The landscape of youth sports has changed significantly in recent decades.

Highly competitive youth leagues have largely replaced more laid-back pickup games. Kids are increasingly specializing in a single sport year-round, rather than bouncing from one game to the next with long, languid off-seasons in between. Experts say that fundamental shift in how kids and parents approach sports — and how much kids play — may have consequences when it comes to a child or adolescent’s risk of injury.

“We see a lot of kids playing through fatigue and playing through pain,” which can increase a child’s risk of getting hurt, says Dr. Alfred Atanda, a pediatric orthopedic surgeon and director at the Nemours Center for Sports Medicine at Alfred I. duPont Hospital for Children in Wilmington, Delaware. “With free play and informal play and recreational play, people are less likely to do that.”

Research has documented a rise in overuse injuries from repetitive physical activities without allowing adequate time for the body to heal — such as injuries to the elbow from pitching in baseball or to the shoulder, associated with swimming. And now, a recent study finds a rise in ACL, or anterior cruciate ligament, tears in youth. The latest research published in the journal Pediatrics in March supports what clinicians have long suspected and research looking at ACL reconstructions seemed to indicate — that this common knee injury is on the rise in younger athletes. Kids who participate in organized sports such as soccer, football and basketball that place added demand on their knees tend to be at higher risk for injuries to the ligament. The ACL, anchored in the middle of the knee, is relied upon, after all, to make quick cuts or change direction — as when making a sharp side-to-side move on the playing field or court.

Looking over a 20-year period at patients ages 6 to 18 years, the study found a 2.3 percent increase in the annual incidence of ACL tears. “Female patients had significantly higher rates of injury in the younger ages, but in the 17- to 18-year-old age group male patients had a significantly higher incidence,” the researchers reported. The study looked at insurance data to determine the rates of ACL tears per 100,000 patient-years (based on the number of patients and the total years they were studied) from 1994 to 2013. “We definitely saw the frequency over the last 20 years has been increasing in [young] athletes, especially 14 to 18, who are most susceptible to having ACL injuries,” says senior study author Dr. Marc Tompkins, an assistant professor of orthopedic sports medicine at the University of Minnesota.

“One of the concerns is about just how competitive kids are being at this point in sports,” Tompkins says. “We’re seeing often times more early sports specialization — so earlier in life kids are doing one sport and doing it more frequently than they used to.” Previous research has linked an increase in ACL surgical consults involving young patients to high-demand year-round sports at an earlier age, better awareness by clinicians’ of the signs and symptoms of ACL tears, an increase in female participation in sports and the use of MRI to diagnose knee issues. While doctors may be better equipped to ferret out ACL injuries today, experts say that actual ACL tear rates are increasing.

[See: 9 Sports Injuries That Sideline Kids.]

Reducing ACL Injuries in Young Athletes

To reduce the risk for ACL injuries, experts advise a number of strategies, including some that run counter to the current culture of youth sports — like the push many feel to play one sport year-round.

“Kids are having to specialize or being encouraged to specialize at a much younger age with no really valuable evidence that that produces a more elite athlete,” says Dr. Henry Ellis, pediatric orthopedic surgeon at Texas Scottish Rite Hospital for Children in Dallas and assistant professor of orthopedics at University of Texas Southwestern. “When they specialize, they don’t have the ability to cross train and have their body do other activities, and they don’t give themselves an opportunity to rest.”

His advice: Allow kids to play a variety of sports to help prevent injuries.

Another tip clinicians stressed: Play just for fun sometimes. Though competing at a higher level of competition can be enjoyable, Ellis says, it’s important to alternate playing at a lower level of competition or just for fun to reduce the demands on the body and risk of injury. Such free play, or unstructured physical activity, provides kids the opportunity to slow down, alleviates pressure to play through pain or discomfort and gives the body more time to recover from more rigorous competition.

Additionally, experts suggest the same kind of focus on practicing and playing hard be applied toward proactively protecting kids — to the extent possible — from ACL injuries through neuromuscular training programs.

These injury prevention programs are intended — among other things — to improve balance, increase the strength of both the quadriceps and the hamstrings and promote what’s called co-contraction. Some athletes are quadriceps-dominant when they land or pivot — that is, “the quadriceps and hamstring are not contracting equally and the quadriceps is activating more during the activity,” Ellis says, and that can put more strain on the ACL. Improving quadriceps and hamstring co-contraction during a landing can help prevent ACL injuries, he notes.

There are training programs available, such as Sportsmetrics and another offered by FIFA 11+. To ensure exercises are done correctly, it’s recommended that athletes at least initially work with a certified trainer, coach or another professional who’s received training on the program; check, too, about costs associated with any programs, as some online resources are free, while fees are charged for others. These should typically be started six weeks prior to the season beginning, Ellis says, with some maintenance training performed before practices and before games.

[See: 8 Signs You Are Made to Be an Athlete.]

Treating ACL Tears

The signs of an ACL tear range from a popping sensation when the injury occurs to severe pain and instability or the knee “giving out.” For those with a suspected tear, experts recommend seeing an orthopedic or sports medicine specialist regarding a proper diagnosis and treatment options.

Though not all kids will need surgery, research finds that delaying treatment can lead to an increased risk of further damage or knee issues, including osteoarthritis, in the future. Parents should carefully talk over treatment options including different surgical approaches that account for the fact that many younger patients’ knees are still growing.

In a child, it’s very important to determine if their growth plates in the knee are still open, Ellis says. “When you have continued growth left, this often times requires specialized techniques in order to avoid injury to the growth plate,” he says. Examples would be extra-articular ACL reconstruction or an all-epiphyseal technique, in which the reconstruction occurs in the small area of bone that’s below or above the growth plate.

[See: 10 Concerns Parents Have About Their Kids’ Health.]

While ACL reconstruction outcomes are generally good for kids and teens, risks remain, from infection and bleeding to reinjury. “The rate of re-rupture of the operative leg or tear to the other knee is still higher than in adults,” Ellis says. “We think this is primarily due to the increase in activity that kids and teens put their knee through following surgery. It is also due to early return to athletic activity without complete rehabilitation.” As with prevention, experts say, allowing adequate time for the body to recover from surgery before returning to the playing surface is critical.

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What?s the Fix for Increasing ACL Tears in Kids? originally appeared on usnews.com