Prevalence of childhood and adolescent soccer-related overuse injuries

Sinding-Larsen-Johansson disease. Clinical features, imaging findings, conservative treatments and research perspectives: a scoping review

Objective

This review aims to consolidate existing research on the pathogenesis, clinical diagnosis, imaging outcomes, and conservative treatments of Sinding-Larsen-Johansson disease (SLJD), identifying literature gaps.

Design

Scoping Review.

Methods

A comprehensive literature search was conducted across databases including PubMed, Scopus, Medline OVID, Embase, Web of Science, and Grey literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews. The quality of included studies was assessed using the Joanna Briggs Institute (JBI) checklist.

Results

The body of evidence on SLJD, primarily derived from case studies, reveals limited and often conflicting data. Key findings include: (1) SLJD commonly presents as localized knee pain in physically active adolescents, particularly males, (2) ultrasound and MRI are the most effective diagnostic tools, (3) conservative treatment, which mainly focuses on activity limitation, yields positive outcomes within two to eight months.

Conclusions

Our review shows that SLJD mainly affects physically active adolescents aged 9-17 years. The authors recommend conservative treatment, rest and/or cryotherapy, passive mobilization, muscle restraint, isometric exercise, and NSAIDs. Further cohort studies are necessary to refine the management and application of the SLJD treatment database.

Adolescents and adults with patellofemoral pain exhibit distinct patellar maltracking patterns

BACKGROUND

Chronic idiopathic patellofemoral pain is associated with patellar maltracking in both adolescents and adults. To accurately target the underlying, patient-specific etiology, it is crucial we understand if age-of-pain-onset influences maltracking.

METHODS

Twenty adolescents (13.9 ± 1.4 years) and 20 adults (28.1 ± 4.9 years) female patients with idiopathic patellofemoral pain (age-of-pain-onset: < 14 and > 18 years of age, respectively) formed the patient cohort. Twenty adolescents and 20 adults (matched for gender, age, and body mass index) formed the control cohort. We captured three-dimensional patellofemoral kinematics during knee flexion-extension using dynamic MRI. Patellar maltracking (deviation in patient-specific patellofemoral kinematics, relative to their respective age-controlled mean values) was the primary outcome measure, which was compared between individuals with adolescent-onset and adult-onset patellofemoral pain using ANOVA and discriminant analysis.

FINDINGS

The female adolescent-onset patellofemoral pain cohort demonstrated increased lateral (P = 0.032), superior (P = 0.007), and posterior (P < 0.001) maltracking, with increased patellar flexion (P < 0.001) and medial spin (P = 0.002), relative to the adult-onset patellofemoral pain cohort. Post-hoc analyses revealed increased lateral shift [mean difference ± 95% confidence interval = -2.9 ± 2.1 mm at 10° knee angle], posterior shift [-2.8 ± 2.1 mm, -3.3 ± 2.3 mm & -3.1 ± 2.4 mm at 10°, 20°& 30°], with greater patellar flexion [3.8 ± 2.6 mm & 5.0 ± 2.8 mm, at 20°& 30°] and medial spin [-2.2 ± 1.7 mm & -3.4 ± 2.3 mm at 20°& 30°]. Axial-plane maltracking accurately differentiated the patient age-of-pain-onset (60-75%, P < 0.001).

INTERPRETATION

Age-of-pain-onset influences the maltracking patterns seen in patients with patellofemoral pain; with all, but 1, degree of freedom being unique in the adolescent-onset-patellofemoral pain cohort. Clinical awareness of this distinction is crucial for correctly diagnosing a patient's pain etiology and optimizing interventional strategies.

