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“Growing Pains” Injury and Skeletal Immaturity Ken Knecht, PT, MS, SCS, CSCS.

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Presentation on theme: "“Growing Pains” Injury and Skeletal Immaturity Ken Knecht, PT, MS, SCS, CSCS."— Presentation transcript:

1 “Growing Pains” Injury and Skeletal Immaturity Ken Knecht, PT, MS, SCS, CSCS

2 Understanding the Population Children are not “Little Adults”

3 Understanding the Population “What’s the Difference?” “What’s the Difference?” Skeletal Maturity Skeletal Maturity Physiology Physiology Strength (and the Ability to Develop It) Strength (and the Ability to Develop It) Psychological Maturity Psychological Maturity

4 Understanding the Population “What’s the Difference?” “What’s the Difference?” Skeletal Maturity Skeletal Maturity Physiology Physiology Strength (and the Ability to Develop It) Strength (and the Ability to Develop It) Psychological Maturity Psychological Maturity

5 Growth & Development of the Young Athlete Middle Childhood (6-9 yrs) Middle Childhood (6-9 yrs) Maturation of Throwing and Kicking Patterns Maturation of Throwing and Kicking Patterns Entry Level Sports (soccer, baseball/softball) Entry Level Sports (soccer, baseball/softball) Males and females can still compete with parity Males and females can still compete with parity Males slightly Stronger; Girls better Balance Males slightly Stronger; Girls better Balance Running gait and speed are fairly equal Running gait and speed are fairly equal Late Childhood to Early Adolescence (10-15 yrs) Late Childhood to Early Adolescence (10-15 yrs) Onset of Puberty Onset of Puberty “Growth Spurt” – Tanner Stage 3 “Growth Spurt” – Tanner Stage 3 Differences emerge between sexes Differences emerge between sexes Skill Acquisition and Development Easiest Skill Acquisition and Development Easiest

6 Growth and Development of the Young Athlete Late Adolescence/Adulthood (16-20 yrs) Late Adolescence/Adulthood (16-20 yrs) Increases in Strength & Size become more gradual Increases in Strength & Size become more gradual “Late Bloomers” may continue to lag behind “Late Bloomers” may continue to lag behind Skeletal maturity Skeletal maturity

7 Growth and Development Anatomic Changes Associated with Puberty Anatomic Changes Associated with Puberty BoysGirls (Mean Age) BoysGirls (Mean Age) Peak Height Velocity (14 yrs) Peak Height Velocity (12 yrs) Skeletal Maturity (16 yrs) Skeletal Maturity (14 yrs) **Introduction of Sex hormones (Athl Ther Today 2002)

8 Growth and Development Significance of Peak Height Velocity Significance of Peak Height Velocity The “Growth Spurt” The “Growth Spurt” ~ Tanner Stage 3 ~ Tanner Stage 3 Bone growth rate can exceed soft tissue accommodation Bone growth rate can exceed soft tissue accommodation Hamstrings, Hip flexors, Quadriceps, and Plantarflexors Hamstrings, Hip flexors, Quadriceps, and Plantarflexors Decreased Coordination Decreased Coordination Tightness can affect growth centers Tightness can affect growth centers

9 Growth and Development  Significance of Tanner Staging  5 stages of Physical development  Stage 1 = Early Development  Stage 5 = Full Maturity  Correlation between Tanner stage and physeal closure.  Same Chronologic age ≠ Bone Age  Assists with the differential diagnoses

10 Growth and Development  Tanner Stage 5  Signals end of growth  Marked by full development of secondary sexual characteristics  Males will have full facial hair  Females will have final breast development

11 Skeletally Immature Distinctions Growth “Tissues” Growth “Tissues” Physis Physis Apophysis Apophysis Articular Cartilage Articular Cartilage Issues: Issues: Susceptibility to injury Susceptibility to injury Bone weakest link Bone weakest link Surgical Challenges Surgical Challenges

12 “Growth Tissue” Physis (Growth Plate) Physis (Growth Plate) Responsible for longitudinal growth of bone Responsible for longitudinal growth of bone Growth centers close distal to proximal Growth centers close distal to proximal Growth centers begin to close in females approximately 18 – 24 months following menarche Growth centers begin to close in females approximately 18 – 24 months following menarche Skeletal Maturity Completed Skeletal Maturity Completed ~18 yrs females;~21 yrs males ~18 yrs females;~21 yrs males Injury to Physis could create growth disturbance (early closure or bony bridging) Injury to Physis could create growth disturbance (early closure or bony bridging)

