Musculoskeletal Injuries in
Sporting Children and Adolescents
Malcolm Martin
Highly Specialist Physiotherapist
MSc, MCSP, MMACP, AACP
Gatwick Park Physiotherapy Department
Active Children?
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Introduction
• Low self confidence in paediatric clinical
skills reported among GPs and
Physiotherapists
• A need for teaching has been identified
• Spire Gatwick Park Physiotherapists are
now able to assess & treat 6yrs and above
• Competencies to treat this age group
required
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Childhood Injury Incidence
Up to 40% of sports
injuries presenting at
A&E in 5-14 age
range
The average peak age
for presentation
reported as 13yrs
Missed Diagnoses
• Missed or incorrect diagnosis can have long
term serious consequences
• May adversely affect a child’s development
and thus their physical and sporting
potential
• Important to understand tissue
pathogenesis
Outline
• Understand anatomy of immature skeleton
& physiology of growth tissues
• Revise common sports injuries in growing
children
• Outline appropriate treatment &
rehabilitation strategies and what advice
you could provide to children and their
parents
Zone of Growth
Metaphysis
Physis
Secondary
ossification
centre
Epiphysis
(pressure epiphysis)
Apophysis
(Traction
Epiphysis)
Ossicles
(Osgood Schlatter
lesion)
Zone of
Growth
Injury to Growth Tissue
• The majority of sporting injuries are related to
the zone of growth:
• Metaphysis
• Physis
• Epiphysis
–
–
Traction Epiphysis (site of tendon insertion) *
Pressure Epiphysis (cartilaginous block becomes joint surface)
Embryonic Development
Issues in Aetiology
Injury is multi-factoral
• Sporting issues
• Physical issues
• Developmental issues
Developmental Issues
Developmental Stages
• 1. Neonate – up to 4 wks of life
• 2. Infancy- up to 2 yrs
• 3. Early childhood -3-5 yrs
• 4. Late childhood 6-10 yrs*
• 5. Pre-Adolescence & Adolescence*
Stages of Maturation
• Mid Growth Spurt
6.5 – 8.5 yrs
• Adolescent Spurt
10 – 12 yrs (girls)
• Adolescent Spurt
13 – 14 yrs (boys)
• Full Maturation
~ 16 (girls)
• Full Maturation
18 – 19 yrs (boys)
Paediatric Musckuloskeletal
Tissue
• Children are not mini-adults
• The immature skeleton contains growth
tissue not present in the adult
• Growth tissues represent sites of weakness
particularly when metabolically active
• Peak injury rate is during growth spurt at
onset of adolescence
Classification of Injury
• Articular Epiphyseal Lesions eg.
Perthes, Freibergs infraction
• Physeal or Growth Plate Injury
• Apophyseal Injuries eg. Sever’s, Osgood
Schlatters
Diagnostic Pitfalls
• Achilles tendonitis
• Patella tendonitis
• Hamstring ischial insertion tendonitis
Injury related to maturation
• Severs
9 – 13 yrs
• Sinding Larsson Johansson (SLJ)
8-12 yrs
• Ischial apophysitis
14 – 17 yrs
• Osgood Schlatters
Apophysitis 9-13 yrs boys >
• Osgood Schlatters
Avulsion
14-17 yr
Injury related to
maturation
• AIIS
Apophysitis 11-15 yrs boys >
• AIIS
Avulsion
14 – 15 yrs
Principles of Treatment
• These are the same for apophysitis at all
sites!
• Avulsion injury – similar principles apply at
all sites
• Most can be treated conservatively
• A few require ORIF
Apophysitis of the Calcaneus
• Sever’s Disease: seen as an apophysitis
rarely as an avulsion. Classic overuse injury
often linked with biomechanical
abnormality; calcaneus valgus/varus
• Ossification site appears at age 8+,
normally fuses by age 14yrs
• Injury common in the age group: 9-13
boys> girls, as late as 17yrs in delayed
puberty
Severs
SAGITTAL MRI
AXIAL MRI
Signs & Symptoms
• Pain below the TA insertion and occurs
during sport often at its worst after sport
• Patient often limps and c/o pain on walking
• Swelling is absent or minimal
Treatment
• Easily diagnosed-X-ray usually normal or
whispy appearance of apophysis
• Mild cases – reduce training load,
orthotics/footwear/heel pad, address
biomechanical issues, ICE, NSAID
• Severe cases- 4-6 weeks rest with gradual
return to sport following sport specific
rehabilitation
Apophysis of the Tibial
Tubercle
• At the tibial tubercle we see either an
apophysitis- ie. Osgood Schlatter’s disease
or an avulsion fracture. The type of lesion is
maturation dependent
• The apophysis develops from several
ossification centres and ossification begins
at approx 9 yrs in girls and 11 yrs in boys
with fusion at 12-13 yrs in girls and 13-14
in boys
Osgood-Schlatter Disease
Osgood Schlatter Lesion
• Peak age is 12-14 yrs. More common in
boys
• Commonly an overload injury caused by
repetitive traction on the anterior portion of
the developing ossification centre of the
tibial tuberosity
Signs and Symptoms
• Local pain and or swelling/prominence of
tibial tubercle. May feel warm and will be
tender
• Often painful during sport and aches after
and on walking
• Kneeling & squatting often painful
• X-ray
–
–
can rule out # or tumour
Identify abnormal fragmentation of ossification centre
Treatment
• Rest proportion to severity. Most severe
immobilisation in long leg POP and PWB for
2-6 wks
• Gradual PRE expect hiccups with modified
training & technique
• Intractable cases may require ossicle
removal
Avulsion Tibial Tubercle
• Type I, II, III
• Type I with minimal displacement
conservation treatment – closed reduction
protected in long leg POP NWB for 3/52
• Commence gentle PRE but no resisted
quads work until 6/52
• Sports specific resistance at 12 weeks and
RTS at 4/12
Surgical Treatment
• In type II & III may prefer fixation with
pins, staples or screws
The Lower Patella Pole
• May present as an apophysitis aka Sinding
Larsson Johansson (SLJ)
• Similar history to Osgood Schlatter’s and
more common in boys aged 10-14yrs
• X-ray can confirm avulsion
Sinding Larsson
Johansson (SLJ)
SLJ
Signs & Symptoms
• Usually slow onset overuse traction injuryhistory of gradually deteriorating pain
initially after sport, then during and after
sport
• Pain localised to distal patella pole, patella
tendon at insertion and swollen in more
severe cases.
