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By Mary F. Pols
Sixteen-year-old Kristen Lore is struggling with a big question. For the last 10 years, most of the Walnut Creek girl’s free time has been spent running around on a soccer field. She adores the game. But last summer, while defending the ball from two opponents, she tore her anterior cruciate ligament (ACL), the ligament that stabilizes the knee. It took a three-hour surgery to repair the damage. Now she’s wearing a Velcro-fastened black “boot” that goes from her toes all the way to the top of her thigh and is sidelined at least until this spring. And there’s no guarantee that her knee will ever be as good as new. The question before her is, Is the sport worth this price?
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Soccer had exacted a physical toll on Kristen, even before the ACL rupture. She’s broken both ankles on the field. The recovery time for those injuries was much shorter than the expected nine- to 12-month rehabilitation from the ACL surgery. Having two comebacks under her belt has clearly instilled a sense of confidence. “I’m kind of tough,” she says, in the tone of a teenager who is not boasting, but just communicating the facts as she sees them.
“Soccer isn’t work for her,” her mother, Sharon, interjects. “It’s fun. No matter what kind of a day she’s had, she comes home energized from it.”
Since the injury, however, the rhythm of Kristen’s life has undergone a radical shift. Her afternoons and weekends are suddenly more free. “It’s definitely, like, a big change,” Kristen says. As she speaks, she rests a hand on the boot, which looks like the product of a Parisian fashion designer’s wild imagination, haute couture intended to go stomping down the runway. “It’s nice to have time to do schoolwork, but I miss getting out there.”
The boot is a sign of the times: Area pediatricians and surgeons are overwhelmed by the number and severity of the sports injuries they are encountering in their examination rooms among younger and younger patients. At Children’s Hospital in Oakland, a new surgeon was just added to the overworked pediatric orthopedic team. In Walnut Creek, the Sports Medicine Center for Young Athletes, which opened in 2007 to handle overflow from Children’s Hospital, is treating more than 500 young patients a month, the bulk of them injured playing sports.
“You see things that aren’t supposed to be happening to kids,” says Christy Boyd, a pediatric sports medicine specialist based in Livermore. “The first year [on the job] I was shocked at what I saw.” Ruptured ACLs used to be the affliction of college-age athletes or professionals, from soccer to basketball players. But in the last decade, the injury has become much more common among teenage and even preteen players. In the last year Boyd says she’s seen ACL tears in a 13-year-old basketball player, a 12-year-old soccer player, and even a 7-year-old trampoline enthusiast. Other common afflictions include stress fractures, torn menisci (the tissue in the knee that helps distribute the body’s weight), and pitcher’s arm, or damage to the ulnar collateral ligament (UCL), which, in extreme cases, can also require surgery.
Medical experts point to a series of factors that might be driving up the number of injuries on the athletic field. They cite the level of competition, the pressure to perform, and the drive to specialize in an individual sport at an early age, rather than building overall strength through a diversity of sports. Compounding the tendency to specialize are the multiple opportunities to play, regardless of the season. A young player like Kristen can hopscotch from her club team to her high school team and back again, booking up her entire calendar year with practices, games, and tournaments. Unless she gets injured.
Her surgeon at Children’s Hospital, Dr. Jim Policy, sent her home with a DVD of the whole operation, footage that she doesn’t exactly consider entertaining, but is willing to share. In it, the torn ligament waves like a piece of kelp from the bones. One of Policy’s sharp instruments comes into view and begins gobbling up the tattered ligament. After the cleanup is complete, he takes ligaments from her hamstring and knits her a new stand-in for the ACL, anchoring it through the bone.
While the internal view of her knee plays on a laptop, looking like some underwater art house film, Kristen gingerly takes off the boot to show the external scars from the operation. They’re small and hardly noticeable, five points of entry above and below the knee. “It’s not bad at all,” she says. Her mother leans forward and touches the side of her left thigh. “But see how much her muscles have atrophied on this leg,” she says, “just since the operation.” It’s true. The surgical incisions may be small, but the overall impact on these young, strong legs is much more obvious.
For Kristen, it could be a long, hard road back to the soccer field. Policy says that recovery can be up to a two-year process, and that young athletes tend to play in a somewhat diminished capacity for their first year back on the field.
Kristen was lucky in at least one sense. At 16, she was at a developmental stage where surgery was a clear option. Had she been younger, Policy might have had to wait. There are major complications involved in performing surgeries on preadolescent children whose growth plates are still serving their purpose, namely allowing the bone to grow with the child. Any interference with the growth plate could lead to stunted or uneven growth. In the long term, according to Policy, the risk isn’t worth it. Faced with, say, an 11-year-old patient with an ACL injury, surgeons generally advise waiting a year before having the surgery. Even then, the circumstances are far from ideal, because it’s rare that the body is done growing at 12, and surgeons have to work around the tricky growth plate.
