1. title Bolton Wanderers Academy Jamie Miller - Physiotherapist

2. Overuse and other growth related injuries in the young and adolescent athlete Identification, management and prevention Jamie Miller (Academy Physiotherapist BSc Hons, CSP, HPC)

3. Aim of the Presentation To make all those who have direct contact with young athletes aware of the risk of overuse and growth-related injury To give the coaches an insight into specific injuries likely to occur Give some knowledge of how to manage and prevent these injuries

4. Academy History and System Established in 1998 Replaced the National Football School at Lilleshall To develop more high quality domestic players Includes boys of 9-19 years of age 9-16 Schoolboys 17-19 Scholars

5. BWFC Academy System U9-16’s train up-to 3 times a week and play up-to 1 game Matches every Sunday at other Academies across the North of England Regular tournaments and International competitions from the age of 9 Participation in Training Camps and Developmental Weekends

6. BWFC Academy Medical Provisions 2 Full-Time Physio’s 2 Full-Time Fitness and conditioning Coaches Part-Time Doctor 8 Part-Time Physio’s Podiatrist Chiropractor Dietition

7. Overuse Injuries What is an overuse injury? An injury that develops over a period of time due to too much repetitive activity The injury becomes worse if activity is continued It is the result of repetitive and unrepaired micro-trauma

8. Overuse Injuries Can occur at any age Young footballers are particularly vulnerable – because the body’s skeleton and tissues are still immature and developing – Nature and demands of the game Will hinder a player’s development Can be missed or ignored by coaches and parents!

9. Overuse Injuries TYPICAL ‘BUZZ WORDS’ ASSOCIATED TO OVERUSE INJURIES: Aching Painful after training Worse at night Gets worse when playing Inflammation Swelling Tender Stiffness No Direct Trauma Pain Discomfort Hurts to touch Missing Training Goes within hours/days

10. Overuse Injuries 4 MAIN CAUSES: LOAD (amount of playing/training) TECHNIQUE POSTURE (growth and development) EQUIPMENT (playing surface/footwear etc)

11. Overuse Injuries Recent Trends and Medical Insight Overuse injuries are increasing Intense training is starting at a younger age Much more physical activity for ‘gifted players’ Training must be adapted to a child’s development and age

12. Growth Spurts 10-15 years of age Vulnerable time for injury Immature bone structure is under immense pressure from mature muscles Muscle tissue matures more rapidly than skeletal bone tissue Growth plates of bones are subject to stress Bone grows faster than muscle, therefore muscles can become tight = reduced flexibility

13. The Growing Bone! 5 Specific areas of growth: Apophysis Diaphysis Articular Cartilage Epiphysis Metaphysis Articular Cartilage

14. The Growing Bone!

15. Fractures can occur in the young athlete due to the line of weakness between the epiphyseal plate and the formed bone, and the relative weakness of apophyseal cartilage compared with musculotendinous complex There are 3 types of fracture seen in the younger athlete: Metaphyseal fractures Growth plate fractures Avulsion fractures The Growing Bone!

16. Children and Exercise Physical Development A basic knowledge of skeletal growth and development is important in understanding the many aspects of performance and ability in sporting activity at different ages – it is also the key to appreciating many different injuries that occur in children

17. Growth Related Injuries in the Young Athlete It is during the early and adolescent years that the body’s muscles and bones develop and grow. During growth, the soft tissues are relatively stiffer and stronger than the bones, which are relatively soft and weak. Therefore, the young player is particularly vulnerable to injury during periods of growth

18. Children and Exercise Physical Development Children grow and develop physically at different rates and at varying ages Not only do they grow at different rates, but there are also changes in body proportions that can put limitations on their ability to perform The peak rate of growth occurs at age 12 in girls and age 14 in boys

19. Physical & Physiological Demands of a Young Player POWER PROPRIOCEPTION COORDINATION BALANCE AGILITY AEROBIC &ANAEROBC FITNESS ACCELERATION FLEXIBILITY ENDURANCE EXPLOSIVE POWER STRENGTH

20. Developmental ‘Windows of Opportunities’ AGE 6-9Peak speed velocity 7-11Agility, balance, co-ordination and speed 11-14Peak motor control velocity 14-17Peak aerobic velocity 15-17Peak speed velocity 16+Peak strength velocity

21. Developmental Windows of Opportunities The early foundation years are often overlooked by coaches and parents, and therefore the acquisition of knowledge and skills may be decreased. Therefore depending on child’s developmental levels, their lack of skills at a certain age may place them at risk of injury! This therefore needs to be address in their training!