Acceleration profile of high-impact movements during young football games: a cross-sectional study involving healthy children

Repetitive high-impact movements cause growth-related injuries in children. This study aimed to identify which movements during junior football games require >6 G and >8 G acceleration and the frequency at which they occur. Additionally, we compared the components of acceleration among movements with >8 G resultant acceleration. Eleven young male footballers (10.7 ± 0.4 years) played 8-a-side games while wearing a tri-axial accelerometer on their upper back. The number and frequency of the movements that generated >6 G and >8 G were calculated, and each directive acceleration of the top five items was compared using two-way ANOVA to examine the effect of movements. The frequency of movements that generated >6 G and >8 G acceleration during junior football games was 8.70 case/min and 2.62 case/min, respectively. The top five >8 G movements were braking and pre-braking in shuffle, slowdown, stop, and run/jog items. The vertical acceleration was significantly greater during braking in shuffle than during slowdown, stop, and run/jog and also greater during stop and pre-braking in shuffle than during run/jog movement. This pilot study suggests that decelerated movements mainly provoked high-impact situations and may be key actions for preventing overuse injury in young footballers.

A systematic review on conservative treatment options for OSGOOD-Schlatter disease

OBJECTIVES

Osgood-Schlatter disease (OSD) is a sport- and growth-associated knee pathology with locally painful alterations around the tibial tuberosity apophysis. Up to 10% of adolescents are affected by OSD. Treatment is predominantly conservative. The aims of this systematic review are to comprehensively identify conservative treatment options for OSD, compare their effectiveness in selected outcomes, and describe potential research gaps.

METHODS

A systematic literature search was conducted using CENTRAL, CINAHL, EMBASE, MEDLINE, and PEDro databases. In addition, ongoing and unpublished clinical studies, dissertations, and other grey literature on OSD were searched. We also systematically retrieved review articles for extraction of treatment recommendations.

RESULTS

Of 767 identified studies, thirteen were included, comprising only two randomised controlled trials (RCTs). The included studies were published from 1948 to 2019 and included 747 patients with 937 affected knees. Study quality was poor to moderate. In addition to the studies, 15 review articles were included, among which the most prevalent treatment recommendations were compiled.

CONCLUSION

Certain therapeutic approaches, such as stretching, have apparent efficacy, but no RCT comparing specific exercises with sham or usual-care treatment exists. Carefully controlled studies on well-described treatment approaches are needed to establish which conservative treatment options are most effective for patients with OSD.

Operative Treatment of Bipartite Patella in Pediatric and Adolescent Athletes: A Retrospective Comparison With a Nonoperatively Treated Cohort

Background:

Bipartite patella (BPP) is a developmental anomaly that forms when incomplete patellar ossification leaves a residual fibrocartilaginous synchondrosis between ossification centers. Repetitive traction forces across the synchondrosis can cause knee pain, most commonly presenting in adolescence. Symptoms frequently resolve with nonoperative management. Few surgical case series exist to guide treatment approaches for refractory pain.

Purpose:

To investigate the clinical features, surgical techniques, and outcomes associated with operative treatment of symptomatic BPP in pediatric and adolescent athletes and to compare features of the series with a large control group managed nonoperatively.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective medical record review was conducted of all patients aged ≤20 years who were diagnosed with symptomatic, radiologically confirmed BPP between 2003 and 2018 at a single tertiary-care pediatric hospital (N = 266). Demographic and clinical variables were analyzed, and additional radiologic and perioperative variables were collected for the surgical subcohort.

Results:

Of the 266 patients included, 27 were treated operatively (10.2%). When compared with those treated nonoperatively (with rest, physical therapy, cryotherapy, and anti-inflammatory medications), the operatively managed group experienced a longer duration of symptoms before first presentation (21.5 vs 7.6 months; P < .001) and were more likely to be older (mean age, 15.4 vs 12.4 years; P < .001), female (59.3% vs 35.6%; P = .03), and competitive athletes (100% vs 84.5%; P = .02). In the 27 patients treated operatively, procedures were categorized as isolated fragment excision (n = 9), fragment excision with lateral release (n = 8), isolated lateral release (n = 5), fragment screw fixation (n = 4), and synchondrosis drilling (n = 1). The mean time between surgery and return to sports was 2.2 months. Four patients (14.8%) reported residual symptoms requiring secondary surgery, including lateral release (n = 1), excision of residual fragment (n = 1), and fixation screw removal (n = 2).

