Holly J. Benjamin, MD, FACSM, discusses her topic of Pediatric Sports Injuries: Physeal and Apophyseal Overuse Injuries
HOLLY J BENJAMIN: Good morning, everyone. Thanks, Sherwin, and thanks, Marty, so much for having me today and for all of you for coming to the course. Dr. Ho inspired me to do my course. We'll be in our 11th year this year, but he's in his 21st year. So it's really exciting. And primary care sports medicine is important, I think, to make sure-- one of the inspirations is to make sure that you all have that perspective and know that one of our goals throughout the course, even from the surgical perspective, but is to integrate that so the primary care perspective is understood well. So our goals today are to talk about pediatric sports injuries, physeal and apophyseal overuse injuries. I have nothing to disclose. And just a brief overview. I mean, we certainly know that there are a lot of kids that are doing sports today. But there are over 30 million in organized sport activity, over 7 million ages 5 to 17 in school programs, and another 25 million that do unstructured, recreational sports as well. So therefore, of course, there are thousands of injuries. And I think what's really hard in pediatrics is to realize that some kids have the possibility of having a career-ending injury or having a problem that causes them to quit their sport. And there's a lot of things that are associated with that as well. So there's a variety of injuries that you see-- sprains and strains, fractures, tendinitis, and cartilage injuries. Of those, fractures in the growth plate and cartilage injuries are actually more common in kids than adults. So we're going to focus on that. The profile of the modern athlete. I think that this has changed a bit, certainly from when I was growing up as an athlete, and certainly even in the-- this is my 20th year at the university and realizing that kids really do come in and say, I need to do well in my sport because I need a college scholarship. They're tying money to that, sometimes as young as age 10, 11, and 12-years-old. The other thing that we've seen is there's no longer-- it's sort of a dying breed-- the three-sport athlete, because if you want to be good at baseball, you need to do year-round baseball, and if you want to be good at soccer, you have to do year-round soccer. So we used to have that sort of built-in seasonal change for just those good athletes that had multi talents. So they sort of cross-trained in a sense, because they could change sport to sport. And we hypothesized that in the risk of overuse injuries that early sports specialization is a huge risk factor. And then there's the idea too that there is those few, small, select group of athletes that seem to be genetically gifted, that, if you will, they acquire those sports-specific skills at younger ages. And those are sort of the young, talented athletes that we see. But there's both a physical and psychological component that go into sport readiness. So we don't have really time to go into detail on that. But I think it's important that you remember that sometimes those don't correlate well. So sometimes you have a physically gifted athlete, but who's psychologically not ready to advance at too fast of a process. Our objectives today, just to summarize, are to identify and understand various contributing factors to overuse growth plate injuries, to be familiar with treatment principles. I want you all to feel very comfortable, give a good approach to diagnosis and treatment of these common injuries, because these really are what primary care folks should be able to take care of today. And those are the lists that we're going to go over. All right. So just reminding you about the anatomy in the weak link, that we have to just remember that there's two types of growth plates. There's the physis, which is where axial and longitudinal growth occur, here. And then there's the epiphysis, which is the end of the long bone, diaphysis and metaphysis, and the apophysis, which is a special growth plate where a tendon attaches. And you'll see them, what they look like on the radiograph there. We don't spend too much time on that. But just to remind you, one of the reasons all the growth plates look black on x-rays is because they have cartilaginous zones. And that actually contributes to some of the injuries that we see. And again, take-home point, the weak link. An injury occurring at the end of a long bone is a growth plate injury until proven otherwise. So this is a pediatric pearl that you need to remember. In terms of the history and examination, remember the mechanism of injury is very important. We see direct traumatic injuries that can injure the growth plate. But what we'll focus on today, again, are the repetitive, indirect trauma, or the overuse growth plate injuries that you see. through different types of forces, compression, tension, and shear. And of those, just like in concussions, shears