SPECIAL ISSUE ARTICLE

Injury Prevention in Youth Sports

Andrea Stracciolini, MD, FAAP, FACSM; Dai Sugimoto, PhD, ATC; and David R. Howell, PhD

ABSTRACT sports than girls, sustained more inju-

ries that were traumatic and bony in
Children and adolescents are now participating in competitive sports at younger nature.3 In comparison, girls sustained
ages and with increasing intensity. As a result, increasing numbers of young athletes are more overuse injuries, and experienced
presenting to pediatricians for care of sports-related injuries and advice about preven- patellofemoral pain syndrome (PFS)
tion. Understanding and identifying modifiable risk factors for injury in the young ath- at a rate of approximately 3 times
letic population is a critical first step in injury prevention. Risk factors vary by sport, age, greater.3 Girls and boys also appear to
and sex. This article reviews the most common risk factors for injury and the evidence possess different injury risk factors,4-8
to support proposed strategies for prevention. [Pediatr Ann. 2017;46(3):e99-e105.] perhaps due to the different movement
patterns they have been documented

D
espite heightened awareness, neuromuscular training to improve to demonstrate.9,10 The differences in
many concepts pertaining to muscle strength and teach movement injury patterns are also, in part, related
youth sports injuries remain patterns). By understanding the risk to sport selection. A recent study in-
unknown, including an understand- factors for injury and evidence-based vestigating overuse injuries in ath-
ing of all the factors that place the prevention strategies, pediatricians letes age 5 to 17 years found that girls
youth athlete at risk for injury and the can play a critical role in making youth sustained more overuse injuries than
best strategies for prevention.1,2 The sports safer by providing individual- boys (63% vs 40%, respectively), and
most commonly researched risk fac- ized advice regarding injury risk and 46% of this difference could be at-
tors include age, sex, sport selection, prevention. tributed to their chosen sports’ char-
growth/maturation phase, pattern of acteristics (eg, contact/noncontact,
previous injuries, biomechanics, de- EPIDEMIOLOGY team/individual).11
gree of sports specialization, and sleep Patterns of sport participation and
patterns. For risk factors that are mod- injury vary by sex. A recent epidemio- OVERUSE OR REPETITIVE STRESS
ifiable, such as muscle strength and logic investigation of sports injuries INJURY
movement patterns, there has been re- sustained by athletes age 5 to 17 years Leaders in the field of pediatric
search to investigate the effectiveness reported that boys, who tend to partici- sports medicine first introduced the
of targeted prevention programs (eg, pate in more team and contact/collision concept of “overuse injury” in chil-
dren in the early1980s.12 Perhaps more
Andrea Stracciolini, MD, FAAP, FACSM, is a Primary Care Sports Medicine Physician and the Director appropriate terminology is repetitive
of the Section of Performing Arts, Division of Sports Medicine, Boston Children’s Hospital; an Assistant stress injury, as these injuries are of-
Professor of Pediatrics, Harvard Medical School; and a Researcher, The Micheli Center for Sports Injury ten the result of repetitive loading of
Prevention. Dai Sugimoto, PhD, ATC, is the Director of Clinical Research, The Micheli Center for Sports the musculoskeletal system with inad-
Injury Prevention; a Researcher, Division of Sports Medicine, Boston Children’s Hospital; and an Instruc- equate rest and recovery time to allow
tor, Harvard Medical School. David R. Howell, PhD, is a Postdoctoral Research Fellow, The Micheli Center for structural repair and adaptation.13
for Sports Injury Prevention. Repetitive stress injury can occur to
Address correspondence to Andrea Stracciolini, MD, FAAP, FACSM, Division of Sports Medicine, the muscle-tendon unit, bone, bursa,
Department of Orthopaedic Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA neurovascular structures, and phy-
02115; email: [Link]@[Link]. sis/apophysis. The National Athletic
Disclosure: The authors have no relevant financial relationships to disclose. Trainers’ Association speculates that
doi: 10.3928/19382359-20170223-01
more than one-half of all sports-related

