CURRENT Diagnosis and Treatment Pediatrics, (Current Pediatric Diagnosis & Treatment) 22nd Edition

27. Sports Medicine

Rachel A. Coel, MD, PhD, FAAP, CAQSM

Quynh B. Hoang, MD, FAAP, CAQSM

Armando Vidal, MD

Sports medicine as a separate discipline has grown since the 1980s in response to an expanding body of knowledge in the areas of exercise physiology, biomechanics, and musculoskeletal medicine. As more children participate in recreational and competitive activities, pediatric health care providers are encountering more young athletes in their practice. Familiarity with the common medical and orthopaedic issues faced by athletically active children and knowledge of which injuries necessitate referral to a sports medicine specialist are essential.

BASIC PRINCIPLES

Pediatric Injury Patterns

Although young athletes have injuries and issues similar to those of adults, there are many injuries that are unique to the pediatric and adolescent athlete. An understanding of the differences between adult and pediatric injury patterns is important to foster an appropriate index of suspicion for situations unique to pediatrics.

Components of a long bone include the diaphysis, metaphysis, and epiphysis. In the pediatric bone architecture, the presence of cartilaginous growth plates and apophyses predispose children to unique injury patterns that are different from their adult counterparts. Open growth plates or physes and their various stages of development are important factors to consider when treating young athletes. The physes are located at the ends of the long bones and are the primary ossification centers where length is added to the immature skeleton. The physis is a weak link in the musculoskeletal complex and has a high risk of fracture during periods of rapid growth. The surrounding soft tissues, including ligaments and tendons, are relatively stronger than the physis. The epiphyses are secondary centers of ossification that also contribute to long bone formation and, like the adjacent articular cartilages, are vulnerable to trauma. Injuries that involve the epiphysis can lead to joint deformity. The apophyses are secondary centers of ossification that add contour but not length to the bone. The apophysis is the attachment site of the muscle-tendon unit and is vulnerable to both acute and chronic overuse traction injury during times of rapid growth. Unlike injuries to the physis and epiphysis, however, apophyseal injuries do not result in long-term growth disturbance. Recognizing injuries to growth centers is important because of the risk for partial or complete physeal arrest. Complications of growth plate injury can lead to limb length discrepancy or angular deformity.

Strength Training

Strength is defined as the peak force that can be generated during a single maximal contraction. Strength training uses progressive resistance to improve an athlete’s ability to resist or exert force. This can be achieved by a variety of techniques, including body weight, free weight, or machine resistance. The benefits of strength training include improved performance, endurance, and muscular strength. Strength training can be safely started in prepubescent athletes as early as 7 and 8 years old if designed appropriately with a focus on lighter resistance, increased repetitions, proper technique and mechanics, coordination, and building self-confidence. Children mature at varying paces, and strength training programs should be individualized to accommodate for these unique differences. All strength training regimens should be modified as needed to remain age-appropriate and pain-free. Tanner staging (see Chapter 34) helps define readiness for progression to more strenuous programs. Power lifting and maximal weight lifting should be restricted to athletes who have reached or passed Tanner stage V. To prevent injuries, care should be taken to instruct children on the proper use of weight-training equipment at home. Children and adults with disabilities can benefit from weight-training programs modified to meet their specific needs.

Faigenbaum AD et al: Youth resistance training: updated position statement paper from the national strength and conditioning association. J Strength Cond Res 2009;23(Suppl):S60–S79 [PMID: 19620931].

Myer GD et al: When to initiate integrative neuromuscular training to reduce sports-related injuries and enhance health in youth? Curr Sports Med Rep 2011;10(3):155–166 [PMID: 21623307].

FITNESS & CONDITIONING

Compared to children who are sedentary, physically active youth tend to develop greater agility and skills and maintain better fitness throughout their lifetime. Young children and adolescents should participate in physical activity for 60 minutes or more each day. To improve overall fitness and reduce the risk of injury, children and adolescents should focus on three different components of exercise:

1. Resistance (strength) training (progressive resistive loads in a variety of modalities).

2. Neuromuscular conditioning (mixture of basic fundamental and specialized motor control exercises aimed at improving general health and sports performance). Examples include core strength exercises, agility, and plyometrics.

3. Integrative training (curriculum of diverse skills, increasing fitness, and appropriate rest periods). Examples include developing fundamental skills and technique, learning proper movement mechanics, aerobic and anaerobic conditioning.

Periodization is a training concept that emphasizes variations in the volume and intensity of training throughout the year in a conditioning program. Continuously varying the specific type and goals of training provides adequate recovery from each strenuous exercise session and avoids overtraining, burnout, and overuse injuries.

Myer GD et al: When to initiate integrative neuromuscular training to reduce sports-related injuries and enhance health in youth? Curr Sports Med Rep 2011;10(3):155–166 [PMID: 21623307].

SPORTS NUTRITION

Proper nutrition in young athletes focuses on maintaining an appropriate energy balance; creating healthy eating and hydration habits; and avoiding harmful food, drink, and supplement choices. Keeping an adequate nutritional intake will increase lean muscle mass, maximizing strength, endurance, immunity, and training benefit. Athletes should be encouraged to balance caloric intake with energy expenditure, eat whole grains, avoid processed foods, focus on healthy fats and proteins, and maintain proper hydration. Carbohydrates should compose 55%–60% of a young athlete’s diet, with fat and protein making up 25%–30% and 12%–15%, respectively. Hydration can come mainly from water if the exercise lasts less than 1 hour, after which time a carbohydrate-containing sports drink is appropriate. Water or sports drinks should be consumed every 15–20 minutes during prolonged exercise greater than 1 hour or in hot playing conditions. A light snack and hydration are recommended prior to and immediately after an extended workout. To avoid excessive caloric and sugar intake, sports drinks are not recommended at meals or times other than prolonged exercise. The average athlete eats a well-balanced diet not necessitating nutritional supplementation. However, if food allergies or improper dietary intake is confirmed, an athlete may benefit from a daily multivitamin. In general, nutritional sports supplements are not recommended and extreme caution is suggested when considering their use. The supplement industry is not well-regulated and contamination with toxic and banned substances has been noted in the past. Similarly, energy drinks are not recommended for use in any youth under the age of 18 years due to high levels of caffeine and other stimulants contained in such beverages.

ACSM, ADA, DOC: Nutrition and athletic performance. Med Sci Sports Exerc 2009;709–731 [PMID: 11128862].

Committee on Nutrition and Council on Sports Medicine and Fitness: Sports drinks and energy drinks for children and adolescents: are they appropriate? Pediatrics 2011;127(6): 1182–1189 [PMID: 21624882].

Kleinman R (ed): Pediatric Nutrition Handbook, 6th ed. AAP; 2009.

PREPARTICIPATION PHYSICAL EVALUATION

The ultimate goal of the preparticipation physical evaluation (PPE) is to promote the health and safety of athletes. Its primary objectives are to screen for conditions that may be life threatening or disabling and for conditions that may predispose to injury or illness. Secondary objectives of the PPE include establishing a medical home, determining the general health of the individual, assessing fitness for specific sports, and counseling on injury prevention and health- related issues. The ideal timing of the examination is at least 6–8 weeks before training starts. This allows time to further evaluate, treat, or rehabilitate any identified problems.

Preparticipation History

The medical history is the most important part of the encounter, identifying 65%–77% of medical and musculoskeletal conditions. Therefore, obtaining a thorough and accurate history is essential in identifying conditions that may affect a child’s ability to safely participate in sports. Many key elements should be explored with the athlete. A standardized PPE form, endorsed by six medical societies including the American Academy of Pediatrics (AAP), is available in the fourth edition of the PPE monograph (Bernhardt and Roberts 2010) or on the Internet. This monograph, formulated based on current literature, policies, consensus statements, expert opinion, and extensive peer review, is currently the recommended standard for the preparticipation physical examination in the United States. Figure 27–1A and B contain copies of the PPE form. The history includes the following areas:

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image Figure 27–1. A: Preparticipation Physical Evaluation form.

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image Figure 27–1. B: Preparticipation examination.

A. Cardiovascular History

The routine use of electrocardiogram (ECG) and echocardiography in the preparticipation cardiovascular screening in athletes remains a highly debated topic in sports medicine and sports cardiology. Despite ongoing controversy, the American Heart Association (AHA) currently recommends against its routine usage in asymptomatic athletes because of its low sensitivity, high false-positive rate, limited resources, lack of trained physicians to interpret the ECG, and poor cost-effectiveness due to the low prevalence of disease. In 2007, the AHA updated its consensus statement on cardiovascular screening stating its position to this effect. According to the AHA, the goal of the PPE is to reduce cardiovascular risk associated with physical activity. The 2007 AHA recommendations for cardiovascular screening are incorporated in the fourth edition PPE monograph and include the following 12-point screen:

Personal Medical History:

1. Chest pain or discomfort with exercise

2. Syncope or near syncope associated with exercise

3. Excessive shortness or breath or fatigue associated with exertion

4. History of heart murmur

5. History of elevated blood pressure

Family Medical History:

6. Premature death before age 50 years due to heart disease

7. Disability from heart disease in a close relative younger than 50 years

8. Knowledge of specific cardiac conditions: hypertrophic or dilated cardiomyopathy, long QT syndrome, other ion channelopathies, Marfan syndrome, or arrhythmias

Physical Examination:

9. Auscultation of heart murmur in supine and standing position

10. Palpation of radial and femoral pulses

11. Physical stigmata of Marfan syndrome

12. Brachial blood pressure taken in seated position

Sudden cardiac arrest is the leading cause of death in young athletes, accounting for 75% of all sudden deaths. Addressing these areas may help identify potentially life-threatening cardiac lesions. However, clinicians should keep in mind that there are currently no outcome-based studies that demonstrate the effectiveness of the PPE in preventing sudden cardiac death in athletes. In the United States, the most common causes of sudden cardiac death on the playing field are hypertrophic cardiomyopathy (HCM) and congenital coronary artery anomalies, with HCM accounting for one-third of sudden cardiac deaths in young athletes. Any athletes with cardiovascular symptoms require further evaluation before allowing them to participate in sports. Any activity restrictions or sports disqualification for an athlete should be made in consultation with a cardiologist.

B. History of Hypertension

Any history of hypertension requires investigation for secondary causes of hypertension and target organ disease. An athlete with hypertension who exercises may cause their blood pressure to rise even higher, placing them at increased risk for complications. Athletes should also be asked about the use of stimulants (ie, caffeine, nicotine) and a family history of hypertension. The diagnosis of hypertension in children younger than 18 years is based on gender, age, and height, and the blood pressure must be measured on three separate occasions. Blood pressure measurements with values from 90% to 95% of gender, age, and height-based norms are considered prehypertension; values from 95% to 5 mm Hg above the 99% of norms are defined as stage 1 hypertension; and values greater than 5 mm Hg above the 99% of norms are defined as stage 2 hypertension.

Athletes with prehypertension are eligible to participate in sports. Counseling regarding lifestyle modifications should be made, including healthy dietary changes, weight management and daily physical activity. Those with stage 1 hypertension, in the absence of end-organ damage, may also participate in competitive sports but with appropriate subspecialist referral if the individual is symptomatic, have associated heart disease or structural abnormality, or have persistent elevated blood pressure on two additional occasions despite lifestyle modifications. Athletes who have stage 2 hypertension or end-organ damage should not be cleared to participate in competitive sports until their blood pressure is evaluated, treated, and is under control.

C. Central Nervous System

A history of frequent or exertional headaches, seizure disorders, concussion or head injuries, recurrent stingers or burners, or cervical cord neuropraxia may affect an athlete’s ability to participate in sports. These conditions require further evaluation, rehabilitation, or informed decision-making prior to clearance for sports participation. The fourth edition PPE monograph provides an updated review and recommendations on concussions in sports. (See also section Concussion.)

