1 - Kids and Sports Injuries (Dr. Luke Spellman)

In our first podcast, Dr. Luke Spellman, pediatrician, joins Dr. Dustin Arnold, chief medical officer, to discuss the topic of kids and sports injuries.

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Submit your questions at: https://www.unitypoint.org/cedarrapids/submit-a-question-for-the-mailbag.aspx

If you have a topic you'd like Dr. Arnold to discuss with a guest on the podcast, shoot us an email at stlukescr@unitypoint.org.

Transcript

Dr. Arnold:         
This is LiveWell Talk On...Kids and Sports Injuries. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's Hospital. Participation in any sport, whether it's recreational, club sport, can teach kids to stretch their limits and learn sportsmanship and discipline, but any sport also carries the potential for injury. By knowing the causes of sports injuries and how to prevent them, you can help make athletics a positive experience for your child, and hence the team. Joining us today is UnityPoint Clinic Pediatrician, Dr. Luke Spellman, to look further into this topic. Dr. Spellman is also certified and completed a fellowship in sports medicine. Welcome.

Dr. Spellman:       
Thank you. Nice to be here.

Dr. Arnold:        
So tell me a little bit about this fellowship in sports medicine. How long did it last? Was it one or two years? There is a board certification. What made you interested in that?

Dr. Spellman:       
Sure. I always had a general interest. I also wanted to be in an area where my, my wife's an ear, nose and throat surgeon, so I looked in the Ohio area when she was completing her residency and I really came into it. I was a, been a lifelong athlete and loved sports in high school, so it was really just a general interest I had. And when I researched it after I started my pediatric residency, I just, I didn't really didn't want to end my education there and my hope was to get into a fellowship. So I was fortunate enough to end up at Akron Children's hospital, in a two year sports medicine fellowship and with a pediatric interest, and ended up working with athletes there of all ages and especially young athletes to college age. So traveled with lots of sports teams, had a great experience and sometimes I wish I was still there. It was a great experience.

Dr. Arnold:        
That's outstanding.

Dr. Spellman:      
Yeah.

Dr. Arnold:         
It's that time of year. It's August, I'm sure your clinic's starting to fill up with pre-school physicals and participation physicals. What is your general approach to assessing those individuals for potential participation in organized sports?

Dr. Spellman:      
So a lot of time and thought has gone into the pre-participation physicals, generally state-to-state, the questionnaire on the first page of those is very similar. And actually I've been to a couple of different symposiums relative to pre-participation through my fellowship and a couple academies I've been a member of in the past. And really the idea of those questions is to really hone down and look and see if there's any red flags prior to, you know, extensive participation in sports. So they're well thought out. They look at cardiac, they look at respiratory, they look at a couple other other specific areas. And people that put those together thought a lot and they tried to hone down again to what specifically if there's a flag that we need to approach before we can safely have an athlete participate in sports.

Dr. Arnold:        
I know this, this next question is probably best answered by referring to individual sports, but what is the most common injuries that you see in your practice?

Dr. Spellman:       
So my practice, we recently moved to the area and I was in a pediatric practice for about 10 years and I had a younger population. Generally in kids, you know, below the age of puberty for either female or male, majority of injuries in kids in sports is just, it's really related to overuse. So I would say there's some acute injuries. The nice thing about kids is they sort of bend and they don't break when they're younger. So really a lot of the injuries in kids really comes down to some acute injuries that we can handle. But more so overuse injuries with growth plates. So that's where you get into a lot of injuries in young kids. We you get into high school, that the high school athlete can vary greatly, from a pre-puberty kid to a, basically an adult. So you actually get some different injuries in that scope of time, so you have to be really thoughtful of age and where their bone growth is at that time too. So some definitely some more acute injuries in the high school population. But you also see those kids that are sort of late bloomers. They get some of the younger injuries that we experienced, like a little leaguer's elbow, shoulder, or like an Osgood-Schlatter, which is, you know, a growth plate, irritation of the knee.

Dr. Arnold:        
I can imagine that the contact sports have more injuries than non-contact sports. However, just this week, Journal of American Medical Association had a little that in kids just normal activity leads to more concussions than sports, which made sense, kids are all over the place running around. But what are the best ways to prevent injuries in sports? I know, you may want to comment on multi-sport athletes and how does that impact the ability to prevent injuries?

