Common Overuse Adolescent Injuries David B. Gealt, D.O. Assistant Professor UMDNJ-SOM Assistant Professor UMDNJ-RWJ Cooper Bone and Joint Institute Cooper University Hospital August 24, 2011

Understanding Normalcy Inverted Everted Normal Bow-leggedKnock-kneed Normal

Understanding Normalcy, cont. These are abnormal foot types…a normal or neutral foot type is a happy medium between these two. Pes planus = Flatfoot Pes cavus = High arch foot

Best Foot Forward A person who runs properly: A person who runs properly: Lands on heel Lands on heel Foot rolls to ball of toe while turning inward (pronates) Foot rolls to ball of toe while turning inward (pronates) A person who runs flat footed: A person who runs flat footed: Lands on heel AND ball of foot Lands on heel AND ball of foot Foot rolls inward excessively, which also causes the lower leg to turn inward Foot rolls inward excessively, which also causes the lower leg to turn inward A person who runs with a high arch: A person who runs with a high arch: Lands hard on heel Lands hard on heel Doesn’t pronate enough to allow the impact of running to be absorbed through the body Doesn’t pronate enough to allow the impact of running to be absorbed through the body The feet and outer part of knee and hip bear the brunt of each step The feet and outer part of knee and hip bear the brunt of each step

The Right Shoe: Basic Qualities How often do you need new shoes? How often do you need new shoes? It depends on how much running you do per week… It depends on how much running you do per week… Ex: Jog mi/wk, replace shoes every 3-4 mos Ex: Jog mi/wk, replace shoes every 3-4 mos Worn-out shoes (esp if soles are worn down unevenly) can be dangerous Worn-out shoes (esp if soles are worn down unevenly) can be dangerous They don’t provide proper support/stability anymore They don’t provide proper support/stability anymore Be aware of your foot type before purchasing new shoes Be aware of your foot type before purchasing new shoes With all the new shoes available, choosing a shoe is no easy task…this is where running shoe store experts come in! With all the new shoes available, choosing a shoe is no easy task…this is where running shoe store experts come in!

Shoe Inserts Some flat-footed runners may turn their feet inward to such a degree that good running shoes alone aren’t good enough Some flat-footed runners may turn their feet inward to such a degree that good running shoes alone aren’t good enough Prescription orthotics are custom-designed from a mold of the foot Prescription orthotics are custom-designed from a mold of the foot Sport orthotics should be made of soft, but firm materials Sport orthotics should be made of soft, but firm materials

Stress Fractures Caused by repeated loading stresses Caused by repeated loading stresses Most commonly in metatarsals (esp 2-4) Most commonly in metatarsals (esp 2-4) Other common sites are tibia and sesamoids Other common sites are tibia and sesamoids First symptom is pain, often vague but localized First symptom is pain, often vague but localized History is extremely important History is extremely important Usually 2-3 weeks into season Usually 2-3 weeks into season Often after radical increases in training Often after radical increases in training

Stress Fractures, cont. X-rays may not be positive for 3-4 weeks! X-rays may not be positive for 3-4 weeks! If the clinician has a high degree of suspicion, an early diagnosis can be made by bone scans and MRI If the clinician has a high degree of suspicion, an early diagnosis can be made by bone scans and MRI

Stress Fractures: Treatment Usually accommodative Usually accommodative Pneumatic CAM walker (pictured) Pneumatic CAM walker (pictured) Cast boot Cast boot Below knee cast Below knee cast Orthotic with aperture cut-outs for involved metatarsal to redistribute forces around it Orthotic with aperture cut-outs for involved metatarsal to redistribute forces around it

Achilles Tendonitis Most important cause is inadequate heel cord flexibility Most important cause is inadequate heel cord flexibility Other causes Other causes Instability of foot and heel strike Instability of foot and heel strike Running on unyielding surfaces Running on unyielding surfaces Inadequate shoes Inadequate shoes

Shin Splints The most common running injury The most common running injury Symptoms include tightness and aching in the front or back of the leg muscles during and after running Symptoms include tightness and aching in the front or back of the leg muscles during and after running X-rays or MRIs must be taken to be sure of diagnosis X-rays or MRIs must be taken to be sure of diagnosis Other possible diagnoses with similar symptoms: Other possible diagnoses with similar symptoms: Stress fracture Chronic compartment syndromes Periostitis Myositis Tendonitis

Anterior Shin Splints Often caused by change in running surfaces (from soft to hard), change in running pattern or change in shoes Often caused by change in running surfaces (from soft to hard), change in running pattern or change in shoes Treatment Treatment Shoe inserts or orthotics Shoe inserts or orthotics Ice massage Ice massage Strengthening exercises Strengthening exercises Change in running surface (hard to soft) Change in running surface (hard to soft) Wearing shoes with thick, shock-absorbing soles Wearing shoes with thick, shock-absorbing soles

