Musculoskeletal Injuries in Sporting Children and Adolescents

Malcolm MartinHighly Specialist Physiotherapist

MSc, MCSP, MMACP, AACP

Gatwick Park Physiotherapy Department

Active Children?

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Introduction

•Low self confidence in paediatric clinical skills reported among GPs and Physiotherapists

•A need for teaching has been identified•Spire Gatwick Park Physiotherapists are now able to assess & treat 6yrs and above

•Competencies to treat this age group required

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Childhood Injury Incidence

Up to 40% of sports injuries presenting at

A&E in 5-14 age range

The average peak age for presentation

reported as 13yrs

Missed Diagnoses

•Missed or incorrect diagnosis can have long term serious consequences

•May adversely affect a child’s development and thus their physical and sporting potential

•Important to understand tissue pathogenesis

Outline

•Understand anatomy of immature skeleton & physiology of growth tissues

•Revise common sports injuries in growing children

•Outline appropriate treatment & rehabilitation strategies and what advice you could provide to children and their parents

Zone of Growth

Zone of Growth

Metaphysis

Physis

Secondary ossification centre

Apophysis(Traction Epiphysis)

Ossicles (Osgood Schlatter lesion)

Epiphysis (pressure epiphysis)

Injury to Growth Tissue

•The majority of sporting injuries are related to the zone of growth:

•Metaphysis

•Physis

•Epiphysis– Traction Epiphysis (site of tendon insertion) *– Pressure Epiphysis (cartilaginous block becomes joint surface)

Embryonic Development

Issues in Aetiology

Injury is multi-factoral

•Sporting issues

•Physical issues

•Developmental issues

Developmental Issues

Developmental Stages•1. Neonate – up to 4 wks of life•2. Infancy- up to 2 yrs•3. Early childhood -3-5 yrs•4. Late childhood 6-10 yrs*•5. Pre-Adolescence & Adolescence*

Stages of Maturation

•Mid Growth Spurt 6.5 – 8.5 yrs

•Adolescent Spurt 10 – 12 yrs (girls)

•Adolescent Spurt 13 – 14 yrs (boys)

•Full Maturation ~ 16 (girls)

•Full Maturation 18 – 19 yrs (boys)

Paediatric Musckuloskeletal Tissue

•Children are not mini-adults

•The immature skeleton contains growth tissue not present in the adult

•Growth tissues represent sites of weakness particularly when metabolically active

•Peak injury rate is during growth spurt at onset of adolescence

Classification of Injury

•Articular Epiphyseal Lesions eg. Perthes, Freibergs infraction

•Physeal or Growth Plate Injury

•Apophyseal Injuries eg. Sever’s, Osgood Schlatters

Diagnostic Pitfalls

•Achilles tendonitis

•Patella tendonitis

•Hamstring ischial insertion tendonitis

Injury related to maturation

•Severs 9 – 13 yrs

•Sinding Larsson Johansson (SLJ) 8-12 yrs

• Ischial apophysitis 14 – 17 yrs

•Osgood Schlatters Apophysitis 9-13 yrs boys >

•Osgood Schlatters Avulsion 14-17 yr

Injury related to maturation

•AIIS Apophysitis 11-15 yrs boys >

•AIIS Avulsion 14 – 15 yrs

Principles of Treatment

•These are the same for apophysitis at all sites!

•Avulsion injury – similar principles apply at all sites

•Most can be treated conservatively

•A few require ORIF

Apophysitis of the Calcaneus

•Sever’s Disease: seen as an apophysitis rarely as an avulsion. Classic overuse injury often linked with biomechanical abnormality; calcaneus valgus/varus

•Ossification site appears at age 8+, normally fuses by age 14yrs

•Injury common in the age group: 9-13 boys> girls, as late as 17yrs in delayed puberty

Severs

SAGITTAL MRI AXIAL MRI

Signs & Symptoms

•Pain below the TA insertion and occurs during sport often at its worst after sport

•Patient often limps and c/o pain on walking•Swelling is absent or minimal

Treatment

•Easily diagnosed-X-ray usually normal or whispy appearance of apophysis

•Mild cases – reduce training load, orthotics/footwear/heel pad, address biomechanical issues, ICE, NSAID

•Severe cases- 4-6 weeks rest with gradual return to sport following sport specific rehabilitation

Apophysis of the Tibial Tubercle

•At the tibial tubercle we see either an apophysitis- ie. Osgood Schlatter’s disease or an avulsion fracture. The type of lesion is maturation dependent

•The apophysis develops from several ossification centres and ossification begins at approx 9 yrs in girls and 11 yrs in boys with fusion at 12-13 yrs in girls and 13-14 in boys

Osgood-Schlatter Disease

Osgood Schlatter Lesion

•Peak age is 12-14 yrs. More common in boys

•Commonly an overload injury caused by repetitive traction on the anterior portion of the developing ossification centre of the tibial tuberosity