D. History of Chronic Diseases

Diseases such as reactive airway disease, exercise-induced asthma, diabetes, renal disease, liver disease, chronic infections, or hematologic diseases should be noted.

E. Surgical History

Surgical history may influence participation in certain sports. Full recovery with no long-term impact on athletic performance is required prior to clearance.

F. Infectious Mononucleosis

Ask about infectious mononucleosis in the last 4 weeks. The risk for splenic rupture is highest within the first 3 weeks of illness and can occur in the absence of trauma. Therefore, physical activity should be avoided during the first 3–4 weeks after the infection starts. The athlete may return to play once clinical symptoms are resolved and risk for splenic rupture is assessed as minimal. The use of serial abdominal ultrasound to assess spleen size to aid in return to play decisions is debatable. Parameters for spleen size based on ethnicity, sex, height, and weight have not yet been established so determining when spleen size has normalized based on imaging becomes difficult.

G. Musculoskeletal Limitations and Prior Injuries

The physician should inquire about joints with limited range of motion, muscle weakness, and prior injuries that may affect future performance. Chronic pain or soreness long after activity may reflect overuse syndromes that should be evaluated.

H. Menstrual History in Females

The physician should pay particular attention to the so-called female athlete triad: amenorrhea disordered eating and osteoporosis.

I. Nutritional Issues

The physician should record methods the athlete uses to maintain, gain, or lose weight. Eating disorders or inadequate nutritional intake could lead to persistent or recurrent injury, including stress fractures. Vitamin D deficiency has become increasingly common in female athletes due to inadequate dietary intake or decreased sunlight exposure.

J. Medication History

Inquire about the use of prescription, over-the-counter medications, and supplements. Not only will medications reveal problems omitted in the medical history, but the information will also provide data on current medications whose side effects may suggest activity modifications. Documenting drug use may provide the opportunity to explore with the patient the drawbacks of performance-enhancing compounds such as anabolic steroids, creatine, stimulants, and narcotics.

Armsey TD, Hosey RG: Medical aspects of sports: epidemiology of injuries, preparticipation examination and drugs in sports. Clin Sports Med 2004;23:255 [PMID: 15183571].

Bernhardt DT, Roberts WO: Preparticipation Physical Evaluation, 4th ed. American Academy of Pediatrics; 2010.

Burrows M et al: The components of the female athlete triad do not identify all physically active females at risk. J Sports Sci 2007;25:12 [PMID: 17786682].

McCambridge TM et al: Council on Sports Medicine and Fitness: Policy Statement—athletic participation by children and adolescents who have systemic hypertension. American Academy of Pediatrics. Pediatrics 2010 Jun;125(6):1287–1294 [PMID: 20513738].

Maron BJ., Doerer JJ., Haas TS., et al: Profile and frequency of sudden death in 1463 young competitive athletes: from a 25 year U.S. national registry: 1980-2005. Circulation 2006; 114(Suppl II): 830.

Maron BJ et al: Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity and Metabolism: endorsed by the American College of Cardiology Foundation. Circulation 2007;115(12):1643–1655. [PMID: 17353433].

National Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents: The fourth report on the diagnosis, evaluation and treatment of high blood pressure in children and adults. Pediatrics 2004;114:555–576 [PMID: 15286277].

Putukian M, O’Connor FG, Stricker P: Mononucleosis and athletic participation: An evidence-based subject review. Clin J Sport Med 2008;18(4):309–315 [PMID: 18614881].

Seto C: The preparticipation physical examination: an update. Clin Sports Med 2011;30:491–501 [PMID: 21658544].

Physical Examination

The physical examination should be focused on the needs of the athlete. It may be the only time an athlete has contact with medical personnel and can be used to promote wellness along with screening for physical activity. Figure 27–1B is an example of a preparticipation physical examination form endorsed in the fourth edition of the PPE monograph (Bernhardt and Roberts 2010). The examination should include routine vital signs, including blood pressure measurements obtained in the upper extremity. The cardiovascular examination should include palpation of pulses, auscultation for murmurs while sitting and standing, evaluation for physical stigmata of Marfan syndrome, and assessment of any cardiovascular symptoms as previously described. The musculoskeletal examination is used to determine strength, range of motion, flexibility, and previous injuries. Included is a quick guide that can be used to screen for musculoskeletal abnormalities (Table 27–1). The remainder of the examination should emphasize the following areas:

Table 27–1. The screening sports examination.a

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A. Skin

Are there any contagious lesions such as herpes or impetigo?

B. Vision

Are there any visual problems? Is there any evidence of retinal problems? Are both eyes intact?

C. Abdomen

Is there any evidence of hepatosplenomegaly?

D. Genitourinary System

Are any testicular abnormalities or hernias present?

E. Neurologic System

Are there any problems with coordination, gait, or mental processing?

F. Sexual Maturity

What is the individual’s Tanner stage?

Recommendations for Participation

After completing the medical evaluation, the physician can make recommendations about sports clearance. The options include the following:

• Cleared for all sports without restrictions

• Cleared for all sports without restrictions with recommendations for further evaluation or treatment

• Not cleared: pending further evaluation, for any sports, or for certain sports

Table 27–2 is a composite of recommendations for sports participation organized by body system. Recommendations for sports participation with specific medical conditions can be found on the AAP website.

Table 27–2. Recommendations and considerations for participation in sports.

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Anderson BR, Vetter VL: Return to play? Practical considerations for young athletes with cardiovascular disease. Br J Sports Med 2009;43:690 [PMID: 19734504].

Ansved T: Muscular dystrophies: influence of physical conditioning on the disease evolution. Curr Opin Clin Nutr Metab Care 2003;6:435 [PMID: 12806128].

Bernhardt DT, Roberts WO: Preparticipation Physical Evaluation, 4th ed. American Academy of Pediatrics; 2010.

Braith RW: Exercise for those with chronic heart failure. Phys Sportsmed 2002;31:29 [PMID: 20086544].

Draznin MB: Type 1 diabetes and sports participation: strategies for training and competing safely. Phys Sportsmed 2000;28:49 [PMID: 20086616].

Firoozi S et al: Risk of competitive sport in young athletes with heart disease. Heart 2003;89:710 [PMID: 12807837].

Harris G et al: Diabetes in the competitive athlete. Curr Sports Med Rep 2012 Nov/Dec; 11(6):309–315 [PMID: 23147019].

Howard GM et al: Epilepsy and sports participation. Curr Sports Med Rep 2004;3:15 [PMID: 14728909].

Hull J et al: Managing respiratory problems in athletes. Clin Med 2012;12(4):351–356 [PMID: 22930882].

Jaworski C et al: Infectious disease. Clin Sports Med 2011; 30: 575–590 [PMID: 21658549].

Maron BJ et al: Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism. Circulation 2007;115:1643–1655 [PMID: 17353433].

Maron BJ: Hypertrophic cardiomyopathy: Practical steps for preventing sudden death. Phys Sportsmed 2002a;30:19 [PMID: 11984027].

Maron BJ: The young competitive athlete with cardiovascular abnormalities: causes of sudden death, detection by pre- participation screening, and standards for disqualification. Card Electrophysiol Rev 2002b;6:100 [PMID: 11984027].

Maron BJ et al: 36th Bethesda Conference. Eligibility recommendations for competitive athletes with cardiovascular abnormalities. J Am Coll Cardiol 2005;45(8):1318–1321 [PMID: 15837280].

Platt LS: Medical and orthopaedic conditions in Special Olympics athletes. J Athl Train 2001;36:74 [PMID: 16404438].

Putukian M, O’Connor FG, Stricker P: Mononucleosis and athletic participation: an evidence-based subject review. Clin J Sport Med 2008;18(4):309–315 [PMID: 18614881].

Rice SG; Council on Sports Medicine and Fitness, American Academy of Pediatrics: Medical conditions affecting sports participation. Pediatrics 2008;121(4):841–848 [PMID: 18381550].

Salim MA, Alpert BS: Sports and Marfan syndrome. Phys Sportsmed 2001;29:80 [PMID: 20086576].

Sanyer O: Down syndrome and sport participation. Curr Sports Med Rep 2006;5:315–318 [PMID: 17067499].

Tarnopolsky MS: Metabolic myopathies and physical activity: when fatigue is more than simple exertion. Phys Sportsmed 2002;30:37 [PMID: 20086530].

REHABILITATION OF SPORTS INJURIES

Participation in sports benefits children not only by promoting physical activity but also by the acquisition of motor and social skills. All sports participation, however, carries an inherent risk of injury. Injuries are classified as either acute or chronic. Chronic injuries occur over time as a result of overuse, repetitive microtrauma, and inadequate repair of injured tissue. When the demands of exercise exceed the body’s ability to recover, overuse injury may occur. Overuse injury accounts for up to 50% of all injuries in pediatric sports medicine. Risk factors for overuse include year round participation, participation in more than one sport at a time, poor mechanics, and training errors such as increasing exercise volume, load, frequency, or intensity too quickly. To avoid overuse injury, athletes should train with a regular variety of resistances, power, speed, agility, skills, and distance. Adequate periods of rest and recovery should be incorporated into every training regimen in order to ensure proper healing of stressed tissues. Treatment measures such as corticosteroid or platelet-rich plasma injections are more commonly used in skeletally mature athletes.

Present trends in injury rehabilitation and prevention focus on core stability training and dynamic warm-up and stretching. Core exercises emphasize isometric holds that activate the core and pelvis. They utilize light single limb movements to challenge endurance over protracted time periods. Programs should be age-appropriate and modified as needed to exercise in a pain-free range. The development of back pain during a core program signifies poor technique, overly complicated curriculum, or a prior back injury. Exercise programs can be obtained from the website resource: http://www.webexercises.com.

Dynamic warm-up and stretching programs concentrate on light movement prior to exercise. Dynamic programs use controlled, full active range of motion of each joint for an overall excitatory and stretching effect prior to exercise. The aim is to initiate light perspiration and increase heart rate, peripheral circulation, and connective tissue suppleness through simple excitatory activity. In contrast to traditional static stretching regimens in which athletes hold a stretching position for a distinct period of time, an appropriate dynamic curriculum will incorporate aerobic activity and moving stretches into sport-specific movement preparation. Areas of focus include joint range of motion, proprioception, coordination, balance, flexibility, muscular contraction, and stimulation of the central nervous system and energy resources. For example, athletes may work through a series of exercises such as side shuffle, high knee stepping, bear crawls, and double-leg hopping over cones three times. Static stretching is appropriate after exercise is complete. A useful website to design a dynamic stretching program can be found at: http://www.webexercises.com

Acute injuries or macrotrauma are one-time events that can cause alterations in biomechanics and physiology. Response to an acute injury occurs in predictable phases. The first week is characterized by an acute inflammatory response. During this time, initial vasoconstriction is followed by vasodilation. Chemical mediators of inflammation are released, resulting in the classical physical findings of local swelling, warmth, pain, and loss of function. This phase is essential in healing of the injury. The proliferative phase occurs over the next 2–4 weeks and involves repair and clean-up. Fibroblasts infiltrate and lay down new collagen. Lastly, the maturation phase allows for repair and regeneration of the damaged tissues.

The management of acute sports injuries focuses on optimizing healing and restoring function. The goals of immediate care are to minimize the effects of the injury by reducing pain and swelling, to educate the athlete about the nature of the injury and how to treat it, and to maintain the health and fitness of the rest of the body. The treatment for an acute injury is captured in the acronym PRICE:

• Protect the injury from further damage (taping, splints, braces)

• Rest the area

• Ice

• Compression of the injury

• Elevation immediately

Nonsteroidal anti-inflammatory drugs (NSAIDs) may reduce the inflammatory response and reduce discomfort. These medications may be used immediately after the injury. When safely and appropriately managed, therapeutic use of physical modalities, including early cold and later heat, hydrotherapy, massage, electrical stimulation, iontophoresis, and ultrasound, can enhance recovery in the acute phase.

