What All Parents of Active Children Should Know About Sports Injuries
By Jason Lazarus*1
Our 10 year old son, Ryan, tore his Anterior Cruciate Ligament (ACL) in his left leg this past summer. I have frequently been asked, isn’t 10 years old very young to tear an ACL? Yes, for children that young, it is rare, but not unheard of. And for adolescents and teenagers, ACL injuries are occurring more frequently, likely due to early sport specialization, and the increase in travel sports and year-round training2. Some children who tear their ACL also tear their Medial Collateral Ligament (MCL) at the same time. I wanted to share our experience with our son, so that other parents of sports playing children may benefit from what we learned. At the end of this article, I include some take-away tips for parents.
As an initial matter, injuries to a child’s ACL (or MCL or meniscus for that matter) may not be immediately apparent. Our son, who was trying out for flag football and fell on his knee, was in pain for less than a full day. And while he was unable to put much weight on his foot the next morning, by the following afternoon he was walking fine, and even running without any difficulty. As a precaution, we had Ryan examined by an orthopedist. X-rays showed no broken bones or any other damage, but the orthopedist found it irregular that Ryan could not straighten out his leg entirely, so he ordered an MRI.
The MRI took us all by surprise – it showed a complete tear to Ryan’s ACL in his left leg, and it also appeared that Ryan suffered an initial, partial tear to his ACL at least 6 months prior. Partial ACL tears, in which there is not a complete disruption of all ACL fibers, occur more frequently in children than in adults, and non-operative treatment may still be recommended for certain patients. While it’s likely that Ryan’s initial, partial tear of his ACL occurred during soccer season, we watched all of his games and he never complained of any injury.
The initial orthopedist we consulted with recommended against surgically repairing Ryan’s ACL until his growth plates were closed, or for at least six years or more. He also opined that Ryan could continue playing youth sports, so long as he wore a leg brace. His concerns - possibly disrupting Ryan’s growth - were well-intentioned. Historically, the recommendation for young children was to delay surgery even for completely torn ACLs until the child reached skeletal maturity. And for an inactive child, this recommendation may still make sense. But for an active child who plays year-round sports, we learned that this was not the best advice.
The more recent understanding in the medical community is that playing sports on a damaged and non-repaired ACL can do significant, and possibly irreparable damage to a child’s knee within a few months, even while wearing a leg brace. So after consulting with a handful of orthopedists, including Dr. Scuderi, who is also Ryan’s Jiu-Jitsu instructor, and Dr. Romano, who spent several hours with Ryan, the consensus was that Ryan needed surgery and should cease playing any sports until the ACL had fully healed (or for 7 months to a year after the surgery).
Importantly, performing an adult ACL surgery is very different than one on a young child whose bones have not matured. The surgical techniques involved are different, as particular emphasis is placed on avoiding the child’s growth plates, so as to prevent growth disturbance or limb deformity in the child. Thus, if your child sustains an injury of this nature, it would be well advised to consult with a pediatric orthopedic surgeon, and preferably, one with a sub-specialty for the specific body part in question. In our case, we focused our efforts on selecting a pediatric orthopedic surgeon with a specialty in performing “open-growth plate” ACL surgeries.
Even among these specialized pediatric orthopedists, there are different surgical options for young children with open growth plates.
In our case, after speaking with a handful of orthopedists, they collectively recommended three distinctly different surgical techniques, none of which had universal superiority3. Thus, we not only evaluated different surgeons, but also the different proposed surgical techniques, including by speaking to these surgeons and reading literature on the internet and articles in medical journals. There are several factors involved when deciding on the appropriate surgical technique for a child with open growth plates, including the extent of the injury, the activity level of the child, the child’s skeletal age (which is frequently assessed using radiographs or x-rays of the left hand), and the child’s puberty stage (also known as “Tanner stages”). Selecting the appropriate surgical technique can be critical in avoiding growth disturbance or limb deformity in the child, and for decreasing the risk of a recurring injury.
We did not feel constrained geographically in selecting a surgeon, as we were able to consult with a couple of very highly recommended, out of state pediatric surgeons with ACL surgical expertise via telephone and “Facetime”, after sending them Ryan’s MRIs and other records. We were also ready to make a long weekend trip and travel out of state for Ryan’s pre-surgery consult and surgery. Also, the out of state pediatric surgeons with whom we consulted were covered under our insurance, so it would not have been that much more expensive for the surgery.
