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Key Considerations in Treating Teenage Athletes
As teenagers finish up their school years and prepare for summer break, many start a grueling time of year of sports. We then see teenagers in our hospitals and clinics from June through September for various lower extremity conditions and injuries in staggering numbers. The variety of issues with which they present can range from simple to complex. Over my 30 years of practice, the severity and frequency of lower extremity conditions in this population have seemingly increased.1-5 And, it always seems to worsen during the summer months.
Let’s be direct; teenage athletes have become big business for everyone involved. Coaches, parents, communities, local businesses, and more potentially benefit from teen sports. I remember when AAU basketball was the only travel organization, but now there is travel everything. These teams have even become the subject of FBI investigations for steering money and players to high-profile collegiate programs.6 And now that the NCAA allows name, image, and likeness (NIL)7 deals, the pressure on teenage athletes to perform earlier and earlier is upon us.
Understanding the Impact of Multi-Sport Involvement
We all watched the meteoric rise of Tiger Woods (golf), Lebron James (basketball), Jennifer Capriati (tennis), and Freddy Adu (soccer), not to mention the Ball brothers’ (and their father’s) reality TV and social media exploits. Thanks to them, everyone wants to be a social media influencer. And now that we are in the age of NIL and non-fungible tokens (NFTs),8 I believe they will alter sports forever, with teenage athletes vying more and more for that “golden ticket” into collegiate sports. This also means that many kids play as many sports as time will allow. One only has to look at scouting reports for college prospects to see that “all-around athlete” has become a category, one that teenagers are coached to promote themselves as.9 Thirty of 32 first-round draft picks in the 2017 NFL draft were multi-sport athletes in college.10
Ultimately, there is plenty of evidence supporting the benefits of playing multiple sports,9,10 but playing multiple sports at the same time throughout the summer is the issue (see tables to left). Multiple pediatric studies echo this concern, especially about the lack of rest and its link with injuries.11 Competitions around-the-clock, multiple games in a day, sometimes at odd hours to avoid the elements or capture precious ice or field time, at the very least can also lead to sleep disturbances, sets these kids up for injury and illness.10 These risks and sacrifices used to be for the chance for a scholarship, but now with NIL and other factors, I see the economic impact, too.
Observations Upon Treating Teenage Athletes
Along with the pressures and ramifications of the schedule, in my practice, we continue to see an escalation in overuse and athletic injuries. Treating teenage athletes is no picnic. Despite the volume of conditions you encounter, I find very few need surgery ... now. The primary treatment I pursue in almost all cases is education and preparation of both parents and the athlete that they simply can not continue at this pace. As we discuss specific cases below, that will be the overwhelming theme. Sure, non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, ice, and inserts will remain go-to treatments, but one must also stress rest.
Somewhere in the process, I find you will get pushback, usually from parents, rarely from the teenager. And if you get to the point that you prescribe not playing sports, don’t be offended when the parents request a second opinion. There is nothing wrong with second opinions. More times than I can count, these parents seek out multiple opinions, often in multiple disciplines, until they hear the desired advice, regardless of the level of the athlete’s pain or dysfunction.
Amazingly, I rarely see teenagers complain when we recommend taking a break. It is much more the parents and coaches who complain about things like non-refundable tournament entrance fees or travel expenses, or even expensive equipment costs they can’t recoup. Talent is a ruthless curse, especially in states or communities that find it hard to compete with sports meccas like California, Texas, or Florida. The drive for their child to be the best in their school, city, and state is a powerful motivator for parents, and, as a result, I find they will drive their teenagers harder than any coach.
As an athlete myself, it saddens me to see these teenagers’ summers ruined by sports. I wouldn’t trade all my years playing, but was it all worth it? I wish someone would have told me earlier on what was realistic for me. I played Division III tennis in college, and had the time of my life. But did that justify the money running to football camps across the country, the multiple concussions, and heat exhaustion? Unlike so many of my patients, I never had any orthopedic issues, but I didn’t keep the schedules that these kids do now.
