1. “Growing Pains” Injury and Skeletal Immaturity
Ken Knecht, PT, MS, SCS, CSCS

2. Understanding the Population
Children are not
“Little Adults”

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

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

5. 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

6. 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

7. 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)

8. 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

9. 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

10. 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

11. Skeletally Immature Distinctions
Growth “Tissues”
Physis
Apophysis
Articular Cartilage
Issues:
Susceptibility to injury
Bone weakest link
Surgical Challenges

12. “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)

13. Anatomical Review

14. 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

15. Salter Harris Fractures
Separated Above Lower Through E Rammed

16. Salter Harris Fracture
Distal Fibula
Usually an inversion/supination injury
Type I-II are the most common
Type I often misdiagnosed as ankle sprain

17. Salter Harris Fracture
Key Finding on Physical Exam:
Point of Maximal Tenderness
Usually PTP at ATFL also

18. 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

19. Little League Shoulder
Epiphysiolysis of proximal humerus
Rotational forces
Distractional forces
Overuse injury associated with pitching
Quantity
Intensity
Age

20. Phases of Throwing

21. Little League Shoulder
Clinical Findings
Lateral, proximal shoulder pain
Weak & painful EROT and Abd
Palpable tenderness over physis
Radiographic widening of physis?

22. 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

23. “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

24. Apophysitis Overuse injury Often during periods of rapid growth
May remain symptomatic until closure of apophysis
Possible to result in an avulsion fracture

25. Sever’s Disease aka: Calcaneal Apophysitis Common During Growth Spurt
Heel pain
Tight gastroc/soleus
Foot pronation
Running/jumping athletes
+ Squeeze Test

26. 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

27. Osgood-Schlatter’s Disease (OSD)
Apophysitis of the Tibial Tubercle
Traction Injury
Commonly seen
Boys aged 10 –15
Girls aged 8 –13

28. Osgood-Schlatter’s Disease (OSD)
Palpable tenderness
X-rays may be positive for displacement
In severe cases tubercle can avulse

29. Osgood-Schlatter’s Disease (OSD)

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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 (???)

36. Avulsion Fractures
AIIS avulsion fracture in a 14 yr old soccer player

37. 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

38. 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

39. “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)

40. 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

41. 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

42. 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

43. Osteochondritis Dissecans (OCD)
Epiphyseal microtrauma with osteochondral separation
Commonly Lateral aspect of Medial femoral condyle
Etiology is multifactorial
Trauma, ischemia, hereditary, idiopathic (?)
Under debate

44. Osteochondritis Dissecans (OCD)

45. 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

46. 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

47. Clinical Summary Bone weakest link in pre pubescent
Same Chronological age ≠ Bone Age
Tanner staging helps differential
Protect Growth centers

48. THANK YOU!!!

49. 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 ; Fax: