AAP Musculoskeletal Boot Camp Overuse Injuries in Young Athletes Teri McCambridge, MD Assistant Professor of Pediatric and Orthopedics University of

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1 AAP Musculoskeletal Boot Camp Overuse Injuries in Young Athletes Teri McCambridge, MD Assistant Professor of Pediatric and Orthopedics University of Maryland Medical System 1

2 Disclosures I have no relevant financial relationships with the manufacturers of any commercial products and or providers of commercial services discussed in this CME activity. I do not intend to discuss unapproved/investigative use of a commercial product/device in my presentation. 2

3 15 y.o. female basketball player CC: knee pain x 2 months Plays on AAU and high school team Hurts with ADL and jumping No night time pain No acute trauma, swelling, locking or instability No relief with heat 3

4 Physical examination Normal except: PTP inferior to patella Weak quadriceps Decreased hamstring flexibility

5 The most likely diagnosis is: A. Patellar tendonitis B. Patellar dislocation C. Patellofemoral Pain D. ACL tear E. Meniscus tear F. Osgood Schlatter 5

6 Patellar Tendonitis (Jumper s knee)

7 Treatment Principles Protection Relative Rest Ice Compression Elevation Medication Motion (ROM) Modalities Strength 7

8 12 y.o. male basketball player CC: Pain and swelling of the knee x 3 month Plays on AAU, school and rec team Takes ibuprofen and applies ice before playing No acute trauma No pain at rest or at night time Pain with running, worse when hit on knee No locking, catching or giving out Limping at times 8

9 Physical Examination Normal except: Enlarged tibial tubercle PTP at tibial tubercle Inflexible hamstring and quadriceps

10 The most likely diagnosis is: A. Patellar tendonitis B. Patellar dislocation C. Patellofemoral pain D. ACL tear E. Meniscus tear F. Osgood Schlatter 10

11 Osgood Schlatter s Traction apophysitis at the tibia tuberosity Age range Bilateral in 20 30% Usually dominant leg Common in Basketball players

12 Diagnosis Often made based on physical and examination, age, and history alone X ray needed only if atypical age or history of a pop and significant swelling. MRI is not needed for diagnosis or treatment.

13 When is mandatory rest recommend? Inability to perform terminal knee extension Inability to do a controlled box step up Loss of knee flexion (secondary to pain)

14 Treatment options R.E.S.T (If you trust them) Knee immobilizer In severe cases Limited time (2 weeks) Physical Therapy Eccentric Quad Flexibility Braces Tincture of time

15 What about Knee pain at Inferior Pole of Patella?

16 11 y.o. basketball player Knee pain with jumping PTP at inferior pole of patella No swelling No feeling of a pop What is the diagnosis? Sinding Larsen Johansson

17 Sinding Larsen Johansson Irregularity inferior pole Acute or gradual onset Presents between 8 12 years of age Pain with running, jumping and climbing Point tenderness end of knee cap Inability to lift leg or significant swelling requires medical evaluation

18 Beware of Infrapatellar Pain with Swelling

19 Patellar Sleeve Fracture: Late Elementary School Acute traumatic pain Associated with hemarthrosis and extension lag Small bony avulsion is associated with a large cartilaginous injury Requires urgent orthopedic referral Immobilize straight until evaluation

20 14 y.o. Female Cross Country Runner 3 months of insidious onset of knee pain Worse with running, going up stairs, and prolonged sitting Describes a U shaped distribution of pain under the knee cap and occasionally posterior pain. No Injury, no swelling, and she is still running What is your Diagnosis?

