Sports-related acute and chronic avulsion injuries in children and adolescents with special emphasis on tennis

Apophyseal Avulsion of the Rectus Femoris Tendon Origin in Adolescent Soccer Players

Apophyseal avulsions of the rectus femorus tendon (RFT) at the anterior inferior iliac spine (AIIS) can occur in adolescents, often while performing soccer. Patient-reported outcomes (PROMs) and time to return to sport of these patients are relatively unknown. Therefore, the aim of this study was to assess the PROMs and return to sports of patients with AIIS avulsions and compare the results with those reported in the literature. This is a case series of seven consecutive patients presenting at our hospital between 2018 and 2020 with an apophyseal avulsion of the RFT from the AIIS. The patients were assessed with use of the WOMAC and Tegner scores and return to sports was evaluated. All patients were male soccer players (median age 13 years; range, 12–17). They were all initially treated non-operatively. One of the patients subsequently needed excision surgery of a heterotopic ossification because of non-transient hip impingement. All other patients recovered after a period of relative rest. Median time to return to sports was 2.5 months (range, 2–3). At a median follow-up of 33 months (range, 18–45), the WOMAC (median, 100; range, 91–100) and Tegner scores (median, 9; range, 5–9) were high. In accordance with the existing literature, most patients with apophyseal avulsions of the AIIS recover well with non-operative treatment. However, the avulsion can lead to hip impingement due to heterotopic ossifications possibly needing surgical excision. Sport resumption is achievable after 2–3 months, and patient-reported outcomes are highly satisfactory in the long term.

Avulsion injuries: an update on radiologic findings

Avulsion injuries result from the application of a tensile force to a musculoskeletal unit or ligament. Although injuries tend to occur more commonly in skeletally immature populations due to the weakness of their apophysis, adults may also be subject to avulsion fractures, particularly those with osteoporotic bones. The most common sites of avulsion injuries in adolescents and children are apophyses of the pelvis and knee. In adults, avulsion injuries commonly occur within the tendon due to underlying degeneration or tendinosis. However, any location can be involved in avulsion injuries. Radiography is the first imaging modality to diagnose avulsion injury, although advanced imaging modalities are occasionally required to identify subtle lesions or to fully delineate the extent of the injury. Ultrasonography has a high spatial resolution with a dynamic assessment potential and allows the comparison of a bone avulsion with the opposite side. Computed tomography is more sensitive for depicting a tiny osseous fragment located adjacent to the expected attachment site of a ligament, tendon, or capsule. Moreover, magnetic resonance imaging is the best imaging modality for the evaluation of soft tissue abnormalities, especially the affected muscles, tendons, and ligaments. Acute avulsion injuries usually manifest as avulsed bone fragments. In contrast, chronic injuries can easily mimic other disease processes, such as infections or neoplasms. Therefore, recognizing the vulnerable sites and characteristic imaging features of avulsion fractures would be helpful in ensuring accurate diagnosis and appropriate patient management. To this end, familiarity with musculoskeletal anatomy and mechanism of injury is necessary.

[Apophyseal avulsion in the pelvic region in childhood and adolescence]

BACKGROUND

The importance of the apophyseal plates during growth is often underestimated. They act as a muscular insertion and influence the joint mechanics by the load-dependent change in shape.

PATHOMECHANISMS

An anatomically functional adaptation occurs as protection from overloading. In special kinds of sports with highly dynamic movements, sudden changes of direction and eccentric/concentric muscle activities the resulting stress may exceed the strength of the apophyseal plate. In adolescence this results in a total or partial tearing of the apophysis in the sense of an avulsion injury. In the pelvic region the ischial tuberosity, the anterior superior and inferior iliac spine are mainly affected.

DIAGNOSTICS

The medical history and clinical diagnostics are supplemented by conventional radiographic imaging. Sectional imaging diagnostics are usually unnecessary.

TREATMENT

Conservative management by reduced (partial) weight bearing and physiotherapy represents the gold standard in treatment. In cases with a fragment displacement >1.5-2.0 cm and in competitive athletes an open reduction should be considered.

