The Young Athlete

• Where does long bone growth occur?

  at the epiphyseal growth plate
• Where do tendons attach to bone?

  the apophysis
• The epiphyseal plate is how much weaker than surrounding bone?

  2-5x weaker
• What percentage of childhood fractures occur at the epiphyseal plate?

  15-30%
• 4 differences between child and adult bones:

  • there is increased vulnerability at the epiphyseal plate
  • tendon/ligament attachment sites are weak, cartilaginous plates that are predisposed to avulsions
  • the metaphysis/diaphysis in children is more resilient than mature adult bones
  • during rapid growth periods, children’s bones grow faster than their muscles, causing their tendons to stretch
• Increased vulnerability at the epiphyseal plate:

  • due to shear, rotational, and/or compression forces
  • most resistant to tension
  • the periosteum is a major support system in this area
  • injury can be acute or due to repetitive impacts
  • common fractures = distal radius, distal/proximal humerus, distal femur/tibia/fibula
• Salter-Harris classification system:

  • type 1 = complete separation of the metaphysis and epiphyseal plate without bone fracture
  • type 2 = separation along epiphyseal plate that goes through a portion of the metaphysis (triangle shaped)
  • type 3 = intra-articular and extends from joint surface to the epiphyseal plate and extends along the plate to the periphery
  • type 4 = fracture from joint surface, through epiphyseal plate, and through a portion of the metaphysis, producing a complete split
  • type 5 = uncommon compression fracture
• Little League Shoulder

  • stress fracture
  • type 1 fracture
  • occurs at the proximal epiphyseal plate of the humerus in 11-16 year olds
  • due to tension and rotational force
  • pain is in dominant shoulder
  • treatment is abstinence from throwing for 4-6 weeks
  • healing occurs uniformly
• Slipped Capital Epiphysis:

  • femoral head stays in place
  • femoral neck slips upward
  • occurs in children 12-15
  • might be gradual or sudden
  • might see deceased hip abduction and internal rotation
  • might also see shortened leg and external rotation
  • this is a surgical emergency
• Tendon/ligament attachment sites are weak, cartilaginous plates that are predisposed to avulsions:

  • aka: apophysis
  • due to repetitive forces, increased FITT, and growth patterns
  • might see decreased tensile strength around puberty
  • might also see more muscle-tendon tightness during growth spurts
• Avulsions around the pelvis:

  • common sites include the ischial tuberosity, ASIS, and AIIS
  • due to running, kicking, or slipping
  • athlete hears a popping sound which is followed by pain
  • there could also be poorly localized pain around the groin for avulsion of the AIIS
  • might see pain on palpation (ex. the ASIS might displace inferior over the AIIS)
  • might feel pain with passive stretch or resisted flexion
• How do you manage avulsions of the pelvis?

  management:

  • ice it
  • support with a protected gate
  • go for imaging
  • maintain core stability
  • maintain static balance
  • maintain cardio
  • progress your ROM and strength
  • progress functional strength and power
• How long does it take for the ischial tuberosity to heal after an avulsion?

  3-4 months
• How long does it take the ASIS/AIIS to heal after an avulsion?

  6-8 weeks
• Metaphysis/diaphysis in children is more resilient than mature adult bones:

  • they withstand greater deflection without fracture
  • deflection = bone deforms but does not crack
  • children usually experience Greenstick fractures
  • Greanstick = incomplete fracture; occurs opposite to the bending force; it is a common wrist injury
• Greenstick fracture clinical cues:

  • may not experience typical pain
  • tender on palpation
  • bump or swelling from bent bone
  • decreased ROM or pain with weight-bearing activities
• How do we manage Greenstick fractures?

  management:

  • refer for x-ray
  • standard immobilization
  • heals quickly (3-4 weeks)
  • regain ROM
  • regain strength
• During periods of rapid growth, bone lengthens before muscles, causing tendons to stretch:

  • injury to apophysis is called: apophysitis
  • “itis” = inflammation
  • this is an over-use injury due to repetitive motion during periods of growth
  • minimal muscle-tendon injury
• Little League Elbow:

  • it is an apophysitis of the medial epicondyle
  • due to forces during cocking and early acceleration
  • may see medial elbow pain
  • may see a decrease in velocity/control of the ball
  • may see tenderness on the medial epicondyle
  • may see pain with wrist flexion and pronation
  • may see valgus stress
  • may see tenderness on lateral side
• How to manage Little League Elbow?

  management:

  • ice it
  • support or protect with a brace or splint
  • refer for imaging
  • complete local rest for 4-6 weeks
  • maintain lower body/core stability
  • begin a throwing program: start with long tosses, non-competitive pitches that focus on form and technique, and refrain from playing for 2-3 days if pain returns
• Osgood-Schlatter/Sinding-Larsen-Johansson:

  • due to continuous contraction/stretching of the quads
  • causes softening or partial avulsion of the apophysis
  • most common during growth spurts and high level activities

  Areas of causation:

  • OS occurs at the tibial tuberosity
  • SLJ occurs at the inferior pole of the patella

  What are they?

  OS =

  • over-use injury of the knee that causes painful bump and swelling on shin-bone
  • occurs at 8-13 for girls and 10-15 for boys

  SLJ =

  • pain at the bottom of the patella due to swelling or irritation of the epiphyseal plate
  • occurs in children 10-15
• What are the signs of and how to we manage OS and SLJ?

  signs:

  • tightness of surrounding muscles
  • excessive pronation

  management:

  • self-limiting conditions
  • activity modification
  • address imbalances
  • cryotherapy
• Sever’s Disease:

  • calcaneal apophysitis
  • aka: Achilles tendon
  • usually seen in boys 8-12 years of age
  • it is the second most common site for apophysitis (first = OS)
  • due to an increase in activity or during a growth spurt
  • seen in children with small gastrocnemius-soleus muscle complexes
• What are the signs of and management for Sever’s Disease?


  Signs:

  • tenderness over posterior aspect of the heel
  • decreased dorsiflexion ROM
  • over pronation in the heel

  Management:

  • similar principles as OS and SLJ
  • insert heel lift to decrease pain
  • stretch the plantar flexors
  • strengthen the plantar flexors
  • correct/manage over-pronation
• Bottom Line:

  • distinguish appropriate mechanisms of injury
  • take note of pain on palpation of epiphyseal plate
  • see if replication of stress causes an increase in plate pain
  • see if it requires immediate medical attention
  • take note of any pain with activity (especially after increasing FITT)
  • see if pain subsides with rest
  • check for any deformities of the bones
  • check for swelling
  • see if there is pain with regular palpation