pediatric musculoskeletal development & sports issues · pediatric musculoskeletal development...

Pediatric Musculoskeletal Development & Sports IssuesTOM BUSH DNP, FNP-BC, FAANP

CLINICAL ASSOCIATE PROFESSOR

UNIVERSITY OF NORTH CAROLINA AT CHAPEL HILL

SCHOOLS OF NURSING AND MEDICINE

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Objectives

• Describe conditions that predispose children and adolescents to sports injury

• Identify common injuries in the pediatric population

• Discuss risk factors and treatment strategies for sports injuries in the pediatric population

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Overuse Injuries

• Microtrauma to bone, muscle or tendon from repetitive stress without time to heal• Pain after activity

• Pain during activity without change in performance

• Pain with activity that restricts performance

• Chronic pain at rest

• Year round sports participation• 50% of pediatric sports injuries associated with overuse

• Overtraining leads to burnout

Armstrong & Hubbard, 2016 3

Overuse Injuries

• Injuries more common during peak growth velocity• More likely if underlying biomechanical problem

• Sound training regimen• Maximum of 5 days a week

• At least 1 day off from organized activity

• 2-3 months off per year

• Cross-training in off season and with overuse injury

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Overuse Injuries

• Preventing burnout• Age-appropriate games- should be fun

• 1-2 days off from organized sports each week

• Longer breaks every 2-3 months• Cross-train to maintain conditioning

• Focus on wellness• Listen to body for cues to slow down or alter training

Howard, 2016 5

Overuse Injuries

• Endurance events• Shorter in duration/length

• Careful attention to safety and environmental conditions• Hyopthermia

• Hyperthermia• Child less able to handle heat stress

• Gradual increase in time/mileage• 10% weekly

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Overuse Injuries

• Year-round training and multiple teams• Focus on one sport or early specialization

• Becoming more common

• One or more teams simultaneously

• Motivation for over involvement• Meeting needs of child or parent?

• College scholarship or Olympic team

• Less than 0.5% of high school athletes make it to professional level

• Athletes who participate in a variety of sports• Have fewer injuries • Play sports longer than those who specialize before puberty

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Overuse Injuries

• Guidance• Assess and identify child’s motivation

• 1-2 days off per week

• 2-3 months off per year

• Emphasize fun, skill acquisition and safety

• One team per season• If two, keep training with guidelines above

• Be alert for symptoms of burnout• Nonspecific complaints, fatigue, poor academic performance

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Sports Injuries

• Traction apophysitis• Overuse injury that occurs in growing child

• Tendon pulls on area of growing bone

• Children and teens seldom get tendonitis

• Repetitive stress and microtrauma• Elbow- little leaguer elbow

• Proximal tibia- Osgood-Schlatter disease

• Calcaneous- sever disease

• Pelvis

Armstrong & Hubbard, 20169

Little Leaguer Elbow

• Traction apophysitis of the medial epicondyle or olecranon• Skeletally immature throwing athlete

• Medial epicondyle or olecranon avulsion• Older child closer to maturity (12-14)

• Ulnar collateral ligament sprain or tear

• Compression injuries• Osteochondritis dissecans

• 12 and older after capitellum

has ossified

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Little Leaguer Elbow

• History• History of overuse

• Number of pitches, innings, year round participation

• Premature use of curveball

• Mechanical symptoms if loose body

• Pain is most common symptom and may be loss of extension in later stages of OCD• Medial in apophysitis, avulsion & UCL injury

• Lateral in OCD and Panner disease

• Posterior in olecranon apophysitis/avulsion

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Little Leaguer Elbow

• Radiographs help establish diagnosis• Contralateral views helpful

• MRI may be needed • OCD, Panner disease, UCL injuries

• Treatment• Rest from throwing for 3-6 months or longer

• PT to maintain strength and restore motion

• Avoid immobilization beyond acute phase

• Surgery for fixation, microfracture or excision of loose body

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Throwing Athlete

• Tremendous kinetic energy through shoulder• Proper wind up and follow through is critical

• Anterior shoulder pain• Impingement

• Subtle instability• May be primary instability with secondary impingement

• Aggressive rehab• Relative rest, selective stretching, strengthening of cuff

and scapular stabilizers

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Patella/quadriceps tendinopathy

• Common in adolescent athlete• Sinding-Larsen-Johansson Disease in preadolescents

• Overuse or overload syndrome

• Associated with jumping sports

• May occur with erratic exercise habits

• Weight gain may play role

• Anterior knee pain

• Pain with sitting, squatting or kneeling

• Climbing stairs often increases pain

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Patella/quadriceps tendinopathy

