Dr Frye serves as teaching faculty for the Michigan State University College of Human Medicine, East Lansing. She also is a nonsurgical pediatric orthopedics and sports medicine physician in Grand Blanc, MI.

Stacy Frye, MD

	Although many issues related to walking are benign, early recognition of these classic clinical presentations is essential for initiating further workup when indicated.

“Is it normal for my child to walk like that?” “Are my daughter’s legs supposed to turn in that way?”

 Concerns regarding the appearance of a child’s lower extremities are a common reason for visits to the pediatrician and a frequent source of orthopedic referrals.

 Musculoskeletal exam findings change as a child grows and develops. It is crucial for the pediatric clinician to be able to recognize normal pediatric orthopedic variants in order to differentiate conditions that can be treated with reassurance and education from those warranting further evaluation and workup. The aim of this article is to provide guidance on the diagnosis and management of 7 common lower limb positional variations in children and adolescents (Table).

	Accurate diagnosis of rotational and angular problems starts with a detailed history. Is there a family history of pediatric orthopedic or neurologic issues? Does the limb appearance or the way the child walks resemble anyone else in the family? Oftentimes, a sibling walked the same way or a parent will describe having bowed legs or knock knees as a child but outgrew it. How long has this been a concern, and does it seem to be improving or worsening over time? Are there any systemic signs such as fever or fatigue? Ask about pain, falls, and tripping. Inquire about underlying nutritional issues, growth concerns, developmental delay, and history of injury.

 These can be red flags of something other than a normal variant.

	Physical examination includes a generalized musculoskeletal examination, and should always include observation of gait and rotational profiles of the legs.3 Key assessment points are: 1) foot progression angle; 2) internal and external rotation of the hips; 3) thigh-foot angle; 4) heel bisector; and 5) limb position and arch appearance while standing in bare feet.

The foot progression angle (FPA) describes the inward or outward position of the foot relative to the direction of ambulation. Watch the child walk. Focus on 1 foot at a time and observe them walking toward you as well as walking away from you. Inward FPA is quantified in negative degrees (ie, internal tibial torsion [ITT] has an FPA more negative than -10°) or outward (positive value). Normal FPA ranges from -5° to +15°.

 Slight out-toed gait is most common. Keep in mind that FPA does not identify the source of limb rotation, however, it helps quantify severity and can be monitored for change.

	Rotational profile of the lower limbs is best assessed with the patient in the prone position with the pelvis flat to the table. Internal rotation, external rotation, and thigh-foot angle should be evaluated. Internal rotation increases over childhood, peaking in mid-childhood at ages 6 to 8 years.

 This explains the normal variant of femoral anteversion during that time. External rotation is greatest in the newborn and then declines rapidly. This also explains the common finding of outtoeing in infants/toddlers.

	Thigh-foot angle (TFA) compares the axis of the thigh with the axis of the foot (heel bisector). With the patient prone and knees flexed to 90°, the ankle is put into a natural position. If the foot points outward, the angle is positive, and if it points inward, the angle is considered negative-just as is done with the foot progression angle. A thigh-foot angle that is inward at least -10° is consistent with internal tibial torsion.

	Examination should include inspection of the lower limbs and feet both at rest and during motion. While seated, the heel bisector can be determined by drawing a line through the mid-heel up through the forefoot. A normal heel bisector should go between toes 2 and 3. Metatarsus adductus will present with a heel bisector that extends more laterally through toes 3, 4, or 5, and the lateral border of the foot will be convex rather than straight.

	Red flags include an asymmetrical deformity, leg length discrepancy, limitation in joint movement, tenderness, pain with range of motion, and short stature (<25th percentile).

 In these situations, consider further evaluation including but not limited to radiographs and lab work (calcium, vitamin D, alkaline phosphatase, phosphorus, for example).

	Intoeing gait is the most common parental concern regarding how children walk. Nearly 2 in 1000 children have intoeing gait and it is typically bilateral.

 The 3 most common reasons for intoeing are metatarsus adductus, internal tibial torsion, and femoral anteversion. The conditions classically present in that order: metatarsus adductus in an infant, internal tibial torsion in a toddler, and femoral anteversion is seen most commonly in a school-aged patient.

	Metatarsus adductus (MA) is a typically flexible deformation that is believed to occur from intrauterine positioning. It occurs in 1 in 5000 births and is more common in males, twins, and preterm babies.

 There is medial deviation of the forefoot relative to the hindfoot, resulting in a curved foot appearance. The heel bisector will be at the 3rd toe or more lateral. The majority of children improve on their own. More than 90% of children diagnosed before age 1 will self-resolve.