• Fat pads effused in more severe cases
• Difficulty kneeling, squatting
• Powerful or rapid knee extension provokes
• Stairs often painful, cannot sit x-legged
• Can usually walk without limping unless
avulsed
Treatment
• Conservative as per Osgood Schlatter’s
• Gradual return to sport after 3-6 weeks rest
when pain free to palpation. Can take 2-3
months in difficult cases
• Surgery = usually closed reduction
Management of Apophysitis
• Reduce inflammation
• Protect are & reduce mechanical stress eg
PWB, Orthotics, strapping
• Gradual return to sport following
appropriate rehab
• Prevention – footwear, orthotics,
equipment, flexibility advice
Soleus Stretch
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Avulsion #’s
• Children are vulnerable during major
growth spurts
• At this time AVOID
–
–
–
–
Heavy one sided bias
Ballistic training
High reps ex’s
Excessive explosive loading (e.g. sprinting)
Avulsion # Treatment
• Aim to allow # healing by promoting
optimum conditions and to prevent
complications
• Rest via early reduction of activity – bed
rest, POP/cast/strapping
• Conservative managment vs surgical
fixation
Daily Mail Mar 03 2014
• Children as young as seven are suffering back problems
due to poor posture and their lazy lifestyle, say experts.
• A new study of 154 10-year-olds also reveals up to 10
per cent of the child population may have already
triggered a time-bomb that will lead to bad backs in
adulthood.
• Experts claim that poor classroom seating and lugging
heavy school bags are major causes of back pain in
later life
• Hours spent watching TV and playing video games are
also believed to have contributed to the “epidemic of
poor posture”.
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Posture Correction
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Soleus Stretch
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Malcolm Martin Profile
Highly Specialist Physiotherapist MSc, MCSP, MMACP, AACP
•
•
•
Following service in the Armed Forces, Malcolm qualified as a chartered
physiotherapist in 1996 from Brunel University. He spent five years gaining a
wide range of experience in London teaching hospitals as well as working
full-time at Fulham football club treating and rehabilitating youth and senior
professional football players before arriving at Spire Gatwick Park Hospital in
2001.
He has completed a Masters degree in physiotherapy and has conducted
research into the effectiveness of physiotherapy and ergonomic
interventions to address changes to cervical postural.
Malcolm is a member of the Musculoskeletal Association of Chartered
Physiotherapists (MACP) as well as the Acupuncture Association of Chartered
Physiotherapists (AACP) and uses his specialised musculoskeletal skills
together with his knowledge of exercise rehabilitation and a western
approach to acupuncture to treat his patients at Spire Gatwick Park Hospital.
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Gatwick Park Physiotherapy Department
Why send your patients to us?
•
We are able to assess and treat adults and children from 6 years of age with
a wide range of musculoskeletal conditions using a wide range of treatment
modalities including e.g. acupuncture.
•
Our dynamic team of full and part-time physiotherapists have a wide range
of experience and post graduate expertise in managing adult and paediatric
musculoskeletal conditions, undertaking post-operative rehabilitation as well
as the management and treatment of respiratory disease and continence
and pelvic floor conditions.
•
We offer a wide range (08.00-19.30) of appointment availability including
early morning and evening appointments
•
No waiting list so minimal delay between referral and assessment is
guaranteed.
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•
The physiotherapy team have direct access to the results obtained from the
hospital’s on-site state of the art MRI and CT diagnostic scanning facilities
and have an excellent working relationship with a wide range of multidisciplinary team members including orthopaedic consultants and
radiography staff to ensure the optimal management of each patient
•
As well as providing assessment and treatment of a number of sport related
and non-sport related musculoskeletal conditions we can also provide advice
on correcting posture and biomechanical assessment for apparent gait
anomalies
•
We also provide free lunchtime GP practical training sessions
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