Transcript Photo of Man and Child

Pediatric and Adolescent
Sports Medicine: Introducton
to Orthopaedics
Stephen P. England, MD MPH
Park Nicollet Orthopaedics
Pediatric Sports Medicine
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Fueled by public
interest in fitness and
sports culture
Continues to undergo
rapid growth
Increasing
participation by girls
in sports (e.g. Title IX)
Improvements in
diagnostic and
treatment technology
Pediatric Sports Medicine
Injury Profile
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the majority of injuries are minor
no harmful effect on the growth plates
secondary to repetitive cyclic loading
no lasting sequelae
Pediatric Sports Medicine
 Only
5-7% of injuries
will require surgery
or hospitalization
 Vast majority are
secondary to overuse
Pediatric Sports Injuries
Epidemiology
• 3/100
• 7/100
• 11/100
primary school
junior high school
high school
Pediatric Sports Injuries
Epidemiology
• 1/14 (7%) adolescents seen in an
emergency room for an acute
sports-related injury
Gallager, et al
Classification of Sports Injuries
Overuse Sydromes
• Frictional (Patello-femoral syndrome)
• Tractional (Osgood-Schlatter disease)
• Cyclic
(shin splints, stress fractures)
Classifications of Sports Injuries
Chronic Instability
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ankle
knee
shoulder
elbow
Classification of Sports Injuries
Acute Trauma
• ligament injuries
• fracture
• physeal injury
“Child athletes are not small adult
athletes”
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hyperelastic joints
malleable bones
epiphyses
apophyses
psychologic implications
management by proxy
“Child athletes are not small adult
athletes”
• all complaints must be thoroughly
investigated
• be vigilent for burnout
Osgood-Schlatter’s Disease
History
• 11-15 years of age
• jumping or running athlete
• presents as focal pain directly over the tibial
tubercle
• pain is exacerbated by running and jumping
Osgood-Schlatter’s Disease
Physical Exam
• tenderness and mild swelling of tibial
tubercle
• prominence of tibial tubercle is a late
physical finding
Osgood-Schlatter’s Disease
Management
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rest
ice
oral anti-inflammatory medication
quadricep stretching exercises
Osgood-Schlatter’s Disease
Management
• return to participation may be accompanied
by a change of position
• mild pain during activity is not an absolute
contraindication to participation
• mild symptoms may persist until closure of
the underlying growth plate
Sinding-Larsen-Johansson (SLJ)
Disease
History and Physical
• 10-12 years of age
• pain and tenderness at the proximal or distal
pole of the patella
• secondary to tension of the quadriceps at its
insertion site
Sinding-Larsen-Johansson Disease
Management
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rest
ice
anti-inflammatory medications
counsel family regarding the spontaneous
resolution over a period of 12-18 months
Little Leaguer’s Elbow
(traction apophysitis of the medial epicondyle)
History
• secondary to distractive force during late
cocking and acceleration phases of throwing
• frequently seen in pitchers and infielders
• also seen in immature tennis players
Little Leaguer’s Elbow
(traction apophysitis of the medial epicondyle)
Physical Exam
• pain on the medial aspect of the elbow
• localized swelling over the medial epicondyle
• x-rays - fragmentation, sclerosis, and widening
of the medial epicondylar apophysis
Little Leaguer’s Elbow
(traction apophysitis of the medial epicondyle)
Management
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ice
oral anti-inflammatory medication
rest until symptoms abate
stretching and strengthening once pain resolves
Little Leaguer’s Elbow
(traction apophysitis of the medial epicondyle)
Management
• alteration of throwing style to reduce the degree
of sidearm delivery is advisable during
rehabilitation
• rest a minimum of 3-4 weeks
• pain with pitching is not tolerated
• frank avulsion in older throwers is not
uncommon and frequently requires surgical
repair
Sever’s Disease
(traction apophysitis of the calcaneus)
History
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9-12 years of age
common in field sports
frequently bilateral
due to excessive tightness of the
calf muscles and plantar fascia
Sever’s Disease
(traction apophysitis of the calcaneus)
Physical Exam
• tenderness over the posterior aspect of the heel
• restriction in dorsiflexion of the ankle
• x-ray - fragmentation and sclerosis of the
calcaneal apophysis
Sever’s Disease
Sever’s Disease
(traction apophysitis of the calcaneus)
Management
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rest
calf and plantar fascia stretching
shock-absorbing shoe inserts
modify activities or sports
Patello-femoral Syndrome
History
• poorly localized anterior knee pain
• frequently bilateral
• pain increases with:
• increased activity
• prolonged sitting (movie sign)
• ascending or descending stairs
Patello-femoral Syndrome
Physical Exam
• tenderness over the inferomedial aspect
of the patella
• tenderness over the medial soft tissues
• lateral tilting of the patella
• increased passive translation medially
and laterally
Patello-femoral Syndrome
X-rays / Workup
• AP, lateral, skyline view of both knees
• Skyline views may reveal lateral