Management depends on whether the adductus is flexible or rigid. Flexible MA is either actively correctable (the child can make his/her foot point straight) or passively correctable (foot can be stretched to/past neutral by the clinician). Flexible MA is typically managed with observation, gentle stretching, and reassurance. It is best to stretch multiple times/day, such as with each diaper changing or feeding. In some cases, children with flexible MA can benefit from treatment with bracing, orthopedic footwear, or serial casting to more aggressively improve flexibility and position at rest.

	Families can be reassured that surgery to straighten the foot is seldom required. Surgery may be considered if metatarsus adductus is diagnosed late or if there is a rigid deformity. This is typically pursued after age 4 years.

	Internal tibial torsion (ITT) occurs when the tibia twists inward. This can occur before birth as the legs rotate to fit in the confined space of the womb. After birth, an infant’s legs should gradually rotate to align properly. If the lower leg remains turned in, the result is ITT. When the child begins walking, the feet turn inward because the tibia in the lower leg points the foot inward.

	Internal tibial torsion typically is bilateral and presents in toddlers aged 1 to 4 years.

 Parents may describe the child as frequently tripping, being clumsy, or stepping on his/her own feet while walking. Torsional issues such as ITT become more obvious with fatigue or fussiness.

	Rotational issues can be seen during gait observation. Children with ITT will have knees directed straight ahead while walking, but inward rotation of the lower leg(s) causing intoed gait. Physical examination shows a thigh-foot angle of at least -10° and an inward foot progression angle.

	As the tibia grows longer, it usually untwists on its own. Tibial torsion almost always improves without treatment, and usually before school age. Ninety-five percent of children will spontaneously resolve, usually by preschool or kindergarten.

 Splints, special shoes, and exercise programs have not been shown to speed the process. Surgery to reset the bone (tibial rotational osteotomy) may be done in a child who is aged at least 8 to 10 years and has a severe twist that causes significant functional issues. This is rare.

	Femoral anteversion occurs when the femur is medially rotated on its long axis from birth. The shape of the proximal femur allows the hip joint to have significantly more internal rotation than external. As a result, both the knees and the feet point inward. It is often most obvious in children aged about 5 or 6 years.

	Rotational profile shows the hips to have at least 60° of internal rotation. Families may describe the child as having “poor turnout” in ballet class or may say the child doesn’t like to sit “crisscross applesauce” in school. Children often sit in the W position, with their knees bent and their feet flared out behind them.

	They also may complain of their knees bumping into each other while walking-a finding casually referred to as “kissing knees.”

	Femoral anteversion is also nearly always a benign condition that improves gradually in most children (>80%) by age 10 years, although it may not ever resolve completely.

 Mild to moderate femoral anteversion should also be considered a variant of normal anatomy, rather than a pathologic entity. There are no braces or exercises that will improve or correct this problem. Imaging typically is not needed. Furthermore, there is no evidence that sitting position, such as W-sitting, impacts this condition, and thus children should be allowed to sit in whatever position they find comfortable. If the femoral anteversion is severe and persists, the only definitive treatment would be rotational osteotomy of the femurs after age 10 years. This surgery is performed very rarely-less than 1% of children with this condition.

NEXT: Knock knee, flatfoot, and pronation

	Genu valgum is another common normal variant of alignment in children that typically corrects itself with normal growth. While standing, the legs are angled inward so that the knees come close to each other and the ankles are farther apart. The deformity most commonly comes from the femur. Knock knees are most exaggerated in toddlers aged between 2 and 4 years. Genu valgum is considered a normal variant of alignment (physiologic knock knee) until age 7 years. Up to 75% of children aged 3 to 5 years have knock knees, and up to 95% of these children will self-resolve by age 7 years.

	On physical examination, the intermalleolar distance can be measured with the knees approximated; up to 8 cm between the ankles is normal. Make sure to assess thigh-foot angle and hip rotational profile, as the same appearance can be attributed to a combination of increased femoral anteversion and external tibial torsion. Surgical treatment is quite rare, but is considered for severe progressive deformity. Guided growth technique and osteotomy are surgical options.

	Curving of the legs in which the knees are far apart is termed genu varum. In the first 12 months of life, bowed legs are physiologic. They begin to straighten as the child grows. Genu varum typically improves by about age 18 months, but in many children, it persists a little longer. Ninety-five percent of children with bowed legs will improve by age 4 years with normal growth.

Recommended: How to perform a better physical exam

	On examination, the legs should appear symmetric and the bowing should appear smooth/gradual along the leg versus an abrupt angular change. Standing intercondylar distance can be measured with the feet together; up to 6 cm is considered normal.

	If a child also has ITT, the ITT can complicate matters by making the bowing appear worse than it really is because the side of the knee is visible relative to the foot rather than the front. Fortunately, both conditions typically improve around the same age with normal growth.

	For physiologic bowing, the treatment is generally observation. Special devices/shoes typically are not needed. However, bracing and/or surgery may be indicated for pathologic genu varum because of conditions such as rickets or Blount disease.