are probably most likely to cause some of the most traumatic injuries that we see. It's always a concern when you see swelling around a joint, or any loss of range of motion, asymmetry, or deformity. So those are certainly things to watch out for. In terms of diagnostic studies, we do recommend radiographs. And we probably have an even lower threshold for doing radiographs in the pediatric population so that we can visualize that growth plate well. There are instances where comparison views can be helpful. And I'll go through that in the course of the talk and point that out. And then sometimes we have to go onto traditional imaging. Bone scans or MRIs can be very helpful as well. And that's going to be an important lecture that you hear later on and over the course of the next couple of days from Dr. Stacy. So again, a take-home point. If I only put a few words on the slide, it's probably a take-home point. But it's not all about the workload. So what does that mean? The three main things are the way I think about overuse injuries in kids. And that is, why did one particular athlete on a team get injured, and the rest of the team didn't? Well, it could be any one of these three things. I think it's easiest for us to focus on the workload and say, maybe they're running too many miles or throwing too many pitches in baseball, or something like that. And so it's easy to tell an athlete to rest. But so much of what I do in practice is because an athlete has done rest or they've changed their workload and decreased it, but that hasn't fixed the problem. So a lot of what I'm doing in the office is focusing on the genetics and biomechanics. Is the fact that the athlete is loose-jointed, is that helping them be a better pitcher or a better swimmer, or is that hurting them and setting them up for injury? Is it the biomechanics? Is it the athlete, the baseball pitcher that grew three inches and put on 10 pounds and started throwing a curveball when he was 13? Is it his technique that's wrong? What's going on with that? So those are kind of a good way of thinking about why they're injured. And as I said, sometimes you can prioritize those as well, so that you focus on that in the course of your treatment. So sometimes it's mostly about changing the workload. But a lot of the time, it's mostly about changing the biomechanics. The genetics is hard to change. All right. There's a couple different ways to think about pathophysiology of injury as well. And that's intrinsic and extrinsic factors. The intrinsic factors refer to just your normal alignment, growth, and development. And then if you think of a kiddo that's constantly growing-- the way I explain it to patients is, the bones grow first. The muscles and tendons have to catch up, in which case there's sort of inherently muscle tendon imbalances in a lot of these athletes. And that can be a risk factor for injury. And then they go through periods of changing flexibility as well, and then the general conditioning. The extrinsic factors are a little bit different. But that includes training errors, environment, and equipment. So this young athlete here is actually 17, but she's very petite. And she's playing with an oversized tennis racquet with a fairly large grip. So when we saw her, that was something that we addressed in the course of her treatment. So let's go to some cases. A 12-year-old, right-hand dominant, baseball pitcher with a one month history of shoulder pain with pitching, recent loss of velocity. He grew four inches in the last six months and has a new coach. So what is his diagnosis? You can shout it out if you want. Little league shoulder. This is pretty straightforward. Well, what is that? That's a Salter-Harris one physeal fracture, some people call it, or a stress injury to the proximal humoral growth plate. Typically, ages 11 to 13, it often has an insidious onset of shoulder pain. So it may hurt while they're pitching, but more commonly they're having difficulty recovering after pitching the way they used to with a sore arm for longer than expected. And then the other red flags in the history are a loss of velocity or a loss of accuracy. So in any overhead athlete those are good kinds of questions to pick up on something sooner rather than later. And then on exam, you may or may not find tenderness at the proximal humerus and pain with resisted internal rotation, as well as often mimic some impingement signs as well. So the differential diagnosis is a stress fracture, or osteochondrosis of the physis, which are very similar in little league shoulder, or instability problems, which usually instability is more of a cause of impingement syndrome or rotator cuff tendinitis. And then we certainly have to worry about the labrum. And you'll hear more about that from Dr. Ho as well. But there are different types of labral injuries, such as a SLAP lesion being common. And not to forget that the humerus is one of the more common sites for