22. Overtraining Overtraining and overuse injuries are directly related to training volume and intensity It can occur when there is an imbalance between exercise and recovery

23. Common Growth Related Injuries FOOT & ANKLE: Severs Disease KNEE & SHIN: Osgood Schlatters Disease Sinding-Larsen-Johansson Disease Shin Pain Chondromalacia Patella

24. HIP: Perthes’ Disease Slipped Capital Femoral Epiphysis (SCFE) BACK: Spondylolsis (Parr’s Fractures) Common Growth Related Injuries

25. Severs Disease Inflammation and damage of the achillies tendon attachment into the heel Typically seen in ages of 7-10 years Second most common osteochondrosis seen in the young athlete Presents at time of rapid growth Caused by an excessive traction pull on the bone

26. Severs Disease - Management This will always settle, usually within 6-12 months! Activity modification, until pain-free Heel-raise PRICE (on acute onsets) Stretching of calf muscles Looked at biomechanically Strengthening exercise for the ankle plantarflexors

27. Osgood Schlatters Disease Most commonly seen injury and may persist for up- to 2 years! Occurs at the patella tendon attachment into the growth plate on the tibial tuberosity of the knee Extremely common in the young athlete at the time of a growth spurt! Will be painful over the tibial tuberosity, which will be aggravated by exercise Caused by repeated excessive pull by the tighter quads on the immature bone structure

28. Osgood Schlatters: Osgood Schlatters Disease

29. Osgood Schlatters Disease - Management Activity modification (will help reduce pain) PRICE (for acute episodes of pain) Stretching of the quads and soft-tissue work Correction of biomechanical abnormalities Orthotics

30. Siding-Larsen-Johansson Disease Similar condition to Osgood Schlatters Affects the inferior pole of the patellar at the superior attachment of the patella tendon Multiple micro-trauma to patellar tendon insertions Much less common than Osgoods Schlatters Management is similar principles to that of Osgood Schlatters

31. Sinding-Larsen-Johansson:

32. Chondromalacia Patella Articular cartilage of the patella is eroded by excessive wear and tear at a young age

33. Perthes Disease Osteochondrosis affecting the femoral head Can present as a limp or ache in the groin, thigh or knee Usually only occurs on one side Typically affects children aged 4-10 May be associated with a delay in skeletal maturation

34. Perthes Disease - Management The condition usually resolves and return to sport is when the player is symptom-free. A long-term concern may be the development of osteoarthritis The age and severity of the condition will affect the management Rest from aggravating activities ROM exercises

35. Slipped Capital Femoral Epiphysis (SCFE) A SCFE may occur in older children, aged between 12-15 Occurs typically in overweight boys who tend to be late maturers The slip may occur suddenly, or most commonly gradually There is a widening of the growth plate and the vascular supply may become compromised This needs immediate surgical intervention!

36. SCFE :

38. Spondylolysis (Pars Fracture) Most troublesome and common type of back pain Stress fracture of the Pars Interarticularis (often referred to a Pars Fracture) Occurs because of continual hyperextension and rotation of the lumbar spine Generalised low back ache and leg pain Pain is aggravated by lumbar extension Common in young cricketers (bowlers)

39. Spondylolysis: Stress Fracture Spondylolysis (Pars Fracture)

40. Spondylolysis - Management Restrict athletic activity Stretching programmes Strengthening programmes There is not a set period of time, but when aggravating maneuvers are pain-free and there is no local tenderness, a gradual progression to the back full activity over 4-6 weeks should be started, with pain as a guide

41. Prevention Strategies Understanding: Coach, Parents, Player and Medical Team Avoid excessive, repetitive and monotonous exercises Use of proper technique, equipment and playing surface Monitor flexibility and growth rate Training sessions to fit to developmental age and skill base!

42. Our Prevention Strategies Biomechanical Screening Monitoring of flexibility and growth spurts Orthopaedic Assessment Growth prediction Conditioning work Educate players, coaches and parents and work closely with them

43. Take Home Messages and Conclusions! Be aware of overtraining and overuse injuries Keeping your ‘eyes and ears’ open is an important factor in recognizing an overuse injury. Potential problems can be minimised by early recognition and prompt action Be aware of developmental times of growing children and ‘Windows of Opportunity’ to maximize your sessions and reduce possible injury Sometimes ‘less is more’! Be aware off the tight, aching and stiff player who complains of no direct trauma

44. Be aware of ‘hot spot’ areas of the body: Back Hip Knee Heel Knowledge of the processes of growth and development will enable you to make more informed decisions about training sessions/programmes and procedures for children Take Home Messages and Conclusions!

45. THANKYOU!