Pediatric Sports Medicine | Texas Scottish Rite Hospital for Children

$Physician examining patient with avulsion fracture of the medial epicondyle at Texas Scottish Rite Hospital for Children$

SPORTS MEDICINE

Our world-renowned sports medicine experts are ready to help your injured athlete get back in the game. At Scottish Rite Hospital, we have unparalleled experience treating concussions, stress fractures, and knee, shoulder, elbow and hip injuries in young and growing athletes.

Pediatricians, pediatric orthopedic surgeons, physical therapists, athletic trainers, psychologists and others work side by side with each athlete, their parents and coaches to develop the best game plan for recovery.

Our Sports Medicine practice is located at:
7000 West Plano Parkway
Plano, Texas 75093

Monday – Friday, 8 a.m. – 4:30 p.m.

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OUR SERVICES

SHOULDER

As a shallow ball-and-socket joint, the shoulder allows for a wide range of motion for overhead sports like baseball and volleyball. This range of motion also increases the risk of instability and injury to the joint. Repetitive motions or a single, forceful event may lead to tissue damage, resulting in changes to the shape of the bones and soft tissues. Many shoulder problems in young athletes are preventable. And early recognition often allows nonsurgical treatment with faster recovery.

The collarbone is the only bony attachment of the shoulder to the trunk. Soft tissues surround the collarbone to provide stability and a great amount of mobility for the arm. A collarbone fracture most often occurs with high-force traumatic events.

SYMPTOMS

Pain at the site of the break is the most typical symptom of this injury. In some cases, damage to other vessels and nerves in this area may cause symptoms further down the arm. An athlete with a collarbone fracture naturally places the arm in a guarded position by wrapping the forearm across the stomach. The shoulder on the injured side often appears to be lower than the noninjured side.

PREVENTION

In some sports, such as football, pads and gear may protect the collarbone. In other sports, proper balance of strength and flexibility in the neck and shoulder muscles may aid in preventing collarbone injuries. These injuries are often unpredictable and unpreventable.

DIAGNOSIS

X-rays are most useful in confirming diagnosis and guiding treatment.

TREATMENT

Nonoperative approaches include using a sling to immobilize the arm for comfort and monitoring the natural healing process of the bone. This proves effective in most cases. Surgical intervention is only a consideration where natural healing is not likely to promote normal function of the shoulder.

RETURN TO SPORTS

After a period of 6-8 weeks, with pain resolved and X-ray evidence of good bone healing, an athlete may often return to sports with instructions to progress as tolerated. For some collision sports such as hockey and football, a longer healing time may be recommended.

A complex network of nerves called the brachial plexus extends from the neck into the arm to allow the hand to feel and move. An extreme stretch to the brachial plexus can cause short-lasting symptoms with damage to the nerve tissues. Most often, this injury occurs with a fall on the head and shoulder. This is a common injury in high school and collegiate football players and occurs less frequently in adolescent athletes.

SYMPTOMS

Neurological symptoms include numbness, tingling and pain in the arm only on one side. These typically last less than 15 minutes, but in some cases may last days or weeks. Because the injuries can occur together, the athlete should be evaluated for signs and symptoms of a sports concussion.

PREVENTION

Proper equipment for the position played and proper tackling form for the tackler and the player being tackled may reduce the risk of a burner.

DIAGNOSIS

A fall combined with the description of one-sided neurological symptoms is typically sufficient for diagnosis. Imaging may rule out other problems in the neck, especially for patients with persistent symptoms or a history of multiple stingers.

TREATMENT

In the early phase, rest, a sling for comfort and nonsteroidal anti-inflammatory drugs (NSAIDs) may be used. Typically, healthy athletes will recover quickly and will not need treatment. Surgical treatment for this is extremely rare. Rehabilitation may be recommended for neck and shoulder strengthening.

RETURN TO SPORTS

Without signs and symptoms of another injury, athletes can typically return to sports quickly when they are symptom-free.

The bony surface of the shoulder socket is very shallow. A circle of soft tissue, called the labrum, sits on the edges to make the socket deeper. As the ball moves around in the socket, bone or other soft tissues may stretch or compress the labrum.