Dr. Spellman:       
In general, following the safety guidelines and common sense helps decrease injury. So like kids that are in sports that utilize equipment, having good equipment. Now, equipment itself does not prevent injury. So there's no football helmet out there that's going to prevent every concussion. So if people tell you that, that's just not the case. The other component to that is, besides using like good equipment, using common sense, it's also teaching good fundamental skills. So teaching kids how to, like if they're in football, how to tackle with their head up, how not to lead with their head, or working like, especially a young female athlete who's going to be more susceptible knee injury, utilizing some of the jump programs, getting their, their core strength up, getting their lower extremity strength up. So there's a lot of different ways to prevent injury. Honestly, a lot of it comes down to common sense too.

Dr. Arnold:        
As far as the injuries and return to play, you know, as an adult physician, if I have an adult and I'm like, they have surgery or an illness and I said, well, you can return activity in four weeks, you need to rest and recover and you know, gradually return. Tell that to a high schooler, which it's a six to eight week season and you say they need to rest for four weeks, you know, they're gonna tear you apart on that, or the parents might. So, so with these overused and strains typically how much rest they need prior to returning?

Dr. Spellman:      
So it varies based on injury and type of athlete and also age. You know, there's three common things I talk about with parents, the three R's. Rest, rehab, return to play. If you skip one of those R's, you're going to lead that kid to another injury or make that kid more susceptible to an injury. You really, it's really the job as the pediatrician or sports medicine physician or adult family medicine doctor, orthopedic doctor to work with kids and their parents to devise a plan that keeps the kids safe and decreases the risk of injury. There are some injuries where kids can actually have a little discomfort but they are safe and we're not gonna make them more susceptible to injury. So it really is based on the type of injury. But at the same point, and I, and I talk to parents, I talk to athletes about this, you know you have a freshmen for example that comes in and they have an injury and you know, adolescents think, okay they're day-to-day, they think in the moment. Sometimes you have to give them a little perspective. You have to talk to talk to them about, listen, we have your whole career ahead of you. If we don't even a typical age ankle sprain, if we don't treat this appropriately, we don't rest this, rehab it and return to your play appropriately. you're gonna be dealing with this your whole high school career. So you know, you're there to be a good resource to them, but sometimes you have to be, you know, straight with them and tell them, you know, my goal in all of this is to safely return you to play, so it might take a little time and, or you might have a little discomfort with this, but I don't think we're going to increase your risk of injury. So it's very specific to the situation, but there's some general guidelines you can follow that will keep everything appropriate and safe.

Dr. Arnold:         
Can you explain the situations when you'd use ice as compared to heat, to treat an injury?

Dr. Spellman:       
So I think of anything acute and swelling, like say an ankle, an ankle sprain, very common entity, but a pretty bad injury actually. Acute sprains, strains, swelling typically responds to ice. But if you look at the studies too a lot of acute injuries, strains, sprains actually respond to both heat and ice. So what I typically say is acute, acutely, like right after it happens, the night of the injury, the few days afterwards, I usually talk about utilizing ice and decreasing swelling. You know, for another example would be a teenager that gets a pretty significant knee injury, gets a lot of swelling. So ice really works well for acute swelling, but sometimes, you know, with say, for example, a hamstring strain, sometimes alternating heat and ice actually works well too. So the end result is what I talked to about with my patients is acutely ice, but also think about heat a little later on and do what feels best, what makes you feel the best when you're doing it?

Dr. Arnold:         
Speaking of heat, we can't ignore it this time of summer, particularly last week when it was in the 90s with the heat index, well over a hundred heat and training camps are gonna be starting here. What's your recommendation as far as heat and activity for these high school camps we'll be starting here in the next week?

Dr. Spellman:      
Well, I think that comes back to what I talk about common sense. You know, if you're in an environment where there's a lot of heat, lot of humidity, you're at risk to have a pretty significant heat injury. So those kids, a general good rule of thumb is to drink fluids and if we talk about like electrolyte fluids, waters, things like that, before they get thirsty. You know, at the college level, we very seldom ran into injuries like this because the training staffs were so good about watching the kids and they even had in the bathrooms, they had urine charts to watch the concentration od their urine. So it really comes down to now, and I do think coaches and I do think schools are doing a lot better job. It really comes down to pre-hydration and then continued hydration with breaks during practices. The way that practices are run now I really do think are a lot different back 20 years ago when I was going through. We just didn't have a great understanding and I feel like we didn't quite have a good plan back then for two-a-day practices. I do think schools, coaches, training staffs are doing a lot better job. In regard to other things. If you start to get some symptoms, some lightheadedness, vomiting, abdominal pain, things like that you need to be pulled out of practice, get into a cool environment and hydrate.

