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Sports Injuries in the Pediatric Athlete:
Considerations for the Stars of Tomorrow
Eric D. Parks, MD
Watauga Orthopaedics
Kingsport, TN
Disclosure Statement of
Unapproved/Investigative Use
I, Eric D. Parks, MD,
DO NOT anticipate discussing the
unapproved/investigative use of a
commercial product/device during this
activity or presentation.
Disclosure Statement of
Financial Interest
I, Eric D. Parks, MD
DO NOT have a financial
interest/arrangement or affiliation with
one or more organizations that could be
perceived as a real or apparent conflict of
interest in the context of the subject of this
presentation.
Outline
• Why Exercise?
• Epidemiology
• Pressures/Risk factors for
injury
• Overuse Injuries
– Osteochondroses
•
•
•
•
•
Knee
Pelvis
Elbow
Shoulder
Foot
– Spondylolysis
– Stress Fractures
• Acute Injuries
– Pediatric Fractures
• Summary
Why Exercise?
• Regular exercise increases self-esteem, and reduces
stress/anxiety
– Farmer ME. Am J Epidemiol. 1998
• Athletes are less likely to be heavy smokers and use
drugs
– Kino-Quebec, 2000. Physical Activity: a determinant of health in youth
– Escobedo LG. JAMA. 2003
• Athletes are more likely to stay in school
– Zill N. Adolescent Time Use, Risky Behavior and Outcomes. 1995
• Learn teamwork, self-discipline, sportsmanship,
leadership, and socialization
– Cahill BR. Intensive Participation in Children’s Sports. 1993
• Builds self-esteem, confidence, fitness, agility
Childhood Obesity
Exercise
• Current public health guidelines
60min of exercise/day
– Strong WB. J Pediatr. 2005
recommend
What fits into your busy schedule better,
exercising 1 hour a day or being dead 24
hours a day?
• Physical activity declines significantly during adolescence
– Brodersen NH. Br J Sport Med. 2006
• Overweight children perceive themselves to be just as active as
their non-overweight contemporaries
– Gillis LJ. Clin J Sport Med. 2006
• The energy expended playing active Wii Sports games was not
intense enough to contribute to daily recommendations
– Graves L. Br J Sports Med. 2008
Some Active Kids on Our Hands
• ~45 million children/adolescents 6-18 yo participate in
organized sports on a yearly basis
– 1997- 32 million
– 2008- 44 million
• 7 million adolescents participate in organized highschool sports on a yearly basis
– 4.1 million males
– 2.9 million females
• National Federation of State High School Associations. 2005
Sports Injuries
Epidemiology
• 30-40% of all accidents in children occur during sports
• ~2.5 million sports injuries treated annually in ER for
patients ≤18 yrs old
• Sports/over-exertion leading cause for all injury related visits
to PCP
• Rate of sports injuries was 2.4 per 1000 exposures
• 10-14 year olds at greatest risk
• 22% of adolescents experience some sports-related injury
– 62% occurred during organized sports
– 20% during physical education classes
– 18% during non-organized sports
Sports Injuries
Epidemiology
• 25-30% occur during organized sports
• 40% occur during non-organized sports
– Hergenroeder AC. Pediatrics. 1998
• males >> females
• males 10-19 y/o
– football, basketball & bicycle injuries MC
• females 10-19 y/o
– basketball, bicycle & gymnastics injuries MC
• Backx FJG. Am J Sports Med. 1991
Sports Injuries
Financial Burden
• $588 million in direct expenses
• $6.6 billion indirect costs
– US Consumers Product Safety Commission. Jan 2006
• Sports are the leading cause of injury and hospital
emergency room visits in adolescents
– Emery CA. Clin J Sport Med. 2003;13:256-268
• CDC estimates that ½ of all sports injuries in children
are preventable
Sports Injuries
Epidemiology
• 30-50% of adolescent sports-related injuries are
overuse
– Watkins J. J Sports Med Phys Fitness. 1996;36(1):43-48.