A labral tear can occur in a single traumatic event such as a dislocation or in repeated episodes of shoulder instability. In adults, this most likely occurs with repetitive movements that cause wear and, ultimately, tear. Softball pitchers, volleyball players and baseball pitchers are more likely to have overuse injuries to the labrum.

SYMPTOMS

Pain with activity, especially throwing and overhead activity, and instability are common symptoms of labral tears. Range of motion is usually normal.

PREVENTION

Stabilization exercises for the shoulder and shoulder blade can improve the strength of the muscles. More importantly, the stabilization exercises can put the shoulder in its best position, both for performance and for injury prevention.

DIAGNOSIS

A thorough conversation about symptoms, activities and any injuries can help a provider make a preliminary diagnosis. Radiographic X-rays and an MRI may help assess the bone and soft tissue, including the labrum. SLAP or Bankhart lesions are the most common tears in adolescent athletes.

TREATMENT

Not all labral tears require surgery. The athlete’s symptoms, like pain and instability, and ability to perform daily activities help determine if surgical treatment is required.

RETURN TO SPORTS

Nonoperative treatment plans sideline athletes for a short period of time to allow focused rehabilitation. After a surgical procedure, restrictions from sports and other activities vary from 4 to 6 months. Returning to sports is most safe after completing a rehabilitation program designed specifically for the athlete.

Extreme rotation of the arm in the cocking phase can push the shoulder to its limits with every pitch. Over time, this repeated rotation often stresses and widens the growth plate, creating a bruising bone pain. The result: Little League Shoulder.

SYMPTOMS

Early signs and symptoms of Little League Shoulder include pain in the shoulder after throwing that resolves with rest. Pain that doesn’t resolve after rest may be an indication of a more advanced problem needing further evaluation.

PREVENTION

Since pitching requires full body control, hip and trunk strengthening is an important component of training. Focusing on form, not force, is critical for young athletes. It’s also smart to follow pitch count guidelines and progress to advanced pitches at appropriate ages. Periods of rest are important to allow the tissues to recover between events and seasons. Stabilization exercises for the shoulder blade can improve posture and form.

DIAGNOSIS

A thorough diagnosis includes a conversation about past medical history, the current injury, onset of symptoms, as well as sport exposure. The latter includes position played, frequency of practices and games, length of seasons and number of pitches for baseball. X-ray imaging of the injured shoulder and opposite side can help to rule out a fracture and evaluate the growth plate for signs of stress.

TREATMENT

Early recognition and forced rest can help an athlete successfully return to sports with no permanent changes in bony structure. Continued throwing can cause changes to the bony structure or soft tissues that permanently damage shoulder mobility. Symptom management with anti-inflammatories and ice may be required, but often, resting the arm provides relief.

RETURN TO SPORTS

After a period of forced rest, often 6-8 weeks or longer, the pain typically improves and your athlete may return to throwing in a progressive routine: throwing short sessions and slow pitches and progressing to longer sessions and faster pitches. Rest is recommended for any symptoms that return with throwing.

Shoulder joint mobility allows for extreme motions in sports like baseball, gymnastics and volleyball. But that mobility also puts the shoulder at risk of injury.

Extreme forces in certain positions can cause the ball of the upper arm bone, the humerus, to feel unstable or even slip out of the socket completely, resulting in shoulder dislocation. Some athletes are predisposed to this because of naturally weak ligaments or changes to the bony surfaces with repetitive activity.

Approximately 9 out of 10 athletes who’ve experienced shoulder dislocation are likely to experience another.

SYMPTOMS

Severe pain with a traumatic dislocation often improves quickly when the shoulder returns to its normal position. With repetitive dislocations, there may be no pain because the tissues have changed over time to allow this movement to occur easily.

PREVENTION

Strengthening exercises for the shoulder’s rotator cuff muscles and muscles around the shoulder blade can improve stability. These exercises can also improve the body’s ability to respond to changes in movement. This is a combination of proprioception and neuromuscular control.

DIAGNOSIS

A thorough conversation about episodes of instability and dislocation help a provider confirm the diagnosis. X-ray or other imaging of the shoulder can help rule out a fracture and evaluate the joint surfaces and soft tissue for changes.

