Musculoskeletal and Sports Medicine Curriculum Guidelines for Pediatric Residents

Abstract

Musculoskeletal (MSK) and sports-related conditions are relatively common in the pediatric population. Pediatric residencies should provide residents with the knowledge and skills to assess and manage both acute and chronic MSK and sports injuries and complaints. Residents should develop the competencies and attitudes to safeguard and promote a healthy and active lifestyle for youth. Programs can use a variety of educational tools, both in the clinic and on the field, to provide a well-rounded MSK curriculum throughout the residency years. This article provides a review of general pediatric sports medicine curriculum guidelines and suggested implementation strategies.

Introduction

The curriculum in pediatric residencies is very dynamic, with residents covering many educational topics during their 3 years of training. Despite studies showing that musculoskeletal (MSK) complaints are common in primary care, pediatric residents and general pediatricians have reported deficiencies in their sports medicine education.

MSK complaints account for an estimated 10% to 15% of all visits to primary care physicians (¹), and one study found that the prevalence of pediatric MSK complaints increased as children age, from 2.4% to 5.7% at age 3 to 27.5% to 36% at age 14 (²). Unfortunately, in a study of general pediatricians, 51% reported that they could have used additional training in sports medicine (³). A survey of Post-Graduates Year 3 (PGY-3) and chief residents found that 29% of programs did not include MSK examination teaching in their curriculum, and lectures were the primary method of sports medicine education in 77% of the programs (⁴). Another study reported less than 6 hours of total lecture time on sports medicine topics in 83% of pediatric residency programs (⁵).

Given the increase in chronic diseases related to inactivity and medical conditions affecting the MSK system, educating our future pediatricians in sports medicine topics and the MSK examination is increasingly important and should be improved and standardized. Sports medicine clinical experience occurs in the ambulatory setting, where patients commonly present, including the outpatient clinics, urgent care, and the emergency department (^6,7). Education should be implemented in various forms, including didactic lectures, conferences, journal clubs, and workshops. Hands-on training is particularly important to help trainees learn the MSK physical examination. This article provides residency programs with an outlined strategy to implement a longitudinal sports medicine and MSK curriculum within the educational competencies defined by the Accreditation Council for Graduate Medical Education (ACGME). Although it is out of the scope of this article to present an in-depth review of all MSK and sports-related conditions, general concepts, and some select conditions are summarized below. The Recommended Curricular Guidelines for Pediatric Residents — Sports Medicine Curriculum Guidelines contains a more exhaustive list of MSK and sports-related conditions (⁸).

Competencies

The ACGME Pediatric milestones include six competencies and recommend that pediatric residents obtain a level 3 competency as a target for graduation (⁹). To allow healthy and safe participation in sports and other physical activity (PA) and to help combat rising rates of obesity in the pediatric population, it is important to evaluate the musculoskeletal system (¹⁰). Each competency, and its relationship to MSK health, is highlighted within this section.

Patient Care and Medical Knowledge

A pediatric resident should be able to perform a sports medicine history and MSK physical examination for the appropriate body part, recognizing the difference between skeletally immature and mature individuals (²). For example, a resident should be able to recognize epiphyseal injuries in a skeletally immature athlete and the difference in fracture management of a preschooler versus an older adolescent.

Pediatric residents should be able to generate a differential diagnosis and a treatment plan. They also should understand the indications for referring to orthopedics, physical therapy, podiatry, and other related specialists (¹¹).

Practice-Based Learning Improvement and Systems-Based Practice

As many pediatric patients with an MSK concern have imaging as a part of their evaluation, pediatric residents should understand the indications for ordering an X-ray or magnetic resonance imaging (MRI). Pediatric residents should be able to recognize growth plates and common fractures on X-ray. They should be able to identify pediatric conditions that require urgent referral, including, but not limited to, Legg-Calve-Perthes disease, slipped capital femoral epiphysis (SCFE), spondylolistheses, and supracondylar fractures (¹²).

General pediatricians often perform preparticipation physical evaluations (PPE) for athletes. Although state-specific practices vary, many school districts require a PPE form be completed before allowing participation in school-sponsored sports. Pediatric residents should be able to perform an age-appropriate and activity-specific PPE (¹³). The American Academy of Pediatrics (¹⁴), American Medical Society for Sports Medicine (¹⁵), and the National Athletic Trainers Association (¹⁶), among other national organizations, have guidance regarding the PPE.

Interpersonal and Communication Skills and Professionalism

Daily PA is vital to manage and decrease obesity. Pediatric residents should be able to provide guidance for exercise prescription and participation to all youth.

Pediatric residents should be able to identify resources and refer individuals who qualify for adaptive sports programs, if not offered locally (¹⁷). Pediatric residents should be aware of racial, sex, and socioeconomic disparities that exist in sports and be able to identify barriers to sports participation (¹⁸). Pediatric residents should gain the skills to advocate for safe and equal participation for all youth in all sport types.

Pediatric residents should have a general understanding of and be able to communicate the positive and negative effects of sports specialization and some simple strategies to reduce the risk of concussion and overuse injuries (^19,20).