The recovery phase can be lengthy and requires athlete participation. Physical therapy prescription is a common treatment modality. Initial treatment is focused on joint range of motion and flexibility. Range-of-motion exercises should follow a logical progression of starting with passive motion, then active assistive and finally active movement. Active range of motion is initiated once normal joint range has been reestablished. Flexibility exercises, particularly dynamic stretches, are sport-specific and aimed at reducing tightness of musculature. Strength training can begin early in this phase of rehabilitation. Initially only isometric exercises (static muscle contraction against stable resistance without movement of a joint or change in length of a muscle) are encouraged. As recovery progresses and flexibility increases, isotonic (change in length of a muscle without varying resistance) and isokinetic (change in length of a muscle against variable resistance without varying speed) exercises can be added to the program. These should be done at least three times per week.

As the athlete approaches near-normal strength and is pain-free, the final maintenance phase can be introduced. During this phase, the athlete continues to build strength and work on endurance. The biomechanics of sport-specific activity need to be analyzed and retraining incorporated into the exercise program. Generalized cardiovascular conditioning should continue during the entire rehabilitation treatment. Typically, return-to-play guidelines after an injury include the attainment of full joint range of motion, nearly full and symmetric strength, full speed, and nearly full sport-specific agility and skill.

Brooks GP et al: Musculoskeletal injury in the young athlete: overview of rehabilitation for nonoperative injuries. UpToDate 2012, Aug 22.

Faccioni A: Dynamic warm-up routines for sports. Faccioni Speed and Conditioning Consultancy 2004 [web PDF].

COMMON SPORTS MEDICINE ISSUES & INJURIES

INFECTIOUS DISEASES

Infectious diseases are common in both recreational and competitive athletes. These illnesses have an effect on basic physiologic function and athletic performance. Physicians, parents, and coaches can adopt the guidelines listed in Table 27–3.

Table 27–3. Sports participation guidelines: infectious diseases.

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Active skin infections are common reasons to exclude athletes from sports participation. Herpes simplex, staphylococcal, molluscum, and tinea skin infections are commonly seen and most easily transmitted in sports with skin-to-skin contact and shared equipment usage. In particular, athletes are at high risk for infection with community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). Recent reports of outbreaks in sports teams have prompted many sports organizations to adopt specific protocols to deal with the problem. Transmission is primarily by skin-to-skin contact and clinical manifestations are most commonly skin infections and soft tissue abscesses. Early treatment of CA-MRSA soft tissue infections by incision and drainage followed by appropriate antibiotic treatment is important to prevent significant morbidity and possible mortality.

Benjamin HJ, Nikore V, Takagishi J: Practical management: community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA): the latest sports epidemic. Clin J Sport Med 2007;17:393–397 [PMID: 17873553].

Selected Issues for the Adolescent Athlete and the Team Physician: A consensus statement. Med Sci Sports Exerc Nov 2008;40(11):1997–2012 [PMID: 19430330].

Rice SG and the Council on Sports Medicine and Fitness, American Academy of Pediatrics: Medical conditions affecting sports participation. Pediatrics 2008;121(4):841–848 [PMID: 18381550].

HEAD & NECK INJURIES

Head and neck injuries occur most commonly in contact and individual sports. The sports with the highest incidence of brain injury are football, bicycling, baseball, and horseback riding. Concussions most commonly occur in football, ice hockey, rugby, boxing, basketball, lacrosse, soccer, bicycling, judo, and baseball/softball. The optimal treatment of these injuries has not been established and multiple guidelines have been developed. As a general rule, treatment of head and neck injuries in young children should be more conservative because of their developing central nervous systems.

1. Concussion

Concussion is a complex process that occurs when a direct blow to the body or head translates forces into the brain. Even in the presence of neurologic symptoms, concussions are usually not associated with structural changes in brain tissue detectable by standard imaging studies. Instead, they may cause metabolic and vascular changes in cerebral tissues. Consequently, there are complex alterations in physiologic function, such as catecholamine surges and failure of cerebral blood flow autoregulation, leading to the common symptoms we ascribe to this type of injury. Symptoms may appear and evolve over the first few hours after injury. Confusion, headache, visual disturbance, posttraumatic amnesia, and balance problems are common symptoms. It is important to note that concussion does not have to involve loss of consciousness. Concussion should be suspected in any athlete with somatic, cognitive, or behavioral complaints as listed in Table 27–4. Observers may notice physical signs, behavioral changes, or cognitive impairment in the injured athlete. Diagnosis may be aided by the use of the Sport Concussion Assessment Tool v.3 (SCAT3) and the Child-SCAT3 (ages 5–12 years), which also provide standardized patient handouts (available at http://bjsm.bmj.com/content/47/5/259.full.pdf and http://bjsm.bmj.com/content/47/5/263.full.pdf). Regardless of level of participation or elite status, any athlete suspected of sustaining a concussion in a practice or competition should be immediately removed from play. The athlete should not be left alone in the initial hours after the injury in order to monitor for deterioration. An athlete diagnosed with a concussion should not be permitted to return to sport on the day of injury. In the acute setting, computed tomography (CT) is rarely indicated beyond the first 24 hours after injury. CT should be considered during initial evaluation if the patient displays deteriorating or altered mental status, prolonged loss of consciousness, repeated vomiting, severe headache, signs of skull fracture, or focal neurologic deficit or if he/she experienced a severe mechanism of injury.

Table 27–4. Concussion: symptom checklist.

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Symptoms associated with concussions usually follow a predictable pattern and most resolve in 7–10 days. Children and adolescents tend to have a longer recovery interval. Acute management of concussion includes an early period of physical and cognitive rest (1–2 days), the exact duration of which is currently unknown. Return to school and light noncontact physical activity may be reasonable early during the recovery period if symptoms are not exacerbated. In young athletes, interventions may include modified school attendance, decreased school work, reduction in technological stimulation (television, internet, computer games, cellular phone use), proper nutrition and hydration, and adequate rest and sleep. Before athletes are allowed to return to sports participation, symptoms should be resolved both at rest and during exercise without the aid of medication and a graduated return-to-play protocol should be completed. Return to play is a six-step progression with each step lasting 24 hours: (1) when asymptomatic at rest for 24 hours, progress to (2) light aerobic exercise, followed by (3) sport-specific exercise, then begin (4) noncontact drills, followed by (5) contact practice drills, and finally (6) release to game play. If any symptoms recur during any of the steps, the athlete should not move to the next stage and should rest for 24 hours, thereafter restarting at the previous step where the athlete was asymptomatic. Commonly, it is recommended that an athlete follow up with a medical provider for clearance for return to contact or collision sports, and many states have passed legislation requiring medical assessment of concussed youth and medical clearance for return to play. Current expectations are that children should return to school prior to return to sport. In general, conservative return to play guidelines should be used in children.

Among commonly used assessment tools are the SCAT3, Standardized Assessment of Concussion (SAC), Balance Error Scoring System (BESS), computerized testing, and symptoms checklist (see Table 27–4). Neuropsychological testing may be helpful in assessing the cognitive function of concussed athletes, but it should not be used as the only source of clinical decision making. It may assist in management decisions for athletes with complex cases or severe or prolonged symptoms and is best performed and interpreted by a qualified neuropsychologist. Preseason testing may provide a comparison to help practitioners assess acute concussive status, but there is no solid evidence currently to support the use of baseline neuropsychological testing.

The long-term effects of concussions or contact/collision sports have yet to be established; specifically, a cause-and-effect relationship has not been proven between concussions and chronic traumatic encephalopathy (CTE). Second impact syndrome is a controversial diagnosis primarily based on anecdotal reports. There is no universal agreement on the existence of this reported phenomenon. Advocates endorse a rare but potentially deadly complication of repeated head injury, causing loss of vascular autoregulation, catecholamine surge, increased cerebral blood pressure, and subsequent malignant cerebral edema without intracranial hematoma. Consequences include massive brain swelling and herniation leading to seizure, coma, and, possibly, death. Opponents suggest the phenomenon is actually the well-established condition of diffuse cerebral swelling, a known complication of head injury, particularly in younger individuals. The decision to retire an athlete from high risk or contact/collision sport is a sensitive and challenging one. There is currently little evidence to support a standardized approach to retirement decisions. However, considerations should include total number of concussions; increasing frequency; occurrence with serially less force; and prolonged, more severe, or permanent symptoms/signs.

Child-SCAT3. Br J Sports Med 2013;47:263 [PMID: 23479481]. http://bjsm.bmj.com/content/47/5/263.full.pdf.

McCrory P, Davis G, Makdissi M: Second impact syndrome or cerebral swelling after sporting head injury. Curr Sports Med Rep 2012;11:21–23 [PMID: 22236821].

McCrory P et al: Consensus statement on concussion in sport: the 4th international conference on concussion in sport held in Zurich, November 2012. Br J Sports Med 2013;47:250–258 [PMID: 23479479].

Randolph C: Baseline neuropsychological testing in managing sport-related concussion: does it modify risk? Curr Sports Med Rep 2011;10(1):21–26 [PMID: 21228656].

SCAT3. Br J Sports Med 2013;47:259 [PMID: 23479480]. http://bjsm.bmj.com/content/47/5/259.full.pdf.

Schatz P, Moser RS: Current issues in pediatric sports concussion. Clin Neuropsychol 2011:1–16 [PMID: 21391151].

Wetjen NM, Pichelmann MA, Atkinson JLD: Second impact syndrome: concussion and second injury brain complications. J Am Coll Surg 2010;211(4):553–557 [PMID: 20822744].

2. Atlantoaxial Instability

Atlantoaxial instability is common in children with Down syndrome because of hypotonia and ligamentous laxity, especially including the annular ligament of C1. Consequently, this condition causes increased mobility at C1 and C2. Most cases are asymptomatic. Lateral cervical neck films in flexion, extension, and neutral position evaluate the atlantodens interval (ADI). ADI is normally less than 2.5 mm, but up to 4.5 mm is acceptable in this population. Children with an ADI greater than 4.5 mm should be restricted from contact and collision activities, as well as any sport requiring excessive neck flexion or extension.

Dimberg EL: Management of common neurologic conditions in sports. Clin Sports Med 2005;24:637 [PMID: 16004923].

Klenck C, Gebke K: Practical management: common medical problems in disabled athletes. Clin J Sport Med 2007;17(1): 55–60 [PMID: 17304008].

Winell J: Sports participation of children with Down syndrome. Orthop Clin North Am 2003;34:439 [PMID: 12974493].

3. Burners or Stingers

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Symptoms appear on the same side as an injury to the neck and shoulder.

image Burning pain or numbness in the shoulder and arm.

image Weakness may be present.

Burners or stingers are common injuries in contact sports, especially football. The two terms are used interchangeably to describe transient unilateral pain and paresthesias in the upper extremity. These cervical radiculopathies or brachial plexopathies typically occur when the head is laterally bent and the shoulder depressed, causing exacerbation of a degenerative cervical disk or stenosis, a compressive injury to a cervical nerve root on the symptomatic upper extremity, or a traction injury to the brachial plexus of the ipsilateral shoulder. Symptoms include immediate burning pain and paresthesias down one arm generally lasting only minutes. Unilateral weakness in the muscles of the upper trunk—supraspinatus, deltoid, and biceps—also tends to resolve quickly, but can persist for weeks. The most important part of the workup is a thorough neurologic assessment to differentiate this injury from a more serious brain or cervical spine injury. The key distinguishing feature of the stinger is its unilateral nature. If symptoms persist or include bilateral complaints, headache, change in mental status, or severe neck pain, a diagnostic evaluation should include a careful neurological examination and possibly cervical spine radiographs including flexion/extension views, magnetic resonance imaging (MRI) scans, and electromyography (EMG).

