1. Evaluation and Management of Sports Injuries in Children
Michelle Sirak, MD
Division Director
Pediatric Physical Medicine and Rehabilitation
Goryeb Children’s Hospital

2. Disclosure
None

3. Learning Objectives
Identify acute and chronic sports injuries in the child athlete
Evaluate and triage acute and chronic sports injuries
Discuss issues and concerns that are unique to the child athlete

4. Common Acute Sports Injuries
Bruises/Contusions
Injury after a fall or a bump
Swelling and inflammation of soft tissue, muscle, bone
Abrasion
Injury after a scrape
Injury to skin/cut
Basic first aid
Laceration
Tearing/breaking of skin
Medical Attention

5. Common Acute Sports Injuries
Sprain
Ligament
Bone to Bone
Overstretched/partially torn
Strain
Muscle
Irritation/Inflammation/P artial Tear with in Muscle
Ligament Tear
Dislocation
Bone moves out of joint
Fracture
Broken Bone
Growth Plate Injuries & Fractures

6. Evaluate Situation Safety Immobilize Talk to the child Once over
Cervical Spine
Limb
Talk to the child
Once over
Above and below suspected injury

7. Management - RICE {R} Rest {I} Ice {C} Compression {E} Elevation
Rest the injury
Encourage activity with uninjured parts
Alternate sports
{I} Ice
48 hrs
15 – 20 min on/45 – 60 min off
Ice after activity/end of day x several months until symptoms gone
{C} Compression
Bandage, taping, brace
Early
When weight bearing
{E} Elevation
Above the heart to prevent pooling and swelling
4 – 5 x/day while icing

8. Case 1
A 13 year old girl complains of "twisting" her left ankle while playing field hockey. She was running on the field towards the goal. She does not recall exactly in which direction her ankle twisted. She did not feel or hear any "snaps," "pops," or "clicks." She denies sustaining any other injuries and has not sustained any previous injury to her left ankle.
On exam she is able to bear some weight on the ankle but it is starting to swell and is painful. Distally, her toes are pink, with brisk capillary refill and intact sensation to light touch. Tenderness can be elicited by palpation over the anterior aspect of the ankle joint.

9. Lateral Ankle Sprain “Rolling over” the ankle
Stretch or tear of 1 or more ligaments in the ankle joint
Graded I, II, III based on severity

10. Evaluate Weight Bear Range of Motion Pulses & Capillary Refill
Anterior Draw >5mm
Talar Tilt >5-10 degrees

11. Evaluate
Higher Up the Leg
Syndesmosis Injury
Maisonneuve Fracture

12. Lateral Ankle Sprain RICE Crutches until weight bear without pain
Early Mobilization
X-ray?
Conservative
Physical Therapy
ROM, Strength, Pain Free activities
Grade 3 = Surgical

13. Case 2
A 15 year old boy complains of sharp pain in the back of his right leg. He was running towards the goal while playing soccer. He felt a “pop” and burning sensation in the leg at the time of the injury. It is worse when he tries to actively bend his knee and with walking.
On exam he is able to bear weight on his right leg. The back of his thigh is tender to palpation. Pain is elicited when trying to stretch the right leg and when actively bending the right knee against resistance.

14. Hamstring Strain
Forceful hamstring contraction (concentric) or knee extension (eccentric)
Stretch or tear of muscle or tendon
“pulled” muscle
Grade I strain – Grade III complete tear

15. Evaluate Swelling Bruising Tenderness to palpation over muscle belly
Pain when stretching the muscle
Pain with resisted contraction of the muscle

16. Hamstring Strain RICE Weight-bearing reduction if needed Imaging
Gentle Stretching
Strengthening
Thigh Wrap for support

17. Case 3
A 16 year old girl complains of sharp pain in the left knee. She was “cutting” to the left to avoid her opponent when she felt and heard a loud painful “pop” in her knee. Her knee immediately began to swell and feels stiff. When she tries to bear weight on her left leg she feels that the knee will give way.
On exam she has visible swelling of the left knee. There is tenderness along the joint line of the knee. She is unable to fully bend or straighten her knee.