TREATMENT

With early recognition, physical therapy can help improve motion and stability while relieving pain. Most athletes return to play after an initial injury. In cases of repetitive injury, surgical reconstruction may be required. Physical therapy after a reconstruction helps to regain shoulder mobility and strength.

RETURN TO SPORTS

The collarbone is attached to the shoulder with soft tissues, including tough ligaments. With an injury such as a strong blow directly on the shoulder from a hit or fall, or an impact on an outstretched arm, the ligaments holding the collarbone can tear. In some cases, the collarbone visibly separates from the shoulder at the acromioclavicular (AC) joint.

SYMPTOMS

Typically, there is severe pain and limited ability to move the shoulder at the time of injury. Swelling and bruising follow soon after.

PREVENTION

Proper equipment for the position played and proper tackling form for the tackler and the player being tackled can reduce the risk of an AC joint separation.

DIAGNOSIS

The joint may appear abnormal in a visual exam. With a physical exam, there is tenderness at the AC joint. An X-ray typically rules out a clavicle or collarbone fracture. An AC joint separation is categorized based on the severity of the injury.

TREATMENT

In the early phase, rest and activity restrictions are recommended. Immobilization in a sling helps rest the shoulder during healing. Most cases will heal on their own with these treatments, and surgery is rarely needed.

RETURN TO SPORTS

Follow-up physical exams are important to assess the tightness of the healing ligament and the mobility of the shoulder. Returning to sports before healing puts the shoulder at risk of a more severe injury.

Successful pitching requires the arm to tolerate large forces. The tissues in the front of the shoulder become longer with repeated stretching at high speeds. Over time, the tissues in the back become shorter and, together, this limits the range of motion and can lead to thrower’s shoulder or Glenohumeral Internal Rotation Deficiency (GIRD).

SYMPTOMS

Generalized pain in the front of the shoulder may be a sign of changes in the shoulder, or it may be a sign of injury.

PREVENTION

It is unclear if this change in shoulder motion is necessary for successful pitching. Therefore, preventing symptoms related to this change is the goal. Recognizing signs and symptoms and responding promptly with proper rest are the most important steps.

DIAGNOSIS

A thorough diagnosis includes a conversation about past medical history, the current injury, onset of symptoms, as well as sport exposure. The latter includes position played, frequency of practices and games, length of seasons and number of pitches for baseball. Imaging is essential when the physical exam suggests other tissues may have been damaged.

TREATMENT

Treatment typically revolves around learning exercises like shoulder blade stabilization to reduce injury related to excessive rotation in one direction. Treating a change in motion may not be necessary, unless the symptoms are directly related to a change in motion.

RETURN TO SPORTS

Returning to the field is dependent upon the athlete’s ability to pitch with proper form and to be symptom-free. Other diagnoses and treatment plans may delay the athlete from returning to sports.

ELBOW

The elbow is a combination hinge-and-pivot joint made up of three bones: the upper arm bone (humerus) and the two bones in the forearm (radius and ulna). The hinge part of the joint lets the arm bend like the hinge of a door; the pivot part lets the lower arm twist and rotate. 

Muscles, ligaments and tendons hold the elbow joint together.

Cartilage, or soft tissue, protects the bony surfaces. It’s also found in young bones at areas that are still growing. These growth areas are at risk for injury.

Elbow injuries in young athletes are on the rise, partly due to year-round training and competition. Overuse injuries often occur in throwing sports and gymnastics. Early recognition of signs and symptoms can prevent problems and even career-changing injuries. In youth sports, preventing elbow injuries, particularly those requiring surgery, is a priority.

This is the most common condition in child athletes, typically caused by excessive throwing. The throwing motion puts stress on the middle side of the elbow because the tendons and ligaments of the forearm are pulling on the growing bone.

Pain typically occurs on the inside “bump” of the elbow during or after activity like throwing or pitching. Repeated pulling can tear ligaments and tendons away from the bone. This tearing may pull tiny bone fragments with it in the same way a plant takes soil with it when uprooted. This can disrupt normal bone growth, resulting in deformity and instability with throwing.