Flexible flatfoot is a normal variant that is often familial and secondary to ligamentous laxity across the arch. Early on, parents can be reassured that almost all babies have flat feet. There is a medial plantar fat pad that obscures the arch from birth. More than 40% of children aged 3 to 6 years have flat feet. About 1 in 7 people have flat feet as adults (roughly 14%).

 Arch development can continue up to age 8 years as the muscles and ligaments in the arch mature and tighten.

	Physical examination should be done with and without weight bearing. With the child seated and legs hanging from the exam table, the arch is typically revealed without bearing weight. The Jack toe raise test-passive dorsiflexion/extension of the great toe-can also be done to emphasize a flexible arch. During weight bearing, the arch will flatten but reappears when the child stands on his/her tiptoes. These maneuvers help distinguish flexible flatfoot from rigid flatfoot. Rigid flatfoot warrants further workup, including imaging to rule out other conditions such as tarsal coalition or congenital vertical talus.

	Observation is typically recommended in children aged 8 years and younger, as the arch is still developing and symptoms are rare before age 8 years. Occasionally, however, pain can flare with activity or children can have difficulty with shoe wear. Research has shown that the use of orthotics, shoe inserts, special shoes, or exercises do not stimulate arch development. However, they can provide support and comfort. Reconstructive surgery is reserved for the rare severe cases that do not respond to conservative treatment.

	Pronation is a normal foot motion that refers to the action of the foot as weight is applied through the gait cycle. Essentially, the heel and ankle roll inward after the heel strikes the ground, and as weight is transferred to the midfoot, the arch flattens out. Pronation is normal; however, problems can arise when there is overpronation. This places increased stress on the muscles and ligaments of the foot. Treatment is almost always nonsurgical.

Next: Detecting developmental dysplasia of the hip

	Careful clinical evaluation can determine if the child is having pain or if pronation is affecting the overall limb alignment. A first step can often be trying an over-the-counter arch supports to provide better foot support, improve alignment, and decrease premature shoe wear/tear. Ankle braces can be used during sports to give additional support.

	Variations in the lower limb appearance can raise concern among parents and clinical providers. Whereas the majority of rotational and angular issues are benign in children, recognition of the classic clinical presentations is important in order to diagnose quickly and correctly and initiate further workup when indicated.

	1. Molony D, Hefferman G, Dodds M, McCormack D. Normal variants in the paediatric orthopaedic population. 

. 4th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2008:135-154.

	3. Lincoln TL, Suen PW. Common rotational variations in children. 

	4. Staheli LT, Corbett M, Wyss C, King H. Lower-extremity rotational problems in children. Normal values to guide management. 

	5. Jones DHA , Hill RA . Children’s orthopaedics: normal development and congenital disorders. In: Russell RC G, Bulstrode CJK, Williams NS , eds. 

Bailey and Love’s Short Practice of Surgery

. 23rd ed. London: Arnold; 2000, 420-440.

	6. Jones S, Khandekar S, Tolessa E. Normal variants of the lower limbs in pediatric orthopedics. 

	7. Hunziker UA , Largo RH , Duc G. Neonatal metatarsus adductus, joint mobility, axis and rotation of the lower extremity in preterm and term children 0-5 years of age. 

	8. Dietz FR . Intoeing-fact, fiction and opinion. 

	9. Widhe T. Foot deformities at birth: a longitudinal prospective study over a 16-year period. 

	10. Wall EJ. Practical primary pediatric orthopedics. 

 ed, vol 2. Philadelphia, PA: WB Saunders; 2002.

	12. Rerucha CM, Dickison C, Baird DC. Lower extremity abnormalities in children. 

	13. Staheli LT. Rotational problems in children. 

	14. Staheli LT. Torsion-treatment indications. 

	15. Green WB. Genu varum and genu valgum in children. In: Schafer MF, ed. 

. Vol 43. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1994:151

Articles

Concerns regarding the appearance of a child’s lower extremities are a common reason for visits to the pediatrician and a frequent source of orthopedic referrals. The aim of this article is to provide guidance on the diagnosis and management of 7 common lower limb positional variations in children and adolescents.

7 lower limb positional variations

	Pediatric sports and activity participation is on the rise. It is estimated that up to 45 million children are involved in some form of athletics.

 On the whole, exercise is something to be encouraged in today’s children, with benefits of improving physical fitness, increasing social interaction with peers, decreasing stress, achieving self-efficacy, and gaining experience in goal setting, teamwork, and commitment.

	With the increase in the number of children involved in sports, however, there is also an increase in competition. Athletes and their families look for ways to rise above their competitors and gain an advantage. It is now common for young athletes to specialize in a single sport early on and play year round. Today’s children work with personal trainers, strength coaches, nutritionists, and skill specialists. The “off–season” has become obsolete for many young athletes. Parents are investing significant time and money into helping their children gain a competitive edge because often that edge increases the likelihood of success. How kids train, where they train, who they work with, and what they use are all factors in today’s sports culture.