Hip Impingement after Anterior Inferior Iliac Spine Avulsion Fractures: A Case Report with Review of the Literature

Avulsion fractures of the anterior inferior iliac spine (AIIS) are rare injuries in adolescent athletes. We present a case of a 15-year-old male who sustained an avulsion injury to his right AIIS when kicking a soccer ball. The patient had chronic pain and extra-articular subspinal impingement leading to decreased hip flexion and rotation. The injury occurred 1.5 years prior to symptom onset, and we were the first health care providers to manage the injury. We attempted six months of nonoperative management including activity modifications and nonsteroidal anti-inflammatory (NSAID) therapy without improvement. Although this injury can often be managed nonoperatively, his symptoms required excision of the AIIS and associated heterotopic ossification. He had an excellent outcome with return to soccer and no pain at his final follow-up visit two years after surgery. Due to the limited literature guiding the surgeon's management of AIIS avulsion injuries with associated heterotopic ossification, we provide a review of the literature detailing pre- and postoperative ranges of motion, surgical approach, fixation or excision of the avulsion fragment, and return to sport in this patient population.

Growth pattern of lumbar bone mineral content and trunk muscles in adolescent male soccer players

INTRODUCTION

Previous studies have reported that the peak in lean body mass (LBM) precedes the peak in bone mineral content (BMC). However, it is unknown whether the trunk region growth is similar.

MATERIALS AND METHODS

We investigated the difference between pubertal peak age in the increase of LBM in the trunk (trunk LBM) and pubertal peak age in the increase of BMC in the lumbar spine (lumbar BMC) in a longitudinal study of 201 Japanese male adolescent soccer players. The age of peak height velocity (PHV) and the developmental age were calculated. The participants were followed over a 2-year period, with height and dual-energy X-ray absorptiometry scans taken every 6 months.

RESULTS

The trunk LBM (ρ = 0.732, p < 0.0001) and the lumbar BMC (ρ = 0.621, p < 0.0001) significantly correlated with the developmental age. The increase of trunk LBM and lumbar BMC was significantly different according to the developmental stages (Kruskal-Wallis test; p < 0.0001 and p < 0.001, respectively). We used a cubic spline to estimate the developmental age, when the increase reached its peak: the peak age of the increase in trunk LBM was estimated to be - 0.08 years (approximately - 1 month) prior to PHV age, whereas the peak age of the increase in lumbar BMC was estimated to be 0.42 years (approximately 5 months) after the PHV age.

CONCLUSIONS

The maximal increase in trunk LBM occurs just before PHV age and approximately 6 months before the maximal increase in lumbar BMC during the pubertal growth spurt in the Japanese adolescent male soccer players.

Chronic ischial tuberosity avulsion nonunion fracture treated with a platelet-rich plasma injection as a bone graft

We present a case of an 18-year-old with a 2-year history of buttock pain who failed extensive treatment for a perceived hamstring strain. Upon evaluation, he was diagnosed with an ischial tuberosity nonunion avulsion fracture. The patient underwent bone grafting via an ultrasound guided leukocyte rich platelet-rich plasma injection followed by the use of a bone stimulator to enhance the bone healing. At 3 months, he was asymptomatic and had radiographic evidence of excellent bone healing. He remained asymptomatic at 1 year and had resumed full activities. This case report is the first in the literature to describe the treatment of a chronic ischial tuberosity nonunion avulsion fracture with the use of platelet-rich plasma as a bone graft.

Surgical fenestration and rehabilitation of a sports traumatic non-union ischial tuberosity fracture - Case report

INTRODUCTION

Ischial tuberosity fractures and complications may be an under recognized diagnosis in adolescent athletes. Operative interventions differ and may include anchor re-fixations, resections and osteostimulating drilling and partial hamstring releases. This case report illustrates a novel and less invasive management of a non-union following a proximal ischial tuberosity avulsion. This approach has to our knowledge not previously been described.