Treatment consists of removal from play and observation. The athlete can return to play once symptoms have resolved, neck and shoulder range of motion is pain-free, reflexes and strength are normal, and the Spurling test is negative. The Spurling test is performed by having the head extended, rotated, and flexed to the ipsilateral shoulder while applying an axial load. Restriction of same day return to play should be considered in athletes with a history of multiple stingers, particularly if sustained in the same season. Preventative strategies include always wearing well-fitting protective gear, proper blocking and tackling techniques, and maintaining neck and shoulder strength. Long-term complications are possible, including permanent neurologic injury or repeated occurrence of stingers, which would necessitate further workup and possible lifetime exclusion from contact or collision sports.

Cantu RC, Li YM, Abdulhamid M, Chin LS: Return to play after cervical spine injury in sports. Curr Sports Med Rep 2013;12:14–17 [PMID: 23314078].

Standaert CJ, Herring SA: Expert opinion and controversies in musculoskeletal and sports medicine: stingers. Arch Phys Med Rehabil 2009;90:402–406 [PMID: 19254603].

SPINE INJURIES

As children have become more competitive in sports, spine injuries have become more common. Sports with a fairly high incidence of back injuries include golf, gymnastics, football, dance, wrestling, and weightlifting. Back pain lasting more than 2 weeks indicates a possible structural problem that should be investigated.

Acute injury to the spine often results from an axial load injury. Patients present with focal tenderness of the thoracic or thoracolumbar spine. Evaluation includes plain radiography that may demonstrate anterior wedging of the thoracic vertebra, representing a compression fracture. When significant spinal tenderness or any neurologic abnormalities are present, radiographs are often followed by CT or MRI. Treatment of minor compression fractures includes pain control, bracing, rest from high-risk sports, and physical therapy. With appropriate rehabilitation, athletes can usually return to contact activity within 8 weeks.

1. Spondylolysis

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Injury to the pars interarticularis.

image Usually presents as lower back pain with extension.

Spondylolysis is an injury to the pars interarticularis of the vertebral complex, resulting in a stress reaction or an acquired stress fracture. The pars interarticularis is the bony connection between the inferior and superior articulating facets. Injuries to the pars interarticularis, or pars defects for short, are present in 4%–6% of the population. In adolescent athletes, however, the incidence of spondylolysis in those presenting with lower back pain is close to 50%. As such, it should be high on the differential when evaluating lower back pain in this population. The incidence of pars defects in athletes such as gymnasts, dancers, divers, and wrestlers is significantly increased because of the repetitive flexion/extension motions combined with rotation. Repetitive overload results in stress fractures. Spondylolysis occurs at L5 in 85% of cases. The athlete presents with midline low back pain that is aggravated by extension, such as arching the back in gymnastics. There may be palpable tenderness over the lower lumbar vertebrae, with pain on the single leg hyperextension test (Stork test). Tight hamstrings are another common physical finding. Evaluation includes anteroposterior (AP) and lateral radiographs of the lumbar spine. Although oblique radiographic views of the lumbar spine are helpful to look for the so-called Scottie dog sign, they are falling out of favor because they do not significantly improve diagnostic accuracy and increase radiation exposure. Single photon emission computed tomography (SPECT) scan, CT scan, and MRI can be useful to determine the presence of an active spondylotic lesion. Bone/SPECT scan shows stress reaction or pars injury before other radiographic changes. CT provides excellent definition of bony anatomy and can document healing. MRI is an alternative to detect pars interarticularis problems. With the use of high magnetic field strength and fat saturation techniques, high-resolution MRI images can now show subtle bone marrow edema of early stress injuries and are becoming popular, particularly for pediatric patients because of the lack of radiation exposure. There is currently no gold standard for the treatment of spondylolysis. The goal is to alleviate painful symptoms and allow the athlete a safe return to play. Management includes refraining from hyperextension and high-impact sporting activities, stretching of the hamstrings, and core and back stabilization exercises. Athletes can cross-train with low-impact activity and neutral or flexion-based physical therapy. Bracing is controversial. Outcome studies show similar results regarding return to sports and bony healing whether or not braces are worn. It is important to note also that clinical outcome does not necessarily correlate with healed pars fracture versus bony nonunions (when the fractured bone fails to heal). Satisfactory outcomes (asymptomatic patients and return to sports) can be achieved regardless of bony healing status. Typically, return to play is often delayed 8–12 weeks or longer based on clinical signs of healing. Most symptomatic spondylolysis improves with rest and activity modifications (with or without radiologic evidence of healing). Once asymptomatic, an athlete can usually return to sports without restrictions. Surgery is reserved for refractory cases that fail conservative measures.

2. Spondylolisthesis

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Bilateral pars interarticularis injury resulting in forward slippage of one vertebra over the one below it.

image Usually presents as back pain with extension.

image Hyperlordosis, or possible step-off of lumbar spine.

When a bilateral pars stress fracture (spondylolysis) occurs, slippage of one vertebra over another causes a spondylolisthesis. Patients present with hyperlordosis, kyphosis, pain with hyperextension, and, in severe cases, a palpable step-off. A standing lateral radiograph is used to make the diagnosis and to monitor for any progression of slippage. These injuries are graded from 1 to 4 based on the percentage of slippage: grade 1 (0%–24%), grade 2 (25%–49%), grade 3 (50%–74%), and grade 4 (75%–100%).

Treatment is often symptom based. Asymptomatic athletes with less than 25% slippage often have no restrictions and are followed on a routine basis for radiograph assessment. Management of symptomatic spondylolisthesis requires a period of activity modifications, particularly protection from spine extension and impact activities, coupled with a regimen of stretching of the hamstrings and core and back stabilization exercises. Bracing may also be considered. Surgical intervention is considered for slippage greater than 50%, progressive spondylolisthesis, or intractable pain despite nonoperative treatment. If surgery is required, the athlete must understand that he or she cannot return to activities for at least 1 year and may not be able return to previous sporting activities.

3. Disk Herniation

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Back pain worse with flexion and sitting.

image Radiculopathy can be present.

image Positive straight leg raise.

Discogenic back pain accounts for a small percentage of back injuries in children. These injuries are almost unheard of in preadolescence. Back pain can originate from disk bulging, disk herniation, or disk degeneration. Most injuries occur at L4–L5 and L5–S1 vertebrae. Not all disk bulges found on MRI are symptomatic. In adolescents, most disk herniations are central rather than posterolateral. Risk factors include heavy lifting, excessive or repetitive axial loading of the spine, rapid increases in training, or trauma. Symptoms include back pain, which may be increased with activities such as bending, sitting, and coughing. Although not as common as in adults, radicular symptoms of pain down the leg can also occur and are often associated with large disk herniations. Evaluation includes physical and neurologic examinations, including straight leg testing, sensory testing, and checking reflexes. If symptoms persist, evaluation usually begins with radiographs and an MRI, which is the imaging test of choice for diagnosing disc herniation. EMG may also be considered in the presence of radiculopathy.

Treatment usually is conservative as most disk herniations, even if large, improve spontaneously. The athlete can rest the back for a short period, with avoidance of prolonged sitting, jumping, or hyperextension and hyperflexion of the spine, as these activities may increase pressure on the disk, leading to aggravation of symptoms. After a short period of rest, a structured physical therapy program should begin, focusing on core and pelvic stabilization, peripelvic flexibility and sports or activity specific conditioning. If symptoms persist, a short course of oral steroids may be indicated. Surgery is recommended for patients who fail conservative therapy, have significant or progressive radiculopathy, or who have progressive neurologic deficit.

Curtis C, d’Hemecourt P: Diagnosis and management of back pain in adolescents. Adolesc Med State Art Rev 2007;18:140–164 [PMID: 18605395].

Eddy D et al: A review of spine injuries and return to play. Clin J Sport Med 2005;15:453 [PMID: 16278551].

Kim H, Green D: Spondylolysis in the adolescent athlete. Curr Opinion Ped 2011;23:68–72 [PMID: 21150440].

Lavelle W et al: Pediatric disk herniation. J Am Acad Orthop Surg 2011;19: 649–656 [PMID: 22052641].

Selected issues for the adolescent athlete and the team physician: a consensus statement. Med Sci Sports Exerc Nov 2008;40(11):1997–2012 [PMID: 19430330].

SHOULDER INJURIES

Shoulder injury is usually a result of acute trauma or chronic overuse. Acute injuries around the shoulder include contusions, fractures, sprains (or separations), and dislocations. The age of the patient affects the injury pattern, as younger patients are more likely to sustain fractures instead of sprains. Sprains (ligaments) and strains (muscle and tendon) are generally defined as low grade soft tissue injuries that do not result in functional compromise of a structure.

1. Fracture of the Clavicle

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Injury by fall on to shoulder or outstretched hand.

image Severe pain in the shoulder.

image Deformity over clavicle.

Clavicular fractures occur from a fall or direct trauma to the shoulder. Focal swelling, deformity, and tenderness are present over the clavicle. The diagnosis is made by radiographs of the clavicle; the fractures are most common in the middle third of the bone.

Initial treatment is focused on pain control and protection with a sling and swathe. Early range of motion is permitted based on pain level. Progressive rehabilitation is important. Athletes cannot return to contact sports for 8–10 weeks. Absolute surgical indications for acute clavicular fractures include open fractures or neurovascular compromise. Fracture nonunion is unusual in young patients. However, there is recent evidence in the adult population recommending surgical stabilization for fractures that are very displaced or shortened. The role of acute surgical stabilization in the pediatric and adolescent population in regards to shortening is still being defined. Patients with recurrent fractures or nonunion typically will also require surgical fixation.

2. Acromioclavicular Separation

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Injury with fall on shoulder.

image Severe pain in the shoulder.

image Deformity over acromioclavicular joint.

A fall on the point of the shoulder is the most common cause of acromioclavicular separation. Tearing of the acromioclavicular joint capsule and possibly the coracoclavicular ligaments occurs. The injury is classified by the extent of the injuries to these ligaments. Athletes present with focal soft tissue swelling and tenderness over the acromioclavicular joint. More severe injuries are associated with deformity. Patients have a positive cross-arm test, in which pain is localized to the acromioclavicular joint. Radiographs are necessary in this setting to assess the degree of injury and to evaluate for a coexisting fracture or growth plate injury.

Treatment is supportive, with rest and immobilization in a sling followed by progressive rehabilitation. Return to activity can be accomplished in 1–6 weeks depending on the severity of the injury and the persistence of symptoms. Full range of motion and full strength must be achieved prior to being cleared to return to sports.

3. Fracture of the Humerus

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Injury with significant fall on outstretched arm.

image Severe pain in proximal humerus.

image Swelling and/or deformity over proximal humerus.

Fractures of the humerus occur from a severe blow or fall on the shoulder. Pain and swelling are localized to the proximal humeral region. The fractures can include the physes or may be extraphyseal. A significant amount of displacement and angulation can be tolerated in this location because of the young athlete’s potential for remodeling and because of the intrinsic range of motion of the shoulder. Careful assessment of the brachial plexus and radial nerves are needed to rule out associated nerve damage.

Treatment consists of a sling for 4–6 weeks followed by progressive rehabilitation.

4. Acute Traumatic Anterior Shoulder Instability (Anterior Shoulder Dislocation/Subluxation)

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Injury with an abducted and externally rotated arm.

image Severe pain in the shoulder.

image Squared-off shoulder on examination.

image Reduced range of motion of the shoulder.