	Sports nutrition is an influential tool in the athlete’s toolbox. Adjustments in nutritional status can be done safely to improve energy balance, reduce fatigue, support bone and muscle growth, increase bone mass, and aid in muscle contraction. Societal and individual pressures to “be the best” and “win at all costs,” however, push an increasing number of athletes to experiment with performance-enhancing substances (PES), including supplements, energy drinks, prescription medications, and banned/illicit substances.

	Like choosing the fuel for a car, the food that an athlete consumes directly affects performance. Athletes strive to be at their best and, along with their parents, seek guidance on ways to be stronger, leaner, and able to withstand the demands of training and competition. As medical providers, this is an opportunity not only to screen for nutritional issues and PES use but also to educate regarding nutritional needs in growing, active bodies.

	Diets with insufficient nutrients provide suboptimal fuel for workouts, increase the risk of nutrient deficiencies that can lead to illness or fatigue, and can hinder bone and muscle growth and recovery. Sports nutrition focuses on proper intake of macronutrients (carbohydrates, protein, fat) and micronutrients (calcium, iron, folate, vitamin B6, zinc).

 Research shows that insufficiencies exist in adolescent diets, particularly in athletes participating in sports with an emphasis on body composition and appearance (wrestling, gymnastics, dance).

 An overview of critical micronutrients is provided in Table 1.

	Proper intake of macronutrients is essential for energy balance. Carbohydrates are the main fuel during athletic activity. Protein is critical to muscle building, maintenance, and repair. Fat is a major energy source, particularly during light-to-moderate intensity exercise and endurance sports. Restriction of fat and increased consumption of protein are increasingly common practices in the young athletic population.

 These can be healthy modifications when done within reason, but should still be part of a well-balanced diet and not taken to the extreme. Recommendations regarding macronutrient intake are summarized in Table 2.

NEXT: Making the most of anticipatory guidance

	Keeping athletes well hydrated during activity is important for maintaining performance and regulating body temperature. Hydration before, during, and after activity should be part of each athlete’s routine. Children and adolescents are at higher risk of dehydration compared with adults because of a higher body surface area to body mass ratio, decreased efficiency at transporting heat to the skin, and increased heat production during exercise.

Recommended: Are kids eating too much pizza?

	All beverages provide hydration, but research consistently shows that water is the drink of choice for sports lasting less than 1 hour of exertion.

 For these shorter events, replacing water (rather than glucose, electrolytes) is the main concern. For children doing prolonged or vigorous intensity exercise lasting longer than 60 minutes, loss of water and electrolytes will increase. Studies have shown that consuming a sports drink containing carbohydrates in these instances helps avert fatigue and maintain performance.

	Caution should be exercised, however, when selecting a rehydration drink. In the majority of young athletes, water is appropriate and should be encouraged as the first choice. For the average child doing routine activity, sports drinks are not necessary and expose kids to added sugar and calories without significant nutritional value. Sports drinks contain 2 g to 19 g of carbohydrate per serving and range from 10 to 75 calories per serving.

 They are not indicated for use during meals or snacks, and sports drinks should not be a regular substitute for water or low-fat milk.

	Advocacy and action is needed because advertisements aimed at young people blur the impression of what is healthy, and daily access to unhealthy choices continues. Although full-calorie sodas are being removed from school vending machines, beverage manufacturers are replacing them with sports drinks. In 2006, sports drinks were the third fastest-growing beverage category in the United States after energy drinks and bottled water. The trade group representing beverage manufacturers reported that sports drinks increased their market share in schools from 14.6% in 2004 to 20% during the 2006–2007 school year.

	Although the terms are often used interchangeably, it is important to note that sports drinks and energy drinks are not the same. The main ingredients and the intended uses are very different, yet often this is not realized by the young athletes who consume them or by the parents who provide them. Sports drinks are beverages designed to replenish water and electrolytes lost during exercise. They may contain carbohydrates, minerals, electrolytes, and flavoring. In contrast, energy drinks are beverages advertised to boost energy, decrease fatigue, improve concentration, and increase mental alertness. These effects are attributed to the inclusion of nonnutritive stimulants, including caffeine, guarana, taurine, ginseng, L-carnitine, creatine, and glucuronolactone.

The actual amount of stimulant in many energy drinks is not specified on the container or able to be found on the Internet, and the majority of energy drinks contain multiple stimulants, which increases concern for adverse effects. For example, caffeine and guarana are often used together in energy drinks. Yet, guarana is a plant extract that contains caffeine; 1 g is equal to approximately 40 mg of caffeine.

 The total amount of caffeine contained in some products exceeds 500 mg (equivalent to 14 cans of common caffeinated soft drinks).