PRESENTATION OF CASE

The patient, a 14 years old female athlete, was complaining of sharp pain in the right side of the groin region, after an acute injury during a handball game. The pain was concentrated at the insertion of the adductor muscle group to the superior pubic ramus and the pubic symphysis. She was referred to our orthopaedic sports clinic after 6 months of unsuccessful conservative treatment. An MRI scan showed an ischial tuberosity non-union with a displacement less than 10 mm. Nine months after injury a surgical procedure was performed with the patient under general anaesthesia. An ultrasound guided fenestration of the non-union of the ischial tuberosity with a 1.6 mm Kirshner wire was performed. The enthesis was fenestrated 10 times, using a 1.2 mm syringe. Finally, a 5 ml local anaesthetic was injected in the area. 17 months after the trauma and 8 months postoperatively the patient had a full return to normal day activities including pain free squats and lunges. Radiologically the non-union was healed.

CONCLUSION

This novel and less invasive surgical procedure may therefore be seen as a possible treatment option to non-union of the ischial tuberosity with minimal displacement.

Articular and peri-articular hip lesions in soccer players. The importance of imaging in deciding which lesions will need surgery and which can be treated conservatively?

Soccer is one of the most popular sports worldwide engaging millions of participants each year. During play, injuries occur rather frequently and most of them involve the hip joint and the surrounding structure. In professional athletes, injuries are often complex scenarios and in the case of misdiagnosis, patients' return to play is delayed or it may progress to a more serious injury with consequent damage for their career and for the soccer team. The most frequent articular pathologies are Femoro-acetabular impingement and labral tears. Stress fracture, avulsion, ischiofemoral impingement, subspine impingement, athletic pubalgia, muscle injuries and Morel-Levallèe lesion are the most frequent hip peri-articular pathologies whereas snapping hip may be both intra- or extra-articular pathology. With an increasing number of football players, the radiologist plays a crucial role in the detection and characterization of the extent of the injuries. This article reviews the current imaging concepts frequently seen in injuries around the hips of professional football players focusing in particular on the most suitable therapeutic approaches, whether surgical or conservative.

The role of ultrasound as a problem-solving tool in the assessment of paediatric musculoskeletal injuries

Musculoskeletal trauma in the paediatric population covers a wide range of injuries; although many overlap with their adult counterparts, others are exclusive to the immature skeletal system. Ultrasound is a versatile tool particularly suited to both the imaging of children and the dynamic assessment of musculoskeletal injuries. This pictorial review aims to discuss a range of injuries, focusing on those commonly encountered in children. We shall describe the muscle-tendon-bone complex and changes that occur with increasing skeletal maturity and how this affects the type of injury encountered.

Pediatric avulsion fractures of pelvis: current concepts

PURPOSE OF REVIEW

Provide the reader with an evidence-based update on the importance of accurate diagnosis of commonly missed avulsion fractures of pelvis apophyses, the necessary imaging studies, the feared complications and the recent treatment recommendations.

RECENT FINDINGS

Accurate diagnosis of avulsion fractures of pelvis apophyses is high yield as misdiagnosis leads to improper treatment. They should be differentiated from muscle strain and apophysitis. These fractures are usually associated with good outcomes; however, missed diagnosis can lead to further displacement, nonunion, functional limitation, femoroacetabular impingement and infection. A/P and frog lateral pelvis radiograph show the fracture and its displacement in the majority of cases. Conservative treatment, consisting of a short period of rest and immobilization followed by passive stretching then progressive resisted activity before return to sports, is recommended in minimally displaced avulsions. Surgical treatment is favored in displaced fractures (>15 mm), as it is associated with quicker return to sports.

SUMMARY

Treating physicians should keep a high index of suspicion in pediatric and adolescent patients presenting with typical clinical exam findings. Pelvic Anteroposterior and frog leg radiographs are often diagnostic. Missed diagnosis can aggravate the prognosis of a usually benign condition. Adequate medical or surgical treatment should then be administered.

Anterior Inferior Iliac Spine Deformity as a Cause for Extra-articular Hip Impingement in Young Athletes After an Avulsion Fracture: A Case Report

Extra-articular hip impingement from prior traumatic injury to the anterior inferior iliac spine (AIIS) is an uncommon cause of groin pain in young athletes. Currently, the most common treatment for this injury is arthroscopic decompression. However, hip arthroscopy is not universally available and requires advanced skills. We report 2 cases of the development of extra-articular hip impingement from unusual bony exostoses off the AIIS after traumatic injury in 2 young athletes who underwent open surgical resection. The multidisciplinary sports medicine team should be aware of the development of extra-articular impingement from traumatic injury to the AIIS and that open surgical resection is a viable alternative to arthroscopic decompression.

