Take your pick. Either your child is an overweight couch potato who watches TV all day, or you have a stressed-out athlete with back problems, shin splints and chronic tendinitis.
Today's parents must sometimes feel those are the only options. Kids don't seem to simply go outside and play anymore. Instead, they compete.
In the past decade sports camps, leagues and travel teams have been added to school athletics. Sports like soccer and baseball now have more than one season. The result is that some pre-teens are dealing with the training regimen and game schedules of elite athletes.
"More and more kids are starting to specialize in one sport, and with that specialization come injuries," says Marty Sataloff, head athletic trainer at McDonogh School, who's been working with young athletes since the mid-'70s. "Kids don't play in their back yards anymore. They go from sports camps to school teams. It becomes a bigger and bigger deal younger and younger."
The injuries are often overuse injuries, such as tendinitis, stress fractures, shin splints and rotator cuff problems. They may start small as a twinge or soreness. The athlete doesn't mention the relatively minor pain to a coach or parent but simply plays through it. He or she applies a little ice, takes a few ibuprofen.
No pain, no gain, right?
As the athlete continues to play through the "minor" injury, repetitive stress on the same body part -- hitting another 100 forehands, practicing the same pitch again and again, running a few more miles -- may eventually lead to debilitating pain, doctors' visits and enforced time off.
Seventeen-year-old Rachael Baitch started gymnastics at age 4. After 11 years she gave it up because she was tired of dealing with chronic back problems.
"If I had to do it over again," she says, "I would try more variety of sports."
Last year Rachael ran track for Bel Air High School. She had to stop when she suffered a stress fracture (a hairline break often caused by repetitive stress) running hurdles. She still hopes to compete in college.
"I'm running occasionally and doing sit-ups and push-ups," she says. "But right now I'm pretty much laying low."
Doctors have been worried for years about the effects of intensive training on the developing bones, ligaments and tendons of gymnasts and ballet dancers, who start early and often specialize. But in the last few years young soccer, basketball and lacrosse players, swimmers and runners have been filing into sports medicine clinics and pediatricians' offices with overuse injuries.
It's been a disturbing enough change that the American Academy of Pediatrics this summer issued a policy statement on the subject, recommending that young athletes be encouraged not to concentrate on one sport until adolescence.
The recommendation is controversial. For one thing, the authors of the paper, which was published in the July issue of the organization's medical journal, admit that much of the information is anecdotal. Studying kids at risk is difficult because it's hard to define them, and the sports and training regimens vary widely.
And one could argue that overuse injuries are acceptable risks.
"In truth, to compete professionally, in college, or even in high school, you have to be pretty good," says Dr. William Howard, director of sports medicine at Union Memorial Hospital. "I haven't seen any harm at all -- none -- in starting at an early age and getting good at it. [Overuse injuries] are part of the hazard. You can get tendinitis. You can treat it. If you want to make the team you have to concentrate on your sport."
Howard believes the policy statement is overstated. "Imagine our Olympic teams -- the gymnasts, the swimmers," he says. "Where would they be if they weren't allowed to specialize before age 14?"
He does urge parents to be sure their children understand that when they stop enjoying the sport it's OK to quit. If they have pain they need to have it checked out. And well-defined periods of rest should be built into their schedules.
"Only milking cows needs to be done twice a day for 365 days a year," he says. "Take a month off. There's no harm to it."
Sidelined by injury
Patrick McGrath started playing baseball at age 5. He's 16 now and on the bench, waiting for his rotator cuff to heal. Waiting isn't quite the right word, because he goes to a physical therapist twice a week and does exercises and stretches on his own twice a day.
He was doing fine, says his mother Claudia, until he made varsity at Broadneck High School in Annapolis and also played on summer and fall teams, including a travel team that went to a tournament in Ohio.
"That's when it may have started," she says. "Athletes just expect to have pain, so he kept throwing. It wasn't anybody's fault. But eventually he said, 'I can't do this.' The minute his coaches knew, they said absolutely not until you have a doctor's OK."
