Adolescent Health Care: A Practical Guide
Common Orthopedic Problems
Keith J. Loud
Robert J. Bielski
Musculoskeletal problems, including athletic injuries, are among the most common reasons for adolescents to seek medical attention. Appropriate management of these concerns can not only decrease morbidity and prevent sequelae but also earn the valuable and oft elusive confidence of the patient.
General Principles of Musculoskeletal Care
Despite a lack of adequate training, health care providers for adolescents can provide most initial care for orthopedic problems. Recommended resources include:
- Reference materials
- An encyclopedic text such as Essentials of Musculoskeletal Care, 3rd Edition, published jointly by the American Academy of Pediatrics (AAP) and American Academy of Orthopedic Surgeons (AAOS)—a comprehensive, practical guide to the diagnosis and treatment of virtually all orthopedic problems encountered in primary care practice.
- A diagnostic manual such as Physical Examination of the Spine and Extremities, by Stanley Hoppenfield—a classic text that clarifies the musculoskeletal examination.
- Physical therapy: A strong working relationship with a local physical therapist. Physical therapy is a mainstay in the treatment of many musculoskeletal conditions.
- Orthopedic care: Easy access to orthopedic specialty care when needed.
General Indications for Referral to an Orthopedic Surgeon for Patients with Acute Trauma of an Extremity
Evaluation, treatment, and criteria for referral for specific injuries are discussed in the following sections. In general, plain radiographs (x-rays) should be considered for any significant unilateral complaint with greater urgency for pain which wakes a patient from sleep, or any unexplained or persistent bilateral complaints.
There are general criteria for immediate consultation regardless of the injury site. They include the following:
- Obvious deformity
- Acute locking (joint cannot be moved actively or passively past a certain point)
- Penetrating wound of major joint, muscle, or tendon
- Neurological deficit
- Joint instability perceived by the adolescent or elicited by the health care provider
- Bony crepitus
If the primary health care provider evaluating the patient has training in the evaluation and functional rehabilitation of musculoskeletal injuries, the threshold for referral will be higher.
Treatment and Rehabilitation of Injuries—General Concepts
The prevention of long-term sequelae of injury depends on complete rehabilitation, characterized by full, pain-free range of motion (ROM) and normal strength, endurance, and proprioception.
There are four phases of rehabilitation:
- Limit further injury and control pain and swelling.
- Improve strength and ROM of injured structures.
- Achieve near-normal strength, ROM, endurance, and proprioception of injured structures.
- Return to activity (exercise, sport, or work) free of symptoms.
Avoid predicting time frames for return to participation; individuals progress at different rates and disappointment may ensue if goals are not reached as promised.
Phase 1: Limit Further Injury and Control Pain and Swelling
- The affected part must be rested and protected. Patients should apply whatever devices are necessary (e.g., wrap, splint, crutches, sling) so that they can become pain free and protect the site from further injury.
- Elevation, compression, and ice should be applied as often as possible during waking hours. Iceshould be
applied continuously for 20 minutes, directly to the skin and three or four times a day for the first few days.
- Analgesic medication (e.g., acetaminophen, nonsteroidal anti-inflammatory drugs [NSAIDs]), if prescribed, should be dosed regularly to achieve therapeutic steady state levels, not “as needed”. Physical therapists can apply electrical stimulation to achieve pain relief in the acute setting.
- Noninjured structures should be exercised to maintain cardiovascular fitness. For instance, patients with a lower-extremity injury could do seated weight lifting or swim with their arms pulling and without leg action. Those with an upper-extremity injury could ride a stationary bike.
- Athletes should attend practice sessions so that they are not as likely to withdraw psychologically.
Phase 2: Improve Strength and Range of Motion of Injured Structures
- Specific exercises should be done within a pain-free ROM. For example, isometric exercises can be started on the first day if there is little pain-free ROM but the subject is able to contract the muscles.
- Relative rest is the cardinal principle, and that means that the patient should do everything possible, so long as it does not cause pain within 24 hours of the activity.
- Analgesic medication should be continued, not to mask the pain and allow premature return to play, but to interrupt the cycle of pain, muscle spasm, inflexibility, weakness, and decreased endurance. In addition to reducing swelling, ice pack is a good analgesic modality.
- General fitness maintenance should continue, as described for phase 1. Other activities, such as water jogging for lower-extremity injuries, may be added.
Phase 3: Achieve Near-Normal Strength, Range of Motion, Endurance, and Proprioception of Injured Structures
- Exercise is progressed so long as the subject follows the relative rest principle.
- Healing of ligaments treated nonoperatively manifests as minimal laxity with provocative testing, normal ROM, no tenderness along the ligament or pain with stretching, and progressively less pain with activities of daily living.
- Healing of muscle tendon units manifests as no tenderness or pain with functional testing, full ROM, and progressively less pain with activities of daily living.
Phase 4: Return to Exercise or Sport Free of Symptoms
- Premature return is likely to result in further injury or another injury.
- Successful rehabilitation minimizes the risk of reinjury and returns the injured structures to baseline ROM, strength, endurance, and proprioception.
- Functional rehabilitation should be sport specific. For example, a baseball pitcher with an upper-extremity injury needs to rehabilitate to normal strength and ROM, but, before throwing a baseball in a game, he or she should practice throwing gently and work up to full speed over days to weeks, depending on the specific diagnosis and chronicity of the injury.
Large Muscle Contusions
The prototype injury in this category is the quadriceps contusion. This injury occurs from a direct blow to the thigh. It occurs in all sports and is very common in football, although the players wear thigh pads.
The athlete's presentation can range from feeling a mild discomfort or “Charlie horse” after the game to being unable to bear weight immediately after the trauma. The pathophysiology of the injury is bleeding in and around the quadriceps muscle as a result of the contusion. The quadriceps immediately goes into spasm, resulting in pain and disability. If the bleeding is not arrested immediately, it can be substantial.
