Common Overuse Adolescent Injuries

1. 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

2. Understanding Normalcy Inverted Normal Everted Bow-legged Knock-kneed Normal

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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.

9. 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

10. Most important cause is inadequate heel cord flexibility Other causes Instability of foot and heel strike Running on unyielding surfaces Inadequate shoes Achilles Tendonitis

11. 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 Periostitis Myositis Tendonitis Shin Splints

12. Often caused by change in running surfaces (from soft to hard), change in running pattern or change in shoes Treatment 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

13. 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 Treatment Custom molded orthotics Stretching exercises Ice massage Posterior Shin Splints

14. 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

15. 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

16. Therapy is planned after assessing patellar mechanics and leg alignment Treatment quadriceps isometric strengthening exercises, NSAIDs, bracing, orthotics Runner’s Knee,cont.

17. 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.

18. 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

19. Treatment - “PRICES” • P - Protection • R - Rest • I - Ice • C - Compression • E - Elevation • S - Support

20. 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

21. 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

22. The Traction Apophysitises:Anatomy • Associated with the growth cartilage • Located at three sites: • Epiphyseal plate • Joint Surface • Apophyseal insertions of major muscle-tendon units

23. The Traction Apophysitises:Anatomy • Sites of active growth in a child • Consists of columns of growth cartilage uniting tendon with a bone

24. Foot Calcaneal apophysis Knee Tibial tuberosity Inferior pole of the patella The Traction Apophysitises:Common Locations

25. 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

26. The Traction Apophysitises:Osgood-Schlatter Disease • At risk sports – repetitive impact sports • Football • Hockey • Soccer • Basketball • Running • Gymnastics

27. 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

28. 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

29. Osgood-Schlatter Syndrome • Tx is via reassurance and analgesics

30. 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

31. 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)

32. 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)

33. 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

34. 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

35. The Traction Apophysitises:Sever’s Disease • Physical Exam • Pain over posterior heel

36. 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

37. Keep in mind that there are many alternate training techniques, an athlete does not have to give up all training when injured Cycling Swimming Water running in waist-high water Rowing Upper body ergometer Etc. ALSO remember the concept behind the original injury so you can help to prevent it in the future Conclusion