PEDIATRIC ANNALS • Vol. 46, No. 3, 2017 e99

 SPECIAL ISSUE ARTICLE

overuse injuries in young athletes may This is mainly due to physiologic and ence in injury rates, including greater
be preventable with preseason and anatomic changes that occur during ligamentous laxity in girls,24 neuro-
in-season conditioning programs that growth, which affect risk factors such muscular differences between girls
incorporate resistance training and as growth plate activity/vulnerability, and boys that develop during puberty
improvement in functional movement muscle strength, and flexibility. appear to be the most important fac-
skills as their primary objectives.14 In young girl athletes, the period of tor that contributes to girls being at an
rapid growth or peak height velocity increased risk for ACL injury.25 Dur-
INJURY RISK FACTORS (PHV) just prior to the onset of men- ing puberty, girls and boys experience
Previous Injury arche may be the most vulnerable pe- relatively rapid increases in body mass
There is consistent evidence that the riod for musculoskeletal injury. PHV and height, and elevation of their cen-
strongest predictor of future injuries is has been associated with a transient ters of mass; boys have a surge of tes-
a previous injury.15 This finding high- decrease in bone density, which may tosterone during this time. This testos-
lights the important role of the prepar- lower the threshold for acute, traumat- terone surge during puberty for boys
ticipation evaluation (PPE) in injury ic fracture as well as repetitive stress who are athletes results in an increase
prevention. The PPE provides the pe- injury to bone (ie, stress fractures).19 in muscle mass and strength, both
diatrician with a unique and valuable Further evidence that injury risk may serving to improve muscular control
opportunity to identify previous inju- be related to maturation phase is the about the joints and increase core sta-
ries that may be incompletely healed higher injury rate observed in peripu- bility. Girls, however, do not have this
or rehabilitated, and recommend ap- bertal girls who are gymnasts (Tanner same burst of testosterone, and thus do
propriate treatment before clearing the stages 2 and 3) compared with gym- not experience as much muscle growth
athlete for full participation.16 For ex- nasts at either higher or lower stages as boys. Therefore, pubertal girls tend
ample, an athlete may report an ankle of development, regardless of com- to have less effective muscular con-
sprain that occurred 2 months prior, petitive level.20 Similarly, DiFiori et trol of their joint movements and de-
and is currently pain-free but demon- al.21 found that adolescent gymnasts creased core stability during athletic
strates some weakness in the muscles between age 10 and 14 years are more maneuvers, which is thought be the
around that ankle. In a typical case of likely than older gymnasts to have main reason girls have higher ACL in-
recurrent ankle sprain, a rehabilitation chronic wrist pain, even after adjusting jury rates than boys.25 A key tenet of
program of strength and propriocep- for intensity of training, age of initia- this decreased core stability for girl
tion exercises should be recommended tion of training, years of training, and athletes is the absence of increases in
before clearing the athlete for full par- sex. As such, a temporary reduction in strength and muscle recruitment at the
ticipation. training load or restructuring the train- hip and trunk.26 These muscles appear
ing schedule to allow for more rest be- to play an important role in supporting
Growth tween training sessions may be effec- and stabilizing the knee.
The concept of the growth process tive strategies for reducing the risk for Biomechanical investigations have
as a risk factor for sports injury in injury during these vulnerable periods identified “dynamic knee valgus” (in-
young athletes was highlighted by Mi- of growth. ward collapse of the knee in the frontal
cheli and Fehlandt,17 who observed that plane due to a combination of hip in-
children may be more susceptible to Biomechanics ternal rotation and hip adduction) dur-
repetitive stress injury than adults due How athletes use their muscles dur- ing athletic movements as a contribut-
to the unique vulnerability of growth ing athletic maneuvers and the result- ing risk factor for both ACL injury and
cartilage and growing soft tissues as ing joint movement patterns can af- PFS.27 In fact, dynamic knee valgus has
well as the growth process itself. For fect the risk for injury, especially to been identified as the most sensitive
example, prepubertal children sustain the anterior cruciate ligament (ACL). (73%) and specific (78%) risk factor
significantly more injuries that were Throughout puberty, girl athletes have for future ACL injury in adolescent girl
classified as bone-related and trau- higher rates of ACL injuries compared athletes.25 As girls go through pubertal
matic. The pubescent athletes, in com- to boys in similar sports.22,23 Although maturation, they tend to perform ath-
parison, were more likely to sustain sex-based anatomic and physiologic letic maneuvers (eg, cutting and jump-
soft tissue and overuse-type injuries.18 changes may partly explain this differ- landing) with increasing amounts of

