Before 21-year-old Owen Thomas became captain of the football team at the University of Pennsylvania, he was a star athlete in my suburban community, one hour north of Philadelphia. Since age 9 he had played on various local teams, so when he killed himself in April 2010 it was shocking to the many people who knew him. Five months later another ripple went through our town when doctors revealed Thomas had CTE—chronic traumatic encephalopathy, a progressive, degenerative disease of the brain that may cause depression and has been found primarily in athletes with a history of repeat concussions. Former NFL players—including Dave Duerson, who took his life this past February after leaving a note saying he wanted his brain to be studied—are increasingly being diagnosed with CTE. As talk about Owen circulated, an alarming number of friends and neighbors had their own stories to share about concussions in young athletes. "It worries me," said a mom whose son is a football captain at our high school. "One boy got a head injury the first week of practice and was out for three weeks. Another quit football after middle school because he'd already had two concussions."
There is a groundswell of awareness about head injuries across the nation; between 1998 and 2008 the concussion rate in high school sports quadrupled. Experts believe the rise is a result of coaches, parents and players who are more likely to report head-banging incidents that may once have been dismissed. In other words, a vast, hidden crisis is now being revealed. "Before, a lot of our statistics were estimates, and were the tip of the iceberg," says Mark Halstead, M.D., assistant professor in the departments of pediatrics and orthopedics at Washington University in St. Louis. "Now athletes and trainers are reporting concussions more often, but they are still an underexposed problem."
As it turns out, concussions are just one symptom of a larger issue: Many kids get hurt playing sports. Football players lead the pack in both concussions and overall injuries, sustaining more than half a million a year—including fractures and ligament sprains, according to the Center for Injury Research and Policy (CIRP) at Nationwide Children's Hospital, in Columbus, Ohio. Girls' soccer is second in terms of concussions. But high rates of serious injuries that bench kids for at least three weeks—and sometimes cause more long-term damage—plague sports like ice hockey, basketball and gymnastics. The most common injuries are broken bones and sprains in hands, fingers, wrists, ankles, knees and shoulders. Less frequently reported overuse injuries like stress fractures and tendinitis account for up to half of all sports-related injuries in kids, according to the American Academy of Pediatrics.
All told, CIRP estimates that 1.3 million high school athletes were injured in the 2009-2010 school year. In fact, high school football players have twice as many serious, season-ending injuries as college players, even though college players are injured more frequently. And the estimates are even higher for kids under age 14: about 3.5 million sustained injuries, according to Safe Kids USA. The reason middle school athletes are so vulnerable is that students are developing at different rates. "You could have a small kid against a kid who is much bigger and more physically mature, and that imbalance in size and speed can result in a lot of harm," explains Dr. Halstead.
Even more disturbing is that bodily damage seems to be accepted—even expected—by athletes. "The culture of sports says that injury is just part of the game, the unavoidable price kids pay to play," says Dawn Comstock, Ph.D., principal investigator at Nationwide Children's Hospital. "That's just not right. We can do a much better job of making youth sports safer." Organizations such as Little League and Pop Warner try to prevent injuries by controlling factors like number of pitches thrown and grouping players by weight. But some intensive programs and hard-driving coaches still emphasize performance over safety. At an Oregon high school's football training camp in August 2010, for example, 12 players ended up in the hospital with severe upper-arm-muscle injuries after a new coach ordered kids to do strenuous push- ups and chair dips nonstop for four to five minutes.
Sometimes coaches don't even realize they're being too tough. "Kids feel embarrassed if they're hurting or can't keep up, so they don't say anything," says Cynthia LaBella, M.D., medical director of the Institute for Sports Medicine at Northwestern University's Children's Memorial Hospital in Chicago. "They feel compelled to please the coach, who thinks everyone is doing okay, so he pushes even harder. Then it's a big shock when a kid comes in with a doctor's note saying that he can't participate."
It doesn't help that our hypercompetitive culture increasingly forces kids not only to specialize in one sport but to start at a very young age—as early as elementary school. "There's a feeling in the sports community that you have to train early and intensely to keep up," Dr. LaBella says. "Practices are longer and more arduous, kids play more games over an extended period of time and there's more emphasis on winning than acquiring skills." Travel teams may play three or more games in a single day during weekend tournaments. And young athletes are quick to learn that the coach won't put them in the game unless they're one of the best players. The result: Bodies don't adequately recover from repetitive stress on specific muscles, bones and tendons. Preliminary research at Dr. LaBella's institute suggests that kids who specialize in one sport before puberty are at higher risk for overuse injuries and are more likely to burn out and quit their sport.
Many parents assume that proper equipment is the key to safety, but experts caution against becoming complacent. "Young athletes need gear that is sized and fitted correctly and in good repair," says Comstock, but that's a tall order with growing kids. "What fits one season won't fit the next," Dr. LaBella says. There's also a new controversy over whether helmets do more harm than good. Some critics say kids actually play rougher when wearing helmets or heavy gear because they think they're better protected.
