apophyseal injuries:growth related musculoskeletal issues - westchester health pediatrics
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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: [email protected]: 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: [email protected]: www.drericsmall.com