On examination, the health care provider needs to consider a femoral fracture, which would be characterized by severe pain and the inability to bear weight. A quadriceps contusion is characterized by more diffuse tenderness over the quadriceps muscle. The athlete, typically, can bear weight but may not be able to extend the knee actively. With passive flexion of the knee while the athlete is in the prone position, the patient experiences pain as the quadriceps, which is in spasm, is stretched. The injury can be graded according to the degree of passive knee flexion that the patient can permit.
Treatment (Using Quadriceps Contusion as an Example)
- Stop bleeding and RICE (rest, ice, compression, elevation):The key is to stop further bleeding by applying ice for 20 minutes. When not applying ice, apply a tight compression wrap around the thigh and have the patient elevate the leg. The player should keep the knee in full flexion as much as possible during the first 24 hours after the injury.
- Analgesics:Cyclooxygenase inhibitors should not be given because they might promote decreased clotting. Acetaminophen can be given for pain.
- Exercise:The patient should start isometric quadriceps contractions as soon as possible. In moderate to severe injuries, treatment by a sports-trained physical therapist is essential. In experienced hands, the use of ultrasound can promote rapid recovery from this injury. Therapy that is too timid or too aggressive can retard recovery. If the bleeding is extensive and the athlete is reinjured before the hematoma has resolved, he or she is at risk for development of myositis ossificans, which can be career threatening and may require surgical excision if functional ability is compromised.
The Knee—General Principles
History of the Injury
On the basis of the description of the mechanism of injury, the events after the injury, and the factors that worsen or improve the pain, the health care provider should be able to prioritize the most likely diagnoses.
- Knee pain that occurs while running straight, without direct trauma or fall.
- Chronic pain: Likely to be patellofemoral syndrome (PFS) or dysfunction.
- Acute pain: Consider osteochondritis dissecans (OCD) and pathological fracture. Any teen with knee pain without a history of trauma and with an equivocal examination that does not pinpoint the diagnosis needs to have a radiographic examination of the knee. In addition, if the hip examination finding is abnormal, radiographs of the hip are needed to rule out slipped capital femoral epiphysis manifested as knee pain. Osgood-Schlatter disease and patellofemoral dysfunction do not require radiographs to establish a diagnosis.
- Knee injury that occurs during weight bearing, cutting while running, or an unplanned fall. Consider internal derangement including ligamentous and meniscal tears and fracture. A player who injures the knee while cutting, without being hit or having direct trauma, has an anterior cruciate ligament (ACL) tear until proved otherwise.
- A valgus injury to the knee (i.e., a force delivered to the outside of the knee, directed toward the midline) is likely to tear the medial collateral ligament, possibly the ACL, and either the medial or lateral meniscus.
- Chronic anterior knee pain that is worse when going up stairs and/or after sitting for prolonged periods, or after squatting or running, is likely to be patellofemoral dysfunction. In general, if the patient does not give a history of the knee giving out or locking, sharp pain, effusion, the sensation of something loose in the knee, or the sensation that something tore with the initial injury, then the injury probably is not significant. If there is hemarthrosis within 24 hours of the injury, then internal derangement is present and a diagnosis must be sought. At the game site, if the patient can be evaluated within 1 hour or so of the injury, the ability to bear weight and walk without pain is the best indicator that he or she has probably not suffered a major injury and does not need to be referred immediately.
The physical examination should include the following:
- Observation of gait (weight bearing? antalgic gait?)
- Inspection for swelling and discoloration
- Observation of vastus medialis obliquus contraction, looking for reduced bulk and tone
- Peripatellar palpation (tenderness over the tibial tuberosity is diagnostic of Osgood-Schlatter disease; peripatellar pain is characteristic of patellofemoral dysfunction)
- Observation of quadriceps and hamstring flexibility
- Inspection for evidence of meniscal tears (McMurray and modified McMurray tests)
- Inspection for evidence of ligamentous instability, including valgus and varus testing (for medial collateral and lateral collateral ligaments, respectively)
- Lachman test and pivot shift test (ACL); sag sign and posterior drawer test (posterior cruciate ligament)
Radiographic Evaluation of Knee Injuries
Any one of the following criteria would be an indication for a radiograph after an acute knee injury:
- Inability to bear weight
- Fibular head tenderness
- Isolated tenderness of the patella
- Inability to flex the knee beyond 90 degrees
These decision rules, collectively referred to as the Ottawa Knee Rule, had a sensitivity of 100% in detecting knee fractures in adults and could potentially reduce the use of plain radiographs by 28% (Steill et al., 1996a).
Anteroposterior and lateral views are standard. The sunrise view details the patellofemoral joint and should be ordered if patellar dislocation is suspected, while the tunnel view should be ordered if suspicious for OCD, ACL injury, or other intraarticular pathology.
Magnetic resonance imaging (MRI) evaluation in the acute or chronically injured knee should not be routine (O'Shea et al., 1996). MRI should be reserved for diagnostic dilemmas and for patients who do not respond to conservative management. The most commonly missed diagnoses are chondral fractures, ACL tears, fibrotic fat pad, and loose bodies (Oberlander et al., 1993). In experienced hands, the MRI added nothing to the diagnosis of knee injuries based on history and physical examination (Oberlander et al., 1993). This emphasizes the clinical (and financial) importance for primary care and emergency room health care providers to have good physical examination skills for diagnosing common musculoskeletal injuries.
Acute Knee Injuries—General Principles of Treatment
- Establish a working diagnosis.
- Use the Ottawa Knee Rule.
- Relative rest: Prescribe use of crutches if the patient cannot bear weight without pain. An elastic wrap is adequate in the initial phase of treatment, or until a definitive diagnosis is made and a treatment regimen planned. Knee immobilizers have a limited role in the management of acute knee injuries because they are bulky and awkward, offer no structural support, and lead to calf strain if the patient tries partial weight bearing with the foot in the plantar-flexed position.