Pediatric resident training should include the mental health issues that can arise for elite youth athletes, and residents should be able to screen youth athletes with history taking (²¹). Pediatric residents should be able to recognize the red flags, symptoms, and signs associated with sports-related abuse, including but not limited to physical abuse, neglect, sexual abuse, and/or emotional/psychological abuse (²²), and feel competent to screen youth athletes for sexual violence within their sport (²¹).

Lastly, it is expected that pediatric residents are able to communicate effectively with a wide range of stakeholders about sports medicine health care, including patients/athletes, parents, coaches, school administrators, and other health care professionals. Advocacy to prevent injury is crucial to allow healthy, long-lasting participation in sport (²³).

Attitudes

After acquiring the appropriate skills in the evaluation of the musculoskeletal system, pediatric residents should demonstrate attitudes that promote healthy movement behaviors for all pediatric patients (²⁴).

Pediatric residents should be aware of the expectations and stresses young athletes face, from themselves or from their parents, coaches, and peers; pediatric residents should be supportive when discussing these stressors (²⁵).

Pediatric residents should understand the importance of the preparticipation evaluation of athletes and be aware of athletes with both acute and chronic injuries. They should show a willingness to complete PPEs to prevent delay in sports participation (²⁶).

Pediatric resident training should include addressing the potential concerns for athletes with underlying medical issues and special needs, including those participating in adaptive sports. Pediatric residents should provide unbiased support and promote healthy PA in all individuals, irrespective of socioeconomic status, sex, race, sexual orientation, ethnicity, or ability. Pediatric residents should understand and demonstrate awareness of the positive impact of PA on both physical and mental health for all individuals (²⁵).

Awareness of resource allocation is crucial to avoid unnecessary harmful and/or costly interventions. Pediatric residents should demonstrate an awareness of what investigations are appropriate and cost-effective for each patient. The Choosing Wisely Partnership provides example scenarios of potentially unneeded and costly interventions that can be adapted to the clinical scenarios at hand (²⁷).

Pediatric residents should be aware of any implicit bias that may exist when treating individuals. For example, pain from an acute or chronic injury has historically been undertreated in Black and Hispanic populations (²⁸). Residents should treat all pain equally, regardless of socioeconomic status, sex, race, sexual orientation, ethnicity, or ability.

Pediatric residents should understand the benefits of PA and be aware of appropriate rehabilitation strategies for acute MSK injuries to help speed recovery, maximize function, and minimize the risks of reinjury, chronic pain, and disability (²⁹).

Finally, pediatric residents should be aware of and favor prevention strategies as an important part of MSK system care, especially in youth athletes, to minimize injury and harm (²⁴).

Knowledge and Skills

There have been several recent studies that have shown success in teaching medical trainees MSK medicine. An integrated curriculum, including combinations of lecture, simulation, hands-on small group teaching, integrative electronic platforms, and patient clinical experiences, appears to result in improvement in knowledge and skills (^4,30–38). As of now, there is not enough research on the topic to suggest which of these methods will provide improved and lasting learning. To develop the skill set needed to care for youth with MSK and sports-related complaints, a coordinated and comprehensive curriculum taught by experts and specialists will likely be the ideal environment to teach pediatrician MSK care. General concepts and specific knowledge areas are highlighted in the section below.

Knowledge

The majority of graduating pediatric residents will work in a job where they are likely to see frequent MSK complaints and obesity complications associated with a sedentary lifestyle. Graduating pediatric residents should have the knowledge and skill to promote sport and activity benefits while minimizing the risk of injury. To assess, diagnose, treat, and refer MSK and sports-related complaints appropriately, a graduating resident should have exposure to the following educational topics: general health and fitness knowledge (Table 1), general MSK knowledge (Table 2), and athlete care (Table 2).

Table 1 - General health and fitness topics benefits of sports participation: Physical, mental, psychosocial.

• Basics of exercise prescription and promotion of PA for health

• Basic exercise physiology, including aerobic, anaerobic, and strength training

• Basic knowledge of the concepts of sport readiness

• Implications of early sport specialization

• MSK growth and development, including physiologic skeletal conditions (e.g., physiologic genu varum, genu valgum, and femoral anteversion) and motor milestones and maturation

• The PPE and its use to promote health and safe participation of youth in sports

• Anticipatory guidance on primary injury prevention, including use of well-fitted and sport-appropriate equipment (e.g., mouth guards, helmets), exercise-related nutritional needs, and prevention of heat illness

• Understanding of the unique needs of athletes based on level of sport (i.e., recreational, youth, high school, college, national)

• Disparities in health, fitness, and sport in youth

Table 2 - General MSK knowledge and athlete care topics: MSK anatomy and physiology.

• MSK injury categories: apophysitis, sprain, strain, fracture, mechanical back pain, tendinopathy, and osteochondrosis

• MSK history taking, including the importance of assessing the mechanism of injury

• MSK imaging, including indications, contraindications, and interpretation of radiographs. Some knowledge of utility for advanced MSK imaging may be helpful for some pediatricians.

• MSK laboratory evaluation, including indications, contraindications, and interpretation of laboratories for MSK concerns or common medical concerns in the youth athlete.

