Pediatric Sports Injuries and Overuse Syndromes

M. Catherine Sargent, MDDirector, DCMC Pediatric & Adolescent Sports

Medicine Program

Central Texas Pediatric Orthopedics

Disclosure

• No financial or material support has been received from any commercial enterprise.

• No off-label or unapproved use of drugs or products is presented or endorsed in this presentation.

Learning Objectives:

1. To understand the frequency and variable severity of pediatric sports injuries & issues.

2. To recognize & manage pediatric sports injuries.

3. To recognize & address overtraining issues in pediatric athletes.

Pediatric Sports Participation

• Team sports: 27million(age 6-17)(sporting goods manufacturers)

• Organized sports (Nat’l Council of Youth Sports)

– 60million (age 6-18)– 44million > 1 sport/ year

• Sports Injury Rates– Sport specific– Increasing? Decreasing?

• MSK injuries down 10.8% in 2005 & 12.4% in 2010 (5-14yo). – National Electronic Injury Surveillance System – ER visits only

Pediatric Sports

• Acute Injuries– Sprains, Strains, Fractures & Dislocations

• Football: 10-35 injuries/1000 hrs played

• Overuse Injuries• Overtraining Issues

Fractures & Dislocations

• More common than sprains & strains in kids– Slower healing– Bone heals w/o scar

Signs • Pain• Point tenderness• Swelling• Deformity

Fractures & Dislocations

Evaluation & Treatment

• Check neurovascular status frequently

• Splint promptly to avoid ongoing injury

• Orthogonal x-rays – Include joint above & below injury site*

Missed Monteggia Fracture

• Wrist x-rays only -> missed monteggia fracture• Radial head dislocation with ulnar shaft fracture • Bado classification- radial head is:

– 1-anterior– 2-posterior– 3-lateral– 4-associated with radial shaft fx

Stingers

• Sudden burning & numbness of arm– Lateral arm, thumb &/or index finger– Stinging lasts 30-60min

• Weakness – Shoulder, arm & wrist– Persists 1-2 minutes– Resolves spontaneously

Stingers

• Traction or compressing injury – Cervical Nerve Roots– Brachial Plexus

• Usually C5-C6 dermatomes• Cervical stenosis increases risk

• Football– Defensive back, Linebacker or Offensive lineman– 70% college players– Spear tackling (illegal)

• Wrestling

Stingers - Management

• Rule out C-spine injury: – Bilateral Sx– Spasm, limited neck AROM

• Return to play– No Pain– No Numbness– No Weakness– Full neck AROM

• Recurrent stingers: – Neck roll or “Cowboy Collar”

Gleno-humeral (shoulder) dislocation• Mechanism

Forced Abduction and External Rotation

• SymptomsPainRestricted motion+/- parasthesias

• DiagnosisPE X-ray series

• AP, Scap Y, Ax lat

Usually anterior-inferior

Gleno-humeral (shoulder) dislocationTreatment of Gleno-humeral dislocation• Relocation• Sling +/- swathe• Rehab• Early surgery?

Recurrence?• Refer• MR Arthrogram superior to MRI to detect labral injuries

>80% of <18yo suffer recurrent dislocations*• Kids soft tissues stronger than hard tissues• Greater damage = greater residual instability

May need stabilization surgery

ACL Tears

– Plant & twist injury, non-contact– Female 4-7x > Males, weak core & Hip– “Pop”, pain, ++effusion– Complete tear

• Unable to walk• Requires reconstruction

– Incomplete tear (sprain)• May be able to walk• May respond to rehab only if >50% maintained

– Acute mgmt: knee immobilizer, crutches, NV check– Xrays* & MRI

Pediatric ACL Tear Treatment

• Conservative treatment:– PT: quadriceps & hamstrings– Counseling about risks of recurrent

injury– Bracing & Activity modification

• no cutting/ contact sports

• Risk: – Recurrent instability episodes– Intra-articular damage– Sedentary Lifestyle

Pediatric ACL Reconstruction

• Transphyseal Reconstruction• Risks: Physeal closure • Growth arrest, valgus deformity, recurvatum• Safe in early – mid adolescents (Tanner 2, 3 & 4)

• Physeal sparing reconstruction• Non-anatomic• ITB autograft• Longterm outcome?

– Recurrent tears – Residual instability– Over constrained lateral compartment

Overuse & Overtraining Issues

Overuse Injuries

Physiolysis Syndromes & Apophysitis• Traction +/or pressure on growth plate

Epiphyseal Injuries• Osteochondritis Dissecans

Stress Fractures

Overuse Injuries

Physiolysis Syndromes & Apophysitis

• Little League Shoulder• Distal Radius Stress Syndrome• Little League Elbow (medial epicondylitis)• ASIS Apophysitis• Osgood Schlatters/ SLJ• Sever’s Disease

Distal Radius Stress Syndrome

• Gymnasts, tumblers & cheerleaders• Compressive loads (tumbling, Horse, Vault)• Traction forces (bars)

• Symptoms– Pain – particularly in wrist extension– Swelling & tenderness at radial physis

Distal Radius Stress Syndrome

X-ray• Wide physis/ lucency• Sclerosis

Treatment• Rest 8-12 weeks• PT : forearm,

shoulder & core strength

Osgood-Schlatters Disease

• Athletic early adolescents• Activity and post-activity pain, tenderness at tubercle• 20% Bilateral• Traction apophysitis (Incomplete avulsion fx)

• Swelling & intermittent activity related pain x 18-24mo

• Tx: MICE, NSAIDs, Quad & HS stretching

Epiphyseal Issues: Osteochondritis Dessicans

• Etiology unknown• 20-30% Bilateral• Variable symptoms

– Effusion– Pain, activity related– Locking, loose body rare

• Natural Hx is age dependent– Juvenile (open DF physis)– Adolescent (physis part

closed)– Adult (closed physis)

OCD Treatment• Stable lesions

– Non-op Tx: activity modification – +/- brief immobilization

• Unstable lesions– ATS Drilling – +/- Fixation– Excision, OC grafting/ microfx

• Best case = 3 to 6 month healing time

Overuse Issues

Year-round training in 1 sport +/- multiple teams= high risk • Soccer, baseball, and gymnastics

<0.5% HS athletes play professional sports!

Single-Sport Kids have > injuries & play for a shorter time!

Multiple similar sports pose higher overuse risk• e.g. soccer, field hockey, lacrosse

Participation on only 1 team per season is recommended

Maximum 10% weekly increase in training time, # of repetitions, or total distance.

Conclusions

• Sports participation & training entails risk– Brief, post-participation pain may respond to MICE & Stretching– When to refer?

• Acute fractures or dislocations• Persistent or increasing pain • Swelling• Locking or loose body sensation• Limping

• Inactivity entails risks, probably greater– Obesity– De-conditioning

Thank You