18. Anterior Cruciate Ligament (ACL) Tear
Most commonly injured knee ligament in athletics
One of major ligaments in middle of the knee
Connects femur to tibia
Keeps the knee stable
Cutting, deceleration, hyperextension

19. ACL Tear Noncontact injuries most common
Contact injuries may involve other structures
MCL
Medial Meniscus
Increased
Female
Lax ligaments
Knock Knee

20. Evaluate Swelling Tenderness along the joint lines of the knee
Range of Motion
Anterior Drawer test

21. ACL Tear RICE Partial Weight Bearing Imaging Physical Therapy Surgery?
Goal complete rehab in 1 year

22. Case 4
A 14 year old boy presents to the emergency room having jammed his middle finger during a basketball game.
There is significant swelling at his PIP joint with displacement of his middle phalanx in relation to the proximal phalanx. He is unable to flex or extend his finger secondary to pain. Sensation on the medial and lateral border of the digit is intact with normal capillary refill.

23. Dislocation Moves out of joint Finger Immediate pain
Jammed force to end of joint
Twisting
Hyperextension
Immediate pain

24. Shoulder & Knee/Patella

25. Evaluate Deformity Unable to bend/straighten dislocated joint
SPLINT AS IS!!!

26. Finger Dislocation X-ray Realignment Splint/Buddy Tape 3 – 6 weeks
Fracture
Realignment
Splint/Buddy Tape 3 – 6 weeks
RICE
Occupational Therapy
Stretching/ROM
Strengthening

27. Case 5
A 17 year old girl slides into second base while playing softball and collides with the second baseman. She immediately hears a snap and feels pain in her leg.
She is unable to stand or weight bear on the leg and there is an obvious deformity of the lower leg. She has sensation throughout the leg but is unable to move the leg.

28. Fracture Broken Bone = Emergency Care EMS/9-1-1 Splint AS IS
Severe Pain
Hear/feel snap
Difficult to move/weight bear on injured part
Injured part moves unnaturally
Visible Deformity
EMS/9-1-1
Splint AS IS

29. Fracture Simple Comminuted Closed Open (Compound)
One fracture line, bone is broken into 2 pieces
Comminuted
More than one fracture line with more than 2 bone fragments at the fracture site
Closed
Skin in fracture area is not broken, break is not exposed to the outside
Open (Compound)
Skin over the fracture is broken, exposing the broken bone

30. Fracture

31. Growth Plate Injuries/Fractures
Where bone is growing
Weakest during growth spurt
Female 10 – 11 yo → 15 – 17 yo up to 3”/yr
Male yo → 16 – 17 yo up to 4”/yr
Cessation of growth
Limb length discrepancies

32. Acute Injuries Eye Injury Dental Emergency DENTIST
Cover with Paper Cup
Doctor/ED
Dental Emergency
Lost/Broken tooth
Sterile gauze moisten with saline/milk
Out from socket
Rinse with saline/milk
Place back in socket
DENTIST

33. Chronic Injuries Overuse Newer Phenomenon
Repetitive action with too much stress on musculoskeletal system without adequate recovery time
Newer Phenomenon
Used to play different sports/season
Now year round training

34. Causes of Overuse Injuries
#1Training Errors
Too much, too soon, too fast
Problem with equipment - growth
Environmental Conditions
Hot
Dehydration → muscle dehydrated = increase risk of injury
Cold
Decrease blood flow to muscle

35. Causes of Overuse Injuries
Poor Nutrition
Inadequate Hydration
Anatomic Misalignment
Knock kneed, bow legged, flat feet, high arches
Muscle Imbalance
Growth Spurt
Tighter muscles decrease flexibility
Prior Injury
Deconditioning or Out of Shape!

36. Shin Splints Microscopic tearing of muscle attaching to bone on shins
Pain, inflammation & irritation along leg
Repeated running on hard surface/hills
Tx:
RICE
Arch Support
Stretching
Strengthening
Decrease mileage

37. Osgood-Schlatter Disease
Pain at Tibial Tuberosity where tendon attaches from patella
Rapid growth 10 – 15 years old
Overuse
Tight quads, hamstring, calf muscles
Painful bump below knee

38. Osgood-Schlatter Disease
RICE
Pain Free Activities
Strengthening
Stretching
6 – 24 months from start of pain to resolve
Return when
Bump not painful
Pain free ROM
Jog, sprint, cut, jump pain free

