“growing pains” injury and skeletal immaturity
DESCRIPTION
“Growing Pains” Injury and Skeletal Immaturity. Ken Knecht, PT, MS, SCS, CSCS. Understanding the Population. Children are not “Little Adults”. Understanding the Population. “What’s the Difference?” Skeletal Maturity Physiology Strength (and the Ability to Develop It) - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/1.jpg)
“Growing Pains”Injury and Skeletal
Immaturity
Ken Knecht, PT, MS, SCS, CSCS
![Page 2: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/2.jpg)
Understanding the Population
Children are not “Little Adults”
![Page 3: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/3.jpg)
Understanding the Population
“What’s the Difference?” Skeletal Maturity Physiology Strength (and the Ability to Develop It) Psychological Maturity
![Page 4: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/4.jpg)
Understanding the Population
“What’s the Difference?” Skeletal Maturity Physiology Strength (and the Ability to Develop It) Psychological Maturity
![Page 5: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/5.jpg)
Growth & Development of the Young Athlete
Middle Childhood (6-9 yrs) Maturation of Throwing and Kicking Patterns Entry Level Sports (soccer, baseball/softball) Males and females can still compete with parity
Males slightly Stronger; Girls better Balance Running gait and speed are fairly equal
Late Childhood to Early Adolescence (10-15 yrs) Onset of Puberty “Growth Spurt” – Tanner Stage 3 Differences emerge between sexes Skill Acquisition and Development Easiest
![Page 6: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/6.jpg)
Growth and Development of the Young Athlete
Late Adolescence/Adulthood (16-20 yrs) Increases in Strength & Size become more
gradual “Late Bloomers” may continue to lag behind Skeletal maturity
![Page 7: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/7.jpg)
Growth and Development Anatomic Changes Associated with
Puberty Boys Girls
(Mean Age)
Peak Height Velocity (14 yrs) Peak Height Velocity (12 yrs)Skeletal Maturity (16 yrs) Skeletal Maturity (14 yrs)
**Introduction of Sex hormones (Athl Ther Today 2002)
![Page 8: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/8.jpg)
Growth and Development Significance of Peak Height Velocity
The “Growth Spurt” ~ Tanner Stage 3 Bone growth rate can exceed soft tissue
accommodation Hamstrings, Hip flexors, Quadriceps, and
Plantarflexors Decreased Coordination Tightness can affect growth centers
![Page 9: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/9.jpg)
Growth and Development Significance of Tanner Staging
5 stages of Physical development Stage 1 = Early Development Stage 5 = Full Maturity
Correlation between Tanner stage and physeal closure. Same Chronologic age ≠ Bone Age Assists with the differential diagnoses
![Page 10: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/10.jpg)
Growth and Development Tanner Stage 5
Signals end of growth Marked by full development of
secondary sexual characteristics Males will have full facial hair Females will have final breast development
![Page 11: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/11.jpg)
Skeletally Immature Distinctions
Growth “Tissues” Physis Apophysis Articular Cartilage
Issues: Susceptibility to injury
Bone weakest link Surgical Challenges
![Page 12: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/12.jpg)
“Growth Tissue” Physis (Growth Plate)
Responsible for longitudinal growth of bone
Growth centers close distal to proximal Growth centers begin to close in females
approximately 18 – 24 months following menarche
Skeletal Maturity Completed ~18 yrs females; ~21 yrs males
Injury to Physis could create growth disturbance (early closure or bony bridging)
![Page 13: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/13.jpg)
Anatomical Review
http://www.davidlnelson.md/images/Physis_normal_annotated4.jpg
![Page 14: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/14.jpg)
Salter-Harris Fractures Type I: Fracture line extends across the physeal
plate. Often undetected on X-ray Type II: Fracture line extends through the physeal
plate and metaphysis Type III: Fracture line extends from the joint surface
through the epiphysis and across the physis causing a portion of the epiphysis to become displaced
Type IV: Fracture line extends from joint surface through the epiphysis, physeal plate and metaphysis causing a fracture fragment
Type V: Crush injury to the growth plate
![Page 15: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/15.jpg)
Salter Harris Fractures
Separated Above Lower Through E Rammed
![Page 16: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/16.jpg)
Salter Harris Fracture Distal Fibula
Usually an inversion/supination injury Type I-II are the most common Type I often misdiagnosed as ankle
sprain
![Page 17: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/17.jpg)
Salter Harris Fracture Key Finding on Physical Exam:
Point of Maximal Tenderness Usually PTP at ATFL also
![Page 18: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/18.jpg)
Salter Harris Fracture Boot immobilization (casting)
Depending on Type; 2-3 weeks + Types III & IV require surgery
Pain free weight bearing status Rehabilitation for post
immobilization ROM, strength, balance & proprioception Sport specific training
![Page 19: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/19.jpg)
Little League Shoulder Epiphysiolysis of
proximal humerus Rotational forces Distractional forces
Overuse injury associated with pitching Quantity Intensity Age
![Page 20: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/20.jpg)
Phases of Throwing
www.hughston.com/hha/b_16_1_1a.jpg
![Page 21: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/21.jpg)
Little League Shoulder Clinical Findings
Lateral, proximal shoulder pain Weak & painful EROT and Abd Palpable tenderness over
physis Radiographic widening of
physis?