e100 Copyright © SLACK Incorporated

 SPECIAL ISSUE ARTICLE

dynamic knee valgus, presumably

due to relative weakness in the hip
and trunk muscles.28-30 Given that hip
strength plays a key role in modifying
dynamic knee valgus, neuromuscular
training programs aimed at building
hip and core strength have been inves-
tigated for their preventive effect on
ACL injuries.31 A recent meta-analysis
of 14 ACL injury prevention stud-
ies found significantly lower rates of
ACL injuries in those who performed
preventive neuromuscular training as
compared to those who maintained
their usual training routine.32,33 Some
training programs also reduced rates
of PFS and ankle sprains.34,35 The
most effective programs included
three main components: (1) strength-
Figure 1. Training targeting improving hip muscle strength by using a slide board. From The Micheli
ening exercises for the hip and core Center for Sports Injury Prevention (Waltham, MA) with consent of both participants.
(Figure 1 and Figure 2),36 (2) plyo-
metrics (repetitive jumping exercis-
es),36,37 and (3) feedback to athletes
about proper form (ie, avoiding dy-
namic knee valgus).38 The largest ef-
fect on ACL injury reduction was seen
for girls age 4 to 18 years.32,34,39 Pe-
diatricians can play a key role in edu-
cating girls and their parents about
these evidence-based prevention pro-
grams, especially those in their early
teens who participate in sports with the
highest rates of ACL injury (ie, soccer,
basketball, gymnastics).40-42 More in-
formation about ACL injury preven-
tion including links to specific training
programs for athletes and coaches can
be found on the American Academy of
Pediatrics Council on Sports Medicine
and Fitness website.43
Figure 2. Training for peri scapular and upper trunk muscles, and core muscle strength and stabilization.
Early Sports Specialization From The Micheli Center for Sports Injury Prevention (Waltham, MA) with consent of both participants.

Early sports specialization is a new

trend in the culture of youth sports that children are playing sports with in- specialized in one sport had increased
may add to injury risk. Sports special- creased intensity and more of them are risk of anterior knee pain disorders,
ization has been defined as “year-long, specializing in a single sport, starting when compared to multisport athletes.
intensive training in a single sport at as young as age 7 years.45 Hall et al.46 An even larger study of youth athletes
the exclusion of other sports.”44 Young have shown that adolescent girls who demonstrated that sport specialization