bone tumors, like in osteosarcoma. Quite rare, but something you have to think about. So what do the x-rays look like if they're abnormal little league children? And remember in all these overuse growth plate injuries a majority of the x-rays are often normal. But here you can see on the right side there's significant widening of the physis. And on the left side there's a normal appearing physis as well. So hopefully, you can see the significant widening there and the normal appearance on the left. So if your x-ray is abnormal, that's what it will look like. And what's the treatment? Weeks to months of rest from throwing. The one thing that's interesting about the physeal injuries in kids is they usually need more rest than your typical sprains, strains, or tendinitis. Physical therapy's important. So while I may rest them from their inciting event, like pitching or running, but I will start therapy usually sooner rather than later, and work on core and conditioning, and flexibility, and progress to sport-specific exercises. And then a gradual return to sports, such as pitching, with a focus on the pitch counts, as well as biomechanics. So we all know who's on the left, Kerry Wood. You can see eyes on target. It looks like you could put a straight line right through him. And this guy, out of the local newspaper, I want to give a business card to, because he looks a little crooked. He's throwing across his body. He doesn't have that 90 degree angle. So that's what our little leaguers tend to look like more commonly. And see he certainly would be at risk, because if he's all wobbly with a weak core, then he's going to have to be an arm thrower to have any significant velocity there as well. All right. Moving right along. Case two. 13-year-old, right-hand dominant, baseball pitcher with a one-month history of medial elbow pain. His activity related loss of pitch velocity, denied any numbness, tingling, clicking, locking, or other pain in the elbow. And she wants to know if she can pitch tonight. Anyone? Can she pitch? No. Probably not a good idea. So her differential diagnosis is apophysitis, medial epicondyle avulsion fracture, tendinitis, ulnar collateral ligament injury, ulnar neuritis, or, again, the more rare things, like neoplasm infection, or osteochondritis dissecans. Although, that tends to occur more laterally. So again, with the elbow, remember, you tend to get valgus stretching injuries medially and compression injuries laterally. So little league elbow, sometimes known as valgus overload syndrome, is an eponym. But it refers to inflammation or widening at the medial epichondyle, ages 10 to 14 years, medial elbow pain, and, again, very similar to little league shoulder. We're sort of distinguishing between poor biomechanics, too many pitches, or some combination of both. Low threshold for x-rays. I think this is one of the most helpful places to look at comparison views as well. Sometimes additional imaging is required. And realize that radiographs can frequently be normal, somewhere between 60% and 85% of the time. So if you only have tenderness over that medial epichondyle, that's enough in the right setting to make the diagnosis of little league elbow. You do not rely on an abnormal radiograph to do that. All right. So here you can see that x-rays are labeled with a capitulum trochlear radius, medial epichondyle, lateral epichondyle, and the olecranon on the lateral view. Treatment, again, similar to little league shoulder. Four to six weeks of rest from throwing. Avoid weights and resistance exercises, such as push-ups, or too much pressure on the elbow. But focus on flexibility and core strengthening. Elbows are something we want to see sooner rather than later, because they have a lot more complications than the shoulder, including instability, weakness, difficulties with associated cartilaginous injuries. And there can be issues at the growth plates indeed, a [INAUDIBLE] fractured as well, with deformities and delayed unions. Treatment, again, just to summarize, part of what gets built into treating this is then to build in a prevention program, which involves warm ups, flexibility, strengthening. Pay attention to pitch types and counts. There's a lot of information available on that on little league websites. USABaseball is very helpful. And there's links to throwing programs and things like that. The recommendation is for pitchers to only pitch nine months out of the year. They can cross-train. But they really should have some time off from pitching. Case three, wrist pain in a gymnast. A 12-year-old, right-hand dominant, level six gymnast with a three-month history of wrist pain. Pain was worse with weight bearing and wrist extension. There's no swelling, clicking, or trauma. And the diagnosis is-- anyone? Shout it out. Gymnast wrist. Distal radial physeal injury. And we've had coffee, and so we're raring to go. Weight lifters and gymnasts, again, this is pretty unique, because