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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

2 Active Children? © Spire Healthcare

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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 © 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

6 Missed Diagnoses Missed or incorrect diagnosis can have long term serious consequences May adversely affect a childs development and thus their physical and sporting potential Important to understand tissue pathogenesis

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

8 Zone of Growth Metaphysis Physis Secondary ossification centre Apophysis (Traction Epiphysis) Ossicles (Osgood Schlatter lesion) Epiphysis (pressure epiphysis)

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)

10 Embryonic Development

11 Issues in Aetiology Injury is multi-factoral Sporting issues Physical issues Developmental issues

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*

13 Stages of Maturation Mid Growth Spurt 6.5 – 8.5 yrs Adolescent Spurt10 – 12 yrs (girls) Adolescent Spurt13 – 14 yrs (boys) Full Maturation~ 16 (girls) Full Maturation18 – 19 yrs (boys)

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

15 Classification of Injury Articular Epiphyseal Lesions eg. Perthes, Freibergs infraction Physeal or Growth Plate Injury Apophyseal Injuries eg. Severs, Osgood Schlatters

16 Diagnostic Pitfalls Achilles tendonitis Patella tendonitis Hamstring ischial insertion tendonitis

17 Injury related to maturation Severs 9 – 13 yrs Sinding Larsson Johansson (SLJ) 8-12 yrs Ischial apophysitis14 – 17 yrs Osgood SchlattersApophysitis9-13 yrs boys > Osgood SchlattersAvulsion yr

18 Injury related to maturation AIISApophysitis11-15 yrs boys > AIISAvulsion 14 – 15 yrs

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 Severs 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

21 Severs SAGITTAL MRIAXIAL MRI

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

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

24 Apophysis of the Tibial Tubercle At the tibial tubercle we see either an apophysitis- ie. Osgood Schlatters 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

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

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

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 Schlatters and more common in boys aged 10-14yrs X-ray can confirm avulsion

32 Sinding Larsson Johansson (SLJ)

33 SLJ

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 Schlatters 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

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 © Spire Healthcare

39 Avulsion #s Children are vulnerable during major growth spurts At this time AVOID – Heavy one sided bias – Ballistic training – High reps exs – 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. © Spire Healthcare

42 Posture Correction © Spire Healthcare

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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 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 The physiotherapy team have direct access to the results obtained from the hospitals 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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