++
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.
++
++
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.
+
Rice
SG; Council on Sports Medicine and Fitness, American Academy of Pediatrics: Medical conditions affecting sports participation. Pediatrics 2008;121(4):841–848
[PubMed: 18381550]
.
+
Selected Issues for the Adolescent Athlete and the Team Physician: A consensus statement. Med Sci Sports Exerc 2008 Nov;40(11):1997–2012
[PubMed: 19430330]
.
++
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.
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Symptoms appear after a traumatic blow causing sudden movement to the head.
Headache, dizziness, light or noise sensitivity, balance issues, fatigue, fogginess, and concentration difficulties are commonly present.
Focal neurologic symptoms should raise concern for acute intracranial process or bleed and prompt more immediate workup.
Efforts should be made to normalize activities of daily life as soon as possible by following the return to learn steps.
Return to contact sports should take place only after the patient is back to normal with no symptoms and has successfully completed the return to play protocol.
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Concussion is a complex process that occurs when a direct blow to the body or head translates forces into the brain, causing a transient alteration of neurologic function. 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 (SCAT5) and the Child-SCAT5 (ages 5–12 years), which also provide standardized patient handouts (available at: https://bjsm.bmj.com/content/51/11/851 and https://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097492childscat5.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.
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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.
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Among commonly used assessment tools are the SCAT5, 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.
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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.
+
Davis
GA
et al: The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5): background and rationale. Br J Sports Med 2017;51:859–861
[PubMed: 28446452]
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+
McCrory
P, Davis
G, Makdissi
M: Second impact syndrome or cerebral swelling after sporting head injury. Curr Sports Med Rep 2012;11:21–23
[PubMed: 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
[PubMed: 23479479]
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+
Randolph
C: Baseline neuropsychological testing in managing sport-related concussion: does it modify risk? Curr Sports Med Rep 2011;10(1):21–26
[PubMed: 21228656]
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+
Schatz
P, Moser
RS: Current issues in pediatric sports concussion. Clin Neuropsychol 2011:1–16
[PubMed: 21391151]
.
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2. Atlantoaxial Instability
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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 or who have neurologic symptoms with neck flexion or extension should be restricted from contact and collision activities, as well as any sport requiring excessive neck flexion or extension until evaluation by an orthopedic specialist.
+
Dimberg
EL: Management of common neurologic conditions in sports. Clin Sports Med 2005;24:637
[PubMed: 16004923]
.
+
Klenck
C, Gebke
K: Practical management: common medical problems in disabled athletes. Clin J Sport Med 2007;17(1):55–60
[PubMed: 17304008]
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+
Winell
J: Sports participation of children with Down syndrome. Orthop Clin North Am 2003;34:439
[PubMed: 12974493]
.
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3. Burners or Stingers
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
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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 neurologic 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 neck 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. Preventive 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.
+
Ahearn
BM, Starr
HM, Seiler
JG: Traumatic brachial plexopathy in athletes: current concepts for diagnosis and management of stingers. J Am Acad Orthop Surg 2019;27(18):677–684
[PubMed: 30741724]
.
+
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
[PubMed: 23314078]
.
+
Standaert
CJ, Herring
SA: Expert opinion and controversies in musculoskeletal and sports medicine: stingers. Arch Phys Med Rehabil 2009;90:402–406
[PubMed: 19254603]
.
++
As children have become more competitive in sports, spine injuries have become more common. Sports with a fairly high incidence of spine 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.
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
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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 scans 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.
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Bilateral pars interarticularis injury resulting in forward slippage of one vertebra over the one below it.
Usually presents as back pain with extension.
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%).
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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.
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Back pain worse with flexion and sitting.
Radiculopathy can be present.
Positive straight leg raise.
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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 disk herniation. EMG may also be considered in the presence of radiculopathy.
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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 or epidural steroid injection may be indicated. Surgery is recommended for patients who fail conservative therapy, have significant or progressive radiculopathy, or who have progressive neurologic deficit.
+
Kim
H, Green
D: Spondylolysis in the adolescent athlete. Curr Opinion Ped 2011;23:68–72
[PubMed: 21150440]
.
+
Lavelle
W
et al: Pediatric disk herniation. J Am Acad Orthop Surg 2011;19:649–656
[PubMed: 22052641]
.