The trend toward younger patients with sports injuries doesn’t appear to be slowing. “Higher levels of competition seem to be encroaching on younger and younger age groups,” says Policy. “You’re seeing more soccer clubs geared toward 11- and 12-year-olds than you ever saw in the past. When you play club soccer year-round, your body never gets a break. We don’t fully understand what the underlying reasons for it are, but skeletally immature bodies don’t seem to tolerate that as well.” The medical profession is racing to keep up with these young patients. “I think we’ve had a little of the tail wagging the dog,” Policy says. “Sports just took off, and the sports medicine practice and the science have been about five years behind the sports themselves. We’re doing our best to come up with solutions.” Policy has the kind of gentle sincerity you’d want at your bedside, but when he talks about this issue, he sounds like the slightly harried owner of a business that is far busier than he ever anticipated it would be.
In the last year, the issue of girl’s soccer and ACL injuries has received a lot of national attention, in large part thanks to Michael Sokolove’s 2008 book Warrior Girls: Protecting Our Daughters From the Injury Epidemic in Women’s Sports. Sokolove cites statistical evidence that girls are five times more likely to suffer ACL tears than boys, and also that girls tend to work harder and more fiercely on their recovery. He refers to a study [Study date?] from Southern California suggesting that those numbers can be reduced by nearly 75 percent if teams regularly utilize a series of strength-training exercises designed specifically for young female bodies. The “Warrior Girls” theory has made its way into conversation on the sidelines at East Bay soccer games. Ironically, just a month before Kristen’s accident, Sharon Lore had ripped out an article about those strength-training exercises from a magazine. She still has it.
“The ACL injuries, it’s almost like they’re part of the game,” sighs Christy Boyd. “And there are just as many ACL injuries in basketball and volleyball as in soccer.”
Boyd and others say that the problem affects both boys and girls. Like Policy, they cite the amount of time kids spend on the playing field. “Our boys are not too much different,” Boyd says. “Overuse is a gender-neutral issue.” It can crop up in any sport, she says, often manifesting itself as a stress fracture. “I find that when you read pediatric texts from 10 years ago, there’s hardly a mention of a stress fracture,” she says. In her practice, they’re commonplace.
“It just amazes me how little we let our kids rest,” Boyd says. Her perspective is particularly compelling because she’s an athlete herself. She ran track as an undergraduate at Stanford, where her name is still in the record books. She married an assistant women’s soccer coach at UC Berkeley. It was while accompanying her husband on a recruiting trip to a tournament in San Diego that she had what might be described as an epiphany. It was Easter weekend, and the championship game was slated for that Sunday morning. “I looked around and thought, for all these families to have to give up their Easter Sunday just doesn’t seem right,” she remembers, shaking her head. Since then Boyd has laid down a simple ground rule for her own daughter, who at three has already expressed interest in soccer: no traveling club sports until she’s at least 12.
“I’m still a huge youth sports fan,” Boyd continues. “But do I think kids need to play 12 months out of the year? No. Do college students play year-round? No. We need to modify the youth culture.”
The Lore family are hardly fanatics. Kristen isn’t a superstar, or a member of either of Contra Costa’s elite teams, the Mustang Mavericks or the Pleasanton Rage. She’s a solid player who pins her college hopes on academics rather than a soccer scholarship. And she’s paid attention to her core strength: When Kristen was evaluated at the Sports Medicine Center for Young Athletes in Walnut Creek, her physical therapist told the Lores that the contact Kristen had while defending the ball was more likely the culprit than any physical weakness.
“It was good to know that her body didn’t give out on her,” Sharon Lore said. “But I don’t know. Do the refs need to step in more? Is it just part of the sport? I don’t know what the answer is.”
The big question, whether devotion to sport is worth this kind of injury, is still on the table. It is weighed particularly carefully by Sharon, perhaps because she’s not just a mother, but also a sonographer. “Do we want her to continue if it is going to happen again?” Sharon says. “I don’t think it’s worth it. You have your whole life ahead of you at 16.” She pauses and looks at her daughter before adding, “But I’m not an athlete.”
“She didn’t play anything,” Kristen says, laughing.