- Ice: Apply for 20 minutes three or four times a day.
- Start isometric quadriceps contractions on the first day if possible. If the patient cannot contract the quadriceps and it is anticipated that he or she will be unable to do so for some days, consider an electrical stimulation unit to contract the quadriceps until the patient is able to do so.
- Maintain elevation of the leg as much as possible.
- Use a compression wrap.
- Prescribe analgesic medication.
- Refer the patient for physical therapy.
The Knee—Specific Conditions
Subluxation and Dislocation of the Patella
Instability of the patellofemoral joint may permit the patella to dislocate partially out of the intercondylar groove. The patella then snaps back into place, in contrast to a complete dislocation, in which the patella continues to complete lateral dislocation. These episodes usually occur while the quadriceps is contracting with the knee in flexion and the foot fixed to the ground.
Subluxation and lateral dislocation of the patella are prevalent in the second and third decades of life, with a slightly higher prevalence in females.
Symptoms include pain, giving way of the knee, a popping or grinding sensation, and swelling. Physical findings may be similar to those of PFS, which is frequently associated with recurrent subluxation or dislocation. Subluxation of the patella can mimic the clinical picture of a torn meniscus. Complete dislocation is usually a dramatic event and is easy to diagnose, with the patella visible on the lateral side of the joint. Patellar dislocations often reduce spontaneously, so the health care provider may not see the patella in a dislocated position.
- Subluxation of the patella
- Prescribe physical therapy for a quadriceps-strengthening program.
- Temporarily restrict or modify activity.
- Use a patellar sleeve to stabilize the patella. Alternately, the patient may be taught to do McConnell taping to stabilize the patella.
- Refer for surgery only if all other therapies fail.
- Dislocation of the patella
- Reduction often occurs spontaneously.
- Gentle straightening of the knee by lifting the foot may allow the patella to slide into place. Sedation may be necessary to effect a reduction.
- Radiographs should be taken, because the dislocation and reduction generate sufficient force to fracture the bone in up to 10% of cases.
- Immobilize the knee in a knee immobilizer for 3 weeks, followed by physical therapy (PT) for range-of-motion and quadriceps-strengthening exercises. Use of a patellar stabilizing brace or McConnell taping is often effective.
- Recurrent dislocation In some nonoperative treatment, therapy and bracing is successful, but when the patient has more than one dislocation, surgical intervention may be needed to realign the extensor mechanism.
Osgood-Schlatter disease is a painful enlargement of the tibial tubercle at the insertion of the patellar tendon. It is a common problem, especially among active adolescent males.
During development of the anterior tibial tubercle, a small ossification center develops in the largely cartilaginous tubercle. With developing muscle mass during puberty, this small area comes under great traction stress from the patellar tendon, and small fragments of cartilage or of the ossification center can be avulsed. The problem is often aggravated by activities that involve quadriceps femoris contraction, such as running and jumping, with resultant additional stress on the tubercle.
- Males have a greater prevalence than females.
- Mean age at onset: Onset usually coincides with the period of rapid linear growth.
- Females: 10 years, 7 months
- Males: 12 years, 7 months
In a study by Yashar et al. (1995), the average bone age matched chronological age in adolescents with Osgood-Schlatter disease. This is in contrast to slipped capital femoral epiphysis, in which skeletal maturation is often delayed.
- Pain and soft tissue swelling over the tibial tubercle.
- Point tenderness and warmth over the tibial tubercle.
- Normal knee joint with full ROM.
- Unilateral involvement more common than bilateral involvement.
- Duration usually lasts several months but can last longer.
- History: Pain at the tibial tubercle, aggravated by activity and relieved by rest.
- Physical examination: Tenderness and swelling of the tibial tubercle.
- Radiograph: Not essential for diagnosis but generally done only to eliminate the possibility of other processes. The radiograph may reveal soft tissue swelling anterior to tibial tubercle and/or fragmentation of the tibial tubercle.
- Explanation: Careful explanation of the condition to the adolescent and to his or her parents is essential to alleviate fears and misconceptions.
- Restriction of activity: If symptoms are mild, the patient may continue in the chosen sport. If symptoms are more severe, curtailing of running and jumping activities for 2 to 4 weeks is usually sufficient.
- Immobilization: If symptoms are severe or fail to respond to restriction of activity, immobilization with a knee immobilizer for a few weeks is effective. Immobilization should also be strongly considered when the patient has difficulty actively bringing the knee to full extension.
- NSAIDs and ice: These may provide symptomatic pain relief.
- Knee pads: Knee pads should be used for activities in which kneeling or direct knee contact might occur.
- Surgery: Surgery is rarely indicated. If the patient continues to have symptoms after skeletal maturity, he or she may have a persistent ossicle that does not unite with the rest of the tibial tubercle. Simple excision of this fragment may bring relief.
The prognosis is excellent, but adolescents should be informed that the process might recur if excessive activity is performed. Usually, when growth is completed the problem stops, leaving only a prominent tubercle. The patient may still have difficulty kneeling on the prominent tubercle, even into adulthood. Rarely, patients with Osgood-Schlatter disease may fracture through the tibial tubercle.
PFS, patellar malalignment syndrome, or patellofemoral dysfunction is a frequent cause of knee pain among adolescents, accounting for as much as 70% to 80% of knee pain problems in females and 30% in males. It is also the leading cause of knee problems in athletes. The term patellofemoral pain syndrome may be used currently, because it is a better descriptive term for part of the pathophysiology of the condition. The condition has traditionally been known as chondromalacia patellae. However, this term implies actual softening and damage to the patellar articular cartilage, whereas many individuals have no changes in their articular surface, so this term should be abandoned.
