Pediatric overuse injuries in sports

Stress fractures of the hand and wrist in athletes

Stress fractures of the upper extremity are reported less often than their lower extremity counterpart. This review aims to provide a comprehensive overview of an important and often missed diagnosis in pediatric athletes: hand and wrist stress fractures.

Apophyseal injuries in soccer players

Soccer is the most popular sport worldwide, and it is associated with high injury rates, with most of these injuries occurring in the lower extremities. Particularly, in youth soccer players with immature skeleton, the physeal plate is two to five times weaker than the surrounding fibrous structures, and therefore more vulnerable to injury. The physeal plate consists of epiphyses and apophyses, with the former serving as tendon attachment sites and being subject to traction forces. There are two types of apophyseal injury: (i) apophyseal avulsion, which consists of an acute separation across the physeal plate; and (ii) apophysitis, an injury caused by chronic and repetitive contraction of musculotendon unit, leading to inflammation of the growth plate cartilage. Apophyses of the hip and pelvis are the most commonly injured in youth soccer players, due to vigorous contractions during sports activities and the fact that they tend to fuse later compared to other epiphyseal centers, making them more susceptible to injury. In this review, we will discuss the anatomy of lower limb apophyses and clinical and imaging findings of apophyseal injuries in youth soccer players, as well as briefly review treatment options and complications.

Focused extracorporeal shockwave therapy for youth sports-related apophyseal injuries: case series

BACKGROUND

Apophyseal overuse injuries are self-limited with skeletal maturity; however, they may be a source of significant pain and time lost from training. There is a lack of consensus for its management with the current available treatment, which might lag behind the ongoing development of regenerative medicine. The current retrospective case study aimed to assess the potential effectiveness and short-term safety of extracorporeal shockwave therapy (ESWT) in apophyseal injuries.

METHODS

Data from 22 growing athletes [15 patients with Osgood-Schlatter disease and seven patients with Sever's disease] who received ESWT at a sports medicine unit in a university hospital were reviewed. All patients received low energy (= 0.1 mJ/mm2) level-focused ESWT using electrohydraulic generation technology. The clinical focusing technique was used upon applying ESWT.

RESULTS

The number of sessions received to achieve full recovery ranged from 1 to 3 sessions. The time from treatment initiation to previous activity level was 2 weeks in 14 patients (63.3%), 4 weeks in seven patients (31.8%) and 11 weeks in one patient (4.5%). No adverse events were reported. No recurrence occurred up to 3 months after the last session.

CONCLUSION

ESWT is a potentially safe and effective treatment for apophyseal injuries. It may facilitate an early return to sport activities.

Characteristics of Pressure on the Apophysis in the Course of Paediatric Heel Pain-Preliminary Report

Increased pressure on the heel apophysis is often implicated as a cause of paediatric heel pain. However, there are few reports on the causes of the increased pressure and its origin. Therefore, the aim of this study was to analyse the distribution of pressure on the feet in children with heel pain. The study included 33 paediatric patients with non-traumatic heel pain, i.e., 24 boys (73%) and 9 girls (27%), aged on average 11.2 years (±3 years). Pedobarographic diagnostics proved a decrease in the pressure on the heels in relation to the ground and the transfer of the projection of the centre of gravity to the forefoot. While standing, the average contribution of the pressure on the heel was 0.52, SD = 0.14 in children with normal and reduced weight. In overweight children, the average pressure on the heel was higher (0.60, SD = 0.08), but the small number of children with this characteristic (n = 4) did not allow conclusions to be drawn in this area. Heel underload was also demonstrated during gait. However, the assessment of this aspect requires additional observational analyses in the field of propulsion and gait phases. The reduced pressure on the heel promotes apophysis traction, causing intracanal compression. Studies have shown that the causes of apophysis traction may be postural defects (in particular, forward inclination of body posture) and overpronation of the foot, or defects in the metatarsal area.