Conclusion:

BPP can cause knee pain in adolescent athletes and is generally responsive to nonoperative treatment. Patients undergoing surgical treatment—most commonly female competitive athletes with prolonged symptoms—represented 10% of cases. A variety of surgical techniques may be effective, with a 15% risk of persistent or recurrent symptoms warranting reoperation. Prospective multicenter investigations are needed to identify optimal candidates for earlier interventions and the optimal operative treatment technique.

Prevalence of Hip or Groin Pain in Adolescents: A Systematic Review and Meta-Analysis

Musculoskeletal pain is a common cause of pain in adolescence and can be an important predictor of future pain. The prevalence of hip or groin pain that could potentially affect different adolescent populations has not yet been systematically reviewed. This systematic review aimed to determine the prevalence of hip or groin pain in this population. Five electronic databases were searched until January 2019 for eligible studies that included males and females 13 to 19 years of age. Study selection, data extraction, and risk of bias assessments were completed by 2 independent researchers. Based on inclusion criteria, 8 population-based, 8 clinical, and 4 sports populations were included. Studies were conducted in Europe, North America, and Australia. The prevalence was dichotomized into "0 to 3 months" and "3 months and above." Meta-analyses were performed to estimate the prevalence from 0 to 3 months, and individual estimates were reported for studies of 3 months and above. The overall prevalence of hip or groin pain in all adolescents from 0 to 3 months was 12% (95% confidence interval [CI] 6%, 23%) based on 10 studies, and was 7% (95% CI 6%, 10%) based on 7 population studies. Caution should be applied to these estimates due to substantial study heterogeneity. The pain prevalence in cerebral palsy from 0 to 3 months based on 4 studies was 13% (95% CI 10%, 15%). Individual prevalence estimates were 6% and 31% in obese and 4% in hypermobility populations, respectively, and ranged from 6% to 100% in 4 sports studies. The validity of these estimates is compromised by poor methodological quality.

Factors Associated With Knee Pain and Heel Pain in Youth Soccer Players Aged 8 to 12 Years

Background:

Soccer is played by many children younger than 12 years. Despite its health benefits, soccer has also been linked to a high number of sport-related injuries.

Purpose:

To investigate the relationship between clinical factors and knee or heel pain in youth soccer players.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Study participants included 602 soccer players aged 8 to 12 years who were asked whether they had experienced episodes of knee or heel pain. Data were collected on age, body mass index, years of playing soccer, playing position, and training hours per week. Associations of clinical factors with the prevalence of knee or heel pain were examined by univariate and multivariate logistic regression analyses.

Results:

Episodes of knee and heel pain were reported by 29.4% and 31.1% of players, respectively. Multivariate analyses revealed that older age and more years of playing soccer were significantly and positively associated with the prevalence of knee pain (P = .037 and P = .015 for trend, respectively) but did not identify any significant associations for heel pain.

Conclusion:

In this study of youth soccer players, knee pain was associated with older age and more years of play, but heel pain was not significantly associated with any factor.

Are Hip Physical Examination Findings Predictive of Future Lower-Body Injury Rates in Elite Adolescent Female Soccer Athletes at Minimum 5-Year Follow-Up?

CONTEXT

Although elite adolescent female soccer athletes have unique injury risk factors and management challenges, limited epidemiological data exist for this population.

OBJECTIVE

To describe lower-body injury patterns and to determine whether a screening hip physical examination is predictive of future injuries in elite adolescent female soccer athletes.

DESIGN

Prospective cohort study.

SETTING

One US premier soccer club.

PARTICIPANTS

One hundred seventy-seven female soccer athletes aged 10-18 years (mean [SD] 14.6 [1.8] y) completed a demographic questionnaire and screening hip physical examination that included range of motion and provocative tests.

