Pediatric Sports Medicine
Organized sports for children are increasing in the United States. The potential physical, psychological, and social benefits of participation in such programs are many. However, negative consequences can also occur. Both children and their parents are often driven by the many tangible rewards for exceptional performance. This has resulted in a major increase in injuries associated with organized sports. These can be divided into two groups and are addressed below.
Overuse syndromes result from placing a highly repetitive stress on a given structure until injury occurs. This can produce several patterns of injury that are unique to the growing skeleton. Shin Pain Shin pain is a nonspecific symptom complex characterized by pain along the anterior aspect of the leg with activity. Persistent shin pain requires investigation to identify an underlying etiology. The differential diagnosis includes stress fractures, shin splints, periostitis, nerve entrapment, muscle strain, infection, tumors, and exercise-induced compartment syndrome.
Repetitive application of a load to a bone can produce a stress fracture. This usually presents with the gradual onset of activity-related pain. The tibia and metatarsals are the sites most common affected. Initial radiographs may be normal, whereas a bone scan will demonstrate early increased uptake. These findings must be interpreted carefully, because stress fractures can easily imitate infection, osteoid osteomas (an inflammatory lesion of bone), and malignant neoplasms. Treatment is directed at avoidance of the offending activity. Casting or bone grafting may be necessary if spontaneous healing fails.
Most throwing syndromes result from repetitive valgus stress at the elbow. Osteochondrosis of the capitellum, or so-called Little League elbow, is commonly seen in baseball pitchers and gymnasts. Patients complain of pain, grinding, and reduced range of motion of the elbow. Radiographs show fragmentation of the capitellum with or without a loose body. Treatment involves activity modification or avoidance, strengthening, and surgery if a loose body is present. Other throwing syndromes seen less frequently include epiphysiolysis (slipping of the humeral epiphysis through the physis) of the proximal humerus, osteochondritis of the radial head, and stress injury or fracture to the medial epicondyle.
Ligamentous injuries and fractures of the ankle, knee, and shoulder often occur in association with participation in organized sports. Each injury requires careful evaluation to avoid confusing “simple” sprains with more complex physeal injuries or osteochondral fractures. Major swelling, hemarthrosis, or inability to bear weight should prompt x-ray evaluation.
Ankle sprains are a common sports injury. The usual mechanism is inversion of the ankle, producing varying degree of disruption to the lateral stabilizing ligaments or the anterior ankle capsule. Treatment is based on the severity of the injury and follows the basic principles of rest, ice, compression, and elevation (“RICE”). For most sprains, rehabilitation exercises, taping, or a compressive ankle brace are adequate. More severe injuries may require casting or, rarely, surgical reconstruction of the ligaments.
Acute Knee Injuries
Acute knee injuries, especially those associated with hemarthrosis or inability to walk, require careful assessment. In the younger child, ligamentous injury is decidedly rare, with avulsions of bone at ligamentous insertions, osteochondral fractures, or physeal injury more common. In the adolescent, pure ligamentous disruption is similar to the adult pattern of injury. A clinical history of a forceful twisting injury to the knee, associated with a “pop,” pain, and rapid onset of swelling, suggests a major injury. Examination of the knee after acute injury is often compromised by pain and swelling. Radiographs, including standard, oblique, and stress views, are helpful. In some instances, examination under anesthesia may be necessary. Treatment is age and diagnosis specific. Many problems, such as acute patellar dislocation, anterior cruciate ligament tears, and collateral ligament injuries, are initially managed with bracing and an aggressive rehabilitation program. In children, ligamentous reconstruction is delayed until skeletal maturity.
Anterior Cruciate Ligament (ACL) ACL injuries are being found more commonly than was thought in the past. This is especially true in adolescent females, and with participation in soccer. The incidence of ACL injuries is four times greater in teenage girls playing soccer than their male counterparts. The reasons for this may be related to a greater degree of ligamentous laxity in adolescent females.
The diagnosis of an ACL injury in children may be more difficult than is typical for adults. Common signs of ACL injury in children include a “pop” in the knee, followed by the knee filling with a tense collection of fluid shortly after the injury. This swelling is usually actually blood, known as a hemarthrosis. It is a painful injury, and many kids will have difficulty walking afterwards. If you suspect a significant injury has occurred to your knee, or your child’s knee, then it is important that you have an x-ray of the knee. In skeletally immature athletes, it is possible to injure the growth plate above or below the knee, or to pull off a large fragment of bone called the tibial eminence where the ACL attaches. It is important to recognize these fractures because they would change the type and urgency of surgical treatment for the injury. There are several ways to confirm if the ACL has been torn. For many complete tears, a standard examination of the knee for instability will often reveal laxity of the ACL. However, due to the strength of the secondary restraints of the knee (other ligaments, muscles, tendons, etc) the exam is not always reliable.
Mechanical testing with the KT 1000 will sometimes differentiate an ACL injury in one knee when comparing it to the opposite side. If uncertain, an MRI of the knee will usually show whether the ACL is torn, and offers the added benefit of looking at the associated structures such as the meniscus, supporting ligaments of the knee, and the weight bearing surfaces of the knee joint. The gold standard for confirming the diagnosis is arthroscopy of the knee.
Having an ACL injury as a adolescent is clearly different than having this injury as an adult. Most kids that sustain ACL injuries are actively participating in sports and wish to continue to do so. It is clearly established that the risk of developing additional injuries to the knee such as meniscal injuries is greater without a functional ACL. Additionally, it is difficult to expect teenagers to modify or quit sports that they enjoy at such a young age. Most ACL reconstruction requires the creation of a “tunnel” that crossed the growth plates adjacent to the knee. There have been concerns that this would result in significant disturbance in the growth of the leg. This was used as the rationale to not reconstruct the ACL prior to the end of growth. However, there is now a growing track record for ACL reconstruction prior to skeletal maturity that indicates that the risk of growth disturbance is not as great as previously thought. Other than children < 10 years old (in whom fractures are more common anyway…) ACL reconstruction is well tolerated. The benefits in the active teenage athlete seem to outweigh the risks
Acute Shoulder Dislocation
Dislocation of the shoulder is rare in children but may occur in adolescence. The most common mechanism is that of forced abduction and external rotation of the shoulder producing an anterior dislocation. Immediate reduction under sedation is recommended. The incidence of chronic instability and recurrence is higher when the initial dislocation occurs before 20 years of age.