“Growing Pains”Injury and Skeletal

Immaturity

Ken Knecht, PT, MS, SCS, CSCS

Understanding the Population

Children are not “Little Adults”

Understanding the Population

“What’s the Difference?” Skeletal Maturity Physiology Strength (and the Ability to Develop It) Psychological Maturity

Understanding the Population

“What’s the Difference?” Skeletal Maturity Physiology Strength (and the Ability to Develop It) Psychological Maturity

Growth & Development of the Young Athlete

Middle Childhood (6-9 yrs) Maturation of Throwing and Kicking Patterns Entry Level Sports (soccer, baseball/softball) Males and females can still compete with parity

Males slightly Stronger; Girls better Balance Running gait and speed are fairly equal

Late Childhood to Early Adolescence (10-15 yrs) Onset of Puberty “Growth Spurt” – Tanner Stage 3 Differences emerge between sexes Skill Acquisition and Development Easiest

Growth and Development of the Young Athlete

Late Adolescence/Adulthood (16-20 yrs) Increases in Strength & Size become more

gradual “Late Bloomers” may continue to lag behind Skeletal maturity

Growth and Development Anatomic Changes Associated with

Puberty Boys Girls

(Mean Age)

Peak Height Velocity (14 yrs) Peak Height Velocity (12 yrs)Skeletal Maturity (16 yrs) Skeletal Maturity (14 yrs)

**Introduction of Sex hormones (Athl Ther Today 2002)

Growth and Development Significance of Peak Height Velocity

The “Growth Spurt” ~ Tanner Stage 3 Bone growth rate can exceed soft tissue

accommodation Hamstrings, Hip flexors, Quadriceps, and

Plantarflexors Decreased Coordination Tightness can affect growth centers

Growth and Development Significance of Tanner Staging

5 stages of Physical development Stage 1 = Early Development Stage 5 = Full Maturity

Correlation between Tanner stage and physeal closure. Same Chronologic age ≠ Bone Age Assists with the differential diagnoses

Growth and Development Tanner Stage 5

Signals end of growth Marked by full development of

secondary sexual characteristics Males will have full facial hair Females will have final breast development

Skeletally Immature Distinctions

Growth “Tissues” Physis Apophysis Articular Cartilage

Issues: Susceptibility to injury

Bone weakest link Surgical Challenges

“Growth Tissue” Physis (Growth Plate)

Responsible for longitudinal growth of bone

Growth centers close distal to proximal Growth centers begin to close in females

approximately 18 – 24 months following menarche

Skeletal Maturity Completed ~18 yrs females; ~21 yrs males

Injury to Physis could create growth disturbance (early closure or bony bridging)

Anatomical Review

http://www.davidlnelson.md/images/Physis_normal_annotated4.jpg

Salter-Harris Fractures Type I: Fracture line extends across the physeal

plate. Often undetected on X-ray Type II: Fracture line extends through the physeal

plate and metaphysis Type III: Fracture line extends from the joint surface

through the epiphysis and across the physis causing a portion of the epiphysis to become displaced

Type IV: Fracture line extends from joint surface through the epiphysis, physeal plate and metaphysis causing a fracture fragment

Type V: Crush injury to the growth plate

Salter Harris Fractures

Separated Above Lower Through E Rammed

Salter Harris Fracture Distal Fibula

Usually an inversion/supination injury Type I-II are the most common Type I often misdiagnosed as ankle

sprain

Salter Harris Fracture Key Finding on Physical Exam:

Point of Maximal Tenderness Usually PTP at ATFL also

Salter Harris Fracture Boot immobilization (casting)

Depending on Type; 2-3 weeks + Types III & IV require surgery

Pain free weight bearing status Rehabilitation for post

immobilization ROM, strength, balance & proprioception Sport specific training

Little League Shoulder Epiphysiolysis of

proximal humerus Rotational forces Distractional forces

Overuse injury associated with pitching Quantity Intensity Age

Phases of Throwing

www.hughston.com/hha/b_16_1_1a.jpg

Little League Shoulder Clinical Findings

Lateral, proximal shoulder pain Weak & painful EROT and Abd Palpable tenderness over

physis Radiographic widening of

physis?

Little League ShoulderTreatment

Aggressive rest to allow physeal healing Address any ROM imbalances & Scapular

dysfunction GIRD, posterior capsule Sick Scapula Scapular stabilization & strengthening

Rotator cuff strengthening Review of throwing mechanics

Return to throwing progression Modification of throwing volume (pitch counts) May need to alter position

Address entire kinetic chain Core strengthening Lower extremity strength/flexibility and proprioception

“Growth Tissue” Apophysis

Cartilaginous structure usually located at the end of long bones

Attachment site for musculotendinous unit

Tensile forces can create inflammation = Apophysitis

Susceptible to Avulsion Fracture

Apophysitis Overuse injury Often during periods of rapid growth May remain symptomatic until

closure of apophysis Possible to result in an avulsion

fracture

Sever’s Disease aka: Calcaneal

Apophysitis Common During Growth

Spurt Heel pain Tight gastroc/soleus Foot pronation Running/jumping athletes + Squeeze Test