13 Anatomical Review

14 Salter-Harris Fractures Type I: Fracture line extends across the physeal plate. Often undetected on X-ray Type I: Fracture line extends across the physeal plate. Often undetected on X-ray Type II: Fracture line extends through the physeal plate and metaphysis Type II: Fracture line extends through the physeal plate and metaphysis Type III: Fracture line extends from the joint surface through the epiphysis and across the physis causing a portion of the epiphysis to become displaced Type III: Fracture line extends from the joint surface through the epiphysis and across the physis causing a portion of the epiphysis to become displaced Type IV: Fracture line extends from joint surface through the epiphysis, physeal plate and metaphysis causing a fracture fragment Type IV: Fracture line extends from joint surface through the epiphysis, physeal plate and metaphysis causing a fracture fragment Type V: Crush injury to the growth plate Type V: Crush injury to the growth plate

15 Salter Harris Fractures S eparated A bove L ower T hrough E R ammed

16 Salter Harris Fracture Distal Fibula Distal Fibula Usually an inversion/supination injury Usually an inversion/supination injury Type I-II are the most common Type I-II are the most common Type I often misdiagnosed as ankle sprain Type I often misdiagnosed as ankle sprain

17 Salter Harris Fracture Key Finding on Physical Exam: Key Finding on Physical Exam: Point of Maximal Tenderness Point of Maximal Tenderness Usually PTP at ATFL also Usually PTP at ATFL also

18 Salter Harris Fracture Boot immobilization (casting) Boot immobilization (casting) Depending on Type; 2-3 weeks + Depending on Type; 2-3 weeks + Types III & IV require surgery Types III & IV require surgery Pain free weight bearing status Pain free weight bearing status Rehabilitation for post immobilization Rehabilitation for post immobilization ROM, strength, balance & proprioception ROM, strength, balance & proprioception Sport specific training Sport specific training

19 Little League Shoulder Epiphysiolysis of proximal humerus Epiphysiolysis of proximal humerus Rotational forces Rotational forces Distractional forces Distractional forces Overuse injury associated with pitching Overuse injury associated with pitching Quantity Quantity Intensity Intensity Age Age

20 Phases of Throwing

21 Little League Shoulder Clinical Findings Clinical Findings Lateral, proximal shoulder pain Lateral, proximal shoulder pain Weak & painful EROT and Abd Weak & painful EROT and Abd Palpable tenderness over physis Palpable tenderness over physis Radiographic widening of physis? Radiographic widening of physis?

22 Little League Shoulder Treatment Aggressive rest to allow physeal healing Aggressive rest to allow physeal healing Address any ROM imbalances & Scapular dysfunction Address any ROM imbalances & Scapular dysfunction GIRD, posterior capsule GIRD, posterior capsule Sick Scapula Sick Scapula Scapular stabilization & strengthening Scapular stabilization & strengthening Rotator cuff strengthening Rotator cuff strengthening Review of throwing mechanics Review of throwing mechanics Return to throwing progression Return to throwing progression Modification of throwing volume (pitch counts) Modification of throwing volume (pitch counts) May need to alter position May need to alter position Address entire kinetic chain Address entire kinetic chain Core strengthening Core strengthening Lower extremity strength/flexibility and proprioception Lower extremity strength/flexibility and proprioception

23 “Growth Tissue” Apophysis Apophysis Cartilaginous structure usually located at the end of long bones Cartilaginous structure usually located at the end of long bones Attachment site for musculotendinous unit Attachment site for musculotendinous unit Tensile forces can create inflammation = Apophysitis Tensile forces can create inflammation = Apophysitis Susceptible to Avulsion Fracture Susceptible to Avulsion Fracture

24 Apophysitis Overuse injury Overuse injury Often during periods of rapid growth Often during periods of rapid growth May remain symptomatic until closure of apophysis May remain symptomatic until closure of apophysis Possible to result in an avulsion fracture Possible to result in an avulsion fracture

25 Sever’s Disease aka: Calcaneal Apophysitis aka: Calcaneal Apophysitis Common During Growth Spurt Common During Growth Spurt Heel pain Heel pain Tight gastroc/soleus Tight gastroc/soleus Foot pronation Foot pronation Running/jumping athletes Running/jumping athletes + Squeeze Test + Squeeze Test