39. Patellofemoral Pain Syndrome (Runner’s Knee)
Pain around/behind the kneecap
Walk, run, sit long period of time, downhill, downstairs
Intermittent knee swelling
RICE
Knee Brace/Shoe Orthotic
Physical Therapy
Strengthen VMO

40. Growth Plate Overuse Injuries
Little Leaguer’s Shoulder
Proximal Humeral Epiphysitis
Overuse of growth area of the humerus with widening of growth plate
Little Leaguer’s Elbow
Medial Apophysitis
Medial epicondyle pain
Muscles that bend the wrist attach to medial epicondyle

41. Stress Fracture Lower Body Injury without insufficient recovery
Shin
Foot
Toes
Injury without insufficient recovery
Avoid Impact
Boot to quicken healing
Back (Spondylolysis)
Fracture of pars interarticularis
Hyperextension
Twisting
Gymnastics, dancing, skating, football
Bracing 3 – 9 months PT

43. Prevention Re injury most common injury Proper warm up/stretching
Return to sport before sufficient healing and recovery is not complete
Increase risk of injury to adjacent body part
Proper warm up/stretching
Pace self, ease back into sport
Proper Equipment
Safe playing surface
Adequate adult supervision & safety
Prepare child for sport
training/conditioning

44. Prevention Trust Body Cues Listen to “I’m Tired” Rest Days
Pain/sore
Listen to “I’m Tired”
Rest Days
Vary intensity of the workout
Vary the type of physical activity
Hydration
8 oz. beyond thirst prior to game
4 – 8 oz. every min during activity

45. ? Concussion ? 18 yo Female falls off bicycle
17 yo Male falls off skateboard and lands on knees
16 yo Female hits head on metal bed frame
10 yo Male is hit in the head with
books when opening his locker

46. Does your management change if:
Feels totally fine
Is dizzy, but really wants to play because today is the final practice before decision is made on who makes the team
Feels fine, but on exam balance is terrible
Mom is standing right behind you giving you the stink eye

47. Concussion
May be caused by a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head

48. Biokinetics of Concussion
Acceleration-deceleration and rotational forces
Helmet?

49. Typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously
May result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance NOT a structural injury

50. Pathophysiology of Concussion
Brain obligate aerobic organ fueled by glucose delivered via blood circulation
Brain activity increases = blood flow to brain increases
Coupled relationship of oxygen and glucose

51. Consequences
Mismatch of metabolic supply and demand may = cell dysfunction, increased cell vulnerability to second traumatic insult/stress
Each insult need to consider if insult initiated above chemical cascade
No abnormality on STANDARD structural neuroimaging studies is seen
Newer imaging is showing evidence of injury
Functional MRI

53. Classification of Concussions
Consensus Statement Zurich 2012:
ABANDONED Simple vs. Complex & Grading terminology
Majority 80 – 90% resolve in a short (7 – 10 day) period
Recovery time frame may be LONGER in children and adolescents

54. Epidemiology 8.9% of all reported high school athletic injuries
F > M in similar sports
? F weaker neck muscles and smaller head mass?
? M more reluctant to report injury?
Football, F Soccer, M Lacrosse, M Soccer, F Basketball, Wrestling, F Lacrosse, Softball, M Basketball, M & F Volleyball, Baseball

55. Pre-season Baseline Testing
Standard Pre-participation Sports Physical
Concussion History including any head, face, or cervical spine injuries where concussions may have been missed
Identify athletes that fit into a high risk category = education/prevention opportunity
Neurocognitive Testing - baseline

56. “My cat’s OK I can play, I got my cat scanned”

57. Symptoms Immediate Sleep Disturbance Headache Dizziness Double Vision
Nausea
Light/Sound Sensitivity
Feeling Foggy
LOC
Amnesia
Behavioral Changes
Cognitive Impairment
Sleep Disturbance

58. On-field/Sideline Evaluations
Cervical Assessment on Field
Address first aid issues
Any Suspicion of concussion
REMOVE
NFL Docs “eye in the sky”
SCAT3 – rapid sideline screening
3_(2013).pdf
Serial monitoring for deterioration over next few hours

59. Management Physical and Cognitive REST until symptom RESOLUTION
Do NOT need to awaken throughout the night, observe for normal breathing pattern
“Cocoon Therapy” AKA a whole list of what you CANNOT do
VS.
Do what you can tolerate/does
not worsen symptoms
“fastest way to recovery and stop spending time
with me is to listen to your symptoms.
You cannot push through a concussion”