PEDIATRIC ANNALS • Vol. 46, No. 3, 2017 e101

 SPECIAL ISSUE ARTICLE

TABLE 1. Concussion Risk Factors and

Prevention Strategies
Actions Pediatricians Can Take to Reduce the Risk for Injury Among high school athletes, con-
in Youth Sports cussion comprises up to 10% of all
• Encourage general health maintenance and fitness year-round sport-related injuries.54 Despite con-
• Suggest temporary reductions or restructuring in training load to allow for more adequate rest cussion being a fairly prevalent injury,
between training sessions during vulnerable periods of growth
there are relatively few studies on pre-
• Educate young women athletes and their parents about neuromuscular training programs to
vention, and the strategies investigat-
reduce anterior cruciate ligament and other lower extremity injuries
ed to date, which include both primary
• Encourage participation in neuromuscular training programs aimed at building hip and core
strength especially for young prepubescent girl athletes (optimally before signs of injury)
and secondary prevention, have shown
• Encourage proper sleep hygiene including maximizing sleep quantity and quality each night
limited effectiveness. Primary preven-
• Encourage plenty of time for free play, “cross training,” and sport diversity early in childhood
tion aims to prevent the injury before
(delaying specialization in a single sport until late adolescence) it ever occurs. Secondary prevention
• Encourage proper sport-specific gear use and fit aims to reduce the adverse effects of
• Enforce early recognition of sport-related concussion and removal from competition until a concussion that have already oc-
medical evaluation, treatment, and clearance for return to sport criteria have been met curred. This is done by detecting and
• Educate young athletes about the symptoms of concussions and encourage them to report treating the injury as soon as possible,
symptoms promptly to coaches, trainers, and parents and making recommendations to pre-
• Support and advocate for policies that promote fair play and rule enforcement as well as youth vent re-injury or prolonged recovery.
sports schedules that do not compromise sleep Protective equipment is commonly
cited as a means of primary concus-
sion prevention. However, evidence to
support the notion that any protective
is a risk factor for overuse injury, in- Sleep equipment reduces the likelihood that
dependent of training volume.47 No There are some recent data docu- an athlete will sustain a concussion is
evidence currently exists to support menting an apparent association be- scant to date. Helmets, for instance,
the notion that sports specialization tween sleep duration and sport-related are often discussed as a means of con-
before puberty is necessary to achieve injury risk.50 Among adolescent elite cussion prevention in sports such as
elite status for the majority of sports.48 athletes, those who reported more ice hockey or American football, as
In fact, research has shown that par- than 8 hours of sleep per night on athletes are required to wear them as a
ticipation in multiple sports may fa- typical weekdays had significantly re- part of their routine equipment. Mod-
cilitate transfer of skills from one duced odds of sustaining an injury.51 ern helmets were designed to prevent
sport to another, and in doing so, may In a survey of young athletes age 6 skull fractures. However, there is no
better promote youth athletic devel- to 18 years, Luke et al.,52 found that good evidence to show that any type
opment than specialization.49 Addi- fatigue-related injuries were related of helmet prevents a concussion.55
tionally, participation in a variety of to sleeping <6 hours the night before One primary prevention method
sports exposes the growing body to a the injury. Furthermore, additional re- that may reduce concussion risk is
wider range of physical challenges, search supports a relationship between neck strengthening. This is based on
which may result in more balanced good sleep hygiene and improved a study suggesting that greater neck
neuromuscular development and less sports performance.53 Thus, counsel- strength was associated with reduced
repetitive stress, theoretically reduc- ing young athletes about proper sleep odds of sustaining a concussion in
ing the risk for injury. Both the Ameri- hygiene may be a simple and effective contact sport athletes.56 The theory
can Academy of Pediatrics45 and the way to reduce youth sports injuries. is that stronger neck muscles may re-
American Medical Society for Sports More information about the relation- duce head acceleration after a blow to
Medicine13 recommend that children ships between sleep and athlete health the head.
diversify sports training during early and performance can be found in an Thus far, research shows the most
and middle adolescence, and delay article by Copenhaver and Diamond effective strategies for primary con-
specialization until late adolescence. (this issue). cussion prevention are rule changes

