Play Ball (Carefully, and Not All the Time)!

By Wendy Plump

No one is asking children to give up their sports. But it’s getting a little crazy out there.

In one generation, sports have gone from child’s play to a proving ground for elite athletes—many of whom haven’t even graduated eighth grade—who commit to strenuous schedules, trainers, travel teams, coaches, aggressive tactics, and year-round seasons that give a young body no quarter for rest and growth. Coaches book flights to cities far beyond their hometowns. Parents shell out thousands of dollars for participation fees. And college recruiters wait eagerly in the background until it’s time to dangle offers that are impossible to resist.

Maybe we should pause for a moment to think about where all of this is going.

When did cheerleading become a sport where a 10-year-old girl is at risk for a serious brain injury?” asks Dr. Emil Matarese, director of the Concussion Program at Capital Health’s Capital Institute for Neurosciences in Pennington. He recalls a client who was referred to him after a cheer fall that left her so disoriented she couldn’t recite the date of her own birthday. “The girls at the base of the pyramid she was on were supposed to catch her. But because of their young age and inexperience, they flinched, and this girl landed on her head. This was the first time I’d seen a child that young with a concussion.

“I’ve spent a large portion of my career doing this,” adds Dr. Matarese, “and I’ve come to realize that what was previously thought of as a minor insult, what we used to call ‘ringing one’s bell,’ is in fact a potentially life-altering and serious injury. We are now at a stage in our society where we are pushing younger and younger athletes to achieve skill sets that previously were reserved for those in college or on professional sports teams. We’re seeing more serious head injuries, more forceful blows, in younger athletes than we ever have.”

Concussions are not always detected by routine examination, he cautions. The young cheerleader was taken to an emergency room where personnel told her that her brain looked normal. Yet her impairment was so obvious that, by the time she got to Dr. Matarese, she looked like “a deer in the headlights.” Every concussion is different. Some require a few weeks of rest. Others may need a year or more of monitoring. Social and academic skills can suffer.


The adolescent brain is not fully developed, so injuries that go untreated can have a lifelong impact. In addition, assumptions about the sports that cause such injuries are not complete. It isn’t always football and rugby that put athletes at risk. Two of the more serious head injuries Dr. Matarese treated occurred in a young golfer whose skull was cracked by a golf ball and a tennis player who fell on the court.

A deeply compassionate neurologist who also serves as an advisor for the Brian Injury Alliance of New Jersey, Dr. Matarese acknowledges the benefits of sports. He spells them out without hesitation. But if we are going to push our competitors, he says, then parents, coaches, teachers, and athletes themselves must be vigilant on behalf of young people who are putting their health on the line. In most cases, a concussion is a temporary, recoverable neurological deficit. But when it goes untreated and the brain is exposed to a second injury, Second-Impact Syndrome can cause permanent impairment, or worse.

Another young woman, a junior in high school, came to Dr. Matarese’s practice after she had received a full scholarship to Harvard University. But during a softball tournament, she was struck in the head with a ball. The young woman did not mention the injury. Three days later, she was struck in the head again. The back-to-back blows caused such neurological damage that the young woman barely finished high school and needed enrollment in a special program to complete a community college education.

“She was never able to achieve her full potential in life. I could cry,” says Dr. Matarese. “Over time, as long as there is no permanent damage, most concussions should fully resolve. If it’s an isolated incident, the patient will get better. But if they keep playing and don’t give the brain time to rest and heal, you will keep seeing these devastating events in otherwise healthy, talented young athletes.”


Dr. John Lawrence of the Children’s Hospital of Philadelphia (CHOP) doesn’t need statistics to demonstrate the pronounced increase in pediatric and adolescent sports injuries. He sees it in his office every day.

An attending orthopedic surgeon at CHOP with expertise in anterior cruciate ligament (ACL) reconstruction, Dr. Lawrence says the rising number of injuries is evidence of two trends: an increase in the number of young female athletes, who are more than twice as susceptible to ACL injuries as young men; and dramatic rates of overuse.

“If you’re a kid playing soccer now, it’s not enough to just play intramural soccer,” says Dr. Lawrence. “The mentality of most of the patients coming to my office is, ‘We have to start playing and specializing in a sport at an exceptionally early age, and we’ve got to play year-round.’ There’s your spring play, then your summer league, then your fall, indoor league, and your winter league. There’s always a push for these kids to get to the next-best development teams and the state cups and the national competitions. “If you’re a kid playing soccer now, it’s not enough to just play intramural soccer,” says Dr. Lawrence. “The mentality of most of the patients coming to my office is, ‘We have to start playing and specializing in a sport at an exceptionally early age, and we’ve got to play year-round.’ There’s your spring play, then your summer league, then your fall, indoor league, and your winter league. There’s always a push for these kids to get to the next-best development teams and the state cups and the national competitions.  “Now,” he adds, “there are travel soccer teams for 6-year-olds.”

