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Chapter 14
Sports Injuries in Children and
Adolescents
Elliot M. Greenberg and Eric T. Greenberg
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Introduction
• More than 38 million children participate in sports.
• With participation is inherent risks.
• Sports injuries in children include both traumatic and
overuse conditions.
• Account for about 25% of all childhood reported injuries
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Anatomic and Physiologic Differences of the
Skeletal Immature Athlete
• Bone composition
– Presence of growth plates
– Physeal fractures can be caused by overuse as well
as trauma.
– Present of apophysis (secondary growth centers)
– Decreased muscle tendon flexibility during growth
spurts
– Advantage in bone healing
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Anatomic and Physiologic Differences of the
Skeletal Immature Athlete—(cont.)
• Muscular properties
– Recent reports have shown that prepubescent
children can demonstrate strength gains.
– There is support for safe and effective strength
training with supervision by a trained adult.
– Decreased flexibility during growth spurt, which
could lead to more injury.
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Examination
• History
– Recent changes should be noted.
– Nature of the injury
– Use age-specific language.
– Know the athlete’s playing position, level of player
(recreational to elite), years of participation, and
primary sport.
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Physical Examination
• Perform standardized examination principles
• Ligamentous laxity in pediatrics should be respected.
– 0/9 is normal, 9/9 is highly lax
• Running examination in running athletes
• Should include closed kinetic chain activities
– Identifies sources of the pain, musculoskeletal
malalignments, abnormal joint motion, muscle
atrophy, and muscular weakness
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Physical Examination—(cont.)
• Muscle testing should include functional movement
testing
– Functional tests provide information regarding
balance, alignment, body awareness, strength,
control, and core stability.
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Upper Extremity Examination and Treatment
• Shoulder
– Include postural assessment
– Note scapular position, thoracic kyphosis, and
general appearance.
– Shoulder movement
• Overhead athletes have less internal rotation than
external, and this can be normal if less than 20
degrees difference.
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Upper Extremity Examination and Treatment—
(cont.)
• Elbow
– Look at biomechanics of the transfer of movement
from lower extremities to upper extremities.
– Note any limitations in the biomechanical chain.
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Upper Extremity Examination and Treatment—
(cont.)
• Scapular stabilization in an endurance capacity should be
included in any upper extremity rehab program.
• After the regaining of function, a return to throw program
can be developed.
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Treatment Planning
• Begin exercising with the limb below shoulder level,
within pain-free ROM prior to exercising above 90
degrees of shoulder elevation.
• Scapulo-thoracic musculature, particularly posterior
muscles such as middle and lower trapezii, is
another important focus of quality rehabilitation.
• Focus should be on stabilization and endurance.
• The role of the core and hip/pelvic musculature in
shoulder rehabilitation is also important.
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Treatment Planning—(cont.)
• Shoulder multidirectional instability (MDI) is
another common problem in this age group.
– Typically results from generalized ligamentous
laxity
– Recognition of this disorder and counseling
regarding injury risk due to systemic
ligamentous laxity will benefit the patient.
• Traumatic dislocation that does not result in a tear
of the antero-inferior glenoid labrum but simply
stretches the capsule
• Avoidance of horizontal glenohumeral extension
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Treatment Planning—(cont.)
• Alter the position of the extremity during exercises.
• Generalized shoulder pain resulting from overuse or
rapid advancement of training protocols is often
caused by tendinitis with secondary impingement.
– Findings would be positive special test results,
a tight posterior rotator cuff or shoulder
capsule, weakness of the posterior
scapulothoracic musculature and external
rotators, and forward rounded shoulders.
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The Pediatric Throwing Athlete
• Athletes are predisposed to certain injuries.
• Principles can be applied to any overhead activity like
volleyball, tennis, and swimming.
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“Little League” Shoulder
• Encountered in the pediatric and adolescent athlete
• Defined as a stress reaction or fracture of the
proximal humeral physis
• Plain films or bone scans are often used but are
sometimes not definitive.