SYMPTOMS

Elbow pain with throwing or after activity
Pain and tenderness on the inside of the elbow (on the bump)
Soreness for days to weeks
Worsening control with throwing
Inability to throw desired distance
Difficulty fully straightening or bending the elbow
Locking of the elbow

TREATMENT

Rest. Continuing to throw may lead to major complications and jeopardize a child’s ability to remain active in a throwing sport.
Common recommendations include 2-4 weeks of complete rest.
Apply ice packs to bring down any swelling.
Proper stretching and strengthening.
May require a cast or splint if the pain does not resolve with rest.
Therapy to focus on flexibility, strength, trunk and scapular stabilization.
Focused training to improve throwing form is needed.
Surgery to stabilize the medial epicondyle is rarely necessary, especially in girls over 12 years and boys over 14 years.

An avulsion fracture occurs when the muscles and tendons pull off a piece of bone that is connected by cartilage to the main bone. A strong pull of the forearm muscles, during a pitch, for example, can cause an avulsion fracture of the medial epicondyle on the inside of the elbow.

With this injury, the athlete will typically hear a pop and will have severe pain, swelling and bruising. The child may or may not have had elbow pain before the injury. With operative or nonoperative treatment, most kids may return to the same level of sports following treatment.

SYMPTOMS

May hear a pop or giving way
Immediate pain on inside of the throwing elbow
Immediate, visible swelling and bruising
May have pain with wrist movement
May have numbness or tingling in the ring finger and little finger
Unable to bend the elbow or pick up heavy objects

TREATMENT

Ice may be helpful to reduce inflammation in early stages.
Anti-inflammatory medication may be needed.
For fractures in good position, a splint is recommended for 2-3 weeks.
In all cases, aggressive range of motion early in healing stages (within 2-3 weeks) is recommended.
Therapy to focus on flexibility, strength, trunk and scapular stabilization.
Strengthening and proper throwing progression 8-12 weeks following injury.
Focused training to improve throwing form is needed.

With repeated throwing, inflammation of the cartilage on the back of the elbow can occur. When this occurs, a growing athlete may have pain during follow-through or when straightening the elbow. In the older adolescent, bone spurs and stress fractures can also occur in this area. Without proper rest and treatment, pieces of cartilage can tear away; removal of these loose pieces may require surgery.

SYMPTOMS

Pain in the back of the elbow during follow-through and when straightening arm
Pain in the back of the elbow that becomes gradually worse over time
Inability to completely straighten the arm
Popping and locking may be present, but is rare

TREATMENT

Rest. Continuing to throw with this problem may lead to major complications and permanently jeopardize a child’s ability to play.
Common recommendations include 2-4 weeks of complete rest.
Ice pack may help reduce inflammation.
Anti-inflammatory medication may be needed.
Therapy to focus on flexibility, strength, trunk and scapular stabilization.
Focused training to improve throwing form is often necessary.
Surgery is only needed in severe cases.

Excessive throwing may also lead to a less common condition called osteochondritis dissecans (OCD). Pulling of the muscles on the inside of the elbow causes pushing, or compression, of the bones on the outside. The pressure on the immature bones can loosen a piece of the bone and cartilage.

SYMPTOMS

Dull achiness on the outside of the elbow
Pain that worsens with activity and improves with rest
Pain that gradually worsens over time
Inability to completely straighten the arm
Popping and locking

TREATMENT

Rest. Continuing to throw with this problem may lead to major complications and permanently jeopardize a child’s ability to play.
Strict throwing restrictions protect the elbow from further injury.
Immobilization may be necessary in severe cases or if restrictions are ignored.
If the elbow does not heal or the tissue becomes unstable or loose, surgery may be the best option.
Therapy to focus on flexibility, strength, trunk and scapular stabilization.
Resume throwing at a minimum of 6-12 months.
Focused training to improve throwing form is often necessary.

Elbow stability is crucial for throwing athletes. The ulnar collateral ligament (UCL) is the most important stabilizer for the inside of the elbow. With repetitive throwing, the UCL becomes stretched and develops small tears. This is painful and ultimately leads to instability in the elbow. Typically, the pain is on the inside of the elbow – just below the bony bump where medial epicondyle apophysitis can occur.

These injuries rarely occur with a single event or throw. They’re more common in older adolescents, but may occur in younger athletes as well. An MRI with contrast injected in the joint gives the best view of a tear.

