apophyseal injuries:growth related musculoskeletal issues - westchester health pediatrics

ERIC SMALL, MD, FAAPMedical Director of Sports Medicine

Apophyseal Injuries:Growth Related Musculoskeletal Issues

March 31, 2016

ERIC SMALL, MD, FAAP

Former Chair, Council on Sports Medicine and Fitness

American Academy of PediatricsWestchester Health Associates

Assistant Clinical Professor of Pediatrics, Orthopedics, and Rehabilitation MedicineMount Sinai School of Medicine, NY, NY

914-666-7900email: drericsmall@gmail.comwebsite: www.drericsmall.com

Outline

• Definition/Background• Case Studies• Prevention

Differential Diagnosis

• Benign Musculoskeletal Pain of Childhood• Hypermobility Syndrome• Apophysitis/Apophyseal Injuries

Benign Musculoskeletal Pain of Childhood

• Pain does not occur with activity• Pain usually occurs at night• Pain of the thighs, knees, or calves• Pain is relieved with massage and OTC• Active child/PE is normal

Hypermobility syndrome

• 5-10% of population• Females greater than

males• Genu Recurvatum/Elbow

hyperextension/Marshall stage V for thumb opposition

Apophyseal Injuries

• Muscle/tendon/bone friction/inflammation• Severity of pain related to muscle

imbalances, tightness, and specific sports and movement patterns

• Extremely common but not often talked about

Benign Musculoskeletal Pain/Growing Pains

Apophysitis/Apophyseal Injury

Hypermobility Syndrome

At night During/After Activity During activity and at rest

Less than 10 years of age

10-16 6-18

No swelling Swelling and pinpoint tenderness

No swelling, diffuse tenderness

Massage and NSAID’s Decrease Impact activity/Flexibility/Core strength

Core strength/Postural training

Examples

• Sever’s Disease• Iselin’s Disease• Osgood Schlatter• Sinding Larsen

Johanssen Syndrome• Hip Apophysitis

11 year old boy presents with 2 week history of bilateral heel pain (right greater than left). He is now limping every day toward the end of the day.

Sever’s Disease• Calcaneal Apophysitis• Boys/Girls 9-12• Tight

hamstrings/calves• Running especially in

cleats• Tanner I-II

Teaching Points• 1/3 of patients will develop hip pain in 2-3

years• If stretching/strengthening is not instituted

pain may persist for up to two years• With proper exercise pain becomes minimal

1 month into treatment.

Sever’s Disease Other Points• 1/3 will develop Osgood Schlatter in 1-2

years• 1/3 will develop Hip Avulsion Injury/hip

apophysitis in 2-3 years

Physical Exam

• Pain at distal 1/3 of Achilles

• Check out you tube video

Management• Decrease running by

50%• Calf/hamstring stretches

3-4 times per day• Introduce

biking/elliptical

Teaching Points

If pain/stiffness occurs at rest or upon awakening then think of rheumatologic problems, lyme.

12 year old figure skater presents with lateral foot pain.Her foot hurts her with inversion/eversion.

Iselin’s Disease

• 5th metatarsal apophysitis• Peroneus Brevis inserts into the 5th

metatarsal (responsible for foot eversion)

Iselin’s Disease

• 5th metatarsal apophysitis

• Boys/Girls 9-12• Strong ankle

inversion/weak eversion

Iselin’s Syndrome

Management

• Taping• Walking boot• Eversion strengthening• Balance training• Dorsiflexion

stretching/strengthening

13 year old boy presents with a painful bump

below his knee. It hurts him when he runs, jumps, and

squats. He is limping toward the end of the day.

Osgood Schlatter Disease

• In peak growth spurt (9-12 girls, 12-15 boys)• First described in 1903• Tanner III-IV• Related to how much running, jumping, and

squatting

• Mild-minimal widening

• Moderate• Severe

Severity of Tibial Tubercle Separation

OSD Physical

• Pain at anterior tibia tubercle

• Tight in hamstrings (SLR 30 degrees)

• Check out YouTube video

OSD MANAGEMENT• Hamstring/Quad Stretches 3 - 4 times per

day• Cho-pat Osgood Schlatter Band• Neoprene Knee sleeve with patella cut-out• Do not immobilize• Biking and swimming encouraged

10 year old with anterior knee painHas pain with running and jumpingAt times no painAt other times severe pain

• Ages 10-13 • Jumper’s Knee• Pain at inferior pole of patella• Basketball, soccer, gymnastics, figure

skating• Tanner I-II

Sinding Larsen Johanssen Syndrome

Management

• Make sure there is no avulsed fragment• Neoprene knee sleeve• Eliminate Jumping/Decrease running by 50%

15 year old girl with anterior hip painPain with runningPain with kicking

Hip Apophysitis• Ages 13-16• Tanner IV-V• Sprinting Sports• Soccer, lacrosse, running to first base in

baseball, hurdles

Physical Exam

• Tenderness at iliac crest• Tenderness at anterior superior iliac spine• Tenderness at anterior inferior iliac spine• Tight in hamstrings/hip flexion• Weak in core, weak in hip abduction, adduction

Iliac Crest Avulsion Fracture

Hip Avulsion Fracture• Anterior inferior iliac

spine• Origin of rectus

femoris muscle

Interesting casesAppendectomy

Exploratory Laparoscopy

Management

• No sprinting or kicking for 2-4 weeks• Bike 3 times per day, hip flexor, hamstring,

quad stretching, core stability• Ice afterwards

Other Teaching Points• If have “Osgood Schlatter and Sever’s at same time, think of JRA or

spondyloarthropathy• About 1% may morph into complex regional

pain syndrome.

Prevention Strategies

• Do not play two sports teams in the same season (especially soccer, lacrosse)

• Avoid excessive running in cleats• Allow 2-3 days off from sport per week• Consider taking 1 week off

Prevention Strategies II• Consider switching positions: ie. Catcher to

outfield-midfield to defense• Do not premedicate with antiinflammatories• Do not play with a limp

Thank you and good luck!!!

Have a good season!!!

ERIC SMALL, MD, FAAP

Former Chair, Council on Sports Medicine and Fitness

American Academy of PediatricsWestchester Health Associates

Assistant Clinical Professor of Pediatrics, Orthopedics, and Rehabilitation MedicineMount Sinai School of Medicine, NY, NY

914-666-7900email: drericsmall@gmail.comwebsite: www.drericsmall.com

Eric Small, MDPediatric Sports Medicine

666 Lexington AveMount Kisco, NY

Email: drericsmall@gmail.com914-666-7900