Acute traumatic anterior shoulder instability occurs when significant force is applied to the abducted and externally rotated shoulder. Most often, the humeral head is dislocated in an anterior and inferior direction. The patient has severe pain and a mechanical block to motion. Some patients will spontaneously reduce within seconds or minutes of their injury. Most patients, however, require immediate closed reduction on the field or in the emergency room. Radiographs are helpful to confirm the position of the humeral head as well as to evaluate for coexisting fracture. MRI may be required for accurate visualization of fractures and cartilaginous injury.

Optimal follow-up treatment for glenohumeral dislocation in young athletes has not been established. Initially, the shoulder is immobilized for comfort. Range-of-motion exercises and progressive rehabilitation are initiated. Prolonged immobilization does not decrease the risk of recurrence, and is discouraged. Because of the high risk of recurrence, options for treatment should be individualized, with consideration given to both nonoperative and surgical management.

5. Rotator Cuff Injury

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Injury can be acute or chronic.

image Pain is described as diffuse or anterior and lateral.

image Overhead activities exacerbate the pain.

Shoulder injuries are often a consequence of repetitive overuse and tissue failure. Rotator cuff tendonitis and bursitis are the most commonly observed rotator cuff injuries in youth sports. Rotator cuff tears in children and adolescents are exceedingly rare. These overuse injuries typically occur in sports requiring repetitive overhead motions. Muscle imbalances and injury can cause the position of the humeral head to be abnormal, which may cause entrapment of the supraspinatus tendon under the acromial arch. Patients with nontraumatic shoulder instability due to ligamentous and capsular laxity (also known as multidirectional instability) are prone to overuse rotator cuff injury. These athletes present with chronic pain in the anterior and lateral shoulder, which is increased with overhead activities. Diagnostic workup includes plain radiographs and an outlet view to look for anatomic variability. The rehabilitation of this injury is geared toward reduction of inflammation, improved flexibility, and core stabilization and strengthening of the scapular stabilizers and rotator cuff muscles. A biomechanics evaluation can assist athletes in the recovery process by building sport-specific skills and eliminating substitution patterns. Surgery is rarely indicated.

6. Little League Shoulder

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Participation in a throwing sport.

image Pain with throwing.

image Pain in the lateral aspect of the humerus.

image Swelling around the shoulder.

image Widening of the proximal humeral physis on radiographs.

Proximal humeral epiphysitis, or “Little League shoulder,” is an overuse injury that occurs in children aged 11–14 years who play overhead sports such as baseball. The patient presents with activity-related pain in the lateral aspect of the proximal humerus. Examination often shows tenderness over the proximal humerus. Absence of findings on office examination does not preclude this diagnosis. The hallmark feature is pain with throwing. Radiographs show widening, sclerosis, and irregularity of the proximal humeral physis. Comparison views are often helpful when considering this diagnosis.

Treatment consists of rest from throwing or other aggravating activity. Physical therapy is initiated during the rest period. Return to play can only be considered after a period of rest has significantly decreased the pain and the athlete has proceeded through a progressive throwing program. Healing can take several months. Signs of radiographic healing may lag behind the athlete’s clinical progress and normal radiographs are not necessarily required to return an athlete to play. Permanent sequelae such as fracture, growth arrest, or deformity is extremely rare but can occur in chronic cases that are not treated appropriately.

Mariscalco MW, Saluan P: Upper extremity injuries in the adolescent athlete. Sports Med Arthrosc Rev 2011;19:17–26 [PMID: 21293234].

Brophy RH, Marx RG: The treatment of traumatic anterior instability of the shoulder: nonoperative and surgical treatment. Arthroscopy 2009;25:298–304 [PMID: 19245994].

Sciascia A et al: The pediatric overhead athlete: what is the problem? Clin J Sports Med 2006;16:6 [PMID: 17119360].

ELBOW INJURIES

Injuries in the elbow are quite common and have both chronic and acute etiologies. They often occur in athletes involved in throwing or overhead sports. Although acute injuries to the elbow are common, chronic overuse injuries are becoming more and more prevalent in young athletes. Risk factors leading to overuse elbow injury include single sport specialization, year-round participation, longer competitive seasons, insufficient rest, and poor biomechanics. The term Little League elbow is used loosely to encompass a variety of causes of elbow pain in young throwing athletes. These injuries include medial epicondylitis, apophysitis, medial epicondyle avulsion fracture, and osteochondritis dissecans (OCD) of the capitellum. It is intended, however, to refer to medial epicondyle apophysitis, an overuse elbow injury resulting from repetitive valgus stress from overhead throwing.

When the elbow is evaluated, it is helpful to divide the examination into specific anatomic areas, discussed as follows.

1. Medial Epicondyle Apophysitis (Little League Elbow)

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Participation in a throwing sport.

image Pain over the medial epicondyle, especially with pitching.

image Swelling of medial elbow.

Little League elbow is a traction injury to the medial epicondylar physis, which develops in young overhead throwing athletes, particularly baseball pitchers, between the ages of 9–12 years. The biomechanical forces generated around the elbow during throwing, namely repetitive valgus stress, can result in shearing, inflammation, traction, and abnormal bone development. The symptoms are primarily swelling, medial elbow pain, performance difficulties, and weakness. The pain localizes to the medial epicondyle, which may be tender to palpation, and worsened with valgus stress. Wrist flexion and forearm pronation may increase symptoms. The physician should inquire about the exposure to throwing, including pitch counts, the number of practices and games, and the duration of the season. Workup includes elbow radiographs, with comparison films of the unaffected side, to look for widening of the apophysis. Rarely, MRI is used to confirm the diagnosis.

Treatment of the injury includes complete rest from throwing activities. It is not uncommon for a player to be restricted from throwing for up to 6 weeks. Competition can be resumed once the player is asymptomatic and has progressed through a graduated, age-appropriate throwing program. The key approach for this injury is prevention. Children should be properly conditioned and coached in correct throwing biomechanics. Guidelines for Little League pitching limits in youth baseball have been developed and are outlined in Table 27–5.

Table 27–5. Guidelines for pitching limits in youth baseball.

image

2. Panner Disease

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Participation in a throwing sport.

image Pain over the lateral elbow.

image Swelling and flexion contracture.

Panner disease refers to developmental osteochondrosis of the capitellum that results from overuse injury. The lesion involves disordered ossification of the capitellum, which is the lower end of the humerus that articulates with the radius. This condition occurs in children aged 5–12 years who play sports that involve overhead throwing and in gymnasts. The repetitive lateral compressive forces from loading the elbow in these sports compromises the blood supply to the growing epiphysis, leading to degeneration of the ossification center, or osteochondrosis. The child may have dull aching in the lateral elbow that worsens with throwing. Swelling and reduced elbow extension usually are present. Radiocapitellar compression test will also elicit pain—with elbow fully extended, arm is actively pronated and supinated. Radiographs show an abnormal, flattened capitellum, with fragmentation and areas of sclerosis. This should be distinguished from OCD of the capitellum, which typically occur in older children (see as follows). Treatment is conservative, using rest, ice, and splinting. Avoid activities that load the elbow for 3–6 months. The child can return to play once symptoms resolve, and there is evidence of healing on follow-up radiographs. The natural history of this condition is one of complete resolution of symptoms and, ultimately, normal ossification of the capitellum.

3. Ulnar Collateral Ligament Tear

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Sudden forceful tensile stress on ligament from a fall or from valgus stress to elbow during overhead throw.

image Feeling a pop or sensation of elbow giving out.

image Medial elbow pain.

image Tenderness distal to medial epicondyle.

Once the medial epicondylar physis closes in a skeletally mature athlete, valgus forces are then transmitted to the ulnar collateral ligament, resulting in a sprain or tear. Patients present with medial elbow pain and are often unable to fully extend the elbow. Examination reveals tenderness just distal to the medial epicondyle, and there may be instability with valgus stressing. Treatment is conservative, including rest, ice, and physical therapy directed at range of motion and strengthening. Surgery may be suggested for those with persistent pain or instability and who desire to continue participating in overhead sports.

4. Osteochondritis Dissecans

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Participation in a throwing sport.

image Pain over the lateral elbow, especially with pitching.

image Tenderness over radiocapitellar joint.

image Elbow flexion contracture.

Lateral elbow pain in a slightly older throwing athlete, usually aged 13–15 years, can be secondary to osteochondritis dissecans (OCD), which is a more worrisome diagnosis than Panner disease. Unlike Panner disease, which is self-limiting, OCD lesions can lead to permanent destruction of the bone. It is an injury to the subchondral bone and its overlying articular cartilage. Although it can involve different sites of the elbow, including the olecranon, radial head, or trochlea, it most commonly affects the capitellum. Repetitive valgus compressive forces can lead to avascular necrosis of the capitellum, which can ultimately result in the formation of loose bodies in the joint. The athlete presents with lateral pain, swelling, lack of full extension, and occasionally locking. Radiographs show lucency of the capitellum with surrounding sclerotic bone. MRI can more fully delineate the lesion. The prognosis for high-grade lesions is guarded.

A child with OCD should be seen by either a sports medicine specialist or an orthopedic surgeon with expertise in upper extremity injuries. Treatment is based on classification and can be either conservative or surgical. For early or stable OCD lesions, particularly in skeletally immature individuals, management includes throwing activity restrictions and range of motion exercises. More advanced lesions or those with persistent symptoms despite conservative treatment may require surgical intervention.

5. Lateral Epicondylitis

Lateral epicondylitis (also known as tennis elbow) is common in skeletally mature athletes participating in racquet sports. It is a tendinopathy of the extensor muscles in the forearm, which inserts onto the lateral epicondyle causing lateral elbow pain. The pain is increased by wrist extension. Initial treatment is aimed at inflammation control. Stretching and strengthening of forearm muscles are the primary interventions during the subsequent phases. Stroke mechanics may need to be altered and a forearm brace used to decrease the forces in the extensor muscles.

6. Posterior Elbow Pain

Posterior elbow pain is uncommon. Etiologies include dislocations, fractures, triceps avulsions, olecranon apophysitis, and olecranon bursitis.

Benjamin HJ et al: Little League elbow. Clin Sports Med 2005;15:1 [PMID: 15654190].

Gerbino PG: Elbow disorders in throwing athletes. Orthop Clin North Am 2003;34:417 [PMID: 12974491].

Hang DW et al: A clinical and roentgenographic study of Little League elbow. Am J Sports Med 2004;32:79 [PMID: 14754727].

Harris SS, Anderson SJ: Care of the Young Athlete, 2nd ed. American Academy of Pediatrics; 2010.

Little League. http://www.littleleague.org.

Kobayashi K et al: Lateral compression injuries in the pediatric elbow: Panner’s disease and osteochondritis dissecans of the capitellum. J Am Acad Orthop Surg 2004;12:246–254 [PMID: 15473676].

HAND & WRIST INJURIES

The hand is the most common area of injury in children and accounts for a large proportion of emergency room visits. All hand and wrist injuries have the potential for serious long-term disability and deserve thorough evaluation. A thorough neurovascular examination as well as evaluation of rotational or angular deformity or malalignment is critical. Examples of complications include loss of range of motion, dysfunction, deformity, limb length discrepancy, and arthritis.

1. Distal Phalanx Injury

Tuft injury requires splinting for 3–6 weeks or until the patient is pain-free. If there is significant displacement, a surgical K-wire can be used for reduction. Nail bed injury often requires nail bed suturing, splinting, and drainage of subungual hematomas. Nail avulsions should be replaced into the nail fold, and if not possible, a substitute material should be interposed into the nail bed as a stent. Patients with nail bed injuries should be advised that nail regrowth may appear irregular or may not occur at all.

