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Adolescent Ortho. Anthony Beutler, MD Primary Care Sports Medicine. Top 10 “The Caddie” Comments. Dr. Brennan: “I think I’m going to drown myself in that lake.”. Caddie: “Think you can keep your head down that long?. Objectives.

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adolescent ortho

Adolescent Ortho

Anthony Beutler, MD

Primary Care Sports Medicine

top 10 the caddie comments
Top 10 “The Caddie” Comments

Dr. Brennan: “I think I’m going to drown myself in that lake.”

Caddie: “Think you can keep your head down that long?

  • Describe the unique role of “growth” as a risk factor for adolescent musculoskeletal overuse injures
  • Discuss the clinical presentation and management of common overuse injuries unique to adolescents
  • Data Collection on injury rates in children and adolescents is very poor
  • Overload injuries are epidemic secondary to adult training regimens
  • “Growth” site injuries predominate with Osgood-Schlatter disease thought to be the most common
  • Young athletes complaining of pain generally “have something going on” and not just the aches and pain of athletic activity
growth cartilage
Growth Cartilage
  • Growth Plate (epiphyseal plate)
  • Artic. Cartilage
  • Apophysis (tendon insertion)
top 10 the caddie comments1
Top 10 “The Caddie” Comments

Dr. Howard: “I’d move heaven and earth to break 100 on this course.”

Caddie: “Try heaven; you’ve already moved most of the earth!”

osgood schlatter s disease clinical features
Osgood-Schlatter’s DiseaseClinical Features
  • History- Young Athlete complains of painful enlargement of the tibial tuberosity; pain worse with activity
  • Physical- Tender Tibial Tubercle; tight extensor mechanism
  • Imaging- May be fragmentation of the Anterior Tibial Tuberosity
osgood schlatter s disease differential diagnosis
Osgood-Schlatter’s DiseaseDifferential Diagnosis
  • Sinding-Larsen-Johansson Disease
  • Osteochondroma
  • Bi-partite Patella
  • Patellofemoral Pain Syndrome
  • Osteochondritis Dissecans
  • Tibial Tubercle Avulsion Fracture
top 10 the caddie comments2
Top 10 “The Caddie” Comments

Dr. Nasin: “Do you think I can get there with a 5 iron?”

Caddie: “Eventually.”

osteochondritis dissecans clinical description
Osteochondritis DissecansClinical Description
  • Avascular Necrosis of Subarticular Bone probably secondary to repetitive trauma involving bone with a marginal blood supply
  • Most Commonly involves the lateral aspect of the medial femoral condyle
  • Males more commonly affected; disorder is frequently bilateral
osteochondritis dissecans differential diagnosis
Osteochondritis DissecansDifferential Diagnosis
  • Osteosarcoma
  • Discoid Meniscus
  • Osteochondral Fracture
top 10 the caddie comments3
Top 10 “The Caddie” Comments

Dr. Ho: “Please stop checking your watch all the time. It’s a distraction.”

The Caddy: “It’s not a watch – it’s a compass.”

sever s disease clinical features
Sever’s DiseaseClinical Features
  • History- Most Commonly seen in early adolescence; presents with heel pain in the morning and with activity
  • Physical- Tenderness over the Calcaneus; tight hamstrings and gastrocsoleus
  • Imaging- May see fragmentation or sclerosis of the calcaneus apophysis
sever s disease differential diagnosis
Sever’s DiseaseDifferential Diagnosis
  • Stress Fracture
  • Reflex Sympathetic Dystrophy
sever s disease treatment
Sever’s DiseaseTreatment
  • Activity Modification
  • Heel Cord Flexibility
  • Heel Lifts
  • Immobilization for 2-3 weeks
top 10 the caddie comments4
Top 10“The Caddie” Comments

Dr. Meyering: “That can’t be my ball. It’s too old.”