Comparison of pediatric performance athlete injuries presenting to emergency departments

OBJECTIVE

Pediatric injuries in performance sports represent a significant healthcare burden and account for over 50,000 annual Emergency Department (ED) visits in the United States. The objective of this study was to characterize and compare pediatric injury presentation across the most common performance sports.

METHODS

The National Electronic Injury Surveillance System (NEISS) database was retrospectively analyzed for pediatric injuries (3-18 years) related to gymnastics, dance, or cheerleading from 2015-2019. Cases were categorized as children (˂11 years) or adolescent (≥11 years). Injuries were categorized as orthopedic (fractures, dislocations, sprain, strains), non-orthopedic (contusion, internal injury, laceration), concussion, or other/unknown. Case narratives were used to categorize mechanism of injury as contact or non-contact. Appropriate sample NEISS weights estimation was applied for statistical analysis and Confidence Intervals (CI).

RESULTS

A total of 393,110 injuries were observed over the five-year study period, with a mean of 78,622 annual injuries. Gymnastics, dance, and cheerleading accounted for 136,422 injuries, 96,416 injuries, and 160,272 injuries, respectively. Most cases were adolescent (71%; 95% CI: 68-74%) and occurred in a sports-related setting (65%, 95% CI: 57-72%). Gymnastics had the highest proportion of injuries among children (50%) as compared to dancers (25%) or cheerleaders (12%) (p < 0.01). Non-contact injuries most affected the lower extremity (43-68%) and resulted in an orthopedic diagnosis (63-71%), and contact injuries had a higher proportion of injuries affecting the head, neck, and face (29-51%) and non-orthopedic diagnoses (29-38%). Gymnastics had the most upper extremity non-contact injuries (42%) and dance the most lower extremity non-contact injuries (68%) (p < 0.01). Cheerleading had the highest incidence of overall concussions (8%), contact injuries (47%), and concussions due to contact injury (15%).

CONCLUSION

Pediatric gymnasts, cheerleaders, and dancers have important similarities and differences in injury pattern which may lead to the development of sport-specific injury prevention programs for pediatric performance athletes.

Iselin Disease With a Rare Presentation in an Elderly Patient: A Case Report

We report the case of a 55-year-old female with a rare presentation and different pathophysiology of Iselin's disease. Iselin's disease is a rare condition caused by traction apophysitis of the peroneus brevis tendon at the base of the fifth metatarsal bone. It is usually a case in the adolescent age group due to their repetitive use of the peroneus tendon in daily activities, but not in the elderly group.  This type of apophysitis is rare and easily missed or misdiagnosed as a fracture in the base of the fifth metatarsal bone. However, a simple radiographic image can confirm the diagnosis. In this case, we aim to raise awareness of Iselin's disease for better comprehension of the clinical presentation, differential diagnosis, radiological features, management, and prognosis of Iselin's disease.

Applying the Principles of Motor Learning in Preventative Programs of Overuse Injuries in Young Athletes: A Scoping Review

This study aimed to review the scope of overuse injury prevention programs in young players through the lens of application of motor learning principles. From 280 studies found in the initial search, 13 studies were selected based on a series of inclusion criteria. The selected studies were categorized based on the type of intervention resulting in multicomponent (two studies), Fédération Internationale de Football Association 11+ (five studies), neuromuscular training (two studies), Fédération Internationale de Football Association Medical Assessment and Research Center (two studies), educational (one study), and stability (one study). The studies that had an effective preventative role to reduce overuse injuries applied some principles of motor learning to their intervention, such as contextual interference, variability of practice, task constraints, the power law of practice, transfer of learning, and explicit methods. There is a gap in the literature related to explicit applications of motor learning principles in the design of preventative interventions for overuse injury.