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All parents get fun poked at them now and again by their children. This mother-daughter moment cuts to what many experts say is at the heart of the matter. More kids are participating in sports today than in Sharon Lore’s generation. There are more opportunities, more club teams, more spin-offs of club teams, more organized sports for younger athletes. Being a jock has more widespread appeal than it did in earlier generations, particularly for young women, thanks in part to the progress and change brought about by Title IX, the educational amendment that banned sex discrimination in the schools, including in athletics. “Now it’s cool to be 5 foot 10 and an athlete,” says Walnut Creek–based orthopedic surgeon Laura Timmerman. “It is a whole different mind-set. They are the homecoming queens. They are the campus heroes.”
High school sophomore Daniel Brinckerhoff was crazy for baseball, starting with T-ball at age five. “He knows baseball so well,” his mother, Alice, says. “He can remember all these stats. He can tell you anything about baseball. It’s just a passion for him.”
“He’s probably a perfect example of someone who plays pretty much year-round,” she says.
Daniel was drawn to pitching early in his Little League experience. The allure is understandable: You are the center of the game. As local pitching coach Jeff Pick demonstrates, it’s a hard position, both mentally and physically challenging. Standing on the Campolindo baseball field, Pick brings his pitching arm up, his elbow crooking this way, his shoulder rolling that way. Simultaneously, his foot does something almost balletic. The combination of movements is undeniably weird, even when it is done right.
“Pitching is not a natural act,” Pick says with conviction. “Everything you do as a coach is to lessen the chances of players getting hurt.”
Daniel, who occasionally takes lessons from Pick, started having problems with his pitching arm in eighth grade, right after a double-header where he’d played catcher and then pitcher for his pony team. His parents had asked the coach to make sure that Daniel didn’t go back and forth between the two positions, since both require a lot of throwing. As Alice Brinckerhoff remembers, the coach was anxious to hold a lead, so he sent Daniel to the mound for the second game after he’d been behind home plate for the first. That night, Daniel told his parents he’d screwed up his arm. “This was just a preseason game,” she remembers. “I mean, who cares? I regret not speaking up.”
The Brinckerhoffs took Daniel to see Walnut Creek orthopedic surgeon Laura Timmerman, who diagnosed the injury as an irritation of the growth plate. She recommended he stay away from baseball for four months.
“I tell patients, a lot of times, to find something else to do, to change it up,” Timmerman says. “One of my favorite lines I use to explain this to them is from Top Gun: ‘You’re writing checks your body can’t cash.’”
Timmerman knows pitching arms; her particular expertise is Tommy John surgeries (the procedure named after the Dodgers pitcher who bounced back after the surgery in 1974). “I see four or five elbows every day I’m in the office.” She encourages parents of aspiring pitchers to help their sons save those arms for later. “Sometimes I get these dads in my office who think they’ve got Nolan Ryan,”
Timmerman says. “I’ll tell them, here’s what the pros are looking for. They want a 17- to 18-year-old who has played baseball, with a healthy, strong arm. They are looking for a well-rounded athlete they can teach to pitch. It’s okay to play another sport.”
If a young athlete like Daniel Brinckerhoff lived in a different climate, he might be drawn to a variety of sports. In New England, maybe he’d spend autumn on the football field and his winters playing hockey. But watching Pick out there on the Campolindo diamond in late fall, you can see why Daniel has devoted so much of his year to baseball: because he can. There’s not a cloud in the sky, and the sun is so intensely hot that Pick stops his lessons about every five minutes to yell, “Water break.” Pick agrees that year-round play is one of the biggest factors in overuse injuries. Teaching boys how to throw a baseball has been his livelihood for the last 13 years, but if Pick had his druthers, every player would have a mandatory break.
“I’d shut it down,” Pick says. “For two months. Maybe three.”
The fewer pitches kids have to throw—that is, the more strikes and fewer balls they pitch—the less chance they have of getting hurt. To wit, Pick has several rules for his young pupils. Learn how to throw a fastball and then how to surprise the batter with a slow ball. From ages 8 to 14, they should be focusing on mechanics, as basic as those in a piano lesson, Pick says. They’re not even supposed to try to throw a curve ball until high school; it’s too challenging for a young body. No weight lifting until 16 or maybe, even better, until college.
The numbers certainly suggest that such caution is needed. A study published in 2006 in the American Journal of Sports Medicine showed that adolescents who pitch competitively more than eight months per year are five times more likely than their counterparts who pitch eight months or less annually to end up in surgery by the time they are 20. “It is anecdotal that the national numbers are going up,” says Glen S. Fleisig, director of research for the American Sports Medicine Institute (ASMI), who coauthored that study. “But it’s factual that we’re seeing more young pitchers come in with injuries.” His colleague, Dr. James R. Andrews, who specializes in Tommy John surgeries, has seen a steady increase in high school age pitchers on his operating table. Between 1995 and 1998, eight percent of his Tommy John patients were high school age. Between 2003 and 2006, that proportion rose to 24 percent.