e102 Copyright © SLACK Incorporated

 SPECIAL ISSUE ARTICLE

and rule enforcement. In a review of male gender, and soccer participation incidence of injury in Texas high school
basketball. A prospective study among
the available evidence regarding the were more likely to be associated with
male and female athletes. Am J Sports Med.
effect of rule changes on concussion better self-reported behaviors and at- 1999;27(3):294-299.
risk, Benson et al.57 concluded that in- titudes toward reporting concussion 7. Hosea TM, Carey CC, Harrer MF. The gen-
troducing fair play rules and eliminat- symptoms.63 Thus, like many of the der issue: epidemiology of ankle injuries in
athletes who participate in basketball. Clin
ing body checking in youth ice hockey other sports injury prevention strate- Orthop Relat Res. 2000;372:45-49.
are effective strategies for preventing gies discussed in this review, the ef- 8. Waterman BR, Belmont PJ Jr, Cameron
concussions. Pediatricians can sup- fectiveness of concussion education KL, Svoboda SJ, Alitz CJ, Owens BD. Risk
factors for syndesmotic and medial ankle
port policies that promote fair play may vary with age, sex, and sport. sprain: role of sex, sport, and level of com-
and rule enforcement, and can advo- petition. Am J Sports Med. 2011;39(5):992-
cate for rule changes that decrease CONCLUSION 998.
9. Willy RW, Manal KT, Witvrouw EE, Da-
concussion risk. Pediatricians can influence sports
vis IS. Are mechanics different between
The most commonly researched injury prevention efforts by encour- male and female runners with patel-
method of secondary prevention of aging young athletes to participate lofemoral pain? Med Sci Sports Exerc.
concussion is athlete education, as in preventive training programs that 2012;44(11):2165-2171.
10. Willson JD, Petrowitz I, Butler RJ, Kerno-
studies have shown that many athletes focus on functional movement and zek TW. Male and female gluteal muscle
do not report their symptoms after a hit strength building initiated early when activity and lower extremity kinematics
to the head and continue to play, put- children are more receptive to training during running. Clin Biomech (Bristol,
Avon). 2012;27(10):1052-1057.
ting themselves at risk for additional and before injury ensues. Anticipatory 11. Stracciolini A, Casciano R, Friedman HL,
injury or prolonged recovery.58,59 The guidance that promotes healthy sleep Meehan WP 3rd, Micheli LJ. A closer look
goal of education, therefore, is not to patterns, multiple sport participation, at overuse injuries in the pediatric athlete.
Clin J Sport Med. 2015;25(1):30-35.
prevent the initial injury from occur- with adequate rest and recovery time,
12. Micheli LJ. Overuse injuries in children’s
ring, but rather to improve clinical are simple ways that pediatricians can sports: the growth factor. Orthop Clin
outcomes after injury. In a survey of help prevent sports injuries in youth. North Am. 1983;14(2):337-360.
approximately 500 college athletes, Future research surrounding risk fac- 13. DiFiori JP, Benjamin HJ, Brenner J, et al.
Overuse injuries and burnout in youth
the two most common reasons given tors for youth sports injury is war- sports: a position statement from the Amer-
for not reporting symptoms were ranted to continue prevention efforts ican Medical Society for Sports Medicine.
(1) feeling the concussion was not (Table 1). Clin J Sport Med. 2014;24(1):3-20.
14. Valovich McLeod TC, Decoster LC, Loud
serious and that they could continue KJ, et al. National Athletic Trainers’ As-
to play without any danger to them- REFERENCES sociation position statement: prevention
selves, and (2) the fear of being re- 1. Caine D, Maffulli N, Caine C. Epidemiolo- of pediatric overuse injuries. J Athl Train.
gy of injury in child and adolescent sports: 2011;46(2):206-220.
moved from play.60 Athlete education injury rates, risk factors, and prevention. 15. Kucera KL, Marshall SW, Kirkendall DT,
programs focus on how to recognize Clin Sports Med. 2008;27(1):19-50. Marchak PM, Garrett WE Jr. Injury history
concussion symptoms and the risks 2. Micheli LJ, Glassman R, Klein M. The pre- as a risk factor for incident injury in youth
vention of sports injuries in children. Clin soccer. Br J Sports Med. 2005;39(7):462.
of continuing to play with symptoms. Sports Med. 2000;19(4):821-834. 16. Weaver NL, Marshall SW, Miller MD.
Studies investigating the effect of such 3. Stracciolini A, Casciano R, Levey Friedman Preventing sports injuries: opportunities
education programs have shown vari- H, Stein CJ, Meehan WP 3rd, Micheli LJ. for intervention in youth athletics. Patient
Pediatric sports injuries: a comparison of Educ Couns. 2002;46(3):199-204.
able results. For example, studies of
males versus females. Am J Sports Med. 17. Micheli LJ, Fehlandt AF Jr. Overuse in-
high school football players showed 2014;42(4):965-972. juries to tendons and apophyses in chil-
that despite demonstrating an in- 4. Dougan BK, Horswill MS, Geffen GM. Ath- dren and adolescents. Clin Sports Med.
creased knowledge about concussion letes’ age, sex, and years of education mod- 1992;11(4):713-726.
erate the acute neuropsychological impact 18. Stracciolini A, Casciano R, Levey Friedman
symptoms and the danger of continu- of sports-related concussion: a meta-analy- H, Meehan WP 3rd, Micheli LJ. Pediatric
ing to play, many did not change their sis. J Int Neuropsychol Soc. 2014;20(1):64- sports injuries: an age comparison of chil-
attitude toward reporting symptoms or 80. dren versus adolescents. Am J Sports Med.
5. Powell JW, Barber-Foss KD. Sex-related 2013;41(8):1922-1929.
abstaining from play after a concus- injury patterns among selected high school 19. Faulkner RA, Davison KS, Bailey DA,
sion.61,62 A similar study of nearly 500 sports. Am J Sports Med. 2000;28(3):385- Mirwald RL, Baxter-Jones AD. Size-cor-
high school athletes from a variety of 391. rected BMD decreases during peak linear
6. Messina DF, Farney WC, DeLee JC. The growth: implications for fracture incidence
sports showed that younger age, fe-