2. Distal Interphalangeal Injury

Mallet finger or extensor tendon avulsion occurs more commonly in ball-handling sports. The mechanism of injury is an axial load or forced flexion against an actively extending finger, causing avulsion fracture or rupture of the extensor digitorum tendon. Athletes present with a flexion contracture at the distal interphalangeal (DIP) joint and inability to actively extend the distal phalanx. Referral to an orthopedic surgeon is necessary. Conservative treatment consists of splinting in extension for 4 weeks for fractures and 6–8 weeks for tendon rupture. Surgery may be required if the initial fracture involves greater than 30% of the joint space or poor healing with loss of function occurs.

Jersey finger, or flexor tendon avulsion, occurs in contact sports, particularly American football. The mechanism of injury is forced extension against an actively flexed finger. The fourth (“ring”) finger is the most commonly injured digit. Athletes present with tenderness, swelling, and inability to flex at the DIP. The examiner can test the function of the flexor tendon by holding the proximal interphalangeal joint in extension while having the injured athlete attempt flexion at the DIP joint. The injured finger should be splinted in a comfortable position and immediately referred to an orthopedic surgeon, as definitive treatment is often surgical.

3. Thumb Injury

Gamekeeper’s thumb is an injury to the ulnar collateral ligament from forced abduction of the thumb metacarpophalangeal (MCP) joint. It is a common skiing injury to those who fall while holding on to their ski poles. Patients will complain of pain over the medial aspect of the MCP joint and pain with apposition or pinching. If a radiograph shows an avulsed fragment that is displaced less than 2 mm, a thumb spica cast can be used. If there is no fragment, less than 35 degrees of lateral joint space opening, or less than 15 degrees difference in joint space opening compared to the uninjured thumb, a spica cast for 4–6 weeks is indicated. Surgery is required for more serious injuries.

4. Hand Fractures

All finger fractures should be assessed for growth plate involvement, rotation, angulation, and displacement. If stable and not displaced, these fractures can be splinted for 3–4 weeks and buddy-taped for immediate return to sports. However, spiral or oblique fractures of the middle phalanx, intra-articular fractures, and severely angulated physeal fractures are considered unstable and should be referred to an orthopedic surgeon.

Boxer’s fracture is a neck fracture of the fourth or fifth metacarpal, typically caused by poor punching technique or punching into a hard surface. Less than 40 degrees of angulation in the fourth or fifth metacarpals is acceptable. Assessment of displacement and rotational deformity is critical, as displaced or rotated fractures require reduction and fixation. Prior to definitive treatment with hand-based casting for 4 weeks, boxer’s fractures may be temporarily immobilized with an ulnar gutter splint with the MCP joints flexed to 70 degrees.

5. Wrist Injury

Most swollen wrists without evidence of gross deformity or instability can be splinted temporarily for several days. Radial and ulnar fractures, which are fairly common in children, must be ruled out. Particular attention should be paid to the growth plates and the scaphoid bone. Typically, distal radius and ulna fractures require casting for 3–6 weeks in either a short or long arm cast, depending on the involvement of one or both bones and the severity of displacement or angulation. Torus, or buckle, fractures may be placed in a rigid wrist brace or short arm cast for 3–4 weeks. Scaphoid fractures are caused by a force applied to a hyperextended wrist, most commonly a fall onto an outstretched hand. Despite normal radiographs, if evidence of snuffbox tenderness and swelling is present, there is tenderness along the volar aspect of the scaphoid, or there is pain with radial wrist deviation or active wrist range of motion; the wrist must be further evaluated, either by MRI acutely or immobilized for 10 days and then reassessed both clinically and with follow-up radiographs. A nondisplaced scaphoid fracture requires at least 6 weeks of immobilization in a thumb spica cast. Nonunion can occur, particularly in fractures of the proximal pole of the scaphoid, related to the poor blood supply of this carpal bone. Displacement requires operative management. Gymnast’s wrist has chronic wrist pain due to repetitive overloading of the distal radial physis. Athletes complain of dorsal wrist pain, worsened with weight bearing on the affected upper extremity or active extension of the wrist. This overuse stress injury may cause long-term growth abnormalities or degenerative wrist joint changes, which may ultimately require surgical intervention. Athletes should be placed in a rigid wrist brace or short arm cast for 4 weeks and undergo a period of relative rest and activity modification.

Anz AW et al: Pediatric scaphoid fractures. J Am Acad Orthop Surg 2009;17:77–87 [PMID: 19202121].

Carson S et al: Pediatric upper extremity injuries. Pediatr Clin North Am 2006;53:41–67 [PMID: 16487784].

Cornwall R, Ricchetti ET: Pediatric phalanx fractures: unique challenges and pitfalls. Clin Orthop Relat Res 2006 Apr;445: 146–156 [PMID: 16505727].

Mariscalco MW, Saluan P: Upper extremity injuries in the adolescent athlete. Sports Med Arthrosc Rev 2011;19(1):17–26 [PMID: 21293234].

Sutijono D, Silverberg MA: Nailbed injuries. Medscape Reference. Updated: May 30, 2012. http://emedicine.medscape.com/article/827104-overview#a0199.

Williams AA, Lochner HV: Pediatric hand and wrist injuries. Current Rev Musculoskeletal Med 2013;6:18–25 [PMID: 23264097].

HIP INJURIES

Because the pelvis and hip articulate with both the lower extremities and the spine, this area is rich in ligaments, muscle attachments, and nerves. Injuries in young children are rare, but sprains, strains, and avulsion fractures can occur. Additionally, athletes can be susceptible to overuse injury involving the hip.

1. Hip Avulsion Fractures

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Fractures at apophyseal areas.

image Pain with weight bearing.

image Focal pain over the site of injury.

Avulsion fractures around the hip in adolescents occur at apophyseal regions such as the ischial tuberosity, anterior superior iliac spine, anterior inferior iliac spine, and iliac crest. The mechanism of injury is a forceful, unbalanced muscle contraction that causes avulsion of the muscle tendon insertion. The athlete presents with a history of an acute traumatic incident; often a “pop” is felt and the athlete is immediately unable to bear weight. Range of motion of the hip is limited secondary to pain and focal tenderness is present over the apophysis.

Treatment is conservative. Surgical management is rarely required even in displaced fractures. The athlete is typically placed on crutches for the first couple of weeks for pain control and to normalize gait. After the acute phase, an athlete can progress to weight bearing as tolerated. The rehabilitation phase focuses on regaining motion, flexibility training and pelvic, and core strengthening. Progressive return to activity can often be accomplished in 4–6 weeks, if full range of motion, full strength, and sport-specific skills have been achieved.

2. Slipped Capital Femoral Epiphysis

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Pain in the hip or knee, or both.

image Loss of internal rotation of the hip.

image Radiographs in the frog-leg position show widening of the physis and epiphyseal slippage.

Slipped capital femoral epiphysis occurs in children aged 11–16 years. The physis is weakened during times of rapid growing and is susceptible to shearing failure either acutely secondary to a traumatic injury or insidiously from chronic overload. Patients complain of groin, thigh, or knee pain and often have a limp. Examination shows painful range of motion of the hip, limited internal rotation, and obligatory external rotation when the hip is flexed. Radiographs include AP and frog-leg lateral films, which demonstrate widening of the physis and epiphyseal slippage or displacement of the femoral head relative to the femoral neck.

Treatment consists of immediate non–weight-bearing and urgent referral to an orthopedic specialist for open reduction and internal fixation. Failure to identify this injury can result in permanent hip deformity and damage resulting in early arthritis. Rehabilitation is a component of the postsurgical treatment. Return to activity is progressive over months. (See also Chapter 26.)

3. Acetabular Labral Tears

Acetabular labral tears are an increasingly recognized cause of anterior hip and groin pain in athletes. The majority of hip labral tears occur as a result of some underlying hip disorder such as femoroacetabular impingement (FAI) or hip dysplasia. Because of the stress and range of motion requirements for most athletics, these injuries tend to present and be more symptomatic in the athletic population. Athletes with this injury typically do not report an acute traumatic event that precipitated their symptoms. Symptoms often develop insidiously rather than acutely. Athletes present with deep anterior hip or groin pain that worsens with activity and is resistant to treatment. Radiographic findings can be normal. An MRI arthrogram is used to demonstrate the tear. Treatment typically starts conservatively and requires rest. Ultimately, treatment is tailored to the athlete’s particular needs and symptoms. Arthroscopy to repair the tear and address any underlying structural issue that caused the tear is often required.

4. Adductor Strain

An adductor strain or a groin pull is generally caused by forced abduction during running, falling, twisting, or tackling. Sports that require quick directional changes place athletes at risk for these types of injuries. The associated pain is in the adductor muscle. There is often pain with hip adduction or flexion and tenderness over the adductor tubercle. Treatment includes rest, ice, and protection—often with crutches, and strengthening of the muscle when it heals.

5. Hamstring Strain

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Mechanism is forced knee extension.

image Pain with tearing or popping sensation in the posterior leg.

image Pain with resisted knee extension.

Hamstring strain is a common injury in athletes. The majority of these injuries occur in the muscle belly and can be treated successfully with nonoperative management. The mechanism of injury is forced extension of the knee or directional changes. Typically, the athlete with a hamstring strain suddenly stops playing and grabs the back of the knee. There are three grades of injury. Examination reveals pain on palpation of the muscle and occasionally a defect. Pain also occurs with knee flexion against resistance.

Initial treatment is focused on minimizing swelling, bruising, and pain. The thigh should be iced and compression applied. In moderate and severe injuries, crutches may be needed for a short duration. The athlete can walk as soon as he or she can tolerate the activity. It is particularly important to stretch the hamstring because, as a two-joint muscle, it is more susceptible to injury than other types of muscle. Eccentric strengthening is an important component of rehabilitation.

6. Quadriceps Contusion

Quadriceps contusion is caused by a direct injury to the muscle that causes bruising, swelling, and pain. The amount of damage is directly related to the amount of force. The anterior and lateral thigh regions are most commonly injured, often in contact sports such as football and lacrosse.

Treatment is rest, ice, and protection for the first 24 hours. The knee should be kept in a fully flexed position. Two to 3 days after the injury, range-of-motion exercises may begin in both flexion and extension. Once 120 degrees of motion has been established and movement does not cause pain, the athlete may return to competitive activity. If the muscle remains firm on examination after 2 weeks, radiographs of the thigh should be obtained to rule out myositis ossificans, an abnormal deposition of calcium in the muscle that may be induced by aggressive stretching of the muscle too early in the clinical course.

7. Hip Dislocation

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Usually produces posterior dislocation.

image Leg is flexed, adducted, and internally rotated.

image Hip pain is severe.

image This is an on-site emergency and must be treated quickly.

The hip is a very constrained joint and is inherently very stable. Therefore, hip dislocations are very rare and typically occur only in high energy or forceful injuries. Most hip dislocations occur in the posterior direction. Athletes with this injury typically have severe pain and any motion of the hip or leg is poorly tolerated. Classically, these athletes present with an acutely painful hip following a major impact and the hip is locked in flexion, adduction, and internal rotation. Hip dislocations in skeletally mature athletes are often associated with acetabular and femoral neck fractures. The preadolescent, skeletally immature competitor may have an isolated dislocation without fracture. Hip radiographs and advanced imaging such as a CT or MRI scan are needed to completely evaluate the injury.

This injury is an emergency. The athlete should be transported immediately to the nearest facility that has an orthopedic surgeon available. Severe bleeding, avascular necrosis, and nerve damage can result with delay in relocation. Most athletes can be relocated in a closed fashion. Once reduction has been established in an uncomplicated case, protected weight bearing on crutches for 6 weeks is recommended followed by another 6 weeks of range-of-motion and strengthening exercises. An athlete may return gradually to competition after 3 months, when strength and motion are normal.

Surgery can be necessary if there is an associated fracture, labral tear, loose body, or if a concentric reduction cannot be achieved in a closed fashion.

