Injury Problems in Injury Problems in Children and Children and AdolescentsAdolescents

School of Health Care Professions, University of Salford

Steve Aspinall BSc (Hons) GSR

LecturerDirectorate of Sport

IntroductionIntroduction

• Sport has many benefits, including improved:Sport has many benefits, including improved:– physical fitnessphysical fitness

– co-ordinationco-ordination

– self disciplineself discipline

– team workteam work

– personal satisfaction and accomplishment.personal satisfaction and accomplishment.

But there is a negative But there is a negative side….side….

• However, as the popularity of organized However, as the popularity of organized sports activities for children and sports activities for children and adolescents has increased , so has the adolescents has increased , so has the injury risk.injury risk.

• Children and adolescents can be more Children and adolescents can be more susceptible to injuries as not only are susceptible to injuries as not only are they still growing but they are still they still growing but they are still developing motor and cognitive skills.developing motor and cognitive skills.

Differences in Bone and Differences in Bone and Soft Tissue Structure That Soft Tissue Structure That Can Result In Age Related Can Result In Age Related Soft Tissue Injury Soft Tissue Injury • BoneBone

– Growth Plate Pathology, junction between epiphyseal Growth Plate Pathology, junction between epiphyseal plate and the metaphysis is vulnerable to injury.plate and the metaphysis is vulnerable to injury.

– Tendon attachment sites(apophyses) relatively weak.Tendon attachment sites(apophyses) relatively weak.

– Hormonal ResponsivenessHormonal Responsiveness

• Muscle & TendonMuscle & Tendon– Decreased Relative Flexibility During Growth SpurtDecreased Relative Flexibility During Growth Spurt

• LigamentLigament– Greater Relative StrengthGreater Relative Strength

Overuse?Overuse?

• Overuse is the most prevalent sports Overuse is the most prevalent sports related injury mechanism.related injury mechanism.

• Sustained exercise imparts stresses and Sustained exercise imparts stresses and strains on the musculoskeletal system. strains on the musculoskeletal system. Although these are below macroscopic Although these are below macroscopic tissue failure they still result in microscopic tissue failure they still result in microscopic damage. If the rate of this repetitive damage. If the rate of this repetitive microtrauma exceeds the rate of healing microtrauma exceeds the rate of healing then an overuse injury occurs. then an overuse injury occurs.

Apart From Strains and Apart From Strains and Sprains, Sprains, What What OtherOther Injuries might we see?Injuries might we see?

• Acute FracturesAcute Fractures– Metaphyseal Fractures- Most common Metaphyseal Fractures- Most common

in the forearm and low leg. Often in the forearm and low leg. Often “Greenstick” or incomplete fractures as “Greenstick” or incomplete fractures as the long bones are more resilient and the long bones are more resilient and elastic. elastic. • If uncomplicated, heal relatively quickly, If uncomplicated, heal relatively quickly,

sometimes in only 3 weeks. sometimes in only 3 weeks.

– Growth Plate FracturesGrowth Plate Fractures• Of particular concern due to the risk of interruption Of particular concern due to the risk of interruption

to the growth process.to the growth process.

• Any doubt or concern of this injury then specialist Any doubt or concern of this injury then specialist orthopedic referral is mandatory orthopedic referral is mandatory

– Avulsion FracturesAvulsion Fractures• Occur at the attachment of ligaments or tendons to Occur at the attachment of ligaments or tendons to

bones where the tendon or ligament is pulled away bones where the tendon or ligament is pulled away with its apophyseal attachmentwith its apophyseal attachment

• Treatment involves reduction of pain and swelling, Treatment involves reduction of pain and swelling, restoration of ROM and eventually a progressive restoration of ROM and eventually a progressive conditioning program.conditioning program.

• Shoulder PainShoulder Pain– Fractures of the humerus, clavicle, acromion Fractures of the humerus, clavicle, acromion

or corocoid process caused by acute trauma.or corocoid process caused by acute trauma.

– Dislocations-More common in adolescents. Dislocations-More common in adolescents. Treat properly or reoccurrence will occur.Treat properly or reoccurrence will occur.

