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Musculoskeletal Injuries in Sporting Children and Adolescents Malcolm Martin Highly Specialist Physiotherapist MSc, MCSP, MMACP, AACP Gatwick Park Physiotherapy.

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Presentation on theme: "Musculoskeletal Injuries in Sporting Children and Adolescents Malcolm Martin Highly Specialist Physiotherapist MSc, MCSP, MMACP, AACP Gatwick Park Physiotherapy."— Presentation transcript:

1 Musculoskeletal Injuries in Sporting Children and Adolescents Malcolm Martin Highly Specialist Physiotherapist MSc, MCSP, MMACP, AACP Gatwick Park Physiotherapy Department Introduce myself Following service in the Armed Forces, I qualified as a chartered physiotherapist in 1996 from Brunel University. I 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. It was managing MSK injuries sustained by the youth players at Fulham in particular which exposed me to unique injuries they can sustain. I have subsequently developed this interest with post graduate training (in musculoskeletal injuries in sporting children and adolescents) I completed a Masters degree in physiotherapy and has conducted research into the effectiveness of physiotherapy and ergonomic interventions to address changes to cervical postural.  I am a member of the Musculoskeletal Association of Chartered Physiotherapists (MACP) as well as the Acupuncture Association of Chartered Physiotherapists (AACP) and combine specialised musculoskeletal skills together with my knowledge of exercise rehabilitation and a western approach to acupuncture to treat his patients at Spire Gatwick Park Hospital.

2 Active Children? Whilst some children play lots of sport e.g. for club and school team all will take part in school PE. So perhaps we need to consider all children to be participants in some form of sport. And for different reasons, as we shall discover, some will be more prone to injury than others © Spire Healthcare

3 We also need to consider other predisposing factors in the development of MSK injury or illness.
Eg. Poor posture – my hobby horse. The potential importance of this will also be something I will touch on. © Spire Healthcare

4 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 I saw this as a good opportunity to plug the value of physiotherapy in the management of paediatric MSK conditions and GPH in particular as a place for you to refer children who you suspect of having MSK conditions which are unlikely to require a consultant opinion N.B. If less than 6 should be seen in an NHS paediatric dept . We are well placed at GPH to provide excellent MSK screening and treatment for children 6 yrs and older in view of our direct links with orthopaedic consultants such as Mr Bhat and MR and CT imaging and the fact that we are a team of physiotherapists with a wide range of experience and expertise With regard to competency to treat this age group we might also use the term confidence to treat this age group. Paediatric medicine is poorly covered if at all at undergraduate level in physiotherapy training programmes and I suspect in medical school. Physiotherapists gain competency largely from working with children in ie. Football academy, gymnastics club etc. as well as Post graduate courses A Competency framework has been developed at GPH to ensure that the treatment and management of children & adolescents is of the highest standard in all departments within the hospital. © Spire Healthcare

5 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 Injuries to sporting children are very common Up to 40% of sports injuries presenting to A&E are in the 5-14 yr age range (Maffuli N, Caine DJ 2005) The average peak age for presentation reported as 13yrs (Burt EY et al 2001)

6 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 For example, we need to be mindful that the early arrest of growth plate can lead to deformity It is therefore important that we understand the issues involved in injury pathogenesis It is important to appreciate that a child is not a mini adult The immature skeleton contains growth tissue that is not present in the adult Growth tissues represent sites of weakness particularly when they are metabolically active

7 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 As a parent myself I have realised that the health and welfare of one’s children become one of if not the most important drivers in your life There is a strong sense of wanting to do the right thing for my children and give them every opportunity Ironically this can subsequently lead to some of the very problems I am going to talk about in relationship to overuse Therefore, sometimes the parents of the child need the advice and education I hope to remind you why children develop certain age related conditions and will focus on some of the lower limb conditions you are more likely to see in practice

8 Zone of Growth Metaphysis Physis Secondary ossification centre
Epiphysis (pressure epiphysis) Zone of Growth Apophysis (Traction Epiphysis) Revision of long bones A number of interchangeable terms for the same anatomical feature makes this a bit confusing – at least for me! Metaphysis- Primary ossification centre ossifies within the shaft of long bones Physis or epiphyseal plate- a thicker zone of cartilage persists between the metaphysis and epiphysis = the growth plate Epiphysis– as the secondary ossific centre grows and fills the pressure epiphysis. A layer of specialised hyaline cartilage persists on the superior surface = the joint surface Traction Epiphysis is the cartilaginous plate at the tendon insertion. Also known as the apophysis Ossicles (Osgood Schlatter lesion)