INTERVENTIONS

At least 5 years after baseline screening, athletes completed an electronic follow-up injury survey. Injury was defined as pain that interfered with sporting activity.

MAIN OUTCOME MEASURES

In addition to descriptive analyses of athletes' injury profiles, associations between players' baseline demographics and subsequent injury profiles were evaluated using chi-square tests, and potential predictors of injury based on players' baseline hip examinations were evaluated using multivariable logistic regression.

RESULTS

Ninety-four of 177 athletes (53%) were contacted for follow-up, and 88/94 (93.6%) completed the survey. With mean follow-up of 91.9 (9.3) months (range 66-108 mo), 42/88 (47.7%) reported sustaining a new lower-body injury. The low back was the most common injury region (16/42, 38.1%). Almost half of all injured athletes (20/42, 47.6%) sustained overuse injuries, and 16/42 (38.1%) had an incomplete recovery. Higher body mass index and reaching menarche were associated with sustaining an injury (P = .03 and .04, respectively). Athletes' baseline hip examinations were not predictive of their subsequent rate of lower-body, lumbopelvic, overuse, or incomplete recovery injury (all P > .05).

CONCLUSIONS

Lower-body injuries were common in elite adolescent female soccer athletes, with over one third of injured athletes reporting permanent negative impact of the injury on their playing ability. Baseline hip physical examinations were not associated with future injury rate.

Overuse injuries in sport: a comprehensive overview

BACKGROUND

The absence of a single, identifiable traumatic cause has been traditionally used as a definition for a causative factor of overuse injury. Excessive loading, insufficient recovery, and underpreparedness can increase injury risk by exposing athletes to relatively large changes in load. The musculoskeletal system, if subjected to excessive stress, can suffer from various types of overuse injuries which may affect the bone, muscles, tendons, and ligaments.

METHODS

We performed a search (up to March 2018) in the PubMed and Scopus electronic databases to identify the available scientific articles about the pathophysiology and the incidence of overuse sport injuries. For the purposes of our review, we used several combinations of the following keywords: overuse, injury, tendon, tendinopathy, stress fracture, stress reaction, and juvenile osteochondritis dissecans.

RESULTS

Overuse tendinopathy induces in the tendon pain and swelling with associated decreased tolerance to exercise and various types of tendon degeneration. Poor training technique and a variety of risk factors may predispose athletes to stress reactions that may be interpreted as possible precursors of stress fractures. A frequent cause of pain in adolescents is juvenile osteochondritis dissecans (JOCD), which is characterized by delamination and localized necrosis of the subchondral bone, with or without the involvement of articular cartilage. The purpose of this compressive review is to give an overview of overuse injuries in sport by describing the theoretical foundations of these conditions that may predispose to the development of tendinopathy, stress fractures, stress reactions, and juvenile osteochondritis dissecans and the implication that these pathologies may have in their management.

CONCLUSIONS

Further research is required to improve our knowledge on tendon and bone healing, enabling specific treatment strategies to be developed for the management of overuse injuries.

Association between trunk pain and lower extremity pain among youth soccer players: a cross-sectional study

Background

Soccer is a high-intensity sport with a high injury rate. Among youth soccer players, lower extremity pain is a major problem that could be associated with trunk function. This study investigated the association between lower extremity pain and trunk pain among youth soccer players.

Methods

A cross-sectional study involving youth soccer players participating in the Miyagi Amateur Sports Association was conducted using a self-reported questionnaire. A multiple logistic regression analysis was used to examine the association between trunk pain and lower extremity pain. Covariates were sex, age, body mass index, height increase, number of days of training per week, practice time per day on weekdays or weekends, competition levels, frequency of participation in games, and previous injuries.

