Common Apophyseal Problems in the Athlete

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1 Disclosure Common Apophyseal Problems in the Athlete Mark Halstead, MD November 19, 2009 Faculty Disclosure Information In the past 12 months, I have no relevant financial relationships with the manufacturer of any commercial product and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation. Objectives Define the physis and its related parts Discuss common overuse and acute injuries to the physis in the young athlete The Physis What is it? Physis Epiphysis Metaphysis Diaphysis Apophysis The Elbow Medial Epicondyle The Elbow Medial Epicondyle C-R-I-T-O-E

2 Medial Epicondylar Apophysitis History and Physical Triad of medial elbow pain, loss of velocity, diminished effectiveness PE Tender over medial epicondyle +/- swelling Pain with valgus stress Often with flexion contracture Medial Epicondylar Apophysitis Know ossification centers Be aware of avulsion fracture Comparison studies very helpful (AP view of normal elbow) Can consider stress radiographs Imaging Medial Epicondylar Apophysitis REST Start weeks Gradual resumption of throwing Avoiding breaking pitches Treatment Medial Epicondyle Avulsion Fracture Due to acute valgus stress and forceful flexor-pronator contraction Hx : Acute episode One throw Fall with valgus stress to elbow (wrestling) Exam : Often limited motion, hard to extend Tender medially Swelling Medial Epicondyle Avulsion Fracture Anatomy Tx : OR vs conservative Debated? 2mm? mm? Doesn t t matter More likely an issue of what patient does for activity 2

3 Anatomy The Physis Ages growth areas fuse around pelvis Femoral epiphysis 18 yrs Lesser/Greater trochanter yrs Iliac crest yrs ASIS yrs AIIS yrs Ischial tuberosity yrs Anterior Superior Iliac Spine (ASIS) Sartorius muscle Running, hurdling, sprinting Knee flexed, hip extended forcefully Anterior Inferior Iliac Spine (AIIS) Rectus femoris Often due to forceful kick Hip hyperextended with flexed knee Ischial tuberosity Hamstring muscles Hurdling, long jump, splits; Knee extended with hip flexed 3

4 Avulsion fractures Less Common : Iliac crest Rare : greater and lesser tuberosity Treatment Crutches initially Rest (!) Can take weeks to return Can recur if return is too soon Iliac Apophysitis Iliac Apophysitis Most frequent in the immature runner Pain along anterior iliac crest w/running PE : reproduce pain w/resisted abduction of affected hip Xray : (-)( Tx : Self-limited; limited; Relative rest; Improve running technique; NSAIDs 4

5 Osgood-Schlatter Common cause of pre- adolescent knee pain Traction apophysitis First described 1891 by Paget Osgood and Schlatter published separate papers on topic 25% bilateral Osgood-Schlatter Rapid bone growth, slow soft tissue growth Traction at tibial tuberosity apophysis Can swell Production of heterotopic bone formation On exam Pain forced extension Tender over tibial tubercle May have swelling/prominence of tibial tubercle Tight quads/hamstrings Treatment Ice Relative rest Stretching Patellar strap NSAIDs Complication Avulsion fracture Osgood-Schlatter Sinding-Larsen Larsen-Johansson Similar to Osgood- Schlatter Also traction apophysitis Affects inferior pole of patella Treatment and causes identical to Osgood The Heel Sever s Most common cause of heel pain in preadolescent Frequent seen in sports requiring cleated shoes Misdiagnosed as plantar fasciitis PE : Tender over posterior aspect of heel Often pain with compression of heel If severe, patient will walk on toes/limp Usually no swelling The Heel Sever s Xrays : Frequently normal Be aware of possible stress fracture Treatment : Viscoelastic gel cushions Rest? Turf shoes Calf stretching (gastroc( and soleus) Ice 5

6 The Heel Sever s The Foot Iselin s Often misdiagnosed as a 5 th metatarsal avulsion fracture Less common form of apophysitis Can be seen commonly in gymnasts, dancers Pain at base of 5 th metatarsal Key : No injury history Don t t let radiologist xray interpretation fool you. If child reports no injury, probably telling the truth The Foot Iselin s The Foot Iselin s PE : ttp over 5 th metatarsal base Possible swelling locally Usually no bruising May tend to avoid putting pressure on lateral foot Xray : Key distinction for fracture determination is orientation of fragment Treatment : ice, rest,? Peroneal/post tib strengthening,? Need for orthotics Take Home Points THANK YOU Don t t forget the apophysis Tendinitis is NOT a common diagnosis in the growing child Growth plate is weak link Beware of the pulled muscle in the growing child If xray in question, compare to opposite side 6