Common Adolescent Sports and Overuse Injuries

1
Common Adolescent Sports and Overuse Injuries

• Brian E. Grottkau, M.D.
• Massachusetts General Hospital for Children

2
Pediatric Sports Injuries Introduction

• Participation in both organized and informal
  athletic activities increasing among children and
  adolescents
• Competitive sports common at younger age
• Participation by girls increasing most rapidly
• More susceptible to sports related injuries due
  to their immature skeletons

3
Pediatric Sports Injuries Introduction

• gt800,000 children age 14 and under treated in
  ERs for sports-related injuries each year
• Most injuries result from falls, being struck by
  an object, hyperextension or overuse
• More than ½ of all organized sports-related
  injuries among children can be prevented

4
Overuse Injuries in Children

• 30-50 of injuries in immature athletes due to
  overuse
• Varies widely by sport approx 20 soccer 80
  gymnastics
• Sports requiring repetitive motion microtrauma
• gymnastics, dance, pitching, running, etc
• Stress injuries spectrum from tendonitis to
  overt fracture

5
General Sports Injury Prevention in Children

• Always ensure that proper protective equipment is
  worn helmets, face/mouth guards, body
  protection/pads
• Ensure that equipment meets standards
  environment is safe
• Proper pre-conditioning for sport, good
  warm-up/cool down, proper training to avoid
  overuse injury
• Treat injuries early to avoid more serious injury

6
Pediatric Sports Keeping it Fun
FUN HEALTHY FRIENDSHIP
CHILDREN ARE NOT JUST SMALL ADULTS
7
No Pain No Gain Striving for Perfection!
8
Common Pediatric Sports and Overuse Injuries
Outline

• Spine Spondylolysis/Spondylolisthesis
• Injuries of the Lower Extremity
• Hip Avulsion fractures of pelvis
• Knee Anterior vs. Structural Knee Pain
• Diagnosis and Management
• Avoiding pitfalls
  Referred pain in children
• Ankle Sprain vs Fracture in Children,
  Severs disease

9
Pediatric Sports and Overuse Injuries Outline

• Injuries of the Upper Extremity
• Shoulder Instability traumatic vs
  atraumatic
• Impingement
• Little league shoulder
• Elbow Little league elbow
• Osteochondritis dissecans

10
Spondylolysis Spondylolisthesis Introduction

• Bilateral or unilateral defects of the pars
  interarticularis
• In children usually due to stress fracture
  through the pars isthmic
• Found in approx 6 of population, not always
  associated with pain
• Spondylolisthesis Forward displacement
• of vertebrae on another
• occurs in approx 1/3rd of pts with pars defects

11
Spondylolysis and Spondylolisthesis

• Usually order PA/Spot lateral Lumbar spine, often
  best seen on Oblique views, may need bone scan or
  SPECT scan for diagnosis
• Slip is classified into five grades depending on
  degree of displacement
• 1 0-25
• 2 26-50
• 3 51-75
• 4 76-100
• 5 complete displacement

12
Spondylolysis and Spondylolisthesis
13
(No Transcript)
14
Spondylolysis and Spondylolisthesis

• L5-S1 level most commonmay have tenderness at
  this level, may have hyperlordosis or palpable
  defect, frequently have hamstring tightness
  (limited SLR)
• More common in sports requiring hyperextension
  (gymnastics, wt lifting, wrestling)
• Increased pain with extension of lumbar spine

15
Diagnostic Tests for Spondylolysis

• Standing one leg standing hyperextension test
• Pain increases with extension of the lumbar spine

16
Spondylolysis Management

• Management Activity modification, NSAIDS,
  Physical therapy, Boston overlap/anti-lordotic
  brace, Bone Stimulator, Therapeutic pars
  injections to decrease pain
• Acute pain will usually decrease with above
  conservative management

17
Spondylolysis Return to Sports

• Sport are started gradually and cut back if
  symptoms recur
• Pain-free fibrous non nonunion (no bony healing)
  is acceptable end outcome
• Maintenance training program, avoidance of spine
  hyperextension, early treatment of symptoms
  prevents longer rehab if spondy becomes
  symptomatic again

18
Spondylolisthesis Operative Treatment

• Operative Treatment Rarely required in
  spondylolysis
• Grade III spondylolisthesis and above will
  usually require operative stabilization in
  children
• Involves short level fusion usually L4-S1,
  pedicle screw fixation with autograft/ allograft