– Impingement-Usually secondary to atraumatic Impingement-Usually secondary to atraumatic instability caused by repetitive stress.instability caused by repetitive stress.

– Tendinopathy & Impingement-Frequently a Tendinopathy & Impingement-Frequently a combination of overuse, poor technique and combination of overuse, poor technique and muscular/biomechanical problems.muscular/biomechanical problems.

• Elbow PainElbow Pain– Repetitive stress in throwing sports and Repetitive stress in throwing sports and

gymnastics can lead to traction injury on the gymnastics can lead to traction injury on the medial aspect of the elbow and compression medial aspect of the elbow and compression injury on the lateral side. Unless dealt with, injury on the lateral side. Unless dealt with, can lead to bony thickening, loose body can lead to bony thickening, loose body formation, contractures and nerve injury.formation, contractures and nerve injury.

– Very important that young athletes have Very important that young athletes have adequate rest between training sessions and adequate rest between training sessions and are properly coached.are properly coached.

• Wrist painWrist pain– Acute wrist pain could be result of a fracture Acute wrist pain could be result of a fracture

with the scaphoid most commonly affected.with the scaphoid most commonly affected.

– Dorsal wrist pain-usually due to distal radial Dorsal wrist pain-usually due to distal radial or ulnar growth plate injury. Less common or ulnar growth plate injury. Less common causes include sprains and fractures. causes include sprains and fractures. Treatment generally involves relative rest, Treatment generally involves relative rest, splinting, modalities and NSAID’s.splinting, modalities and NSAID’s.

• Low Back PainLow Back Pain– Similar to those in mature adult.Similar to those in mature adult.

– Minor soft tissue injuries usually respond well Minor soft tissue injuries usually respond well to a reduction in activity.to a reduction in activity.

– Spondylolysis/listhesis- stress fractures from Spondylolysis/listhesis- stress fractures from repeated hyper extension in ballet, repeated hyper extension in ballet, gymnastics, volleyball, fast bowling in cricket gymnastics, volleyball, fast bowling in cricket and serving in tennis. In these cases, the and serving in tennis. In these cases, the amount of hyperextension must be reduced.amount of hyperextension must be reduced.

• Hip PainHip Pain– More common in the younger athlete than adultMore common in the younger athlete than adult

– Apophysitis-Excessive strain on one of the muscle Apophysitis-Excessive strain on one of the muscle attachments around the hip joint, usually the attachments around the hip joint, usually the attachment of rectus femoris, sartorius or the attachment of rectus femoris, sartorius or the iliopsoas attachment to the lesser trochanter. iliopsoas attachment to the lesser trochanter. Treatment involves a reduction in activity, modalities Treatment involves a reduction in activity, modalities as required and the correction of predisposing factors.as required and the correction of predisposing factors.

– Perthes disease-An osteochondrosis affecting the Perthes disease-An osteochondrosis affecting the femoral head. Most common in children between 4 femoral head. Most common in children between 4 and 10 years. Dependent upon severity, treatment will and 10 years. Dependent upon severity, treatment will range from rest to surgery. range from rest to surgery.

– Slipped femoral epiphysis- Usually in Slipped femoral epiphysis- Usually in adolescents, between the ages of 12 & adolescents, between the ages of 12 & 15 years. Most common presenting 15 years. Most common presenting symptom is a limp. Can be a matter of symptom is a limp. Can be a matter of considerable concern.considerable concern.

– Also “irritable hip” is common in Also “irritable hip” is common in children, presents with limp and poorly children, presents with limp and poorly localized pain but all tests are negative localized pain but all tests are negative and cause is not identified. Treated and cause is not identified. Treated with rest.with rest.

• Knee PainKnee Pain– Osgood-Schlatter disease-An osteochondritis Osgood-Schlatter disease-An osteochondritis

at the growth plate of the tibial tuberosity. at the growth plate of the tibial tuberosity. Common in adolescents at the time of the Common in adolescents at the time of the growth spurt. Associated with high levels of growth spurt. Associated with high levels of exercise, especially in sports involving lots of exercise, especially in sports involving lots of running and jumping. Self limiting, but can running and jumping. Self limiting, but can persist for up to 2 years. This should be persist for up to 2 years. This should be treated with activity modification, ice as treated with activity modification, ice as required and modification of predisposing required and modification of predisposing factors.factors.