Still, research shows that wearing equipment generally reduces the risk of injuries. Schools can use old helmets if they have them, but they should send them off-site annually for reconditioning, says Brian Robinson, chair of the Secondary School Committee at the National Athletic Trainers' Association. Unfortunately, up to half a million young players use hand-me-down helmets that haven't been properly updated within two years, according to a recent New York Times investigation. Even worse, it was discovered that re-conditioning companies sometimes fail to follow proper testing procedures and return defective helmets to youth teams. "Schools are at the mercy of these companies," says Robinson, who is also head athletic trainer at Glenbrook South High School in Glenview, Illinois. The helmets Glenbrook receives appear to be in good shape, he says, but no one can be sure just by looking.
There's also the glam and glory factor to consider. Some parents encourage their kids to excel at a sport in the hope that they'll nab college scholarships or go pro. The fact that less than 1% of high school players make it to the professional level doesn't prevent kids from being "dazzled by what they see in pro and college sports—not only the admiration and money and how their heroes train and play," Dr. LaBella says, but also their bone-crunching hits. Even the enormous amount of attention devoted to pro athletes with brain injuries—most recently a hockey player—can further glamorize a life in the limelight. And with a nonstop stream of games being shown on multiple sports-only cable stations, the lure of fame trickles down to kids. ESPN broadcasts the Little League World Series live, for example, and colleges that want first dibs on outstanding talent woo players as early as middle school. "All of this pressures kids to train harder at younger ages," Dr. LaBella says.
Ultimately, the one indisputable factor contributing to the increase in injuries is the large number of kids who are now heading for the field. "More than half of all high school students play sports," says Comstock. And while that's good news overall—fighting obesity, building self-esteem, encouraging fitness and teaching teamwork are just a few of the benefits of organized sports—parents, coaches and players need to champion safety as they cheer from the sidelines.
Rules of Protection
Fortunately, kids can thrive in sports without being sidelined by injuries.
- Athletes should take off one or two days a week to let muscles rest, says the American Academy of Pediatrics. On no-practice days, don't encourage a baseball player to throw pitches in the backyard or a soccer star to run an extra mile to stay competitive. During the summer, instead of enrolling your kid in an intensive one-sport camp, let her body rebuild. If she worries about getting out of shape, have her cross-train or try other sports that use different muscle groups.
- Don't let your child increase his training time, number of repetitions or total distance by more than 10% a week. For example, if he currently runs 20 miles a week for track, he shouldn't run more than 22 miles next week. "It's when kids exceed the 10% rule that we see injuries," says Brian Robinson of the National Athletic Trainers' Association.
- Be on the lookout for signs of burnout, such as complaints about muscles or joints, overall fatigue or reluctance to play. "When kids are physically tired and bored with a sport, skills and technique can get sloppy, which increases injury risk," Robinson says. If you're cajoling your child into participating, it may be time to consider another sport or a less intense team.
- Support coaches and referees who strictly enforce rules and penalties for illegal play. Ten percent of fractures are due to rule violations—and fractures keep kids on the sidelines more than any other injury.
- Talk to your teen's trainer about including moves such as lunges, jumps and squats, which strengthen the muscles that reinforce and protect the knees.
Heading Off Concussions
Why young athletes are especially at risk for a devastating brain injury:
A decade ago a kid who was "dinged" or "had his bell rung" might be put back in the game 15 minutes later. "People didn't have the understanding that concussion is a serious brain injury," says Mark Halstead, M.D., of Washington University in St. Louis. Concussions result when a blow to the head causes the brain to rotate or slosh inside the skull, disrupting normal cell function. "Now we know that after just one concussion, it doesn't take as heavy a blow to cause the next," Dr. Halstead says. In fact, a second head injury on the heels of an unhealed earlier concussion can trigger severe swelling inside the skull. "It's rare, but about five kids a year die from this second impact," Dr. Halstead says. "It seems unique to players under 20." Even the kids who survive second-impact brain injuries can be neurologically devastated, says Thomas Pommering, D.O., division chief of Nationwide Children's Hospital Sports Medicine center. "The developing brain is more susceptible to damage," he says. Multiple concussions may also have additional cumulative, long-term effects, including depression and memory loss.
Players who suffer a head impact should seek medical attention immediately if they experience headache, nausea, confusion, dizziness, double vision, sensitivity to light, forgetfulness or trouble with balance. "Concussion isn't as obvious as, say, a knee injury, when the player hobbles off the field," Dr. Halstead says. "The player needs to tell someone he doesn't feel right." Healing requires both physical and mental rest—activities requiring concentration can make symptoms worse. "We recommend taking a few days off school, and avoiding standardized tests, driving and even video games," says Dr. Halstead. In most cases symptoms resolve within about 10 days.
A Dangerous Jolt
Energy drinks score high with young athletes enticed by promises of better performance, increased concentration and improved reaction time. But some of these beverages, containing up to 500mg of caffeine, may also cause dehydration, dizziness, sleeplessness and potentially dangerous heart palpitations. For sustained strength, encourage your child to fuel up naturally on protein and complex carbohydrates by eating a peanut butter sandwich on whole-wheat bread an hour before playing.