+
Selected issues for the adolescent athlete and the team physician: a consensus statement. Med Sci Sports Exerc Nov 2008;40(11):1997–2012
[PubMed: 19430330]
.
++
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.
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1. Fracture of the Clavicle
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Injury by fall on to the shoulder or outstretched hand.
Severe pain in the shoulder.
Tenderness, swelling, and/or deformity over the 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.
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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 8–12 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.
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2. Acromioclavicular Separation
++
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Injury with fall on the shoulder.
Severe pain in the shoulder.
Tenderness, swelling, and/or deformity over the acromioclavicular joint.
++
A fall on the point of the shoulder is the most common cause of acromioclavicular (AC) 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.
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Treatment of low-grade AC injuries 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. More severe injuries may require surgical intervention.
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3. Fracture of the Humerus
++
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Injury with significant fall on outstretched arm.
Severe pain in the proximal humerus.
Tenderness, swelling, and/or deformity over the 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 and often a hanging arm cast to allow for gravity to reduce the fracture for 4–6 weeks followed by progressive rehabilitation with return to play at 8–12 weeks when bony healing, full range of motion, and strength have been achieved.
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4. Acute Traumatic Anterior Shoulder Instability (Anterior Shoulder Dislocation/Subluxation)
++
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Injury with an abducted and externally rotated arm.
Severe pain in the shoulder.
Squared-off shoulder on examination.
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. Return to play in-season can be considered with appropriate counseling and when rehabilitation has achieved full range of motion and strength. A brace is often used when an athlete returns to sport in season. Because of the high risk of recurrence in the adolescent population, options for treatment should be individualized, with consideration given to both nonoperative and surgical management.
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5. Rotator Cuff Injury
++
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Injury can be acute or chronic.
Pain is described as diffuse or anterior and lateral.
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, including traumatic tears, in children and adolescents are exceedingly rare. Most commonly, rotator cuff injuries are overuse injuries and 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.
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6. Little League Shoulder
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Participation in a throwing sport.
Pain with throwing.
Pain in the lateral aspect of the humerus.
Swelling around the shoulder.
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.
+
Brophy
RH, Marx
RG: The treatment of traumatic anterior instability of the shoulder: nonoperative and surgical treatment. Arthroscopy 2009;25:298–304
[PubMed: 19245994]
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+
Mariscalco
MW, Saluan
P: Upper extremity injuries in the adolescent athlete. Sports Med Arthrosc Rev 2011;19:17–26
[PubMed: 21293234]
.
++
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, Panner disease, 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.
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When the elbow is evaluated, it is helpful to divide the examination into specific anatomic areas, discussed as follows.
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1. Medial Epicondyle Apophysitis (Little League Elbow)
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Participation in a throwing sport.
Pain over the medial epicondyle, especially with pitching.
Tenderness and swelling of the 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 and 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 worsens 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.
++
++
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Participation in a throwing sport.
Pain over the lateral elbow.
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.
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3. Ulnar Collateral Ligament Tear
++
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Sudden forceful tensile stress on ligament from a fall or from valgus stress to elbow during overhead throw.
Feeling a pop or sensation of elbow giving out.
Medial elbow pain.
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.
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4. Osteochondritis Dissecans
++
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Participation in a throwing sport.
Pain over the lateral elbow, especially with pitching.
Tenderness over the radiocapitellar joint.
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 can then become involved. 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 stability of the lesion 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, impingement, fractures, triceps avulsions and tendinitis, olecranon apophysitis, and olecranon bursitis.
+
Gerbino
PG: Elbow disorders in throwing athletes. Orthop Clin North Am 2003;34:417
[PubMed: 12974491]
.
+
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
[PubMed: 15473676]
.
+++
HAND & WRIST INJURIES
++
The hand and wrist are the most common area of injury in children and account 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.
++
Gamekeeper’s or skier’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.
++
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 volar/dorsal angulation in the fourth or fifth metacarpals is acceptable. Assessment of displacement and rotational deformity by looking at the cascade of the fingers while the patient holds a loose fist 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.
++
Most swollen wrists without evidence of gross deformity or instability can be splinted temporarily for several days. Distal 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 area of the bone. Displacement requires operative management. Gymnast’s wrist is 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
[PubMed: 19202121]
.
+
Cornwall
R, Ricchetti
ET: Pediatric phalanx fractures: unique challenges and pitfalls. Clin Orthop Relat Res 2006 Apr;445:146–156
[PubMed: 16505727]
.