• Exam• Tender at inferior or superior patella pole

• May be mild edema • No joint effusion

• Fullness of infrapatellar bursa

• AROM is normal but painful

• Quadriceps atrophy if longstanding condition

• Rule out other soft tissue conditions

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Patella/quadriceps tendinopathy

• Treatment is primarily symptomatic• Period of rest

• Few days to a few weeks

• Consider brief immobilization

• Analgesia with acetaminophen or tramadol

• PT with focus on ROM, extensor stretching and quadriceps strength• Ultrasound or iontophoresis may help

• Knee sleeve with patella cutout or patella tendon strap

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Sever Disease/Calcaneal Apophysitis • Repetitive stress and micro trauma

• Posterior heal pain and may have limp

• Apohysis closes • 9 years in female

• 11 years in male

• Tenderness on heel squeeze

• Radiographs not diagnostic• Irregularity and sclerosis are normal

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Sever Disease/Calcaneal Apophysitis • Differential Diagnoses

• Achilles tendinopathy• Can be associated with reactive arthritis or seronegative

spondyloarthropathies

• Infection• Likely unilateral, local swelling, elevated ESR

• Tumor• Likely unilateral, local swelling, night pain

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Sever Disease/Calcaneal Apophysitis • Treatment

• Activity modification

• Heel lift (short term)

• Achilles stretching

• Ice after activity

• Casting if severe

• Consider infection or neoplastic disease if recalcitrant

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Female Athletes

• Desire to change weight

• Menarche, menstrual regularity and LMP• Eating disorders and amenorrhea

• Osteopenia and osteoporosis

• Sudden cardiac death less likely in females

• Females more likely • Patellofemoral syndrome, foot disorders, stress

fractures, ACL rupture

Armstrong & Hubbard, 2016 20

UNC School of Nursing

Scoliosis

• Lateral curvature of the spine of > 10°• Small curves are not scoliosis

•Thoracic or lumbar spine (occasionally both)• Associated vertebral rotation with kyphosis or lordosis

•May be congenital• Vertebral anomalies

•Commonly idiopathic

•May be secondary to other disorder• Cerebral palsy

• Muscular dystrophy

• Myelomeningocele

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Idiopathic Scoliosis

Curve size Girls:Boys

6-10° 1:1

11-20° 1.4:1

>21° 5.4:122

•Develops in early adolescence• Male = female in curves < 10°• Female 7X more likely to have significant,

progressive curve requiring treatment• Progression typically girls at age 10-16 years• Not associated with pain

• Pain suggests primary condition and requires further evaluation.

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Scoliosis Evaluation

• Is there a curve?

• Is it structural?

• Is it idiopathic?

•How large is the curve?

•How mature is the patient?

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Scoliosis

•Physical exam• Forward bending test

• Observe from behind• Elevation of rib cage, scapula or paravertebral muscle mass

positive finding.

• Also assess • Skin• Leg length• Feet alignment• Neuromuscular status

• Beware!• Left side thoracic curves have high incidence of spinal cord

abnormalities.

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Is there a curve?

Richard Henderson Stock Photo 25

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26Richard Henderson Stock Photo

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27Richard Henderson Stock Photo

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Is there a curve?

28https://commons.wikimedia.org/wiki/File%3A

Scoliometer.jpg

UNC School of NursingIs there a curve?

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Inclination does not correlate with degree of curve or clinical significance. Inclinations of more than 5°-7° require further evaluation.

https://commons.wikimedia.org/wiki/File%3AScoliometer.jpg

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Is the curve structural?

30Richard Henderson Stock Photo

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Is the curve structural?

Richard Henderson Stock Photo 31

•Postural curves• Pain• Leg length inequality• Behavioral

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Is the curve idiopathic?

•Congenital• Vertebral anomalies

•Neuromuscular• Cerebral Palsy• Myelomeningocele• Muscular dystrophy• Polio

•Miscellaneous• Post surgical• Marfan syndrome• Trauma

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Congenital Scoliosis

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Beware!•Unusual curves

• Left thoracic curves

•Unusual symptoms• Significant pain• Radiculopathy

•Unusual findings• Neurologic deficit

• Skin changes

• Hair patches

• Asymmetry of lower extremities

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How large is the curve?

By Weiss HR, Goodall D [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons 35

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How large is the curve?

https://de.wikipedia.org/wiki/Datei:Scoliosis_cobb.svg#/media/File:Scoliosis_cobb.svg

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•Diagnostic tests• PA and lateral full-length

radiographs with patient standing and knees straight

• Measure Cobb angle• Describe as if patient is

being examined from behind

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How mature is the patient?