Posterior Shin Splints Mostly caused by abnormal foot function in which the posterior muscles are overworked Mostly caused by abnormal foot function in which the posterior muscles are overworked Posterior muscles fatigue and fibers can tear loose from attachment to leg bone Posterior muscles fatigue and fibers can tear loose from attachment to leg bone Treatment Treatment Custom molded orthotics Custom molded orthotics Stretching exercises Stretching exercises Ice massage Ice massage

Runner’s Knee a.k.a. Chondromalacia Patella Knee pain may appear during or after running Knee pain may appear during or after running Frequently worse with running uphill or climbing stairs Frequently worse with running uphill or climbing stairs Patellofemoral pain is in and around kneecap, often associated with swelling and a sense that the knee cap is “off track” Patellofemoral pain is in and around kneecap, often associated with swelling and a sense that the knee cap is “off track”

Chrondromalacia (Patellofemoral Syndrome) Seen in young active persons, either gender, female predominance Seen in young active persons, either gender, female predominance Subactue onset of patellar pain, worse walking, stairs, little pain at rest, theater sign Subactue onset of patellar pain, worse walking, stairs, little pain at rest, theater sign Running Hills Running Hills Joint shows reproduction of pain on pressing patella against femoral condyles—pushing down on kneecap Joint shows reproduction of pain on pressing patella against femoral condyles—pushing down on kneecap

Runner’s Knee, cont. Therapy is planned after assessing patellar mechanics and leg alignment Therapy is planned after assessing patellar mechanics and leg alignment Treatment Treatment quadriceps isometric strengthening exercises, quadriceps isometric strengthening exercises, NSAIDs, NSAIDs, bracing, bracing, orthotics orthotics

Ankle Sprains The ankle sprain is most common single injury seen by sports medicine physicians. The ankle sprain is most common single injury seen by sports medicine physicians. This injury is often viewed as minor, but can be associated with prolonged disability and recurrent instability in 25-30% of patients. This injury is often viewed as minor, but can be associated with prolonged disability and recurrent instability in 25-30% of patients.

Returning to Ambulation 1.non-wgt bearing (crutches) 1.non-wgt bearing (crutches) 2.Touch Down- Partial wgt bearing w/ crutches 2.Touch Down- Partial wgt bearing w/ crutches 3.Full 4 point gait- Full wgt bearing w/ crutches 3.Full 4 point gait- Full wgt bearing w/ crutches 4.Once crutch on opposite side 4.Once crutch on opposite side 5.Cane 5.Cane 6.Nml gait 6.Nml gait

Treatment - “PRICES” P - Protection P - Protection R - Rest R - Rest I - Ice I - Ice C - Compression C - Compression E - Elevation E - Elevation S - Support S - Support

Treatment - Support Prevents re-injury during rehab and on return to activity Prevents re-injury during rehab and on return to activity Use taping and/or bracing, air-stirrups, laced Swed-O/McDavid, Kalassy velcro wrap, or Active ankle Use taping and/or bracing, air-stirrups, laced Swed-O/McDavid, Kalassy velcro wrap, or Active ankle

The Traction Apophysitises: Introduction Categorized as overuse injuries Categorized as overuse injuries Once thought to be found only in elite, highly trained athletes Once thought to be found only in elite, highly trained athletes With the growth of organized sports for children and adolescents, have seen a large increase in these types of injuries With the growth of organized sports for children and adolescents, have seen a large increase in these types of injuries

The Traction Apophysitises: Anatomy Associated with the growth cartilage Associated with the growth cartilage Located at three sites: Located at three sites: Epiphyseal plate Epiphyseal plate Joint Surface Joint Surface Apophyseal insertions of major muscle- tendon units Apophyseal insertions of major muscle- tendon units

The Traction Apophysitises: Anatomy Sites of active growth in a child Sites of active growth in a child Consists of columns of growth cartilage uniting tendon with a bone Consists of columns of growth cartilage uniting tendon with a bone

The Traction Apophysitises: Common Locations Foot Foot Calcaneal apophysis Calcaneal apophysis Knee Knee Tibial tuberosity Tibial tuberosity Inferior pole of the patella Inferior pole of the patella

The Traction Apophysitises: Osgood-Schlatter Disease First recorded in 1903 simultaneously by both R.B. Osgood and C. Schlatter First recorded in 1903 simultaneously by both R.B. Osgood and C. Schlatter Osgood believed this was caused by microavulsions of the tibial tubercle from the insertion of the quadriceps mechanism Osgood believed this was caused by microavulsions of the tibial tubercle from the insertion of the quadriceps mechanism Age range is 10 – 15 years old Age range is 10 – 15 years old Girls 11 – 13 years old Girls 11 – 13 years old Goys 12 – 14 years old Goys 12 – 14 years old