+
Mariscalco
MW, Saluan
P: Upper extremity injuries in the adolescent athlete. Sports Med Arthrosc Rev 2011;19(1):17–26
[PubMed: 21293234]
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+
Williams
AA, Lochner
HV: Pediatric hand and wrist injuries. Current Rev Musculoskeletal Med 2013;6:18–25
[PubMed: 23264097]
.
++
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.
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1. Hip Avulsion Fractures
++
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Fractures at apophyseal areas.
Pain with weight bearing.
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 usually conservative. Surgical management is reserved for significantly 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.
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2. Slipped Capital Femoral Epiphysis
++
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Pain in the hip or knee, or both.
Loss of internal rotation of the hip.
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 and is associated with obesity and some endocrinopathies such as hypothyroidism. 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 or, in unstable cases, they may not be able to bear weight. 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 surgical stabilization. Failure to identify this injury can increase the chance of avascular necrosis 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 an underlying anatomical abnormality 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 often present with deep anterior hip or groin pain that worsens with activity and is resistant to treatment. Radiographic imaging generally shows no acute findings but will outline the structural aberrancies that may have caused the labral tear over time. An MRI is used to demonstrate the tear. Treatment typically starts conservatively and requires rest and physical therapy. 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.
++
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.
++
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Mechanism is forced knee extension.
Pain with tearing or popping sensation in the posterior leg.
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 thigh. 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 to tamponade any further hematoma formation. 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.
++
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Usually produces posterior dislocation.
Leg is flexed, adducted, and internally rotated.
Hip pain is severe.
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 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 with inability to move or weight bear on the limb 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.
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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.
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9. Iliotibial Band Syndrome
++
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
++
Iliotibial (IT) band syndrome and associated trochanteric bursitis result when the bursa and IT band become inflamed because of repetitive friction from the underlying greater trochanter and lateral femoral condyle. This condition can cause pain when the hip or knee is flexed as a result of reduced flexibility of the IT 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. Pain is reproduced when the hip or knee is actively flexed from a fully extended position. Patients may also have a positive Ober test. The Ober test is used to measure flexibility of the IT band. The patient lies on his or her side with the affected leg on top. The examiner stabilizes the pelvis with one hand while the other hand moves the tested leg into knee flexion, hip abduction and extension and then lowers the leg into adduction until it stops via soft tissue stretch, posterior rotation of the pelvis, or both. The test is positive if the tested leg fails to adduct parallel to the table in a neutral position.
++
Initial treatment is to alter the offending activity and then start a stretching program geared at the IT 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.
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10. Femoral Neck Stress Fractures
++
Femoral neck stress fractures are generally the result of repetitive microtrauma. They commonly occur in running athletes who have rapidly 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 to the risk of stress fracture should be given to the female athlete with the triad of energy imbalance and possible disordered eating, amenorrhea or oligomenorrhea, and low bone density.
++
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 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 completion of the fracture or displacement and reduce the risk of avascular necrosis. A compression-sided fracture (on the inferior aspect of the femoral neck) is less likely to become displaced; treatment is conservative and involves a period of 6 weeks on crutches.
+
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
[PubMed: 21419965]
.
+
Kovacevic
D, Mariscalco
M, Goodwin
RC: Injuries about the hip in the adolescent athlete. Sports Med Arthrosc Rev 2011;19:64–74
[PubMed: 21293240]
.
++
Knee injuries are some of the most common sports-related problems. The knee is stabilized through a variety of ligaments, tendons, and 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.
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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.
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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 IT 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. The use of braces providing proprioceptive feedback during competition is controversial.
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B. Patellar Tendonitis (“Jumper’s Knee”)
++
Patellar tendonitis is an 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. Physical therapy, icing, and activity modification can help facilitate healing.
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C. Osgood-Schlatter Disease (Tibial Tubercle Apophysitis)
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Insidious onset of activity-related anterior knee pain in adolescents.
Swelling and pain over the tibial tubercle.
Progressive fragmentation of tibial tubercle apophysis.
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Osgood-Schlatter disease 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 pre-teen 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.
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D. Sinding-Larsen-Johansson Disease (Apophysitis of the Inferior Pole of the Patella)
++
Sinding-Larsen-Johansson disease 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.
++
The treatment of the above knee disorders 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.
