COVID-19 and Sports Medicine Q&A

Have a student athlete sidelined from spring athletics due to the COVID-19 pandemic? Not sure if you should schedule that sports physical? In this episode of Just Kids Health, Children’s pediatric sports medicine physicians — Dr. Natalie Ronshaugen and Dr. Kody Moffatt — field questions to help you keep your young athlete healthy so they’re ready to get back to play when the time is right.

Topic Breakdown

1:23 – Dr. Ronshaugen and Dr. Moffatt’s experience with sports medicine
6:47 – Dr. Ronshaugen and Dr. Moffatt’s current roles in sports medicine at Children’s
11:10 – Stopping sports amid COVID-19
13:26 – What getting back into sports may look like
16:27 – Staying active while staying home
21:30 – Nebraska School Activities Association’s response to pre-participation exams during COVID-19
28:09 – Easing restrictions on elective procedures

Transcript

Here at Children’s Hospital & Medical Center in Omaha, Nebraska, it’s all kids — all day, every day. Our pediatric experts are here to answer your questions and weigh in on hot topics, helping you keep your child healthy, safe, and strong. We’re here for you. Listen in.

Dr. Moffatt: Hi, this is Dr. Kody Moffatt. I’m one of the sports medicine physicians here at Children’s Hospital & Medical Center. And welcome to our discussion

Dr. Ronshaugen: Hi, I’m Dr. Ronshaugen. I’m one of the other sports medicine physicians here at Children’s Hospital & Medical Center, and we’re excited to be here and talk about the new world of sports in a world where there’s not so much sports going on. So we’re just going to dive in with some questions here.

Dr. Ronshaugen and Dr. Moffatt’s experience with sports medicine

Dr. Ronshaugen: I think it’s worth just talking about some of our experiences with professional athletes. Dr. Moffatt has worked quite a bit with professional athletes, I’ve worked with professional athletes as well. So, Dr. Moffatt, do you want to just start by talking about your experience with professional athletes?

Dr. Moffatt: Absolutely. I had the pleasure of working primarily in professional hockey early in my career, both in minor leagues and a few games in the National Hockey League, and made a lot of friends and a lot of experiences. And it’s really, I think, amazing to work with people who are truly the best in the world at what they do. It really is a different mindset from everybody in the organization from top to bottom — whether it be the athletes’ coaches, strength coaches, athletic trainers, physicians, equipment managers, the people in the front office. It’s just an intense, different mindset.

But it’s also very tough on family life. I had those experiences and kind of moved away and changed my career. I’ve done several things at the high school level with different high schools in the area and volunteering for high school interests on a state and national level in areas of sports medicine.

Injuries are very similar. I think it’s important to be a bit more conservative and realize that the seventh-grade athlete is trying to play for their future and for the enjoyment of the game. They’re not trying to win the Stanley Cup.

Dr. Ronshaugen: Yet.

Dr. Moffatt: But they may want to compete like they’re trying to win the Stanley Cup, which is great. But it’s not — we need to keep in mind — that it’s not their job, and some of the more aggressive things that you would do with somebody in the NFL or Major League Baseball, or the NHL or MBA, you probably should not do in the sophomore high school football player.

Dr. Ronshaugen: Yeah, totally agree.

So my experiences for sports medicine are, like Dr. Moffatt said, a little bit varied. I have done some work with helping on the sidelines of NHL hockey as well — I worked with the Colorado Avalanche, which was a blast. And like Kody was saying, it is so cool to work with people who are the top of their field and where you have all the resources in the world at your disposal. And you can really get away with pushing these athletes really, really hard. It’s such a cool experience. So I’ve worked with them, I’ve worked some with the NBA, I worked with the Denver Nuggets.

I think the biggest difference there — particularly I just think of concussion management. When I was treating concussions in the NBA, the biggest difference was like — a junior high kid I could have up on the exam table to test their facial nerves. And those NBA players — I’d have to have them almost sit on the floor so I could reach their face because they’re so tall.