Recommended: When pill parties turn deadly for teens

	Protein and amino acids are also advertised in sports and energy drinks, often purported as “muscle recovery” drinks. Clinical trials have not supported their use in young athletes. Research has not shown an advantage in consuming these drinks over healthy food choices. In fact, low-fat chocolate milk is just as good, if not better, an option for postexercise protein recovery. The American Academy of Pediatrics (AAP) discourages use of energy drinks or stimulant-containing beverages in children and adolescents.

	The AAP defines a PES as “a substance taken in nonpharmacologic doses specifically for the purposes of improving sports performance. A substance should be considered performance enhancing if it benefits sports performance by increasing strength, power, speed, or endurance (ergogenic) or by altering body weight or body composition. Furthermore, substances that improve performance by causing changes in behavior, arousal level, and/or perception of pain should be considered performance enhancing.”

	A considerable amount of research has been done on these substances in the last few decades. However, data are lacking on the effects in children and adolescents. Despite the lack of reliable clinical data, these substances continue to be used by athletes to boost performance and by nonathletes to improve appearance and self-image. Examples of PES are listed in Table 3.

	The use of products to improve athletic performance is nothing new. There is evidence that Olympians used mushrooms, strychnine, and dried figs to increase strength, focus, and endurance as early as 776 BC.

 Drug testing and legal consequences are intended to deter use of PES, but the focus has been on collegiate and professional athletes.

There has been relatively little effect on high school and youth athletes.

	A 1995 US Supreme Court ruling authorized school drug testing for student athletes, however, the National Federation of State High School Associations reported only 13% of high schools actually test their student athletes.

 The majority of these schools focus drug testing on marijuana, opiates, and alcohol. Less than a third include steroids or substances common in the athletic/gym culture.

	Performance-enhancing substances are used widely among children and adolescents. Children are exposed to these substances at younger ages than in years past because of increased marketing and anecdotal evidence in the sports community. Elementary and middle school athletes are being taken to travel team practices long distances from home, and many are working with personal trainers and specialized coaches. Professional scouts now follow high school athletes, and collegiate coaches can be seen scoping out youth tournaments.

	The cost of education is also on the rise, and for many families, athletics is the ticket to higher education. There are pressures to excel in academics, in athletics, and in the social scene. These pressures are falling on younger, more impressionable shoulders than ever before. Children and adolescents turn to PES to gain a competitive edge or an emotional boost. Athletes seek to improve performance. Nonathletes may see PES as a way to increase social acceptance, step up their school performance, or improve physical appearance. The potential for serious health complications is overshadowed by the potential for success, status, and respect.

	A dietary supplement is defined as “a product (other than tobacco) that is intended to supplement the diet. It bears or contains 1 or more of the following dietary ingredients: a vitamin; a mineral; an herb or other botanical; an amino acid; a dietary substance to supplement the diet by increasing the total daily intake; or a concentrate, a metabolite, constituent, extract, or combination of these ingredients.”

 It is intended for ingestion in the form of a pill, capsule, tablet, or liquid. Dietary supplements also are not recommended “for use as a conventional food or as the sole item of a meal or diet.”

 There is a lack of regulation on safety and distribution because approval by the US Food and Drug Administration (FDA) is not necessary for these products to reach the marketplace.

 Manufacturers’ claims do not need to be proven before appearing on labels. The burden of proof is on the FDA.

More: Insufficient evidence for iron screening in kids

	Children and adolescents have easy access to supplements in health food stores, local supermarkets, and large chain retailers. A wide array of powders, drinks, pills, and bars are available to customers with claims of increasing muscle, decreasing fat, gaining weight, shedding pounds, increasing focus, improving endurance, reducing hunger, and boosting energy. It’s a proverbial candy store for athletes. Creatine is one of the most commonly used supplements by young athletes. Other substances used for the goals of enhancing performance include vitamins B and E, chromium, vanadium, L-carnitine, and sodium bicarbonate.

	Creatine is a common supplement used by young athletes and is easily found over the counter (OTC). Research shows that 8.2% of high school athletes use creatine, with up to a third of those students reporting daily use.

 National use by all adolescents is certainly more, given that these studies have looked only into use by athletes.

	Creatine is a substance found naturally in the body, particularly in skeletal muscle. It is commonly used by athletes to increase how quickly energy is supplied to muscle by helping generate adenosine triphosphate (ATP). It increases protein synthesis and water retention, allowing muscle cells to become bigger and heavier. Athletes supplementing with creatine have been found to break down less protein in the body and show more muscle strength earlier in training sessions.

 The greatest benefit seems to be in short-burst, repetitive actions such as wrestling and weightlifting. It is commonly taken before and after workouts.

	The most common adverse effects of creatine are muscle cramping and intestinal discomfort. Insufficient research has been done on the effects in young athletes, and the bulk of studies have tested the manufacturer’s “recommended” doses of 5 g/day rather than the commonly used doses of 20 to 30 g/day among athletes.