Sever’s Disease Treatment Activity modification

Aggressive rest Stretching!!! Immobilization may be necessary Can continue to play if pain is mild (no

limp) Typically resolves in several weeks

(months?) Footwear or insert

Osgood-Schlatter’s Disease (OSD)

Apophysitis of the Tibial Tubercle

Traction Injury Commonly seen

Boys aged 10 –15 Girls aged 8 –13

Osgood-Schlatter’s Disease (OSD)

Palpable tenderness X-rays may be

positive for displacement

In severe cases tubercle can avulse

Osgood-Schlatter’s Disease (OSD)

Sinding-Larsen-Johansson (SLJ)

Apophysitis of the inferior patellar pole

Anterior knee pain with impact activities

Commonly seen Boys aged 10 –15 Girls aged 8 –13

Sinding-Larsen-Johansson (SLJ)

Palpable tenderness Inferior pole sometimes

patellar tendon May have quadriceps

lag X-rays may be positive

for displacement Differential diagnosis

Patellar sleeve fracture

Treatment for OSD and SLJ Activity modification Stretching quads and hams Strengthening progression Plyometric training to work on soft

landings May not have complete resolution of

symptoms In OSD permanent bump is likely

Apophysitis of Hip/Pelvis 7 sites at the femur and pelvis During phase of rapid growth Pain and inflammation at

ossification centers Iliac crest (common)

Pain with resisted trunk rotation/side bend and/or hip abduction

Seen in Runners, Football, and occasionally Baseball pitchers

Apophysitis of Hip/Pelvis Treatment

Rest Activity modification Trunk and pelvis

flexibility Core and hip

strengthening Treat the entire kinetic

chain Technique adjustment

Running gait

Avulsion Fractures Same areas affected as apophysitis Occur with sudden, forceful contraction or stretching

Bone is the weakest link Common sites include ASIS and Ischial tuberosity. Often misdiagnosed as pulled muscle Radiographic evaluation necessary for accurate

diagnosis Surgery if displacement is greater than 2-3cm (???)

Avulsion Fractures

AIIS avulsion fracture in a 14 yr old soccer player

Little League Elbow Traction apophysitis of Medial epicondyle of

Humerus Overuse injury

Volume Velocity Increased mound to plate distance Breaking Pitches?

Valgus stress during late cocking/acceleration

Flexor pronator muscle group UCL?

Clinical presentation Medial elbow pain Diminished throwing speed and accuracy Poor or altered throwing mechanics

Little League Elbow Treatment

RICE: Make rest your friend Activity modification 6-12 weeks

No pitching or overhand throwing Stretching

GIRD is Probable; Assess and address!!! Strengthening

Forearm, posterior cuff, core, contralateral leg Assess throwing mechanics Functional progression to throwing program Identify and correct training errors

“Growth Tissue” Articular Cartilage

Infrastructure similar to Physis Increased Cellular activity Not yet “Adult” solidity

Repetitive Injury or Excessive shearing forces may result in Osteochondritis Dissecans (OCD)

Osteochondritis Dissecans (OCD)

Impact and shear forces cause bone bruising

Cause is usually repetitive trauma Genetic predisposition?

Subchondral bone death Secondary damage to overlying cartilage “Lesion of dissection” vs dessication May affect any joint

Most frequently seen at knee, elbow, ankle

Osteochondritis Dissecans (OCD)

Risk Factors Age: Occurs most often in people between

the ages of 9 and 18

Sex: Males are 2-3X more likely than females.

Sports participation: Sports that involve rapid changes in direction, jumping or repeated throwing may increase your risk

Osteochondritis Dissecans (OCD)

ICRS Classification of OCD Grade I – Stable with continuous

but softened area with intact cartilage

Grade II – Stable with partial discontinuity

Grade III – In situ lesions with complete discontinuity

Grade IV – Empty defects with dislocated or loose fragments

Osteochondritis Dissecans (OCD)

Epiphyseal microtrauma with osteochondral separation

Commonly Lateral aspect of Medial femoral condyle

Etiology is multifactorial Trauma, ischemia, hereditary,

idiopathic (?) Under debate

Osteochondritis Dissecans (OCD)

OCD of Femoral Condyle Clinical presentation

Insidious onset of pain aggravated by activity

Intermittent joint effusion Giving way, catching, or locking Symptoms suggestive of PFPS Confirmed with diagnostic imaging

OCD of Femoral Condyle Conservative Management

Immobilization Weight bearing restriction Activity restriction

Surgical intervention Extent depends on Grade

Debridement /drilling Refixation Loose body removal Operative resurfacing ACI

Clinical Summary Bone weakest link in pre pubescent Same Chronological age ≠ Bone Age

Tanner staging helps differential Protect Growth centers

THANK YOU!!!

Ken Knecht PT, MS, SCS, CSCSBoard Certified Sports Clinical SpecialistThe Sports Medicine & Performance Center at CHOP Specialty Care Center at Virtua Health and Wellness Center, 2nd Floor200 Bowman Drive, Suite D260Voorhees, NJ 08043856-719-9932; Fax: 267-425-5416

knecht@email.chop.edu