Results

The final study population comprised 1139 youth soccer players (age, 6-15 years; male, 94.2%). Lower extremity pain with concomitant trunk pain occurred in 61.8% (42/68). Trunk pain was significantly associated with lower extremity pain (adjusted odds ratio [OR], 6.82; 95% confidence interval [CI], 3.99-11.67). Back pain and hip pain were significantly associated with knee pain (adjusted OR [95% CI]: 7.63 [3.70-15.76] and 3.84 [1.89-7.83], respectively), ankle pain (adjusted OR [95% CI]: 9.03 [4.42-18.44] and 5.43 [2.77-10.62], respectively), and both knee and ankle pain (adjusted OR [95% CI]: 13.67 [6.01-31.09] and 5.98 [2.56-13.97], respectively).

Conclusions

Trunk pain was associated with lower extremity pain among youth soccer players. Clinicians and coaches should consider comorbidities while treating those players.

Editorial Commentary: Got Evidence? What We Really Need Is an Algorithm for Treating Symptomatic Bipartite Patella

Bipartite patella is an uncommon but potentially troublesome problem for young athletes. Numerous uncontrolled retrospective studies have reported good results after various treatments. What is needed are studies that will guide workup and support treatment decisions based on the condition of the cartilage surfaces of the fragment, presence of pseudoarthrosis, and size and location of the fragment. To support decisions, we need prospective comparative studies, either randomized or, at least, prospective cohort studies that identify patients at the time of presentation, document key decision points, and follow patients to successful resolution of symptoms.

Articular Cartilage Repair of the Knee in Children and Adolescents

Articular cartilage predominantly serves a biomechanical function, which begins in utero and further develops during growth and locomotion. With regard to its 2-tissue structure (chondrocytes and matrix), the regenerative potential of hyaline cartilage defects is limited. Children and adolescents are increasingly suffering from articular cartilage and osteochondral deficiencies. Traumatic incidents often result in damage to the joint surfaces, while repetitive microtrauma may cause osteochondritis dissecans. When compared with their adult counterparts, children and adolescents have a greater capacity to regenerate articular cartilage defects. Even so, articular cartilage injuries in this age group may predispose them to premature osteoarthritis. Consequently, surgery is indicated in young patients when conservative measures fail. The operative techniques for articular cartilage injuries traditionally performed in adults may be performed in children, although an individualized approach must be tailored according to patient and defect characteristics. Clear guidelines for defect dimension–associated techniques have not been reported. Knee joint dimensions must be considered and correlated with respect to the cartilage defect size. Particular attention must be given to the subchondral bone, which is frequently affected in children and adolescents. Articular cartilage repair techniques appear to be safe in this cohort of patients, and no differences in complication rates have been reported when compared with adult patients. Particularly, autologous chondrocyte implantation has good biological potential, especially for large-diameter joint surface defects.

Patellofemoral Kinematics and Tibial Tuberosity-Trochlear Groove Distances in Female Adolescents With Patellofemoral Pain

BACKGROUND

Patellofemoral pain (PFP) is a prevalent disorder among female adolescents. Overuse is frequently cited as the cause of pain for this population. What is currently unclear, however, is if the patella demonstrates abnormal tracking patterns relative to the femoral trochlear groove in female adolescents with PFP.

PURPOSE

The aim of this case-control study was to determine if abnormal patellar tracking patterns are present in female adolescents with PFP. The secondary aim was to identify if an increased tibial tuberosity-trochlear groove (TT-TG) distance is associated with the observed kinematic patterns.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twenty female adolescent knees from 12 patients with PFP and 20 age-matched female knees from 13 healthy controls were recruited for this study. Patellofemoral kinematics (eg, lateral patellar displacement) during a repetitive knee extension-flexion maneuver was quantified by dynamic cine phase-contrast magnetic resonance imaging (MRI). Static MRI scans were used to determine the TT-TG distance.

RESULTS

Relative to the control cohort, female adolescents with PFP demonstrated significantly greater lateral displacement at 10° (3.2 mm; P < .001), 20° (2.3 mm; P < .001), and 30° (1.7 mm; P = .014) of knee flexion. A subgroup within this cohort (7 knees from 5 patients) demonstrated extreme lateral maltracking >2 SDs of the mean of the control cohort. This subgroup also demonstrated a greater TT-TG distance relative to the controls (Δ = 4.2 mm; P = .001).