 The American College of Sports Medicine (ACSM) recommends creatine not be used by anyone aged younger than 18 years.

 Collegiate teams are prohibited from supplying creatine or other supplements directly to their student athletes.

	Prescription medication use is also prevalent in sports.

 Beta agonists are used for stimulation in competition, however, nonathletes have used them to add definition to muscle (by stimulating fat breakdown). They are banned by the International Olympic Committee if there is no medical indication. Interestingly, the percentage of Olympic athletes with a documented diagnosis of exercise-induced asthma increased from 15% in 1984 to 60% in the 1996 Olympic games.

 Beta blockers are used in accuracy sports to control anxiety. Diuretics are used to shed weight quickly and define muscle mass, effects commonly appealing to wrestlers. Narcotics help to decrease pain and consequently allow continued participation.

	There is an extensive list of substances banned by the major governing bodies in sports, and although some of these substances may seem unlikely to show up in our local schools (human growth hormone [HGH], antiestrogens, erythropoietin), several including stimulants and caffeine are commonplace in the United States today. Anabolic steroids are the most common banned substance found on positive drug tests in competitive athletes.

 Used predominantly by male athletes, anabolic steroids are also being used by female athletes and nonathletes. Studies show estimates of anabolic steroid use of 4% to 11% in high school boys and up to 3.3% in high school girls.

 The Centers for Disease Control and Prevention (CDC) found that 6.4% of 12th grade boys had tried steroids; nearly a third of these students were nonathletes.

Recommended: Treating injuries in the wilderness

	Anabolic steroids are used to increase muscle strength and size, increase body weight, and decrease the effects of cortisol to essentially preserve muscle mass. Although the emotional effects of steroids are often discussed as an adverse effect, research is now showing the increased aggression as an attraction for young athletes. Adolescent males have admitted that the increased aggression pushes them to train more intensely and be more assertive during competition and workouts.

 Anabolic steroids can be taken orally, transdermally, or intravenously. Most users take 5 to 10 times the physiologic dose, and some athletes admit using up to 100 times the physiologic amount.

	Human growth hormone has garnered media attention in professional sports, and research has shown use by high school students looking to improve their athletic performance.

 Its appeal has been linked to decreasing subcutaneous fat resulting in a more toned appearance. Because HGH also causes fluid shifts in the body soon after use, this reinforces the idea that the athlete is getting effects quickly, another appealing feature for adolescents.

	Antiestrogen use has been discussed among college and professional athletes, yet there is little evidence of use in younger athletes. These increase levels of androgens in the blood by blocking the conversion of androgens to estrogens.

	Blood doping is another performance-enhancing practice. Various methods exist, all of which increase the number of red blood cells in the bloodstream and artificially increase the blood’s ability to deliver oxygen to skeletal muscles.

 The most popular forms are injected erythropoietin and red blood cell transfusion. Blood doping increases endurance and stamina. It has been used in endurance sports such as cycling, distance running, and swimming.

	Caffeine and stimulants (eg, amphetamine and methylphenidate) are banned substances that are common in popular culture as well as in the sporting arena.

 Caffeine shows ergogenic (performance-enhancing) properties at high doses (3-6 mg/kg). Athletes and nonathletes use stimulants, easily found in energy drinks, OTC supplements, alternative medications, and soft drinks, to stimulate the central nervous system, increase focus and energy, and work out longer. Caffeine, ephedrine, guarana, and ephedra alkaloids (eg, Ma Huang) are widely available. Effects are variable, however, and more research is needed to know the extent of the impact on children and adolescents.

	Open communication is essential to understanding what young athletes are doing to improve their appearance and performance. It is also important for finding out what they may be considering. This is an opportunity to educate and guide them to make safe and knowledgeable choices. After all, the pressure to succeed, to win, to get stronger, and to make it to the next level can be all consuming. Although some families will reach out to their pediatrician for guidance, many families (and kids on their own) will be drawn to the “quick fix” that promises to transform the athlete into someone who is “bigger, better, faster, and stronger.” Advertisements glorify the possible effects of these substances, but the young athlete’s safety is not typically the focus. Guidance needs to be provided when young athletes struggle between the desire to “win at all costs” and the drive to do the right thing.

Next: A cautionary note on rest or withdrawal following a concussion

	A well-directed interview and exam need to be used for screening. Incorporating questions into the preparticipation physical interview is one way to address these issues as part of a more casual/nonassuming conversation.

 In addition to interviewing the young athlete, there is also a need to address the parents about their observations, intentions for use/training styles, and concerns. It is important to ask in the same tone as other screening questions, such as those inquiring about a history of asthma, concussion, or family heart disease.