21 The most likely diagnosis is: A. Patellar tendonitis B. Patellar dislocation C. Patellofemoral pain D. ACL tear E. Meniscus tear F. Osgood Schlatter 21

22 Patellofemoral Pain Syndrome (PFPS) A catch all term which refers to pain in and around the patella 22

23 Patellofemoral Pain Syndrome (PFPS) Symptoms Dull aching to sharp stabbing pain Burning or sandpaper under kneecap Grinding Worse with sitting (Theatre sign) Worse up & down stairs (esp. Down!) Giving way (false instability) 23

24 PFPS General Treatment Guidelines Stretching Strengthening Cryotherapy Training Modification* Shoewear Prescription* 24

25 Other Knee conditions: A. Patellar tendonitis B. Patellofemoral pain C. Patella Dislocation D. ACL tear E. Meniscus tear F. Osgood Schlatter These conditions are not overuse and result in an effusion If suspected Refer to Orthopedics or Sports Medicine 25

26 10 y.o. Soccer Player with Heel Pain CA

27 10 y.o. soccer player complains of worsening heel pain for 6 months Plays on school team and travel team Practice or game 7 days/ wk (sometimes 2x/day) Plays year round except 2 weeks off in December 27

28 10 y.o. soccer player complains of worsening heel pain for 6 months Pain is worse after playing Limping at home and school Takes ibuprofen prior to playing Pain at the side of both heels and front of ankle 28

29 Physical Examination Normal except: Slight limp PTP lateral side calcaneus Decreased Achilles flexibility Unable to single leg hop

30 The most likely diagnosis is: A. Calcaneal stress fracture B. Plantar fasciitis C. Calcaneal apophysitis (Sever disorder) D. Achilles tendon rupture E. Peroneal tendonitis 30

31 Treatment Rest Ice Heel cups (with activity) Shoes with arch support and heel counter Remove cleats shoes Avoidance of barefoot walking Achilles Stretching Casting, rarely When Should You Seek Medical Advice??

32 Evaluate further if: Swelling around the heel Unable to walk normally on the heel after rest and PRICE. Foot is colder then the opposite side and hypersensitive to touch. Fevers, chills, weight loss, or other signs of illness. Redness or warmth around the heel unrelated to activity.

33 What else causes heel pain?: Osteoid Osteoma Calcaneal stress fracture Tarsal coalition Achilles tendonitis Plantar Fasciitis Os Trigonum Cancer (rarely)

34 High Jumper with Heel Pain CaSFX

35 Calcaneal Stress Fracture

36 STRESS FRACTURES 5 10% of all sports related injuries are stress fractures 95% of stress fractures occur in the lower extremity Tibial stress fractures are the most common Incidence in runners is 20%

37 Stress Fracture: Risk Factors Female Recent change in Sport Freshman year in school Poor diet (low in calcium and vitamin D) Medications (steroids) Training errors/shoes Multiple sports teams simultaneously

38 Presentation Gradual onset of pain with recent change in activity Eventually pain at rest or with walking Absence of acute trauma History of menstrual irregularity Pain on palpation or with resisted muscle testing Possible swelling

39 STRESS FRACTURE What they Look like

40 Femoral neck Anterior tibial cortex Fifth metatarsal Navicular Talus Sesamoids Medial malleolus Patella STRESS FRACTURE HIGH RISK Should be referred to and managed by a specialist

41 Potential modifications Modify training program for Freshman athletes/injured athletes Calcium 1500 mg/day and 800 IU of Vitamin D Screen for female athlete triad 2 month break from sport/year Insure proper shoe wear and regular replacement 1 2 days a week off of impact or throwing activity

42 Upper Extremity Injuries

43 14 y.o. Male Loss of elbow extension of 2 months duration Pain on lateral elbow with throwing No acute trauma, fevers, chills, swelling, pain, or locking. He is a pitcher for a tournament team and showcase team. His physical exam is notable for a flexion contracture of 10 degrees, but otherwise negative exam. What is your leading differential?

