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Common Overuse Adolescent Injuries. David B. Gealt, D.O. Assistant Professor UMDNJ-SOM Assistant Professor UMDNJ-RWJ Cooper Bone and Joint Institute Cooper University Hospital August 24, 2011. Understanding Normalcy. Inverted. Normal. Everted. Bow-legged. Knock-kneed. Normal.

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Common Overuse Adolescent Injuries

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common overuse adolescent injuries

Common Overuse Adolescent Injuries

David B. Gealt, D.O.

Assistant Professor UMDNJ-SOM

Assistant Professor UMDNJ-RWJ

Cooper Bone and Joint Institute

Cooper University Hospital

August 24, 2011

understanding normalcy
Understanding Normalcy







understanding normalcy cont
Understanding Normalcy,cont.

These are abnormal foot types…a normal or neutral foot type is a happy medium between these two.

Pes cavus = High arch foot

Pes planus = Flatfoot

best foot forward
A person who runs properly:

Lands on heel

Foot rolls to ball of toe while turning inward (pronates)

A person who runs flat footed:

Lands on heel AND ball of foot

Foot rolls inward excessively, which also causes the lower leg to turn inward

Best Foot Forward
  • A person who runs with a high arch:
    • Lands hard on heel
    • Doesn’t pronate enough to allow the impact of running to be absorbed through the body
    • The feet and outer part of knee and hip bear the brunt of each step
the right shoe basic qualities
How often do you need new shoes?

It depends on how much running you do per week…

Ex: Jog 60-70 mi/wk, replace shoes every 3-4 mos

Worn-out shoes (esp if soles are worn down unevenly) can be dangerous

They don’t provide proper support/stability anymore

Be aware of your foot type before purchasing new shoes

With all the new shoes available, choosing a shoe is no easy task…this is where running shoe store experts come in!

The Right Shoe:Basic Qualities
shoe inserts
Some flat-footed runners may turn their feet inward to such a degree that good running shoes alone aren’t good enough

Prescription orthotics are custom-designed from a mold of the foot

Sport orthotics should be made of soft, but firm materials

Shoe Inserts
stress fractures
Caused by repeated loading stresses

Most commonly in metatarsals (esp 2-4)

Other common sites are tibia and sesamoids

First symptom is pain, often vague but localized

Stress Fractures
  • History is extremely important
    • Usually 2-3 weeks into season
    • Often after radical increases in training
stress fractures cont
X-rays may not be positive for 3-4 weeks!

If the clinician has a high degree of suspicion, an early diagnosis can be made by bone scans and MRI

Stress Fractures,cont.
stress fractures treatment
Usually accommodative

Pneumatic CAM walker (pictured)

Cast boot

Below knee cast

Orthotic with aperture cut-outs for involved metatarsal to redistribute forces around it

Stress Fractures:Treatment
achilles tendonitis
Most important cause is inadequate heel cord flexibility

Other causes

Instability of foot and heel strike

Running on unyielding surfaces

Inadequate shoes

Achilles Tendonitis
shin splints
The most common running injury

Symptoms include tightness and aching in the front or back of the leg muscles during and after running

X-rays or MRIs must be taken to be sure of diagnosis

Other possible diagnoses with similar symptoms:

Stress fracture

Chronic compartment syndromes




Shin Splints
anterior shin splints
Often caused by change in running surfaces (from soft to hard), change in running pattern or change in shoes


Shoe inserts or orthotics

Ice massage

Strengthening exercises

Change in running surface (hard to soft)

Wearing shoes with thick, shock-absorbing soles

Anterior Shin Splints
posterior shin splints
Mostly caused by abnormal foot function in which the posterior muscles are overworked

Posterior muscles fatigue and fibers can tear loose from attachment to leg bone


Custom molded orthotics

Stretching exercises

Ice massage

Posterior Shin Splints
runner s knee a k a chondromalacia patella
Knee pain may appear during or after running

Frequently worse with running uphill or climbing stairs

Patellofemoral pain is in and around kneecap, often associated with swelling and a sense that the knee cap is “off track”

Runner’s Kneea.k.a. Chondromalacia Patella
chrondromalacia patellofemoral syndrome
Chrondromalacia (Patellofemoral Syndrome)
  • Seen in young active persons, either gender, female predominance
  • Subactue onset of patellar pain, worse walking, stairs, little pain at rest, theater sign
  • Running Hills
  • Joint shows reproduction of pain on pressing patella against femoral condyles—pushing down on kneecap
runner s knee cont
Therapy is planned after assessing patellar mechanics and leg alignment