	Examples of screening questions could include:

	o   Do you use anything to help you in sports or competition?

	o   Do you take any herbs, vitamins, or natural medicines?

	o   What is your typical training routine? Do you use anything to help improve your workouts (such as muscle recovery drinks, medicines)?

	o   Do you take any supplements to help your appearance or workouts?

	o   What do you typically drink to hydrate during the day? Do you use energy drinks or protein/nutrition shakes?

	o   Is there anything kids at school are using to get an edge?

	Educational programs have been designed to teach students about the facts and myths of PES and nutrition.

 Research has shown that open dialogue and talking about these topics is more effective than simply providing written handouts. Children who have had discussions with teachers or providers are less likely to use supplements and steroids, and they are more likely to retain the new information.

	Pediatricians are the primary contact for many adolescents, and even their parents, within the medical community. As the number of children involved in sports and activities increases and the competition stiffens, more and more athletes and families are looking for ways to gain an advantage. Year-round training, early sports specialization, personal training, and travel teams are just part of the puzzle. Advances in sports nutrition and use of PES are an added challenge as providers aim to provide comprehensive care and guidance. The pediatric medical community needs to be actively involved, having knowledge of substances being used, educating families in an approachable, noncritical manner, and having an open dialogue with children during visits.

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	2. Castillo EM, Comstock RD. Prevalence of use of performance-enhancing substances among United States adolescents. 

	3. American College of Sports Medicine, American Dietetic Association, Dietitians of Canada. Joint Position Statement: nutrition and athletic performance. American College of Sports Medicine, American Dietetic Association, and Dietitians of Canada. 

	4. Nisevich PM. Sports nutrition for young athletes: vital to victory. 

	5. Spear BA. Nutrition management of the child athlete. In: Nevin-Folino NL. 

 2nd ed. Chicago, IL: American Dietetic Association; 2003.

	6. Meyer F, O’Connor H, Shirreffs SM; International Association of Athletics Federations. Nutrition for the young athlete. 

	7. American College of Sports Medicine, Sawka MN, Burke LM, et al. American College of Sports Medicine position stand. Exercise and fluid replacement. 

	8. Black J. Should drinks like Gatorade sport the ‘junk food’ label? 

http://www.washingtonpost.com/wp-dyn/content/article/2007/09/25/AR2007092502281.html

	9. Committee on Nutrition and the Council on Sports Medicine and Fitness. Sports drinks and energy drinks for children and adolescents: are they appropriate? 

	10. Gomez J; American Academy of Pediatrics Committee on Sports Medicine and Fitness. Use of performance-enhancing substances. 

	11. Calfee R, Fadale P. Popular ergogenic drugs and supplements in young athletes. 

	12. Koch JJ. Performance-enhancing: substances and their use among adolescent athletes. 

	13. Supreme Court of the United States. 

Vernonia School District 47J, Petitioner v Wayne Acton, et ux, etc

	14. Dietary Supplement Health and Education Act of 1994. Public Law No. 103-417. October 25, 1994.

	15. Greydanus DE, Patel DR. Sports doping in the adolescent: the Faustian conundrum of hors de combat. 

	16. Grunbaum JA, Kann L, Kinchen S, et al. Youth risk behavior surveillance-United States, 2003. 

	17. Rickert VI, Pawlak-Morello C, Sheppard V, Jay MS. Human growth hormone: a new substance of abuse among adolescents? 

	18. Holland-Hall C. Performance-enhancing substances: is your adolescent patient using? 

	19. Goldberg L, MacKinnon DP, Elliot DL, Moe EL, Clarke G, Cheong J. The adolescents training and learning to avoid steroids program: preventing drug use and promoting health behaviors. 

	Dr Frye serves as teaching faculty for the Michigan State University College of Human Medicine, East Lansing. She also is a nonsurgical pediatric orthopedics and sports medicine physician in Grand Blanc, Michigan. The author has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.

Pediatric sports and activity participation is on the rise. It is estimated that up to 45 million children are involved in some form of athletics.1 On the whole, exercise is something to be encouraged in today’s children, with benefits of improving physical fitness, increasing social interaction with peers, decreasing stress, achieving self-efficacy, and gaining experience in goal setting, teamwork, and commitment.

Juiced: What kids do to compete

	Sports participation is on the rise among youth in the United States. As we continue to address childhood obesity, it is encouraging to see that the number of high school students playing sports has continued to increase yearly since 1983.

 The National Federation of State High School Associations (NFHS) estimates that 55.5% of all high school students play organized interscholastic sports.

 Nearly 7.8 million students participated during the 2013-2014 school year, up over 80,000 from the previous year and up over 1 million from 2002.

	Sports offer the potential benefits of improving physical fitness, boosting self-esteem, learning about dedication and discipline, and increasing strength and coordination. Interscholastic competition provides an opportunity for teamwork, challenge, and camaraderie.