Incidence of calcaneal apophysitis (Sever's disease) and return-to-play in adolescent athletes of a German youth soccer academy: a retrospective study of 10 years

Background

Calcaneal apophysitis, or Sever's disease, is the most common cause of heel pain in childhood and adolescence. It is regarded as an overuse syndrome. Studies on the incidence of calcaneal apophysitis in young athletes and their associated return-to-play time are lacking in the current literature. The aim of our current study was to identify the incidence of calcaneal apophysitis in professional youth soccer, the associated time to return-to-play, predisposing factors and their impact on time to return-to-play.

Methods

Retrospective evaluation of injury data gathered from a German youth soccer academy in the years 2009–2018. In total, 4326 injury cases in 612 players were included in the study. The diagnosis and the follow-up visits were carried out in a weekly consultation hour at the youth academy.

Results

During the observation period of 10 years, 22 cases of calcaneal apophysitis were detected. The incidence of calcaneal apophysitis per 100 athletes per year was found to be 0.36. The mean age of the affected athletes at the time of diagnosis was 11.8 ± 2.1 years (MW ± SD). The complaints were unilateral in 20 and bilateral in two cases. Three of the 22 detected cases of calcaneal apophysitis (13.6%) were recurrent injuries. The mean time to return-to-play of the affected athletes was 60.7 ± 64.9 days (MW ± SD). Athletes with recurrent complaints showed longer recovery time and time to return-to-play when compared to players with primary diagnosed disease. Our results could show that neither age nor body mass index at the time of diagnosis had an impact on time to return-to-play.

Conclusions

This is the first study investigating the incidence of calcaneal apophysitis and the associated time to return-to-play in youth elite soccer. Calcaneal apophysitis results in substantial time loss for the athletes. Further prospective clinical studies are required to fully understand the etiology and risk factors for calcaneal apophysitis and therefore develop preventive strategies.

Common Pediatric Musculoskeletal Issues

This article reviews injuries encountered in active pediatric patients and discusses common presentations, diagnostic criteria, treatment modalities, and prevention. An emphasis is placed on overuse injuries, including a review of physeal and apophyseal injuries encountered in skeletally immature, active patients as well as back disorders often encountered in adolescents. This article is not meant to be comprehensive, but it offers directions for management of these patients in the outpatient primary care setting.

Symptomatic Venous Thromboembolism After Adolescent Knee Arthroscopy

BACKGROUND

The frequency of knee arthroscopy procedures is increasing in pediatric and adolescent patients. In general, complications after these procedures in adolescents are uncommon. The purposes of this study are to report the incidence of venous thromboembolism (VTE) in adolescent patients after knee arthroscopy procedures, as well identify risk factors in this patient population.

METHODS

Medical records were reviewed in all pediatric and adolescent patients (≤19 y) who underwent an arthroscopic knee procedure from 2010 to 2014 and were diagnosed with a symptomatic VTE in the postoperative period. Demographic features were recorded, and included age, sex, body mass index, clinical characteristics (diagnosis, type of surgical intervention, tourniquet time), VTE risk factors [family history of VTE, obesity (body mass index >30), oral contraceptive use, and smoking use/exposure] and treatment (anticoagulation type/duration).

RESULTS

Out of 2783 patients who underwent knee arthroscopy during the 5-year study period, 7 patients (3 males, 4 females, mean age, 16.9 y, range, 15 to 18) developed a symptomatic postoperative VTE (incidence, 0.25%, 95% confidence interval, 0.11%-0.54%). There were 6 unilateral deep venous thrombosis, and 1 bilateral deep venous thrombosis. Arthroscopic procedures performed in this cohort included anterior cruciate ligament reconstruction (3), isolated lateral release (1), meniscectomy (2), and patellar realignment with arthroscopic lateral release, open tibial tubercle osteotomy, and open proximal medial retinacular reefing (1). VTE was diagnosed an average of 9 days following surgery (range, 3 to 16). All patients were initially treated with low-molecular-weight heparin, and 2 were converted to warfarin. Mean duration of anticoagulation treatment was 64 days (range, 28 to 183). All patients had at least 1 identifiable medical or surgical risk factor, including oral contraceptive use (2), smoking (2), obesity (2), an arthroscopically assisted open procedure (4), or tourniquet time >60 minutes (3).

CONCLUSIONS

VTE after adolescent knee arthroscopy has not been well described. The incidence is ∼0.25%. Previously established risk factors for VTE were present in 100% of the affected population. Low-molecular-weight heparin was used to successfully treat this complication.

LEVEL OF EVIDENCE

Level IV.

Gymnast's wrist in a 12-year-old female with MRI correlation

We describe a case of chronic overuse injury of the distal radial physis (gymnast's wrist). While the radiographic appearance of this entity has been reported, there are limited studies highlighting the MR appearance of this entity. This lesion is being seen with increasing frequency in young, elite gymnasts. If this injury goes unrecognized, there is potential for abnormal osseous development, with premature physeal fusion, abnormal joint inclination and even Madelung deformity.

Balance and postural control in basketball players

Abstract Introduction: Basketball is one of the most popular sports involving gestures and movements that require single-leg based support. Dorsiflexion range of motion (DROM), balance and postural control may influence the performance of this sport. Objective: To compare and correlate measures of balance, postural control and ankle DROM between amateur basketball athletes and non-athletes. Methods: Cross-sectional study, composed by 122 subjects allocated into one control group (CG = 61) and one basketball group (BG = 61). These groups were subdivided into two other groups by age: 12-14 years and 15-18 years. The participants were all tested for postural balance with the Star Excursion Balance Test (SEBT), postural control with the Step-down test and DROM with the Weight-bearing lunge test (WBLT). Between-groups differences were compared using repeated-measures multivariate analysis of variance. Normalized reaching distances were analyzed and correlated with the WBLT and Step-down test. Results: There was no difference in the scores of WBLT (P = .488) and Step-down test (P =. 916) between the groups. Scores for the anterior reach (P = .001) and total score of SEBT (P = .030) were higher in BG. The values for the posterolateral (P = .001) and posteromedial reach (P = .001) of SEBT were higher in BG at the age of 15-18. The correlation between the anterior reach of the SEBT and WBLT was significant in BG between 12-14 years (r = 0.578, P = .008), and in the CG between 15-18 years (r = 0.608, P=.001). Conclusion: The balance was better in the BG, although adolescents between 15-18 years have better balance control for the posteromedial and posterolateral reaches of the SEBT.

The Pediatric International Knee Documentation Committee (Pedi-IKDC) Subjective Knee Evaluation Form: Normative Data

BACKGROUND

Children are participating in sports at an increasingly younger age, which has contributed to an increased incidence of knee injuries among this population. Because of increased interest in the application of patient-reported outcome measures in orthopaedic surgery to evaluate treatment results, numerous knee outcome scores, including the International Knee Documentation Committee Subjective Form (IKDC), have been used to evaluate the knee. Although the IKDC has been validated only in adults, it is also being used for children because of a lack of appropriate outcome scores in the pediatric population. To address this concern, a pediatric version of the IKDC (Pedi-IKDC) was developed and evaluated for reliability, validity, and responsiveness. However, normative data for the Pedi-IKDC have not been established.

PURPOSE

We aimed to aid the interpretation of Pedi-IKDC scores by characterizing normative data in children and adolescents and to validate the Pedi-IKDC by examining differences in scores among children who had a history of knee surgery or limited activity compared with those who did not.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

We conducted a cross-sectional survey of 2000 children and adolescents aged 10 to 18 years living in the United States, who were recruited by ORC International to obtain equal numbers of participants by sex and by integer age group. Participants were asked to complete the Pedi-IKDC for 1 study-designated "index" knee (right or left) and to provide demographic data and information on their knee surgery history and recent (4-week) activity limitations. Raw Pedi-IKDC total scores were rescaled to a 0 to 100 scale. We used nonparametric Wilcoxon or Kruskal-Wallis tests to compare subgroup scores, and we used the van Elteren test to adjust for age. Unadjusted and adjusted P values were similar, and only unadjusted values are reported.