19
(No Transcript)
20
(No Transcript)
21
Pelvic Avulsion Fractures

• Very common injury in children and adolescents
• Most common in boys between age 12-14 years
• Mechanism of injury is often a sudden forceful
  muscle contraction (sprinting, kicking ball)
• Most common at ischial tuberosity (hamstring and
  adductor attachment) and ASIS (quadriceps, rectus
  femoris attachment)

22
Pelvic Avulsion Fractures

• Localized tenderness on physical exam
• Pain with ROM and stretch (hamstring stretch will
  be painful in ischial tuberosity avulsion fx)
• Antalgic Gait, Limping, Pain worse with activity
• AP x-ray of Pelvis

23
(No Transcript)
24
(No Transcript)
25
Iliopsoas Avulsion Fracture
26
(No Transcript)
27
Pelvic Avulsion Fractures Treatment

• Conservative treatment Rest from sport/activity,
  crutches, NSAIDs
• Symptoms usually decrease in 2-4 weeks
• Often 2-3 months of activity modification needed
• Physical Therapy program often helpful
• Surgical fixation controversial

28
Common Sports Injuries of the Lower Extremity
The Knee
29
Knee Injuries Common in Many Sports
30
Anterior Knee Pain The Headache of the Knee

• Chronic knee pain in any part of extensor
  mechanism of knee
• Spectrum includes patellofemoral pain syndrome,
  Osgood Schlatter disease, Sinding-Larsen-Johansson
  syndrome
• Pain often has gradual and insidious onsetno
  known trauma or injury
• Usually no complaints of knee locking, acute
  swelling, or giving way/buckling

31
Adolescent Patellofemoral Knee Pain

• Many names patellofemoral pain, anterior knee
  pain, runners knee, chondromalacia patellae
• Very commonmost common in adolescent females
• Contributing factors biomechanical (larger Q
  angle, weaker quadriceps/ VMO muscle, tight
  hamstrings/ITB)
• Overuse repetitive injury
• Dull anterior poorly localized knee pain often
  worse with stairs, uneven terrain, keeping knee
  flexed

Greater Q angle in Females
32
Anterior Knee Pain Management

• Manage conservatively with NSAIDS, physical
  therapy, isometic exercises, activity
  modification
• Often frustrating problem to treat in the
  adolescent activity modification hard for
  athlete
• Physical therapy Emphasis of strengthening VMO,
  improving patella tracking, correcting
  biomechanical faults, etc.
• Generally responds well to conserv. tx AVOID
  surgery

33
Patellofemoral InstabilityAcute Dislocation

• Patellofemoral instability multifactorial
  Femoral anteversion, genu valgum, patella alta,
  quadriceps weakness
• Congenital dislocation (rare), traumatic
  dislocation, adolescent recurrent dislocation
  (usually relocates spontaneously)
• Usually manage conservatively, if instability
  persists.consider operative correction

34
Osgood Schlatter Disease of the Knee

• Traction apophysitis of tibial tubercle due to
  repetitive microtrauma
• Common cause of knee pain in early adolescence
• females age 8-13, males age 10-15
• Pain located over tibial tubercle---worse with
  activity
• Can take 18-24 months to resolve
• Activity modification, NSAIDS, if severe pain and
  compliance an issue short course of
  immobilization

35
Osgood Schlatters Disease of the Knee
Prominent tibial tubercle
X-rays are NOT generally needed to make diagnosis
36
Sinding-Larsen-Johansson Syndrome

• Traction apophysis of the distal pole of patella
  repetitive microtrauma
• Most common in active males during growth spurt
  11-15 yrs
• Jumpers Knee
• Self-limiting Resolves in approx 6-12 months,
  responds to activity modification, NSAIDS,
  physical therapy (quad strengthening)

Ossification/fragmentation seen at distal pole of
patella
37
Common Intra-articular Knee Injuries

• Osteochondritis dissecans
• Meniscus Injury
• Anterior Cruciate Ligament Injury

38
Osteochondritis Dissecans of the Knee

• Fragment of cartilage and subchondral bone
  separates from articular surface
• Unknown Etiology repetitive microtrauma,
  ischemia, genetic component
• May involve the medial or lateral condyle or
  patella, bilateral in approx 30
• Lateral side of medial condyle involved in 80 of
  cases
• Symptoms pain, locking, recurrent mild effusion

39
Large OCD Medial Femoral Condyle
40
Very Large OCD Medial Femoral Condyle
41
Osteochondritis Dissecans Management

• Classified (Type 1-4) based on degree of
  displacement
• Best seen on tunnel or notch view x-rays
• Manage Type 1-2 with activity modification, knee
  immob. for comfort, Type 3-4 will occasionally
  need surgical stabilization

