Pediatric Athletic Overuse Injuries. Susan Haralabatos, MD OPSC Annual Meeting 2018

Transcription

1 Pediatric Athletic Overuse Injuries Susan Haralabatos, MD OPSC Annual Meeting 2018

2 Text I have no disclosures

3 Overview Etiology, Physiology &Anatomy Common Physeal Overuse Injuries Stress Fractures Concussion Prevention

4 The Numbers >35 million children, 5-18, are involved in organized sports Additional children involved in individual sports More than half of injuries are due to repetitive trauma Many of the overuse injuries are preventable

5 Contributing Factors Year-round participation Early Sport Specialization De-conditioning Push to early skill development Lack of education Myths Financial

6 Year Round Participation Travel teams Off season Club teams Showcases & camps Tournaments Indoor leagues Personal coaches and trainers

7 Early Sport Specialization Encouraged or required by coaches As early as elementary school Up or Out

8 Trend to Early College Recruitment

9 Trend to Early College Recruitment

10 De-conditioning Less unstructured freeplay More screen time Cultural lifestyle norms

11 Skill Development Push to bring skills down to a lower age group National recognition Practice makes perfect / 10,000 hour rule

12 Lack of Education general safety and injury prevention physical conditioning concussion management

13 Athletic Superstar Myth Only 1% of HS athletes will receive a Division I scholarship 1/6,000 HS football players will play in NFL 1/4,000 HS baseball players will play professionally 2-3/10,000 HS basketball players drafted to NBA

14 Financial Factors Youth Sports is a 15 BILLION dollar industry Most participants affluent

15 Anatomy of Growing Bone Physis Apophysis Tension vs Compression Injury Children are not small adults

16 Growth Plate Tremendous changes due to growth and remodelling in growing child Stress related injuries add to balance and disrupt the zone of endochondral ossification

17 The Weak Link Bone is a living tissue Rapid changes at physis increase risk for acute & chronic injury Individual maturation & development variable

18 Symptoms of Overuse Injury Insidious onset of pain or discomfort Absence of acute trauma Often associated with sudden increase or change in activity level

19 Stages of Overuse Injury Stage 1: Pain with activity Stage 2: Pain during activity without a change in performance Stage 3: Pain during activity that restricts performance Stage 4: Chronic unremitting pain even when at rest

20 Radiographic Signs of Overuse Widening of the physis / growth plate Adjacent sclerosis of the metaphysis On MRI bone edema appears white on T2

21 Shoulder Primarily overhead athletic activities Proximal humerus responsible for 80% of longitudinal growth Physis closes relatively late

22 Little League Shoulder Shoulder pain in immature pitchers Tension osteochondrosis Risk Factors

23 Little League Elbow medial tension & lateral compression more likely to require surgery can lead to articular injury racket sports, gymnastics

24 Little League Elbow

25 Throwing mechanics

26 Olecranon Apophysitis Sx: pain with acceleration & follow through, weakness, limited ROM Due to triceps contraction Another overuse injury associated with baseball

27 Distal radius >80% of load is across radio-carpal joint gymnasts & weight lifters severe cases can lead to growth arrest altering mechanics of wrist joint

28 Spondylolysis Chronic injury to pars interarticularis Common in gymnasts, swimmers, football front linemen

29 Spondylolysis

30 Pelvis Multiple apophyses close later than long bones Multiple muscle attachments May have acute on chronic injury

31 Anterior Superior Iliac Spine Attachment of Sartorius Sprinters, hurdlers, runners May have neuropraxia of lateral femoral cutaneous nerve

32 Anterior Inferior Iliac Spine Attachment for rectus Sprinters, jumpers and kickers

33 Ischial Tuberosity Most common injury Origin of hamstrings Common in hurdlers, long jump, gymnasts, cheer leaders Can have sciatic nerve neuropraxia

34 Other Hip Conditions Snapping Hip FAI - Femoral Acetabular Impingement LCPD - Legg Calve Perthes Disease SCFE - Slipped Capital Femoral Epiphysis

35 SCFE Usually boys Obese, African American external rotation of affected limb PE: obligate external rotation with flexion of the hip May present with complaints of knee pain!

36 Knee common area of complaint Osgood-Schlatter Sinding-Larsen-Johansson Jumper s knee (patellar tendonitis) IT Band friction syndrome Patellofemoral pain

37 Knee Pain: consider other diagnoses SCFE Discoid meniscus Meniscal tear Osteochondritis dissecans Malalignment (genu varum/valgum) Foot and ankle issues Stress fracture

38 Foot Sever s disease Base of the 5th metatarsal Flat foot

39 Stress Fractures Bone is a living tissue with a balance of breakdown and build up Occur when muscles become fatigued and transfer stresses to the bone Most occur in WB bones of lower leg and foot

40 Stress Fractures Sx: insidious onset of vague pain Usually associated with abrupt increase in training In girls, associated with Female Athlete triad PE: localized bone pain MRI best for diagnosis

41 Stress Fracture Locations tibial shaft - runners fibula metatarsals (2-4) & foot femur - endurance runners, jumpers pelvis - soccer & other jumping sports sacrum - female runners spine / spondylolysis - repeated hyperextension upper extremity - tennis

42 Stress Fractures Early in process, plain films may be negative MRI most sensitive Bone edema on T2 and STIR sequences Increased cortical signal and periosteal reaction Fracture line will appear black on all images

43 Female Athlete Triad Amenorrhea / limited menses / menstrual cycle changes Eating disorder / inadequate caloric intake for level of activity Osteopenia / decreased bone density

44 Concussion Overexposure Injury One concussion increases risk for second Results are cumulative Children take longer to recover than adults Preseason ImPACT testing

45 Treatment of Overuse Injury Rest / Recovery Ice after activity Consider NSAIDs Physical Therapy Education

46 Prevention: Individual Education Improve flexibility Improve core strength Improve biomechanics Correct alignment

47 Prevention: Family Education Encourage cross training & general fitness Delay sport specialization Time off Burnout Remind athletes & parents to listen

48 Prevention: Coaches Education & training Provide literature when possible May need individual discussion with family permission

49 Know when to ask for help!

50 American Academy of Pediatrics Council on Sports Medicine & Fitness: Prepare Pre-participation physical (PPE) at least 6 weeks prior to beginning season Maintain general fitness ImPACT testing when appropriate Discuss diet at visit (Calcium & Vitamin D for bone health)

51 American Academy of Pediatrics Council on Sports Medicine & Fitness: Play Smart Avoid specialization until late adolescence Participate in a variety of sports Limit participation to 5 days/week One team & one sport per season

52 American Academy of Pediatrics Council on Sports Medicine & Fitness: Rest Up Take at least one day off per week from organized activity Combined three months off per year Remain physically active during extended rest

53 American Academy of Pediatrics Council on Sports Medicine & Fitness: Training Increase no more than 10% per week Cross-train Vary sport-specific drills

54 Resources STOP (Sports Trauma & Overuse Prevention) American Orthopedic Society for Sports Medicine

55 Resources American Academy of Pediatrics Council on Sports Medicine & Fitness

56 THANK YOU Masterfulphysician.com