• 15% of all adolescent injuries are to the physes
and apophyses
– Pill SG. J Musculoskeletal Med. 2003;20:434-442
Definitions
• Physis
– Primary ossification center located at the ends of long bones
– Responsible for longitudinal growth
• Apophysis
– Secondary ossification center located where major tendons attach to
bone
– Provide shape and contour to growing bone but add no length
• Osteochondroses
– disorders affecting bone and cartilage together
• Osteochondrosis
– disease of the ossification centers in children
• Apophysitis
– irritation of the musculotendinous attachment
The Physis
• Cartilage is less resistant to tensile forces than bones,
ligaments, and muscle-tendon units
• Bones grow faster than muscle-tendon units
• Same injury leading to a muscle strain in an adult may
result in growth center injuries in adolescents
• The “Weak Link”
General Anatomy
Physeal Anatomy
• Zone of Growth
– Longitudinal growth
– Area of greatest concern
• Zone of Maturation
– Calcification
– Replaced by osteoblasts
– MC area for fracture
• Zone of Transformation
– Complete remodeling
– Metaphyseal vessel penetration
Impact of Growth on Injury Risk
• Injuries tend to be most common during peak
growth velocity
• Peak height velocity precedes peak flexibility gains
• Decreased BMD in the 2-3 yrs preceding peak
height velocity
Pathophysiology
• Repetitive tensile forces
• Stress to the physis
• Microtrauma leads to:
–
–
–
–
–
Pain
Inflammation
Widening
Avulsion
Microfracturing
• Long term complications exist for physeal injuries
Overuse
• “When microtrauma occurs to bone, muscle, or
tendonious units as a result of repetitive stress with
insufficient time to heal.”
Risk Factors for Injury
• Intrinsic
– ↑ vulnerability to stress in growing skeleton
– Inability to detect injury
– Skeletal variants
• Pes planus, overpronation, patella alta, external
tibial torsion
Risk Factors for Overuse
Extrinsic
•
•
•
•
•
•
•
Pressure
Training errors
Sports camps
Year round training
Single vs Multi-sport
Early specialization
Improper technique
•
•
•
•
•
•
Weekend tournaments
Motivation sources
Personal coaches
Team vs club sport
10 yr / 10,000 hr rule
Evaluation programs
The Gradual Progression
• Multi-sport athlete
• Recent increase in activity
• Pain with activity, not with rest, still normal
performance
• Pain with activity, rest, and decline in
performance
Key Points During Evaluation
• History and physical exam
– Recent change in activity or training
• Insidious onset of pain that worsens with activity and
improves with rest
• Point tenderness with or without swelling
• Pain with passive stretch of attached ligament/ muscletendon unit
• Pain with firing muscle-tendon unit against resistance
• Radiographs?
– Help to rule out other pathology
Treatment
General Principles
•
•
•
•
•
•
•
•
Relative rest
Cross training
Flexibility
Ice
Counter-balance bracing
?NSAIDS
ORIF with certain avulsions
Resection of retained, non-fused ossicles
Patellofemoral Friction Syndrome
•
•
•
•
Most common cause of anterior knee pain
Estimated prevalance of 20%
Mean age 14 years
“The Great Imitator” of symptoms
– Location and quality of pain
• Walking stairs, incline/decline
• “Theatre sign”
PFS
Risk Factors and Treatment
•
•
•
•
Muscle imbalances
Flexibility issues
Over-pronation, pes planus
Specific sports
• Treat from the hip to the waist
• Orthotics, bracing, taping?
Osgood-Schlatter’s Disease (OSD)
Tibial Tubercle Apophysitis
• Occurs in 20% of young athletes
– most common pediatric overuse injury
•
•
•
•
20% of OSD is bilateral
Girls 8–13yo
Boys 10-15yo
Aggravated by running, jumping, or other explosive
activities
• Occasionally aggravated by kneeling or direct trauma
Osgood-Schlatter’s Disease (OSD)
Tibial Tubercle Apophysitis
• Point tender +/- swelling at tibial tubercle
• Pain with quadriceps stretch or contraction,
poor quad flexibility
• Widened physis or fragmented tibial tubercle on
radiographs
• Tight quadriceps or hip flexors
– Postive Thomas test
Osgood-Schlatter’s Disease
Sequelae
Osgood-Schlatter’s Disease (OSD)
Radiographs
Osgood-Schlatter’s Disease (OSD)
Pathology
•
•
•
•
•
Chronic traction/stress at apophysis
Cartilage swelling
Cortical bone fragmentation
Patellar tendon thickening
Infrapatellar bursitis
• Long term- prominent tibial tubercle, intratendon ossicles, ? ↑ risk of rupture
Osgood-Schlatter’s Disease (OSD)
Risk Factors
•
•
•
•
•
Repetitive explosive activities
Recent increase in activities
Tight quadriceps and/or hip flexors
External tibial torsion
Patella alta
Osgood-Schlatter’s Disease (OSD)
Treatment
•
•
•
•
•
•
Relative rest
Quadriceps and hip flexor stretching
Ice
NSAIDs
Cho-Pat strap
Knee pads
Sinding-Larsen-Johansson Syndrome
(SLR)
• Apophysitis at the inferior
the patella
• 10-12 years old
• Most common in running
jumping athletes
– Basketball, soccer, gymnastics
• “Adolescent Jumper’s Knee”
pole of
&
El salto del Colacho- “the devil’s jump”
Sinding-Larsen-Johansson Syndrome
(SLR)
• Tenderness at the inferior pole of the patella
• Pain worsened with
explosive
activity
• Tight quadriceps
• Radiographs may reveal fragmentation of the
