbow and shoulder (especially among pitchers) are the most common baseball injuries (Chapters 679.2 and 679.3). The most important consideration is limitation of the number of pitches and advising players and coaches that they should stop immediately when they experience elbow pain and if it persists, having a medical evaluation. It has been recommended that a young pitcher pitch no more than approximately 6 times the pitcher’s age in years.

Deaths in baseball are rare and are caused by chest wall trauma with the ball (commotio cordis) (Chapter 430) or head injury with the ball or bat. Batting helmets need to be worn properly to try to prevent face and head injuries.

Ballet

Ballet is a very demanding activity that may be associated with delayed menarche and eating disorders in female dancers (Chapter 682). Acute injuries are most often of the lower extremities. As with any repetitive activity, overuse injuries are likely; the key is to make the correct diagnosis and also consider the kinetic chain dysfunction that might have contributed to that injury. A dancer might have an unrehabilitated ankle sprain, causing favoring of that leg, leading to a stress fracture of the contralateral tibia. Foot problems include metatarsal stress fractures, subungual hematomas, calluses and bunions, sesamoiditis, and plantar fasciitis.

Going en pointe is a question that young ballet dancers and their parents may ask. An average age to go en pointe is 12 yr. A function test should be part of that decision: If the child can go en pointe, holding the position without pain and not appearing unstable and weak, then he or she is probably ready to try dancing en pointe.

Ankle problems include anterior and posterior impingement syndromes because of the extremes of range of motion in grand plié and en pointe, respectively. Hip problems include the medial snapping hip syndrome, caused by the iliopsoas tendon’s riding over the anterior hip capsule, and tendinosis of the piriformis, iliopsoas, and rectus femoris. The piriformis syndrome occurs because of the repetitive external hip rotation required in ballet and can manifest as buttock pain and sciatica.

Wrestling

Wrestlers have great fluctuations in weight to meet weight-matched competition standards. Such fluctuations are associated with fasting, dehydration, and then bingeing.

Wrestling holds can produce injury owing to various torques or forces applied to the extremities and spine; wrestling throws with subsequent falls can produce concussions, neck strain, or spinal cord injury. The 2 most common sites of injury are the shoulder and knee. “Stingers” and “burners” are due to a brachial plexopathy (see Football).

Shoulder subluxation is common. Patients are often aware of their shoulder’s slipping in and out (Chapter 679.2). Hand injuries are usually not severe and include recurrent metacarpophalangeal and proximal interphalangeal sprains. Treatment of hand injuries includes splinting and taping.

Knee injuries are common and potentially serious and include prepatellar bursitis, medial and lateral sprains, and medial and lateral meniscus tears (Chapter 679.6). Prepatellar bursitis is caused by acute or recurrent traumatic impact to the mat. Swelling occurs over the patella, and patients have no limitation of motion except full flexion. If the skin has been broken, septic bursitis has to be considered. The physician must try to distinguish traumatic from infected bursitis, which can require aspiration of the bursa. Treatment of traumatic bursitis includes protective padding, ice, nonsteroidal anti-inflammatory drugs (NSAIDs), and occasionally aspiration if flexion is impaired. Rarely bursectomy is needed if there are several recurrences.

Dermatologic problems include herpes simplex (herpes gladiatorum), impetigo, staphylococcal furunculosis or folliculitis, superficial fungal infections, and contact dermatitis. The first two are contraindications to wrestling until the infection is no longer contagious. If herpes infections recur, suppressive oral antiviral agents should be used.

Football

Football continues to be the sport with the highest number of injuries, one of the greatest number of participants, and one of the sports with a high injury rate. In terms of the severity of injury, defined as days lost per injury, the average injury in football is less severe than in many other sports. Most of the injuries are sprains, strains, and contusions that, once treated, appropriately result in minimal time away from football.

Although the majority of catastrophic sports injuries in the USA have occurred in football, severe injuries are rare. Catastrophic is defined as a fatal injury or a severe injury with or without permanent severe functional disability. Disabling injuries include cervical spine and cerebral injuries.

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