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Sports and Overuse Injuries

The physis is a well organized layer of cartilage separating primary and secondary ossification centers until the growth plates close in late adolescence, and the physis, if you look over here really refers to the area where axial and circumferential growth occur here sports injuries, overuse injuries, children. The epiphysis is really more of an area here, this is the femur, this is the tibia. It’s where musculotendinous unit attaches to bone and both of these areas do close.

About 15 to 20% of injuries occur to long bones involving the growth plate, the occur in a ratio of 2 to 1, upper versus lower extremity and an injury ratio of 2 to 1 for boys versus girls. This number is really not adjusted for injury rates, so we really don’t know if boys are hurt more often than girls, or if it’s just because boys are a little bit more exposed to the potential for injury because of more participation. The peak incidence occurs during the growth spurt and as I will talk about the contributing factors to these kinds of injuries, really, the growth spurt is significant because the bone is growing very fast and you worry about muscle tendon imbalances and flexibility issues as the soft tissues of the body.

In general, in the history and exam, an injury occurring at the end of a long bone is a physeal injury until proven otherwise. As you know, we consider the growth plate the weakest structure around the joint and that which is most likely to be injured. It’s more common than dislocations or ligament injuries, and again, there may be direct trauma or again, focusing on the overuse aspect of this talk, repetitive indirect trauma. You may see pain, swelling, loss of motion, asymmetry and deformity.

Again, diagnostic studies, at this course you are going to see tons and tons of radiographs. Radiographs are essential. If you have bony tenderness and you suspect a growth plate injury, I would x-ray what you’re worried about. Of course, always obtain two views. Consider comparison views. As we go through the talk, I will point out where I think comparison views tend to be more helpful. Additional imaging can be helpful. This is a 15-year-old patient I saw who had several months of wrist pain that really didn’t seem to be very distinct bony pain at the distal radius, however, she really didn’t respond that quickly to casting and appropriate therapy and we got a bone scan just to confirm whether there was anything going on.

We gave her about six more weeks of relative rest, a brace and some strengthening exercises and her pain did resolve about three months after the original injury. Again, some of the detail may be lost, but in regard to x-rays and special views, I wanted to give you some good examples. We in sports try to think very functionally, and I think if you look at someone, it’s important to think of looking at your athletes in both the standing and sitting position. We have gone so far as to do that radiographically as well. So here, this is a standing bilateral AP and the advantage of this is you get two for the price of one. You have a free comparison. So it’s something to think about.

This was, I believe, a 13 or 14-year-old boy who presented with one year of painless knee swelling. What you can’t really appreciate probably in the back of the room, the one thing that was clear clinically as well as on the x-ray, here, you can see the edge of the shadow of his patella versus here, and what he had was a high riding patella on the right side as well as his effusion and what you definitely can’t see in the back of the room, is there is a hint of a little pathology here, so this you can clearly see in much more detail, this is what we call a tunnel or a notch view and this brings in much more detail that he had an osteochondral defect here. What the notch view is doing, is really opening up the joint a little bit more.

Again something I eluded to earlier, what contributes particularly to overuse injuries, but it can also contribute to acute injuries are intrinsic and extrinsic factors. The intrinsic factors really refer to growth, anatomic alignment which are not very easy to control, but muscle tendon and balance, flexibility and conditioning are important factors to look at when you are assessing the athlete and they also can be potentially addressed in terms of potential and rehabilitation. In terms of extrinsic factors, training errors, environment and equipment all play a significant role. It’s helpful to be familiar with these issues in regard to sports.

We are going to talk now about some sports specific injuries. Little leaguer shoulder, proximal, humeral, epiphyseolysis. What that is, a fracture through the proximal epiphyseal cartilage of the proximal humerus. It is commonly seen in ages 11 to13, they may be a high performance athlete, can be males or females, and again, extrinsic and intrinsic factors are all playing a roll in this injury, so repetitive throwing, improper biomechanics, joint laxity, under developed musculature, muscle tenon imbalances and then of course your open growth plates.

You may or may not see on your radiographs widening of the physis, but that’s really what you’re looking for. We don’t really have a good example of the x-ray, but we will talk about the differential diagnosis. Again, it can be the osteochondrosis of the physis, but you think about stress fractures potentially, instability, impingement syndrome, what’s called a slap lesion.

I would like to point out in kids, impingement syndrome with rotator cuff tendinitis, in kids, the instability is the most common inciting factor to cause rotator cuff tendinitis, so these often go hand in hand in kids. So treatment of little leaguers shoulder, if I point out the diagram here, genetics, joint laxity, the throwing mechanics, and then the pitches per week, the point of showing this and having all the circles overlap, again, just reinforces the idea.

We emphasize a gradual return to pitching, biomechanics are very important, particularly, I find, with the shoulder and elbow. There is sometimes a need to find a pitching coach or therapist who does video tape analysis and can really watch someone in slow motion. Fortunately, little league has gotten very good at setting some limits and guidelines on numbers of pitches.

Little leaguer’s elbow, again, moving down the arm refers to widening between the medial epicondyle and the underlying humerus. When we think of using the term little leaguer’s elbow, we are really not talking about ligamentous injury or anything else, we are really trying to specifically talk about the bony injury. However, the little leaguer’s elbow has been used.

Moving down the arm, the distal radius. Again, 45% of long bone fractures involve the radius, about 75% occur distally. It’s a common overuse injury in weight lifters and gymnasts, and again because of the stresses weight lifters have lifting the weights with the wrist and at this extreme dorsiflexed or extended position, particularly with military press, bench, inclines, and the gymnast, you can imagine just about every activity they do for tumbling to bars, they are bearing their body weight on their wrist.

Moving down to the pelvis, again, pain in the hip area can be very poorly localized and really hard to pin down. It’s nice that they come in and say they hurt in their hip, groin or buttock, but it can also be knee or thigh pain, so if they do present and localize the pain, then again, you can have insidious onset or acute onset, we are worried more about actual true avulsions.

There may be a bony union, the treatment is again relative rest, they tend to do well, they tend to not be unstable. You can use anti-inflammatories and icing. This happens with the mechanism of injury, a plant and a twist, but it has to do definitely with flexibility, so that’s a very important part of treating this and trying to prevent it from reoccurring. Then next most common area that I see happens to be the hamstrings pulling off.

Again, sometimes we can’t find something wrong, in this patient after extensive x-rays and blood tests, we confirmed what we already suspected, you are not big boned, you’re fat, most of the time if the bone hurts, there is something to find.