• Recognition of urgent or emergent MSK conditions that could present to a pediatrician (e.g., compartment syndrome, septic arthritis, osteomyelitis, malignancy, juvenile rheumatoid arthritis, slipped capital femoral epiphysis)

• Making return-to-play decisions

• Diagnosis and management of common medical conditions in youth athletes (e.g., asthma, menstrual dysfunction, iron deficiency, energy deficiency, chronic illness, hypertension, cardiovascular disease, skin conditions, and mental health concerns)

• Basics of sideline management of injury

• Basics of care for special athlete populations, including athletes with disabilities (physical and intellectual) and transgender athletes

• Pediatric head injury or concussion initial evaluation and management

• Basics of youth fracture care and bone healing

Skills

All graduating residents should have exposure and proficiency with a basic regional MSK examination and PPE. A study of third-year pediatric residents rated the teaching of the joint examination and PPE as the most poorly taught components of the physical examination (⁴). Only one third of residents surveyed reported any MSK examination training at the residency level (⁴).

While the skills and procedures performed by a pediatrician will likely vary based on community medical resources and clinical setting, exposure to the following procedures should be a goal of a pediatric MSK curriculum (Table 3). New graduates may find themselves in the growing field of pediatric urgent care, in which they will be expected to be competent in many of the listed procedures (³⁹). While several of the following are required procedures for pediatric residencies, several additional MSK procedures were performed, as surveyed office-based pediatricians noted, and they also are included below (⁴⁰). The resident also should have the knowledge of the indications, contraindications, risk, benefits, and alternatives to the procedures they perform.

Table 3 - MSK and sports medicine skills basics of a regional MSK physical examination, based on patient complaint.

• Basics of the examination component of the PPE

• Splinting and immobilization of orthopedic injuries

• Use of braces, boots, or other durable medical equipment (DME)

• Reduction of fractures or dislocations, such as patella, shoulder, and radial head, and postreduction care

• Subungal hematoma trephination

• Joint aspiration and injection

• Digital blocks

• Stabilization of MSK emergencies (e.g., compartment syndrome, spinal cord injuries, hip and knee dislocations, unstable fractures, and any injury with potential neuromuscular compromise)

• Management and resuscitation, including basic life support, for life-threatening emergencies that may be encountered at sports events, including anaphylaxis, status asthmatics, blunt trauma, traumatic brain injury, spinal injury, and cardiac arrest

• Implementation of home exercise program

Preparticipation Evaluation

The PPE was developed to screen for medical conditions or injuries that might increase the risk of sports involvement for young athletes, with a focus on promoting safe participation rather than exclusion (⁴¹). While only 0.3% to 1.3% of athletes are ultimately excluded, 3.2% to 13.9% require further evaluation before participation (⁴¹). Pediatric residents should be fundamentally familiar with the most recent PPE monograph (⁴¹), as previous studies indicate only 37% of practicing primary care physicians with membership in the authoring organizations reported awareness of the standardized approach (⁴²). Providers aware of the monograph report increased satisfaction in performance, increased comfort in appropriate referral to specialists, and decreased sense of obstacles in completion (⁴²). While ideally performed by the patient's primary care provider for continuity of care and documentation, residents should be aware of the advantages and disadvantages of single provider versus station-based models (⁴³). Pediatric trainees should be aware of the limitations and debate over the optimal strategy for cardiac screening, including a complete cardiovascular history and physical (⁴⁴). Additionally, residents should be cognizant of the controversies surrounding additional use of electrocardiogram (ECG) and/or echocardiogram and athlete-specific criteria for ECG interpretation (⁴⁵). As such, they also should understand when to refer to cardiology for further evaluation before sports clearance. Residents should have competency in the remaining complete systems-based examination, including a comprehensive MSK examination, to assist in injury prevention and evaluation. Knowledge of established recommendations for participation with chronic medical conditions, visual disorders, and infectious concerns will further help residents appropriately categorize athletes for sport eligibility (⁴¹). Finally, pediatric residents should be aware of the growing focus on mental health screening and adapting recommendations for male, female, and transgender athletes, as well as for athletes with disability (⁴¹).

Heat Illness

Pediatric residents should understand the physiology of heat illness, know the mechanisms by which heat is generated and dissipated, and appreciate the processes by which the thermoregulatory system fails. They should be able to identify both intrinsic and extrinsic risk factors for heat illness, including age, dehydration, co-morbid conditions, medications, training errors, and lack of acclimatization. They should be familiar with the concept of Wet Bulb Globe Temperature, the risk of sports participation based on various weather conditions, and when to cancel events because of a high risk of heat illness. Residents must be able to differentiate the various types of heat illness, including heat exhaustion, heat stroke, exercise-associated collapse, heat cramps, and hyponatremia. With particular focus on heat exhaustion and heat stroke (both exertional and nonexertional), they should recognize the symptoms and physical examination findings, including temperature ranges, associated with these conditions. Residents should know how to treat the various types of heat illness, including when and how to monitor patients, how to cool and hydrate them, and when it is appropriate to transport patients for further evaluation and management. It is crucial that residents appreciate how an improper medical response can increase the risk of death from heat stroke. Residents also should understand when athletes may return to sports participation following recovery from heat illness. Finally, residents should be able to counsel patients on ways to prevent heat illness, especially with regard to proper hydration and acclimatization techniques (^46–48).