But a lot of those injuries, like Kody was saying, are really similar injuries. It’s just a different approach because our high school and junior high school athletes are doing school first. That’s their job. They’re trying to get into college or learn as much as they can in school, and sports should be second. But we want to be able to try to balance that — make that balancing act for them feasible. So I’ve also done some stuff with ultra-marathons and elite runners at that level. And that’s — ultra-marathoning is its own level of crazy, but again, it’s just super fun to work with people who are the top of their field and willing to push themselves that hard. It’s a cool area.

Dr. Moffatt: Natalie, you touched on again the difference between the professional athletes and our junior high and high school athletes. And not only is it their emotional level and skill level that’s different, but the athletes that we work with now — many of them are still growing, they’ve got open growth plates. And when we talk about concussions and head injuries, there’s just so much brain development that occurs between a 12-year-old, 14-, 16-, and 18-year-old compared, to somebody who is in their mid-to-late 20s and is a professional athlete.

Dr. Ronshaugen: Absolutely.

Dr. Moffatt: So we have to be prepared to deal with those differences.

Dr. Moffatt’s and Dr. Ronshaugen’s current roles in sports medicine at Children’s

Dr. Moffatt: What other types of injuries do you think you see in your clinics here and now, and what do we do now?

Dr. Ronshaugen: I see a lot of overuse injuries. And a lot of my clinics are filled with overuse injuries. Kids who are trying to do the best they can as they are training for sport, and sometimes over-training or over-training certain muscles and not focusing on their physical fitness as a whole. I spend a lot of time educating people on making sure that they’re physically fit as a whole, that they are mechanically sound and able to use all of their muscles to do a motion.

For instance, we treat a lot of little league elbow and little league shoulder, which are overuse injuries usually associated with pitching. And oftentimes it can be associated not only with pitching more pitches than we probably should stress that young arm, but sometimes it’s a mechanical deficit that kids don’t realize that they have. So being able to kind of tease out, “Oh, we need a stronger core in this kid,” “We need to take a longer stride,” “We need to adjust the way the arm is getting twerked not sidearming quite so much.” I think that is a fun puzzle that I’m doing a lot more of here in Omaha.

Dr. Moffatt: I agree, and I think that puzzle changes as kids grow.

Dr. Ronshaugen: Absolutely.

Dr. Moffatt: Especially when they’re in that early adolescent growth spurt and their center of gravity is changing, and it’s going to force them to have to move completely differently — whether that’s throwing a baseball, swinging a golf club, running, dance. And it’s those mechanical changes that bring about the things that cause overuse pain and bring young people into our offices. And trying to sort out those mechanical puzzles, as it kind of relates to their anatomy and growth and development, is what we do.

I think the other part that we both see quite a bit of is young people with concussions.

Dr. Ronshaugen: Yeah.

Dr. Moffatt: Again, concussions in young people are completely different than adults. They respond differently, they recover differently, and there’s the kind of the educational piece. Things like Shakespeare and algebra are hard to do on a normal teenage brain, and when you injure that brain and while it’s recovering, schoolwork gets that much harder. And along with the return to play issues, the more important concept of returning to learning — being able to be a student again, I think, is a huge part of what we do. And again, it looks completely different in a 12-year-old compared to a 14-year-old and 16-year-old.

Dr. Ronshaugen: Yeah. And I think one of the things that we really work on at our practice, too, is to try to help be that liaison between the student, the parent, to understand what’s going on with their concussion. But also working with the schools because that’s just a piece of the adult concussion patients don’t have to deal with. “How am I going to get through this AP class that I signed up for and was a breeze three months ago? How am I going to graduate on time? How am I gonna make sure that I don’t fall behind in this math class that was already hard before I was concussed?”

These are all questions that are unique to our adolescent athletes and something that we work really hard to try and…be a conduit to make it just a little bit easier than it has to be.

Stopping sports amid COVID-19

Dr. Moffatt: I think it’s going to be enjoyable to finally get back into sports whenever we can, from just a public health standpoint. I think back in mind, the kind of D-Day where this all hit, was March 12. You and I were both covering different sites of the state high school basketball tournament.