26 Sever’s Disease Treatment Activity modification Activity modification Aggressive rest Aggressive rest Stretching!!! Stretching!!! Immobilization may be necessary Immobilization may be necessary Can continue to play if pain is mild (no limp) Can continue to play if pain is mild (no limp) Typically resolves in several weeks (months?) Typically resolves in several weeks (months?) Footwear or insert Footwear or insert

27 Osgood-Schlatter’s Disease (OSD) Apophysitis of the Tibial Tubercle Apophysitis of the Tibial Tubercle Traction Injury Traction Injury Commonly seen Commonly seen Boys aged 10 –15 Boys aged 10 –15 Girls aged 8 –13 Girls aged 8 –13

28 Osgood-Schlatter’s Disease (OSD) Palpable tenderness Palpable tenderness X-rays may be positive for displacement X-rays may be positive for displacement In severe cases tubercle can avulse In severe cases tubercle can avulse

29 Osgood-Schlatter’s Disease (OSD)

30 Sinding-Larsen-Johansson (SLJ) Apophysitis of the inferior patellar pole Apophysitis of the inferior patellar pole Anterior knee pain with impact activities Anterior knee pain with impact activities Commonly seen Commonly seen Boys aged 10 –15 Boys aged 10 –15 Girls aged 8 –13 Girls aged 8 –13

31 Sinding-Larsen-Johansson (SLJ) Palpable tenderness Palpable tenderness Inferior pole sometimes patellar tendon Inferior pole sometimes patellar tendon May have quadriceps lag May have quadriceps lag X-rays may be positive for displacement X-rays may be positive for displacement Differential diagnosis Differential diagnosis Patellar sleeve fracture Patellar sleeve fracture

32 Treatment for OSD and SLJ Activity modification Activity modification Stretching quads and hams Stretching quads and hams Strengthening progression Strengthening progression Plyometric training to work on soft landings Plyometric training to work on soft landings May not have complete resolution of symptoms May not have complete resolution of symptoms In OSD permanent bump is likely In OSD permanent bump is likely

33 Apophysitis of Hip/Pelvis 7 sites at the femur and pelvis 7 sites at the femur and pelvis During phase of rapid growth During phase of rapid growth Pain and inflammation at ossification centers Pain and inflammation at ossification centers Iliac crest (common) Iliac crest (common) Pain with resisted trunk rotation/side bend and/or hip abduction Pain with resisted trunk rotation/side bend and/or hip abduction Seen in Runners, Football, and occasionally Baseball pitchers Seen in Runners, Football, and occasionally Baseball pitchers

34 Apophysitis of Hip/Pelvis Treatment Treatment Rest Rest Activity modification Activity modification Trunk and pelvis flexibility Trunk and pelvis flexibility Core and hip strengthening Core and hip strengthening Treat the entire kinetic chain Treat the entire kinetic chain Technique adjustment Technique adjustment Running gait Running gait

35 Avulsion Fractures Same areas affected as apophysitis Same areas affected as apophysitis Occur with sudden, forceful contraction or stretching Occur with sudden, forceful contraction or stretching Bone is the weakest link Bone is the weakest link Common sites include ASIS and Ischial tuberosity. Common sites include ASIS and Ischial tuberosity. Often misdiagnosed as pulled muscle Often misdiagnosed as pulled muscle Radiographic evaluation necessary for accurate diagnosis Radiographic evaluation necessary for accurate diagnosis Surgery if displacement is greater than 2-3cm (???) Surgery if displacement is greater than 2-3cm (???)

36 Avulsion Fractures AIIS avulsion fracture in a 14 yr old soccer player AIIS avulsion fracture in a 14 yr old soccer player

37 Little League Elbow Traction apophysitis of Medial epicondyle of Humerus Traction apophysitis of Medial epicondyle of Humerus Overuse injury Overuse injury Volume Volume Velocity Velocity Increased mound to plate distance Increased mound to plate distance Breaking Pitches? Breaking Pitches? Valgus stress during late Valgus stress during latecocking/acceleration Flexor pronator muscle group Flexor pronator muscle group UCL? UCL? Clinical presentation Clinical presentation Medial elbow pain Medial elbow pain Diminished throwing speed and accuracy Diminished throwing speed and accuracy Poor or altered throwing mechanics Poor or altered throwing mechanics