5-19o

20-29o

Pre menarche 1:4 probably

Post menarche not likely! 1:4

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Curve progression

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Scoliosis treatment

• If angle < 50° at skeletal maturity• Progression usually ceases.

• If angle > 60° at skeletal maturity• progression into adulthood common and may

compromise respiratory function.• Unusual if angle less than 90° and healthy

•Back pain may occur in adulthood.• Not usually a major disability

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Scoliosis treatment

•Observation• Frequency depends on curve and remaining growth.

•Bracing for progressive curves at 20-40°• Goal is to stop progression

• Not helpful for curves that are unlikely to progress or when little growth remains.

• Not helpful for large curves.

• May not work even with well made orthosis

•Surgery• Spinal fusion for curves of > 50° and for curves of 40 to 50 ° that are

likely to progress.

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Scoliosis treatment

•Secondary scoliosis more likely to progress• Consider bracing or surgery prior to guidelines

recommended for idiopathic scoliosis.

•Refer immediately• Convex left curve• Significant pain• Abnormal neuro exam • Deformity of feet

• Regardless of angle

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Fractures• Nonunion uncommon

• Bone remodeling is greater in children• Fractures close to physis

• Fractures in same plane as nearest joint• Angular correction in other planes less reliable

• Rotational deformities typically do not remodel

Bush Stock Photo

Fractures

• Uncommon in children under 3 years• Consider abuse

• After age 3 gradually increases until peaks in adolescence• Incidence higher in boys and in summer

• Fracture patterns unique to pediatrics• Bone is less brittle than adult bone

• Greenstick, torus, plastic deformation, physeal

Overview- Growth• May be tremendous ally in

treatment.

• Splinting dysplasitc hip in newborn will result in normal joint that functions for a lifetime.

• Angular deformities from fracture completely remodel allowing for nonoperative treatment.

• May also exacerbate deformity.

• Damage to physis may lead to progressive angulation or shortening of limb.

https://www.fairview.org/HealthLibrary/Article/89080

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Fracture of the Growth Plate

• Physeal plate is region of low strength

• Common patterns.• Salter-Harris classification

• Fractures that cross physis or result in malalignment have worse prognosis

• Monitor for early posttraumatic closure of growth plate

Mathison, Agrawal, Bachur & Wiley., 201645

Distal radius fracture

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Fracture of the Growth Plate

• Treatment• Goal is maintained reduction during healing.

• Heal rapidly (4-6 weeks)

• Closed reduction and casting most common

• Open reduction and internal fixation required if incongruity of joint surface or physeal plate

• Physeal bars do not appear until 3 months or more after fracture• Follow up at one year with repeat films

General Rehab Recommendations

• Inflammatory phase (0 to 72 hours after injury)• PRICE

• Protection Rest Ice Compression Elevation

• Maintain cardiovascular fitness

• Reparative phase (72 hours to 3 weeks after injury)• Continue protection• ROM and flexibility • Proprioception, strengthening and functional stability

• Maturation phase (3 weeks to 2 years after injury) • Clinical goals for flexibility, proprioception, muscle firing patterns,

strength, endurance, and cardiovascular fitness• Functional goals for power, speed, agility, and sport-specific skills• Balance load to organize tissue healing without tissue disruption

Hubbard & Denegar, 2004Brooks & Hergenroeder, 2016

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References/Resources

• Armstrong & Hubbard. (Eds): Essentials of Musculoskeletal Care, 5th edition. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2016.

• Brooks, G. P., & Hergenroeder, A. C. Musculoskeletal injury in children and skeletally imagure adolescents: Overview of rehabilitation for nonoperativeinjuries. In: UpToDate, Chorley, J., & Wiley, J. F. (Eds), UpToDate, Waltham MA, 2016

• Howard, M., H. Overtraining syndrome in athletes. In: UpToDate, O’Connor, F. G., & Grayzel, J. (Eds). UpToDate, Waltham MA, 2016.

• Hubbard, T. J., & Denegar, C. R. (2004). Does cryotherapy improve outcomes with soft tissue injury? Journal of Athletic Training, 39(3): 278-279.

• Mathison, D. J., Agrawal, D. General principles of fracture management: Fracture patterns and description in children. In: UpToDate, Bachur, R. G., & Wiley, J. F. (Eds), UpToDate, Waltham, MA, 2016

• Scherl, S. A. Adolescent idiopathic scoliosis: Clinical features, evaluation, and diagnosis. In: UpToDate, Phillips, W. & Trochia, M. M. (Eds), UpToDate, Waltham, MA, 2016.

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