Concussion

Pediatric residents should understand the basic pathophysiology of concussion in youth, to tailor and explain cognitive and PA guidelines to the patient and family effectively. Residents should know the pertinent historical items needed to help with the diagnosis and treatment plan, such as commonly associated symptoms, personal history of concussion and recovery pattern, academic history, comorbid conditions, and personal and family history of headache. Residents should be able to implement a symptom checklist (⁴⁹). Knowledge of average recovery times for uncomplicated patients and for those with risk factors for persistent postconcussive symptoms (e.g., ADHD, mental health issues, learning disability) is needed. Residents also should be aware of persistent postconcussive symptom diagnostic criteria.

Residents should understand the functional injury of concussion and be able to apply principles of imaging in acute and nonacute settings. They should understand the radiation exposure associated with computed tomography of the head and be able to counsel families.

Residents should be able to perform neurological examinations, including basic oculomotor and balance examinations, as well as measures of orientation, memory, and concentration. They should understand the role of cervical injury in concussion and be able to perform a neck examination and clear a c-spine (with supervision). They should be aware of referral resources for significant examination findings (e.g., vestibular dysfunction and vestibular physical therapy evaluation).

The ability to counsel families on PA guidelines is important. Knowledge of the role of PA in recovery patterns and the current recommendations for when to start PA is needed (⁵⁰). Likewise, knowledge of techniques on return to learn and cognitive activity is needed. Residents need to understand concepts of return to play that can be adapted to a variety of sports. Residents should have knowledge of local and state requirements needed for concussion evaluation and clearance for return to sport.

Apophyseal Injuries

Injuries to the apophysis, whether acute or overuse, are common in the growing athlete. Pediatric resident knowledge of the various apophyses in the growing athlete is essential to develop proper differential diagnoses and to provide appropriate management.

Pediatric residents should understand that the most common apophyseal problems in the growing athlete affect the knee, foot, hip, and elbow. They should be educated on common risk factors for these injuries, including athlete strength and flexibility deficits, improper mechanics, and overuse. Pediatric residents should be able to obtain a condition history that includes pain provoked with PA, as well as any effect on daily activities and movements, if the pain is more severe. Residents should understand that imaging studies are not always necessary but are dictated by the history and examination. They should be trained to develop a treatment plan that is problem specific and, for apophyseal injuries, is typically managed with conservative measures, such as modifying activities, padding, or bracing the area, improving strength and flexibility deficits (with home exercises or a physical therapy referral), and evaluating mechanical issues that may lead to abnormal stress on the apophysis (^51–55).

Shoulder Injuries

Pediatric residents should be educated in shoulder pathology, which is common in overhead athletes, such as throwers and swimmers. Shoulder pain can be caused by acute injuries or overuse/chronic injuries. Pediatric residents also should understand appropriate activity modifications (e.g., pitch counts), which can help decrease the risk of shoulder injuries in young athletes (⁵⁶).

Pediatric residents should understand the most common acute and chronic/overuse shoulder injuries in youth athletes. Common acute injuries include glenohumeral instability (dislocation and subluxation), acromioclavicular injury (grades I to VI, clavicle fracture, proximal humerus fracture, and sternoclavicular joint dislocation (which, though rare, can be a medical emergency). Common chronic/overuse injuries include rotator cuff injury (tendinopathy/tears/impingement), labral injury (superior labrum anterior and posterior tears), Little League shoulder (proximal humeral physeal injury), multidirectional instability, and biceps tendonitis. Two relatively uncommon overuse injuries in young athletes are thoracic outlet syndrome and weight-lifter shoulder (distal clavicle osteolysis).

Pediatric residency education should include the assessment of the injured shoulder, including a comprehensive shoulder history and physical examination. When taking a history for a patient with shoulder pain, pediatric residents should be taught to assess the following: location, duration, radiation, ameliorating and aggravating factors, and distal neurological symptoms. The shoulder examination should start at the neck, specifically to rule out cervical injuries. A neurovascular examination should include the pulses and the integrity of the axillary nerve. The common shoulder landmarks feature the muscles and joints. The provocative tests for the shoulder are an important way to differentiate among diagnoses.

Pediatric residents should understand that the treatment for shoulder injuries is similar to other MSK injuries, but there are some unique challenges. Acute shoulder injuries sometimes require stabilization/reduction (especially dislocations) and immobilization for a period of time (⁵⁷). Chronic injuries will often require rest and appropriate rehabilitation that includes restoring range of motion and strength. It is important to identify the underlying cause of the injury (instability, specific weakness, and/or overuse) and to address the underlying risk factors to help prevent the injury from recurring.