translation or tilting of the patella
• MRI is not necessary for typical cases
Patello-femoral Syndrome
Management
• goal = strengthen the quadriceps
• stabilization of patella within the femoral
trochlea
• isometric quadriceps strengthening in full
extension is preferred
Patello-femoral Syndrome
Management
• “quad sets” with straight leg raising
• gradually increase ankle weights to 10%
body weight
• return to participation may require a patella
stabilization brace
• soft tissue or osseus surgery may be
required for those failing conservative
treatment
“Shin Splints”
Shin Splints
• Shin splints is a catch-all term referring
to a collection of conditions (medial
tibial stress syndrome, tibial stress
fracture, exercise-induced compartment
syndrome)
• exercise-induced mid leg pain
• bilateral - 50%
• must work-up stress fracture, exercise
induced compartment syndrome
Shin Splints
History
• recent change in training regimen,
shoes, or running surface
• exercised-induced mid leg pain
Shin Splints
Physical Exam
• perform a complete exam of lower
extremities
• tenderness along the tibial margin
• pain is diffuse rather than focal
(stress fracture)
Shin Splints
Management
• Rest, ice, and compression
• anti-inflammatory medication
• counseling on training techniques may be
necessary prior to resuming sports
Stress Fractures
History
• well localized unilateral leg pain
• occurs with sports and non-athletic
activities
Stress Fractures
• repetitive stress applied in excess of a
bone’s ability to repair itself
• typically occurs when an athlete begins
training
• less common than in adults
• incidence increases throughout childhood
Stress Fractures
Incidence
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tibia
55%
fibula
20%
pars interarticularis 15%
femur
5%
metatarsals
5%
Stress Fractures
Sports
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running
basketball
gymnastics
football
ice skating
24%
13%
21%
9%
15%
(tibia)
(tibia)
(pars)
(pars)
(fibula)
Stress Fractures
Work-up
• x-rays
• cortical lucency
• periosteal reaction
Stress Fractures
Stress Fractures
Stress Fractures
Management
• eliminate running and other repetitive
loading activities
• failure to heal may necessitate
immobilization, protected weight-bearing
and surgical fixation
Physeal Injury
Little Leaguer’s Shoulder
• 12-15 year old pitchers
• gradual or sudden onset of pain in the
shoulder
• symptoms increase during the follow
through stage of the pitch
Physeal Injury
Little Leaguer’s Shoulder
• secondary to repetitive overuse
• seen in the proximal humeral physis of
adolescent pitchers
Physeal Injury
X-ray diagnosis
• widening of the proximal humeral physis
Little Leaguer’s Shoulder
The range of athletes
Physeal Injury
Management
• rest until resolution of the physeal
changes
Ligamentous Injury
The Knee
• medial collateral ligament (MCL)
• anterior cruciate ligament (ACL)
Medial Collateral Ligament
(MCL)
• less common than physeal injuries
• occurs most commonly in children prior to
the growth spurt and in adolescents after
growth plate closure
• secondary to a valgus force on the knee
Medial Collateral Ligament (MCL)
Physical Exam
• effusion is minimal
• valgus stress in 30 degrees of flexion
produces pain and demonstrated laxity
proportionate to the severity of the injury
Medial Collateral Ligament (MCL)
 rest
and early motion with full weight-bearing
when tolerated
 return to sports when full motion and strength
are attained
 rest ranges from 2-6 weeks
Anterior Cruciate Ligament (ACL)
• mechanism of injury
• Hyperextension
• valgus stress and external rotation of a
flexed knee
• usually occurs during running when
changing direction
• an audible “pop,” swelling within 12
hours, and an inability to continue playing
Anterior Cruciate Ligament (ACL)
Physical Exam
• excessive anterior displacement of the
tibia with respect to the femur
• absence of a firm endpoint to tibial
translation is best demonstrated in 30
degrees of flexion
Anterior Cruciate Ligament (ACL)
• X-ray
• MRI
identifies osseous avulsions of
the ACL
confirms ACL injury and
identifies associated meniscal
damage
Anterior Cruciate Ligament (ACL)
Management
• conservative treatment (bracing and
strengthening)
• surgical treatment for more mature
adolescents (transphyseal vs overthe-top)
ACL Repair
Ankle Injuries
• Physeal plates
• Ankle ligaments (sprains)
Ankle sprain vs Fibular fracture
Acute ligmentous ankle injuries
Work-up
• assess site of maximal tenderness
• distinguish between physeal injury and
ligament injury
• x-rays - AP, lateral, “mortise” view
Acute ligamentous ankle injuries
• Grade 1 Mild
minimal swelling, pain, and disability
• Grade 2 Moderate
partial disruption of ligaments with difficulty with
weight-bearing
• Grade 3 Severe
complete ligament disruption with extensive
bleeding and disability
Acute ligamentous ankle injuries
• 90% involve the lateral ligaments
• 33% will require only 2 weeks of
immobilization
Acute ligmentous injuries
Management
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R.I.C.E.
Grade 1
Grade 2
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Grade 3
1 week off if necessary
2 weeks on crutches with
progressive weight-bearing
7-10 days of strict
immobilization followed by 4-8
weeks of “relative”
immobilization
Conclusion