PEDIATRIC OVERUSE INJURIES. Nick Monson, DO Assistant Professor University of Utah Orthopedic Center U of U Sports Medicine Symposium

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1 PEDIATRIC OVERUSE INJURIES Nick Monson, DO Assistant Professor University of Utah Orthopedic Center U of U Sports Medicine Symposium

2 MINI-ME Little adults Different injury patterns Ligaments > bones Changing bodies GROWTH PLATE

3 GROWTH PLATE ANATOMY Epiphysis Physis Metaphysis Diaphysis

4 OSSIFICATION CENTERS AGE 2 AGE 4 AGE 7 C AGE 11 CR AGE 9 CRI CRITOE CRITO

5 GOOD: REMODELING

6 BAD: GROWTH DISTURBANCE

7 INTRINSIC FACTORS Growth and Development Growth cartilage present at the physes, apophyses and articular surfaces in skeletally immature athletes in a growth spurt are less resistant to forces than either mature or prebuscent bone. Dissociation between bone matrix formation and occurrence of bone mineralization during the growth spurt = relative diminished bone strength Anatomic Alignment Flexibility Biomechanics Strength and Conditioning Energy Availability, Menstrual Irregularity

8 EXTRINSIC FACTORS Equipment (C) Workload (B) >16 hours/week 3.5x risk > 100 innings/year Scheduling (B) Soccer <14 more injuries than older (occurred earlier in the season rather than game related) 42% increase HS all year vs < 3 seasons/year

9 Location High Risk Low risk Hip/ Pelvis L Spine Femoral Neck Stress (Tension Sided) Pars Interarticularis Stress Femoral Shaft Stress Congenital Spondylolysis, Pedicle Stress Leg Anterior Tibial Stress Medial Tibial Stress, Fibular Stress Ankle Medial Malleolar Stress, Talar Dome Osteochondral Defect, Talar Neck Stress Distal Fibular Stress Foot Talar Navicular Stress 2 nd -4 th MT Stress Cuboid Stress Knee Patellar Stress, OCD patella/condyle Tibial Tub and Inferior Patellar pole apophysitis Shoulder/Arm Effort Thrombosis Proximal Humeral Physeal Stress, Elbow Wrist OCD Capitellum, Non-Union Medial Epi Distal Radial Physeal Medial Epicondyle Apophysitis DiFiori JP, Benjamin HJ, Brenner JS, et al. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Br J Sports Med2014;48:287 8.

10 HIP/PELVIS Stress of neck (tension sided) Majority are compression sided, not tension If not treated, non-union AVN. Stress of shaft 4% of stress fractures Typically conservative Iliac Crest/Pelvis/Sacrum Anatomy % of stress fractures

11 SPINE Spondylolysis Imaging: MRI/BoneScan/CT/SPECT 48.5% in peds evaluated for back pain Non-union in 14-70% Average time to return: 5.4 months Risk of listhesis minimal if unilateral

12 SPINE Pedicle Likely early predictor of spondylolysis

13 LEG Anterior Tibial Stress Dreaded Black Line Tension sided Prognosis worse multiple anterior black lines Fibular Stress Medial Tibial Stress Posterior mid to distal 1/3 of tibia Periostitis tib post Proximal 1/3 of tibia most common site of stress

14 ANKLE Medial Malleolar Stress Rare Osteochondral Defect of Talar Dome LAMP Talar Neck Stress Rare Distal Fibular Stress

15 FOOT CalcaneusàCuboidàTalusàNavicularàCuneiforms Talar Navicular Stress Kohler s Metadiaphyseal Base of 5 th Metatarsal Appear to behave as adult fractures Sesamoids

16 FOOT 2 nd -4th Metatarsal Stress Cuboid Stress Sever s age 8-12 most common Iselin Age 8-14

17 KNEE 60% of growth of femur and 70% of tibia comes from around the knee. Patellar Stress OCD Patella/Femoral Condyle Probable relation to secondary physis MRI to stage; unstable related to articular fluid behind lesion

18 KNEE Osgood Schlatter s Sinding Larsen Johansson PFPS F>M 2-10x

19 SHOULDER Effort Thrombosis (Paget Schroetter) Typically 2/2 TOS Acromial apophysiolysis à os acromiale Fusion varies from 18-25

20 SHOULDER Little Leaguer s Shoulder Mechanics, breaking balls, pitch count Worse in late cocking or deceleration phases

21 ELBOW Non Union of the Medial Epicondyle OCD Capitellum Usually teens, loose body

22 ELBOW Panner s Disease Usually age 5-10 Little League Elbow Younger, usually apophysitis rather than UCL Greater than 80 pitches per game More than 8 months of competitive pitching per year Fastball speed>85mph Continued pitching despite arm fatigue/pain Participating in showcases

23 WRIST Radial Epiphysitis Repetitive loads,10-85% of female gymnasts May cause growth disturbance. + variance in 8-20%

24 THANK YOU