Girls' injuries are different from boys'.
In soccer, basketball and softball—when girls and boys play by the same rules—girls have a higher rate of severe injuries like fractures and ligament sprains, and double the risk of concussion. Experts believe body differences are largely to blame, especially after puberty, when injury rates markedly diverge. Girls use their thigh muscles more than their hamstrings, rely on ligaments more than muscles to control joints and usually favor a dominant leg. "When girls land after a jump, their knees tend to rotate inward more than boys' do, which puts more pressure on the joint and supporting structures," says Dr. Pommering of Nationwide Children's Hospital. Girls also have weaker neck muscles than boys, which may make them less able to withstand a blow to the head.
"Post-puberty, girls start to match boys in height and weight but haven't developed the same burst of muscle to control their new bodies," says Dr. LaBella. They tend not to lift weights like boys do, which is why some coaches have started to add strength training—squats and lunges —to girls' workouts. Plus, females who strive to stay thin may be even more at risk of getting hurt. "Girls are especially likely to sustain stress fractures in sports where performance is partly judged on physical appearance, like gymnastics, diving or figure skating," says Dr. Pommering.
You wouldn't start a car engine in a closed garage, but that's essentially what happens when workers at ice rinks fire up diesel-fueled Zambonis and other resurfacing machines. Carbon monoxide is one hazard—even low-level emissions can cause headaches and nausea. Another concern is ultrafine particulate matter from combustion, which is linked to poor airway function in skating athletes," says Loren E. Wold, M.D., principal investigator at the Center for Cardiovascular and Pulmonary Research at Nationwide Children's Hospital. The best solution is to use safer electric resurfacing vehicles, he says.
Indoor pools may also cause breathing issues. Chlorine-related irritants can make inhaling difficult, according to the CDC. "Tight spaces concentrate chlorine, so small pools at schools are problematic," says Steven Teich, M.D., Clinical Associate Professor of Surgery at Ohio State University in Columbus. Ask the coach to open the windows to boost circulation.
Play It Safe
No matter which sport your kid loves, there are bound to be risks—and ways to avoid them.
Common injuries: Sprains, strains, fractures, pulled muscles, torn ligaments, internal injuries, concussions, heat stroke.
Must-have gear: New or recently reconditioned helmet, mouth guard, shoulder pads; pads for chest, forearms, elbows, knees, thighs, shins; proper shoes.
Playing defense: Kids should block and tackle only who they can see; dropping their heads and hitting helmet-first increases the risk of head and neck injury, says Brian Robinson of the National Athletic Trainers' Association. Conditioning knees and ankles can protect those injury-prone areas.
Common injuries: Overuse injuries, impact injuries and fractures from being hit by the ball or sliding into bases.
Must-have gear: Batting helmet, preferably with face shield; breakaway bases that decrease the risk of sliding injuries; reduced-impact balls; protective cup; proper cleats.
Playing defense: Helmet should fit snugly without interfering with vision. Clear the field of glass and rocks, and fill in holes where kids could twist an ankle. Consider using wooden bats—getting hit by a bat is one of the most common causes of injury, and metal bats swing faster and hit harder.
Common injuries: Shoulder and upper arm injuries, facial injuries, concussions, lacerations.
Must-have gear: Helmet with a face mask and four-point chin strap; mouth guard; pads for shoulders, elbows and shins.
Playing defense: Consider joining a league that uses the fair-play rule system—without one in effect the injury rate is two to four times higher.
Common injuries: Sprains, strains, fractures, scrapes, cuts, dislocations, injuries to teeth.
Must-have gear: Mouth guards, eye protection, proper shoes.
Playing defense: Make sure floors are swept before practices and games to prevent slipping. Complain if referees overseeing girls' games don't take fouls seriously: Women's basketball has the highest rate of injury caused by illegal activity.
Common injuries: Sprains, strains, contusions, abrasions, fractures, bruises, cuts, scrapes, concussions.
Must-have gear: Shin guards, proper shoes.
Playing defense: Train kids to keep their knees aligned over their toes when landing after a jump to avoid stress on the joints. Headed balls should be struck using the forehead at the hairline, with the chin tucked toward the chest and arms in front of the body for better balance and protection.
Track and Field
Common injuries: Overuse injuries, sprains, strains, scrapes.
Must-have gear: Proper shoes.
Playing defense: Check the soles of shoes: If the black tread has worn down, you should replace them. Pay special attention to pain over a bone—a sign of a stress fracture.
Common injuries: Sprains, strains, fractures, dislocations, abrasions, lacerations, concussions.
Must-have gear: Apparatus that's regularly inspected, ideally multiple times a year by facilities, and before every use by coaches.
Playing defense: Adult supervision is essential. Coaches and competitors should know how to adjust and inspect equipment.
Originally published in the September 2011 issue of Family Circle magazine.