Treating youngsters’ athletic injuries

With children and teens under pressure to star on the playing field, sports injuries have become common. Here’s how to recognize and treat them.

Roughly 30 million children and adolescents in the United States participate in some type of organized sport, and nearly 25% of all injuries sustained by these young athletes are directly related to these activities. The youngsters generally have little time, if any, between seasons, and during the seasons there are few intervening periods of rest. This relentless competition and training causes excessive stress-related injuries to soft tissues and bones.

Common stress and overuse injuries in children and adolescents are often termed apophysitis. In addition to being a secondary ossification center in the growing skeleton, the apophysis is the site of tendon insertion into bone. Apophysitis is caused by micro-avulsion fractures and injuries at the cartilage-bone junction. These injuries are caused by repetitive motion during rapid periods of skeletal growth. The resultant inflammation can lead to pain, swelling, and bony overgrowth. Some common sites of apophyseal injuries include the medial epicondyle of the elbow (known as Little League elbow), the distal pole of the patella (Sinding-Larsen-Johansson syndrome), the anterior tibial tubercle (Osgood-Schlatter disease), and the calcaneus (Sever disease).

Luckily, most injuries can be managed with conservative treatment, education, and adoption of realistic athletic goals. This article will discuss apophysitis diagnoses, treatment, and management, including when it is safe for the patient to return to sports.

Little League elbow

The elbow is the most common site of injury in skeletally immature baseball players 9-12 years of age. Little League elbow is apophysitis of the medial epicondyle caused by throwing for long periods of time or excessively high pitch counts.

Most patients will present to your office with a vague complaint of pain in the medial aspect of the elbow. They may also complain of decreased speed or control of their pitches.

Diagnosis: The diagnosis is often made simply with a detailed history and physical exam. The history should focus primarily on the number of pitches thrown per week. The USA Baseball Medical and Safety Advisory Committee recommends a conservative pitch count of 75-125 per week, or no more than 75 pitches per game. Determine how many teams the patient is on and if there are any resting and throw-free periods during the year.

The clinician should also take into account previous or repetitive elbow injuries, hand dominance, position played, and any changes in velocity or control of pitches. Also look for parasthesias, decreased range of motion, or numbness.

Mild-to-moderate swelling may be noted along the affected elbow joint. The patient will often complain of tenderness to palpation along the medial (and to a lesser degree lateral) epicondyle. He may also complain of tenderness along the distal arm or along the proximal medial forearm.

A number of different forces are at work while an elbow is going through the arc of motion for a throw. During the acceleration and follow-through phase, force is exerted on the medial side of the elbow, with compression on the lateral side. The repetitive force on the medial apophysis at the tendon insertion leads to the inflammation and pain.

Radiographs: Radiographs may be normal or they may reveal bony fragmentation, medial epicondyle hypertrophy, loose bodies, or osteochondral lesions. If any of these irregularities are seen, the patient should be referred to a pediatric sports medicine expert.

Treatment: In the acute phase, the clinician can use splinting, rest, elevation, ice, and nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. Rest from pitching and throwing as well as activity modification to avoid motion in which the elbow would be stressed, such as lifting heavy objects, should be initiated for four to six weeks, followed by a gradual and progressive rehabilitation program. Once full strength and flexibility have been achieved, the athlete can return to a full competitive throwing program.

Encourage the parent and child or adolescent to practice prevention. This consists of precise monitoring of pitch counts and limiting the number of innings pitched. Coaches should be educated about proper pitch counts and the symptoms of Little League elbow. In addition, the clinician should strongly encourage young athletes—especially pitchers and catchers—to take several days of rest between games. The athlete should also have preseason conditioning—a gradual increase in the intensity, velocity, and amount of pitching.

Sinding-Larsen-Johansson syndrome

Sinding-Larsen-Johansson syndrome is an apophysitis caused by chronic repetitive tension in the area of the inferior pole of the patella. Patients usually present with knee pain, which is exacerbated by sports involving jumping and running. The syndrome is most commonly seen in rapidly growing adolescents 11-15 years of age, but it can develop in athletes as young as age 9. The condition is self-limiting and will subside when growth is complete.

Diagnosis: Diagnosis is made through astute clinical evaluation. The clinician must rule out other sources for the pain including fracture, slipped capital femoral epiphysis (SCFE) (remember to examine the hip), and soft-tissue injuries around the knee. The pain at the inferior pole of the patella is exacerbated with maximum flexion or extension of the knee. At times, walking up or down stairs can worsen the pain.

Radiographs: The clinician should obtain anteroposterior and lateral radiographs of the knee if there is the possibility of another diagnosis in the knee region, such as a fracture. Remember that knee pain can sometimes be referred, and an anteroposterior and frog lateral radiograph of the hips should be obtained if there is any suspicion of an SCFE. For Sinding-Larsen-Johansson syndrome, the radiographs may be normal, but they may also show a small ossicle at the inferior pole of the patella (Figure 1).