Back Pain

Evaluation and treatment of back pain is important for pediatric resident education. Back pain is a frequent complaint, occurring in 1% to 6% of school-age children and 37% of adolescents (^58,59). Prevalence increases with age until adolescence, when it nears that of adults (^58,59). Adolescent back pain is predictive of adult back pain, so effective pediatric management may improve lifelong health (⁶⁰).

Pediatric residents should understand the common etiologies of back pain in youth. Similar to adults, the most frequent cause of low back pain in children and adolescents is mechanical (^58,61). However, there are several conditions that uniquely affect youth. Spondylolysis and spondylolisthesis are common injuries to the pars interarticularis from repetitive extension. Disc pathology is unusual in young athletes. Rare, but important, etiologies include infection, inflammatory conditions, malignancies, and cauda equina syndrome. Pediatric residents should develop an understanding of how these conditions typically present, since some require urgent or emergent management.

When taking a history for a patient with back pain, pediatric residents should be taught to determine the location, duration, radiation, aggravating factors, and red-flag symptoms, like paresthesia, incontinence, night pain, and constitutional symptoms. To perform an effective examination, pediatric residents must understand back anatomy and biomechanics. The examination should include inspection of skin, posture, gait, range of motion, palpation, strength, neurologic function, and special tests. If needed, plain radiographs should be limited to anteroposterior and lateral views to limit radiation exposure; however, oblique X-rays of the lumbar spine can be useful if looking for spondylolysis and standard views are inconclusive. MRI is generally considered the advanced imaging of choice, although bone scan and CT have their own advantages.

Pediatric residents should understand the treatment and course of pediatric back pain. Most pediatric back pain resolves within weeks to months. Treatment generally consists of activity modification and physical therapy targeting the core, back, hip flexor, and hamstring muscles. The pharmacologic treatment course is short, if used. Nonsteroidal anti-inflammatory drugs are preferred over other pain medications, such as narcotics. Return to activity varies by etiology. Successful back pain prevention strategies include full rehabilitation of prior injuries, proper lifting and sports techniques, and maintaining adequate strength and flexibility.

Hip Injuries

Pediatric residents should be educated in hip anatomy, pathology, evaluation, and management. The hip is a complex ball and socket joint that can produce an array of injuries and disorders affecting young athletes. Hip injuries account for 5% to 20% of all sports injuries in young athletes (^62,63). Hip injury patterns are affected by sex, age, and sport, with adolescent females being at highest risk for hip injuries (⁶³). Hip pain can lead to mobility dysfunction and morbidity for young athletes.

The majority of sports-related hip injuries are soft tissue or muscular in nature; these hip injuries are most often overuse injuries and treated nonoperatively (⁶⁴). The pediatric hip, however, has variable blood supply and developing apophyses, which can result in unique hip pathologies and injuries not seen in adult athletes. As such, it is important for pediatric residents to have familiarity with nonsport causes of hip pain. These include SCFE, Legg-Calve-Perthes disease, septic hip, and transient synovitis. Common sports-related hip injuries include hip contusions, osteitis pubis, femoral neck stress fractures, snapping hip syndrome, apophyseal avulsion fractures, and labral tears.

Pediatric residents should gain an understanding of the typical mechanism and examination findings seen for these specific injuries. History should include location, duration, radiating symptoms, aggravating factors, and red-flag symptoms, like paresthesia and constitutional symptoms. Physical examination should cover range of motion, strength, palpation, special tests, flexibility, and functional testing. Residents should understand when to order diagnostic imaging, such as pelvis X-rays or ultrasound. The majority of sports hip injuries can be treated with relative rest, home exercises, and physical therapy.

It is important to understand how age changes the differential diagnosis for hip injuries in the pediatric athlete. If hip pain is misdiagnosed, there can be long-term morbidity to these patients. The curriculum should improve residents' knowledge of special examination tests, ordering specific imaging studies and developing a return to activity plan for patients with hip pain.

Knee Injuries

The pediatric/adolescent knee injury curriculum should include a review of the basic knee anatomy and function of associated bones, muscles, tendons, and ligaments (⁶⁵).

Pediatric trainees should be able to evaluate common pediatric and adolescent traumatic knee injuries, including anterior and posterior cruciate ligament tears, medial and lateral collateral ligament tears, physeal fractures, patellar dislocations and subluxations, and meniscus pathology (including discoid meniscus) (⁶⁶). They also should be educated in the assessment of chronic overuse injuries, including apophyseal injuries (i.e., Osgood-Schlatter's disease, Sinding-Larsen-Johansson syndrome), patellofemoral stress syndrome, and osteochondritis dissecans (⁶⁷).

Pediatric residencies should instruct residents on how to conduct a proper history to evaluate knee concerns in patients. Recommended physical examination techniques for trainees should cover range of motion, strength, palpation, ligament testing, special tests, flexibility, and functional testing (^65–67).

Pediatric residents also should be taught how to develop an appropriate differential diagnosis, order necessary imaging studies, create an effective treatment plan, determine readiness for return to play, manage injury complications, project expected outcomes and future risks, and devise effective prevention strategies. Pediatric pearls also should be highlighted, including being able to recognize that hip pathology may present as knee pain in the pediatric age group, thereby requiring a thorough hip evaluation in all children presenting with knee pain (^65–67).

