Overuse Injuries In Young Athletes: Treatment and Prevention Lyle J. Micheli, MD Director, Division of Sports Medicine O Donnell Family Professor of Orthopaedic Sports Medicine Children s Hospital Boston Clinical Professor of Orthopaedic Surgery Harvard Medical School Secretary General International Federation of Sports Medicine 1 2 Organized Sports For Children: Benefits vs. Risks Organized Sports BENEFITS Emotional & social growth Fitness, safety Skills, facilities 3 4 1
Organized Sports CONCERNS Emotional stress Endurance/heat stress Injury Major Risk: Sports Related Injury 1. Children age 5-14 risk group 59.3/1000 vs 25.9/1000 Conn JM, Annest JL, Gilchrist J. Sports and recreation related injury episodes in the US population, 1997-99. Inj Prev. 2003 Jun;9(2):117-23. 2. SRI 41% of all musculoskeletal injury in ER Damore DT, Metzl JD, Ramundo M, Pan S, Van Amerongen R. Patterns in childhood sports injury. Pediatr Emerg Care. 2003 Apr;19(2):65-7. 3. Incidence of SRI increasing, 80% increase over 6 years Jones SJ, Lyons RA, Sibert J, Evans R, Palmer SR. Changes in sports injuries to children between 1983 and 1998: comparison of case series. J Public Health Med. 2001 Dec;23(4):268-71. 5 6 Acute injuries vs. Overuse injuries 7 8 2
Acute Injury 1. Fracture 2. Contusion 3. Sprain 4. Strain 9 10 Injuries Overuse Injury 1. Acute trauma 2. Overuse injury 1. Stress fracture 2. Tendinopathy 3. Chondromalacia 4. Bursitis 5. Fasciitis 11 12 3
Repetitive Microtrauma Overuse Injuries Free play Physical education Organized sports Recurrent microtrauma and anatomical or physiologic predisposition STRESS SYNDROME 13 14 15 16 4
17 18 Risk Factors Risk Factors: Sports Injuries Host Environmental HOST Anatomic alignment Muscle-tendon imbalance Fitness level Growth & maturation Nutrition Gender ENVIRONMENTAL Training Conditioning Surface Footwear Equipment Coaching 19 20 5
Case Report 15 yr old male Hx: Overuse; knee pain; limp PE: No local findings Dx: Muscle strain RX: Ice, NSAIDS 21 22 Risk Factors: Host Anatomic alignment Muscle-tendon imbalance Fitness level Growth & maturation Nutrition Gender 23 24 6
Trouble with knees? Check your feet! George Sheehan 25 26 27 28 7
Risk Factors: Host Anatomic alignment Muscle-tendon imbalance Fitness level Growth & maturation Nutrition Gender 29 30 Cybex Testing Right lower extremity: strength 30 degrees/sec mean S.D. range Quadraceps 69.8 17.1 43-90 Hamstrings 40.6 6.3 28-48 Dorsiflexors 8.3 2.0 6-12 Plantarflexors 50.3 13.3 35-78 31 32 8
33 34 Risk Factors: Host Anatomic alignment Muscle-tendon imbalance Fitness level Growth & maturation Nutrition Gender 35 36 9
37 38 39 40 10
Risk Factors: Host Anatomic alignment Muscle-tendon imbalance Fitness level Growth & maturation Nutrition Gender 41 42 43 44 11
Overgrowth Syndromes: The Knee 1. Patellofemoral stress syndrome 2. Osgood-Shlatters disease 3. Patella tendonitis 45 46 Risk Factors: Host Anatomic alignment Muscle-tendon imbalance Fitness level Growth & maturation Nutrition Gender 47 48 12
Risk Factors: Host Anatomic alignment Muscle-tendon imbalance Fitness level Growth & maturation Nutrition Gender The Female Athlete Triad Amenorrhea Osteopenia Disordered eating overuse injury : stress fracture 49 50 Risk Factors: Environmental Training Conditioning Surface Footwear Equipment Coaching 51 52 13
Sports Training: The Young Athlete How much is enough? How much is too much? Training: Pollack, 1968 INT (VO2 Max) DUR (Mins) Rate INJ (%) 70% 40 x 4 12% 85% 15 x 3 22% 85% 45 x 3 54% 53 54 Sometimes we learn how much is enough by observing how much was too much Overtraining: The Young Athlete Performance Fatigue Growth Endocrine Injury 55 56 14
Volume/Progression 20-22 hours / week 10% rule 57 58 59 60 15
Overuse Syndromes Risk Factors: Environmental Types of training Amount of training Rate of training Training Conditioning Surface Footwear Equipment Coaching 61 62 Fitness Cardiovascular/metabolic Musculoskeletal Strength Flexibility Endurance Body composition Psychological Risk Factors: Environmental Training Conditioning Surface Footwear Equipment Coaching 63 64 16
Risk Factors: Environmental Training Conditioning Surface Footwear Equipment Coaching 65 66 Risk Factors: Environmental Training Conditioning Surface Footwear Equipment Coaching 67 68 17
Risk Factors: Environmental Training Conditioning Surface Footwear Equipment Coaching 69 70 Child Athlete at Risk Growth tissue Growth process Coaching / training 71 72 18
Child Athlete at Risk Growth tissue Growth process Coaching / training 73 74 Growth plate Joint surface Joint apophysis Sites of Injury Growth Cartilage 75 76 19
77 78 79 80 20
Gymnastics Back Wrist 81 82 Wrist Pain: Gymnast Navicular stress fracture Distal radius/ulnar physis Dorsal capsulitis Tendinitis AVN 83 84 21
85 86 87 88 22
Sites of Injury Growth Cartilage Growth plate Joint surface Apophysis 89 90 Little League Elbow 91 92 23
93 94 95 96 24
Recommendations Early Recognition of Symptoms Pain Flexion contracture Tenderness These are nature s warning signals! 97 98 Little League Elbow: Training Volume / Intensity 1. Little League Baseball. 1986 6 innings / wk Little League Elbow: Training Volume/Intensity USA Baseball Medical and Safety Advisory Committee: 2004 2. Iwase T, Ikata MD, Kashiwaguch M. Tokushima University 4,049 baseball age 9-12 Rec: 300 pitch/wk 50/day 99 100 25
Sites of Injury Growth Cartilage Growth plate Joint surface Apophysis 101 102 Osgood-Schlatter Disease Avulsion fracture of the epiphysis of the tibial tuberosity near the attachment of the ligamentum patellae 103 104 26
Overuse Injuries In Children Case Report 16 y/o female hurdler Hx: Overuse; 6 mo. activity related mid-foot pain Working Dx: foot sprain PE: Pain w/ provocative I inversion, tight TA Diagnosis: stress fracture tarsal navicular 105 106 Case Report 15 y/o male soccer player Hx: 6 mo. knee pain; chondromalacia; no response to PT, orthotics PE: Thigh atrophy: night pain Diagnosis: osteogenic sarcoma proximal tibia 107 108 27
Sports Medicine is Preventive Medicine 109 110 Enhancement Performance Prevention of Sports Injuries Sports Medicine Sports Science Participation match Conditioning Training Rules Equipment Children Prevent Injury 111 112 28
113 114 115 116 29
THANK YOU!! Lyle J. Micheli, MD michelilyle@aol.com 117 118 30