Dr. Arnold:        
Great Advice. Yeah. I played college football, and that was in the mid-eighties, and I can remember the coach saying, no water today, we need to be tough, you know, and that would just be insane based upon what we know now.

Dr. Spellman:      
Bad ideas, but fortunately I think we've gotten a little smarter with that.

Dr. Arnold:        
Yeah, I would hope. You talked about the staff, athletic staff, the athletic trainer. I know there's legislation in this state that's moving forward or has to recommend that an athletic trainer be present at games. Do athletic trainers compliment your practice?

Dr. Spellman:       
Yeah, I think they do. I think that's a great, that's some great legislation. You know, it comes down to resources and money sometimes for schools, but if, if we can work together and get training staff on the sidelines, especially athletic training, they add a great resource to the sidelines, and we really do compliment each other well. When I was in my fellowship and working with the various teams, some of my best colleagues, some of the people I respected the most were the athletic trainers in our departments. You know, I think a good rule of thumb for athletic trainers and what I've always talked to them about, they've asked me my opinions on things, is always make safe decisions and if you have a gut feeling about something, you know, pull the kid and be safe about it. And I really haven't in my experience, met any athletic trainers that haven't done a great job since I've been back in Iowa for the last 10 years too.

Dr. Arnold:         
That's outstanding. I know I give lectures at the college level for Athletic Training programs and I'm impressed at their knowledge base, having gone through medical school and being a physician, just the questions I get asked. These are really sharp young people and it is, they are a pleasure to work with. When should a family member seek care? I'm going to give you a quick example, because even as a physician, my daughter was playing volleyball and had just mid thoracic pain, seemed pretty benign to me. but when we finally did go to the physician, because I got sick of her complaining to me, right away, he was like, well, this could be a pars interventricular fracture. You know, cause it's very common in volleyball.

Dr. Spellman:      
Sure.

Dr. Arnold:        
I didn't know that it turned out the MRI was normal and return to play, but when should a parent say, I need to take my kid in to see Dr. Spellman?

Dr. Spellman:     
Jokingly I say, any time it's a doctor's child or nurse's child...

Dr. Arnold:        
Yeah, absolutely.

Dr. Spellman:      
Then bring them in. No I'm just kidding, but you know, I think that comes down to common sense too. Kids generally, if something hurts, they complain appropriately. Adults, it's a little more difficult to figure them out sometimes. Like I've always said that kids are pretty straightforward. So if they have a continued complaint post injury, whether it be their arm, their leg, their foot, then I think one big point, recurrent complaints, continued complaints, that's, that's a good idea to bring them in. Obvious deformity or swelling, especially in a young kid an arm a leg, you know, that could be an acute fracture. So I think that's important too. And I think again, a lot of it comes down to common sense and everything that, especially younger kids do. Younger kids typically will show there's something injured, so if they're, if they have a continued limp or something like that, that is not something to let them do too long because you know, you get into certain age frames or age ranges, you know, that can be a major hip issue or whatnot. So I think common sense is the key. I think, you know, if it's late at night, they bumped their, they bumped their wrist, they bumped their elbow or whatnot and they're doing okay, you ice it, you go through the typical things to nurse an injury and they're doing fine, I think you can watch them close. But if that swelling continues, they're not using the extremity, you start to see a deformity like it looks like the arm has a different curve to it, then I personally wouldn't wait too long on something like that.

Dr. Arnold:         
Good advice. In adults, we would have concern about using a nonsteroidal anti-inflammatory drugs, Advil, naproxen, Aleve for extended periods of time. And there are risk factors, whether it's gastrointestinal ulcers or kidney dysfunction. Is that the same in children?

Dr. Spellman:       
So I've fortunately I haven't, you know, I've used a lot of NSAIDs and a lot, you know, basically the two components for kids would be the two major medications that we use for pain would be an Acetaminophen or typically an Ibuprofen. And I think if you use a short course of that, even a consistent, like one to two weeks with food and you monitor closely, you really don't run into issues with kids. Most kids, if you're looking at over a couple weeks, one to two weeks of like an an anti-inflammatory, then then I'm questioning if we're doing the right thing or have the right diagnosis. But I personally, when I talk to parents about medication, I talk about taking the recommended doses and taking them appropriately. And I think especially with a non, a non-steroid or an NSAID, just making sure they're taking it around the time they eat.

Dr. Arnold:         
What is the compliment of physical therapy to your practice?