PFS is often a result of abnormal biomechanical forces that occur across the patella. Even in an individual with normal anatomy, the force that occurs in this area, especially when the body is supported with one leg and the knee is partially flexed, is tremendous. Abnormal forces can result from the following:
- Quadriceps femoris muscle imbalance or weakness or abnormality in the attachment of the vastus medialis
- Altered patellar anatomy, such as a small- or high-riding patella
- Increased femoral neck anteversion, with associated knee valgus and external tibial torsion, which increases lateral stress on the patella
- Increased Q angle–the angle found between a line drawn from the anterosuperior iliac spine through the center of the patella and a line from the center of the patella to the tibial tubercle (normal, <15 degrees)
- Variations in the patellar facet anatomy
PFS is common in both male and female athletes. There is a higher prevalence among females in the general population but a higher prevalence among males in athletic populations.
- The pain of PFS is characterized by the following:
- Peripatellar or retropatellar location
- Relation to activity: The pain usually increases with activities such as running, squatting, or jumping, and decreases with rest. Often the pain is most acute immediately on getting up to start an activity after a period of sitting.
- Insidious onset
- Positive movie or theater sign: Prolonged sitting with flexed knee is uncomfortable.
- Pain is often severe on ascending or descending stairs.
- Knees may buckle or give out, especially when going up or down stairs.
- Crepitus or a grating sensation may be felt, especially when climbing stairs.
- History of injury to the patella area may be present.
- Symptoms are bilateral in one third of adolescents.
- Two thirds of patients have at least a 6-month history of pain.
- Physical examination
- Inspection of the adolescent with PFS may reveal several anatomical abnormalities.
- Patellar malalignment or squinting patella: With the adolescent's feet together, the two patellae may be displaced anteromedially. This is often found associated with a Q angle of >15 degrees. The Q angle is a measurement of the extensor mechanism alignment and was described previously.
- External tibial torsion
- Genu valgum (which increases the Q angle)
- Tenderness of the articular surface of the patella is elicited by knee extension and by displacing the patella medially and laterally while palpating the undersurface.
- Retropatellar crepitation may be determined by palpating for crepitus with one hand over the knee during flexion and extension. Crepitation is significant only if it is associated with pain.
- Dynamic patellar compression test, or “grind sign,” may be performed by compressing the superior aspect of the patella between thumb and index finger as the adolescent actively tightens the quadriceps in 10 degrees of flexion. Pain is elicited if chondromalacia patella is present. Direct compression of the patella against the femur with the knee flexed will also elicit pain. This test is somewhat unreliable because it can also elicit pain in the asymptomatic knee.
- Knee ROM is usually normal.
- Hamstrings are often tight.
- Joint effusion usually does not occur but can be present in severe cases.
- Decreased bulk of the area around the vastus medialis on the affected side may be present. Thigh circumference should be checked, comparing the normal with the involved side.
The diagnosis is usually made by compatible history and physical examination. Radiographs usually are of little help but are important in excluding other conditions. They should include anteroposterior, lateral, tunnel (to rule out OCD), and tangential views (also known as skyline or Merchant views). Other conditions causing knee pain in the adolescent include meniscal lesions, Osgood-Schlatter disease, tendonitis of the patellar tendon, recurrent dislocation of the patella, and OCD. In addition, hip disorders often manifest as vague knee or thigh pain, especially slipped capital femoral epiphysis.
- Control of symptoms
- Relative rest—reduction of activities such as running, jumping, climbing, and squatting that produce patellofemoral compression forces. Walking and swimming are good exercises to continue.
- NSAIDs, appropriately dosed for a short course.
- Muscle strengthening: Most patients benefit from a formal physical therapy evaluation and can then be moved to a home program. As soon as tolerated, muscle-strengthening exercises should be performed at least once a day. Initially, these should be isometric quadriceps exercises (straight leg raises). Strengthening of the vastus medialis is particularly important. The exercises should be done with a weighted boot or on an exercise machine with the knee in full extension. The weight should be held for 5 seconds and repeated in three sets of 10 repetitions. Stretching of the hamstrings is an essential component of most therapy programs.
- Graduated running: After symptoms are controlled and 6-10 lb of weight are held, a graduated running program can be instituted. Ice may be helpful immediately after exercise.
- Maintenance: When the condition is under control, a maintenance program of quadriceps and hamstring exercises should be done two to three times a week. Most adolescents respond to nonoperative management. An experienced clinician has observed that if a patient can perform straight leg raises of near 15 lb, their symptoms almost invariably disappear.
- Knee braces: Use of these in patients with PFS is controversial. Theoretically, they help keep the patella from moving too far laterally. However, because the patella moves in various planes, knee braces are best used in patients with lateral subluxation visible on examination. The knee brace is not a substitute for muscle-strengthening exercises.
- Taping the knee: Although this may reduce friction, results are also controversial.
- Footwear: Athletic shoes have improved in the last decade, but the quality and age of the athletic shoes are more important than a particular brand name.
- Over-the-counter arch supports or custom orthotics: These can be helpful to some patients. Custom orthotics are expensive and are generally not required, but in some patients these may be more helpful than over-the-counter supports.
- Surgery: This is considered as a last resort for patellofemoral pain. Occasionally a “lateral release” is appropriate if the problem is clearly related to excessive lateral tracking and other measures are unsatisfactory. This involves cutting the lateral retinaculum to reduce the amount of lateral pull.
Osteochondritis Dissecans (OCD)
OCD is a condition of focal avascular necrosis in which bone and overlying articular cartilage separate from the medial femoral condyle or, less commonly, from the lateral femoral condyle. The peak incidence is in the preadolescent age-group. The clinical course and treatment vary according to the age at onset, with children and young adolescents having a better prognosis than older adolescents and adults.