• Palpatory tenderness over the physis is diagnostic if
rotator cuff testing and other test results are
negative.
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“Little League” Shoulder—(cont.)
• Treatment for little league shoulder is primarily rest.
• Review throwing mechanics.
• Then ensure good balance and core strength/function.
• Scapulothoracic strengthening
• Gradually return to throwing program.
• Modify throwing volume.
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Superior Labrum Anterior to Posterior Lesions
(SLAP)
• Result of trauma and overuse
• Throwing athletes are prone to this.
• Can result in laxity in the shoulder
• Treatment is rest followed by rehabilitation.
• Surgical intervention may be necessary to return the
athlete to their level of play.
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Elbow Lesions
Most elbow injuries require:
•
Rest
•
Gentle ROM
•
Strengthening
•
Slow return to sports when pain free
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Elbow Lesions—(cont.)
• Little league elbow
– Traction injury to medial epicondyle due to valgus
stress during throwing
– Pain during throwing
• Panner disease
– In kids 4 to 8 years old
– Necrosis of the capitellum
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Elbow Lesions—(cont.)
• Medial epicondyle apophysitis
– Result of repetitive tensile forces
• Medical epicondyle avulsion fracture
– Stress which causes an avulsion
• Ulnar collateral ligament injury
– Cumulative trauma in young athletes
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Elbow Lesions—(cont.)
• Osteochondritis dissecans (OCD)
– Repetitive microinjury that leads to subcondral
fractures
– Conservative treatment
– Surgical treatment may be indicated.
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Other Shoulder Pathologies
• Multidirectional instability
– Caused by acute traumatic dislocation or by capsular
laxity
– Presents with bilateral shoulder pain with unstable
feeling
– Glenohumeral translation
– May have associated impingements
– Education and strengthening of shoulder stabilizers
– Return to sport training should include activities that
replicate the movement.
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Other Shoulder Pathologies—(cont.)
• Traumatic shoulder dislocation
– Anterior is the most common direction
– Fall in an abducted and externally rotated position
– Conservative treatment is immobilization.
– Treatment is based on symptoms.
– Operative management varies.
– Avoid aggressive ROM.
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Other Shoulder Pathologies—(cont.)
• AC joint separations
– Caused by fall onto the shoulder
• Clavicle fractures
– Surgery only if displaced or comminuted
– Immobilization 2 to 4 weeks
– Slow return to sports
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Other Shoulder Pathologies—(cont.)
• Supracondyle elbow fractures
– Risk of neurovascular complications
• Lateral condyle fractures
• Monteggia fracture
– Radial dislocation with an ulnar fracture
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Forearm, Wrist, and Hand Injuries
• Fractures occur as a result of falls and can occur
anywhere on the radius or ulna.
• Usually treated with reduction and immobilization
• Indications for surgery include open or unstable fracture
or fractures that are not healing.
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Forearm, Wrist, and Hand Injuries—(cont.)
• Gymnast wrist
– Pain from overuse
– Restrict from activities for a period of time
• Scaphoid fractures
– Most common carpal bone fracture
– Sometimes difficult to diagnose on first x-ray
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Forearm, Wrist, and Hand Injuries—(cont.)
• Fracture of the Hook of the Hamate
– Mistimed swing that translates forces
• Boxer’s fracture
– Fracture at the fifth metacarpal
• Finger fracture
– Majority are treated by closed reduction.
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Pelvis, Hip, and Thigh Injuries
• Examination principles
– Detailed history
– Mechanism of injury and location of pain
– ROM
– Muscle testing
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Pelvis, Hip, and Thigh Injuries—(cont.)
• Pelvic apophysitis
–
Growth and immature skeleton lead to tensile forces on the
pelvis
–
ASIS, AIIS, lesser trochanter, iliac crest, and greater trochanter
–
Well-localized dull pain with activity
–
Pain progresses with activity.
–
Treatment is rest and modification of activity.