it's about the only two sports in young ages that we see significant problems with the distal radius. Again, this is pretty easy to examine, unlike the elbow and the shoulder. But tender in the distal radius or pain with axial loading, such as a wall push up or a floor push up, and there is pretty significant complications to a premature growth plate closure, resulting on ulnar overgrowth. And I'll show you what that looks like. So in this radiograph, it's very similar to the proximal humerus I showed you, where there is significant widening here at the distal radial physis, and, actually, a little bit of widening at the ulnar physis as well. And on the MRI and the T1s, you can see the abnormalities in the growth plate. And then here, when we turn the bones black in the [INAUDIBLE], see the significant signal change with whiteness around the distal radius and a little bit there as well in the distal ulna. So pretty abnormal MRI. ISO So the long term complications-- and I apologize. You have to look from right to left on this slide. But here's a normal alignment. The ulna tends to be a little shorter and the physis a little more proximal than the distal radius. The TFCC sits here, which is the Triangular Fibrocartilage Complex. And that let's your wrist deviate. But at six months later, the same patient, the radius really hasn't grown very well. The physis looks maybe a bit sclerotic and narrow. But the ulna's continued to grow. So now look at the alignment between the two physes as well. So now we have positive ulnar variance, ulnar overgrowth. And this person's going to have a lot of trouble deviating that wrist ulnarly as a result. So that's a permanent complication there that has to be dealt with. All right. So treatment for this predominantly is rest of the growth plate if you have gymnast wrist until it's non-tender for about four to six weeks, usually with a brace, rarely with a cast. And then prevention. So return them gradually to weight bearing. All right. Moving on to the knee. The knees are the first thing to go. This is a really bad case of patella baja. This is surgical. All right. Dr. Ho's going to have to fix that. So case for a knee pain. Basketball, 13-year-old with three-month history of unilateral anterior knee pain and swelling. Pain is activity-related. No trauma locking. And they're tender at the tibial tubercle. And they often come in and say their knee is swollen. And you have to distinguish to make sure it's not a joint effusion, that they are indeed referring to the swelling on the knee. So I think we all know what this is, Osgood-Schlatter disease. So the most common causes of anterior knee pain in adolescents. It can occur bilaterally. Girls, it occurs a little younger ages often, and associated with jumping and cutting. So it tends to be tender anteriorly with a bump. What you should not have-- and this is important to remember. You should not have a knee effusion. You should not have knee instability or any problems with range of motion or meniscal signs. X-rays are not necessarily required if it's pretty straightforward. But we do like to look at the growth plates. And that's what it'll look like there. So it has a broad differential diagnosis. And the most important part about this differential diagnosis is to remember that you can have a hip pathology presenting as thigh or knee pain. And Osgood-Schlatter's is so common that sometimes they'll actually have Osgood-Schlatter's but have something else going on in their leg as well. Sinding-Larsen-Johansson is also common. Sometimes you'll see a little ossification avulsion at the inferior pole of the patella. Osgood-Schlatter's, again, is the proximal tibial tubercle. You can see that there. The treatment, again. I have some success with counterforce bracing. Icing is your friend. You can do hamstring and quadricep stretches and work on jump squat mechanics. And that's probably the best way to treat this. All right. So in this young man, why did I emphasize those hips so much? Because this young man had done really well for about four months from Osgood-Schlatter's and then came back and said, my thigh hurts. I think my Osgood-Schlatter's is back. And I apologize. I don't have the pre-op x-ray. But he ended up with a lack of internal rotation of his hip and some thigh pain. And he ended up with a SCFE and had a pinning there as well. So always make sure when you have knee pain that you examine the hips, especially in kids. All right. Case four-- oh. All right. I took part of this out in the interest of time. But I will just go over this briefly. So this is more of a traumatic Osgood-Schlatter's where the tibial tubercle completely avulses and gives you a high-riding patella. And you won't miss this, because this is someone who'll be unable to bend their knee. They'll have significant effusion, and there'll be a history of trauma. And that tibial tubercle's hanging there at the end of the patellar tendon. And that's going to have to be reattached. OK? All right. So I do a little bit of emergency medicine. So I said, I'm sorry. We tried everything. Your knee is dead. However, with Dr. Ho and Dr. Leland, that's usually not the case. We can save any knee. So we'll take care of that there. All right. Case five, heel pain, soccer. 