Foot and Ankle Issues

The foot and ankle are common locations of pain and/or injury in youth athletes. Pediatric residents should be educated about common overuse issues, as well as acute injuries. Learning the basic anatomy, understanding the timing of opening/closing of the physes, and mastering physical examination skills can aid in proper diagnosis and management (⁶⁸).

Pediatric residents should understand the common overuse injuries, including the following: calcaneal apophysitis (Sever's disease), base of the fifth metatarsal apophysitis (Iselin's disease), Achilles tendonitis, peroneal tendonitis, medial tibial stress syndrome, lower extremity stress fractures, flexible flat foot-related pain, and chronic exertional compartment syndrome (⁶⁷). They also should be comfortable evaluating acute injuries, including the following: lateral ankle sprains, Salter-Harris fracture patterns, fifth metatarsal fracture patterns (base vs. Jones), and syndesmotic ankle injuries. Indications for imaging foot and ankle pain also should be reviewed (^68,69).

Pediatric residency education should include a comprehensive foot and ankle history and physical examination. Pediatric residents should be taught to assess the following: location, duration, radiation, ameliorating and aggravating factors, and distal neurological symptoms. Recommended foot and ankle physical examination skills for pediatric trainees include range of motion, palpation, ligament testing, special tests, and functional testing.

Pediatric residency education should include the management of both overuse and acute injuries. Residents should understand the indications for when to splint and/or unload on crutches and should receive training on basic splinting techniques for acute lower extremity injuries, including posterior short leg splints, as well as sugar tong methods (⁷⁰). Trainees should recognize the importance of recommending activity restrictions for anyone with any of the following conditions: inability to bear weight, significant pain, limitations in range of motion and/or strength, and diminished functional ability. Training also should cover the reasons for referral to primary care sports medicine versus pediatric orthopedic surgery, as well as to physical therapy for individuals with the above conditions, as well as for anyone with poor flexibility and/or balance. Pediatric residents should be able to perform a functional examination on athletes and use that examination to assess return to play readiness (^68,69). Indications for bracing and instruction on injury prevention also should be included in the curriculum (^68–70).

Female Athlete Triad and Relative Energy Deficiency in Sport

Pediatric residents should be trained in the evaluation and management of medical conditions that can affect and be affected by athletic participation, including the female athlete triad.

The female athlete triad, first recognized in 1992, is a syndrome describing the three interrelated conditions of disordered eating (DE), amenorrhea, and osteoporosis (⁷¹). Subsequently, it was recognized that the triad's negative health consequences can occur with subclinical/less severe levels of the aforementioned conditions. In 2007, the female athlete triad was redefined as a syndrome of low energy availability (EA) with or without DE, functional hypothalamic amenorrhea, and osteoporosis. Each component was presented as a continuum/spectrum with the intent of allowing earlier recognition and intervention (⁷²).

Pediatric residents must understand that early identification of at-risk athletes is crucial to prevention. Screening of young athletes should occur as part of the PPE and should include the following: 1) menstrual history; 2) history of stress fractures and recurrent/chronic injuries; 3) history of concerns about eating/weight and whether pressure is being put on the athlete by others to lose weight or change eating habits; 4) history of dieting/DE/eating disorders; 5) mental health history and personality factors (i.e., perfectionism, obsessiveness); and 6) training history. The presence of any one component of the triad should prompt further investigation for the others (^72,73).

Pediatric residents should be able to complete a clinical evaluation for the triad. The physical examination should include an assessment of vital signs, weight/BMI, and physical signs of eating disorders (e.g., lanugo, swollen parotid glands, Russell's sign). Female athletes with amenorrhea or prolonged oligomenorrhea should undergo laboratory evaluation to rule out pregnancy and other endocrinopathies. Evaluation of menstrual irregularities in young female athletes can be complicated, as age of menarche is variable, and it can be normal to have irregular menstrual cycles up to 2 years following menarche. The gold standard for evaluating bone mineral density (BMD) is dual-energy X-ray absorptiometry (DXA). Criteria for obtaining DXA scans in female athletes at risk for low BMD have been published by a panel of experts on female athlete triad (⁷³).

Pediatric residents should understand that treatment is centered on restoring energy balance, as low EA is the underlying cause of the triad. Ideally, a multidisciplinary team (primary care/sports medicine provider, dietician, mental health provider, etc.) addresses all of the contributing factors. If nonpharmacologic treatment fails (i.e., the patient remains at an energy deficit and/or menses do not resume) after 1 year, then pharmacologic options may be considered to optimize BMD. Pharmacologic treatment options are extremely limited in adolescents and women of childbearing age, and strong evidence-based research is lacking in these populations. Improving nutrition remains the best and safest way to restore energy balance, which can lead to resumption of normal menses and better bone health in female athletes (⁷³).