PEDIATRIC ANNALS • Vol. 46, No. 3, 2017 e103

 SPECIAL ISSUE ARTICLE

during adolescence. J Bone Miner Res. Powers CM. Hip muscle strength predicts geons evidence-based guideline on manage-
2006;21(12):1864-1870. noncontact anterior cruciate ligament injury ment of anterior cruciate ligament injuries.
20. Caine D, Cochrane B, Caine C, Zemper E. in male and female athletes: a prospective J Bone Joint Surg Am. 2015;97(8):672-674.
An epidemiologic investigation of injuries study. Am J Sports Med. 2016;44(2):355- 42. Sugimoto D, Myer GD, Micheli LJ, Hewett
affecting young competitive female gym- 361. TE. ABCs of evidence-based anterior cru-
nasts. Am J Sports Med. 1989;17(6):811- 32. Myer GD, Sugimoto D, Thomas S, Hewett ciate ligament injury prevention strategies
820. TE. The influence of age on the effective- in female athletes. Curr Phys Med Rehabil
21. DiFiori JP, Puffer JC, Aish B, Dorey F. Wrist ness of neuromuscular training to reduce Rep. 2015;3(1):43-49.
pain in young gymnasts: frequency and ef- anterior cruciate ligament injury in female 43. American Academy of Pediatrics. Council
fects upon training over 1 year. Clin J Sport athletes: a meta-analysis. Am J Sports Med. on Sports Medicine & Fitness. ACL re-
Med. 2002;12(6):348-353. 2013;41(1):203-215. sources. [Link]
22. Stracciolini A, Stein CJ, Zurakowski D, 33. Sugimoto D, Myer GD, Foss KD, Hewett the-aap/Committees-Councils-Sections/
Meehan WP, Myer GD, Micheli LJ. An- TE. Dosage effects of neuromuscular train- Council-on-sports-medicine-and-fitness/
terior cruciate ligament injuries in pediat- ing intervention to reduce anterior cruci- Pages/[Link]. Accessed
ric athletes presenting to sports medicine ate ligament injuries in female athletes: March 1, 2017.
clinic: a comparison of males and females meta- and sub-group analyses. Sports Med. 44. [No authors listed]. Pediatrics. Intensive
through growth and development. Sports 2014;44(4):551-562. training and sports specialization in young
Health. 2015;7(2):130-136. 34. LaBella CR, Huxford MR, Grissom J, Kim athletes. American Academy of Pediatrics.
23. LaBella CR, Hennrikus W, Hewett TE; Coun- KY, Peng J, Christoffel KK. Effect of neu- Committee on Sports Medicine and Fitness.
cil on Sports Medicine and Fitness, and romuscular warm-up on injuries in female Pediatrics. 2000;106(1 Pt 1):154-157.
Section on Orthopaedics. Anterior cruciate soccer and basketball athletes in urban 45. Brenner JS; Council on Sports Medicine and
ligament injuries: diagnosis, treatment, and public high schools: cluster randomized Fitness. Sports specialization and inten-
prevention. Pediatrics. 2014;133(5):e1437- controlled trial. Arch Pediatr Adolesc Med. sive training in young athletes. Pediatrics.
1450. 2011;165(11):1033-1040. 2016;138(3). doi: 10.1542/peds.2016-2148.
24. Boguszewski DV, Cheung EC, Joshi NB, 35. LaBella CR, Huxford MR, Smith TL, Cart- 46. Hall R, Barber Foss K, Hewett TE, Myer
Markolf KL, McAllister DR. Male-fe- land J. Preseason neuromuscular exercise GD. Sports specialization is associated with
male differences in knee laxity and stiff- program reduces sports-related knee pain an increased risk of developing anterior
ness: a cadaveric study. Am J Sports Med. in female adolescent athletes. Clin Pediatr. knee pain in adolescent female athletes. J
2015;43(12):2982-2987. 2009;48(3):327-330. Sport Rehab. 2015;24(1):31-35.
25. Hewett TE, Myer GD, Ford KR, et al. Bio- 36. Sugimoto D, Myer GD, Foss KD, Hewett TE. 47. Jayanthi NA, LaBella CR, Fischer D, Pasul-
mechanical measures of neuromuscular Specific exercise effects of preventive neu- ka J, Dugas LR. Sports-specialized inten-