Avulsion of the Anterior Inferior Iliac Spine Rehabilitation in a Rural Private Practice

An unusual case is presented of an 11-year-old girl presenting for treatment to a semirural private physical therapy practice, not specializing in pediatric care, following an avulsion fracture of the anterior inferior iliac spine. The patient presented initially non-weight-bearing, with little hip movement due to pain. Following treatment, the patient returned to preinjury status including return to full participation in netball. A review of the literature regarding healing and rehabilitation is described. Concepts of neuromuscular retraining were integrated in the rehabilitation program. Recent evidence demonstrates deficiencies in hip and knee control for girls between 11 and 15 years of age. Evidence suggests that these deficiencies may be a precursor to injury and poor outcomes in lower extremity injuries in this patient group.

Overuse Physeal Injuries in Youth Athletes

Context:

Despite rising awareness of the risks associated with sports participation, overuse injuries continue to increase in youth athlete populations. Physeal injuries are one type of overuse injury exclusive to pediatric populations that are often sustained during athletic practice or competition. Overuse physeal injuries are, in theory, preventable; however, little consensus has been reached surrounding the risk factors, prevention, and treatment strategies.

Objective:

This systematic review summarizes the best available evidence concerning overuse physeal injuries in youth and adolescent athletes. It can be used to develop prevention and treatment programs specific to this population.

Data Sources:

PubMed and Academic Search Complete (EBSCOhost) were explored using the keyword physeal injuries from January 1950 through May 2015 to identify 24 studies.

Study Selection:

Original research studies of athletic populations with mechanisms of injury related to sport were chosen.

Study Design:

Systematic review.

Level of Evidence:

Level 3.

Data Extraction:

Data were extracted as available from 24 eligible studies. Study quality was rated using the Oxford Centre for Evidence-based Medicine (OCEBM) guidelines.

Results:

Risk factors for injury include periods of accelerated growth, chronological age, body size, training volume, and previous injury. Injury prevention strategies currently emphasize participation limitations and sport-specific training programs in skeletally immature athletes. The most effective treatment after an overuse physeal injury was an extended period of active rest and joint immobilization when necessary.

Conclusion:

Overuse physeal injuries are multifactorial in nature. Muscular imbalances after accelerated growth periods predispose young athletes to overuse injuries. Modifiable risk factors such as flexibility, strength, and training volume should be regularly monitored to prevent these injuries.

Ultrasound Examination of Pediatric Musculoskeletal Diseases and Neonatal Spine

Ultrasound (US) is a simple, non-invasive imaging modality which allows high-resolution imaging of the musculoskeletal (MSK) system. Its increasing popularity in pediatrics is due to the fact that it does not involve radiation, has an ability to visualize non-ossified cartilaginous and vascular structures, allows dynamic imaging and quick contralateral comparison. US is the primary imaging modality in some pediatric MSK conditions like infant hip in developmental dysplasia (DDH), hip joint effusion, epiphyseal trauma and evaluation of the neonatal spine. US is the modality of choice in infants with DDH, both in the initial evaluation and post-treatment follow-up. US has a sensitivity equivalent to MRI in evaluation of the neonatal spine in experienced hands and is a good screening modality in neonates with suspected occult neural tube defects. In other MSK applications, it is often used for the initial diagnosis or in addition to other imaging modalities. In trauma and infections, US can often detect early and subtle soft tissue abnormalities and a quick comparison with the contralateral side aids in diagnoses. Dynamic imaging is crucial in evaluating congenital instabilities and dislocations, soft tissue and ligamentous injuries, epiphyseal injuries and fracture separations. High-resolution imaging along with color Doppler (CD) is useful in the characterization of soft tissue masses. This article reviews the applications of US in pediatric MSK with emphasis on conditions where it is a primary modality. Limitations of US include inability to penetrate bone, hence, limited diagnosis of intraosseous pathology and operator dependency.

[Apophyseal Avulsions of the Hip Region in Adolescents]

BACKGROUND

In daily practice apophyseal avulsions of sportive adolescents are frequently being diagnosed with a time delay and treated heterogeneously.