Dr. Ronshaugen: Yeah.

Dr. Moffatt: And it was Thursday that the NCAA — Big East — stopped the Creighton game mid-game. They stopped the East Tournament. The NCAA announced that they were all of a sudden canceling March Madness, and went so far that day as to cancel sports in the college world series. And I think it just hit everybody in the sports world like a ton of bricks. This is real and we were at the beginning of entering this real public health crisis. And I for one can’t wait to come out of it. And I do think people will turn to sports, especially youth sports, to try to reconnect and really become more normal again.

Dr. Ronshaugen: Yeah, I mean, what an unprecedented thing to stop an NCAA Big East Tournament basketball game in the middle of the game. I mean, the guts it must have taken to make that phone call and say, “Okay we’re done with the game. I know you’ve gotten halfway through it.”

I think that just goes to show — it’s really hard for a lot of our adolescent athletes, to say, “It’s getting beautiful outside, my baseball team is all very healthy, let’s just go play. Let’s just…”

And the fact that the NBA, the MLB, the US Open, all of these major sports groups have canceled is just one more reminder that this is a big deal and we have to take a break. But it’s so hard, it’s so hard to take a break.

What getting back into sports may look like

Dr. Moffatt: When we can, I probably see it really beginning with smaller groups, smaller teams getting together. I don’t see — people use the term “light switch,” where you flip the light switch and you’re back doing a soccer tournament with 1,000 participants for a long weekend. I think we’re going to start smaller and grow. I’ve had a couple of colleagues in the past week say that this is not going to be like flipping a light switch — it’s going to be like watching a sunrise.

Returning to Everyday Life

“This is not going to be like flipping a light switch — it’s going to be like watching a sunrise.”

—Dr. Kody Moffatt, reflecting on conversations with fellow Children’s Omaha colleagues

Dr. Ronshaugen: Yeah, and some of the sports that are less contact-driven might be able to start a little bit sooner. You know, it’s one thing to start training for cross country by yourself and getting those miles in, and even playing tennis against an opponent that’s far away from you. But it’s a different concept to have a wrestling camp where you’re touching your opponent and right next to their face during that whole practice. So we may see some differences in different sports as they start to come back.

Dr. Moffatt: And I’ve seen so many of the young people we work with are incredibly disappointed, and so are the parents. I mean, families have lost out on the experiences this spring and hopefully, we can all come out of this: #1, being healthy but then, #2, bouncing back from the disappointing times where young people and families got kinda cheated out of proms and spring sports. Hopefully, the graduations will be able to be done in a meaningful way. These are tough times, but I do believe our public health efforts are saving lives, too.

Dr. Ronshaugen: I mean, the initial projections for the number of cases we were going to have in ICUs compared to what we’re actually seeing now — I think that is a huge testament to the amount of work that, specifically the community in Omaha, but across Nebraska, has tried to do to limit contact between people. And it’s not an easy thing, but I think it’s made a huge difference and I’m really proud of our community, actually.

Dr. Moffatt: I am too. I think we’ve responded in a way that kind of Midwesterners do. We think about things, we lean on each other, and for the most part, we all try to be nice to each other.

Dr. Ronshaugen: Yeah.

Dr. Moffatt: You don’t get that everywhere.

Dr. Ronshaugen: You don’t get that everywhere.

Dr. Moffatt: The Midwestern nice feel.

Staying active while staying home

Dr. Ronshaugen: Let’s talk about things that kids can be doing while they’re sitting at home.

Dr. Moffatt: And hopefully not just sitting.

Dr. Ronshaugen: Yes, that was a leading statement.

Dr. Moffatt: We had 6 inches of snow on the ground not too long ago, but now things, again, have gotten nicer. We’re getting the occasional shower but we can still get out and move and do things in responsible ways, and socially distant.