11-year-old boy, club soccer player with a six-week history of heel pain. It hurts on the stairs, but there has been no trauma other than playing soccer six days a week. Flat feet, bad stretcher, and had a growth spurt. So what is this? Soccer heel. Sever's disease. Calcaneal apophysitis. Insidious activity-related heel pain. They may or may not have a bump at the insertion of the Achilles tendon, but far less likely. Bumps are very common in Osgood-Schlatter's, not so common in Sever's disease. Again, girls, sometimes hits a little younger than boys. And the same contributing factors. So you're starting to see some repetition here. Repetitive microtrauma, growth spurts, weak ankles, tight Achilles, biomechanical issues, poor footwear, things like that. So all those things have to kind of mentally run through your mind when you assess these patients. So what does the apophysis look like? It's pretty normal here to look like a half moon, crescent moon, on the back of the ankle. And the Achilles will attach there. They often have what we call a positive calcaneal squeeze test, where they're actually tender over their growth plate as well as in the Achilles tendon. And in an adult, you might be worried about a stress fracture or some nerve pain. But in kids, sometimes it's just the physis that you're squeezing that hurts. Treatment is again pretty self-limiting. At the end of the day, some kids will just naturally grow out of it. But we tend to want to interfere and speed the process along and make them more comfortable. So we do stretching. We look at their shoes, things like that. Case six. Iselin's disease. Base of the fifth metatarsal. It's very important. There's a lot of action that goes on there. But for purposes of this talk, we'll focus on the apophysis, where peroneus brevis attaches. X-rays are often normal. So you actually can see-- this isn't the best example-- a little crescent moon, again, just sitting there at the base of the fifth. So that can be normal on an x-ray. If it looks widened or pulled away, then that can be a stress fracture. And last, case seven, adolescent hip pain. A 16-year-old male, running at full effort, heard a pop in his groin with a 10 out of 10 pain, landed himself in the ER, possibly urgent care, and was unable to bear weight with right inner thigh and groin pain. So you certainly could think about femoral neck stress fracture or things like that, an acute traumatic SCFE or things like that in adults. But we also see apophysitis. So the differential could be an adductor strain, a hip flexors strain, SCFE, Perthes disease, or an apophyseal injury. And on x-ray you should be able to see the injury. Let me point it out to you. Right there is an avulsion. All right. And this is an important slide to remember where everything attaches here. So you have important ones-- the anterior superior iliac spine, the anterior inferior iliac spine. You should know the lesser trochanter. Symphysis pubis can be misaligned, ischial tuberosity for the hamstrings, and the greater trochanter as well. So any of those can give you a similar appearance of apophysitis. All right. Here's another example. If you look here you can see this is more of a healed apophysitis here. This is the normal side here. So see that almost looks like a bone spur when it's all healed up. And last but not least, sometimes there's complications, such as heterotopic ossification. So from a pretty benign avulsion where a hamstring attaches, you've got all of this heterotopic ossification here at the ischial tuberosity. So that's a problem. This young man says, I feel like I'm sitting on a golf ball every time I sit down, especially in a hard char at school. And I said, well, you sort of are. All right. So to summarize teaching points, a pain at the end of a long bone is a growth plate injury till proven otherwise. The growth plate is the weakest link. And what that means is that fractures are sometimes more common than sprains or strains. It's important that you know your anatomy and understand sport biomechanics and know a little bit also about growth and development. And summary, I always say these are treatable. So TREAT. T is Treatable. R is Relative Rest and guided Rehabilitation. We usually don't do complete rest. Education's important. So if you can guide patients to injury prevention websites and guidelines for their sport, that's helpful. Remember to ask the key questions. And then oftentimes it's important that, as primary care providers, you're part of the treatment team. So as much communication as you can do with coaches and parents and therapists, that will help the athlete to get better.