The exact cause is unknown. Postulated factors include the following:
- Trauma: Most patients do not report a single traumatic event. There is often a long history of exercise and participation in sports. It is theorized that earlier participation of children in sports has led to the earlier appearance of osteochondritis lesions (Cahill, 1995).
- Ischemia: Obstruction of blood supply as a cause has been postulated, but evidence is lacking.
- Epiphyseal development: In younger patients with osteochondritis, an accessory nucleus in the epiphyseal area may make the femoral condyle more vulnerable to trauma. Some adolescents have variants of normal growth that may simulate OCD on radiography, causing the condition to be overdiagnosed in younger adolescents.
- Heredity: Heredity plays a minor role in some patients.
- Onset in childhood and early adolescence
- An intermittent, nonspecific knee pain usually related to activity is a common symptom.
- Extension movements of the knee may cause swelling and soreness.
- Symptoms are often present for months to years before consultation.
- The adolescent may walk with the tibia in external rotation on the affected side.
- Localized tenderness over the site of the lesion is best detected with the knee in 90 degrees of flexion and palpation of the femoral condyles. Most lesions are in the posterior femoral condyle, so the knee must be flexed 90 degrees to be able to palpate the OCD lesion.
- A small, firm, movable mass may be palpable in the joint, indicating the presence of loose bodies.
- Quadriceps atrophy may be present.
- Effusion is present on rare occasions.
- Check for a positive Wilson sign: Flex the knee to 90 degrees; internally rotate the tibia on the femur and extend the knee slowly with the tibia in internal rotation. If the sign is positive, pain will occur as the knee reaches 30 degrees of flexion. This pain is often relieved by external rotation of the tibia.
- Thirty percent of individuals have bilateral signs.
- Onset in late adolescence or young adulthood
- Either insidious onset or a history of specific injury with immediate onset of pain and swelling may be present.
- Locking or acute swelling may occur if a bone fragment becomes loose.
- Usually, unilateral involvement is seen.
- Synovial effusion is more common in younger patients than in older ones.
- Examination: The findings are similar to those found in younger patients, except that young adults have a higher prevalence of swelling and unilateral involvement.
- Radiological picture
Anteroposterior, lateral, and tunnel views should be taken. X-ray examination often reveals a well-circumscribed area of subchondral bone separated from the remaining femoral condyle by a crescent-shaped radiolucent line. The separate bone may appear sclerotic or fragmented. The lesion may not be seen on a standard anteroposterior view; it may be best appreciated on the tunnel view. The medial femoral condyle is involved in 75% to 85% of cases, whereas approximately 15% of
cases involve the lateral femoral condyle. In addition to the femoral condyle, the patella, femoral head, and talus may be involved.
- Juvenile versus adult osteochondritis (Table 16.1).
- Children and younger adolescents: Orthopedic or sports medicine referral is recommended for appropriate staging and follow-up, but management is typically nonoperative as listed here:
- Restrict symptom-producing activities.
- Immobilize with cast or knee immobilizer if symptoms are severe.
- Advise regarding use of isometric quadriceps-strengthening exercises.
- NSAIDs are not routinely used but are useful if pain or effusion is present.
- Healing usually occurs within 6 to 12 months.
- If there is a free fragment, surgical intervention is required.
- Older adolescents and adults: Orthopedic consultation is necessary for possible arthroscopy or surgery for either removal or internal fixation of the fragment. Surgery is particularly important in teenagers with progressive fragment formation, increasing bony sclerosis, or articular changes.
The Lower Leg-Shin Splints and Stress Fractures
Patients with these conditions experience lower-extremity pain that initially appears toward the end of exercise. If the condition is left untreated and the adolescent continues in the exercise that caused the injury, the pain will occur earlier in the exercise period and persist longer after the exercise is over. It can occur in any adolescent involved in weight-bearing activity but is most common in runners. A common presentation is medial shin pain. The principal two diagnoses to consider are medial tibial stress syndrome (shin splints) and medial tibial stress fracture, which are discussed here. Other diagnostic possibilities include compartment syndromes and vascular abnormalities, which are not discussed and are less common. If these diagnoses are being considered, referral to a specialist familiar with these conditions is indicated.
On examination, the pain of shin splints should be more diffuse and tenderness should be closer to the muscle, rather than bone, at the muscle–bone interface along the medial tibia. In stress fractures of the medial tibia, the pain should be more pinpoint and over the bone, not muscle. There is an injury spectrum from shin splints to stress reaction to stress fracture, which can be difficult to distinguish clinically. Further diagnostic studies may be indicated. Stress fractures can occur in any bone and are most common in the tibia and fibula.
Plain radiographs of patients with shin splints will be normal but, unfortunately, so will most of the plain radiographs of patients with tibial stress fractures, at least during the first few weeks after the injury. The most sensitive test to diagnose stress fractures has been the bone scan. This is being challenged, but has not yet been replaced, by the MRI. If the bone scan is normal, then the health care provider can be more confident that the diagnosis is shin splints due to medial tibial stress syndrome.
A single best treatment protocol for shin splints and stress fractures of the medial tibia has not been established. One treatment protocol includes the following:
- Relative rest and a functional progressive rehabilitation program. This means doing nothing that hurts within 24 hours of the activity. Alternative activities such as swimming, cycling, and pool running (running in the deep end of a pool supported by a buoyant vest or jacket) can be used to maintain the patient's fitness level while the leg injury is recovering. After 7 to 10 days of pain-free activity, the patient can start on a walking program and progress to a jogging program over 10 to 14 days, as long as he or she remains pain free. At any point in this functional rehabilitation progression, if pain reappears, the adolescent should have 2 or 3 pain-free days before resuming the walk–jog program. After jogging for 7 to 10 days, patients can progress to sprinting and then jumping so long as they remain pain free.
- Apply ice each day for 20 minutes directly to the site.
- Shoe inserts to control overpronation, if appropriate.