– Sinding-Larsen-Johansson disease-Similar to Sinding-Larsen-Johansson disease-Similar to Osgood-Schlatter but less common and affects Osgood-Schlatter but less common and affects the inferior pole of the patella. the inferior pole of the patella.

• Foot PainFoot Pain– Severs Disease-Is a traction apophysitis Severs Disease-Is a traction apophysitis

of the insertion of the achilles tendon of the insertion of the achilles tendon into the calcaneous. Second most into the calcaneous. Second most common osteochondrosis after common osteochondrosis after Osgood-Schlatter disease with similar Osgood-Schlatter disease with similar treatment.treatment.

– There are also various other, relatively There are also various other, relatively uncommon, osteochondrosis affecting uncommon, osteochondrosis affecting the foot.the foot.

So What Are The Risk So What Are The Risk Factors?Factors?

• Training ErrorTraining Error– Abrupt increase in training:Abrupt increase in training:

• IntensityIntensity• DurationDuration• FrequencyFrequency• Inadequate warm-upInadequate warm-up• Improper techniqueImproper technique• Tired, injured, or inadequately rehabilitatedTired, injured, or inadequately rehabilitated

• Musculotendinous imbalanceMusculotendinous imbalance– StrengthStrength

– FlexibilityFlexibility

• Anatomical malalignment/intrinsic Anatomical malalignment/intrinsic structurestructure– Lumbar hyper lordosisLumbar hyper lordosis

– Lower limb length discrepancyLower limb length discrepancy

– Abnormal hip rotationAbnormal hip rotation

– Patellar malalignmentPatellar malalignment

– Genu varum/valgumGenu varum/valgum

– Planus/Cavus footPlanus/Cavus foot

• FootwearFootwear– Poor fitPoor fit

– Inadequate impact absorptionInadequate impact absorption

– Excessive sole stiffnessExcessive sole stiffness

– Insufficient hindfoot support/heel Insufficient hindfoot support/heel countercounter

– Arch supportArch support

– Excessive WearExcessive Wear

• Playing Surface CharacteristicsPlaying Surface Characteristics– Poor shock absorptionPoor shock absorption

• Hormonal statusHormonal status– Delayed menarcheDelayed menarche

– AmenorrheaAmenorrhea

• GrowthGrowth– Prepubescent porus bonePrepubescent porus bone

– Vulnerable growth cartilageVulnerable growth cartilage• Articular cartilageArticular cartilage

– Relative weakness of growth platesRelative weakness of growth plates

– Decrease in flexibility during growth Decrease in flexibility during growth spurtsspurts

– Abnormal developmentAbnormal development

• GeneralGeneral– Poor nutrition/hydrationPoor nutrition/hydration

– Psychological stressPsychological stress

– Poor fitnessPoor fitness

– Size/weight differences amongst same Size/weight differences amongst same ageage

– Inclement weatherInclement weather

• Some activity specific factorsSome activity specific factors– Hyper extension of lumbar spine (gymnastics, Hyper extension of lumbar spine (gymnastics,

dance, cricket, tennis)dance, cricket, tennis)

– Shoulder overuse (swimming, racket sports)Shoulder overuse (swimming, racket sports)

– Wrist/distal radius overuse (gymnastics)Wrist/distal radius overuse (gymnastics)

– Lower extremity (Running, jumping sports) Lower extremity (Running, jumping sports)

(Micheli et al 2000)(Micheli et al 2000)

SummarySummary

• Address the Risk factors including:Address the Risk factors including:– Screening as appropriateScreening as appropriate

– Fitness & conditioning (Inc strength, flexibility, Fitness & conditioning (Inc strength, flexibility, balance & psychological)balance & psychological)

– EnvironmentEnvironment

– Use of appropriate equipmentUse of appropriate equipment

– Enforce safety rulesEnforce safety rules

– Match & group children according to skill level, Match & group children according to skill level, weight and physical maturityweight and physical maturity