GOAL

Using the most actual literature and the own experience the current diagnostic and therapeutic strategies are put into perspective with regards of the needs of the adolescent athlete.

MATERIAL AND METHODS

The apophyseal lesions of the hip area in adolescence are separated in those at the pelvis and those at the proximal femur. They are reviewed according to its frequency and relevance using the most updated literature. The treatment methods reported focus on the degree of dislocation and level of sports activity.

RESULTS

The most frequent apophyseal avulsion of the pelvis is the avulsion of the tuber ischiadicum, followed by the inferior anterior iliac spine the superior anterior iliac spine and the apophysis of the ilium. The most affected structure at the proximal femur is the lesser trochanter, lesions of the greater trochanter are rare. The cause of injury is a specific acute contracture of the muscle inserting at the affected apophysis during different sporting activities. The treatment of pelvic apophyseal injuries is surgical only in cases with considerable fragment dislocation and in high level athletes. At the femoral side the patients are treated almost always conservatively.

DISCUSSION

Despite of modern and efficient osteosynthetic techniques the treatment of avulsion lesions of the hip region is mainly conservative, even in athletes. By applying consequent diagnostic and therapeutic principles the development of pseudarthroses and heteropic ossifications can be minimised.

Acute Avulsion of the Iliac Crest Apophysis in an Adolescent Indoor Soccer

We report a typical case of acute avulsion of the anterior iliac crest apophysis diagnosed in an indoor football player. The injury occurred as a result of a sudden twist of the trunk while kicking. Plain radiographs made the diagnosis. Complementary CT with 3D reconstructions was preferred to ultrasound because of the very strong habitus - 110 kilograms for 1,73 meter - of the 15-year old adolescent. CT confirmed that occult chronic mechanical stress on the iliac apophysis had preceded the acute avulsion and also emphasized the crucial role of the tensor fascia lata in the mechanism of the injury. The patient was successfully treated conservatively. The case is presented with a short review of the literature.

Large ossification mass causing groin pain and limited hip function

Acute avulsion fractures to the anterior inferior iliac spine are unusual, yet well documented injuries, especially in the adolescent skeleton. To our knowledge, chronic avulsion fracture to the anterior inferior iliac spine has not been reported. This report presents a case of chronic avulsion fracture to the anterior inferior iliac spine leading to a large ossification mass resulting in a late presentation of hip with limited function. Surgical excision followed by physiotherapy led to satisfactory resolution of pain and significantly improved the range of flexion.

Surgical management of traumatic avulsion of the ischial tuberosity in young athletes

OBJECTIVE

Complete traumatic avulsion of the ischial tuberosity in young athletes is rare, and the optimal treatment is unclear. The purpose of this article is to present our experience and the efficacy of surgical repair of avulsions of the ischial tuberosity with bony dislocation of more than 2 cm and to discuss the complex postoperative rehabilitation.

METHODS

Three young athletes sustained complete avulsion of the ischial tuberosity with bony dislocation during different sport activities (long jump, soccer, sprinting). The age at the time of injury ranged from 13.8 to 15 years. All underwent surgical repair with reattachment of the hamstring muscle complex to the origin on the ischium. The time from injury to repair varied from 2 to 22 weeks. All patients underwent a specific postoperative rehabilitation program. Follow-up ranged from 12 to 24 months.

RESULTS

All athletes had improved with surgery and had good subjective and objective functional results. One patient needed operative revision 1 day after primary repair because of suture loosening because of excessive muscle contractions during wake up after general anesthesia. Finally, all returned to their preinjury sport at the same level.

CONCLUSIONS

Young athletes with traumatic avulsion of the ischial tuberosity and dislocation of more than 2 cm benefit from operative repair. Good results were achieved in all cases on the basis of functional recovery and patient satisfaction. Chronic complaints could be avoided, and also return to sport was possible. Surgery under spinal anesthesia is recommended.

Tennis-related injuries treated in United States emergency departments, 1990 to 2011

OBJECTIVE

To analyze the patterns and causes of tennis-related injuries using, for the first time, a nationally representative data set.

DESIGN

A retrospective cohort analysis was performed using the National Electronic Injury Surveillance System database.

SETTING

All tennis-related injuries treated in US emergency departments (EDs) from 1990 to 2011 were analyzed.

PATIENTS

During the study period, an estimated 492,002 (95% confidence interval, 364,668-619,336) individuals, aged 5 to 94 years, presented to US EDs for tennis-related injuries.

ASSESSMENT OF RISK FACTORS

Independent variables included patient age and gender, mechanism of injury, and location of injury event.

MAIN OUTCOME MEASURES

Outcome variables included injury diagnosis, body region injured, disposition from ED, and involvement of the net.

RESULTS

Most injuries were sustained by a nonspecific mechanism during play (37.9%) and occurred at a sport or recreation facility (83.4%). Children aged 5 to 18 years had a higher mean injury rate than adults older than 19 years. The most commonly injured body regions were the lower extremities (42.2%) and upper extremities (26.7%). Sprains or strains (44.1%) were the most common type of injury. The number of tennis-related injuries decreased by 41.4% during the years 1990 to 2011, and the tennis-related injury rates decreased by more than 45% during the study period. Among the 3.4% of patients who were admitted to the hospital, two-thirds (65.6%) involved patients 56 years of age or older.

CONCLUSIONS

Despite the decrease in tennis-related injuries, the growing popularity of this sport warrants increased efforts to prevent injuries, especially among child and older adult participants.

An algorithmic approach to mechanical hip pain

BACKGROUND

As our understanding of hip pathology evolves, the focus is shifting toward earlier identification of hip pathology. Therefore, it is vitally important to elucidate intra-articular versus extra-articular pathology of hip pain in every step of the patient encounter: history, physical examination, and imaging.

QUESTIONS/PURPOSES

The objective was to address the following research questions: (1) Can an algorithmic approach to physical examination of a painful non-arthritic hip provide a more accurate diagnosis and improved treatment plan? (2) Does an anatomical layered concept of clinical diagnosis improve diagnostic accuracy? (3) What are the diagnostic tools necessary for the accurate application of a four-layer (osteochondral, inert, contractile, and neuromechanical) diagnosis?

METHODS

An unrestricted computerized search of MEDLINE was conducted. Different terms were used in various combinations.

RESULTS

An algorithmic approach to physical examination of a painful nonarthritic hip, including history, physical examination (specific tests), and advanced imaging allow for better interpretation of debilitating intra- and extra-articular disorders and their effect on core performance. Additionally, it improves our understanding as to how underlying abnormal joint mechanics may predispose the hip joint and the associated hemipelvis to asymmetric loads. These abnormal joint kinematics (layer I) can lead to cartilage and labral injury (layer II), as well as resultant injury to the musculotendinous (layer III) and neural structures (layer IV) about the hip joint and the hemipelvis. The layer concept is a systematic means of determining which structures about the hip are the source of hip pathology and how to best implement treatment.

CONCLUSIONS

A clear understanding of the differential diagnosis of hip pain through a detailed and systematic physical examination, diagnostic imaging assessment, and the interpretation of how mechanical factors can result in such a wide range of compensatory injury patterns about the hip can facilitate the diagnosis and treatment recommendations.

Avulsion fractures of the pelvis - a qualitative systematic review of the literature

OBJECTIVE

To assess a causal relationship between physical activity or boney surgical intervention and the occurrence of avulsion fracture in the pelvis. Secondarily to assess the average age at which avulsion fracture occurs in cases associated with physical activity or boney surgery.

METHOD

A literature search was performed on a variety of databases using text words and MeSH terms. Results were limited to English language. Cases involving trauma or pathological disease were excluded. Causation Criteria scores were calculated for each paper to establish a link between the suspected mechanism of injury and avulsion fracture.

RESULTS

48 papers were retrieved encompassing 66 cases of avulsion fracture. 88% of cases were associated with physical activity while 12% were associated with a history of surgery. Average age in the physical activity cases was 16.8(range 13-43) and 56.4(range 31-74) in the surgery related cases. Causation Criteria scores were definite in 76% of activity related cases and probable in 60% of boney surgery related cases.

CONCLUSIONS

Avulsion fractures of the pelvis represent a highly prevalent pathology among the adolescent athletic population. A population of skeletally mature patients with history of boney surgical intervention are also at risk.