![Page 22: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/22.jpg)
Little League ShoulderTreatment
Aggressive rest to allow physeal healing Address any ROM imbalances & Scapular
dysfunction GIRD, posterior capsule Sick Scapula Scapular stabilization & strengthening
Rotator cuff strengthening Review of throwing mechanics
Return to throwing progression Modification of throwing volume (pitch counts) May need to alter position
Address entire kinetic chain Core strengthening Lower extremity strength/flexibility and proprioception
![Page 23: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/23.jpg)
“Growth Tissue” Apophysis
Cartilaginous structure usually located at the end of long bones
Attachment site for musculotendinous unit
Tensile forces can create inflammation = Apophysitis
Susceptible to Avulsion Fracture
![Page 24: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/24.jpg)
Apophysitis Overuse injury Often during periods of rapid growth May remain symptomatic until
closure of apophysis Possible to result in an avulsion
fracture
![Page 25: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/25.jpg)
Sever’s Disease aka: Calcaneal
Apophysitis Common During Growth
Spurt Heel pain Tight gastroc/soleus Foot pronation Running/jumping athletes + Squeeze Test
![Page 26: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/26.jpg)
Sever’s Disease Treatment Activity modification
Aggressive rest Stretching!!! Immobilization may be necessary Can continue to play if pain is mild (no
limp) Typically resolves in several weeks
(months?) Footwear or insert
![Page 27: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/27.jpg)
Osgood-Schlatter’s Disease (OSD)
Apophysitis of the Tibial Tubercle
Traction Injury Commonly seen
Boys aged 10 –15 Girls aged 8 –13
![Page 28: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/28.jpg)
Osgood-Schlatter’s Disease (OSD)
Palpable tenderness X-rays may be
positive for displacement
In severe cases tubercle can avulse
![Page 29: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/29.jpg)
Osgood-Schlatter’s Disease (OSD)
![Page 30: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/30.jpg)
Sinding-Larsen-Johansson (SLJ)
Apophysitis of the inferior patellar pole
Anterior knee pain with impact activities
Commonly seen Boys aged 10 –15 Girls aged 8 –13
![Page 31: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/31.jpg)
Sinding-Larsen-Johansson (SLJ)
Palpable tenderness Inferior pole sometimes
patellar tendon May have quadriceps
lag X-rays may be positive
for displacement Differential diagnosis
Patellar sleeve fracture
![Page 32: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/32.jpg)
Treatment for OSD and SLJ Activity modification Stretching quads and hams Strengthening progression Plyometric training to work on soft
landings May not have complete resolution of
symptoms In OSD permanent bump is likely
![Page 33: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/33.jpg)
Apophysitis of Hip/Pelvis 7 sites at the femur and pelvis During phase of rapid growth Pain and inflammation at
ossification centers Iliac crest (common)
Pain with resisted trunk rotation/side bend and/or hip abduction
Seen in Runners, Football, and occasionally Baseball pitchers
![Page 34: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/34.jpg)
Apophysitis of Hip/Pelvis Treatment
Rest Activity modification Trunk and pelvis
flexibility Core and hip
strengthening Treat the entire kinetic
chain Technique adjustment
Running gait
![Page 35: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/35.jpg)
Avulsion Fractures Same areas affected as apophysitis Occur with sudden, forceful contraction or stretching
Bone is the weakest link Common sites include ASIS and Ischial tuberosity. Often misdiagnosed as pulled muscle Radiographic evaluation necessary for accurate
diagnosis Surgery if displacement is greater than 2-3cm (???)