control and valgus loading of the knee pre- romuscular training intervention on anterior sive training and the risk of injury in young
dict anterior cruciate ligament injury risk in cruciate ligament injury risk reduction in athletes: a clinical case-control study. Am J
female athletes: a prospective study. Am J young females: meta-analysis and subgroup Sports Med. 2015;43(4):794-801.
Sports Med. 2005;33(4):492-501. analysis. Br J Sports Med. 2015;49(5):282- 48. Jayanthi N, Pinkham C, Dugas L, Patrick B,
26. Myer GD, Chu DA, Brent JL, Hewett TE. 289. Labella C. Sports specialization in young
Trunk and hip control neuromuscular train- 37. Mandelbaum BR, Silvers HJ, Watanabe DS, athletes: evidence-based recommendations.
ing for the prevention of knee joint injury. et al. Effectiveness of a neuromuscular and Sports Health. 2013;5(3):251-257.
Clin Sports Med. 2008;27(3):425-448. proprioceptive training program in prevent- 49. Myer GD, Jayanthi N, Difiori JP, et al. Sport
27. Myer GD, Ford KR, Foss KD, Rauh MJ, Pa- ing anterior cruciate ligament injuries in specialization, part I: does early sports spe-
terno MV, Hewett TE. A predictive model female athletes: 2-year follow-up. Am J cialization increase negative outcomes and
to estimate knee-abduction moment: im- Sports Med. 2005;33(7):1003-1010. reduce the opportunity for success in young
plications for development of a clinically 38. Hewett TE, Lindenfeld TN, Riccobene JV, athletes? Sports Health. 2015;7(5):437-
applicable patellofemoral pain screen- Noyes FR. The effect of neuromuscular 442.
ing tool in female athletes. J Athl Train. training on the incidence of knee injury in 50. Milewski MD, Skaggs DL, Bishop GA, et
2014;49(3):389-398. female athletes. A prospective study. Am J al. Chronic lack of sleep is associated with
28. Ford KR, Shapiro R, Myer GD, Van Den Bo- Sports Med. 1999;27(6):699-706. increased sports injuries in adolescent ath-
gert AJ, Hewett TE. Longitudinal sex dif- 39. Gilchrist J, Mandelbaum BR, Melancon H, letes. J Pediatr Orthop. 2014;34(2):129-
ferences during landing in knee abduction et al. A randomized controlled trial to pre- 133.
in young athletes. Med Sci Sports Exerc. vent noncontact anterior cruciate ligament 51. von Rosen P, Frohm A, Kottorp A, Friden C,
2010;42(10):1923-1931. injury in female collegiate soccer players. Heijne A. Too little sleep and an unhealthy
29. Hewett TE, Myer GD, Kiefer AW, Ford Am J Sports Med. 2008;36(8):1476-1483. diet could increase the risk of sustaining
KR. Longitudinal increases in knee ab- 40. Comstock RCC, Collins CL, McIlvain N. a new injury in adolescent elite athletes.
duction moments in females during ado- National high-school sports-related in- Scand J Med Sci Sports. 2016; doi: 10.1111/
lescent growth. Med Sci Sports Exerc. jury surveillance study, 2009-2010 school sms.12735. [Epub ahead of print].
2015;47(12):2579-2585. year. [Link] 52. Luke A, Lazaro RM, Bergeron MF, et al.
30. Cowley HR, Ford KR, Myer GD, Kernozek ics/colleges/PublicHealth/research/Re- Sports-related injuries in youth athletes: is
TW, Hewett TE. Differences in neuromus- searchProjects/piper/projects/RIO/Docu- overscheduling a risk factor? Clin J Sport
cular strategies between landing and cutting ments/[Link]. Accessed February 28, Med. 2011;21(4):307-314.
tasks in female basketball and soccer ath- 2017. 53. Chang SP, Chen YH. Relationships between
letes. J Athl Train. 2006;41(1):67-73. 41. Shea KG, Carey JL, Richmond J, et al. The sleep quality, physical fitness and body
31. Khayambashi K, Ghoddosi N, Straub RK, American Academy of Orthopaedic Sur- mass index in college freshmen. J Sports