Signs and Symptoms

•Local pain and or swelling/prominence of tibial tubercle. May feel warm and will be tender

•Often painful during sport and aches after and on walking

•Kneeling & squatting often painful•X-ray

– can rule out # or tumour– Identify abnormal fragmentation of ossification centre

Treatment

•Rest proportion to severity. Most severe immobilisation in long leg POP and PWB for 2-6 wks

•Gradual PRE expect hiccups with modified training & technique

•Intractable cases may require ossicle removal

Avulsion Tibial Tubercle

•Type I, II, III•Type I with minimal displacement conservation treatment – closed reduction protected in long leg POP NWB for 3/52

•Commence gentle PRE but no resisted quads work until 6/52

•Sports specific resistance at 12 weeks and RTS at 4/12

Surgical Treatment

•In type II & III may prefer fixation with pins, staples or screws

The Lower Patella Pole

•May present as an apophysitis aka Sinding Larsson Johansson (SLJ)

•Similar history to Osgood Schlatter’s and more common in boys aged 10-14yrs

•X-ray can confirm avulsion

Sinding Larsson Johansson (SLJ)

SLJ

Signs & Symptoms

•Usually slow onset overuse traction injury-history of gradually deteriorating pain initially after sport, then during and after sport

•Pain localised to distal patella pole, patella tendon at insertion and swollen in more severe cases.

•Fat pads effused in more severe cases

•Difficulty kneeling, squatting•Powerful or rapid knee extension provokes•Stairs often painful, cannot sit x-legged•Can usually walk without limping unless avulsed

Treatment

•Conservative as per Osgood Schlatter’s•Gradual return to sport after 3-6 weeks rest when pain free to palpation. Can take 2-3 months in difficult cases

•Surgery = usually closed reduction

Management of Apophysitis

•Reduce inflammation

•Protect are & reduce mechanical stress eg PWB, Orthotics, strapping

•Gradual return to sport following appropriate rehab

•Prevention – footwear, orthotics, equipment, flexibility advice

Soleus Stretch

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Avulsion #’s

•Children are vulnerable during major growth spurts

•At this time AVOID– Heavy one sided bias– Ballistic training– High reps ex’s– Excessive explosive loading (e.g. sprinting)

Avulsion # Treatment

•Aim to allow # healing by promoting optimum conditions and to prevent complications

•Rest via early reduction of activity – bed rest, POP/cast/strapping

•Conservative managment vs surgical fixation

Daily Mail Mar 03 2014

• Children as young as seven are suffering back problems due to poor posture and their lazy lifestyle, say experts.

• A new study of 154 10-year-olds also reveals up to 10 per cent of the child population may have already triggered a time-bomb that will lead to bad backs in adulthood.

• Experts claim that poor classroom seating and lugging heavy school bags are major causes of back pain in later life

• Hours spent watching TV and playing video games are also believed to have contributed to the “epidemic of poor posture”.

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Posture Correction

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Questions?

Soleus Stretch

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Malcolm Martin Profile

Highly Specialist Physiotherapist MSc, MCSP, MMACP, AACP

• Following service in the Armed Forces, Malcolm qualified as a chartered physiotherapist in 1996 from Brunel University. He spent five years gaining a wide range of experience in London teaching hospitals as well as working full-time at Fulham football club treating and rehabilitating youth and senior professional football players before arriving at Spire Gatwick Park Hospital in 2001.

• He has completed a Masters degree in physiotherapy and has conducted research into the effectiveness of physiotherapy and ergonomic interventions to address changes to cervical postural. 

• Malcolm is a member of the Musculoskeletal Association of Chartered Physiotherapists (MACP) as well as the Acupuncture Association of Chartered Physiotherapists (AACP) and uses his specialised musculoskeletal skills together with his knowledge of exercise rehabilitation and a western approach to acupuncture to treat his patients at Spire Gatwick Park Hospital.

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Gatwick Park Physiotherapy DepartmentWhy send your patients to us?

• We are able to assess and treat adults and children from 6 years of age with a wide range of musculoskeletal conditions using a wide range of treatment modalities including e.g. acupuncture.

• Our dynamic team of full and part-time physiotherapists have a wide range of experience and post graduate expertise in managing adult and paediatric musculoskeletal conditions, undertaking post-operative rehabilitation as well as the management and treatment of respiratory disease and continence and pelvic floor conditions.

• We offer a wide range (08.00-19.30) of appointment availability including early morning and evening appointments

• No waiting list so minimal delay between referral and assessment is guaranteed.

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• The physiotherapy team have direct access to the results obtained from the hospital’s on-site state of the art MRI and CT diagnostic scanning facilities and have an excellent working relationship with a wide range of multi-disciplinary team members including orthopaedic consultants and radiography staff to ensure the optimal management of each patient

• As well as providing assessment and treatment of a number of sport related and non-sport related musculoskeletal conditions we can also provide advice on correcting posture and biomechanical assessment for apparent gait anomalies

•  We also provide free lunchtime GP practical training sessions

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