inferior pole and/or calcification at the proximal
patella tendon
Sinding-Larsen-Johansson Syndrome
(SLR)
Patella Sleeve Fracture
Sinding-Larsen-Johansson Syndrome
(SLR)
Treatment
•
•
•
•
•
Relative rest
Quadriceps stretching
Ice
NSAIDs
Cho-Pat strap
Osteochondritis Dessicans
• Avascular necrosis of cartilage bed
• May be result of direct trauma vs iatrogenic
• MC location- lateral portion of medial femoral
condyle
• Age 9-18 years old
• Consider in adolescent presenting with painless
effusion
Osteochondritis Dessicans
Radiographs
• 4 views- AP, lateral, sunrise, and tunnel
• MRI for stability
Osteochondritis Dessicans
Treatment
• Treatment will depend on the stability of the
lesion
• Protected/NWB for 6 weeks
• Bracing
• Follow up imaging
• Unstable- surgical
Sever’s Disease
Calcaneal Apophysitis
• Affects boys and girls equally
• Ages 8-13 years
• Most common in soccer, basketball, &
gymnastics
– Repetitive heel impact & traction stress from the
achilles tendon
• Bilateral in 60% of cases
Sever’s Disease
Calcaneal Apophysitis
•
•
•
•
•
Heel pain worsened with activity
No swelling
Point tender at posterior calcaneus
Pain with medial-lateral compression
Pain with calf stretch or contraction against
resistance
• Tight heel cord, weak dorsiflexors, subtalar
overpronation
Sever’s Disease
Risk Factors
• Repetitive explosive activities
• Repetitive trauma
– Jumping, landing, cleats, etc.
•
•
•
•
Recent increase in activities
Tight heel cord
Before/during rapid periods of growth
Beginning of new season
Sever’s Disease
Treatment
•
•
•
•
•
Relative rest
Heel cord stretching
Heel cups
Ice
NSAIDs
Sever’s Disease
Calcaneal Apophysitis
Pelvic Apophysitis
• 10-14 years old
• Insidious onset of hip pain or
sharp pain
sudden
– Running, jumping, kicking sports
• Point tender
• Pain with stretch or contraction of involved
muscle
• Widening of physis or avulsion of apophysis
Pelvic Apophysitis
Pelvic Apophysitis
• Ischial tuberosity 38%
– Hamstrings & Adductor
• ASIS 32%
– Sartorius
• AIIS 18%
– Rectus Femoris
• Lesser trochanter 9%
– Iliopsoas
• Iliac crest 3%
– ITB/Tensor Fascia Latae
– Abdominal muscles
ASIS Avulsion Fracture
Sartorius
ASIS Avulsion Fracture
Sartorius
AIIS Avulsion Fracture
Rectus Femoris
Ischial Tuberosity Avulsion Fx
Adductors & Hamstrings
Ischial Tuberosity Avulsion Fx
Adductors & Hamstrings
Pelvic Apophysitis
Treatment
•
•
•
•
•
•
•
Relative rest until pain free (~4-6 weeks)
WBAT without limping
NSAIDs
Ice
Stretching & strengthening
Progressive return to activities
Rare need for surgery
Medial Epicondyle Apophysitis
Little League Elbow
• Most common in 9 to 14 y/o overhead athletes
• ~18-29% incidence of elbow pain in youth and HS
baseball players
• Point tenderness over medial epicondyle
• Classically worsened by repetitive throwing
• Hypertrophy of medial epicondyle
• Flexion contracture
• Pain with valgus stress
& milking
maneuver
Medial Epicondyle Apophysitis
Little League Elbow
• X-rays may reveal widening of medial
epicondyle apophysis &/or fragmentation of
medial epiphysis
• 85% of X-rays are normal
– Hang DW. Am J Sports Med. 2004
Medial Epicondyle Apophysitis
Little League Elbow
• The acceleration phase:
• Mechanism:
– Traction injury
– Strong contraction of the flexor-pronator muscle attachments as the arm
is started forward
– Valgus stress causes tension on the UCL
• Valgus moment with throwing:
–
–
–
–
Lateral compression at radiocapitellar joint
Medial tension at epicondyle and UCL
Posterior shear
Hyperextension valgus overload syndrome
Baseball Overuse Injuries
Epidemiology
• Incidence of baseball overuse injuries is 2-8% annually
– Gomez JE. Pediatr Clin North Am. 2002
• Annual incidence of elbow pain in 9-12 y/o baseball players is
20-40%
– Walter K. Contem Ped. 2002
• In adolescents, 52% & 86%increased risk of shoulder and elbow
pain respectively if throwing curve ball or slider
– Lyman. USA Baseball. 2002
• 67% of HS UCL reconstructions began throwing curve ball
before age 14
– Petty 2004
• 6 fold increase in elbow surgeries b/t ’94-’99 and ’00-’04
– Fleisig GL. ASMI. 2005
Medial Epicondyle Apophysitis
• Classic Little League Elbow is an apophysitis of the
medial epicondylar growth plate
• Constellation of Findings:
–
–
–
–
–
–
Apophysitis of Medial Epicondyle
Medial Epicondylitis
Cubital Tunnel Syndrome
UCL Injury rare
Capitellar OCD
Premature closure of proximal radial physis
Medial Epicondyle Avulsions
Little League Elbow
Treatment
• If apophysis not significantly displaced (<5mm)
– (Relative) rest 4 - 6 weeks
– Isometric strengthening, stretching, resistive strengthening
– Throwing mechanics evaluation
– Gradual return to throwing after 6 - 12 weeks
• Interval Throwing Program
– Follow pitch counts & types
• If apophysis significantly displaced (>5mm) surgery is warranted
Little League Shoulder
Proximal Humeral Epiphysiolysis
• Fatigue fracture of the proximal humeral physis
– Does not fuse until ages 14-20
•
•
•
•
•
•
•
•
Typically high-performance male pitchers
Rotatory torque stresses to the epiphyseal growth plate
9-14 years old
Pain
Inability to perform
Decreased ROM
TTP at anterior proximal humerus
Remember– physis is the weak link!