9 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) By definition these injuries cannot occur in adults and it is thus important to understand their pathogenesis Unfortunately I wont have the time to explore the relevant developmental anatomy and subsequent aetiology in any great depth but I hope to provide you with some help with the assessment and management of this unique classification of conditions Today I will be concentrating on a small number of Apophyseal Injuries and more specifically Traction Epiphysis

10 Embryonic Development
Whistle stop overview. Bones are preformed in hyaline cartilage – converted into bone via osteogenesis spreading from an ossification centre Long bones have primary ossification centre in the shaft which develops in I-U life (by 8th week). Secondary centres are in the epiphyses which develop at specific ages after birth in different bones as we grow . Most epiphyses show one centre of ossification but some show multiple eg. the tibia and humerus The timing of ossific centre appearance can make certain bones prone to injury

11 Issues in Aetiology Injury is multi-factoral Sporting issues
Physical issues Developmental issues Sporting issues Coaches and trainers whilst enthusiastic sometimes will have limited understanding of developmental anatomy High expectation levels & pushy parents Inappropriate training schedules Age ‘banding’ School vs club pressures Lack of equipment Lack of pre-participation screening Physical issues Inappropriate morphology Limited flexibility Biomechanical issues Conditioning and fitness Developmental issues Change slide

12 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* This relates to the timing of growth spurts The focus today is on conditions which occur in late childhood (6-10yrs) and pre adolescence and adolescence The timing of ossific centre appearance can make certain bones prone to injury

13 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) Growth rate can vary widely 5 year spread

14 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 Unlike adult tissue, the weakest link is in the growth tissue. That’s where they get injuries and they are most vulnerable during growth spurts when ossific nuclei appear and become active. So we see certain injuries at specific chronological periods during development. So small children, late pubesant children and adults will often present with ligament injury but during growth spurts physes reported to be 2-5x weaker than contiguous fibrous tissue. However, musculo-tendinous injury often occurs at the time of peak height velocity during early and mid-pubescence when individuals are often tight and inflexible. = decrease load and increase mobility work Reminder Adolescent Spurt 10 – 12 yrs (girls) maturing earlier Adolescent Spurt 13 – 14 yrs (boys)

15 Classification of Injury
Articular Epiphyseal Lesions eg. Perthes, Freibergs infraction Physeal or Growth Plate Injury Apophyseal Injuries eg. Sever’s, Osgood Schlatters Articular Epiphyseal Lesions These do not appear to be sports related and include eg. Perthes, Freibergs infraction in the foot (Perthes= loss of b. supply to head of the femur -> dies, Freibergs infraction = osteochondritis of the metatarsal head – usually 2nd toe) Osteochondritis dessicans (Paget 1870) might also be considered an articular epiphyseal lesion Constitute 15% to 30% of all skeletal injuries in children mainly during adolescent growth spurt Physeal or Growth Plate Injury Salter Harris Physeal classification of injuries determined by x-ray findings Physeal injury twice as frequent in boys (peak 12 yrs) as girls (peak 11). Rare under 5 Thought Mr Bendall =/- Mr Bhat would be mentioning this Apophyseal Injuries will be the focus of this talk

16 Diagnostic Pitfalls Achilles tendonitis Patella tendonitis
Hamstring ischial insertion tendonitis This occurs when for example we assess and treat the child as an adult and use for example diagnostic terms like these to describe what we are seeing in the surgery

17 Injury related to maturation
Severs 9 – 13 yrs Sinding Larsson Johansson (SLJ) yrs Ischial apophysitis 14 – 17 yrs Osgood Schlatters Apophysitis 9-13 yrs boys > Osgood Schlatters Avulsion yr All of the above injuries are commonly seen and misdiagnosed as tendon injuries. N. B. The tendon during the above age ranges is far more robust than its insertion and the lesion is thus more likely to be an apophysitis or avulsion Severs vs Achilles tendonitis Sinding Larsson Johansson vs Patella tendonitis Osgood Schlatters Apophysitis vs Patella tendonitis Ischial apophysitis vs Hamstring ischial insertion tendonitis Ischial apophysistis tends to affect sprinters or happens when sprinting This is one example of a number of pelvic apophyses (think of all the muscles which attach to the pelvis!)