–
Strengthening to the surrounding muscles
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Pelvis, Hip, and Thigh Injuries—(cont.)
• Pelvic avulsion fractures
–
Unmanaged apophysitis in adolescents
–
Hear a “pop”
–
May require surgery
• Snapping hip syndrome
–
Friction of the ITB
–
Can be internal or external
–
Treatment is conservative with emphasis on stretching.
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Pelvis, Hip, and Thigh Injuries—(cont.)
• Femoral stress fracture
–
Common in runners
• Femoral acetabular impingement and labral tears
–
Abutment and approximation of the femoral head or neck with
the acetabular ring
–
Deep hip and groin pain in the shape of a “C”
–
Reproduce pain with hip flexion, adduction, and internal rotation
–
Most often need surgical repair
–
Gradual and slow return to sport
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Pelvis, Hip, and Thigh Injuries—(cont.)
• Muscle strains
–
Occur frequently and can cause apophyseal avultions
–
Hamstring strains are common.
• Traumatic hip dislocation
–
In high-impact sports
–
Emergent situation
• Slipped capital femoral epiphysis (SCFE)
–
Posterior slippage of the proximal epiphysis
–
More prevalent in boys who have increased BMI
–
Surgical fixation is required.
–
Protected weight bearing
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Pelvis, Hip, and Thigh Injuries—(cont.)
• Legg–Calve–Perthes
–
Idiopathic osteonecrosis of the capital epiphysis of the femoral
head presenting in males 4 to 8 years old
–
Lack of blood flow can lead to necrosis.
–
Present with pain and limping
–
Limitations in hip IR and abduction
–
Maintain hip mobility and limit pain
–
May require surgery if conservative treatment fails
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Knee Injuries
• Examination
– History
– Mechanism of injury
– Detailed pain assessment
– Gait assessment
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Ligamentous Injuries
• ACL injuries
– Most severe and frequent activity-related injury
– Can cause avulsion fractures more commonly in
children
– Treatment based on degree of injury
– Surgical options
– Post-op rehab focus on effusion management,
maintaining knee extension, and restoration of
quadriceps activation
– Intensive rehab may take months to return to sports
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Ligamentous Injuries—(cont.)
• ACL injury prevention
– Risk increases for females
– Risk increases for athletes above 10
– Injury prevention programs have developed
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Ligamentous Injuries—(cont.)
• MCL injuries
– Valgus stress to the knee
– Usually from a fall from another athlete
– Conservative management with a quicker return to
sports
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Ligamentous Injuries—(cont.)
• PCL injuries
– Direct blow to the knee
– Conservative management
– Quad strengthening
• LCL injuries
– Rare in pediatrics
– Seen with injury to the entire posterior capsule
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Intra-articular Injuries
• Meniscus injury
– Congenital “discoid” meniscus are more likely to
develop a tear.
– Pain, effusion, and snapping or clicking present
– Tears in older children from twisting
– Treatment depends on location.
– Post-op rehab includes limited weight bearing and
ROM.
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Intra-articular Injuries—(cont.)
• OCD
– Knee is the most commonly involved joint.
– Conservative management for the stable lesion
– Rehab for strengthening
– Surgery for unstable lesions
– Rehab protocols vary depending on the surgery.
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Intra-articular Injuries—(cont.)
• Acute patellar dislocation and osteochondral fractures
– Planting or twisting injuries
– Osteochondral fractures typically occur.
– Surgery for displaced fractures
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Overuse Injury
• Patellofemoral pain syndrome
– Caused by biomechanical alterations proximally and
distally
– Dull ache under the knee
– Treatment focuses on removing the offending causes
– Rest and pain-free activities
– Adjunct treatment
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Overuse Injury—(cont.)
• Patellar tendinopathy
– Older adolescents with fused growth plates develop a
tendinopathy.
– Mechanical overuse
– Relative rest
– Stretching and flexibility
• Plica syndrome
– Irritation of the bands of synovial tissue lining the
knee
– Treatment is similar to patellofemoral pain
syndrome.