42
Anterior Cruciate Ligament Injury

• ACL Prevents the tibia from slipping forward
  against the femur
• Uncommon injury in young children fx of tibial
  eminence
• Mechanism of injury usually sudden change in
  direction, landing off balance while jumping,
  hyperextension
• Often hear a pop, immediate pain, giving way,
  and inability to bear weight or continue playing
  sport
• Significant hemarthrosis/edema soon after injury

43
ACL Injuries in Women

• Female athletes sustain 4-8 times more ACL
  injuries than males
• Many theoriesanatomic differences smaller
  intercondylar notch, larger Q-angle, ligamentous
  laxity, imbalance between hamstring and quad
  strength, hormonal differences (estrogen/menstrual
  cycle) improper training/conditioning program
• Multifactorial multiple intrinsic and extrinsic
  causes

44
MRI of complete ACL tear
Large Effusion
Torn ACL
45
MCL Tear Grade III with meniscus tear
46
Meniscus Tears in the Knee

• More common in adolescence, medial meniscus tears
  more common
• Symptoms include pain, snapping, locking, giving
  way, joint line tenderness, joint effusion
• MRI often used in diagnosis, increased signal of
  menisci
• Greater healing potential in children, repair if
  possible/partial menisectomy

47
Avoiding the Pitfalls Referred Pain in Children

• Hip pain can often be referred to the knee in
  children
• Sensory distribution of obturator nerve to medial
  knee
• ALWAYS Examine hip in any child with knee pain
• Misdiagnosis common LCPD Perthes, SCFE
  slipped capital femoral epiphysis

48
Unstable Left SCFE
49
Common Sports Injuries The Ankle
50
Common Ankle Injuries in Children

• Common in young athletes
• Sprains are difficult to distinguish from growth
  plate injuries in children
• Primary ligamentous support for ankle includes
  3-part lateral ligament complex and 5-part medial
  (deltoid) ligament complex

51
Ankle Injuries Assessment

• Tend to occur when joint in position which
  provides little bony stability
• Inversion less stable than eversion
• Less stable when plantarflexed than dorsiflexed
• Determine foot position at time of injury
• Did Patient feel a pop?
• Able to walk after injury?
• Location of pain and swelling

52
Physical Examination of the Ankle

• May be very limited exam due to swelling and pain
• Inspect, palpate ligaments sequentially
• Neurovascular assessment
• Assess anterior drawer (ATFL), talar tilt (CFL
  and deltoid)

53
Anterior Drawer Talar Tilt Tests of the Ankle
Anterior Drawer Test Assesses stability of
anterior talofibular ligament Often very
difficult to assess secondary to significant
swelling and pain
54
Differential Diagnosis Ankle Sprain

• Proximal fibula fracture
• Syndesmotic disruption
• Base of 5th metatarsal avulsion fracture
• Lisfranc fracture-dislocation
• Physeal (Growth plate) fracture

55
(No Transcript)
56
Ottawa Ankle Rules Ankle Radiographs

• Useful way of deciding if X-ray is required
• X-rays needed if
• bony tenderness posteriorly on medial or
  lateral malleolus, tenderness over base of 5th
  metatarsal
• and/or Inability to bear weight

57
(No Transcript)
58
Ankle Rehabilitation Phase I II

• R-Rest
• I-Ice
• C-Compression
• E-Elevation
• Splints, Casts, Crutches Depend on severity of
  injury
• Early weight bearing as tolerated, AVOID
  prolonged immob.

59
Ankle Rehabilitation Phase III

• Functional conditioning with proprioception,
  agility, and endurance training
• Gradual return to play
• Maintenance exercises and protection

60
Heel Pain Severs Disease

• Traction Apophysitis of the calcaneous Activity
  related/Overuse
• Most common cause of heel pain in adolescents
• Most common in active males 10-13 years of age
• Heel tenderness at achilles tendon attachment

61
Heel Pain Severs Disease

• Treat symptomatically Manage with activity
  modification, NSAIDS, heel cord stretching
• Short term immobilization if acutely symptomatic
• Self-limited disorder will not have pain after
  physeal closure

62
Common Injuries of the Upper Extremity Shoulder

• Instability Traumatic vs. Atraumatic
• Impingement/Swimmers shoulder
• Little League Shoulder

63
Shoulder Instability in Young Athletes

• Spectrum of disorders laxity, subluxation, frank
  dislocation
• Anterior instability is most common type of
  glenohumeral instability
• (85-95) differentiate between
  multidirectional instability
• Differentiate between traumatic and atraumatic
  instability