I don’t think a soccer team should be getting together to play or practice, even in small groups, but certainly having siblings get outside in the yard or another open area of grass and being able to kick a soccer ball around and run and do skills and drills with each other. Playing wall ball, doing just other things where we’re moving. Riding bikes, going for a walk or a run, again, being physically active, I think, is important. This does not mean we’re all under house arrest and we can’t enjoy the outdoors.

Dr. Ronshaugen: What a great time to work on things that — we talked about overuse injuries before — but what a great time to work on those other muscles, muscle groups, and really condition your sprinting, your ability to stay active longer. And then working on some of those skills and drills that we often try to push off to the end of practice or just do for a few minutes at the beginning of practice. But really conditioning in a new way so that we’re ready to come back.

Because one of my concerns is that — I don’t know if you’ve got this concern too, Kody — but one of my concerns is we’re going to open up sports, and people will have been sitting more than they should have, and we’re going to have — I mean, I don’t mind seeing people in my clinic, but it’s going to explode because people are not going to be ready for sport. Because they’re not going to go out and condition.

Dr. Moffatt: And I worry about that in relation to the heat, too. Because young people who’ve been inside and not been exposed to heat, and then suddenly get out and exercise in the heat, are just at risk for a whole host of not just musculoskeletal, arms, legs, back problems — but heat illness, as well. I hope people are thoughtful and transition through this process and are prepared.

Dr. Ronshaugen: It’s going to take a little more forethought on the part of parents and on the part of athletes to make sure you are thinking about getting out and working out in the heat gradually and slowly increasing. And making sure you have enough fluids while you’re doing that so by the time we are able to open up, you can sustain being outside for a two-day practice if they do happen, which, good gracious, I hope they do. Fingers crossed.

But I don’t want us to be caught off guard with, “Oh, we can go play now? I haven’t played in three months. I haven’t done anything in three months.” So being conscious about that, I think, is going to be important.

There’s lots of stuff online, you know. I played tennis in college and there’s a hundred volley challenge that you can do with a sibling, a parent in the backyard, and just trying to volley — get 100 volleys with your tennis racket in a row without missing the ball. There are some awesome free apps for working out, for strength training with whatever you’ve got around the house — a milk jug, a can of corn — pushups, things without any weights. There are free apps, there are some paid apps which you probably don’t need. And then working together with your team virtually to figure out, “How do I set up a running program and keep each other accountable so that I can slowly work up my mileage if I’m running cross country?” And there is no reason why you can’t run right now.

Dr. Moffatt: Switching gears for a little bit and talking about getting outside and doing things — I’ve really kind of enjoyed and taken to heart what some of the coaches and adult leaders in the community have done. Creighton Prep, for instance, leaving the lights on in the baseball field as a tribute to the seniors, and other coaches in the area trying to figure out how to honor those high school senior athletes who’ve lost their spring season that they’ve worked for. And I think some of the adult leaders in sports in the area should be commended. They’ve really done a lot to recognize these teenagers.

Dr. Ronshaugen: I think that’s an important piece.

Nebraska School Activities Association’s response to pre-participation exams during COVID-19

Dr. Moffatt: Dr. Moffatt: Natalie, something you and I have been talking about with several of our colleagues earlier as this has all evolved has been the importance of pre-season sports physicals and pre-participation sports physicals. Do you want to comment a little bit on that?

Dr. Ronshaugen: Yeah, so, as many of you may know, the NSAA — the Nebraska School Activities Association — has made a statement saying that they are going to honor last year’s sports physicals based on the fact that there may be some limited availability for well-visits with pediatricians and with other primary care doctors, family practice doctors.