![Page 36: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/36.jpg)
Avulsion Fractures
AIIS avulsion fracture in a 14 yr old soccer player
![Page 37: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/37.jpg)
Little League Elbow Traction apophysitis of Medial epicondyle of
Humerus Overuse injury
Volume Velocity Increased mound to plate distance Breaking Pitches?
Valgus stress during late cocking/acceleration
Flexor pronator muscle group UCL?
Clinical presentation Medial elbow pain Diminished throwing speed and accuracy Poor or altered throwing mechanics
![Page 38: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/38.jpg)
Little League Elbow Treatment
RICE: Make rest your friend Activity modification 6-12 weeks
No pitching or overhand throwing Stretching
GIRD is Probable; Assess and address!!! Strengthening
Forearm, posterior cuff, core, contralateral leg Assess throwing mechanics Functional progression to throwing program Identify and correct training errors
![Page 39: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/39.jpg)
“Growth Tissue” Articular Cartilage
Infrastructure similar to Physis Increased Cellular activity Not yet “Adult” solidity
Repetitive Injury or Excessive shearing forces may result in Osteochondritis Dissecans (OCD)
![Page 40: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/40.jpg)
Osteochondritis Dissecans (OCD)
Impact and shear forces cause bone bruising
Cause is usually repetitive trauma Genetic predisposition?
Subchondral bone death Secondary damage to overlying cartilage “Lesion of dissection” vs dessication May affect any joint
Most frequently seen at knee, elbow, ankle
![Page 41: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/41.jpg)
Osteochondritis Dissecans (OCD)
Risk Factors Age: Occurs most often in people between
the ages of 9 and 18
Sex: Males are 2-3X more likely than females.
Sports participation: Sports that involve rapid changes in direction, jumping or repeated throwing may increase your risk
![Page 42: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/42.jpg)
Osteochondritis Dissecans (OCD)
ICRS Classification of OCD Grade I – Stable with continuous
but softened area with intact cartilage
Grade II – Stable with partial discontinuity
Grade III – In situ lesions with complete discontinuity
Grade IV – Empty defects with dislocated or loose fragments
![Page 43: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/43.jpg)
Osteochondritis Dissecans (OCD)
Epiphyseal microtrauma with osteochondral separation
Commonly Lateral aspect of Medial femoral condyle
Etiology is multifactorial Trauma, ischemia, hereditary,
idiopathic (?) Under debate
![Page 44: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/44.jpg)
Osteochondritis Dissecans (OCD)
![Page 45: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/45.jpg)
OCD of Femoral Condyle Clinical presentation
Insidious onset of pain aggravated by activity
Intermittent joint effusion Giving way, catching, or locking Symptoms suggestive of PFPS Confirmed with diagnostic imaging
![Page 46: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/46.jpg)
OCD of Femoral Condyle Conservative Management
Immobilization Weight bearing restriction Activity restriction
Surgical intervention Extent depends on Grade
Debridement /drilling Refixation Loose body removal Operative resurfacing ACI
![Page 47: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/47.jpg)
Clinical Summary Bone weakest link in pre pubescent Same Chronological age ≠ Bone Age
Tanner staging helps differential Protect Growth centers
![Page 48: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/48.jpg)
THANK YOU!!!
![Page 49: “Growing Pains” Injury and Skeletal Immaturity](https://reader036.vdocument.in/reader036/viewer/2022062814/568166fd550346895ddb62d5/html5/thumbnails/49.jpg)
Ken Knecht PT, MS, SCS, CSCSBoard Certified Sports Clinical SpecialistThe Sports Medicine & Performance Center at CHOP Specialty Care Center at Virtua Health and Wellness Center, 2nd Floor200 Bowman Drive, Suite D260Voorhees, NJ 08043856-719-9932; Fax: 267-425-5416