Little League Shoulder
Proximal Humeral Epiphysiolysis
• Treatment
– Relative rest for 4-6 weeks
– Interval throwing program
– Thrower’s 10 program
Little League Shoulder
Proximal Humeral Epiphysiolysis
USA Baseball Medical & Safety
Advisory Committee
Pitch Counts 2008
USA Baseball Medical & Safety
Advisory Committee
Days Off 2008
Spondylolysis
• Lesion in the pars interarticularis of the neural
arch
Low Back Pain
Epidemiology
• 30.4% in 11-17 year old athletes
– Olsen TL. Am J Public Health. Apr 1992;82(4):606-8
• No cases of spondylolysis in non-ambulatory
(n=143)
– Rosenberg NJ. Spine. Jan-Feb 1981
Spondylolysis
Epidemiology
• Incidence of 6-8% in general population
• 6.4% for Caucasian males
• 1.1% for African-American females
– Roche MA, Rowe GG. Anat Rec. 1951
• Overall incidence of 4.4% by age 6, 5.2% by age 12,
and 6% by adulthood
– Frederickson BE. J Bone Joint Surg. 1984
• Males>>>Females
• 85-95% occur at L5 with the remainder typically at L4
– Amato ME. Radiology. 1984.
Spondylolysis
Clinical Presentation
• Insidious back pain exacerbated by strenuous activity
• Occasional radiation to the buttocks
• Rising to an upright posture against resistance elicits
pain
• Pain exacerbated by hyperextension & rotation bilateral,
unilateral
• Hamstring tightness in 80% of patients
• Tenderness in lumbar spine to palpation
• Hyperlordosis
Spondylolysis
Imaging
•
•
•
•
•
Xrays
Bone scan
SPECT scan
Thin-sliced CT scan
MRI
Spondylolysis
Imaging
Spondylolysis
Treatment
•
•
•
•
•
Relative rest & activity modification
Time (>3 months)
Flexion-based core strengthening
NSAIDs
Bracing?
– If still painful after the above
• Surgery
Stress Fractures
• Mechanism
– repeated forceful impact and repetitive loading
on immature trabecular bone
– repeated microtrauma is greater than ability to
repair
Stress Fractures
History
• Recent change in activity level, equipment, or playing
surface
• Insidious onset of pain
• Worse with activity
• Improves with rest
• Prior stress fractures
• Menstrual irregularities, weight changes, eating disorder,
nutrition
– Female Athlete Triad
Stress Fractures
Clinical Examination
• Focal tenderness may be elicited with
compression or percussion
• Fulcrum test, Hop test, & Tuning fork
• Plain x-rays often normal early in disease
course
– New bone formation after 2-3 weeks
• Further imaging may be needed
– Bone scan or MRI
Stress Fracture
Imaging
Stress Fractures
Treatment
• Relative rest
– Cross-training
– Limit impact activities
•
•
•
•
Immobilization
Gradual return to play
May take 6-8 weeks
Be aware of tenuous stress fractures
– Anterior tibial cortex, tension-sided femoral neck,
Jones, etc.
Summary
•
•
•
•
60 minutes of exercise is recommended daily
Video gaming is not intense enough
Adolescents are not little adults
Overuse injuries occur frequently in adolescents
Summary
• Be wary of overuse physeal injuries
• Know where the common overuse physeal
injuries occur
• Relative rest is a good start with most overuse
physeal injuries
• Know common adolescent fractures, including
physeal fractures
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