CONCLUSION

This study demonstrates abnormal lateral patellar displacement in the absence of patellar tilt in female adolescents with PFP. Because all adolescents from both cohorts participated in impact sports, it appears that rigorous athletic training alone is inadequate to produce symptoms in this population. Rather, PFP may derive from a combination of physical activity in the context of pathological kinematics.

CLINICAL RELEVANCE

Abnormal patellar tracking patterns and abnormal static alignment have been shown to contribute to the etiology of patellofemoral pain in adults. This study demonstrates that pathologic patellar tracking patterns are present in adolescent females with patellofemoral pain.

Patellar Maltracking Persists in Adolescent Females With Patellofemoral Pain: A Longitudinal Study

Background:

Patellofemoral pain is one of the most common conditions seen in sports medicine practices, particularly among adolescent females. However, the natural history of the underlying pathology in patellofemoral pain during puberty remains poorly understood.

Purpose:

The purpose of this longitudinal study is to assess changes in patellar maltracking patterns in subjects with patellofemoral pain as they mature from mid- to late adolescence.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Three-dimensional patellofemoral kinematic data were acquired during active knee extension-flexion using dynamic magnetic resonance imaging in 6 girls (10 knees; mean age, 14.0 years) with clinically diagnosed patellofemoral pain. The subjects then returned as late adolescents (mean age, 18.5 years) for follow-up scanning. Three-dimensional patellofemoral kinematic parameters were evaluated across the range of motion, but comparison between time points was restricted to 10° of flexion. Participation in impact and nonimpact physical activities, pain score based on the visual analog scale, and the anterior knee pain score were also compared across initial and follow-up visits.

Results:

All subjects reported improved patellofemoral pain symptoms at follow-up, and one subject reported complete resolution. However, relative to the initial visit, no differences were found in patellar maltracking. There was a decrease in hours engaged in impact physical activities for all subjects at follow-up.

Conclusion:

This study provides insight into the natural history of patellofemoral pain in adolescent females. The relatively unchanged patellofemoral maltracking across subjects suggests that potential anatomic and kinematic abnormalities contributing to patellofemoral pain during mid-adolescence persist during skeletal maturation. Symptom improvement for these subjects did not result from a change in patellofemoral tracking, but rather from other causes.

Epidemiology of injuries sustained by players during the 16th Under-17 South American Soccer Championship

OBJECTIVE

We performed an epidemiological study of the traumatic injuries during the XVI South American U-17 Football Championship, 2015.

MATERIAL AND METHODS

Observational surveys submitted by the 10 teams medical services of 220 players. Thirty-five games were held and 116 goals (3.31 per game) were recorded.

RESULTS

103 lesions, ie, 2.94 per game or 32.7 injuries per 1,000 min were recorded. Fifty-six were from direct contact and 66 requiring treatment. 36% of the injuries were punished by fault and 26% of the injuries also saw card. Injuries were most common in the ankle (15 cases), Achilles tendon (14 cases) and thigh (14 cases), followed by trauma to the knee and foot (7 cases each), face and the lumbar region (6 cases each), being rare in the upper extremity.

CONCLUSION

Injuries during Soccer World Cup are difficult to predict and prevent, but serious injuries are rare. Is necessary to establish protocols that get adequate health care at all levels to solve problems produce, both in training and during the competition, and be prepared to solve the serious problems that may arise.

Knee hemarthros secondary to osteochondritis dissecans (König disease)

A case is presented of a hemarthrosis associated with osteochondritis dissecans in a young man who arrived in the Emergency unit due to tender and swelling of his right knee one hour after a slightly rotational gesture of the lower limb. Many years before the patient suffered a sports injury in the same knee, but it was never assessed. Radiography studies showed bone fragments inside the synovial capsule, and the joint aspiration was compatible with hemarthrosis. A review of the available information of this uncommon condition is also presented.