Dr. Spellman:       
So physical therapy with sports medicine, if you look at injuries and you look at say what's operative, like what percentage? Over 90% injuries are non-operative injuries and physical therapy to me is...

Dr. Arnold:        
Meaning they don't require surgery.

Dr. Spellman:       
Right, right. So they don't require surgery. So what's the other component to that too? There's that rest component. The big component is rehab. So physical therapy is a huge compliment to sports medicine. And I utilize physical therapy if I can, if it's possible talking with parents even to rehab ankles back, that have an ankle sprain, so they decrease the risk of recurrent injury. Probably the most significant part of my training, if you look at colleagues, you know, it's probably been my relationships with physical therapists and athletic trainers as a sports medicine physician and then fortunately having great orthopedics, you know, training with them to look up to also to, and work with. But it's, to get back to your question, physical therapy is a huge component of safely returning an athlete to play.

Dr. Arnold:         
Well this is usually the point in the podcast where I start to ask questions that I don't know the answers to, but I wish I did. So I know female athletes tend to have more ACL injuries. Why is that?

Dr. Spellman:       
So if you look at the statistics, female athletes are four to six times more likely to have an ACL injury. I think part of that is sort of a question mark, but there are some really good theories with evidence backing. The female athlete, boys and girls are built differently, so if you look at the angle of the hip of a female, they generally have an increased angle of the hip. So, and that's just a natural component of...

Dr. Arnold:        
Being a girl.

Dr. Spellman:      
Being a girl. So you, and if you look at a girl as they develop and they go through puberty, they're, their hip angle even increases. And that's, that's part of the natural development of girls. So one thing with girls, if you look at their risk of injury, just be an older athlete versus like a 10-year-old or 14-year-old, there's probably increased risk there. And then I think if you look at the angle at the hip, that does affect the angle at the knee too. So I think there's that biomechanic component to it. The other thing they talk about is the knee joint is a little more shallow. So if you look at the Tibia and you look, you look at the Femur, the condyles there, the tunnel in that joint is more shallow, so they question if that's a component of it too. And I do think, you have to be especially cautious with girls. So that jump program I talked about lower extremity strengthening, teaching them the appropriate perception, teaching their knees, how teaching them how to land, and then also making sure they're, they have appropriate core strength and lower extremity strength can potentially decrease the risk of that.

Dr. Arnold:        
So a multi-sport female athlete, does she have an advantage versus the single sport female athlete as far as ACL injuries?

Dr. Spellman:      
So I would say theoretically I think she would because you're using different muscle groups and strengthening different muscle groups. But I think it, you know, if you look at the sports, it's there, it's pretty, you basically look at the sports and so an ACL tear in a swimmer's not going to be near as common. You know, the really, I think it's the sport that determines in large the risk. And by and far what I've seen is soccer and girls is probably the big one of the biggest risks, and probably basketball behind that would be my guess off the top of my head versus like a swimming or running. But a lot of cutting sports, it's the sports that get boys too.

Dr. Arnold:        
Keeping on the topic here, ACL injury repaired by orthopedics. What's the recovery time?

Dr. Spellman:       
So, you know, that's changed a little bit, even in my career as a physician. You used to think a full year. And generally, you know, that was sort of the timeframe. So if you heard somebody in the NBA that was recovering from an ACL tear, you know, you'd say, well their maybe out next season, or you heard of a college football player that was returned from an ACL tear and they're going to miss the next season. But that, with the advances in physical therapy and I think the motivation of athletes, that is coming down and sometimes you get, you know, there's some kids that get back within, you know, nine months and they're fully participating. Now I think there's a sweet spot for that. You know, it's like anything, if you push the limit too much, you're probably gonna increase the risk of reinjury or another injury. But, you know, with advances in rehab after that surgery, and you know, and I would give the opinion, look for the opinion of my orthopedics, but I think that's a major component. And props to the orthopedic surgeons too, I think they do amazing things with that surgery.

Dr. Arnold:         
Yeah, they certainly do. We haven't talked about concussions, and I think we'll save that for another podcast. I think we could probably do a whole session on just concussions alone and some of the facts and the fiction and talk about that. So I'd like to wrap up today by saying thank you for joining me. I know you're busy. It's been fantastic information. Again, this was Dr. Luke Spellman, a pediatrician for UnityPoint Clinic Pediatrics. If you have a topic you'd like to suggest for our LiveWell Talk On... podcast, shoot us an email at stlukescr@unitypoint.org. And we encourage you to tell your family, friends, and neighbors about our podcast. Until next time, be well.