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Sports Medicine and Fitness in Pediatrics: A 75-Year History of Working to Reduce Risk While Promoting Safe Participation for All

October 13, 2023
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Commentary From the Council on Sports Medicine and Fitness

Caring for injuries and accidents in children has long been a part of pediatrics. Historically, the care of injuries and accidents in children fell under the umbrella of general pediatrics. There was no dedicated pediatric sports subspecialty, nor was there much emphasis on finding ways for injured patients to return to the very activity that caused the injury. With the advent of organized sports for children, there were more injuries, more pressures to help the injured patients return to the offending activity, and a stronger impetus for a pediatric subspecialty dedicated to the care and prevention of injuries to this population.

The earliest involvement of the American Academy of Pediatrics (AAP) with “sports medicine” issues occurred in the 1930s-1940s, as standards were set for medical care at summer camps. There were no special committees devoted to organized sports or physical fitness until 1969 when the Joint Committee on Physical Fitness, Recreation and Sports Medicine was established. This committee included representatives from the Committees on Youth, School Health, Disaster & Emergency Medical Care, Accident Prevention, and Children with Handicaps. In 1974, this was replaced by the Committee on Pediatric Aspects of Physical Fitness, Recreation and Sports. This was renamed the Committee on Sports Medicine and Fitness, which ultimately merged in 2005 with the Section on Sports Medicine to become the current Council on Sports Medicine and Fitness (COSMF).

Balancing the needs for safety and the need to promote healthy physical activity is at the crux of the field of pediatric sports medicine and is central to the mission of the COSMF. The COSMF has endeavored to be the leader in providing guidance for sports medicine care for youth and a champion for promotion of physical activity, health-related fitness, and safe sports participation for all children and adolescents. Pediatrics has been a valued partner in this journey for 75 years and has facilitated the development of the subspecialty of pediatric sports medicine through its dissemination of influential work that has both shaped policy and provided a scientific foundation for best practices.

The following highlighted articles were chosen because they have helped to fill knowledge gaps, served as “go-to” references for pediatricians and, ultimately, have provided a critical foundation for the growth and maturation of our field.

Sports Medicine and Fitness in Pediatrics: A 75-Year History of Working to Reduce Risk While Promoting Safe Participation for All

Alison Brooks, MD, MPH, FAAP1, Steven J. Anderson, MD, FAAP2

Affiliations: 1Professor, University of Wisconsin-Madison School of Medicine & Public Health, Department of Orthopedics, Division of Sports Medicine, Madison, WI; 2Clinical Professor, University of Washington, Department of Pediatrics, Seattle, WA

Highlighted Articles From Pediatrics

First Quarter Century: 1948 - October 1973

Second Quarter Century: November 1973 - October 1998

Third Quarter Century: November 1998 - Present

Organized sports for children are a relatively recent, mid-20th century development. When injuries occurred from a volitional activity, like organized sports, no longer could the pediatricians managing these problems simply say, “stop doing whatever caused you to get hurt.” To help pediatricians resolve the dilemma of ensuring safety without restricting participation, it became necessary to investigate and more deeply understand the true risks of sports participation. This includes risk assessment related to the particular sport, sports training regimens, sports equipment, and risks related to the individual participant. Initial attempts to reduce injuries involved prohibitions and/or precautions for unsafe sports, unsafe practices, and unsafe individuals. If all risky activities and/or all participants vulnerable to injury were banned from participation, a potential unintended consequence of these “safety” restrictions was that they could restrict overall participation. Pediatrics has helped shepherd a more in-depth analysis of risks related to the participants based on their age, gender, skeletal maturation, and presence of underlying medical conditions. This, in turn, has helped pediatricians become better prepared to deal with the medical consequences of children participating in organized sports.

During the 1960s, the preparticipation sports examination became a requirement for children to participate in school-based organized sports. This was motivated, in large part, by reports of children suffering fatal cardiac events in association with strenuous physical activity in sports settings. A broader listing of more general medical issues impacting sports were initially outlined in a seminal document published in 1988 by the Committee on Sports Medicine and Fitness: “Medical Conditions Affecting Sports Participation.” This statement has been updated and revised in 1994, 2001, and 20081-4 and continues to represent the COSMF’s ongoing efforts to help pediatricians help their patients find a healthy balance between sports and physical activity while managing the medical risks therein.