Caddie: “It’s been a long time since we teed off, Sir.”

little league elbow clinical description
Little League ElbowClinical Description
  • The most commonly recognized injury complex in the young throwing athlete
  • Throwing creates predictable force loads across the elbow
    • Tension across the Medial structures
    • Compression across the Lateral structures
little league elbow clinical features
Little League ElbowClinical Features
  • History- Insidious onset of pain; decreased performance, or loss of motion in the throwing athlete
  • Physical- Tenderness in the medial, lateral or posterior elbow; may demonstrate a mild flexion contracture
  • Imaging- Plain films may be nl; may need bone scan, CT and/or MRI
little league elbow differential diagnosis
Little League ElbowDifferential Diagnosis
  • Panner’s Disease
  • Medial Apophysitis
  • OCD of Capitellum
  • Olecranon Apophysitis
  • Hypertrophy of Ulna
  • Normal Variant
  • Neoplastic Process
  • Neuropathy
little league elbow treatment
Little League ElbowTreatment
  • Medial Stress Lesion- 4-6 weeks of activity modification
  • Lateral Lesions- Orthopedic Consultation
  • Pitching Program
top 10 the caddie comments5
Top 10“The Caddie” Comments

Dr. Burkdall:

“How do you like my game?”

Caddie: “Very good, but personally I prefer golf.”

little league shoulder clinical features
Little League ShoulderClinical Features
  • History- Insidious onset of activity related proximal arm/shoulder pain
  • Physical- Rotator Cuff weakness and impingment in young athlete
  • Imaging- Plain films may demonstrate widening of the epiphyseal plate
little league shoulder differential diagnosis
Little League ShoulderDifferential Diagnosis
  • Rotator Cuff Disorders
  • Glenohumeral Instability
  • Neoplastic Disease
little league shoulder treatment
Little League ShoulderTreatment
  • Sports Medicine Referral
  • No throwing for 3 months
  • Specialized rotator cuff and throwing rehab
  • Gradual return to throwing program (after 3 months)
top 10 the caddie comments6
Top 10 “The Caddie” Comments

Dr. Howe: “This is the worse course I’ve ever played on!”

The Caddie: “This isn’t the golf course. We left that an hour ago.”

Who gets it?

Girls 9–15 yo, Boys 11–18 yo

Most common in obese or rapidly growing

What is it?

Unstable growth plate fracture

Most Common Hip Disorder in Adolescents

Stable vs Unstable

Slipped Capital Femoral Epiphysis


When do I think about it?

ANY Adolescent with hip pain or ext. rotation, thigh pain or knee pain

Hip exam with limited internal rotation or obligate external rotation with flexion

Where do I send the patient next?

Xray in wheelchair

Klein’s Line on AP Hip Films

Orthopedic Surgery – NON-WEIGHT BEARING, next 72 hours

Klein’s Line on AP



Frog Leg

Slipped Capital Femoral Epiphysis

When and What to Do

slipped capital femoral epiphysis imaging
Slipped Capital Femoral EpiphysisImaging
  • Imaging- Frog Leg Pelvis; Bone Scan and/or CT if clinically suspicious
slipped capital femoral epiphysis differential diagnosis
Slipped Capital Femoral Epiphysis Differential Diagnosis
  • Legg-Calve Perthes Disease
  • Stress Fracture
spondylolysis clinical description
SpondylolysisClinical Description
  • The most frequent anatomic lesion diagnosed in the adolescent athlete with low back pain
  • Mechanical injury to the Pars Interarticularis
  • Most commonly involves L5
spondylolysis clinical features
SpondylolysisClinical Features
  • History- Insidious onset; worse with activity, particularly hyperextension; may radiate to the buttocks
  • Physical- Single leg hyperextension test; hamstring flexibility
  • Imaging- Plain films may demonstrate a “collar” on the Scotty dog; Spect Imaging may be needed
spondylolysis differential diagnosis
SpondylolysisDifferential Diagnosis
  • Discogenic Disease
  • Spondylolisthesis
  • Atypical Scheuermann’s Disease
  • Osteoid Osteoma
  • Infection
spondylolysis treatment
  • Consider Orthopedic Referral
  • Activity Modification
  • Lumbo-sacral stabilization program
  • Ant-lordotic bracing
  • Surgical options
  • The most common apophyseal injuries are:
    • Osgood Schlater
    • Sever’s Dz
    • Little Leaguer’s Elbow
    • Little Leaguer’s Shoulder
summary cont
Summary (cont)
  • When ordering x-rays on kids, always order _________ films
  • (T/F) Swollen knees in kids are common and respond well to benign neglect
  • A child who complains of pain with activity usually has: