Overuse injuries in children

Primary Periphyseal Stress Injuries of the Fingers in Adolescent Climbers: A Critical Review

ABSTRACT

The worldwide rise in popularity of climbing and development of climbing as a competitive sport is reflected by its debut at the 2021 Summer Olympic Games in Tokyo. Digital primary periphyseal stress injuries in adolescent climbers may pose a significant risk to long-term skeletal health. The aim of this article is to critically review research on the diagnosis and management of primary periphyseal stress injuries of the fingers in adolescent climbers. We adopted a systematic approach to searching for relevant literature. Articles were identified after searches of the following electronic databases: Discover, Academic Search Complete, PubMed, Embase, SPORTDiscus, and ScienceDirect. Conclusive evidence suggests digital primary periphyseal stress injuries are a consequence of repetitive microtrauma. Pain reported by adolescent climbers on the dorsal aspect of the proximal interphalangeal joint should be investigated promptly to avoid serious negative consequences. Clinicians should be aware of the efficacy of imaging techniques to inform a clinical diagnosis. A conservative management approach is preferred but in rare cases surgical intervention may be necessary. A diagnostic and therapeutic algorithm for digital primary periphyseal stress injuries is presented.

Inconsistencies and Imprecision in the Nomenclature Used to Describe Primary Periphyseal Stress Injuries: Towards a Better Understanding

Stress injuries involving the epiphyseal-physeal-metaphyseal complex affecting the extremities of child and adolescent athletes were first described in the early 1950s. Initially observed in Little League baseball players, these injuries are now known to affect skeletally immature athletes in a variety of sports that involve high-impact repetitive overuse activities. Collectively known as primary periphyseal stress injuries, they may affect the long bones around the shoulder, elbow, wrist, hand, hip, knee, ankle, and foot of young athletes. These injuries respond well to timely treatment and relative rest, while non-compliance with non-operative treatment can produce skeletal growth disruption and resultant limb deformity. A major concern raised from the existing literature on primary periphyseal stress injuries is the long history of inconsistent and imprecise terminology used to describe these injuries. A variety of terms have been used to describe primary periphyseal stress injuries, including those which potentially misinform regarding who may be affected by these injuries and the true nature and pathophysiologic mechanisms involved. These imprecisions and inconsistencies arise, at least in part, from a misunderstanding or incomplete understanding of the nature and mechanism of primary periphyseal stress injuries. In this article, we examine the inconsistent and imprecise nomenclature historically used to describe primary periphyseal stress injuries. We also offer a novel framework for understanding the pathophysiologic mechanisms behind these injuries, and provide suggestions for more standard use of terminology and further research moving forward.

Apophysitis Among Male Youth Soccer Players at an Elite Soccer Academy Over 7 Seasons

Background:

Apophyseal injuries are common in children and adolescent athletes. These injuries are believed to be caused by repetitive overloading, which can create inflammatory and degenerative conditions in growing bone prominences. However, their prevalence, diagnosis, and treatment in young soccer players have been understudied.

Purpose:

To evaluate characteristics of apophyseal injuries in adolescent athletes at an elite soccer academy.

Study Design:

Case series; Level of evidence, 4.

Methods:

All apophyseal injuries between July 2008 and June 2015 were evaluated. For each injury, the authors recorded the type and location, age of the player, injury date, imaging modalities, and time absent from training/competition.

Results:

Over the 7 seasons of this study, 210 apophyseal injuries were documented, including 172 simple apophyseal injuries and 38 apophyseal avulsion fractures. The rate of apophyseal injuries was 0.35 per 1000 hours of training exposure. A total of 196 (93.3%) cases were primary injuries, and the rest (6.7%) were reinjuries. Ultrasonography was the most commonly used imaging modality for diagnosis (172 cases; 81.9%). The most common location of apophyseal injuries was the anterior inferior iliac spine (AIIS). Return to sport was faster in athletes with apophyseal injury at the ischiopubic ramus, those with simple apophyseal injuries, and younger athletes.

Conclusion:

The most common location for apophyseal injury among soccer players was the AIIS. Return to training and competition differed according to injury location, type of apophyseal injury, and age.

Increased medial laxity of the elbow in preadolescent baseball players with or without medial elbow apophysitis

Background

Medial elbow apophysitis is a traction apophysitis observed in the medial epicondyle of the elbow in preadolescent baseball players. The purpose of this study was to determine the relationship between medial elbow apophysitis and elbow valgus instability in preadolescent baseball players.

Methods

The participants were classified into a control group and an injury group; the injury group included participants diagnosed with a medial elbow injury (inclusion criteria were only symptoms of the elbow joint or positive findings on physical examinations, or both). Elbow valgus instability was assessed by measuring the differences in ulnohumeral joint gapping width, with and without gravity stress induced by weight loading of the forearm using ultrasonography.

Results

The control and injury groups consisted of 81 and 23 preadolescent baseball players, respectively. In the throwing elbow, valgus instability in the injury group was significantly greater than that in the control group (1.07 vs. 0.57 mm, P = .001). In the non-throwing elbow, valgus instability in the injury group was significantly greater than that in the control group (0.57 vs. 0.37 mm, P = .011). The area under the curve for valgus instability of the throwing elbow was 0.89 mm (95% confidence interval, 0.64-0.77), and the cut-off value for elbow pain appearance was 0.80 mm.

Conclusion

The increased elbow valgus instability in the injury group was associated with a medial elbow injury. For the elbow valgus instability of the non-throwing side in the injury group, we considered that players with medial elbow apophysitis inherently have elbow laxity.

Primary Periphyseal Stress Injuries in Young Athletes: A Systematic Review

BACKGROUND

Overuse injuries are common in sporting children and adolescents. These injuries are a particular concern when they involve the epiphyseal-physeal-metaphyseal (EPM) complex given their potential to disturb skeletal growth. Specifically, the limits of mechanical tolerance of the EPM complex to repetitive stress may be exceeded by the intense and continuous training characteristic of many youth sports today.

OBJECTIVE

This article describes the present status of knowledge on the occurrence and outcome of primary periphyseal stress injuries (PPSIs) affecting the EPM complex in the extremities of children and adolescents involved in youth sports.

METHODS

A comprehensive review of the sports medicine literature was conducted to determine the nature and extent of PPSIs affecting the EPM complex of the extremities among youth sports participants and the potential for consequent skeletal growth disturbance and resultant limb deformity associated with these injuries.

RESULTS

Our initial search uncovered 128 original published scientific articles reporting relevant data on PPSIs. There were 101 case reports/series, 19 cross-sectional, 1 case-control, and 7 cohort studies with relevant data. The case reports/series studies reported 448 patients with PPSIs involving the extremities. Children and adolescents representing a variety of high impact repetitive youth sports activities-including baseball, badminton, climbing, cricket, dance, gymnastics, rugby, soccer, swimming, tennis, and volleyball-may sustain PPSIs involving the shoulder, elbow, hand and wrist, knee, and ankle and foot. Although incidence data from prospective cohort studies are lacking, data arising from cross-sectional studies suggest that PPSIs may be common in select groups of youth athletes-including the shoulder in baseball players (0-36.6%), wrist in gymnasts (10-83%) and platform divers (52.6%), and fingers in rock climbers (5-58%). Notably, not all stress-related skeletal changes detected on imaging were symptomatic in these studies. When diagnosed and treated with an appropriate period of rest and rehabilitation, most patients studied were able to return to their sport activities. However, our data also show that 57/448 PPSIs (12.7%) produced growth disturbance, and that 28/448 patients (6.2%) underwent surgery for their injuries. Absence of treatment, delayed presentation and diagnosis, and non-compliance with a rest regimen were common in cases that produced growth disturbance.

CONCLUSIONS

PPSIs may affect the extremities of children and adolescents engaged in a variety of youth sports, especially at advanced levels of training and competition. Most skeletally immature patients with PPSIs respond well to timely treatment; however, in extreme cases, PPSIs can progress to produce skeletal growth disruption which may necessitate surgical intervention. Clearly, establishing the early diagnosis of PPSIs and providing timely treatment of these injuries are needed to ensure the skeletal health of youth sports participants. Rigorous prospective longitudinal epidemiological and imaging studies designed to provide incidence rates of PPSIs and to determine the effect of PPSIs on long-term skeletal health are also necessary.

Imaging of Pediatric Lower Limb Sports Injuries

The importance of physical activity during childhood and adolescence has come to light, with an increase in sports-related acute traumatic and overuse injuries as a major disadvantage. A solid understanding of the physiology of the growing skeleton, together with knowledge about age- and sex-related differences in the occurrence of acute traumatic and overuse injuries is necessary. Every musculoskeletal radiologist should also be familiar with the appearances of these injuries on different imaging modalities. This review focuses on all these aspects concerning acute traumatic and overuse injuries among children and adolescents.

Sports-Related Injuries of the Pediatric Musculoskeleton

Worldwide, more than 50 million children and adolescents participate in organized athletic programs annually. Despite the numerous health and well-being benefits, this widespread involvement also leads to acute and overuse injuries that account for millions of medical visits each year. Musculoskeletal injury in childhood may lead to growth disturbance and lifelong disability. Imaging plays a critical role in the diagnosis and management of these injuries. While radiography is sufficient for most long bone fractures, MRI is often necessary for optimal evaluation of injuries involving the radiolucent growth mechanism and articular structures. The following review will discuss the imaging features associated with many sports-related injuries unique to the pediatric musculoskeleton, specifically the lower extremity.

Clinics in diagnostic imaging (202). Osgood-Schlatter disease (OSD)

A 14-year-old boy presented with left anterior knee pain, which was aggravated by exercise and relieved by rest. On clinical examination, there was tenderness at the tibial tuberosity with reproducible pain on resisted active extension of the knee. Radiographs showed heterotopic ossification of the patellar tendon with irregularity and fragmentation of the tibial tubercle. Clinical and radiological findings were consistent with Osgood-Schlatter disease, which is a traction apophysitis of the tibial tubercle commonly occurring in adolescents. The clinical presentation and imaging features are discussed.

Damage of the distal radial physis in young gymnasts: can three-dimensional assessment of physeal volume on MRI serve as a biomarker?

Objective

To explore the use of quantitative volume assessment to identify the presence and extent of stress-related changes of the distal radial physis in gymnasts with suspected physeal injury, asymptomatic gymnasts, and non-gymnasts.

Methods

Symptomatic gymnasts with clinically suspected distal radial physeal injury, asymptomatic gymnasts, and non-gymnasts (n = 69) were included and matched on skeletal age and sex. Volume measurements were performed on coronal water selective cartilage MRI images by creating three-dimensional physeal reconstructions semi-automatically using active-contour segmentation based on image-intensity thresholding. Inter- and intra-rater reliability of the measurements were assessed using intra-class correlation coefficients (ICC) for absolute agreement.

Results

Twenty-seven symptomatic-, 18 asymptomatic-, and 24 non-gymnasts were included with a median age of 13.9 years (interquartile range (IQR) 13.0–15.0 years). Median physeal volume was significantly increased (p < 0.05) in symptomatic- (971 mm³, IQR 787–1237 mm³) and asymptomatic gymnasts (951 mm³, IQR 871–1004 mm³) compared with non-gymnasts (646 mm³, IQR 538–795 mm³). Inter-rater (ICC 0.96, 95% CI 0.92–0.98) and intra-rater (ICC 0.93, 95% CI 0.85–0.97) reliability of volume measurements were excellent. Of the 10 participants with the highest physeal volumes, nine were symptomatic gymnasts.

Conclusion

Increased volume of the distal radial physis can reliably be assessed and is a sign of physeal stress that can be present in both symptomatic- and asymptomatic gymnasts, but gymnasts with suspected physeal injury showed larger volume increases. Future studies should explore if volume assessment can be used to (early) identify athletes with or at risk for physeal stress injuries of the wrist.

Key Points

• The volume of the distal radial physis can be reliably assessed by creating three-dimensional physeal reconstructions.

• Stress-related volume increase of the distal radial physis is present in symptomatic and asymptomatic gymnasts.

• Gymnasts with clinically suspected physeal injury showed larger volume increases compared with asymptomatic gymnasts and may therefore be a valuable addition in the (early) diagnostic workup of physeal stress injuries.

Growth plate injury at the base of the coracoid: MRI features

PURPOSE

To assess the MRI features of growth plate injury at the base of the coracoid process.

MATERIALS AND METHODS

Subjects were identified through retrospective search of our department imaging database and teaching files and the teaching files of two outside academic institutions. The coracoid base growth plate was examined with attention to widening, irregularity, abnormal signal intensity of the growth plate, and the presence of adjacent soft tissue edema. The apposing coracoid and scapular bony surfaces were examined for signal intensity and morphology.

RESULTS

Shoulder MRIs in eight patients with coracoid base growth plate disturbances were retrospectively reviewed (7 males, 1 female, mean age 15 years). Growth plate injury manifested as widening, irregularity and increased signal, apposing bony marrow edema and hypertrophy, and surrounding soft tissue edema. Five subjects were athletes (football, archery, basketball, swimming, rugby), two had a history of neuromuscular disorders, and one subject presented after a fall. Clinical indications included: rule out labral tear (n = 3), rule out rotator cuff tear or fracture after fall (n = 1), nonspecific pain (n = 1), shoulder subluxation, rule out glenoid pathology (n = 1, patient with underlying neuromuscular disorder), muscular dystrophy with shoulder pain (n = 1), and impingement (n = 1). Coracoid growth plate injury was not suspected clinically in any of the patients.

CONCLUSION

Awareness of the imaging appearance of coracoid base growth plate injury can aid in a more accurate diagnosis of shoulder MRI studies in young pediatric athletes. While uncommon, coracoid growth plate injury should be considered when assessing children with shoulder symptomatology.

Imaging of Sports-related Injuries of the Lower Extremity in Pediatric Patients

With increasing participation and intensity of training in youth sports in the United States, the incidence of sports-related injuries is increasing, and the types of injuries are shifting. In this article, the authors review sports injuries of the lower extremity, including both acute and overuse injuries, that are common in or specific to the pediatric population. Common traumatic injuries that occur in individuals of all ages (eg, tears of the acetabular labrum and anterior cruciate ligament) are not addressed, although these occur routinely in pediatric sports. However, some injuries that occur almost exclusively in high-level athletes (eg, athletic pubalgia) are reviewed to increase awareness and understanding of these entities among pediatric radiologists who may not be familiar with them and thus may not look for them. Injuries are described according to their location (ie, hip, knee, or foot and ankle) and pathologic process (eg, apophysitis, osteochondritis dissecans). Examples of abnormalities and normal variants of the anatomy that are often misdiagnosed are provided. The injuries reviewed represent a common and growing subset of pathologic processes about which all pediatric and musculoskeletal radiologists should be knowledgeable. Understanding physeal injury is especially important because missed diagnoses can lead to premature physeal closure and osteoarthritis. ^©RSNA, 2016.