Treatment: Most patients respond well to conservative measures(i.e., rest from painful activity, ice, NSAIDs, and a gradual return to activities). A formal physical therapy plan or home-exercise program focusing on hamstring and quadriceps strengthening and stretching facilitates a pain-free return to sports. If the patient does have ossicles at the inferior pole of the patella, casting may be recommended. In that case, the patient should be referred to a pediatric orthopedic surgeon.

Osgood-Schlatter disease

The most common overuse injury in children is Osgood-Schlatter disease, which is a traction apophysitis at the anterior tibial tubercle. Osgood-Schlatter disease affects teenage boys and preteen girls during their periods of most rapid growth. The exact cause is unknown, but it is commonly thought to be a response to repetitive microtrauma caused by traction at the tibial tuberosity. Osgood-Schlatter is typically seen in youngsters involved in such running and jumping sports as basketball, soccer, gymnastics, football, and volleyball. High impact and poor flexibility are contributing factors.

Roughly 20%-30% of patients will complain of bilateral symptoms. Patients often present with specific knee pain, pointing to the tibial tubercle. Many patients will also present with some swelling in the same area. This is thought to be caused by repetitive microtrauma or microfractures at the patellar tendon- tibial tuberosity interface. Some patients may be left with a residual bony deformity or painful ossification at the distalmost end of the patellar tendon.

Diagnosis: A detailed history and physical exam are needed for diagnosing Osgood-Schlatter disease. After determining all the sports the patient participates in, ask about any history of trauma and characterization of the pain (including a visual analog scale rating, type of pain, how often pain occurs, when it occurs, and what relieves it). Keep in mind that knee pain can often be referred from the hip, so examine the hip to rule out any pathology, such as a septic joint, dislocation, or most commonly an SCFE.

If you begin to suspect hip involvement, obtain radiographs of both the hips and the knee, and, if indicated, refer to a pediatric orthopedic surgeon that day.

Radiographs: Anteroposterior, lateral, and sunrise views of the affected knee (or knees) may demonstrate fragmentation or irregular ossification at the anterior tibial tubercle (Figure 3). Radiographs are rarely indicated unless you suspect other pathology, such as SCFE. Let the physical exam be your guide.

Treatment: Conservative treatment (i.e., rest from painful activities, icing, and analgesics as needed) is the best approach for Osgood-Schlatter disease. Patients respond very well to a flexibility program focused on hamstring stretching and quadriceps strengthening utilizing straight leg raises. Try to convince the patient to cease participating in the sport causing the pain. If patients do not respond well to conservative therapy or resist giving up a sport, refer to a pediatric orthopedic surgeon so he can provide a long leg cast for three to four weeks to let the inflammation resolve.

Sever disease

Calcaneal apophysitis (Sever disease) is the most common cause of heel pain in childhood athletes. The condition is typically seen between ages 9 and 12. This traction apophysitis is usually secondary to repetitive microtrauma or overuse of the heel.

Factors that contribute to this syndrome are a tight Achilles tendon with coinciding tightness of the gastrocnemius-soleus complex. Sever disease is often seen in such high-impact sports as basketball, soccer, track, and gymnastics. The disease is more prominent in the preseason and early training periods, when youngsters are practicing on hard playing surfaces in poorly cushioned shoes (e.g., soccer cleats on hard fields).

Up to 60% of patients are affected bilaterally. Sever disease is self-limiting and has no long-term complications. Diagnosis: As with all other forms of apophysitis, diagnosis is made through thorough history-taking and physical exam. The history should include presentation of symptoms, sports played, pain profile, and any previous foot or ankle injuries.

During the physical exam, a patient will often present with swelling at the distal Achilles tendon or the posterior calcaneus not associated with other pathology in the foot or ankle. Patients will also have exquisite focal tenderness with palpation on medial and lateral compression of the posterior calcaneus. The pain can be so severe at times that the patient may be unable to bear weight on the heel. In addition, he will have a tight tendo Achilles and limited ankle dorsiflexion. He may also present with a significant antalgic gait.

Radiographs: Radiographs of the heel should be obtained to rule out any other pathology, such as calcaneal fracture, bone cyst, or possible tumor. In Sever apophysitis, radiographs usually appear normal but may show possible fragmentation or sclerosis of the calcaneus. (Figure 4)

Treatment: The optimum treatment for Sever disease is education and counseling about its self-limiting nature. In addition, the patient needs to be put on an activity-modification program, including rest and icing when symptoms arise. You should also recommend a home flexibility program to stretch the Achilles tendons. This program should be incorporated into the patient’s everyday routine. NSAIDs can also be used during the acute phase, and heel cushions can help prevent further symptoms.

Most patients are able to return to full pain-free activity in three to six weeks. A useful rule of thumb for these patients is that as soon as they have pain or start to limp, they must stop activity for that day. If they experience pain and limping for three consecutive days, they should be instructed to stop all high-impact activity for one month and perform their Achilles stretching.

Severe pain calls for referral to a pediatric orthopedic surgeon. The patient can be casted for three to four weeks to give the heel a chance to rest and then started on a formal physical therapy regimen to regain strength, agility, proprioception, and range of motion.

Mr. Kleposki is a pediatric orthopedic nurse practitioner in the division of orthopedic surgery at the Children’s Hospital of Philadelphia.

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