The surgical reconstruction of the UCL is named after Tommy John, a baseball player who returned to major league pitching after having this procedure. This surgery doesn’t always lead to improved performance. Though many athletes do return to play after this procedure, preventing the injury is ideal.

SYMPTOMS

Pain over the inside of the elbow with throwing
Gradually increasing pain
May feel unstable or “give way”
Rarely popping

TREATMENT

Rest for at least 6-12 weeks. Continuing to throw with this problem may lead to major complications and permanently jeopardize a child’s ability to play.
Immobilization for 4-6 weeks followed by a hinged elbow brace.
Anti-inflammatory medication.
Therapy to focus on flexibility, strength, trunk and scapular stabilization.
Surgery is typically needed for complete tears or if the elbow is unstable.
Focused training to improve throwing form is often necessary.

HIP

The hip is a ball-and-socket joint with lots of soft tissue to help the bones stay together. Dancers, gymnasts, soccer players and ice hockey players move their hips in extreme motions over and over again, causing problems that can become progressively worse over time. Early recognition of signs and symptoms often results in very successful outcomes without surgery.

Conditions we treat:

Femoral acetabular impingement (FAI)
Labral tears
Snapping hip
Hip and groin strains
Overuse hip conditions (such as those seen in dancers and gymnasts)
Pelvic apophysitis
Pelvic avulsion fractures

Illustration of hip joint with athletic injury labral tear

ANKLE

Young athletes are more likely to break a bone than to have an ankle sprain. Unlike fractures, subtle injuries to the bone or the soft tissue covering the bones may be difficult to diagnose. Symptoms that don’t get better with rest may need a thorough evaluation by a pediatric specialist. Recognizing and responding to symptoms of ankle instability or pain with repetitive activity can help keep young athletes on the field. The risk of ankle injury can be reduced with good training, proper shoes and field maintenance.

Conditions we treat:

Ankle instability
Ankle sprain
Ankle fractures
Stress fractures of the foot and ankle
Cartilage conditions such as osteochondritis dissecans (OCD)
Sever’s disease

Dancer recovering from ankle injury after receiving treatment from Texas Scottish Rite Hospital for Children

CONCUSSION

A concussion is a brain injury that disrupts normal brain function. The usual cause is a sudden blow to the head or body that shakes the brain, damages cells and creates chemical changes. Concussions are quite common. Surprisingly, most athletes who suffer a sports-related concussion do not lose consciousness or experience memory loss.

SIGNS

The athlete may:

Appear dazed or stunned
Be confused
Forget plays
Be unsure of game, score or opponent
Exhibit unsteadiness
Move clumsily
Answer questions slowly
Lose consciousness
Have memory loss
Be more sleepy or tired than usual
Seem sad, nervous or anxious
Be irritable, easily frustrated or upset
Have problems with academic performance

SYMPTOMS

The athlete may complain of:

Headaches
Concentration or memory problems
Nausea
Balance problems or dizziness
Double or blurred vision
Feelings of being “in a fog” or slowed down
Sensitivity to light or noise
Confusion
Just “not feeling right” or “feeling down”

Any athlete who shows signs or symptoms of a concussion should immediately stop playing and not return to any activity until a health care professional with experience and training in diagnosis and management of concussions can provide a diagnosis.

For additional information, view this handout.

This is a collection of tests used to assess the cognitive function of the athlete’s brain. Like many local high schools, our team uses ImPACT™, an online, neurocognitive baseline testing system. Each computerized test measures the ability to perform certain tasks, such as memory and reaction time.

Athletes 10 years of age and older without a recent history of a head injury can take a baseline test, used for future reference. For athletes with a recent head injury, we recommend making an appointment with one of our sports medicine physicians before scheduling a baseline test. In the event of a concussion, an athlete can repeat the test and the Credentialed ImPACT™ Consultant (CIC) can then analyze the results. The comparison of the post-injury scores to the baseline test helps the provider develop an individualized plan for the athlete.

Our Sports Medicine specialists, Shane M. Miller, M.D., and Jane S. Chung, M.D., are Credentialed ImPACT™ Consultants. Along with our athletic trainers, Josh Stevens, A.T.C., L.A.T., I.T.A.T., and Jamie Wightman, A.T.C., L.A.T., O.P.A.-C., I.T.A.T., they have undergone specialized ImPACT™ training to administer and interpret this test as part of their concussion care management.