38 Little League Elbow Treatment Treatment RICE: Make rest your friend RICE: Make rest your friend Activity modification 6-12 weeks Activity modification 6-12 weeks No pitching or overhand throwing No pitching or overhand throwing Stretching Stretching GIRD is Probable; Assess and address!!! GIRD is Probable; Assess and address!!! Strengthening Strengthening Forearm, posterior cuff, core, contralateral leg Forearm, posterior cuff, core, contralateral leg Assess throwing mechanics Assess throwing mechanics Functional progression to throwing program Functional progression to throwing program Identify and correct training errors Identify and correct training errors

39 “Growth Tissue” Articular Cartilage Articular Cartilage Infrastructure similar to Physis Infrastructure similar to Physis Increased Cellular activity Increased Cellular activity Not yet “Adult” solidity Not yet “Adult” solidity Repetitive Injury or Excessive shearing forces may result in Osteochondritis Dissecans (OCD) Repetitive Injury or Excessive shearing forces may result in Osteochondritis Dissecans (OCD)

40 Osteochondritis Dissecans (OCD) Impact and shear forces cause bone bruising Impact and shear forces cause bone bruising Cause is usually repetitive trauma Cause is usually repetitive trauma Genetic predisposition? Genetic predisposition? Subchondral bone death Subchondral bone death Secondary damage to overlying cartilage Secondary damage to overlying cartilage “Lesion of dissection” vs dessication “Lesion of dissection” vs dessication May affect any joint May affect any joint Most frequently seen at knee, elbow, ankle Most frequently seen at knee, elbow, ankle

41 Osteochondritis Dissecans (OCD) Risk Factors Risk Factors Age: Occurs most often in people between the ages of 9 and 18 Age: Occurs most often in people between the ages of 9 and 18 Sex: Males are 2-3X more likely than females. Sex: Males are 2-3X more likely than females. Sports participation: Sports that involve rapid changes in direction, jumping or repeated throwing may increase your risk Sports participation: Sports that involve rapid changes in direction, jumping or repeated throwing may increase your risk

42 Osteochondritis Dissecans (OCD) ICRS Classification of OCD ICRS Classification of OCD Grade I – Stable with continuous but softened area with intact cartilage Grade I – Stable with continuous but softened area with intact cartilage Grade II – Stable with partial discontinuity Grade II – Stable with partial discontinuity Grade III – In situ lesions with complete discontinuity Grade III – In situ lesions with complete discontinuity Grade IV – Empty defects with dislocated or loose fragments Grade IV – Empty defects with dislocated or loose fragments

43 Osteochondritis Dissecans (OCD) Epiphyseal microtrauma with osteochondral separation Epiphyseal microtrauma with osteochondral separation Commonly Lateral aspect of Medial femoral condyle Commonly Lateral aspect of Medial femoral condyle Etiology is multifactorial Etiology is multifactorial Trauma, ischemia, hereditary, idiopathic (?) Trauma, ischemia, hereditary, idiopathic (?) Under debate Under debate

44 Osteochondritis Dissecans (OCD)

45 OCD of Femoral Condyle Clinical presentation Clinical presentation Insidious onset of pain aggravated by activity Insidious onset of pain aggravated by activity Intermittent joint effusion Intermittent joint effusion Giving way, catching, or locking Giving way, catching, or locking Symptoms suggestive of PFPS Symptoms suggestive of PFPS Confirmed with diagnostic imaging Confirmed with diagnostic imaging

46 OCD of Femoral Condyle Conservative Management Conservative Management Immobilization Immobilization Weight bearing restriction Weight bearing restriction Activity restriction Activity restriction Surgical intervention Surgical intervention Extent depends on Grade Extent depends on Grade Debridement /drilling Debridement /drilling Refixation Refixation Loose body removal Loose body removal Operative resurfacing Operative resurfacing ACI ACI

47 Clinical Summary Bone weakest link in pre pubescent Bone weakest link in pre pubescent Same Chronological age ≠ Bone Age Same Chronological age ≠ Bone Age Tanner staging helps differential Tanner staging helps differential Protect Growth centers Protect Growth centers

48 THANK YOU!!!

49 Ken Knecht PT, MS, SCS, CSCS Board Certified Sports Clinical Specialist The Sports Medicine & Performance Center at CHOP Specialty Care Center at Virtua Health and Wellness Center, 2nd Floor 200 Bowman Drive, Suite D260 Voorhees, NJ ; Fax:


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