e104 Copyright © SLACK Incorporated

 SPECIAL ISSUE ARTICLE

Med Phys Fitness. 2015;55(10):1234-1241. 2013;47(5):321-326. Cyriac RL, Pomerantz WJ. High school
54. Gessel LM, Fields SK, Collins CL, Dick RW, 58. Meier TB, Brummel BJ, Singh R, Nerio CJ, football players’ knowledge and attitudes
Comstock RD. Concussions among United Polanski DW, Bellgowan PS. The underre- about concussions. Clin J Sport Med.
States high school and collegiate athletes. J porting of self-reported symptoms follow- 2016;26(3):206-209.
Athl Train. 2007;42(4):495-503. ing sports-related concussion. J Sci Med 62. Kurowski BG, Pomerantz WJ, Schaiper C,
55. Cross KM, Serenelli C. Training and equip- Sport. 2015;18(5):507-511. Ho M, Gittelman MA. Impact of preseason
ment to prevent athletic head and neck inju- 59. Elbin RJ, Sufrinko A, Schatz P, et al. Remov- concussion education on knowledge, at-
ries. Clin Sports Med. 2003;22(3):639-667. al from play after concussion and recovery titudes, and behaviors of high school ath-
56. Collins CL, Fletcher EN, Fields SK, et al. time. Pediatrics. 2016;138(3). doi: 10.1542/ letes. J Trauma Acute Care Surg. 2015;79(3
Neck strength: a protective factor reducing peds.2016-0910. Suppl 1):S21-28.
risk for concussion in high school sports. J 60. Delaney JS, Lamfookon C, Bloom GA, Al- 63. Kurowski B, Pomerantz WJ, Schaiper C,
Prim Prev. 2014;35(5):309-319. Kashmiri A, Correa JA. Why university ath- Gittelman MA. Factors that influence con-
57. Benson BW, McIntosh AS, Maddocks D, letes choose not to reveal their concussion cussion knowledge and self-reported at-
Herring SA, Raftery M, Dvorak J. What symptoms during a practice or game. Clin J titudes in high school athletes. J Trauma
are the most effective risk-reduction strate- Sport Med. 2015;25(2):113-125. Acute Care Surg. 2014;77(3 Suppl 1):S12-
gies in sport concussion? Br J Sports Med. 61. Anderson BL, Gittelman MA, Mann JK, 17.

PEDIATRIC ANNALS • Vol. 46, No. 3, 2017 e105