64
Traumatic vs Atraumatic Shoulder Instability

• Traumatic Instability TUBS
• Traumatic, unidirectional (usually
  anterior)
• Bankart lesion or Hill-Sachs seen on
  x-ray,
• Surgical intervention more frequently
• required
• Atraumatic Instability AMBRII
• Atraumatic, multidirectional, Bilateral,
  REHAB,
• surgical intervention with inferior
  capsular shift
• if fail extensive rehab

65
Shoulder Instability in Children

• Shoulder dislocation is extremely rare in young
  children
• Adolescent usually due to fall or injury during
  contact sports
• Much more likely to have recurrent
  instability/dislocations than adults
• Needs extensive rehabilitation program after
  initial injury

Hill-Sachs lesion (impaction fracture of
humerus)
66
Shoulder Instability Recurrence
YOUNGER PATIENTS MUCH MORE LIKELY TO HAVE
RECURRENCE OF SHOULDER INSTABILITY
67
Breaking the Cycle of Shoulder Pain and
Instability
68
Swimmers Shoulder

• Common syndrome of repeated shoulder impingement
  in swimmers
• Repeated stress to shoulder joint, Subacromial
  impingement
• More common with freestyle and butterfly strokes
• Shoulder pain found in 15-35 of competitive
  swimmers
• More common in adolescence relatively
  underdeveloped shoulder musculature, increased
  laxity, and increase in length intensity of
  practice

69
Swimmers Shoulder Treatment

• Symptoms anterior shoulder pain during or after
  swimming
• May should signs of instability (usually
  multidirectional)or impingement signs
• Differential labrum injury, subluxation, rotator
  cuff tear
• Proximal humeral physis injury (Little
  league shoulder)
• Mainstay of treatment relative rest/ activity
  modification, NSAIDS,
• Physical therapy (strengthening, correct
  imbalance)
• Discourage Overtraining!!!

70
Little League Shoulder Diagnosis

• Chronic stress injury to proximal humeral physis
  (growth plate)
• Widening of proximal humeral physis on x-ray
• Most common in early adolescent males
  participating in overhead sports (baseball
  pitchers)
• Constant stress causes overuse syndrome
  microtrauma
• Adults tendonitis, ligament injury more
  common
• Children stress absorbed by weakest part
  of bonephysis

71
Common Injuries of the Upper Extremity Elbow

• Osteochondritis dissecans of Capitellum
• Little League Elbow Medial Epicondyle
  Apophysitis

72
Adolescent Capitellar Osteochondritis Dissecans

• Avascular necrosis of the capitellum
• Usually secondary to repetitive trauma, overuse
  throwing injury, valgus stress to elbow,
  ?vascular insult of capitellum
• Most common in throwing athletes between age
  11-16
• Clinical findings elbow stiffness, pain
  (lateral), catching/locking
• may see flexion contracture

73
(No Transcript)
74
Osteochondritis Dissecans of Capitellum

• Radiographs loose articular fragments,
  flattening of humeral capitellum, subchondral
  cysts
• MRI, arthroscopic examination helpful in
  diagnosis
• Management activity modification, physical
  therapy, arthroscopic debridement if necessary
  (cont. pain, locking, etc)
• Untreated may progress to early degenerative
  joint disease

75
Little League Elbow Mechanism of Injury

• Elbow is most commonly injured joint in young
  baseball players
• Chronic valgus stress (throwing) can lead to
  separation of the apophysis of the medial
  epicondyle
• Risk factors open growth plates, overuse, and
  poor throwing technique

76
Medial Epicondyle Apophysitis in Pitchers
Medial epicondyle apophysis fails before medial
collateral ligament in children Risk factors
too many pitches/game too many innings/week, poor
mechanics, ? Throwing Breaking ball PE medial
epicondyle tenderness, swelling, loss of full
extension, widening/ fragmentation of apophysis
77
Little League Elbow(Medial epicondyle
apophysitis)

• General Management Principles
• Activity Modification no pitching until
  pain free
• Short period of immobilization to quiet
  symptoms (2-3 weeks)
• Enforce pitch limitation, evaluate
  pitching mechanics
• RICE, NSAIDS, Strengthening/Stretching
  program
• Surgical intervention if physis separated
  by gt 4 mm, loose bodies

Recent attempts to limit pitches Maximum 6
innings/week 80 pitches/game
78
Little League Elbow Management

• Discourage Pitching through the pain
• Important to return to pitching gradually with
  proper technique
• Little League Elbow can lead to permanent
  deformity, reduced range of motion, chronic pain,
  traumatic arthritis if ignored

79

THANK YOU!!
THANK YOU!!!