60. Management Wear sunglasses if photophobia
Sleep in a dark room as much as possible 2 – 3 days, then try to resume normal sleep/wake hours and nap 15 – 20 minutes
Gradually increase exposure to telephone, music, TV by 15 minute intervals as long as symptom free
Feeling better danger zone
Light Activity
Over Sleeping

61. Management: Medications
Avoid and let symptoms be your guide
Extreme headache Rx or OTC but avoid over use
Masking symptoms
Rebound headaches
Melatonin
Sleep
Headaches

62. School Considerations
Attendance
Visual Stimulus
Workload
Physical Exertion
Breaks
Audible Stimuli
Testing
Concussion Team at School?

63. Return to Play (RTP) Symptom free & off medication
Exception: antidepressants
Neurocognitive Testing
Objectively evaluate condition, track recovery
Measures symptoms, verbal & visual memory, processing speed, reaction time
Gradual RTP Protocol:
Proceed 1 level at a time if asymptomatic at current level
24 hrs per level = 1 week to proceed through full rehabilitation protocol
Any symptoms = drop down to asymptomatic level x 24hrs before proceeding
May stretch out RTP if < 13 years old

64. Pediatric & Adolescent Considerations
All recommendations are for ages 10 & up
Less than 10 years old, report symptoms differently
Need to include both child & parent input as well as teacher and school input when appropriate
Neuropsychological testing & Neuropsychologists may play a larger role for school planning/academics
Learning disabilities & ADHD
May take longer to symptom free = prolonged RTP
NO same day RTP
Cognitive rest may require absence from school or modified work load
HUGE STRESSOR!!!!!!!!

65. Prevention Helmets Do Not Prevent Concussions!
Helmets/Headgear
New bike helmet following impact
Football helmets reduce impact force to head but not concussion incidence
Soccer head gear unclear utility, heading can be performed safe? & avoidance does not prevent concussion
Headgear increasing head injuries: female lacrosse, soccer
EDUCATION
Athletes, Parents, Coaches, Athletic
Trainers, Physicians, Health Care Providers, etc.

66. Long Term Effects Chronic Traumatic Encephalopathy
Seen in 18-year old multisport athlete with a history of concussions from football upon autopsy
New football, soccer
3 or more concussions
Increased LOC, post-amnesia, confusion
8 – 16 yo persistent deficits in processing complex visual stimuli
Athletes with 2 or more concussions who are concussion free x 6 months performed similarly on NP testing as athletes with 1st concussion in last week
2 or more concussions lower GPA

67. Second-Impact Syndrome
Sustain an initial head injury then second injury before symptom free from first head injury
Cerebral vascular congestion → diffuse cerebral swelling → death
Pediatric & Adolescents at higher risk for rare condition
All reported cases are of athletes < 20 yo.
Catastrophic football head injuries 3x more likely in high school than in college athletes

68. Retirement From Sport
Consider when sustained 3 concussions in an individual season or more than 3 months of symptoms

70. These Parents are Cray

71. Returning Too Soon “But I CANNOT fall behind in school!”
“But she HAS to take those tests tomorrow!”
“But it’s a REALLY important game!”
“But I am kinda a BIG DEAL!”
“The coach is going to KILL me!”
“The coach is going to kick her off the team!”
“If he misses this season how can he become a professional _______ and I can retire?!?!”

73. Talking the Students and Parents off the Ledge:
If you are injured you are not going to perform your best
You are not going to be the best contribution for your team
You will take longer/not heal
It is easier to reinjure yourself
You are first a child then a student & athlete
Your health is most important
Believe it or not the world will go on!

74. References Kids & Sports by Eric Small, MD
Mild Traumatic Brain Injury in Children and Adolescents by Michael W. Kirkwood & Keith Owen Yeates
The Sports Medicine Patient Advisor Third Edition by Pierre Rouzier, MD
Consensus Statement on Concussion in Sport 4rd International Conference on Concussion in Sport Held in Zurich, November 2012
Physical Medicine and Rehabilitation Board Review
Sports-Related Cervical Spine Injuries: On-Field Assessment & Management
Effect of Amantadine on Post-Concussive Symptoms Poster Presentation
Clinical Report – Sport-Related Concussion in Children and Adolescents

75. Thank You!