Another factor for us in the selection process was the fact that the surgeon’s recommended surgical technique was not dictated by his level of experience, or lack thereof, with another technique. The surgeon we selected had significant experience in performing multiple surgical techniques, including another technique that he recommended against in Ryan’s case4.
At the recommendation of Dr. Romano and others, the doctor who ultimately performed Ryan’s ACL surgery was Dr. Craig Spurdle, a pediatric orthopedic surgeon at Nicklaus Children’s Hospital in Miami, Florida. Dr. Spurdle has performed over 1,500 ACL surgeries on young children with open growth plates, and he trained under the surgeon who helped pioneer the IT Band Physeal Sparing technique that was performed on Ryan.
Fortunately, Ryan’s surgery was successful. After undergoing weekly physical therapy since the surgery, Ryan is looking forward to resuming sports in or around March 2018, about 8 to 9 months from the date that he had the surgery. Ryan will wear a brace while playing sports for one year or so, which may help decrease the risk of a recurring injury. But Ryan’s long term prognosis is excellent, and as parents, we look forward to resume attending his games for years to come.
What should parents take from this article?
- Injuries to a child’s ACL (or MCL or meniscus) may not be immediately apparent, so if your child is in pain or has impaired movement, even if temporary, do not wait to seek medical attention.
- The warning signs of a torn ACL (or MCL or meniscus), including pain and the ability to put weight on the foot, may only be temporary, and these types of injuries generally do not appear on X-rays, making the physical exam by the doctor and the MRI even more important.
- If your child’s injury may require surgery, consult with a pediatric orthopedic surgeon, preferably with a sub-specialty for the specific body part in question.
- It is possible to misinterpret an MRI. So it may be prudent to get a second opinion, even if your child’s doctor opines that there is no injury based on the MRI. It would also be well advised to get a second opinion if there is a surgical or non-surgical recommendation, and if necessary, a third opinion.
- If possible, do not limit yourself geographically in selecting a qualified, experienced surgeon for your child, particularly if they are also covered under your insurance. You should be able to conduct your initial consult via telephone, Facetime or Skype, after submitting your child’s X-rays, MRIs and/or other medical records.
- There are programs designed to reduce the risk of ACL injuries in athletes. For instance, Jump for Sports is an 8 week program based on plyometrics, a type of jump training used to improve leg strength, balance, speed and agility, which research has shown can effectively reduce the risk of ACL injuries. This program is staffed with a sports medicine team which caters to young and growing athletes at the collegiate, high school, middle school, recreational and club level. Interested parents can visit nicklauschildrens.org/JumpForSports.
- Be as informed as possible, and conduct your own research.
* Jason Lazarus is an attorney at Holland & Knight LLP with an emphasis on business litigation and a niche practice of representing health care providers in litigation matters.
[1] This article is dedicated to Dr. Peter Romano, a brilliant and caring orthopedic surgeon, active volunteer with Doctors Without Borders and children’s sports coach, who sadly passed away in October of this year. I am grateful to the orthopedic surgeons who consulted with my wife and me and Ryan, including Dr. Romano, Dr. Gaetano Scuderi, Dr. James Ross, Dr. Michael Busch, Dr. Theodore Ganley and Dr. Craig Spurdle. I would also like to thank the orthopedic surgeons who reviewed and commented on this article, including Dr. Craig Robbins and Dr. Robert Simon.
[2] See Peter D. Fabricant, MD, MPH and Mininder S. Kocher, MD, MPH, Management of ACL Injuries in Children and Adolescents, J. Bone Joint Surg Am., at 600 (2017) (noting that ACL procedures in children under fifteen increased 924% from 1994 to 2006). While beyond the scope of this article, extrinsic risk factors for ACL injuries include the type of sport (with soccer, basketball and lacrosse being the highest risk for girls, and football, lacrosse and soccer being the highest risk for boys); poor playing surfaces; and even cleat configuration.
[3] While beyond the scope of this article, the different surgical techniques, and the pros and cons of each, are discussed in detail in the referenced article, Fabricant and Kocher, supra, at 602-08.
[4] As a side note, one of Ryan’s friends who was having soreness in his knee which lasted for several months consulted with an orthopedist who opined, after reviewing his MRI, that there was no injury. But after a second opinion, it was determined that Ryan’s friend had a torn meniscus in his knee which required surgery. In fairness to that initial doctor, his opinion may have been based on the fact that the injury had occurred too recently and there was too much swelling to detect any injury.