And we just wanted to touch base on that because we wanted to make sure that everybody understood that. That the pre-participation physical, while it is a helpful piece before we start sports, if we can’t get it in before sports, that doesn’t mean that you shouldn’t have it done. The pre-participation physical is often used as a conjoint part of your physical exam with your primary care doctor. And they also look at lots of other things. They look at making sure that your immunizations and vaccines are up to date, they make sure that there aren’t any other medical problems that we need to be addressing. Especially as kids are growing and developing and changing, making sure that everything is doing what it’s supposed to be doing, and that we’re not having any other little health problems that we need to be dealing with, or bigger health problems that we need to be dealing with. And so, while the NSAA has stated that we can put off the formal physical exam that has to go to your school before this year, we want to encourage people to talk to their primary care doctors and see when the most appropriate time that their primary care doctor would like them to come back and be seen, and that this year’s annual exam shouldn’t just be skipped because the PPE wasn’t required.

Dr. Moffatt: And that’s part of what the NSAA had in their messaging, too. That they still really encourage everybody to get into their primary care provider and the American Academy of Pediatrics recommends that every teenager be seen yearly for a healthcare maintenance visit, whether you’re an athlete or not. And the purpose of the PPE evaluation is to look for things that could, at worst, could cause sudden death in a person exercising or find something where — there could be a serious illness or injury that could be prevented or treated is part of participation in sports.

But there’s so much more, like you were saying, that happens in these visits. Whether it be an evaluation to see, do we need vaccines? There’s mental health screening — it’s an opportunity to talk about healthy eating habits on either end of the spectrum, sleep hygiene, mental health, depression, anxiety, suicide prevention screening. There’s a lot that goes into these visits and it’s not just a visit of, “if you have a pulse, you can play.”

Dr. Ronshaugen: It’s not just a checkbox.

Dr. Moffatt: Exactly. These are important to accomplish and I think the NSAA did something that’s going to acknowledge the capacity of the healthcare system — because depending on when primary care physicians are able to see otherwise healthy teen patients…some can do it now, some are unable to because of different restrictions on their practice, and how they’re trying to protect both the healthy and sick people walking into their offices.

And I think this was a measure to hopefully, in the fall, allow young people to be able to participate, but still encourage everyone to get that annual physical in when you can get it done with your primary care provider. What we’re really trying to get away from are these mass physicals at a school, in a gym or a locker room, where you’re running everyone through a quick station-based exam. This really is best served in your primary care doctor’s office where you’ve got the young person who’s hopefully grown up with that primary care provider — they know the past medical history, there’s a relationship there — it allows for a much more meaningful medical process.

Dr. Ronshaugen: We should mention that the NSAA did not excuse 9th graders from this process because they want to make sure that, especially if you haven’t had a pre-participation physical, a sports physical prior to this, we don’t miss you. So freshmen still are required to get this PPE done this summer. It’s just if you had one previously, they’re not requiring that paperwork, that checkmark.

Dr. Moffatt: I think probably the most effective thing, right now while things are relatively stable and we’re all socially isolated, parents — please reach out to your primary care doctors now and find out — are you doing these now? Are you going to start over the summer? What’s their plan? I know that within the Children’s system — the website childrensomaha.org/covid — that continually updates what we’re doing in our offices and how as an organization we’re responding to be able to serve families and parents on kind of a larger public health scale.

Easing restrictions on elective procedures

Dr. Ronshaugen: So I think one other question that keeps coming up is elective procedures. The governor is announcing that some elective procedures can resume in early May. We have been limiting elective procedures currently, and that would include even things like ACL reconstructions and some of the bigger surgeries that are important for people. And I think just to address this — we will be continuing to monitor the community and how the hospitals are doing. And as soon as it’s safe to do so, we’re going to be opening up to procedures like this, but we’re just going to continue to monitor the situation and not open up to these procedures until it truly is safe to do so for our patients.

Dr. Moffatt: I agree, and there are several in the organization that are really trying to be able to keep everybody updated on our website, childrensomaha.org, with frequently answered questions and the kind of ever-changing landscape that we find ourselves in now.

Dr. Ronshaugen: Thanks for having us, and if you have more questions, again go to that childrensomaha.org and there’s lots of information on there. And have a great rest of your day!

Dr. Moffatt: Stay safe, everyone.

Dr. Ronshaugen: Stay safe.

For the latest info about COVID-19 visit childrensomaha.org. Thank you for listening to Just Kids Health.

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