1 / 49

“Growing Pains” Injury and Skeletal Immaturity

“Growing Pains” Injury and Skeletal Immaturity. Ken Knecht, PT, MS, SCS, CSCS. Understanding the Population. Children are not “Little Adults”. Understanding the Population. “What’s the Difference?” Skeletal Maturity Physiology Strength (and the Ability to Develop It)

calista-riley
Download Presentation

“Growing Pains” Injury and Skeletal Immaturity

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. “Growing Pains”Injury and Skeletal Immaturity Ken Knecht, PT, MS, SCS, CSCS

  2. Understanding the Population Children are not “Little Adults”

  3. Understanding the Population • “What’s the Difference?” • Skeletal Maturity • Physiology • Strength (and the Ability to Develop It) • Psychological Maturity

  4. Understanding the Population • “What’s the Difference?” • Skeletal Maturity • Physiology • Strength (and the Ability to Develop It) • Psychological Maturity

  5. Growth & Development of the Young Athlete • Middle Childhood (6-9 yrs) • Maturation of Throwing and Kicking Patterns • Entry Level Sports (soccer, baseball/softball) • Males and females can still compete with parity • Males slightly Stronger; Girls better Balance • Running gait and speed are fairly equal • Late Childhood to Early Adolescence (10-15 yrs) • Onset of Puberty • “Growth Spurt” – Tanner Stage 3 • Differences emerge between sexes • Skill Acquisition and Development Easiest

  6. Growth and Development of the Young Athlete • Late Adolescence/Adulthood (16-20 yrs) • Increases in Strength & Size become more gradual • “Late Bloomers” may continue to lag behind • Skeletal maturity

  7. Growth and Development • Anatomic Changes Associated with Puberty • Boys Girls (Mean Age) Peak Height Velocity(14 yrs) Peak Height Velocity(12 yrs) Skeletal Maturity(16 yrs)Skeletal Maturity(14 yrs) **Introduction of Sex hormones(AthlTher Today 2002)

  8. Growth and Development • Significance of Peak Height Velocity • The “Growth Spurt” • ~ Tanner Stage 3 • Bone growth rate can exceed soft tissue accommodation • Hamstrings, Hip flexors, Quadriceps, and Plantarflexors • Decreased Coordination • Tightness can affect growth centers

  9. Growth and Development • Significance of Tanner Staging • 5 stages of Physical development • Stage 1 = Early Development • Stage 5 = Full Maturity • Correlation between Tanner stage and physeal closure. • Same Chronologic age ≠ Bone Age • Assists with the differential diagnoses

  10. Growth and Development • Tanner Stage 5 • Signals end of growth • Marked by full development of secondary sexual characteristics • Males will have full facial hair • Females will have final breast development

  11. Skeletally Immature Distinctions • Growth “Tissues” • Physis • Apophysis • Articular Cartilage • Issues: • Susceptibility to injury • Bone weakest link • Surgical Challenges

  12. “Growth Tissue” • Physis (Growth Plate) • Responsible for longitudinal growth of bone • Growth centers close distal to proximal • Growth centers begin to close in females approximately 18 – 24 months following menarche • Skeletal Maturity Completed • ~18 yrs females; ~21 yrs males • Injury to Physis could create growth disturbance (early closure or bony bridging)

  13. Anatomical Review http://www.davidlnelson.md/images/Physis_normal_annotated4.jpg

  14. Salter-Harris Fractures Type I: Fracture line extends across the physeal plate. Often undetected on X-ray Type II: Fracture line extends through the physeal plate and metaphysis Type III: Fracture line extends from the joint surface through the epiphysis and across the physis causing a portion of the epiphysis to become displaced Type IV: Fracture line extends from joint surface through the epiphysis, physeal plate and metaphysis causing a fracture fragment Type V: Crush injury to the growth plate

  15. Salter Harris Fractures Separated Above Lower Through ERammed

  16. Salter Harris Fracture • Distal Fibula • Usually an inversion/supination injury • Type I-II are the most common • Type I often misdiagnosed as ankle sprain

  17. Salter Harris Fracture • Key Finding on Physical Exam: • Point of Maximal Tenderness • Usually PTP at ATFL also

  18. Salter Harris Fracture • Boot immobilization (casting) • Depending on Type; 2-3 weeks + • Types III & IV require surgery • Pain free weight bearing status • Rehabilitation for post immobilization • ROM, strength, balance & proprioception • Sport specific training

  19. Little League Shoulder • Epiphysiolysis of proximal humerus • Rotational forces • Distractional forces • Overuse injury associated with pitching • Quantity • Intensity • Age

  20. Phases of Throwing www.hughston.com/hha/b_16_1_1a.jpg

  21. Little League Shoulder • Clinical Findings • Lateral, proximal shoulder pain • Weak & painful EROT and Abd • Palpable tenderness over physis • Radiographic widening of physis?

  22. Little League ShoulderTreatment • Aggressive rest to allow physeal healing • Address any ROM imbalances & Scapular dysfunction • GIRD, posterior capsule • Sick Scapula • Scapular stabilization & strengthening • Rotator cuff strengthening • Review of throwing mechanics • Return to throwing progression • Modification of throwing volume (pitch counts) • May need to alter position • Address entire kinetic chain • Core strengthening • Lower extremity strength/flexibility and proprioception

  23. “Growth Tissue” • Apophysis • Cartilaginous structure usually located at the end of long bones • Attachment site for musculotendinous unit • Tensile forces can create inflammation = Apophysitis • Susceptible to Avulsion Fracture

  24. Apophysitis • Overuse injury • Often during periods of rapid growth • May remain symptomatic until closure of apophysis • Possible to result in an avulsion fracture

  25. Sever’s Disease • aka: Calcaneal Apophysitis • Common During Growth Spurt • Heel pain • Tight gastroc/soleus • Foot pronation • Running/jumping athletes • + Squeeze Test

  26. Sever’s Disease Treatment • Activity modification • Aggressive rest • Stretching!!! • Immobilization may be necessary • Can continue to play if pain is mild (no limp) • Typically resolves in several weeks (months?) • Footwear or insert

  27. Osgood-Schlatter’s Disease (OSD) • Apophysitis of the Tibial Tubercle • Traction Injury • Commonly seen • Boys aged 10 –15 • Girls aged 8 –13

  28. Osgood-Schlatter’s Disease (OSD) • Palpable tenderness • X-rays may be positive for displacement • In severe cases tubercle can avulse

  29. Osgood-Schlatter’s Disease (OSD)

  30. Sinding-Larsen-Johansson(SLJ) • Apophysitis of the inferior patellar pole • Anterior knee pain with impact activities • Commonly seen • Boys aged 10 –15 • Girls aged 8 –13

  31. Sinding-Larsen-Johansson (SLJ) • Palpable tenderness • Inferior pole sometimes patellar tendon • May have quadriceps lag • X-rays may be positive for displacement • Differential diagnosis • Patellar sleeve fracture

  32. Treatment for OSD and SLJ • Activity modification • Stretching quads and hams • Strengthening progression • Plyometric training to work on soft landings • May not have complete resolution of symptoms • In OSD permanent bump is likely

  33. Apophysitis of Hip/Pelvis • 7 sites at the femur and pelvis • During phase of rapid growth • Pain and inflammation at ossification centers • Iliac crest (common) • Pain with resisted trunk rotation/side bend and/or hip abduction • Seen in Runners, Football, and occasionally Baseball pitchers

  34. Apophysitis of Hip/Pelvis • Treatment • Rest • Activity modification • Trunk and pelvis flexibility • Core and hip strengthening • Treat the entire kinetic chain • Technique adjustment • Running gait

  35. Avulsion Fractures • Same areas affected as apophysitis • Occur with sudden, forceful contraction or stretching • Bone is the weakest link • Common sites include ASIS and Ischial tuberosity. • Often misdiagnosed as pulled muscle • Radiographic evaluation necessary for accurate diagnosis • Surgery if displacement is greater than 2-3cm (???)

  36. Avulsion Fractures • AIIS avulsion fracture in a 14 yr old soccer player

  37. Little League Elbow • Traction apophysitis of Medial epicondyle of Humerus • Overuse injury • Volume • Velocity • Increased mound to plate distance • Breaking Pitches? • Valgus stress during late cocking/acceleration • Flexor pronator muscle group • UCL? • Clinical presentation • Medial elbow pain • Diminished throwing speed and accuracy • Poor or altered throwing mechanics

  38. Little League Elbow • Treatment • RICE: Make rest your friend • Activity modification 6-12 weeks • No pitching or overhand throwing • Stretching • GIRD is Probable; Assess and address!!! • Strengthening • Forearm, posterior cuff, core, contralateral leg • Assess throwing mechanics • Functional progression to throwing program • Identify and correct training errors

  39. “Growth Tissue” • Articular Cartilage • Infrastructure similar to Physis • Increased Cellular activity • Not yet “Adult” solidity • Repetitive Injury or Excessive shearing forces may result in OsteochondritisDissecans (OCD)

  40. Osteochondritis Dissecans (OCD) • Impact and shear forces cause bone bruising • Cause is usually repetitive trauma • Genetic predisposition? • Subchondral bone death • Secondary damage to overlying cartilage • “Lesion of dissection” vsdessication • May affect any joint • Most frequently seen at knee, elbow, ankle

  41. OsteochondritisDissecans(OCD) • Risk Factors • Age:Occurs most often in people between the ages of 9 and 18 • Sex: Males are 2-3X more likely than females. • Sports participation: Sports that involve rapid changes in direction, jumping or repeated throwing may increase your risk

  42. ICRS Classification of OCD Grade I – Stable with continuous but softened area with intact cartilage Grade II – Stable with partial discontinuity Grade III – In situ lesions with complete discontinuity Grade IV – Empty defects with dislocated or loose fragments OsteochondritisDissecans(OCD)

  43. Osteochondritis Dissecans (OCD) • Epiphyseal microtrauma with osteochondral separation • Commonly Lateral aspect of Medial femoral condyle • Etiology is multifactorial • Trauma, ischemia, hereditary, idiopathic (?) • Under debate

  44. OsteochondritisDissecans(OCD)

  45. Clinical presentation Insidious onset of pain aggravated by activity Intermittent joint effusion Giving way, catching, or locking Symptoms suggestive of PFPS Confirmed with diagnostic imaging OCD of Femoral Condyle

  46. OCD of Femoral Condyle • Conservative Management • Immobilization • Weight bearing restriction • Activity restriction • Surgical intervention • Extent depends on Grade • Debridement /drilling • Refixation • Loose body removal • Operative resurfacing • ACI

  47. Clinical Summary • Bone weakest link in pre pubescent • Same Chronological age ≠Bone Age • Tanner staging helps differential • Protect Growth centers

  48. THANK YOU!!!

  49. Ken Knecht PT, MS, SCS, CSCS Board Certified Sports Clinical SpecialistThe Sports Medicine & Performance Center at CHOP Specialty Care Center at Virtua Health and Wellness Center, 2nd Floor200 Bowman Drive, Suite D260Voorhees, NJ 08043856-719-9932; Fax: 267-425-5416 knecht@email.chop.edu

More Related