quadriceps isometric strengthening exercises,




Runner’s Knee,cont.
ankle sprains
Ankle Sprains
  • The ankle sprain is most common single injury seen by sports medicine physicians.
  • This injury is often viewed as minor, but can be associated with prolonged disability and recurrent instability in 25-30% of patients.
returning to ambulation
Returning toAmbulation
  • 1.non-wgt bearing (crutches)
  • 2.Touch Down- Partial wgt bearing w/ crutches
  • 3.Full 4 point gait- Full wgt bearing w/ crutches
  • 4.Once crutch on opposite side
  • 5.Cane
  • 6.Nml gait
treatment prices
Treatment - “PRICES”
  • P - Protection
  • R - Rest
  • I - Ice
  • C - Compression
  • E - Elevation
  • S - Support
treatment support
Treatment - Support
  • Prevents re-injury during rehab and on return to activity
  • Use taping and/or bracing, air-stirrups, laced Swed-O/McDavid, Kalassy velcro wrap, or Active ankle
the traction apophysitises introduction
The Traction Apophysitises:Introduction
  • Categorized as overuse injuries
  • Once thought to be found only in elite, highly trained athletes
  • With the growth of organized sports for children and adolescents, have seen a large increase in these types of injuries
the traction apophysitises anatomy
The Traction Apophysitises:Anatomy
  • Associated with the growth cartilage
  • Located at three sites:
    • Epiphyseal plate
    • Joint Surface
    • Apophyseal insertions of major muscle-tendon units
the traction apophysitises anatomy23
The Traction Apophysitises:Anatomy
  • Sites of active growth in a child
  • Consists of columns of growth cartilage uniting tendon with a bone
the traction apophysitises common locations

Calcaneal apophysis


Tibial tuberosity

Inferior pole of the patella

The Traction Apophysitises:Common Locations
the traction apophysitises osgood schlatter disease
The Traction Apophysitises:Osgood-Schlatter Disease
  • First recorded in 1903 simultaneously by both R.B. Osgood and C. Schlatter
  • Osgood believed this was caused by microavulsions of the tibial tubercle from the insertion of the quadriceps mechanism
  • Age range is 10 – 15 years old
    • Girls 11 – 13 years old
    • Goys 12 – 14 years old
the traction apophysitises osgood schlatter disease26
The Traction Apophysitises:Osgood-Schlatter Disease
  • At risk sports – repetitive impact sports
    • Football
    • Hockey
    • Soccer
    • Basketball
    • Running
    • Gymnastics
osgood schlatter syndrome
Osgood-Schlatter Syndrome
  • Affects young adolescents
  • Pain at the inferior aspect of the patella, subacute to chronic onset
  • Joint is tender to palpation, occasionally swelling in region of tibial tubercle
the traction apophysitises osgood schlatter disease28
The Traction Apophysitises:Osgood-Schlatter Disease
  • Clinical manifestations
    • Pain and swelling over the tibial tubercle especially after athletic activities
    • Pain with running, jumping, squatting, kneeling
    • May have permanent “bump” under knee
osgood schlatter syndrome29
Osgood-Schlatter Syndrome
  • Tx is via reassurance and analgesics
the traction apophysitises osgood schlatter disease30
The Traction Apophysitises:Osgood-Schlatter Disease
  • Treatment
    • RICE
    • Bracing
    • Education of disease process to parents and athlete (self-limiting)
    • Modification of sports activity/avoidance of exacerbating activities
the traction apophysitises osgood schlatter disease31
The Traction Apophysitises:Osgood-Schlatter Disease
  • Treatment
    • Stretching and strengthening of the hamstring and quadriceps muscle groups as well as the gastrocnemius-soleus muscle complex
    • Bracing may be needed for restraint or severe cases that dissipate the force of the quadriceps contraction

(chopat strap)

the traction apophysitises sinding larsen johansson syndrome
The Traction Apophysitises:Sinding-Larsen-Johansson Syndrome
  • Similar to Osgood-Schlatter disease
  • Pain is over the distal pole of the patella
  • Like OSD, debate over whether pain is from avulsion fractures vs. patellar tendonitis
  • Analogous to “jumper’s knee” in the skeletally mature athlete (patellar tendonitis)
sever s disease
Sever’s Disease
  • Calcaneal Apophysitis
  • Heel pain is the presenting symptom located over the oscalcis apophysis
  • Most common cause of heel pain in adolescents
  • At risk sports include soccer, running, and gymnastics
sever s disease34
Sever’s Disease
  • + Squeeze Test
  • Treatment
    • Self Limiting
    • Rest from activity; NSAIDS
    • Silicone Heel Cups
    • Stretching of the gastrocnemius-soleus muscle complex and strengthening of the dorsiflexors of the ankle
    • Cam Walker Boot
    • Orthotics if necessary
the traction apophysitises sever s disease
The Traction Apophysitises:Sever’s Disease
  • Physical Exam
    • Pain over posterior heel
the traction apophysitises sever s disease36
The Traction Apophysitises:Sever’s Disease
  • Treatment
    • Stretching of the gastrocnemius-soleus muscle complex and strengthening of the dorsiflexors of the ankle
    • Orthotics if necessary
      • Heel cups or other OTC orthotics
      • Custom orthotics
Keep in mind that there are many alternate training techniques, an athlete does not have to give up all training when injured



Water running in waist-high water


Upper body ergometer


ALSO remember the concept behind the original injury so you can help to prevent it in the future