The Traction Apophysitises: Osgood-Schlatter Disease At risk sports – repetitive impact sports At risk sports – repetitive impact sports Football Football Hockey Hockey Soccer Soccer Basketball Basketball Running Running Gymnastics Gymnastics

Osgood-Schlatter Syndrome Affects young adolescents Affects young adolescents Pain at the inferior aspect of the patella, subacute to chronic onset Pain at the inferior aspect of the patella, subacute to chronic onset Joint is tender to palpation, occasionally swelling in region of tibial tubercle Joint is tender to palpation, occasionally swelling in region of tibial tubercle

The Traction Apophysitises: Osgood-Schlatter Disease Clinical manifestations Clinical manifestations Pain and swelling over the tibial tubercle especially after athletic activities Pain and swelling over the tibial tubercle especially after athletic activities Pain with running, jumping, squatting, kneeling Pain with running, jumping, squatting, kneeling May have permanent “bump” under knee May have permanent “bump” under knee

Osgood-Schlatter Syndrome Tx is via reassurance and analgesics Tx is via reassurance and analgesics

The Traction Apophysitises: Osgood-Schlatter Disease Treatment Treatment RICE RICE Bracing Bracing Education of disease process to parents and athlete (self-limiting) Education of disease process to parents and athlete (self-limiting) Modification of sports activity/avoidance of exacerbating activities Modification of sports activity/avoidance of exacerbating activities

The Traction Apophysitises: Osgood-Schlatter Disease Treatment Treatment Stretching and strengthening of the hamstring and quadriceps muscle groups as well as the gastrocnemius-soleus muscle complex Stretching and strengthening of the hamstring and quadriceps muscle groups as well as the gastrocnemius-soleus muscle complex Bracing may be needed for restraint or severe cases that dissipate the force of the quadriceps contraction Bracing may be needed for restraint or severe cases that dissipate the force of the quadriceps contraction (chopat strap) (chopat strap)

The Traction Apophysitises: Sinding-Larsen-Johansson Syndrome Similar to Osgood-Schlatter disease Similar to Osgood-Schlatter disease Pain is over the distal pole of the patella Pain is over the distal pole of the patella Like OSD, debate over whether pain is from avulsion fractures vs. patellar tendonitis Like OSD, debate over whether pain is from avulsion fractures vs. patellar tendonitis Analogous to “jumper’s knee” in the skeletally mature athlete (patellar tendonitis) Analogous to “jumper’s knee” in the skeletally mature athlete (patellar tendonitis)

Sever’s Disease Calcaneal Apophysitis Calcaneal Apophysitis Heel pain is the presenting symptom located over the oscalcis apophysis Heel pain is the presenting symptom located over the oscalcis apophysis Most common cause of heel pain in adolescents Most common cause of heel pain in adolescents At risk sports include soccer, running, and gymnastics At risk sports include soccer, running, and gymnastics

Sever’s Disease + Squeeze Test + Squeeze Test Treatment Treatment Self Limiting Self Limiting Rest from activity; NSAIDS Rest from activity; NSAIDS Silicone Heel Cups Silicone Heel Cups Stretching of the gastrocnemius-soleus muscle complex and strengthening of the dorsiflexors of the ankle Stretching of the gastrocnemius-soleus muscle complex and strengthening of the dorsiflexors of the ankle Cam Walker Boot Cam Walker Boot Orthotics if necessary Orthotics if necessary

The Traction Apophysitises: Sever’s Disease Physical Exam Physical Exam Pain over posterior heel Pain over posterior heel

The Traction Apophysitises: Sever’s Disease Treatment Treatment Stretching of the gastrocnemius-soleus muscle complex and strengthening of the dorsiflexors of the ankle Stretching of the gastrocnemius-soleus muscle complex and strengthening of the dorsiflexors of the ankle Orthotics if necessary Orthotics if necessary Heel cups or other OTC orthotics Heel cups or other OTC orthotics Custom orthotics Custom orthotics

Conclusion Keep in mind that there are many alternate training techniques, an athlete does not have to give up all training when injured Keep in mind that there are many alternate training techniques, an athlete does not have to give up all training when injured Cycling Cycling Swimming Swimming Water running in waist-high water Water running in waist-high water Rowing Rowing Upper body ergometer Upper body ergometer Etc. Etc. ALSO remember the concept behind the original injury so you can help to prevent it in the future ALSO remember the concept behind the original injury so you can help to prevent it in the future