8. Pelvic Apophysitis

Pelvic apophysitis occurs in competitive adolescent athletes who typically are participating consistently, often year round, in their sport. Common locations are the ischial tuberosity and iliac crest. The athlete presents with pain over the apophysis and pain with resisted hip motion specific to the muscle insertion. Radiographs can show irregularity over the apophysis, or be normal. Treatment consists of relative rest, progressive rehabilitation focusing on flexibility, and pelvis and core stabilization.

9. Iliotibial Band Syndrome

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Overuse running injury.

image Pain over lateral knee or hip.

image Positive Ober test.

Iliotibial band syndrome and associated trochanteric bursitis result when the bursa and IT band become inflamed because of repetitive friction from the underlying greater trochanter. This condition can cause pain when the hip is flexed as a result of reduced flexibility of the iliotibial band and gluteus medius tendons. The bursa is a structure that normally allows for improved motion by reducing friction but becomes pathologic in this condition. Movement is painful and may be limited. Iliotibial band syndrome is best evaluated in a side-lying position and pain is reproduced when the hip is actively flexed from a fully extended hip (Ober test).

Initial treatment is to alter the offending activity and then start a stretching program geared at the iliotibial band and hip abductors. Core and pelvic stabilization are also important. Ultrasound can be beneficial and corticosteroid injections may be used after conservative treatment has failed.

10. Femoral Neck Fractures

Femoral neck fractures (stress fractures) are generally the result of repetitive microtrauma. They commonly occur in running athletes who have increased their mileage. Athletes with this type of injury present with persistent pain in the groin and pain with internal and external rotation. Symptoms often are present with sports, but as the fracture progresses, symptoms often develop during activities of daily living. Athletes with a history of previous stress fracture, disordered eating, or any disorder of calcium metabolism and groin pain should alert the provider to the possibility of this diagnosis. Special attention should be given to the female athlete with triad of eating disorders, amenorrhea, or oligomenorrhea, and low bone density and the risk of stress fracture in this population.

On physical examination, range of motion may be limited in hip flexion and internal rotation. A limp may be present. Pain with hopping on the affected leg is universally present. If plain radiographs are negative, an MRI or a bone scan is indicated.

Treatment is based on the type of fracture. A tension-sided fracture (on the superior aspect of the femoral neck) generally requires internal fixation to prevent femoral displacement and reduce the risk of avascular necrosis. A compression fracture (on the inferior aspect of the femoral neck) is less likely to be displaced; treatment is conservative and involves resting the hip until it heals. Cardiovascular conditioning can be maintained easily through nonimpact exercises and activity.

Cooper DE: Severe quadriceps muscle contusions in athletes. Am J Sports Med 2004;32:820 [PMID: 15090402].

Jacoby L, Yi-Meng Y, Kocher MS: Hip problems and arthroscopy: adolescent hip as it relates to sports. Clin Sports Med 2011;30;435–451 [PMID: 21419965].

Kovacevic D, Mariscalco M, Goodwin RC: Injuries about the hip in the adolescent athlete. Sports Med Arthrosc Rev 2011;19: 64–74 [PMID: 21293240].

KNEE INJURIES

Knee injuries are one of the most common sports-related problems. The knee is stabilized through a variety of ligaments, tendons, and the menisci. Knee injuries can be divided into two groups: those resulting from acute or chronic causes. Acute injuries occur during a well-defined traumatic incident. The mechanism of injury is an important historical feature, although many young patients have difficulty describing the details of the inciting event. The onset of rapid swelling after a traumatic event indicates the presence of a hemarthrosis and likely internal derangements such as fracture, rupture of the anterior cruciate ligament (ACL), meniscal tear, or patellar dislocation.

1. Anterior Knee Pain

The most common knee complaint is anterior knee pain. This complaint can have multiple etiologies but should always include hip pathology as a possible source. Patellofemoral dysfunction (defined as follows) is a common cause of anterior knee pain. The differential diagnosis of anterior knee pain is extensive and requires a thorough examination. The following are the most common knee diagnoses responsible for anterior knee pain.

A. Patellofemoral Overuse Syndrome

Patellofemoral overuse syndrome occurs during running and sports that involve repetitive stress in the lower extremity. The athlete presents with activity-related pain in the anterior knee. In young athletes, it is occasionally associated with swelling and crepitus of the knee joint.

Evaluation of these injuries is comprehensive and requires a “top-down” evaluation of the athlete’s leg from the hip to the foot. Most athletes with this condition, regardless of level or physical condition, typically have hip/core weakness that results in altered knee biomechanics. A comprehensive evaluation of hip alignment and rotation, muscle development, tightness in the hamstrings and iliotibial band, and foot mechanics is necessary to fully understand and treat the cause of this disorder. Most athletes with this complaint often have a multifactorial cause for their symptoms.

Treatment should be geared toward identifying the cause. Often, athletes are overtraining and need to modify current activities. Cross-training may help. Addressing hip and pelvic stability is now a mainstay of treatment for this disorder. Stretching and strengthening of the hamstrings and quadriceps are recommended. Use of braces providing proprioceptive feedback during competition is controversial.

B. Patellar Tendonitis (“Jumper’s Knee”)

This overuse injury is caused by repetitive loading of the quadriceps during running or jumping. This diagnosis is common in jumping sports such as basketball and volleyball. Tenderness is located directly over the patellar tendon at its insertion site at the inferior pole of the patella.

C. Osgood-Schlatter Disease (Tibial Tubercle Apophysitis)

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Activity-related anterior knee pain in adolescents.

image Swelling and pain over tibial tubercle.

image Progressive fragmentation of tibial tubercle apophysis.

This condition is caused by the recurrent traction on the tibial tubercle apophysis (growth plate) that occurs in jumping and running sports. Fragmentation and microfractures of the tibial tubercle occur during its time of rapid growth. The condition occurs in the preteen and adolescent years and is most common in boys aged 12–15 years and girls aged 11–13 years. Pain is localized to the tibial tubercle and is aggravated by activities using eccentric quadriceps muscle movement. The pain can become so severe that routine activity must be curtailed. Radiographs typically demonstrate fragmentation or irregular ossification of the tibial tubercle.

Typically the condition resolves spontaneously as the athlete reaches skeletal maturity. In the interim, pain control using NSAIDs is indicated. Physical therapy and stretching the hamstrings and application of ice after workouts are helpful.

D. Sinding-Larsen-Johansson Disease (Apophysitis of the Inferior Pole of the Patella)

This condition involves a process similar to that in Osgood-Schlatter disease but occurs in younger athletes between ages 9 and 12 years. Traction from the patellar tendon on the inferior pole of the patella results in fragmentation of the inferior patella that is often obvious on a lateral knee radiograph. Treatment and prognosis is similar to Osgood-Schlatter disease.

image Treatment

The treatment of the above knee disorder is similar. As with many injuries, control of pain and inflammation is essential. This begins with relative rest from offending activity and application of ice. Alignment problems and mechanics across the anterior knee can be improved with an effective rehabilitation program that includes flexibility and strengthening. Quadriceps, pelvic, and core strengthening are all important components of this program. Orthotics, in theory, can have an impact on mechanics across the knee joint if they correct excessive pronation or supination.

Knee bracing is controversial and the major benefits are proprioceptive feedback and patellar tracking. Return to activity is often based on symptoms.

2. Posterior Knee Pain

Posterior knee pain often results from an injury to the gastrocnemius-soleus complex caused by overuse. Other causes include a Baker cyst (benign synovial fluid filled cyst in the posterior aspect of the knee), tibial stress fracture, or tendonitis of the hamstring. Treatment is rest, ice, and strengthening exercises after symptoms have improved. Intra-articular injuries such as meniscal tears and cartilage injuries can also cause posterior knee pain and should be considered if symptoms do not improve.

3. Meniscal Injuries

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Medial or lateral knee pain.

image Effusion and joint line tenderness.

image Feeling of locking or of the knee giving way.

image Positive McMurray test.

The meniscus of the knee cushions forces in the knee joint, increases nutrient supply to the cartilage, and stabilizes the knee. Most injuries are related to directional changes on a weight-bearing extremity. Medial meniscus injurieshave a history of tibial rotation in a weight-bearing position. This injury happens frequently in ball-handling sports. Lateral meniscus injuries occur with tibial rotation with a flexed knee, as in exercises such as squatting or certain wrestling maneuvers. These injuries are uncommon in children younger than age 10 years.

image Clinical Findings

The athlete with such an injury has a history of knee pain, swelling, snapping, or locking and may report a feeling of the knee giving way. Physical examination often reveals effusion, joint line tenderness, and a positive McMurray hyperflexion-rotation test. The McMurray test is performed by having the examiner place his/her fingers across the joint lines while flexing the knee maximally. The knee is then rotated while it is brought out into extension. A positive test is evoked when the patient reports pain and the examiner feels an associated click or catch along the joint line. The diagnostic test of choice is MRI of the knee, although standard knee radiographs should be included. It is important to note that the increased vascularity of the meniscus in the pediatric population often causes increased signal changes on MRI that can be confused with a tear. Therefore, an MRI diagnosis of a meniscal tear in a young athlete needs to be correlated with the patient’s clinical symptoms and examination.

image Treatment

Treatment of these injuries is typically surgical because of the limited ability of the meniscus to heal without surgical intervention. Nonoperative management can be considered if the tear is minor and symptoms are minimal. Surgery can entail repairing the tear or removing the torn portion of the meniscus. Typically, every attempt is made to preserve the meniscal tissue in young athletes because of their favorable healing rates and the long-term concern over the development of arthritis in meniscal deficient patients. Meniscectomy (removal of torn tissue) patients can often return to sports 3–6 weeks after surgery. Meniscal repair patients require a period of 6 weeks of crutch protection followed by physical therapy. Return to sport after a repair is typically 3–4 months.

4. Medial & Lateral Collateral Ligament Injuries

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Pain on the medial or lateral portion of the knee.

image Tenderness along the ligament.

image Positive valgus stress test at 0 and 30 degrees.

The medial and lateral collateral ligaments are positioned along either side of the knee and act to stabilize the knee during varus and valgus stress. Medial injuries occur either with a blow to the lateral aspect of the knee, as seen in a football tackle, or with a noncontact rotational stress.

image Clinical Findings

The athlete may feel a pop or lose sensation along the medial aspect of the knee. The examination reveals a mild effusion and tenderness medially along the course of the ligament. A valgus stress test performed in 20–30 degrees of flexion reproduces pain and possibly instability.

Medial collateral ligament (MCL) injuries are graded on a scale of 1–3. Grade 1 injury represents a stretching injury. Grade 2 injury involves partial disruption of the ligament. Grade 3 injury is a complete disruption of the ligament. Radiographs are useful, especially in the skeletally immature athlete, to look for distal femoral or proximal tibial bone injury. MRI scans are used if grade 3 injury or concomitant intra-articular derangement is suspected.

image Treatment

Treatment is almost always conservative. Initial injuries should be iced and elevated. A protective brace is worn and full knee motion in the brace can be permitted within a few days. Weight bearing is allowed and a strengthening program can be started. The athlete should use the brace until pain and range of motion have improved. The use of a functional brace is often required when a player returns to competition. Bracing is temporary until the ligament heals completely and the athlete has no subjective feelings of instability. Return to sports is variable and is dependent on the severity of the tear and other associated injuries. Most isolated, low-grade MCL injuries can return to play in 3–5 weeks.

5. Anterior Cruciate Ligament Injuries

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Pain and effusion of the knee.

image Pain along the lateral joint line.

image Positive Lachman test.

