For the better part of Robbie Salvatore’s young life, hockey has been his passion. Over the years, he would jump at every opportunity to play: summer league; fall league; sports camp. And of course at Darien High School, where he played forward and in his senior year was an assistant captain. “I was used to a lot of hockey,” the eighteen-year-old admits. “It kept me busy.”
Only injury could keep Robbie off the ice. And even then, when his shoulder popped out of place after bumping an opponent, it took many months, and considerable pain, before he was ready to take a break from either hockey or his next-favorite sport, lacrosse.
Last year Robbie finally had arthroscopic surgery for a torn labrum and bone chips in his shoulder, then spent six months recuperating. He was back on the ice this winter for his final hockey season and expected to play lacrosse in the spring.
“He likes to do it,” says his father, Eugene, of Robbie’s busy athletics schedule. “And I want him to do something. I want him to be active. I want him to do his schoolwork, but I think athletics is as important as studying. There’s a lot of life lessons in athletics.”
And more youngsters are learning those lessons than ever before. While the games are fun, there is also a gravity about them that was less evident a generation ago. These days many boys and girls attack their athletic endeavors with the devotion of big leaguers, often in single sports that run through much of the year, and many times pushing their bodies beyond what is prudent.
As a result area doctors are seeing a steady procession of teenage athletes with acute trauma, like Robbie, as well as insidious overuse injuries, such as those experienced by baseball pitchers who throw too much.
“Our culture now is very sports oriented,” explains Marc Silver, a surgeon with Orthopedic Associates of Stamford, which has an office in Darien. “A lot of schools, parents and kids for that matter, are very focused on sports. There’s a certain pressure on kids to do well, and that may make them inclined to either play down their injuries or overuse their extremities in playing that sport.”
Indeed, athletic participation among teenagers is on the rise. According to one national study, 7.3 million high school students took part in sports during the 2006-2007 school year, an increase of 183,000 from a year earlier. (Back in 1971-1972, just 4 million students were involved.)
Thanks to rule changes, attention to safety and better care, the injury rate around the country is actually down from a decade ago. Still, the number of youngsters who do get hurt is tremendous. A national survey of nine high school sports conducted during the 2005-2006 academic year found that athletes suffered 1.4 million injuries, at a rate of 2.4 injuries for every 1,000 games and practices participated in.
Locally, few have a better view of the phenomenon than Diane Murphy-Kivell, the veteran certified athletic trainer at New Canaan High School. Diane has her hands full, to put it mildly, evaluating and treating hundreds of injured young athletes in every sport, from tennis to track to football. “Believe me,” she says, while taking a breather, “there’s plenty of work.”
During the 2006-2007 academic year, 698 of New Canaan High School’s 1,213 students (58 percent) played on at least one of the school’s fifty-two teams, which include freshman, junior varsity and varsity squads. (At rival Darien High School, a breath-taking 919 of 991 boys and girls, 92 percent, were on one or more of fifty-two teams.)
And though no official numbers are available, Diane estimates that last fall alone, including repeat visits, she treated some 2,925 students in her office, 200 on the field during practice or games, and 30 visiting athletes. “We’re talking about everything from A to Z coming through the door,” she says. “From the athlete who has severe blisters, to the athlete with a significant knee injury, to the athlete who has a concussion.”
Diane has seen a lot of changes in the young competitors during her twenty-six years on the job. But probably the biggest difference has been in the female athlete.
“Varsity girls lacrosse, when I started here, I would compare to the freshmen of today,” she says. “And at that time, girls soccer was in its first or second year. The level I see now is extraordinary. They’re bigger. They’re faster. They’re training. They’re weight-lifting. Some of them are playing three seasons of soccer [including outside leagues] to get better.
“You’d be surprised at how hard these girls hit each other when they’re playing. And it’s really not a contact sport; it’s a collision sport.”
For the most part, Diane regards the boom in athletics as a positive. Yet she and many who are involved in sports medicine are disturbed by the surge in overuse injuries in recent years. With girl soccer players, for example, Diane often sees tendinitis of the knee or ankle. Sometimes the athletes have lingering pain in the quadriceps as a result of “constantly striking the ball, striking the ball, striking the ball.”