PAYMENT

Because this service is not covered by most insurance plans, a $23 payment is required at the time of the visit. We accept all major credit cards. We are not able to accept cash or check at this time.

VISIT

Testing appointments are scheduled for one hour. Some athletes may finish the test faster than others, but typically the computerized testing takes about 30-40 minutes. Before starting the test, our staff will ask a few questions about the athlete’s history; however, there will be no physical examination or discussion with a physician.

A parent may remain in the room with the athlete during the test. If additional family members, particularly young siblings, are present, we request they remain in the waiting area with a parent.

RESULTS

Results are provided upon request. At the end of the visit, or anytime in the future, the family may call 469-515-7100 to request a unique code (Passport ID) for another Credentialed ImPACT™ Consultant to access the results.

FEMALE ATHLETE TRIAD

Female Athlete Triad is a medical condition that can affect girls and young women. It involves the following three components: energy availability, menstrual function and bone health. Clinical signs and symptoms may not all occur at the same time, so further evaluation is needed with the presence of any of these problems. Jane Chung, M.D., advises that education and early intervention are keys for young women with Female Athlete Triad.

Young girls who are very lean, who train a lot or who do not have a well-balanced diet may start their menstrual cycle later than others. Some may start in a normal time frame; however, changes to diet and exercise habits may cause the cycle to be less frequent or stop during times of heavy training.

Each athlete has a unique nutritional need to keep their body prepared for training, competition and normal growth. Sometimes, in an effort to achieve a specific weight or appearance, an athlete may restrict calories or make other choices to limit gaining weight. Poor eating habits can lead to changes in several normal body processes. This can actually worsen performance, when an athlete is really trying to improve performance.

Changes in hormone production that cause changes in the menstrual cycle lead to poor bone strength. A diet without proper amounts of calcium also causes bones to become weak. Therefore, athletes with eating issues are at high risk of injuries to bones. These often show up as stress fractures, small breaks in the bone that are difficult to detect but cause pain and require long rest from activity.

OSTEOCHONDRITIS DISSECANS

The surfaces of the bones in the joints are covered with smooth tissue called articular cartilage. Osteochondritis dissecans (OCD) is a problem in this cartilage and the bone just beneath it. It occurs most commonly in the knee, elbow and ankle. Repetitive motions or overuse injuries in these joints put pressure on the cartilage and bones that cause injury over long periods of time.

We see OCD most often in patients that are 12-16 years old. Though it can happen to anyone, we see this problem in athletes that perform repetitive motions like running, jumping, pitching or certain motions in gymnastics.

We’re unsure what causes this in some patients. It could be a change in the blood supply to the bone and cartilage. Sometimes an injury causes the changes. This is called an osteochondral fracture or injury.

Osteochondritis Dissecans

SYMPTOMS

There may be pain in the joint that gets worse with activity. Or there may be symptoms like popping, clicking or swelling in the joint.

TREATMENT

In early stages, your provider may recommend rest and a brace to help the tissues recover on their own. In later stages, more aggressive treatments are required. Pediatric orthopedic surgeons, like Philip L. Wilson, M.D., and Henry B. Ellis, M.D., treat OCD with minimally invasive arthroscopy. The treatment is only necessary after a thorough investigation of the tissues with X-rays, an MRI or diagnostic surgery. Watch a detailed look at the procedure.

RETURN TO SPORTS

In many cases, activities like swimming, diving, biking, golf and yoga are good alternatives for young athletes. Our goal is to keep children active, but to protect joints that are at risk of long-term problems from overuse injuries.

KNEE

Knee injuries and their prevention in youth sports are hot topics. Young athletes have unique risk factors and require unique treatments. All growing bones have sensitive spots called growth centers that are filled with cartilage until the bone takes its final shape. Some growth centers are at risk of injury from running and jumping. Others that help our legs grow symmetrically and straight are at risk of being damaged from fractures or during surgeries for major ligament injuries. In these cases, a pediatric orthopedic surgeon has the expertise to make a plan for treatment and monitoring for the best outcomes.

Conditions we treat: