Chapter 14 Sports Injuries in Children and Adolescents Elliot M. Greenberg and Eric T. Greenberg

1. Chapter 14 Sports Injuries in Children and Adolescents Elliot M. Greenberg and Eric T. Greenberg

2. Introduction • More than 38 million children participate in sports. • With participation is inherent risks. • Sports injuries in children include both traumatic and overuse conditions. • Account for about 25% of all childhood reported injuries

3. Anatomic and Physiologic Differences of the Skeletal Immature Athlete • Bone composition • Presence of growth plates • Physeal fractures can be caused by overuse as well as trauma. • Present of apophysis (secondary growth centers) • Decreased muscle tendon flexibility during growth spurts • Advantage in bone healing

4. Anatomic and Physiologic Differences of the Skeletal Immature Athlete—(cont.) • Muscular properties • Recent reports have shown that prepubescent children can demonstrate strength gains. • There is support for safe and effective strength training with supervision by a trained adult. • Decreased flexibility during growth spurt, which could lead to more injury.

5. Examination • History • Recent changes should be noted. • Nature of the injury • Use age-specific language. • Know the athlete’s playing position, level of player (recreational to elite), years of participation, and primary sport.

6. Physical Examination • Perform standardized examination principles • Ligamentous laxity in pediatrics should be respected. • 0/9 is normal, 9/9 is highly lax • Running examination in running athletes • Should include closed kinetic chain activities • Identifies sources of the pain, musculoskeletal malalignments, abnormal joint motion, muscle atrophy, and muscular weakness

7. Physical Examination—(cont.) • Muscle testing should include functional movement testing • Functional tests provide information regarding balance, alignment, body awareness, strength, control, and core stability.

8. Upper Extremity Examination and Treatment • Shoulder • Include postural assessment • Note scapular position, thoracic kyphosis, and general appearance. • Shoulder movement • Overhead athletes have less internal rotation than external, and this can be normal if less than 20 degrees difference.

9. Upper Extremity Examination and Treatment—(cont.) • Elbow • Look at biomechanics of the transfer of movement from lower extremities to upper extremities. • Note any limitations in the biomechanical chain.

10. Upper Extremity Examination and Treatment—(cont.) • Scapular stabilization in an endurance capacity should be included in any upper extremity rehab program. • After the regaining of function, a return to throw program can be developed.

11. Treatment Planning • Begin exercising with the limb below shoulder level, within pain-free ROM prior to exercising above 90 degrees of shoulder elevation. • Scapulo-thoracic musculature, particularly posterior muscles such as middle and lower trapezii, is another important focus of quality rehabilitation. • Focus should be on stabilization and endurance. • The role of the core and hip/pelvic musculature in shoulder rehabilitation is also important.

12. Treatment Planning—(cont.) • Shoulder multidirectional instability (MDI) is another common problem in this age group. • Typically results from generalized ligamentous laxity • Recognition of this disorder and counseling regarding injury risk due to systemic ligamentous laxity will benefit the patient. • Traumatic dislocation that does not result in a tear of the antero-inferior glenoid labrumbut simply stretches the capsule • Avoidance of horizontal glenohumeral extension

13. Treatment Planning—(cont.) • Alter the position of the extremity during exercises. • Generalized shoulder pain resulting from overuse or rapid advancement of training protocols is often caused by tendinitis with secondary impingement. • Findings would be positive special test results, a tight posterior rotator cuff or shoulder capsule, weakness of the posterior scapulothoracic musculature and external rotators, and forward rounded shoulders.

14. The Pediatric Throwing Athlete • Athletes are predisposed to certain injuries. • Principles can be applied to any overhead activity like volleyball, tennis, and swimming.

15. “Little League” Shoulder • Encountered in the pediatric and adolescent athlete • Defined as a stress reaction or fracture of the proximal humeral physis • Plain films or bone scans are often used but are sometimes not definitive. • Palpatory tenderness over the physis is diagnostic if rotator cuff testing and other test results are negative.

16. “Little League” Shoulder—(cont.) • Treatment for little league shoulder is primarily rest. • Review throwing mechanics. • Then ensure good balance and core strength/function. • Scapulothoracic strengthening • Gradually return to throwing program. • Modify throwing volume.

17. Superior Labrum Anterior to Posterior Lesions (SLAP) • Result of trauma and overuse • Throwing athletes are prone to this. • Can result in laxity in the shoulder • Treatment is rest followed by rehabilitation. • Surgical intervention may be necessary to return the athlete to their level of play.

18. Elbow Lesions Most elbow injuries require: • Rest • Gentle ROM • Strengthening • Slow return to sports when pain free

19. Elbow Lesions—(cont.) • Little league elbow • Traction injury to medial epicondyle due to valgus stress during throwing • Pain during throwing • Panner disease • In kids 4 to 8 years old • Necrosis of the capitellum

20. Elbow Lesions—(cont.) • Medial epicondyle apophysitis • Result of repetitive tensile forces • Medical epicondyle avulsion fracture • Stress which causes an avulsion • Ulnar collateral ligament injury • Cumulative trauma in young athletes

21. Elbow Lesions—(cont.) • Osteochondritis dissecans (OCD) • Repetitive microinjury that leads to subcondral fractures • Conservative treatment • Surgical treatment may be indicated.

22. Other Shoulder Pathologies • Multidirectional instability • Caused by acute traumatic dislocation or by capsular laxity • Presents with bilateral shoulder pain with unstable feeling • Glenohumeral translation • May have associated impingements • Education and strengthening of shoulder stabilizers • Return to sport training should include activities that replicate the movement.

23. Other Shoulder Pathologies—(cont.) • Traumatic shoulder dislocation • Anterior is the most common direction • Fall in an abducted and externally rotated position • Conservative treatment is immobilization. • Treatment is based on symptoms. • Operative management varies. • Avoid aggressive ROM.

24. Other Shoulder Pathologies—(cont.) • AC joint separations • Caused by fall onto the shoulder • Clavicle fractures • Surgery only if displaced or comminuted • Immobilization 2 to 4 weeks • Slow return to sports

25. Other Shoulder Pathologies—(cont.) • Supracondyle elbow fractures • Risk of neurovascular complications • Lateral condyle fractures • Monteggia fracture • Radial dislocation with an ulnar fracture

26. Forearm, Wrist, and Hand Injuries • Fractures occur as a result of falls and can occur anywhere on the radius or ulna. • Usually treated with reduction and immobilization • Indications for surgery include open or unstable fracture or fractures that are not healing.

27. Forearm, Wrist, and Hand Injuries—(cont.) • Gymnast wrist • Pain from overuse • Restrict from activities for a period of time • Scaphoid fractures • Most common carpal bone fracture • Sometimes difficult to diagnose on first x-ray

28. Forearm, Wrist, and Hand Injuries—(cont.) • Fracture of the Hook of the Hamate • Mistimed swing that translates forces • Boxer’s fracture • Fracture at the fifth metacarpal • Finger fracture • Majority are treated by closed reduction.

29. Pelvis, Hip, and Thigh Injuries • Examination principles • Detailed history • Mechanism of injury and location of pain • ROM • Muscle testing

30. Pelvis, Hip, and Thigh Injuries—(cont.) • Pelvic apophysitis • Growth and immature skeleton lead to tensile forces on the pelvis • ASIS, AIIS, lesser trochanter, iliac crest, and greater trochanter • Well-localized dull pain with activity • Pain progresses with activity. • Treatment is rest and modification of activity. • Strengthening to the surrounding muscles

31. Pelvis, Hip, and Thigh Injuries—(cont.) • Pelvic avulsion fractures • Unmanaged apophysitis in adolescents • Hear a “pop” • May require surgery • Snapping hip syndrome • Friction of the ITB • Can be internal or external • Treatment is conservative with emphasis on stretching.

32. Pelvis, Hip, and Thigh Injuries—(cont.) • Femoral stress fracture • Common in runners • Femoral acetabular impingement and labral tears • Abutment and approximation of the femoral head or neck with the acetabular ring • Deep hip and groin pain in the shape of a “C” • Reproduce pain with hip flexion, adduction, and internal rotation • Most often need surgical repair • Gradual and slow return to sport

33. Pelvis, Hip, and Thigh Injuries—(cont.) • Muscle strains • Occur frequently and can cause apophyseal avultions • Hamstring strains are common. • Traumatic hip dislocation • In high-impact sports • Emergent situation • Slipped capital femoral epiphysis (SCFE) • Posterior slippage of the proximal epiphysis • More prevalent in boys who have increased BMI • Surgical fixation is required. • Protected weight bearing

34. Pelvis, Hip, and Thigh Injuries—(cont.) • Legg–Calve–Perthes • Idiopathic osteonecrosis of the capital epiphysis of the femoral head presenting in males 4 to 8 years old • Lack of blood flow can lead to necrosis. • Present with pain and limping • Limitations in hip IR and abduction • Maintain hip mobility and limit pain • May require surgery if conservative treatment fails

35. Knee Injuries • Examination • History • Mechanism of injury • Detailed pain assessment • Gait assessment

36. Ligamentous Injuries • ACL injuries • Most severe and frequent activity-related injury • Can cause avulsion fractures more commonly in children • Treatment based on degree of injury • Surgical options • Post-op rehab focus on effusion management, maintaining knee extension, and restoration of quadriceps activation • Intensive rehab may take months to return to sports

37. Ligamentous Injuries—(cont.) • ACL injury prevention • Risk increases for females • Risk increases for athletes above 10 • Injury prevention programs have developed

38. Ligamentous Injuries—(cont.) • MCL injuries • Valgus stress to the knee • Usually from a fall from another athlete • Conservative management with a quicker return to sports

39. Ligamentous Injuries—(cont.) • PCL injuries • Direct blow to the knee • Conservative management • Quad strengthening • LCL injuries • Rare in pediatrics • Seen with injury to the entire posterior capsule

40. Intra-articular Injuries • Meniscus injury • Congenital “discoid” meniscus are more likely to develop a tear. • Pain, effusion, and snapping or clicking present • Tears in older children from twisting • Treatment depends on location. • Post-op rehab includes limited weight bearing and ROM.

41. Intra-articular Injuries—(cont.) • OCD • Knee is the most commonly involved joint. • Conservative management for the stable lesion • Rehab for strengthening • Surgery for unstable lesions • Rehab protocols vary depending on the surgery.

42. Intra-articular Injuries—(cont.) • Acute patellar dislocation and osteochondral fractures • Planting or twisting injuries • Osteochondral fractures typically occur. • Surgery for displaced fractures

43. Overuse Injury • Patellofemoral pain syndrome • Caused by biomechanical alterations proximally and distally • Dull ache under the knee • Treatment focuses on removing the offending causes • Rest and pain-free activities • Adjunct treatment

44. Overuse Injury—(cont.) • Patellar tendinopathy • Older adolescents with fused growth plates develop a tendinopathy. • Mechanical overuse • Relative rest • Stretching and flexibility • Plica syndrome • Irritation of the bands of synovial tissue lining the knee • Treatment is similar to patellofemoral pain syndrome.

45. Lower Leg Injuries • Shin splints • General term to describe pain in the lower leg • Includes: • Medial tibia stress syndrome • Pain along the anterio-medial plane of the distal to one-third of the tibia with running and jumping • Biomechanical contributing forces • Treatment is rest, followed by low-impact activities, followed by balance and dynamic control exercises.

46. Lower Leg Injuries—(cont.) • Tibial stress fracture • Activities that include repetitive loading to the lower leg • Contributing factors include improper training programs, high BMI, excessive pronation, and/or high or low arch. • Initially treated conservatively unless the athlete fails to improve, which leads to surgical management

47. Lower Leg Injuries—(cont.) • Compartment syndrome • Emergent condition that results from acute trauma to the lower leg • Increase in pressure caused by soft tissue swelling • Fasciotomy may be performed. • Can be chronic, which can be very limiting

48. Ankle Injuries • Most common site for injury • Ankle sprains • Most common is injury to the lateral ligament with an inversion and plantarflexion injury. • Syndesmotic “high sprain” occurs with medial ankle sprains with forced eversion • Treatment involves protection, rest, ice, compression, and elevation. • The severity of the injury dictates the treatment plan.

49. Ankle Injuries—(cont.) • Most common site for injury • Ankle fractures • Physeal fractures in children below age 12 is highly probably with lateral ankle injury. • Management includes cast followed by rehab program. • Triplanefractures in older children cause by forceful forces • Tillaux occurs when ATFL is avulsed.

50. Ankle Injuries—(cont.) • Ankle impingement • Causes by anterior, antereolateral, or posterior pain • Caused by formation of an osteophyte on the distal tibia • Posterior is caused by repetitive pointing of the toes. • Management is rest, NSAIDS, and surgical excision of the bone.