Pediatric residents should be aware the International Olympic Committee recognized that male athletes also can suffer health consequences, due to energy imbalance, and described a syndrome called Relative Energy Deficiency in Sport (RED-S) in an effort to be more inclusive. RED-S is defined as “impaired physiological function including, but not limited to, metabolic rate, menstrual function, bone health, immunity, protein synthesis, cardiovascular health caused by relative energy deficiency.” Identification of RED-S in male athletes can be more difficult, as there are not menstrual changes to indicate a potential problem; however, the other symptoms are similar. Consistent with the triad, it is important to rule out other underlying medical etiologies of symptoms, and the mainstay of treatment of RED-S is restoration of energy balance (⁷⁴).

Implementation

The MSK and Sports Medicine Curricular Guideline is intended to be implemented longitudinally over the 3 years of pediatric residency training. Ideally, residents should have at least an experience with primary care sports medicine or orthopedic specialists. Not every training program is affiliated with a pediatric sports medicine center, and, based on the 2020 ACGME Program Requirements for Graduate Medical Education in Pediatrics, sports medicine is not an ACGME required rotation in pediatrics (⁷⁵). The following are suggestions for ways to optimize the sports medicine and MSK experience for pediatric residents.

Core experiences that would lend well to potential exposure to MSK conditions include outpatient continuity clinics, acute or urgent care clinics, and pediatric emergency departments. Electives, if available, can include primary care sports medicine (family medicine-based, if pediatrics-based is not available), orthopedics (ideally pediatrics), pediatric rheumatology, pediatric physical medicine and rehabilitation, MSK radiology, and sports medicine away rotations. Sideline medical experiences run by physicians within the medical system or in the community can provide additional training. Community allied health professionals (athletic trainers, physical therapists, chiropractors, etc.) also may be helpful liaisons for residents seeking to improve their sports medicine skill set.

The teaching of sports medicine care lends itself well to hands-on training in core conferences and workshops, videos, patient demonstrations, and models. Experience can be provided in MSK physical examination, splinting, taping, casting, interpretation of radiographs, and rehabilitative measures. Real time feedback on a resident's ability to perform various physical examination maneuvers by a preceptor with a strong MSK background is preferred. Online modules and lectures are additional tools that can be used. With the rapid emergence of telehealth or telemedicine, due to the COVID-19 pandemic, there is value in educating residents on how to examine patients virtually, as well (^76,77). See Tables 4A, 4B, 4C for a list of suggested educational resources.

Table 4A - Suggested online educational resources.

Online resources

MSK Examination Instructional Videos:

1. British Journal of Sports Medicine:

2. AMSSM Videos and Tutorials: http://amssm.blogspot.com/p/videos.html

3. ACEP Musculoskeletal Videos: https://www.acep.org/how-we-serve/sections/sports-medicine/musculoskeletal-exam-series/

4. University of California, San Diego, Online Musculoskeletal Examination Tutorial: http://meded.ucsd.edu/clinicalmed/joints.htm

Concussion Management Information

1. Centers for Disease Control and Prevention

a. https://www.cdc.gov/traumaticbraininjury/

b. Concussion Assessment Tools and ED Discharge Instructions: https://www.cdc.gov/headsup/providers/index.html

Teaching blogs and resources:

1. ACEP “The Sports Medicine Core Curriculum Lecture Series.” Holschen J, editor. https://www.acep.org/administration/resources/the-sports-medicine-core-curriculum-lecture-series/.

2. AMSSM Videos and Tutorials: http://amssm.blogspot.com/p/videos.html

3. AMSSM Sports ECG: https://www.amssm.org/ECG-Training-Module.php

Online databases:

1. Orthopedics-based: http://www.wheelessonline.com/

2. Orthopedics-based: https://www.orthobullets.com/

3. Primary Care Sports Medicine: https://www.sportsmedreview.com

4. Sports Medicine Wiki Page: http://wikism.org/Main_Page

National Organizations

1. American Academy of Pediatrics: www.aap.org Sports Medicine Section: https://services.aap.org/en/community/aap-councils/council-on-sports-medicine-and-fitness/

2. American Medical Society of Sports Medicine: www.amssm.org

3. American College of Sports Medicine: www.acsm.org

4. National Athletic Trainers Association: www.nata.org

Table 4B - Suggested Reading educational resources.

Books

1. Khodaee, Morteza, et al. Sports-related Fractures, Dislocations and Trauma. Advanced On-and Off-field Management. Springer International Publishing, 2020

2. O'Connor, Francis, et al. ACSM Sports Medicine: A Comprehensive Review. Lippincott Williams & Wilkins, 2012.

3. Thompson, Jon C. Netter's Concise Orthopedic Anatomy, 2nd ed, Elsevier, 2015.

4. Madden et al. Netter's Sports Medicine, 2nd ed, Elsevier, 2018.

5. Egol, Kenneth A., et al. Handbook of Fractures, 6th ed. Wolters Kluwer,

6. Eiff, M. Patrice, and Hatch, Robert. Fracture Management for Primary Care, 3rd ed. United Kingdom, Saunders/Elsevier, 2017.

7. Brukner and Khan, et al. Clinical Sports Medicine, 5th Ed. Vol 1 Injuries and Vol 2 The Medicine of Exercise. McGraw Hill Education. 2017

8. Miller MD, Thompson SR. DeLee & Drez's Orthopedic Sports Medicine: Principles and Practice. 4th ed. Philadelphia, Pa.: Saunders; 2014.

