Feeley BT, et al. Am J Sports Med. 2016;doi:10.1177/0363546515576899.
Cinque reports receiving support for education from Evolution Surgical. C. LaPrade reports receiving support for education from Evolution Surgical and having a parent who is a consultant for Arthrex, Ossur, Smith & Nephew and Linvatec and who receives royalties from Arthrex, Smith & Nephew, Ossur and Elsevier. R. LaPrade reports being a consultant for Smith & Nephew and Ossur; receiving royalties from Arthrex, Ossur, Smith & Nephew and Elsevier: being on committees for the American Orthopaedic Society for Sports Medicine, Arthroscopy Association of North America and International Society of Arthroscopy, Knee Surgery & Orthopaedic Sports Medicine; and being a member of the editorial boards of the American Journal of Sports Medicine; Journal of Experimental Orthopaedics; Knee Surgery, Sports Traumatology, Arthroscopy; Journal of Knee Surgery and Journal of Orthopaedic and Sports Physical Therapy.
An estimated 27 million U.S. youths participate in team sports and approximately 60 million youths participate in some type of organized athletics.
During the past decade, there has been a growing trend of young athletes specializing in one sport at increasingly younger ages, despite growing evidence that the value of sports specialization is not as beneficial for achieving elite athletic status as previously thought and that it often leads to increased rates of acute and chronic injuries. In a recent consensus statement from the American Orthopaedic Society for Sports Medicine, early sports specialization was broadly defined as participation by prepubertal children (aged younger than 12 years) in intensive training programs or organized sports for more than 8 months per year and participation in one sport such that other sports are excluded.
Examples of early sports specialization have been reflected in the popular media in the television shows like “Friday Night Tykes,” which covers pre-teen football players in Texas, and “The Short Game,” a documentary covering the development of 7- to 8-year-old golfers. These programs emerged at a time when professional athletes are increasingly speaking out against single-sport specialization and a growing body of literature demonstrates the direct relationship between early sports specialization, training volume and the development of overuse injuries.
An 11-year-old boy presented with multiple episodes of atraumatic swelling of his right knee and had persistent pain while skiing. Although the patient denied any specific history of injury or a traumatic event, he had been training and competing at a high level as a competitive skier, competing 6 days a week year-round as a downhill slalom skier. On physical examination, the patient had a full range of motion with a mild effusion and tenderness to palpation over the medial patella facet. He had symmetric 2+ patella glide both medially and laterally. He had a negative J-sign and no appreciable patella baja or alta on exam. There was no crepitation with passive or active range of motion.
Radiographs were obtained and showed no acute bony abnormalities aside from the presence of an anatomic variant, a bipartite patella.
What is the next best step in management of this patient?
See answer below.
MRI, arthroscopic diagnosis and chondroplasty to treat a chondral defect
MRI showed an articular cartilage defect of the medial patellar facet. The patient underwent diagnostic arthroscopy, which showed a 10-mm wide Outerbridge grade 6 focal cartilage defect with delamination on the medial facet of his patella.
The chondral defect was treated with an arthroscopic chondroplasty to ensure the flap of cartilage did not continue to delaminate and cause recurrent effusions and pain with activity (Figure 1).
Despite mounting evidence of the negative effects of early sports specialization, many coaches and parents believe these risks serve as an acceptable means to an end: athletic excellence, collegiate scholarships and long-term financial gains. However, evidence from studies evaluating the effects of early sports specialization on elite performance does not support a direct relationship between specialization and the ultimate athletic performance level achieved. Comparison of professional and non-professional competitive athletes in ice hockey, soccer and triathlon events in a study by Robert F. LaPrade, MD, PhD, FAAOS, and colleagues demonstrated that differences in training regiments toward a focus on sports specialization did not arise until competitors were aged 13, 15 and 20 years, respectively. In the United States, a study of 376 Division I intercollegiate athletes by Robert M. Malina, PhD, reported most athletes had their first organized sports experience in a sport other than their current sport. Moreover, the author noted that 17% of athletes had previously participated exclusively in their current competitive sport. Similar findings by LaPrade and colleagues have been reported in Israel, Sweden and Norway, where athletes who started intense training after age 12 years were more likely to achieve elite status than those athletes who started intense training at a younger age.
Start of elite athlete training
Early multisport participation has been proposed to produce improved long-term performance and foster life-long enjoyment of physical activity and recreational sports. The best available evidence supports the assertion of pre-adolescents and adolescents being involved in multiple sports for the benefit of their physical, psychological and social development. Two recent studies have elucidated the athletic benefit of participating in multiple sports at a young age. The first study, by Ronnie Lidor, PhD, and colleagues, compared 68 elite and 78 near-elite athletes and found the elite athletes were more likely to have participated in more than one sport and have specialized after age 12 years compared with the near-elite athletes. Similarly, the second study, by Karin Moesch, PhD, and colleagues, compared 148 elite and 95 near-elite athletes and found the elite athletes began intense training in a single sport at a later age than the near-elite athletes, who began intense training significantly earlier.
Early sports specialization is increasingly recognized as detrimental for the future physical and mental health of the youth athlete. Conversely, early multisport participation has been identified to generate improved long-term athletic performance, and promote social engagement, while also avoiding burnout. It is recommended that clear information from physicians is communicated to patients that multisport participation will likely enhance the athletic capabilities of pre-adolescents and adolescents, and the significant risk of negative physical and psychological effects of early sport specialization. Furthermore, coaches and parents must be educated about the importance of diverse physical activity and that early sport specialization in youth athletes has not been shown to be beneficial for attaining elite athletic status. Lastly, further research is needed to identify the optimal level of exposure to maximize the training effect in the youth athlete with a minimal risk of injury.
- Feeley BT, et al. Am J Sports Med. 2016;doi:10.1177/0363546515576899.
- LaPrade RF, et al. Orthop J Sports Med. 2016;doi:10.1177/2325967116644241.
- Lidor R, et al. International Journal of Sport Psychology. 2002;33:269-289.
- Malina RM. Curr Sports Med Rep. 2010;doi:10.1249/JSR.0b013e3181fe3166.
- Moesch K, et al. Scand J Med Sci Sports. 2011;doi:10.1111/j.1600-0838.2010.01280.x.
- Outerbridge RE, et al. Clin Orthop Relat Res. 2001;doi:10.1097/00003086-200108000-00002.
- For more information:
- Mark E. Cinque, MD, MS, and Christopher M. LaPrade, MD, who is an orthopedic surgery resident, can be reached at Stanford Medicine, Department of Orthopaedic Surgery, 450 Broadway Ave., Redwood City, CA 94063. Cinque’s email: email@example.com. LaPrade’s email: firstname.lastname@example.org.
- Robert F. LaPrade, MD, PhD, FAAOS, can be reached at Twin Cities Orthopedics, 4010 W. 65th St., Edina, MN 55435; email: email@example.com.
- Edited by Mark E. Cinque, MD, MS, and Filippo F. Romanelli, DO, MBA. Cinque is a elowchief resident in the department of orthopedic surgery at Stanford. He will pursue a fellowship in sports medicine at The Steadman Clinic/Steadman Philippon Research Institute following residency completion. His interest is in complex knee surgery and multiligament reconstruction. Romanelli is a chief orthopedic resident at Rutgers – Jersey City Medical Center with an interest in adult reconstruction. He will be at New York University for his fellowship. For information on submitting Orthopedics Today Grand Rounds cases, please email: firstname.lastname@example.org.