18 Injury related to maturation
AIIS Apophysitis yrs boys > AIIS Avulsion 14 – 15 yrs AIIS – rectus femoris - Kicking action ++, sprinting Apophysitis Adolescent growth spurt. > in boys ?sport related Avulsion > force >muscle power + body weight post adolescent growth spurt AIIS= Anterior inferior iliac spine

19 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

20 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 Biomechanics - Secondary to reduce dorsiflexion, Soleus muscle tightness, +/- sub talar joint stiffness, and occassional talo-crural joint stiffness if experienced previous history of ankle sprain Ossification site – therefore only see it at this age group and therefore need to be aware of its existance and need to be vigilent

21 Severs SAGITTAL mrI Axial MRI
7-year-old girl who presented with 4 weeks of heel pain and swelling. Lateral radiograph of ankle showed no abnormality Sagittal (B) and axial (C) fat-suppressed fast spin-echo T2-weighted images of calcaneum show bone marrow edema within physis (asterisk). Physis is minimally widened (arrows).

22 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 Weight bearing discomfort AM OW Palpation is primary source of diagnosis - location

23 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 Physio- address biomechanical issues, i.e. muscle inflexibility and any joint stiffness

24 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 yrs in girls and in boys

25 Osgood-Schlatter Disease
Osgood-Schlatter Disease. White arrow points to fragmentation of the tibial tubercle (tuberosity) with overlying soft tissue swelling. There is also oedema in the region of the infrapatellar bursa (Blue arrow)

26 Osgood Schlatter Lesion
Peak age is 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

27 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 Often localised Agg via powerful or rapid extension Differential diagnosis via active extension/SLR- If there is an avulsion they will not be able to extend the knee

28 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 Treat as per a # Therefore no ultrasound PRE= Progressive resistance exercise

29 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

30 Surgical Treatment In type II & III may prefer fixation with pins, staples or screws

31 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

32 Sinding Larsson Johansson (SLJ)

33 SLJ 16-year-old male runner with pain at inferior pole of patella. Sagittal gradient T2*-weighted image shows residual ossicle at inferior pole of patella (arrow). Increased signal intensity at proximal insertion of patellar tendon is seen (arrowheads). N.B. boys of 16 yrs who may seem like an adult are not fully skeletally mature!

34 Signs & Symptoms Usually slow onset overuse traction injury-history 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

35 Difficulty kneeling, squatting
Powerful or rapid knee extension provokes Stairs often painful, cannot sit x-legged Can usually walk without limping unless avulsed

36 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 Rest Graded return to sport

37 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

38 Soleus Stretch In my opinion this is probably the most important stretch of the lower limb but the least well known or attempted. If it is tight it is the primary limit to dorsiflexion. Adaptions to this reduction lead to increase in pronation at the sub-talar joint or mid foot if this is stiff. ? Effect in later life- ?hallux valbus, achilles tendonitis and over strain at the knee and hip + ? lsp © Spire Healthcare

39 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)

40 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

41 Daily Mail Mar Children as young as seven are suffering back problems due to poor posture and their lazy lifestyle, say experts. A new study of 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”. Dr. Francis Smith, a radiologist and sports medicine practitioner at Aberdeen Scotland's Woodland Hospital, conducted a posture study of year-olds which found 9 percent of the group had damaged spinal discs. Dr Francis Smith, who led the study, said: “We found degenerative changes in the spine much earlier than we ever would have suspected. This study revises our thoughts on when we should begin preventive back care. Proactive steps should begin early in life, even before puberty”. Read more: © Spire Healthcare

42 Posture Correction = Another reason why parents of children may consult you or me My Masters research has suggested to me that individuals need to be facilitated into understanding what is ideal posture, how to get there and provided with strategies to maintain it. Education and advice Ergonomic advice for home and school? © Spire Healthcare

43 Questions?

44 Soleus Stretch © Spire Healthcare

45 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. © Spire Healthcare

46 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 ( ) of appointment availability including early morning and evening appointments No waiting list so minimal delay between referral and assessment is guaranteed. © Spire Healthcare

47 We also provide free lunchtime GP practical training sessions
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 multi-disciplinary 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 © Spire Healthcare


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