44 Differential Diagnosis a) Loose body b) Arthritis c) Osteochondritis dissecans of capitellum d) Little League elbow e) Panner s disease f) Stress fracture of the olecranon

45 Osteochondritis Dissecans (OCD) What is it? Localized injury to an articular surface resulting in separation of a cartilage segment from the subchondral bone Takahara M. et.al. J Bone Joint Surg 2007:89:

46 OCD: Presentation Demographics: Adolescent pitcher M>F or gymnast Onset of symptoms between 9 25 years of age, mean age of diagnosis Signs/Symptoms: Pain/stiffness Loss of range of motion Catching or locking Decline in performance Swelling

47 OCD: Physical Exam Possible crepitus Tenderness on lateral aspect of elbow No appreciable joint instability Normal wrist/shoulder ROM Normal neurosensory exam Limitation in range of motion Loss of both flexion and extension

48 What to do if OCD is diagnosed on X ray? Limit all weight bearing and throwing activities Refer to a pediatric orthopedic, sports medicine, or upper extremity specialist Discuss treatment will depend on assessment of stability and skeletal age of patient

49 Treatment: What family can expect Rest (months) NSAIDS/ice Physical therapy Healing documented with serial bone scans or MRI Gradual return to activity When Surgery will be considered? Age > 13(M) or 11(F) Failure of conservative measures after 8 12 weeks Displacement of the fragment Significant degenerative changes Restriction in motion (>20) JBJS AM 2007;89:

50 Other common locations for Osteochondritis Dissecans Etiology: Microtrauma Genetics Ischemia Ossification Knee Ankle

51 When should an OCD lesion be considered in a joint? Persistent pain without specific traumatic event in a skeletally immature individual Limited ROM in a joint without trauma Atraumatic effusion (swelling) in a joint Subjective locking or catching in a joint

52 ELBOW OCD: Prevention Strengthen muscles around elbow Avoid L grip giants Avoid training one arm skills Don t ignore elbow pain Gradual increase throwing Don t be the catcher and pitcher Limit Breaking pitches until mature skeletally

53 Case 2: What diagnosis would you consider if this patient was a 11 yo male? a) Loose body b) Arthritis c) Osteochondritis dissecans of capitellum d) Little League elbow e) Panner s disease f) Stress fracture of the olecranon

54 Panner s Osteochondrosis Occurs in males 5 12 years of age Etiology: interference of blood supply to the capitellum Not usually associated with throwing athletes Usually have loss of extension, pain laterally, and occasional swelling Treatment: 3 4 weeks immobilization and then rest

55 Case 3: What diagnosis would you consider if this patient was a 17 yo male? a) Loose body b) Arthritis c) Osteochondritis dissecans of capitellum d) Little League elbow e) Panner s disease f) Stress fracture of the olecranon

56 Olecranon Stress Fracture Rare injury Generally reported in throwers or weight bearing athletes Mechanism impingement of the olecranon in its fossa or traction. UCL insufficiency increases susceptibility Brucker, J. Sports Health 2015; 7 (4):

57 13 Year old Male Baseball Pitcher Acute onset of medial elbow pain after pitching his third game in a week. He felt a pop and had mild swelling medially Exam shows swelling and pain on medial elbow. Elbow extension limited by pain. Pain with wrist flexion and pronation. Negative milking test What is your diagnosis?

58 Your differential A) Ulnar Collateral Ligament tear B) Golfer s elbow (medial epicondylitis) C) Fracture of the medial epicondyle D) Apophysitis of medial epicondyle (Little League Elbow) E) Ulnar neuritis F) Radiculopathy of C8 or T1

59 What is Little League Elbow? Result of valgus overload to the medial elbow from repetitive throwing Presents with medial elbow pain with throwing Frequent in middle school age boys X ray AP, Lateral and Oblique should be obtained. Benjamin, H Little League Elbow. Clin J Sport Med 2005; 15(1):37 40

60 Little League Elbow: (Conservative Treatment) Recommended if separation of apophysis < 5 mm Involves Rest from pitching for a minimum of 6 weeks ICE/NSAIDS Throwers Ten Exercise Program Technique evaluation/modification Gradual resumption of activity with throwing program

61 A Healthy Kids Perspective on Sports!

62 Questions?