- Increase the shock absorption of the patient's shoes, if appropriate, for example, if they have a rigid foot.
- Stretch and strengthen the dorsiflexors (anterior tibialis), plantar flexors (posterior tibialis, gastrocnemius, soleus), and everters (peroneal muscles).
- Analgesic medication or NSAIDs can be used in shin splints for 7 to 10 days but should not be used chronically as it may mask the pain and the adolescent may return to activity too soon. Analgesic medications should not be used on a regular basis (i.e., daily) for stress fractures because the number of pain-free days is the criterion for return to activity in the functional rehabilitation progression.
It is difficult to predict when an adolescent will recover sufficiently from stress fractures and shin splints to return
to exercise or competition. As long as the patient follows a functional rehabilitation program such as the one just outlined, he or she will at least be involved in some rehabilitation toward full activity.
Consideration should be given to bone density evaluation by dual energy x-ray absorptiometry (DXA) in female adolescents with stress fracture, especially in those with a family history or other risk factors for osteoporosis.
Ankle injuries are the single most common acute injury in adolescent athletes (Hergenroeder, 1990). The diagnosis and treatment of ankle injuries in adolescents is the same as in adults, with the exception that teens may have open growth plates that may be the primary injury site, whereas in an adult the primary injury is likely to be torn ligaments.
Acute Ankle Injury
The mechanism of acute ankle injury in 85% of the cases is inversion (turning the ankle under or in). Injuries resulting from eversion are generally more serious because of the higher risk of syndesmosis injury and fracture.
- Physical examination
Acute injury: The best time to examine any musculoskeletal injury is immediately after the injury, when the examination can be most informative. However, patients commonly present with diffuse swelling, tenderness, and decreased ROM hours to days after the injury. The physical examination will be limited in terms of diagnosing specific lesions at this point. At a minimum the examination should include the following:
- Inspect for gross abnormalities, asymmetry, and vascular integrity.
- Palpate for bony tenderness specifically at the medial and lateral malleoli, proximal fibula, anterior joint line, navicular, and base of the fifth metatarsal.
- Assess ability to bear weight.
Three to 4 days after injury: The physical examination may be more informative at 3 to 4 days after injury, when the patient has appropriately used rest, ice, compression, and elevation.
- Inspect for swelling and ecchymosis.
- Assess active ROM in six directions:
- Plantarflexion; plantarflexion and inversion; plantarflexion and eversion
- Dorsiflexion; dorsiflexion and inversion; dorsiflexion and eversion
- Assess resisted ROM in the same six directions.
- Palpate for potential fracture at the sites listed for palpation of bony tenderness.
- Attempt passive ROM—plantarflexion and dorsiflexion, talar tilt, anterior drawer test.
- Assess for pain-free weight bearing with normal gait and then with heel-and-toe walking.
- Associated injuries: Complications associated with ankle sprains
- Up to 15% of all complete ligament tears have an associated fracture. The most common sites are the talus, fifth metatarsal, fibula, and tibia. If there is bony tenderness in patients with open epiphyses, assume that a fracture is present even if the radiography results are negative. Immobilize without weight bearing for 1 week; if tenderness persists, casting for 2 weeks is required. If a fragment is present, it does not always require casting or surgery. If the fragment is small and does not appear to be in the joint space, then treat conservatively and monitor.
- “High ankle sprains”—tibiofibular syndesmosis injury occurs in 6% of ankle sprains. These are more serious injuries than the typical lateral ligament sprain. On examination, there is tenderness proximal to the joint line along the syndesmosis. Pressing the midshaft together and then releasing the pressure may worsen the pain.
- Talar fractures occur in 7% of ankle sprains. The patient complains of delayed healing, catching, locking, or persistent pain. Initial x-ray results may be negative; repeat radiographs or computed tomography (CT) scanning may be required.
- Peroneal subluxation occurs in 0.5% of ankle sprains. Tenderness is present along the tendon sheath, posterior and superior to the lateral malleolus.
Radiographical Examination: Ottawa Ankle Rules
An ankle or foot plain radiograph is indicated if there is bone tenderness at the distal/posterior 6 cm of the tibia or fibula (ankle series) or at the navicular or base of the fifth metatarsal (foot series) or if the patient is unable to take four steps both immediately after the injury and during the examination, regardless of limping (Steill et al., 1996b). The Buffalo Modification of the Ottawa Ankle Rules includes the entire distal 6 cm of the tibia and fibula, not just the posterior portions (Leddy et al., 1998). Stress views are typically not indicated in the evaluation of the acute or chronically injured ankle.
- The goal is to limit disability. Successful treatment is defined not only by the absence of pain but also by return to full ROM, strength, and proprioception.
- Relative rest: As with rehabilitation of all musculoskeletal injuries, advise the adolescent to do nothing that hurts.
- Ice: Used in the same manner as for knee injuries, described earlier.
- Heat during the first 72 hours has a role only if it is applied by an athletic trainer or physical therapist.
- Compression: If using an elastic wrap, always wrap distal to proximal, from the base of the toes to midcalf. Advise the patient not to sleep with the elastic wrap in place.
- Compression and stability can be provided by an air stirrup, which should be used for all acute sprains not complicated by fracture.
- Elevation: For the first 2 to 3 days, elevate the ankle as much as possible.
- If discussing the injury by telephone, advise the patient not to wait to seek treatment. Athletes should seek treatment immediately.
- NSAIDs: Use for pain relief and theoretically to control inflammation, but NSAIDs do not affect the outcome per se. Acetaminophen is another alternative.
- Casting is not indicated for ankle sprains not complicated by fracture (Brostrom, 1966). Casting should not be routine for ankle sprains because it actually worsens the outcome, specifically the time to return to work. The air stirrup provides stability to inversion and eversion but also allows for active dorsiflexion and plantarflexion, which is key in early rehabilitation.