	With the growing number of young athletes taking to the fields, courts, and gyms, there is an increasing need for medical screening. The preparticipation examination (PPE) is considered a standard of care for children and adolescents across the United States. It is a tool for screening athletes prior to beginning training and competition. The goal is to promote participation in athletics and optimize safety. The main objectives of the PPE are to screen for life-threatening or disabling conditions and to screen for conditions that may predispose children to injury or illness.

 The aim is to help young athletes participate, with modifications if need be, rather than prohibit participation.

	Research has shown that 3% to 13% of athletes require further evaluation based on PPE findings and only 0.3% to 1.3% of athletes with injuries are ultimately denied clearance during PPEs.

 These examinations have been used for nearly 40 years; some type of preparticipation physical for student athletes is required in each of the 50 states by the high school level.

 Controversy exists, however, because of a lack of standardization and debatable efficacy. Legislative requirements vary by state for the timing and content of the PPE and qualifications of the examiner.

 The NFHS has not adopted/required a standardized PPE.

 The majority of elementary and middle school-aged athletes have little or no required formal screening-other than routine well-child examinations-prior to training/competition. Elements of the PPE can be incorporated into well child-care visits starting as early as age 6 years.8 Overall, there is wide variation in what is covered at different ages and by different providers, how it is addressed, and the consequent continuity of care. 

More: Should kids with heart conditions play sports?

	With that in mind, the PPE Working Group was established as a joint project of the American Academy of Pediatrics, American Academy of Family Physicians, American College of Sports Medicine, American Medical Society for Sports Medicine, American Orthopaedic Society for Sports Medicine, and the American Osteopathic Academy of Sports Medicine.

 Their recommendations guide physicians doing the PPE and are published in the 

Preparticipation Physical Evaluation, 4th edition 

). The publication is endorsed by the American Heart Association (AHA) and the National Athletic Trainers' Association. The authoring organizations of the PPE-4 agreed that a comprehensive approach offers the best opportunity to screen for risk and determine the general health of the athlete. Efforts continue to improve the effectiveness of the exam, standardize the format, and educate providers and families as to the benefits of formal screening.

 provides the most current comprehensive guidelines as well as suggested screening questions, tools, and forms. (To download sample PPE forms, go to 

.) Among its recommendations is use of the 90-second musculoskeletal screening exam, which it cites as the standard of care (Table).

Recommended: Rest or withdrawal after concussion

	Ideally, the PPE should be completed a minimum of 6 weeks prior to the start of training.

 This allows time for any necessary further workup and treatment without interfering with participation. The 

 recommends a comprehensive physical every 2 years with a brief update exam including questionnaire and problem-focused examinations annually.

 Despite the recommendation, there currently is no standard, evidence-based practice. This is illustrated by a 2006 survey of all states by the Minnesota State High School League Sports Medicine Advisory Committee, which found that 35 states require a yearly examination with or without a mandated form; 11 states require every-other-year comprehensive examinations (6 with interval screening, 5 without); 3 states require comprehensive examinations every 3 years with yearly questionnaires; and several states do not require a standardized form. Therefore, no consensus exists on how frequently the evaluation should be done, which is influenced by local standards, state and school district rules, organization or league requirements, and availability of qualified health professionals.

	The main focus of the PPE is to serve as a screen to detect potentially life-threatening medical conditions, yet the PPE presents a broader potential benefit for our young athletes and their families.  The PPE offers an opportunity for anticipatory guidance and discussion of lifestyle issues (nutrition, weight-control behaviors, training techniques, self-image), and can serve as an entry point to the healthcare system for adolescents. It certainly does not replace the comprehensive well-child visit. Research has shown, however, that it may be the only opportunity for some athletes to have access to medical care.

 In a study of parents’ knowledge of the purposes and content of the PPE, up to one-third indicated the PPE is their student athletes' only contact with the healthcare system, even when up to 90% had an identified primary care provider and insurance-covered yearly health maintenance examinations.

	A comprehensive medical history is essential to the PPE. Research shows that personal and family histories reveal 64% to 78% of conditions that could disallow sports participation or at least warrant restrictions.

 This is more sensitive than the actual physical examination. Musculoskeletal conditions are the most common reason for disqualification at a sports physical.

 History alone has been shown to identify 92% of musculoskeletal issues affecting an athlete.

 It is critical that the history is obtained from both the athlete and the parent/guardian. Use of a medical interpreter and/or PPE form in other languages is vital to obtaining an accurate history when English is the secondary language. Discrepancies are commonly found between histories obtained from athletes and parents independently, and it is unknown which source is most accurate.

 Follow-up is needed for every positive answer for additional information with the goal of identifying chronic conditions, risk factors, and incompletely rehabilitated injuries.

Sports participation is on the rise among youth in the United States. As we continue to address childhood obesity, it is encouraging to see that the number of high school students playing sports has continued to increase yearly since 1983.

Stacy Frye, MD

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