“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 14

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 Shoulder Treatment 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 Surgical intervention 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, CSCS Board Certified Sports Clinical Specialist The Sports Medicine & Performance Center at CHOP Specialty Care Center at Virtua Health and Wellness Center, 2nd Floor 200 Bowman Drive, Suite D260 Voorhees, NJ 08043 856-719-9932; Fax: 267-425-5416 knecht@email.chop.edu