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Sports and Overuse Injuries in Children

Both acute and overuse injuries can occur at a physis. A 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. The epiphysis is really more of an area here, this is the femur, this is the tibia. Itís where musculotendinous unit attaches to bone and both of these areas do close with a bony fusion.

About 15 to 20% of these 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 donít know if boys are hurt more often than girls, or if itís just because boys are a little bit more exposed.

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.

You may or may not see on your radiographs widening of the physis, but thatís really what youíre looking for. We donít 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, whatís 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.

Little leaguerís 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 leaguerís 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 leaguerís elbow has been used.

What happens is the medial side gets stretched, there is a potential for compression on the lateral side of the elbow which is important in the differential diagnosis. Again, this diagram reproduced from that article on throwing injuries and the position in sports medicine. The medial epiphysis is really here. You can see the ulnar collateral ligament sometimes called the medial collateral ligament has three bands that help contribute to it, the anterior band, posterior and transverse band. Here is the annular ligament which is involved in Nursemaidís elbow, this is the radius, this is the ulna.

Imaging, again, low threshold for x-rays, AP lateral and obliques, the elbow is probably where I find comparison views to be the most helpful just because of the variances in the appearance of the major ossification centers of which there are six. You may see physeal widening, you may not, you may need additional imaging, this is not a perfect example, this is a relatively mature elbow here, but again, this is the radius, this is the ulna humerus. What youíre focusing on here is again the medial epicondyle.

The treatment again is very similar to little leaguer shoulder. It takes several weeks of relative rest, you want to avoid weights and resistance exercises initially, so you really want to go slowly, although you can do again the general conditioning. You want to progress to sports specific type activities. I think with the elbows, Iíd have a fairly low threshold for early referral.

This is small and hard to see, but again I just wanted to point out the complexity of the throwing motion, if this emphasizes the importance of trunk stabilization. What I try to emphasize in sports and when Iím teaching about this, is that if you have an athlete who has trouble holding this position with their leg up and they demonstrate trunk instability, then they are going to come down with a short stride here, their shoulder is going to lag behind and they are going to compensate through acceleration and deceleration with arm throwing, that really is one of the more common things that I see contributing that sometimes fails to get addressed in kids who have recurrent problems.

Moving down the arm, the distal radius. Again, 45% of long bone fractures involve the radius, about 75% occur distally. Itís 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 in that position. Repetitive stresses can cause sclerosis and they may cause premature growth plate closure.

Moving down to the pelvis, again, pain in the hip area can be very poorly localized and really hard to pin down. Itís 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, I think they tend to present more acutely or potentially acute on chronic, they have had hip pain for three months and then had an event.

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 thatís 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 the ischial tuberosity.

Moving down to the knee, knee physeal injuries, most common are distal femur, and of course the proximal tibia. Itís a very broad differential diagnosis and really, even just the talk on pediatric knee pain is probably itís own individual talk. It may be cartilage problems, ligament, meniscal injuries, or bad things. I recommend getting very good viewing images of the knee, and particularly if the patient presents with abnormal range of motion or an effusion.

What I want to show here, squeeze in an example of a sky liner or Merchant sunrise view, all those terms can apply. Just to you again, you can get two for the price of one, you can have comparison. Itís as if youíre looking at the patientís knee, so this is right, this is left, and this is a patient who actually presented, a 15-year-old with what seemed to be a patellar dislocation.

Two more additional imaging that I want to show you from my clinic, all these are from my clinic, again, the standing AP, you can see some of the detail is lost, but again, this was an almost 16-year-old male who came in with a twisting injury in basketball and had knee pain, he presented with an effusion and lack of about 10 degrees of extension. Look at this film, physis, he looks pretty skeletally mature and in all the other views werenít any other abnormalities, but he had tremendous femoral condyle type pain when you palpated and his knee seemed very stable to me in terms of ligament, so I suspected the potential for physeal injury.

I sent him for an MRI fairly quickly, and as you can see here, one, you can see his physes are still easily visualized in the MRI, there is this big metaphyseal extension of his fracture here, and although you canít see it as well, he actually had a fracture of the proximal tibia as well, so these were two separate injuries. He was treated in a cylinder leg cast for about four weeks.

The knees are the first thing to go, in kids, I think itís the most common thing, knee pain, I think the examples I showed previously, they come far and few in between all the Osgood-Schlatterís and other more common types of knee pain that we see. Again, pain in the Osgood-Schlatterís is localized to the tibial tubercle. It can affect as many as 205% of athletes, it may be less common in non-athletes, girls, it tends to occur just a little bit younger than the boys, they say more commonly unilateral, but I see a fairly frequent number of cases of bilateral pathology as well. Itís typically associated with jumping and cutting.

Imaging studies, it may be a little bit controversial in terms of should you image these routinely or not. If itís bilateral, if itís classic and they seem to fit into grade I or II, and there is nothing else thatís really worrying you, then I think you can get away without an image and start treatment, and see them back in four to six weeks to make sure that things are going well. If they are not doing well, and if there is anything that worries you, then go ahead and get x-rays.

What we do look for sometimes, this is a 13-year-old boy who had anterior knee pain for several months, and what you look for sometimes and this isnít a great example, but elevation of the tibial tubercle here. What they show you on the side over here is a different patient who had sort of pain along the length of his patellar tendon, he seemed a little bit sore here, seemed particularly tender at the inferior pole of the patella, and he has this sort of inferior patellar sleeve fracture, sometimes an ossicle can actually occur here in this area. Sometimes even in Osgood-Schlatterís you can have ossicles in the distal patellar tendon as well.

Treatment again, first thing is to tell parents that this is a self-limiting condition, kids really do outgrow this problem, the problem is that they show up at 8, 9, 10 years old, it may be several years before t heir growth plates close, and they are going to continue to grow, so flexibility is going to continue to be an issue. Icing the knee can help, prepost exercise, lots of flexibility, as much as you can encourage. Stresses across the knee joint in general, in terms of therapy occur with flexion.

Sever disease, calcaneal epiphysitis, they often present with heal pain, they may or may not have a painful bump at the insertion of the Achilles tendon. Almost at the same age in girls and boys, same contributing factor, growth spurt, weak ankle dorsiflexors repetitive microtrauma, and improper biomechanics. I look for things, again, have them stand.

Just to summarize, pediatric athletes are more susceptible to growth plate injuries, so thatís the thing you want to rule out first, pain at the end of long bones is a bony problem until proven otherwise. Proceed from there, and again, if you feel comfortable as a primary care doctor with basis anatomy and have some knowledge of biomechanics, you should be able to make a good job of diagnosis and initiate diagnostic imaging and even treatment. I want you to feel comfortable with referring as well.