The “medical conditions” statements follow a standardized format whereby they classify various sports based on physical and physiologic demands (ie, contact vs non-contact; static vs dynamic) and then cross-reference with common medical conditions (cardiac, respiratory, GI, GU, neurologic, musculoskeletal, endocrine, hematologic, infectious disease, dermatologic, ophthalmologic, and allergic) providing a reference point for discussion of medially safe participation. All 4 versions, and updates, recognize the risks of sports balanced with the benefits of sports participation and the desire to find some safe sport or activity for every individual—regardless of their gender or health status. This format remains relevant and useful in 2023 and has been designed to keep pace with current medical knowledge, evolving medical needs, and fresh insights from patients, pediatricians, and sports medicine specialists.

The 1968 article, “The Epileptic Child and Competitive School Athletics” actually predates these “medical conditions” statements, yet overall voices this same progressive stance of shared decision-making in discussions about sports participation. Over the time that medical policy decisions have addressed sports participation for those with medical conditions or disabilities, this is one of the earliest statements that recognizes that the benefits of sports participation may outweigh the perceived risks. In stating that “risks should be weighed against the psychological trauma resulting from unnecessarily restricting physical activities,” a precedent promoting safe participation for all was set.5 The 2021 statement, “Promoting the Participation of Children and Adolescents with Disabilities in Sports, Recreation and Physical Activity” illustrates preservation of these core values of inclusive thinking and extension of benefits to all children.6

Title IX in 1972 was an important milestone and influence not only for women’s sports but also pediatric sports medicine. Title IX not only resulted in a surge in female sports participants but forced a closer examination of risks that may be more related to the participant than the sport. The 1975 statement “Participation in Sports by Girls” reflects a necessary change in thinking insofar that it was no longer acceptable to address the risks of female athletes simply by restricting their participation.7 It stated that girls have the same rights to play sports, that they can safely participate in strenuous activity, and that prepubescent boys and girls may safely compete with each other and play on the same team. The 1978 Garrick and Requa8 article “Injuries in High School Sports” was one of the first, and remains one of the best, studies of sports injuries in the adolescent age group, in part, because it included a thorough and equal inclusion of girls’ sports. Data collection for this study occurred only 1 year after the passage of Title IX. As the epidemiology of sports injuries is the foundation of all efforts to promote sports safety, this study’s other key contributions were an early definition of a “sports injury” as something resulting in time loss from play rather than something more rare or extreme such as injuries requiring an emergency department visit or generating an insurance claim. Certified athletic trainers were on-site to collect injury information. Their familiarity with injury diagnoses and their daily presence significantly enhanced the accuracy and utility of injury information gathered.

Despite a disproportionate number of concussions impacting pediatric and adolescent athletes, there has been a notable lack of pediatric-specific research in this area. The initial 2010 clinical report on concussion was crucial in providing pediatricians a pediatric-specific framework for concussion evaluation and management. Between the original statement in 2010 and the revision of 2018, there was an explosion of published research, which helped provide evidence-based guidance that was much more robust than in the first statement. The updated 2018 clinical report “Sport-Related Concussion in Children and Adolescents” has been instrumental in helping the pediatrician synthesize and implement the most current evidence-based approach to the evaluation and treatment of concussion.9 Effective and appropriate management is essential for aiding recovery, lessening the short-term negative effects on athlete well-being, as well as potentially reducing long-term complications. This report is a key reference for every patient, parent, coach, or medical provider dealing with the concussed child or adolescent.

Resistance training is increasingly a part of sports training, school PE classes, after-school fitness programs, as well as rehabilitation and sports injury prevention programs. Understanding the many benefits of developmentally appropriate resistance training and learning to provide medically sound advice on safe resistance training practices can help all youth craft programs that meet their fitness, performance, rehabilitation, and injury prevention goals. The 2020 statement “Resistance Training for Children and Adolescents” helps dispel myths related to weight training and serves as an integral resource for the pediatrician to provide appropriate and up-to-date guidance for parents and youth.10

The clinical report “Anterior Cruciate Ligament Injuries: Diagnosis, Treatment, and Prevention” underscores the advancements that pediatricians have made in diagnosing and managing musculoskeletal injuries impacting children and adolescents. Fortunately, we have long passed the era when this truly devastating injury was termed a “trick knee.” Treatment at that time amounted to little more than recommendations to “rest” and hope that the problem will be outgrown. Today, we advise a more sophisticated approach to precise diagnosis and targeted treatment options, including evidence-based surgery and rehabilitation and neuromuscular prevention programs.11