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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.
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Medial or lateral knee pain.
Effusion and joint line tenderness.
Feeling of locking or of the knee giving way.
Positive McMurray, Apley, and Thessaly tests.
++
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 injuries have 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 10 years.
++
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, Apley test, and/or positive Thessaly 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 Apley test is performed by having the patient lie prone with the knee flexed to 90 degrees. The examiner applies an axial load on the knee and rotates the tibia at the same time. A positive test is evoked when the patient reports pain. The Thessaly test is performed by having the patient stand on the injured leg. The examiner supports the patient by holding his or her outstretched arms. The patient is instructed to flex the knee to 5 degrees and then rotate his or her body and knee internally and externally three times. This is repeated with the knee at 20 degrees of flexion. A test is positive if the patient has joint line pain or a sense of locking or catching in the knee. The diagnostic test of choice is MRI of the knee, although standard knee radiographs should be obtained initially. 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.
++
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 crutch protection followed by physical therapy. Return to sport after a repair is typically 4–6 months.
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4. Medial & Lateral Collateral Ligament Injuries
++
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Pain on the medial or lateral portion of the knee.
Tenderness along the ligament.
Positive valgus or varus stress test at 0 and 30 degrees.
++
The medial collateral ligament (MCL) and lateral collateral ligament (LCL) 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.
++
The athlete may feel a pop or pain sensation along the medial or lateral aspect of the knee. The examination reveals a mild effusion and tenderness medially or laterally along the course of the ligament. A valgus stress test performed in 20–30 degrees of flexion reproduces pain and possibly instability in MCL injuries. A varus stress test performed in 20–30 degrees of flexion reproduces pain and possible instability in LCL injuries.
++
MCL and LCL 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 2–3 injury or concomitant intra-articular derangement is suspected.
++
Treatment is generally 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.
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5. Anterior Cruciate Ligament Injuries
++
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
++
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.
++
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 proximal 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.
++
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 and articular 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 6–9 months after surgery if certain criteria are met, although many young athletes will need 12 months or more before they are ready to return to sports.
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6. Posterior Cruciate Ligament Injuries
++
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Pain and swelling of the knee.
Increased pain with knee flexion.
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.
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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.
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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.
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Francavilla
ML, Restrepo
R, Zamora
KW, Sarode
V, Swirsky
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D: Meniscal pathology in children: differences and similarities with the adult meniscus. Pediatr Radiol 2014;44:910–925
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Frank
JS, Gambacorta
PL: Anterior cruciate ligament injuries in the skeletally immature athlete: diagnosis and management. J Amer Acad Orthop Surg 2013;21:78–87.
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Kocher
MS, Shore
B, Nasreddine
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BE: Treatment of posterior cruciate ligament injuries in pediatric and adolescent patients. J Pediatr Orthop 2012;32:553–560
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Schub
D, Saluan
P: Anterior cruciate ligament injuries in the young athlete: evaluation and treatment. Sports Med Arthrosc Rev 2011;19:34–43
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FOOT & ANKLE INJURIES
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Injuries to 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.
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
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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 bony 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.
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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.
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The adult Ottawa Ankle Rules are used to determine whether obtaining x-rays are necessary and appear to be reliable in patients older than 5 years. Tenderness over the malleoli, tenderness beyond ligament attachments, and excessive swelling are additional reasons to obtain radiographs in young athletes.
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Differential Diagnosis
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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 and Kleiger test (external rotation of the foot in dorsiflexion) are positive. Fractures of the tibial epiphysis, malleoli, fibula, talar dome, or calcaneus may also mimic an ankle sprain.
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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.
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ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Activity-related heel pain in preadolescents.
Pain localized to the calcaneal apophysis and Achilles insertion.
Positive calcaneal squeeze test.
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Sever 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 calcaneal apophysis. Tenderness created by pressing forcefully on the lateral and medial heel constitutes a positive “calcaneal squeeze test.”
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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.
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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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Dowling
S
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Pontell
D, Hallivis
R, Dollard
MD: Sports injuries in the pediatric and adolescent foot and ankle: common overuse and acute presentations. Clin Podiatr Med Surg 2006;23:209–231
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Seah
R, Mani-Babu
S: Managing ankle sprains in primary care: what is best practice? A systematic review of the last 10 years of evidence. Br Med Bull 2011;97:105–135
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