The orthopedist put Patrick on "arm rest": no throwing, lifting or raising his arm above his shoulder. He got two cortisone injections and takes anti-inflammatories. The McGraths are hoping the pain is the result of inflamed tendons. If not, he may have to have surgery to repair the tear.
"All I want to do is get back on the field and play," says Patrick.
And if he had it to do all over again? "Just as soon as I felt pain I'd have it checked out. I was lucky to have coaches who didn't push me, but some [kids] do."
In Patrick's case, it wasn't a matter of focusing exclusively on one sport early. Until high school he also played soccer and basketball. But eventually the extra stress on his shoulder with the expanded season caught up with him.
Both Rachael and Patrick love their sports and are anxious to be back. But doctors are concerned that some parents may push their children because they want to live vicariously through them or because they see the possibility of a college scholarship or professional contract. The child may come to feel his sport is something he has to do, like going to English class.
"Adults are organizing [these leagues]," points out Dr. Andrew Tucker, director of primary care sports medicine at the University of Maryland Medical Center. "Kids don't get together and organize a travel team. The intent is great: to give them opportunities to play, to advance skills and to prepare them for the next level. But the sum total is a situation where the kids are funneled into a single sport quicker than a generation ago."
Dr. Steven Anderson, a clinical professor in the University of Washington pediatrics department, a sports medicine doctor and chairman of the American Academy of Pediatrics committee that wrote the policy statement on young athletes, is staggered at how open the parents of some of his patients are about their ambitions for their children.
"Billy's elbow is sore," he says they say. "He's got to get back and get a college scholarship and a pro career so he can buy me a house." There's so much money out there for the top athletes it's not surprising some parents are pushing their children beyond all reason.
An injury, Anderson feels, may be what brings the real problem into focus for the pediatrician. "If it's a minor injury and the [young athlete] isn't champing at the bit to get back, it may be a red flag. It's not the physical injuries that are our big concern. It's the overall growth and development, including psychological."
Not every overuse injury, of course, is the result of pushy parents or overspecialization. Meg Garner, now 16, developed a stress fracture in her left heel when she switched from cross country to running track for York Suburban High School in York, Pa.
"I had tried swimming, softball, gymnastics, ice skating," she says. "But none of them I had a passion for." She discovered her passion with running.
The sports medicine specialist who treated her, Dr. Teri McCambridge, thinks the stress fracture might have a number of causes: switching to track spikes, which are less supportive than running shoes and didn't work with Meg's orthotics, running too many miles, stressing still-growing bones.
"Mentally I have to realize I can't push myself," Meg says. "I have to always take a recovery day [after a meet] or an easy day when I want to."
Her mother, Denise Garner, mentions the positive things about her daughter's running -- her fitness (Meg had high cholesterol when she was younger) and the social aspect, the esprit de corps on the team.
And Anderson is quick to point out that the American Academy of Pediatrics' policy statement isn't supposed to be a negative message.
"There are too many fat, sedentary kids around," he says. "The bigger health problem is that there aren't enough kids participating in any physical activity. These are just some of our concerns."
Train kids to use common sense
Even if your child specializes in one sport, it's not a foregone conclusion that he or she will get a serious overuse injury. Here are some recommendations from doctors to help prevent stress, both physical and psychological. Adult weekend warriors would benefit from this advice as well.
* Build regular rest days into the practice schedule. This not only rests the body, but it also helps reduce the chance of burn out.
* Use the 10 percent rule for increasing the duration, frequency or intensity of training. None of these should increase more than 10 percent at a time.
* Listen to your body. No pain, no pain is a better guideline than no pain, no gain.
* On the other hand -- realistically, athletes have to play through minor pain. But if the discomfort starts to interrupt training or interfere with daily activities it needs to be professionally evaluated.
* Make it clear to your kids that it's OK to quit when they stop enjoying the sport.
* See that proper warm up and stretching periods are built into the activity.
-- Elizabeth Large