Generation Knife: Will Overuse End Up Ruining Young Athletes?

Youth sports are changing. Children train like Olympians and professionals, an entire generation imbued with laser-focused skill sets, corporeal control, and sport-specific mastery unlike ever before. They drill and compete year-round, applying the brutal and effective measures long predominant for gymnasts and tennis players, figure skaters and ballerinas, to team sports: barely teens pitching inning after inning shortly after football season and then going to quarterback camp; others tumbling for hours then heading to cheer practice to tumble some more.

These children are talented, devoted, and beholden to high-intensity regiments like their idols, and they are getting injured like them too. An entire era of children exists with the unmatched skills and rebuilt joints of seasoned pros—Generation Knife—pushing surgical science and our understanding of development and the human body into the unknown. But who knows what will become of this Generation Knife when their surgically-repaired bodies age? The science can't yet tell us.

The good news is that the overall injury rates of under-18 athletes seems to be falling. A 2013 study in the Journal of Pediatric Orthopedics comparing sports-related injury rates in athletes aged 5-14 from 2000 to the same cohorts in 2005 and 2010, saw the rates continually decreasing.

The bad news is that, whilst overall injury rates are lowering, a specific subset of injury has increased: overuse. Defined by the American Medical Society for Sports Medicine (AMSSM) as injuries accrued via "repetitive submaximal loading of the musculoskeletal system when rest is not adequate to allow for structural adaptation to take place." In other words: running young athletes into the ground. Overuse injuries can have deleterious effects on both the athlete's sporting career and, more importantly, their very development; if, for example, the growth plates are damaged, athletes can face limb shortening and deformity.

A position statement from the ASSM traces the increase in overuse and burnout—in effect a psychological overuse injury—to the rise in high-intensity, professional-style training methods being implemented with children. This emphasis on competitive success and long shot, albeit lucrative, possible rewards—professional contracts, college scholarships, Olympic laurels—has led to an increase in specialization training in youth sport, which in turn leads to the overuse injuries.

The causation is of little doubt. Dr. James Kinderknecht, a sports medicine surgeon at the Hospital for Special Surgery in New York City, said in a phone interview there was "no question" specialization was responsible for the increase in overuse injuries. Dr. Kinderknecht considers many of these injuries to be a "volume issues," and the increased volume of specific work is practically the guiding principle of specialization.

Whereas once youth athletes played a variety of sports throughout the year—or had an off-season with minimal athletic participation—with a focus more on participation and fitness, the new hunger sensed by the ASSM and others involved in youth sport demands high-intensity, insistent training, drilling, and playing of only one sport or practicing even only one sporting motion; think kids who play basketball or soccer on both interscholastic and club teams all year round, or aspiring pitchers who do nothing but pitch. While specialization has led to a generation of athletes with more skill in their given event than ever before, there are serious health and cultural implications which must be considered: is it OK for some 12-year-old boy to have already undergone, say, Tommy John surgery, a good decade before he could hope to be pro, which is already an infinitesimal hope at best? And what does the future hold for these rebuilt athletes—Generation Knife—pushing their musculoskeletal repairs to the limit, playing out practically their entire careers post-surgery?

The obvious overuse culprits are baseball, basketball, and football, the American holy sporting triad; the unnatural and violent throwing motions common in baseball, in particular, lead to unstable shoulders, pushed-to-their-limit rotator cuffs, and frayed and torn ulnal collateral (elbow) ligament requiring Tommy John before hitting high school. Growing bodies are ill-equipped for the constant battering of endless lay-up lines and deep post heaves.

Less common culprits include the anterior crucial ligament (ACL) shredding sports of skiing, soccer, and lacrosse—especially amongst female participants—and lower profile throwing sports like the javelin, wherein an athlete's body basically becomes a flail, an event feared enough that 36 states do not hold NFHS-sanctioned high school javelin competitions. The rise of specialization means that these team sports children are now beginning to be injured in ways that before only their peers in individual sports like gymnastics and dancing—where specialization has long been de riguer—have been.

While the dreaded rotator cuff tear is rare, even amongst pitchers, ACL and UCL surgeries are becoming depressingly common; in a roundtable discussion on high-intensity youth sport for the American Association of Orthopaedic Surgeon's magazine AAOS Now, Dr. Mininder S. Kocher, from the Children's Hospital Boston Division of Sports Medicine, said he rarely used to see ACL injuries in skeletally immature athletes. Not anymore.