The anterior cruciate ligament (ACL) consists of two bundles that prevent anterior subluxation and rotation of the tibia. Most ACL injuries are noncontact and occur with deceleration, twisting, and cutting motions. ACL injuries can also occur with knee hyperextension or from a direct blow to the knee—typically on the lateral side—which causes an extreme valgus stress with both ACL and MCL disruption.

image Clinical Findings

The athlete often reports hearing or feeling a “pop” followed by swelling that occurs within hours of the injury. Evaluation of the knee begins with examination of the uninjured knee. The Lachman test provides the most accurate information about knee stability in relation to the ACL. The Lachman test is performed by holding the knee in 30 degrees of flexion while supporting the tibia and femur. The tibia is pulled anteriorly, and the degree of excursion and the firmness of the endpoint are assessed and compared to the contralateral side. All other structures of the knee should be examined to rule out concomitant injuries. Imaging of the knee includes plain radiographs and an MRI scan. In skeletally immature athletes, a tibial spine avulsion is frequently seen on radiographs rather than a midsubstance ACL tear.

image Treatment

Initial treatment focuses on controlling swelling and pain. Structured physical therapy can be instituted early to assist in regaining range of motion and strength. Conservative treatment includes bracing, strengthening, and restricting physical activity. Knee braces enhance proprioception and control terminal extension. Conservative management can be complicated by continued instability and damage to meniscal cartilage.

Surgical reconstruction is typically indicated for young athletes in cutting sports and is also required for persistent instability. Surgery can be performed 2–6 weeks following the injury if the swelling and motion of the knee have improved. Recent advances in surgical treatment of the skeletally immature athlete have been helpful in dealing with the complicated management of young athletes with ACL tears. Rehabilitation of the knee starts immediately after surgery. A structured ACL physical therapy protocol is initiated with the goals of building strength, muscle reeducation, endurance, agility, and coordination. Return to cutting and pivoting sports can be achieved by 6 months after surgery if certain criteria are met.

6. Posterior Cruciate Ligament Injuries

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Pain and swelling of the knee.

image Increased pain with knee flexion.

image Positive posterior Drawer test.

The posterior cruciate ligament (PCL) runs from the medial femoral condyle to the posterior tibial plateau and has two bundles. Its main function is to prevent posterior tibial subluxation. Injury to the PCL is uncommon; it occurs when the individual falls on a flexed knee with the ankle in plantarflexion or with forced hyperflexion of the knee. The most common sports in which PCL injuries are sustained are football and hockey.

image Clinical Findings

The athlete presents with swelling and pain in the posterior and lateral knee. The examination begins with the uninjured knee and proceeds to the injured side. Confirmatory testing includes the posterior drawer test, performed with the patient supine, the knee flexed to 90 degrees, and the foot stabilized. Grading is based on the amount of translation. Grade 1 (mild) is up to 5 mm, grade 2 (moderate) is 5–10 mm, and grade 3 (severe) is more than 10 mm. Grade 3 injuries are typically indicative that another ligament is injured in addition to the PCL and should alert the provider to an associated injury. Diagnostic imaging includes plain radiographs and MRI scan.

image Treatment

Isolated PCL injuries are almost universally treated nonoperatively. The exception is bony avulsions of the PCL off the femur or tibia. Generally surgical fixation is recommended for these injuries. Ligamentous PCL injuries in isolation are remarkably well tolerated in athletes and can be treated with bracing and a progressive rehabilitation program. PCL injuries with injury to other structures are complex and often require surgical stabilization. Surgical stabilization of these injuries is complicated, and return to sports at the previous level is uncertain after combined injuries that involve the PCL.

Kyist J: Rehabilitation following anterior cruciate ligament injury: current recommendations for sports participation. Sports Med 2004;34:269 [PMID: 15049718].

Lord J, Winell JJ: Overuse injuries in pediatric athletes. Curr Opin Pediatr 2004;16:47–50 [PMID: 14758113].

Schub D, Saluan P: Anterior cruciate ligament injuries in the young athlete: evaluation and treatment. Sports Med Arthrosc Rev 2011;19:34–43 [PMID: 21293236].

FOOT & ANKLE INJURIES

Injuries in the lower leg, ankle, and foot are common in pediatric athletes. The types of injuries sustained typically depend on the age group. Young children tend to have diaphyseal injuries, in contrast to older children in rapid growth, who tend to have epiphyseal and apophyseal injuries. Skeletally mature adolescents are prone to adult-pattern ligamentous injury. Although fractures of the ankle are possible with inversion and eversion mechanisms, the most common acute injury involving the ankle is the lateral ankle sprain.

1. Ankle Sprain

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Mechanism is usually inversion and plantarflexion.

image Swelling and pain in the ankle over the ligament.

image Bruising over the ankle.

When a ligament is overloaded, tearing occurs. These injuries are graded on a scale of 1–3. Grade 1 injury is a stretch without instability; grade 2 is a partial tear with some instability; and grade 3 is a total disruption of the ligament with instability of the joint. The ankle has three lateral ligaments (anterior talofibular, calcaneofibular, and posterior talofibular) and a medial deltoid ligament. Inversion of the foot generally damages the anterior talofibular ligament, whereas eversion injures the deltoid ligament. Lateral ankle sprains are far more common than medial ankle sprains because the deltoid ligament is stronger mechanically than the lateral ligaments. However, medial ankle sprains may have more severe complications, including syndesmotic tearing and instability of the ankle joint requiring surgical stabilization. High ankle sprains involve injury to the tibiofibular syndesmosis, a movable connection in which the adjacent tibia and fibula bones are bound together by ligamentous structures. The syndesmosis supports the integrity of the ankle mortise joint. The ankle mortise is defined as the boney arc formed by the tibial plafond, the medial and lateral malleoli, and the roof of the talus. The mortise provides the wide range of flexibility and motion of the ankle, but its injury causes instability and pain. Syndesmotic injuries do not typically require surgery but do involve longer healing times than low-grade medial or lateral ankle sprains.

image Clinical Findings

Physical examination often reveals swelling, bruising, and pain. Diagnostic testing should be done when a bony injury is suspected. Obtaining radiographs is especially important when evaluating skeletally immature athletes who are more prone to growth plate injury. Medial ankle swelling, tenderness, and bruising warrant ankle three-view radiographs (AP, lateral, mortise) to evaluate asymmetry and instability of the ankle mortise.

The adult Ottawa Ankle Rules are used to determine whether obtaining x-rays are necessary and do not pertain to patients younger than 18 years. Tenderness over the malleoli, tenderness beyond ligament attachments, and excessive swelling are reasons to obtain radiographs in young athletes.

image Differential Diagnosis

Other injuries to consider include injuries to the fifth metatarsal, which can occur with an inversion mechanism. In this injury, the athlete presents with localized swelling and tenderness over the base of the fifth metatarsal. Fractures at the base of the fifth metatarsal can be divided into avulsion, Jones, and diaphyseal fractures. High-ankle sprains (a.k.a. syndesmotic injuries) occur most commonly with dorsiflexion and external rotation. Radiographs are required and the syndesmotic squeeze test is positive. Fractures of the tibial epiphysis, malleoli, fibula, talar dome, or calcaneus may also mimic ankle sprain.

image Treatment

Appropriate treatment of ligamentous ankle injuries is imperative to ensure full recovery and should begin immediately after the injury. Fractures and instability of the ankle mortise require immediate orthopedic surgical referral. Nonoperative management is typical of the vast majority of ankle sprains. Phase 1 care involves immediate compressive wrapping and icing to control swelling and inflammation. Protected weight bearing is encouraged as tolerated in the early phase of rehabilitation. Severe ankle sprains may benefit from a short period of treatment in a lower leg walking boot or cast. Phase 2 begins when the athlete can ambulate without pain. Supervised physical therapy prescription may be beneficial. During this time, ankle range of motion is emphasized, along with isometric contractions of the ankle dorsiflexors. Once 90% of strength has returned, active isotonic (eccentric and concentric exercises) and isokinetic exercises can be added. Phase 3 is designed to increase strength, improve proprioception, and add ballistic activity (more complex movement patterns), as well as sport-specific agility and function. The “foot alphabet” and “balance board” are excellent methods to improve ankle range of motion and proprioception. To restore range of motion, the patient is asked to actively move the ankle by drawing letters of the alphabet with the toes. To restore proprioception, the ability to maintain proper balance and control, balance exercises are performed on a balance board (or wobble board). This could also be done by having the patient stand on one leg while playing catch with a ball. This program can be effective in returning athletes to activity within a few weeks, although up to 6 weeks may be required for return to full activity. The athlete should wear a protective brace for 3–4 months, continue phase 3 home exercises, and ice after exercising.

2. Sever’s Disease

image ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES

image Activity-related heel pain in preadolescents.

image Pain localized to the calcaneal apophysis and Achilles insertion.

image Positive calcaneal squeeze test.

Sever’s disease, or calcaneal apophysitis, occurs in athletes aged 8–12 years who are typically involved in high-impact activities, such as gymnastics and soccer. Causes include overuse, improper footwear, and tightness in the calf musculature and Achilles tendon. Pain occurs about the heel and at the point of muscle tendon insertion onto the growth center of the calcaneus. The athlete presents with activity-related heel pain and examination reveals focal tenderness over the apophysis. Tenderness created by pressing forcefully on the lateral and medial heel constitutes a positive “calcaneal squeeze test.”

Treatment is symptomatic and consists of reassurance and education, relative rest, heel cord stretching, eccentric calf strengthening, ice massage, heel cups, NSAIDs for pain control, and progression to activity as tolerated based on pain level. Activity restriction is not required. Heel cups are rubber or gel infused shoe inserts that provide heel lift and cushion to decrease both tension and impact on the calcaneal apophysis. Refractory cases may benefit from brief immobilization and partial or non–weight bearing in a walking boot or cast followed by supervised physical therapy.

3. Plantar Fasciitis

Plantar fasciitis is a common problem that manifests as heel pain in the adolescent or older athlete. It typically occurs in runners who log more than 30 miles per week and in athletes who have tight Achilles tendons or wear poorly fitting shoes. It is also common in people with cavus feet and in those who are overweight. The pain is worse upon first standing up in the morning and taking a few steps. Differential diagnosis includes navicular or calcaneal stress fracture. A bone spur is often found on examination. Treatment involves local massage, stretching of the gastrocnemius-soleus-Achilles complex, NSAIDs, arch supports, and local steroid injections. Runners may need to cut back on their weekly mileage until these measures eliminate pain.

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PREVENTION

As in all activities, most sports-related injuries can be prevented by education, reducing dangerous behaviors, use of protective equipment, and proper training. Early recognition of injuries, treatment, and appropriate rehabilitation are also crucial to ensure safe sports participation. Protective equipment should be properly fitted and maintained by an individual with training and instruction. Helmets should be used in football, baseball, hockey, bicycling, skiing, in-line skating, skateboarding, or any sport with risk of head injury. Eye protection should be used in sports that have a high incidence of eye injuries. Proper protective padding should be identified and used, including chest pads for catchers; shin guards in soccer; shoulder, arm, chest, and leg padding in hockey; and wrist and elbow protectors in skating. Other primary prevention strategies should also be addressed by coaches, parents, and physicians in order to ensure the safety of children participating in sports. These include inspecting playing fields for potential hazards, adapting rules to the developmental level of the participants, and matching opponents equally in skill level and size.

The use of the preparticipation history and physical examination can identify potential problems and allow for prevention and early intervention. Proper training techniques reduce injuries by encouraging flexibility, promoting endurance, and teaching correct biomechanics. Sports education reinforces the concepts of fitness and a healthy lifestyle along with sport-specific training. Early identification of an injury allows the athlete to modify techniques and avoid micro- and macrotrauma. Once an injury has occurred, it needs to be identified properly and appropriate measures used to minimize morbidity. Rehabilitation of the injury starts as soon as it has been identified. Early and appropriate care offers the athlete an optimal chance for full recovery and return to full participation.

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