ASMI’s reaction to this data was to push for new pitch count rules for young pitchers, which were adopted by the Little League in time for the 2008 season. Fleisig said after some initial reluctance on the part of some coaches, recent surveys showed that these restrictions are being embraced. The pitch count rule protects pitchers only, and for Fleisig, the youth sports problem is hardly limited to baseball.
“The bigger problem today is that kids are specializing more than they did in previous generations,” Fleisig says. “We have 10- or 12-year-olds saying ‘I am a soccer player,’ rather than ‘I’m just a kid who plays a lot of sports.’” He urges parents and coaches to discourage extreme specialization before high school age.
Which brings us back to Daniel Brinckerhoff. After the four-month break suggested by Timmerman, he remained in good playing condition for about 18 months. Then he was sidelined again, this time with a posterior impingement, a piece of cartilage interfering with the bone’s ability to move smoothly within its socket. This time, Timmerman recommended surgery to clean up the cartilage. The Brinckerhoffs agreed. After rehab, Daniel is back on the field again, much to his relief.
“I think these kids see [surgery] as a way to make them better and to allow them to keep doing what they love,” Alice Brinckerhoff says. “It’s not just going to physical therapy every day; it’s a distinct event that is going to get them back out there.”
Young athletes are getting back out there for better or sometimes for much worse. The latter was the case for Megan Holman, who tore her ACL during her junior year of high school when she was playing soccer for both Las Lomas and the Walnut Creek Strikers. She was back on the field six months after surgery. Not long after, she damaged her meniscus, requiring another surgery. “I personally did not rehab correctly,” she admits. To stay competitive, she felt she had to keep playing, and because she loved the game, she had been willing to make that sacrifice. “I know that at the level I was at, you can’t take time off,” she says. “It was like, after two weeks off, you’re out of shape.”
When she went off to college at Chico State, she made a point not to play soccer. Last year, though, she joined an intramural game. Ten minutes into it, she tore the ACL in her other leg. Recovery from that surgery has been slower. “There are things I can’t do,” the 22-year-old says. So many things that it’s quicker for her to list what she can still do: swim, and use the machines at the gym. Soccer, which she still loves, is off-limits, forever—at least competitively. “My orthopedist said if I see a soccer field, run the other way. I just have weak knees. I have done too much damage.”
The hope in the Lore household is for a much better outcome, although Kristen and her mother understand that even with a good recovery and no further injury, the jury is still out on the long-term effects of an ACL tear. As Kristen’s doctor, Jim Policy, notes, research indicates that those who suffer ACL tears, even after successful surgery, have a greater risk of getting arthritis later in life. Kristen has rehab appointments booked through September, and no plans to rush back onto the soccer field. “I’d rather wait it out than risk getting hurt again,” she says.
In the end, she gives a roundabout, but very telling, answer to the question about whether all that soccer was worth the cost of the injury. “I think it’s worth it to do all of this,” she says, indicating her leg in its brace. “If in the end, I can do all I could do before.”
Her mother walks over to the refrigerator with its long line of pictures of Kristen in blue soccer uniforms, her official team photographs from the last decade. The hair styles change as the child morphs into a tween and then an adolescent, and, finally, into the tall, pretty young woman she is now. Sharon runs her finger down these testaments to a young athlete’s devotion to her sport. “I guess we’re not going to have one this year,” Sharon says. Her tone is wistful. She has always understood that this photographic measuring stick of a childhood in sports would run out. Yet neither she nor her daughter is ready for it to be over yet. “Maybe next summer.”
What can kids do to keep from getting hurt while playing sports? Here are five tips from Robin Bousquet, a senior physical therapist at the Sports Medicine Center for Young Athletes in Walnut Creek:
1 PREPARE FOR YOUR SPORT. Don’t expect the first days of practice to get you in shape; you need to be in shape for the first day of practice. That means cardio-vascular, strength, endurance, and flexibility training.
2 KNOW PROPER TECHNIQUES. Whether it is landing a back handspring, or changing directions during a soccer game, learn the technique that fits your sport.
3 TAKE A BREAK. Make sure you have rest intervals, which decrease injuries and prevent heat illness. The length depends on the sport: longer breaks are needed for high-intensity sports or workouts.
4 YOU ARE WHAT YOU EAT (AND DRINK). Follow the best practices for nutrition and hydration to decrease fatigue, which can lead to injuries.
5 DRESS SMART and wear the right gear. The appropriate gear, such as good shoes and helmets, will protect you from preventable injuries.
Published: Diablo, March 2009
Author bio: Mary F. Pols is a freelance writer based in Alameda. Her memoir, Accidentally on Purpose, was published in June.