"Of the approximately 150 ACL reconstructions I perform every year," he said, "two thirds are on skeletally immature patients."

Arthroscopy and arthroscopic surgery have long since made those ACL tears a speed bump for some athletes, rather than the career-killing injury it once was. Arthroscopy involves the insertion of a small viewing instrument—roughly the diameter of a pencil—into a water filled joint. The arthroscope is connected to a television screen, allowing the surgeon to see inside of the joint without having to open it up. Small surgical tools can also be inserted and operated with the aid of the arthroscope, leading to a minimally invasive surgery.

The smaller, less invasive incisions and improved diagnostic and surgical accuracy also make arthroscopy easier on the juvenile body. In conjunction with improved techniques for rehabilitation and the avoidance of growth plate violation, young athletes can reasonably expect to continue being able to play after going under the knife.

Dr. Kinderknecht points to the early 90s as the dawning of the new age of the reconstructed athlete. The tearing of Detroit Lions' star Billy Simms' ACL in 1984 ended his career. But similar injuries to Emmitt Smith while at Florida and the Minnesota Viking's Terry Allen a few years later proved to be recoverable.

Even still, as ESPN's Kevin Seifert pointed out, the late 90s/early 2000s ACL injuries to Jamaal Anderson and Terrell Davis effectively put an end to their playing days. And these were fully developed professionals.

"I think what is more new and novel … in terms of pediatric surgery, [are] approaches to the surgery that avoid injuring the growth plates, and a better understanding of the growth plates," Dr. Kinderknecht said.

Combined with improved rehab techniques, young athletes are now bouncing back from the kinds of injuries which used to fell their heroes.

The advances in surgical procedures and techniques help provide Generation Knife with the physical fortitude to survive their high-intensity environments, but it does not take into account the mental health ramifications of such high-pressure programs; the child pitcher who cannot control his curve early believes he may never get into college, and the cheerleader renders the rest of her stunt group—her sisters—incapacitated and potentially at severe risk of injury were she to miss even just one practice.

Extra attention may need to be paid to the psychological implications of youth surgery. Dr. Brad Donohue of the University of Nevada, Las Vegas—principle investigator for the sport-specific The Optimum Performance Program in Sports, or TOPPS—notes that an array of mental health concerns may follow surgery.

Young patients may be less likely to follow strict medical regiments, their sense of jejune invincibility and immature frontal lobe combining to lead to rash actions.

"Other negative psychological reactions to surgery in children include separation anxiety from caregivers, sleep difficulties, poor academic performance, and behavior problems," Dr. Donohue wrote via email. "These problems are often brought on by physical pain, negative feelings about future athletic performance, and extended time away from friends, teammates, family, and school."

Donohue suggests psychological interventions—including education about the injury and pain and relaxation management techniques—be a part of the young athlete's rehabilitation.

There is no doubt that the highly specialized, intensely trained youth athletes of Generation Knife can take to the field following catastrophic injury better than they ever have before; what remains to be seen is what will await them once they've been there long enough.

Conventionally, a major leaguer coming off Tommy John surgery is being rejuvenated, extended; the fix is, by its very nature, a temporary one, oftentimes coming in the middle or tail-end of their playing days, and it allows for a resurgent return to form. The fate of a surgically repaired ligament which will go through the unmatched rigors and stresses of a long term, possibly high-level career having never been healthy, is unknown.

One looming problem for Generation Knife has already made itself known: the increased risk of arthritis.

"The general public does not think that arthritis is that big a deal, especially at a younger age," Dr. Kinderknecht said.

This is patently untrue; after all, he points out, one would not replace their entire knee if arthritis only hurt a little bit.

"The problem with arthritis is, we don't have a solution for it," he added. "So it's hugely disabling, and it's becoming more and more prevalent all the time. And a lot of these are from traumatic-type situations [as in a post-surgery joint]."

Considered to be a side effect of medical science's inability to properly stabilize, for example, the knee, the true cause of post-surgical arthritis is now unknown; doctor's ability to re-stabilize has improved immensely, with no subsequent decline in arthritic onset.

The mystery is indicative of what awaits the bodies and minds of Generation Knife as a whole; yes, they are more talented than their forbears, and yes, advances in surgical techniques have allowed them a Lazarus-like ability to play beyond damage long considered calamitous, but no one knows what their future may hold.

"How long will it last? That's a question we don't really have an answer for," Kinderknecht said. "We'll need 20 years to be able to answer that."