Young athletes often fail to give their bodies enough time to recuperate, notes Seth Miller, a surgeon with Orthopaedic Neurosurgery Specialists in Greenwich. “There is a greater emphasis on sports and earlier participation,” he says. “But the biggest issue in my mind is specialization in a sport at an early age. When I grew up, you played different sports during different seasons, which physiologically is much easier on the body.”
Many injuries to young athletes involve their growth plates, the soft tissue at the end of bones that has yet to calcify. And though significant fractures of the growth plates do occur and usually require surgery, the greater number of injuries are less threatening.
Dr. Miller specializes in shoulder and elbow problems. (He is the surgeon, in fact, who repaired Robbie Salvatore’s shoulder.) He treats a lot of young patients with “Little League shoulder,” an inflammation of the growth plate that tends to come from pitching too much without giving the arm enough rest. Usually the recommendation is simply to stop throwing, often for as long as several months.
Some patients such as one fourteen-year-old pitcher that Dr. Miller saw recently, shop for medical opinions until they find a diagnosis they like. “The interesting thing is how upset some of the parents become because they want these kids to continue to play,” says Dr. Miller. “I think part of it is our society and our emphasis on sports and the fact that a lot of parents see their children as becoming high-level athletes. The reality is that very few can.”
Last year Little League Baseball, acting on the recommendations of the American Sports Medicine Institute and the U.S.A. Baseball Medical and Safety Advisory Committee, began to restrict the number of pitches youngsters could throw in each game and set rest requirements between games.
The new guidelines limit players age ten and under to 75 pitches per game; eleven- and twelve-year-olds to 85 pitches; thirteen- to sixteen-year-olds, 95; and seventeen- and eighteen-year-olds, 105. Depending on their age and the number of pitches thrown, players must rest from one to three days between outings.
And though the recommendations are often subverted by youngsters playing in multiple leagues during the same season, not to mention throwing at practice or during sessions with private coaches, Dr. Miller encourages coaches and parents to keep vigilant about monitoring their activity.
Other overuse injuries commonly diagnosed in young people involved in sports include ligament damage at the elbow, often from throwing breaking pitches before the arm is fully developed; Osgood-Schlatter disease, an inflammation below the knee where tendon and cartilage meet the tibia; Sever’s disease, a painful condition at the back of the heel where the Achilles tendon meets bone; and spondylolisthesis, in which a vertebra slips forward, often from hyperextending the back.
“If a kid develops localized pain that doesn’t resolve itself within a short period of time, he or she should be evaluated by a physician,” notes Dr. Miller. “Although that sounds obvious, you’d be surprised how some kid will come in to see me after throwing for three or four months with continued elbow pain, and by the time he sees me the condition is that much worse; it would have been solved much more quickly if he’d come in sooner.”
Still, acute injuries like the shoulder injury that sidelined Robbie Salvatore are probably inevitable, especially in contact sports like football and hockey. Among the breaks, tears and pulls that have been part of athletics since the beginning, certain maladies have drawn special attention in recent years.
Female athletes on the high school level, for example, have been found to suffer a disproportionately higher number of anterior cruciate ligament (ACL) injuries than boys, largely because of differences in body structure and leg strength. Many girls run and jump in a stiff-legged fashion. This is of particular concern in sports that involve lateral movement and a lot of jumping, such as basketball or soccer, and it has been remedied to some degree by special running and jumping training programs.
Following the lead of the National Football League, meanwhile, high school football programs have begun paying greater heed to concussions, both by better examining boys who show symptoms like confusion and headaches, and by keeping them off the field until they have been medically cleared to play. Efforts are also under way to produce more-protective helmets.
At New Canaan High School, among other schools, players are encouraged to let coaches and staff know if they notice a teammate walking into the wrong huddle during a football game, for instance, or if he otherwise seems confused. Teachers are asked to look for symptoms in students who may have suffered a concussion. “It may show up in class as a kid not being able to perform quite as well cognitively as he had been,” says Jay Egan, New Canaan High School’s athletic director.
Peter Moley, a physiatrist with the Hospital for Special Surgery in Manhattan, which has a satellite office in Old Greenwich, says that beyond the more obvious injuries that young athletes face, coaches and parents should watch for broader problems as well.