Rehabilitation needs to start on the first day of evaluation.
- Relative rest: Progress off crutches as soon as possible; do pain-free exercise.
- Stretching: Primarily soleus and gastrocnemius, by doing calf stretches.
- Strengthening: Band exercises, toe–heel walking, pain free, and progressive (can be done with the air stirrup on).
- Proprioceptive retraining: Raising on toes with little support (one or two fingers on a chair) and eyes closed for 5 minutes a day.
- Functional progression of exercise: For instance, toe walking → walking at a fast pace → jogging → jogging and sprinting → sprinting and jogging on curves →figure-of-eight running → back to sports participation.
- Air stirrup: The air stirrup should be worn in competition sports for 6 months after the injury (Thacker et al., 1999). The air stirrups are most comfortably worn with low-cut or three-fourth height shoes, and they provide excellent stability.
The leading causes of chronic ankle stability and pain are as follows:
- Strength deficits
- Loss of flexibility
- Loss of proprioception
- Intraarticular pathology
All of these need to be considered in the evaluation, and, if deficiencies are found, referral should be made to physical therapy for rehabilitation.
Tarsal coalition is a congenital abnormality that results in a partial or complete fusion between two bones of the foot. The fusion may be fibrous, cartilaginous, or bony. It is the most common cause of a painful, stiff, flat foot after the age of 8 years.
Tarsal coalition appears to result from a lack of differentiation of mesenchymal tissue in the foot. The condition may be inherited as an autosomal dominant trait.
- Prevalence in the United States is approximately 1%.
- The condition is bilateral in 50% to 60% of patients, but the contralateral side may be asymptomatic.
- Presentation: Pain manifests between 8 and 12 years of age for calcaneonavicular coalitions, between 12 and 15 years for talocalcaneal coalitions. Although this is a congenital condition, pain does not begin until these later years because the coalition begins to ossify at this age.
- Patients often complain of a recurring “ankle sprain.”
- Pain is often felt in the lateral ankle, especially in the sinus tarsi.
- The heel is generally in valgus.
- The patient has a rigid, flat foot. The peroneal tendons are often in spasm, leading to the term peroneal spastic flat foot.
- There is lack of hindfoot motion.
The diagnosis should be suspected in the preteen or teenage patient with insidious or sudden onset of pain in the midfoot to hindfoot associated with a lack of motion in the subtalar joint.
- Physical examination: The most striking finding is the almost complete lack of inversion and eversion of the subtalar joint. The patient is unable to walk on the lateral border of the foot. Tenderness is often found in the sinus tarsi. The sinus tarsi is the conical-shaped cavity located between the anterosuperior surface of the calcaneus and the inferior aspect of the neck of the talus.
- Radiographs: If a coalition is suspected, anteroposterior, lateral, 45-degree oblique, and axial (Harris) views of the calcaneus should be obtained.
- CT and MRI: If the history and physical examination are consistent with a coalition but cannot be demonstrated on plain films, CT or MRI may demonstrate the coalition. MRI is more useful in demonstrating fibrous coalitions. More than one coalition may be present in the same foot.
- Patients who have minimal symptoms or who have only incidental radiographic findings do not require treatment. Longitudinal arch supports may be sufficient to relieve symptoms.
- When patients have significant symptoms, a short leg walking cast for 3 to 4 weeks, followed by the use of a University of California Berkeley Laboratory (UCBL) orthosis may eliminate the symptoms.
- If conservative treatment fails, resection of the coalition with interposition of fat or muscle is indicated. Some coalitions of the talocalcaneal joint are so large that they cannot be successfully resected and arthrodesis may be required.
Slipped Capital Femoral Epiphysis
Slipped capital femoral epiphysis (SCFE) is a disease in which the anatomical relationship between the femoral head and neck is altered secondary to a disruption of the epiphyseal plate.
The femoral head slips posteriorly, inferiorly, and medially on the femoral metaphysis. This occurs through the hypertrophic cell layer of the epiphysis. The condition tends to occur in adolescents because of the following:
- The increased weight burden at adolescence.
- A decreased resistance to the added weight burden secondary to a shift in the femoral epiphysis from a horizontal to an oblique position.
- Increased stress to an area that has not reached bony maturity.
A chronic, gradual slip accounts for 80% or more of cases of slipped capital epiphysis during adolescence and is usually related to the combination of obesity and slow maturation. Acute slips occur secondary to severe trauma, such as a fall or an automobile accident, and are more common in younger children than in adolescents. Most cases of SCFE are unrelated to an endocrine disorder, although the disease has been associated with hypopituitarism, hypogonadism, and hypothyroidism. Endocrine abnormalities are often associated with bilateral slips, and they occur more often in the extremes of the adolescent age-group (before age 9 or after age 16 years).
- Sex: The prevalence is two to four times greater in males than in females.
- Incidence: A representative study (Kelsey, 1971) found the incidence in Connecticut to be 7.79 for African-American males, 6.68 for African-American females, 4.74 for white males, and 1.64 for white females per 100,000 individuals younger than 25 years.
- Season: Onset of symptoms occurs more frequently in spring and summer.
- Average age at onset: Usually, symptoms occur shortly before or during the period of accelerated growth (10–13 years of age in girls, 12–15 years in boys).
- Hip involved: Left hips are affected more commonly in males; no difference is noted in females. Approximately 20% of patients present with a bilateral slip. The contralateral hip should always be examined and visualized radiographically.
- Weight of affected patients: Approximately 88% of patients are obese, with 50% at or above the 95th percentile of weight for age and the 97th percentile of weight for height.
- Bone age: Seventy percent of affected patients have skeletal maturation that is delayed by 6 months or more.
- Pain: Pain is localized to hip or groin in 80% of patients. However, pain may be strictly in the thigh or knee, referred from the obturator nerve. Some patients present with a painless limp.