Another benchmark topic in pediatric sports medicine is addressed by the clinical report “Sports Specialization and Intensive Training in Young Athletes.”12 It epitomizes the delicate balance pediatricians navigate between advocating for regular, healthy physical activity while safeguarding children from physical and psychologic injury associated with excessive activity. The guidance for the pediatrician at the conclusion of the article is justified both scientifically and by collective experience and yet is simple enough conceptually that it is bulletin board material that should be in every pediatric office.

The AAP, with COSMF and Pediatrics, have been major players in the development of the pediatric sports medicine specialty. We extend our sincere thanks and appreciation to the many individuals involved with the writing, review, and publication of the above articles. Their vision, motivation, resourcefulness, patience, and determination has helped establish a strong foundation for our field. As this review of “sports medicine” articles over 75 years has demonstrated, much of the content in Pediatrics has proven to be “timeless,” yet, receptive to updates and revisions as new challenges emerge and as the specialty continues to evolve. The AAP should be proud of the way our predecessors wrote policy that advocated for safe participation for all; addressed the rights of all to participate; addressed the role of the pediatrician in decision-making; and provided useful, precedent-setting guidance for millions of children and families. These statements recognize the risks of participation but also recognize the risks of not participating. They allow for informed consent and recognize mitigating circumstances for individuals. These statements support the pediatricians caring for these children and support a partnership with the patients, families, pediatricians, and medical experts in the field. This collaborative form of decision-making and policy formation has helped us navigate through difficult and uncharted waters. Continuing this philosophy positions us well to address the many challenges that lie ahead. While the field of sports medicine has grown over the years, there are remaining controversies regarding the risks and benefits of sports participation for young people as well as who is optimally qualified to look out for their health and care for their injuries. Controversies and naysayers notwithstanding, the AAP, COSMF, and Pediatrics have been resolute in maintaining an unwavering focus on what is most important: the healthy, active child.

References

  1. Committee on Sports Medicine. Recommendations for participation in competitive sports. Pediatrics. 1988;81(5):737-739
  2. Committee on Sports Medicine and Fitness. Medical conditions affecting sports participation. Pediatrics. 1994;94(5):757-760
  3. Committee on Sports Medicine and Fitness. Medical Conditions Affecting Sports Participation. Pediatrics. 2001;107(5):1205-1209
  4. Rice SG, Council on Sports M, Fitness. Medical conditions affecting sports participation. Pediatrics. 2008;121(4):841-848
  5. Committee on Children With Handicaps. The epileptic child and competitive school athletics. Pediatrics. 1968;42(4):700-702
  6. Carbone PS, Smith PJ, Lewis C, LeBlanc C, Council on Children With Disabilities, Council on Sports Medicine and Fitness. Promoting the participation of children and adolescents with disabilities in sports, recreation, and physical activity. Pediatrics. 2021;148(6):e2021054664
  7. Thornton ML, Eng GD, Kennell JH, McLeod RN Jr, Shaffer TE. Participation in sports by girls. Pediatrics. 1975;55(4):563-563
  8. Garrick JG, Requa RK. Injuries in high school sports. Pediatrics. 1978;61(3):465-469
  9. Halstead ME, Walter KD, Moffatt K, Council on Sports Medicine and Fitness. Sport-related concussion in children and adolescents. Pediatrics. 2018;142(6):e20183074
  10. Stricker PR, Faigenbaum AD, McCambridge TM, Council on Sports Medicine and Fitness. Resistance training for children and adolescents. Pediatrics. 2020;145(6):e20201011
  11. LaBella CR, Hennrikus W, Hewett TE, Council on Sports Medicine and Fitness, Section on Orthopaedics. Anterior cruciate ligament injuries: diagnosis, treatment, and prevention. Pediatrics. 2014;133(5):e1437-1450
  12. Brenner JS, Council on Sports Medicine and Fitness. Sports specialization and intensive training in young athletes. Pediatrics. 2016;138(3):e20162148
  • Online ISSN 1098-4275
  • Print ISSN 0031-4005

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