One growing concern revolves around what is known as the “female athlete triad,” a ravaging combination of osteoporosis, amenorrhea and eating disorders, which play into one another and can be fatal. For many girls who compete, intense training can contribute to the falling off of menstrual cycles. A lack of estrogen from failing to have periods, meanwhile, can play a part in bone loss. And eating disorders — the result of trying to keep weight down, either for competition or to maintain a “feminine” appearance — exacerbate matters.
It is important for women to maximize bone density by their early thirties, says Dr. Moley, before it naturally starts to decrease. Coaches, parents and physicians should keep an eye out for potential problems and educate youngsters that normal periods and proper nutrition are critical.
Dr. Moley, a Darien resident, feels that coaches and trainers should also pay more attention to differences in physical maturity of players on a given team, particularly with boys. Different children mature at different rates. A team might have five or six more advanced players, perhaps having reached their maximum height, who are strong and physically capable. Other members of the squad, however, might be less developed. Bringing them all together for weight-room workouts, especially given youthful competition, can lead to injuries among the less physically able kids as they attempt to do too much too soon.
Practices and games are one thing, says Dr. Moley. But he believes that weight training and other group workouts should be more individualized. More focus should be paid to developing good balance and body mechanics and building smaller muscles, at least during the first couple years of high school.
“We have to look at where we should focus our energy,” he says. “It should really be on protecting these kids, looking at them individually, screening them and saying, ‘Hey, this child is very weak in the core,’ or very weak in the quadriceps or upper body. Let’s avoid these higher-level exercises. Let’s do more work on balance and skills and watch how they move, more than heavy lifting.”
One of his patients, Katie Ceglarski of Darien, suffered a herniated disk last summer while lifting weights in preparation for fall lacrosse at Gettysburg College. Katie, a standout in lacrosse and swimming at Darien High School, admits that she was probably attempting to lift too much weight too soon.
“I couldn’t bend over to brush my teeth,” says the twenty-one-year-old. “I used to be able to put my palms on the ground when I bent over. It got to a point where I couldn’t even bend an inch.”
A senior and team captain, Katie nonetheless played lacrosse deep into the fall. “Katie continued to play,” says her mother, Eileen. “I think that’s the nature of an athlete. They say, ‘Okay, I can play through the pain.’ I don’t think Katie ever thought she was seriously injured. I think she just thought that she had pulled something.”
When Katie finally sought medical attention, visiting Dr. Moley during an October break from school, he set her up on a physical therapy regimen. Over the next three-and-a-half months, she worked with therapists both locally and in Pennsylvania. Much of her rehabilitation involved stretching and working to strengthen her abdomen and back muscles.
Even after she was cleared to return to play this winter, Katie’s activity was restricted. She was instructed to avoid running on hard surfaces, such as gymnasium floors or blacktop. And when her teammates come together for circuit weight training, she has her own exercises that she performs by herself.
Injuries are bound to happen, experts agree. But problems can be avoided when young athletes concentrate on how to perform most effectively. Rest is important. So is proper technique. Baseball pitchers, tennis players and swimmers, among others, do better and are less likely to suffer injuries when they work with coaches to perform repetitive motions properly.
Similarly, involvement in off-season training programs goes a long way toward preventing injuries, says Hunter Greene, a certified athletic trainer with Plancher Orthopaedics and Sports Medicine in Greenwich. High school football players, in particular, returning to practice after summer vacation quickly discover the value of staying in condition.
“If you come in out of shape, you’re behind,” Greene says. “That’s going to set you back in your own performance and in trying to win a position. If you get out there and you’re out of shape or you’re not strong enough or your body is not adapted, then there’s a good chance that you’re going to be injured.”
Nutrition — and along with it, good hydration — also matters. Greene encourages school athletics departments to have their trainers and other experts speak with players about the benefits of eating right. “A lot of kids and a lot of parents have no idea,” he says. “Because nutrition is different for an athlete. You need more calories. You need a good balance. And you need plenty of carbohydrates to put gas in the tank, to put it simply.”
Eugene Salvatore, father of the injured hockey player Robbie, says that sports provide a lot of lessons. And what lessons could be better than a lifelong road map to good health?
“Most people who enjoyed sports when they were young continue that into adulthood,” says Greene. “So if they learn when they’re young, they’re going to be able to enjoy those sports twenty, thirty or forty years down the line. The earlier someone can be educated and start doing the right things, the better off they’re going to be in the long run.”