Pediatric and Adolescent Sports Medicine: Introducton to Orthopaedics

1. Pediatric and Adolescent Sports Medicine: Introducton to Orthopaedics Stephen P. England, MD MPH Park Nicollet Orthopaedics

6. Pediatric Sports Medicine • Fueled by public interest in fitness and sports culture • Continues to undergo rapid growth • Increasing participation by girls in sports (e.g. Title IX) • Improvements in diagnostic and treatment technology

7. Pediatric Sports Medicine • Injury Profile • the majority of injuries are minor • no harmful effect on the growth plates • secondary to repetitive cyclic loading • no lasting sequelae

8. Pediatric Sports Medicine • Only 5-7% of injuries will require surgery or hospitalization • Vast majority are secondary to overuse

9. Pediatric Sports Injuries • Epidemiology • 3/100 primary school • 7/100 junior high school • 11/100 high school

10. Pediatric Sports Injuries • Epidemiology • 1/14 (7%) adolescents seen in an emergency room for an acute sports-related injury • Gallager, et al

11. Classification of Sports Injuries • Overuse Sydromes • Frictional (Patello-femoral syndrome) • Tractional (Osgood-Schlatter disease) • Cyclic (shin splints, stress fractures)

12. Classifications of Sports Injuries • Chronic Instability • ankle • knee • shoulder • elbow

13. Classification of Sports Injuries • Acute Trauma • ligament injuries • fracture • physeal injury

14. “Child athletes are not small adult athletes” • hyperelastic joints • malleable bones • epiphyses • apophyses • psychologic implications • management by proxy

15. “Child athletes are not small adult athletes” • all complaints must be thoroughly investigated • be vigilent for burnout

16. Osgood-Schlatter’s Disease • History • 11-15 years of age • jumping or running athlete • presents as focal pain directly over the tibial tubercle • pain is exacerbated by running and jumping

17. Osgood-Schlatter’s Disease • Physical Exam • tenderness and mild swelling of tibial tubercle • prominence of tibial tubercle is a late physical finding

19. Osgood-Schlatter’s Disease • Management • rest • ice • oral anti-inflammatory medication • quadricep stretching exercises

20. Osgood-Schlatter’s Disease • Management • return to participation may be accompanied by a change of position • mild pain during activity is not an absolute contraindication to participation • mild symptoms may persist until closure of the underlying growth plate

21. Sinding-Larsen-Johansson (SLJ) Disease • History and Physical • 10-12 years of age • pain and tenderness at the proximal or distal pole of the patella • secondary to tension of the quadriceps at its insertion site

23. Sinding-Larsen-Johansson Disease • Management • rest • ice • anti-inflammatory medications • counsel family regarding the spontaneous resolution over a period of 12-18 months

24. Little Leaguer’s Elbow(traction apophysitis of the medial epicondyle) • History • secondary to distractive force during late cocking and acceleration phases of throwing • frequently seen in pitchers and infielders • also seen in immature tennis players

25. Little Leaguer’s Elbow(traction apophysitis of the medial epicondyle) • Physical Exam • pain on the medial aspect of the elbow • localized swelling over the medial epicondyle • x-rays - fragmentation, sclerosis, and widening of the medial epicondylar apophysis

29. Little Leaguer’s Elbow(traction apophysitis of the medial epicondyle) • Management • ice • oral anti-inflammatory medication • rest until symptoms abate • stretching and strengthening once pain resolves

31. Little Leaguer’s Elbow(traction apophysitis of the medial epicondyle) • Management • alteration of throwing style to reduce the degree of sidearm delivery is advisable during rehabilitation • rest a minimum of 3-4 weeks • pain with pitching is not tolerated • frank avulsion in older throwers is not uncommon and frequently requires surgical repair

32. Sever’s Disease(traction apophysitis of the calcaneus) • History • 9-12 years of age • common in field sports • frequently bilateral • due to excessive tightness of the calf muscles and plantar fascia

33. Sever’s Disease(traction apophysitis of the calcaneus) • Physical Exam • tenderness over the posterior aspect of the heel • restriction in dorsiflexion of the ankle • x-ray - fragmentation and sclerosis of the calcaneal apophysis

34. Sever’s Disease

35. Sever’s Disease(traction apophysitis of the calcaneus) • Management • rest • calf and plantar fascia stretching • shock-absorbing shoe inserts • modify activities or sports

36. Patello-femoral Syndrome • History • poorly localized anterior knee pain • frequently bilateral • pain increases with: • increased activity • prolonged sitting (movie sign) • ascending or descending stairs

37. Patello-femoral Syndrome • Physical Exam • tenderness over the inferomedial aspect of the patella • tenderness over the medial soft tissues • lateral tilting of the patella • increased passive translation medially and laterally

38. Patello-femoral Syndrome • X-rays / Workup • AP, lateral, skyline view of both knees • Skyline views may reveal lateral translation or tilting of the patella • MRI is not necessary for typical cases

41. Patello-femoral Syndrome • Management • goal = strengthen the quadriceps • stabilization of patella within the femoral trochlea • isometric quadriceps strengthening in full extension is preferred

43. Patello-femoral Syndrome • Management • “quad sets” with straight leg raising • gradually increase ankle weights to 10% body weight • return to participation may require a patella stabilization brace • soft tissue or osseus surgery may be required for those failing conservative treatment

44. “Shin Splints”

45. Shin Splints • Shin splints is a catch-all term referring to a collection of conditions (medial tibial stress syndrome, tibial stress fracture, exercise-induced compartment syndrome) • exercise-induced mid leg pain • bilateral - 50% • must work-up stress fracture, exercise induced compartment syndrome

46. Shin Splints • History • recent change in training regimen, shoes, or running surface • exercised-induced mid leg pain

48. Shin Splints • Physical Exam • perform a complete exam of lower extremities • tenderness along the tibial margin • pain is diffuse rather than focal (stress fracture)

49. Shin Splints • Management • Rest, ice, and compression • anti-inflammatory medication • counseling on training techniques may be necessary prior to resuming sports

50. Stress Fractures • History • well localized unilateral leg pain • occurs with sports and non-athletic activities