Pediatric and Adolescent Sports Medicine: Introducton to Orthopaedics

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Pediatric and Adolescent Sports Medicine
Introducton to Orthopaedics

• Stephen P. England, MD MPH
• Park Nicollet Orthopaedics

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Pediatric Sports Medicine

• 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

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Pediatric Sports Medicine

• Injury Profile
• the majority of injuries are minor
• no harmful effect on the growth plates
• secondary to repetitive cyclic loading
• no lasting sequelae

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Pediatric Sports Medicine

• Only 5-7 of injuries will require surgery or
  hospitalization
• Vast majority are secondary to overuse

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Pediatric Sports Injuries

• Epidemiology
• 3/100 primary school
• 7/100 junior high school
• 11/100 high school

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Pediatric Sports Injuries

• Epidemiology
• 1/14 (7) adolescents seen in an emergency room
  for an acute sports-related injury
• Gallager, et al

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Classification of Sports Injuries

• Overuse Sydromes
• Frictional (Patello-femoral syndrome)
• Tractional (Osgood-Schlatter disease)
• Cyclic (shin splints, stress fractures)

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Classifications of Sports Injuries

• Chronic Instability
• ankle
• knee
• shoulder
• elbow

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Classification of Sports Injuries

• Acute Trauma
• ligament injuries
• fracture
• physeal injury

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Child athletes are not small adult athletes

• hyperelastic joints
• malleable bones
• epiphyses
• apophyses
• psychologic implications
• management by proxy

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Child athletes are not small adult athletes

• all complaints must be thoroughly investigated
• be vigilent for burnout

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Osgood-Schlatters 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

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Osgood-Schlatters Disease

• Physical Exam
• tenderness and mild swelling of tibial tubercle
• prominence of tibial tubercle is a late physical
  finding

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Osgood-Schlatters Disease

• Management
• rest
• ice
• oral anti-inflammatory medication
• quadricep stretching exercises

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Osgood-Schlatters 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

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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

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Sinding-Larsen-Johansson Disease

• Management
• rest
• ice
• anti-inflammatory medications
• counsel family regarding the spontaneous
  resolution over a period of 12-18 months

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Little Leaguers 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

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Little Leaguers 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

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Little Leaguers Elbow(traction apophysitis of
the medial epicondyle)

• Management
• ice
• oral anti-inflammatory medication
• rest until symptoms abate
• stretching and strengthening once pain resolves

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Little Leaguers 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

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Severs Disease(traction apophysitis of the
calcaneus)

• History
• 9-12 years of age
• common in field sports
• frequently bilateral
• due to excessive tightness of the calf muscles
  and plantar fascia

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Severs 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

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Severs Disease
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Severs Disease(traction apophysitis of the
calcaneus)

• Management
• rest
• calf and plantar fascia stretching
• shock-absorbing shoe inserts
• modify activities or sports

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Patello-femoral Syndrome

• History
• poorly localized anterior knee pain
• frequently bilateral
• pain increases with
• increased activity
• prolonged sitting (movie sign)
• ascending or descending stairs

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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

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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

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Patello-femoral Syndrome

• Management
• goal strengthen the quadriceps
• stabilization of patella within the femoral
  trochlea
• isometric quadriceps strengthening in full
  extension is preferred

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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

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Shin Splints
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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

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Shin Splints

• History
• recent change in training regimen, shoes, or
  running surface
• exercised-induced mid leg pain

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Shin Splints

• Physical Exam
• perform a complete exam of lower extremities
• tenderness along the tibial margin
• pain is diffuse rather than focal (stress
  fracture)

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Shin Splints

• Management
• Rest, ice, and compression
• anti-inflammatory medication
• counseling on training techniques may be
  necessary prior to resuming sports

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Stress Fractures

• History
• well localized unilateral leg pain
• occurs with sports and non-athletic activities

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Stress Fractures

• repetitive stress applied in excess of a bones
  ability to repair itself
• typically occurs when an athlete begins training
• less common than in adults
• incidence increases throughout childhood

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Stress Fractures

• Incidence
• tibia 55
• fibula 20
• pars interarticularis 15
• femur 5
• metatarsals 5

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Stress Fractures

• Sports
• running 24 (tibia)
• basketball 13 (tibia)
• gymnastics 21 (pars)
• football 9 (pars)
• ice skating 15 (fibula)

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Stress Fractures

• Work-up
• x-rays
• cortical lucency
• periosteal reaction

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Stress Fractures
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Stress Fractures
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Stress Fractures

• Management
• eliminate running and other repetitive loading
  activities
• failure to heal may necessitate immobilization,
  protected weight-bearing and surgical fixation

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Physeal Injury

• Little Leaguers 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

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Physeal Injury

• Little Leaguers Shoulder
• secondary to repetitive overuse
• seen in the proximal humeral physis of adolescent
  pitchers

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Physeal Injury

• X-ray diagnosis
• widening of the proximal humeral physis

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Little Leaguers Shoulder
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The range of athletes
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Physeal Injury

• Management
• rest until resolution of the physeal changes

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Ligamentous Injury

• The Knee
• medial collateral ligament (MCL)
• anterior cruciate ligament (ACL)

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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

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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

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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

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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

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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

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Anterior Cruciate Ligament (ACL)

• X-ray identifies osseous avulsions of the ACL
• MRI confirms ACL injury and identifies
  associated meniscal damage

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Anterior Cruciate Ligament (ACL)

• Management
• conservative treatment (bracing and
  strengthening)
• surgical treatment for more mature adolescents
  (transphyseal vs over-the-top)

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ACL Repair
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Ankle Injuries

• Physeal plates
• Ankle ligaments (sprains)

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Ankle sprain vs Fibular fracture
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Acute ligmentous ankle injuries

• Work-up
• assess site of maximal tenderness
• distinguish between physeal injury and ligament
  injury
• x-rays - AP, lateral, mortise view

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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

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Acute ligamentous ankle injuries

• 90 involve the lateral ligaments
• 33 will require only 2 weeks of immobilization

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Acute ligmentous injuries

• Management
• R.I.C.E.
• Grade 1 1 week off if necessary
• Grade 2 2 weeks on crutches with progressive
  weight-bearing
• Grade 3 7-10 days of strict immobilization
  followed by 4-8 weeks of relative
  immobilization

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Conclusion