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Lower Leg Injuries
• Shin splints
– General term to describe pain in the lower leg
– Includes:
• Medial tibia stress syndrome
• Pain along the anterio-medial plane of the distal
to one-third of the tibia with running and
jumping
• Biomechanical contributing forces
• Treatment is rest, followed by low-impact
activities, followed by balance and dynamic
control exercises.
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Lower Leg Injuries—(cont.)
• Tibial stress fracture
– Activities that include repetitive loading to the
lower leg
– Contributing factors include improper training
programs, high BMI, excessive pronation,
and/or high or low arch.
– Initially treated conservatively unless the
athlete fails to improve, which leads to surgical
management
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Lower Leg Injuries—(cont.)
• Compartment syndrome
– Emergent condition that results from acute trauma to
the lower leg
– Increase in pressure caused by soft tissue swelling
– Fasciotomy may be performed.
– Can be chronic, which can be very limiting
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Ankle Injuries
• Most common site for injury
– Ankle sprains
• Most common is injury to the lateral ligament with
an inversion and plantarflexion injury.
• Syndesmotic “high sprain” occurs with medial
ankle sprains with forced eversion
• Treatment involves protection, rest, ice,
compression, and elevation.
• The severity of the injury dictates the treatment
plan.
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Ankle Injuries—(cont.)
• Most common site for injury
– Ankle fractures
– Physeal fractures in children below age 12 is highly
probably with lateral ankle injury.
– Management includes cast followed by rehab
program.
– Triplane fractures in older children cause by forceful
forces
– Tillaux occurs when ATFL is avulsed.
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Ankle Injuries—(cont.)
• Ankle impingement
– Causes by anterior, antereolateral, or posterior pain
– Caused by formation of an osteophyte on the distal
tibia
– Posterior is caused by repetitive pointing of the toes.
– Management is rest, NSAIDS, and surgical excision
of the bone.
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Foot Injuries
• Overuse injuries
– Varies depending on the athlete’s age
– Achilles tendinitis and plantar fasciitis are seen in
older athlete
– Sever’s disease—pain along the calcaneus
• Traction apophysitis of the calcaneus at the
insertion of the Achilles tendon
• Treatment is pain control, restoration of muscle
flexibility, and strengthening of the foot.
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Foot Injuries—(cont.)
• Overuse injuries
– Iselin
• Traction apophysitis to the proximal fifth
metatarsal
• Pain along lateral foot
• Rest and flexibility activities
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Foot Injuries—(cont.)
• Overuse injuries
– Tendinitis and plantar fasciitis
• Pain along the Achilles tendon
• Rest, stretching, orthotics, and balance activities
• Tendonitis in posterior tibialis, flexor hallicus
longus, and peroneal tendons can be seen.
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Foot Injuries—(cont.)
• Traumatic
– Lisfranc (midfoot) injury
• Tarsometatarsal joint
• Low axial metatarsal load on a plantarflexed foot
• Managed conservatively unless unstable
• Return to sports may be questionable.
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Foot Injuries—(cont.)
• Bony abnormality
– Tarsal coalition
• Congenital malformation where two or more tarsal
bones are fused
• Mobility in the midfoot is restricted.
– Accessory navicular
• Congenital formation of a small ossicle next to
navicular
– Conservative and surgical treatments are available.
– Activity modification and orthotics
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Forefoot Injuries—(cont.)
• Fractures
– Metatarsal fractures are a result of trauma with the
fifth metatarsal being the most common.
– May be seen in dancers
– Jones fracture
• Proximal diaphysis of the fifth metatarsal
• Turf toe
– Hyperextension injury to the first MTP
– Ligamentous sprain
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Spine Injuries
• General examination
– Thorough examination
– Onset, duration, and response
– Posture
– Palpation
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Spine Injuries—(cont.)
• Spondylolysis
– Fracture of the pars interarticularis of the lumbar
spine
– Most common
• Spondylolisthesis
– Anterior slippage of one vertebral body on another
– L5-S1 is the most common site.