When a Multi-Sport Teen Athlete Needs Bunion Surgery
A 13-year-old softball player plays on an over-15 travel team. She is a freshman in high school. She has fairly significant bunion deformities, which were initially not that concerning. She started high school and played softball, volleyball, basketball, and then, travel softball. By the summer, her bunions were killing her. She couldn’t practice because her cleats hurt so much. She already had multiple Division II scholarship offers. We got to the point where she needed to quit volleyball and then had to quit basketball before we scheduled her first bunion surgery. The next summer before her junior year, softball travel started ramping up. They were now playing 5 to 6 games in two days. She could hardly walk on her other bunion, and her surgical foot remained swollen. She was miserable. She decided to skip her fall high school softball season to focus on her travel team. She continued to play volleyball because she was getting offers to play volleyball. She had to forgo basketball completely.
We undertook her other bunion surgically during Christmas of 2020. She completed her junior year, but then reality kicked in. She didn’t test well on the ACT and SAT. All of her scholarship offers disappeared. She started her senior year with her dreams dashed by a summer of injuries and poor SAT performance. She doesn’t even play softball for her high school because she had worked so hard during the summer that she now has chronic knee and hip issues. Ultimately, her sports career ended as quickly as it started. Throughout four years of treating her, I encouraged her to work at school as hard as she worked on her batting. She never prepared for the SAT. The stress of sports each summer caught up to her. She headed to community college.
When One Sport Puts Another in Jeopardy
A 15-year-old female sustained an ankle fracture. Her parents informed me that she had multiple Division I scholarship offers to play soccer. But, she did not injure herself during a slide tackle; she fell off a pyramid at cheerleading camp. As many of you know, cheerleading is a big-time sport today and has become simply an extension of gymnastics. This scenario is a prime example of an athlete playing what I refer to as antagonistic sports. Gymnastics is vastly different from soccer. She healed without incident and resumed soccer, but she lost her junior year of high school and travel soccer seasons which resulted in her losing all of her scholarship offers. Ultimately, she ended up playing Division II, but the moral of the story is to concentrate on the one best sport for the athlete. Cheerleading is a great sport, but competitive cheer is prone to injuries, let alone the chronic issues that we see with stunt dismounts. Conversely, if cheerleading was her primary, then one might consider playing soccer just as foolish.
Considering Why These Athletes Play
My last example involves a 16-year-old female with chronic shin splints. She played high school volleyball, travel soccer, travel basketball, and cheerleading for the upcoming boys’ basketball season, all in the fall semester of her junior year. Let’s not forget she was also in choir and an honors student. Her father noted that she came home after every practice and game and laid in a tub of ice to calm her shin splints down. She had either practice or games every night, with no rest for a 6 to 8-week period. She presented to my clinic in hopes of getting inserts. She wanted to start running track so she could run cross country the following fall.
Clinically, she was a significant pronator that no inserts would solve without surgery. I had to have a frank talk with her and the family. She played as many sports as she could to pad her college resume. She wasn’t great at any sport, nor did she have any aspirations to play in college. She was a popular girl who wanted to fit in. Whatever her friends played, she played. She was the daughter of a high-ranking Army officer looking at the Ivy League and the service academies. She left me no choice but to recommend decreasing her sports before she ended up with surgery. Ultimately, she scored so high on her SATs she didn’t need all the sports to get into the school she wanted – Yale.
I see more and more of this scenario of the over-achieving high schooler versus the overly talented athlete trying to do it all. Conversely, I have seen my share of parents demand that I do surgery now instead of simply focusing on their primary sport. Either way, the pain has to be the reason for surgery, not that they can’t perform a sport.
Final Thoughts
The odds of teenagers achieving the “golden ticket” to college, let alone as a professional athlete are very low. We have to be honest with teenagers, even if their parents are in left field fantasizing about their futures. Not everyone will turn into a TikTok or YouTube star dunking a basketball. Very few will ever achieve what the Williams sisters have done on and off the court. More athletes will end up in community college than playing for Alabama. Either way, we as podiatrists must be the voice of reason. Surgery is not always the answer. In my experience, common sense and rest are nearly always the best medicine for teen athletes this summer.
Dr. Spitalny is a staff podiatrist at General Leonard Wood Army Community Hospital and Adjunct Faculty of the SSM Depaul Podiatry Residency Program in St. Louis, Mo.
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