RESULTS

The number of respondents (N = 2000) was uniform with respect to age and sex, with 11% in each age represented (10-18 years). Fifty percent of respondents were female. Forty-nine states plus Washington, DC, were represented. In addition, 68% and 86% of respondents identified themselves as white and non-Hispanic, respectively. Seven percent of respondents (n = 136) respondents reported having prior surgery in 1 or both knees; 4% of these surgeries (n = 79) were in the index knee. The Pedi-IKDC score distribution was skewed left (mean ± SD score, 86.7 ± 16.8; median, 94.6) and 34% of scores reached the ceiling value of 100. Participants who reported prior surgery or limited activity in the index knee had median Pedi-IKDC scores that were approximately 25 points lower than participants without these histories ( P < .0001 for both comparisons). In contrast, although it was statistically significant, the variation by age ( P = .02), race ( P = .02), ethnicity ( P = .01), and level of sports/exercise participation ( P = .04) was much smaller (all ranges of median scores <4.5). There were no significant differences in scores in terms of respondent sex or geographic region.

CONCLUSION

Normative Pedi-IKDC scores were determined in this study. The strong association between Pedi-IKDC scores and prior knee surgery as well as recent activity limitations in the index knee can be used to evaluate clinical outcomes and supports the construct validity of the Pedi-IKDC. There was a large ceiling effect, with 34% of scores at the maximum value of 100. The lack of a sex-based effect and the minor variation with age both simplify the interpretation and use of the Pedi-IKDC. Therefore, Pedi-IKDC score distributions can provide assumptions for use in sample size or power calculations for research.

Incidence of injury based on sports participation in high school athletes

OBJECTIVES

Youth participation in competitive athletics has significantly increased in the past two decades. There has also been a recent rise in the number of sports injuries that physicians are seeing in young athletes. The objective of this study was to assess the likelihood of sports injuries based on several risk factors in a general sample of athletes at a suburban-area high school.

METHODS

This was a cross-sectional study. An online survey was distributed to 2,200 student-athletes at a local high school with a mean age of 15.9 years. Four hundred eighty four (22%) complete responses were received. Data collected in the survey included demographics, frequency of sports participation, level of participation, types of sports played, participation in cross-training, injuries incurred, use of non-steroidal anti-inflammatory drugs, and treatment for sports injuries.

RESULTS

Athletes played an average of 1.6 different sports. The average number of hours of participation in sports annually was 504.3 ± 371.6 hours. The average total number of sports injuries experienced by athletes in our study was 1.7 per participant. 80.8% of respondents reported having sustained at least one sports injury. A higher total number of hours per year of sports participation and playing a contact sport were significantly associated with more reported lifetime sports injuries. Older age, playing a contact sport, and playing on a travel/club team were associated with students using NSAIDs for sports injuries. Older age, playing a contact sport, and doing cross training are also associated with having had surgery for a sports injury.

CONCLUSIONS

Although more hours of participation and playing a contact sport may lead to an increased number of injuries, this risk must be weighed against the myriad of benefits that sports provide for young athletes.

Imaging of physeal injury: overuse

Context:

As the intensity of youth participation in athletic activities continues to rise, the number of overuse injuries has also increased. A subset of overuse injuries involves the physis, which is extremely susceptible to injury. This paper aims to review the utility of the various imaging modalities in the diagnosis and management of physeal injuries in the skeletally immature population.

Evidence Acquisition:

A search for the keywords pediatric, physis, growth plate, x-ray, computed tomography, magnetic resonance imaging, and overuse injury was performed using the PubMed database. No limits were set for the years of publication. Articles were reviewed for relevance with an emphasis on the imaging of growth plate injuries.

Study Design:

Retrospective literature review.

Level of Evidence:

Level 4.

Results:

Three major imaging modalities (radiographs, computed tomography, and magnetic resonance imaging) complement each other in the evaluation of pediatric patients with overuse injuries. However, magnetic resonance imaging is the only modality that offers direct visualization of the physis, and it also offers the best soft tissue contrast for evaluating the other periarticular structures for concomitant injury.

Conclusion:

Imaging has an important role in the diagnosis of physeal injuries, and the information it provides has a tremendous impact on the subsequent management of these patients.

What is a sports injury?

Current sports injury reporting systems lack a common conceptual basis. We propose a conceptual foundation as a basis for the recording of health problems associated with participation in sports, based on the notion of impairment used by the World Health Organization. We provide definitions of sports impairment concepts to represent the perspectives of health services, the participants in sports and physical exercise themselves, and sports institutions. For each perspective, the duration of the causative event is used as the norm for separating concepts into those denoting impairment conditions sustained instantly and those developing gradually over time. Regarding sports impairment sustained in isolated events, 'sports injury' denotes the loss of bodily function or structure that is the object of observations in clinical examinations; 'sports trauma' is defined as an immediate sensation of pain, discomfort or loss of functioning that is the object of athlete self-evaluations; and 'sports incapacity' is the sidelining of an athlete because of a health evaluation made by a legitimate sports authority that is the object of time loss observations. Correspondingly, sports impairment caused by excessive bouts of physical exercise is denoted as 'sports disease' (overuse syndrome) when observed by health service professionals during clinical examinations, 'sports illness' when observed by the athlete in self-evaluations, and 'sports sickness' when recorded as time loss from sports participation by a sports body representative. We propose a concerted development effort in this area that takes advantage of concurrent ontology management resources and involves the international sporting community in building terminology systems that have broad relevance.

Traction apophysitis of the fifth metatarsal base in a child: Iselin's disease

Although Iselin's disease, apophysitis of the fifth metatarsal base, is not infrequent in clinical practice, it is accepted as a rare cause of lateral foot pain in young adolescents. Usually a simple clinical examination and radiographs are sufficient for diagnosis. We present a patient with Iselin's disease and discuss its clinical and radiographic characteristics, differential diagnosis, aetiopathogenesis and treatment.

The approach to elbow pain in the pediatric and adolescent throwing athlete

Elbow pain in pediatric throwing athletes can be very concerning and challenging to diagnose. Diagnosis involves determining whether the injury is chronic or acute in nature and the anatomical location of the pain. Physicians should be aware of the sport-specific forces that predispose athletes with immature skeletons to injury and should be familiar with the common presentations of these injuries. In order to narrow the diagnosis, physicians should gather a detailed history of how and when the pain occurred in addition to performing a thorough physical exam that includes tests, such as the modified milking maneuver and the moving valgus stress test. Appropriate imaging helps physicians to confirm the diagnosis and elucidates any associated pathology in patients. In most cases, the treatment given to patients is conservative and involves rest, ice, non-steroidal anti-inflammatory drugs for pain, and an appropriate physical therapy regimen with a progressive return to play when symptoms have resolved. When patients fail to respond to conservative treatment, surgical intervention may be needed. Knowing when to refer patients for orthopedic evaluation helps athletes return to play quickly and safely.

Mood disorders in youth: exercise, light therapy, and pharmacologic complementary and integrative approaches

The therapeutic value of physical exercise, bright light therapy and dawn simulation, and several pharmacologic treatments, including hypericum (St. John's wort), S-adenosylmethionine, and 5-hydroxytryptophan, are reviewed, with a focus on their use for treating major depressive disorder in children and adolescents and also for alleviating depressed mood in the general (nonclinical) population of youth. For each treatment discussed, all published randomized, double-blind, placebo-controlled trials are summarized, along with some additional selected studies. Nutritional psychopharmacology and several other approaches to treating depression will be presented in an upcoming volume in the Child and Adolescent Psychiatric Clinics of North America.