9. Miller M. Orthopedic Knowledge Update 5: Sports Medicine. 5th edition. Hutchinson M, ed. AAOS. 785p; 2018.

10. American Academy of Pediatrics Council on Sports Medicine and American Academy of Orthopedic Surgeons. Editors: Sally S. Harris, MD, MPH, FAAP and Steven J. Anderson, MD, FAAP. Care of the Young Athlete, 2nd Edition. AAP, 2010.

11. McKeag DM and Moeller JL. ACSM's Primary Care Sports Medicine, 2nd edition. Lippincott Williams & Wilkins, 2007.

Articles

General:

1. AMSSM Top 120 Articles for Fellows (updated annually): http://amssm.blogspot.com/p/amssm-100.html

2. AAP Council on Sports Medicine and Fitness Policy Statements: https://pediatrics.aappublications.org/council_on_sports_medicine_and_fitness

Concussion:

1. Mannix R, Bazarian JJ. Managing pediatric concussion in the emergency department. Ann Emerg Med 2020;75(6):762–6.

2. Harmon KG, Clugston JR, Dec K, et al. American Medical Society for Sports Medicine position statement on concussion in sport. Br J Sports Med 2019;53:213–25.

3. McCrory P, Meeuwisse W, Dvorak J, et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016 Br J Sports Med. 2017;51:838–47.

4. Manley G, Gardner AJ, Schneider KJ, et al. A systematic review of potential long-term effects of sport-related concussion. Br J Sports Med 2017;51:969–77.

Heat Illness:

1. Case DJ, DeMartini JK, Bergeron MF, et al. NATA Position Statement: Exertional Heat Illness. J Athl Train. 2015;50(9):986–1000.

2. Armstrong, LE, Casa, DJ, Millard-Stafford M, et al. Exertional heat illness during training and competition. Med Sci Sports Exerc. 2007;39(3)3: 556–72.

3. Belval LN, Casa DJ, Adams WM, et al. Consensus Statement- prehospital care of exertional heat stroke. Prehospital Emergency Care. 2018;22:3, 392–7. DOI: 10.1080/10903127.2017.1392666

4. Pryor RR, Casa DJ, Holschen JC, et al. Exertional heat stroke: Strategies for prevention and treatment from the sports field to the emergency department. Clin Pediatr Emerg Med. 2013;14(4):267–78. ISSN 1522–8401. https://doi.org/10.1016/j.cpem.2013.10.005.

Cardiovascular:

1. Drezner JA, et al. AMSSM position statement on cardiovascular preparticipation screening in athletes: current evidence, knowledge gaps, recommendations and future directions. Br J Sports Med. 2017; 51(3):153-67.

2. Kovacs R, Baggish AL. Cardiovascular adaptation in athletes. Trends Cardiovascular Med. 2016;26(1): 46–52.

3. Drezner JA, Sharma S, Baggish A, et al. International criteria for electrocardiographic interpretation in athletes. Br J Sports Med. 2017;1:1–28. doi:10.1136/bjsports-2016-097331

Cervical Spine:

1. National Athletic Trainer Association. Appropriate Prehospital Management of the Spine-Injured Athlete. Updated from 1998 document; 2015. https://www.nata.org/sites/default/files/executive-summary-spine-injury-updated.pdf.

2. Consensus Recommendations on the Prehospital Care of the Injured Athlete With a Suspected Catastrophic Cervical Spine Injury. J Athletic Train. 2020;55(6):563–72. doi: 10.4085/1062-6050-0434.19 by the National Athletic Trainers' Association, Inc. www.natajournals.org.

3. Sanchez AR II, Sugalski MT, LaPrade RF. Field-side and prehospital management of the spine-injured athlete. Curr Sports Med Reports. 2005; 4(1):50-5. doi: 10.1097/01.CSMR.0000306072.44520.22

Table 4C - Suggested CME resources.

CME Courses

1. AMSSM Meetings, Workshops, and Conferences: https://www.amssm.org/Conferences.html

2. ACSM Meetings, Workshops, and Conferences: http://www.acsm.org/attend-connect/events-and-conferences

3. AAP National Conference & Exhibition: https://aapexperience.org/future-dates/

4. Sideline Management Assessment Response Techniques (SMART). This course is held at the AMSSM Annual Meeting with a goal of helping enable community physicians develop skills in sideline preparedness. This course includes but is not limited to spine boarding, emergency injury management, and concussion evaluation.

Conclusions

MSK and sports-related conditions are relatively common in the pediatric population. As such, it is essential that those who provide these patients medical care be educated in the evaluation and management of those injuries.

Pediatric residencies should provide residents with the knowledge and skills to assess and manage both acute and chronic MSK injuries and complaints. Residents should develop the competencies and attitudes to safeguard and promote a healthy and active lifestyle in all of the youth they care for, regardless of race, ethnicity, sex, sexual orientation, or level of ability. Programs can use a variety of educational tools, both in the clinic and in the field, to provide a well-rounded MSK and sports medicine curriculum throughout the residency years.