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Spine Injuries—(cont.)
• Treatment involves reducing the offending forces.
• Utilize a TLSO or soft corset.
• Core strengthening/stabilization
• Balance between mobility and stabilization
• Graded return to activity
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Other Spine Pathologies
• Posterior element overuse syndrome
– Refers to a constellation of conditions involving
muscle tendons, ligaments, facet joints, and joint
capsules that creates pain in the lower back
– Treatment consists of rest, activity modification, and
rehabilitation.
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Other Spine Pathologies—(cont.)
• Apophysitis
– Mechanical pain that is irritated with repetitive
motion of the spine
• Stingers
– Traction injury of the brachial plexus C-5 and C6
– Symptoms resolve quickly unless prolonged.
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Sports-Related Concussion
• 50% of all concussions go unnoticed.
• Pathophysiology
– Axonal injury and damage to mitochondria
– If a second injury occurs prior to healing, then the
brain is at higher risk.
• Signs and symptoms
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Sports-Related Concussion—(cont.)
• Risk factors
– History of previous concussion 2 to 5 times greater
risk
– Type of sports
– Age and brain maturity
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Sports-Related Concussion—(cont.)
• Management and return to play
– Assessment of consciousness
– Sideline testing
– Medical follow-up
• Diagnosis and assessment
– Neurophysiologic testing
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Sports-Related Concussion—(cont.)
• Special considerations
– Second impact
– Postconcussion syndrome
– Prevention
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Female Athlete
– Hormonal changes produce a natural increase
in body fat for girls and an increase in lean
body mass for boys.
– With maturation, boys develop larger muscle
fibers than do girls.
– Women present with less muscle strength than
their male counterparts.
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Female Athlete—(cont.)
• After puberty, female athletes have lower maximal
oxygen uptake due to physiologic cardiovascular
differences.
– Lower oxygen-carrying capacity of the blood,
fewer red blood cells, lower hemoglobin
content, smaller hearts, and lower stroke
volume
• In most endurance events, women cannot perform
at the same level as men.
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Musculoskeletal Injuries
• Anatomic differences often predispose females to certain
specific musculoskeletal conditions.
– Wider pelvis, anteverted femurs, a larger Q angle,
external tibial torsion, and increased ligament laxity
• Women are therefore at higher risk for acquiring shoulder
impingement, snapping hip syndrome, ACL rupture,
patellofemoral pain syndrome, stress fractures, and
metatarsal fractures.
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Female Athlete Triad
• Disordered eating, osteoporosis, and amenorrhea
• Prevalence of eating disorders among female
athletes is estimated at 15% to 62% of all
participants.
• Disordered eating represents a serious medical
condition.
• Fatigue, dizziness, cold intolerance, bradycardia,
hair loss, and constipation may be observed.
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Female Athlete Triad—(cont.)
• Osteoporosis is diagnosed by dual-energy x-ray
absorptiometry (DEXA) scans that measures bone
mineral density.
• When a DEXA scan measures bone mineral density
that falls 2.5 standard deviations below the age
norm for an individual, a diagnosis of osteoporosis
is made.
• A smaller decline in bone mineral density from 1 to
2.5 standard deviations below the norm is called
osteopenia.
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Female Athlete Triad—(cont.)
• Maximize performance, improving health and
nutrition, improving training, and deemphasizing
weight and body size
• Increasing muscle mass, balancing nutritional and
energy needs, and performing appropriate sportspecific skills
• Awareness and prevention of the female athlete
triad is the best approach.
– Requires education or reeducation of the
majority members of society who influence
female athletes’ goals, perceptions, and
performance
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Summary
• Developing good exercise habits early in life establishes
healthier lifestyles.
• With the increases in youth recreational and competitive
sports participation comes a heightened inherent risk of
injury.
• Proper prevention and education of parents and coaches
is essential.
• Though youth may participate in the same types of
sports, there are important differences between the two
which need to be respected.
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