Knee injuries are far and away the most common ailment he treats. While ankle injuries are the No. 1 epidemiological sports injury category, there usually is not a significant loss of game time for most of those patients. Knee injuries, however, can take up to a year or more for full recovery.

A 12-year-old, nationally-ranked skier in Dr. Lawrence’s practice crashed during a race and sustained a fracture of her tibia and also broke the attachment point for her ACL. “She’s a wonderful, articulate girl. And we ultimately put her back together again so that she is able to do her normal training as a skier,” says Dr. Lawrence. “But she definitely typifies that explosion of organized sports, in that she’s been ski racing ever since she was knee-high to a toadstool.”

Dr. Lawrence underscores the importance of neuromuscular development programs, here and across the country, that equip young athletes with knowledge about the foundational fitness that staves off injury. Participants learn how to warm up and how to fall; they learn safer positions for loading their joints; and, in general, how the body moves optimally and along specific “tracks” that cut the risk of injury. Other resources indicate, for instance, how many pitches Johnny can throw before he needs to rest his arm. And state and federal guidelines now dictate criteria for the handling of concussions and other athletic injuries.

“If these young athletes can’t get their coaches and clubs to institute these neuromuscular control programs, then they can do it on their own,” says Dr. Lawrence. “The bottom line is, don’t play with pain. Don’t play through pain. It’s a hard message for kids to get because they’re getting the push from multiple directions, from coaches and parents and teammates. But they should know: If they have any sort of pain, stop.”


Dr. Maria Halluska-Handy, a board-certified emergency physician now specializing in non-operative orthopedic care with Bucks County Orthopedic Specialists in Doylestown, Pa., says some of the biggest factors in increased risk for sports injuries are the very fatigue and repetitive use that stem from “four seasons of soccer.” Tendinitis. Hairline fractures. Concussions from collisions. Athletes put themselves at a higher risk for injury when they are doing too much, too soon, and without the requisite rest and recovery time.

“Football, ice hockey, lacrosse, rugby. Overall, those are the highest-risk sports,” says Dr. Halluska-Handy. “But the highest overall numbers of people who get concussions are actually playing girls soccer, and that’s because you have the highest number of participants. Most catastrophic is cheerleading. You’re throwing people up in the air without any kind of head protection. The physics of that couldn’t be more devastating.”

Dr. Halluska-Handy explains that a child or adolescent is not simply a little adult, but another entity altogether. Their brains are different in that they are still growing and developing, their joints are more flexible, and their bones are more “plastic.” They more often have “green-stick fractures,” in which the bone doesn’t break all the way through, the way a young tree branch can be bent and snapped but not broken. The options for treatment and management are therefore also different for adolescents.

One patient recently seen by Dr. Halluska- Handy had a wrist injury from skateboarding, with pronounced swelling and a deformity of the wrist. Dr. Halluska-Handy ended up doing a hematoma block, in which the anesthetic is injected directly into the fracture site to provide the local pain management during manipulation of the fracture. “He handled it like a champ,” she adds. “I am frequently amazed by how well kids can tolerate procedures that will make adults cringe.”

In terms of symptoms that should precipitate an urgent doctor or emergency room visit, Dr. Halluska- Handy looks for simple things: “Is there obvious deformity (bent at a weird angle)? Can you move the part of the extremity below the level of the injury (usually fingers or toes)? Can you feel them? Are they numb or tingly? Is the color and temperature normal? Or is there just extreme pain? In terms of head injury, is there dizziness, nausea, or lightheadedness? Is the pain so severe that it’s disrupting sleep? If so, then, we need to take a look,” she says.

“Just in general, be aware of overuse syndrome. Making sure kids get adequate rest physically and mentally is half the battle to avoid injuries in the first place. Make sure they’re appropriately hydrated. Manage chronic medical conditions — have asthma inhalers up-to-date, for instance. And have an overall idea of when to seek more urgent medical attention.

“And this is going to be a really bad year for ticks that carry Lyme disease,” Dr. Halluska-Handy adds. “So don’t forget to keep checking for them well into the fall season.”