- Click in the hip occurs.
- Internal rotation is diminished and adduction of hip is decreased.
- Decreased flexion of the hip is present.
- The affected leg is often held in slight external rotation and abduction.
- With passive hip flexion, the femur abducts and externally rotates; the leg falls into a “figure of 4” position.
- Limp: A limp is present in 50% of patients; the adolescent with acute slippage may not be able to bear weight on the affected extremity.
- The family often notices a change in gait. The foot externally rotates during ambulation.
- History and physical examination: Consistent signs and symptoms are present. The condition should be considered in any adolescent with hip or knee pain or a limp.
- Radiographical changes: Anteroposterior and frog-leg lateral roentgenograms of the pelvis should be taken.
- In a normal anteroposterior radiograph of the hip, a line drawn on the superior edge of the femoral neck intersects the epiphysis; in a slip, the epiphysis falls below this line (Fig. 16.1).
FIGURE 16.1 In the normal hip on the left, a line drawn on the superior femoral neck intersects the proximal femoral epiphysis. In the hip on the right with a slipped epiphysis, the epiphysis lies completely below a line drawn on the superior femoral neck.
- Earlier and more subtle slips are seen better on the frog-leg lateral views than on the anteroposterior views. More advanced slips show the obvious slippage inferiorly and posteriorly of the femoral head epiphysis on both anteroposterior and frog-leg lateral films. A “true lateral” view can also be helpful.
- Early changes include epiphyseal widening and rarefaction.
- Bone scan: A bone scan may show increased uptake at the involved epiphyseal plate.
- MRI: MRI demonstrates increased blood flow at the epiphysis.
Most cases of SCFE can be diagnosed with plain radiographs. Bone scan and MRI are rarely needed.
Orthopedic referral is required, because surgery is the only reliable treatment. Further slippage can be prevented by the introduction of threaded screws across the epiphyseal plate in situ. (Reduction of the slip is seldom, if ever, indicated.) The condition should be treated promptly, because greater slippage leads to a worse prognosis. Avascular necrosis can occur with acute, large slips. Premature degenerative joint disease is a frequent late development in many patients with severe, chronic slips, even after fixation. For moderate and severe cases, corrective osteotomies can be performed after the growth plate has closed to improve gait and ROM.
Low Back Pain
Low back pain is a common enough presentation in adolescent health care that there is an entire chapter devoted to it in this book (Chapter 17).
Definition and Epidemiology
Pain in the lower limbs is common among children and younger adolescents, with a prevalence of “growing pains” reported at between 4% and 50% of children and adolescents, increasing after the age of 5 years, with peaks at ages 13 in boys and 11 in girls.
Many causes of lower limb pain are possible, including the following:
- Trauma: Fracture, dislocation, contusion
- Infection: Osteomyelitis, septic arthritis, abscess, cellulitis
- Vascular causes: Hemophilia, sickle cell anemia, hemangioma
- Congenital conditions: Tarsal coalition, dislocation of hip
- Slipped femoral capital epiphysis
- Osgood-Schlatter disease
- Osteochondritis Dessicans
- Patellofemoral Syndrome
- Rheumatic disease: Juvenile rheumatoid arthritis, polymyositis
Most of these causes are well delineated by history, physical examination, and appropriate laboratory tests. If all of the above diagnoses have been excluded, some practitioners utilize the term “growing pains.”
- Intermittent pain or ache is usually localized to the muscles of the legs and thighs. The most common sites are the front of the thighs and calves and behind the knees. Less commonly involved sites include the back, shoulder, arm, and groin.
- Bilateral pain is usually present.
- Pain usually occurs late in the day, in the evening, or at night.
- No loss of mobility
- No tenderness, erythema, or swelling
- No fever or symptoms of systemic disease
- Normal laboratory studies and normal findings on radiography
There is no simple approach to a definite diagnosis. After a completely normal thorough evaluation, in our clinical practice we may ascribe the discomfort to a relative imbalance between growth in the long bones and inflexibility in the large muscles of the lower extremities, although there is no evidence to support this teleological explanation.
Conservative therapy involving reassurance, heat, stretching, massage, and judicious use of NSAIDs is usually sufficient.
For Teenagers and Parents
http://orthoinfo.aaos.org. Your Orthopaedic Connection from the American Academy of Orthopaedic Surgeons.
Subluxation of Patella
http://orthopedics.about.com/cs/patelladisorders/a/kneecapdisloc.htm. About subluxation of patella.
http://www.med.umich.edu/1libr/sma/sma_subluxin_sma.htm. From University of Michigan.
http://www.mayoclinic.com/health/osgood-schlatter-disease/DS00392. Mayo Clinic article on Osgood-Schlatter.
http://www.nlm.nih.gov/medlineplus/ency/article/001258.htm. Medline Plus article on Osgood-Schlatter.
http://familydoctor.org/488.xml. American Academy of Family Practice Web site on osteochondritis dissecans.
http://www.mayoclinic.com/health/osteochondritis-dissecans/DS00741. Mayo Clinic article on osteochondritis dissecans.
http://orthoinfo.aaos.org/. Search on shin splints
http://www.mayoclinic.com/health/shin-splints/DS00271. Mayo Clinic article on shin splints.
Slipped Capital Femoral Epiphysis
http://familydoctor.org/282.xml. From American Academy of Family Practice.
For Health Professionals
www.aaos.org. American Academy/Association of Orthopaedic Surgeons.
http://www.emedicine.com/emerg/topic347.htm. Emedicine article on Osgood-Schlatter disease.
http://www.emedicine.com/radio/topic495.htm. Emedicine article on osteochondritis dissecans.
http://www.emedicine.com/radio/topic673.htm. Emedicine article on tarsal coalition.
http://www.emedicine.com/sports/topic122.htm. Emedicine article on slipped capital epiphysis.
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