1. Injury Problems in Children and Adolescents School of Health Care Professions, University of Salford Steve Aspinall BSc (Hons) GSR Lecturer Directorate of Sport

2. Introduction Sport has many benefits, including improved:Sport has many benefits, including improved: – physical fitness – co-ordination – self discipline – team work – personal satisfaction and accomplishment.

3. But there is a negative side…. However, as the popularity of organized sports activities for children and adolescents has increased, so has the injury risk.However, as the popularity of organized sports activities for children and adolescents has increased, so has the injury risk. Children and adolescents can be more susceptible to injuries as not only are they still growing but they are still developing motor and cognitive skills.Children and adolescents can be more susceptible to injuries as not only are they still growing but they are still developing motor and cognitive skills.

4. Differences in Bone and Soft Tissue Structure That Can Result In Age Related Soft Tissue Injury BoneBone –Growth Plate Pathology, junction between epiphyseal plate and the metaphysis is vulnerable to injury. –Tendon attachment sites(apophyses) relatively weak. –Hormonal Responsiveness Muscle & TendonMuscle & Tendon –Decreased Relative Flexibility During Growth Spurt LigamentLigament –Greater Relative Strength

5. Overuse? Overuse is the most prevalent sports related injury mechanism.Overuse is the most prevalent sports related injury mechanism. Sustained exercise imparts stresses and strains on the musculoskeletal system. Although these are below macroscopic tissue failure they still result in microscopic damage. If the rate of this repetitive microtrauma exceeds the rate of healing then an overuse injury occurs.Sustained exercise imparts stresses and strains on the musculoskeletal system. Although these are below macroscopic tissue failure they still result in microscopic damage. If the rate of this repetitive microtrauma exceeds the rate of healing then an overuse injury occurs.

6. Apart From Strains and Sprains, What Other Injuries might we see? Acute FracturesAcute Fractures –Metaphyseal Fractures- Most common in the forearm and low leg. Often “Greenstick” or incomplete fractures as the long bones are more resilient and elastic. If uncomplicated, heal relatively quickly, sometimes in only 3 weeks.If uncomplicated, heal relatively quickly, sometimes in only 3 weeks.

7. –Growth Plate Fractures Of particular concern due to the risk of interruption to the growth process.Of particular concern due to the risk of interruption to the growth process. Any doubt or concern of this injury then specialist orthopedic referral is mandatoryAny doubt or concern of this injury then specialist orthopedic referral is mandatory –Avulsion Fractures Occur at the attachment of ligaments or tendons to bones where the tendon or ligament is pulled away with its apophyseal attachmentOccur at the attachment of ligaments or tendons to bones where the tendon or ligament is pulled away with its apophyseal attachment Treatment involves reduction of pain and swelling, restoration of ROM and eventually a progressive conditioning program.Treatment involves reduction of pain and swelling, restoration of ROM and eventually a progressive conditioning program.

8. Shoulder PainShoulder Pain – Fractures of the humerus, clavicle, acromion or corocoid process caused by acute trauma. –Dislocations-More common in adolescents. Treat properly or reoccurrence will occur. –Impingement-Usually secondary to atraumatic instability caused by repetitive stress. –Tendinopathy & Impingement-Frequently a combination of overuse, poor technique and muscular/biomechanical problems.

9. Elbow PainElbow Pain –Repetitive stress in throwing sports and gymnastics can lead to traction injury on the medial aspect of the elbow and compression injury on the lateral side. Unless dealt with, can lead to bony thickening, loose body formation, contractures and nerve injury. –Very important that young athletes have adequate rest between training sessions and are properly coached.

10. Wrist painWrist pain –Acute wrist pain could be result of a fracture with the scaphoid most commonly affected. –Dorsal wrist pain-usually due to distal radial or ulnar growth plate injury. Less common causes include sprains and fractures. Treatment generally involves relative rest, splinting, modalities and NSAID’s.

11. Low Back PainLow Back Pain –Similar to those in mature adult. –Minor soft tissue injuries usually respond well to a reduction in activity. –Spondylolysis/listhesis- stress fractures from repeated hyper extension in ballet, gymnastics, volleyball, fast bowling in cricket and serving in tennis. In these cases, the amount of hyperextension must be reduced.

12. Hip PainHip Pain –More common in the younger athlete than adult –Apophysitis-Excessive strain on one of the muscle attachments around the hip joint, usually the attachment of rectus femoris, sartorius or the iliopsoas attachment to the lesser trochanter. Treatment involves a reduction in activity, modalities as required and the correction of predisposing factors. –Perthes disease-An osteochondrosis affecting the femoral head. Most common in children between 4 and 10 years. Dependent upon severity, treatment will range from rest to surgery.

13. –Slipped femoral epiphysis- Usually in adolescents, between the ages of 12 & 15 years. Most common presenting symptom is a limp. Can be a matter of considerable concern. –Also “irritable hip” is common in children, presents with limp and poorly localized pain but all tests are negative and cause is not identified. Treated with rest.

14. Knee PainKnee Pain –Osgood-Schlatter disease-An osteochondritis at the growth plate of the tibial tuberosity. Common in adolescents at the time of the growth spurt. Associated with high levels of exercise, especially in sports involving lots of running and jumping. Self limiting, but can persist for up to 2 years. This should be treated with activity modification, ice as required and modification of predisposing factors. –Sinding-Larsen-Johansson disease-Similar to Osgood- Schlatter but less common and affects the inferior pole of the patella.

15. Foot PainFoot Pain –Severs Disease-Is a traction apophysitis of the insertion of the achilles tendon into the calcaneous. Second most common osteochondrosis after Osgood-Schlatter disease with similar treatment. –There are also various other, relatively uncommon, osteochondrosis affecting the foot.

16. So What Are The Risk Factors? Training ErrorTraining Error –Abrupt increase in training: IntensityIntensity DurationDuration FrequencyFrequency Inadequate warm-upInadequate warm-up Improper techniqueImproper technique Tired, injured, or inadequately rehabilitatedTired, injured, or inadequately rehabilitated

17. Musculotendinous imbalanceMusculotendinous imbalance –Strength –Flexibility Anatomical malalignment/intrinsic structureAnatomical malalignment/intrinsic structure –Lumbar hyper lordosis –Lower limb length discrepancy –Abnormal hip rotation –Patellar malalignment –Genu varum/valgum –Planus/Cavus foot

18. FootwearFootwear –Poor fit –Inadequate impact absorption –Excessive sole stiffness –Insufficient hindfoot support/heel counter –Arch support –Excessive Wear Playing Surface CharacteristicsPlaying Surface Characteristics –Poor shock absorption

19. Hormonal statusHormonal status –Delayed menarche –Amenorrhea GrowthGrowth –Prepubescent porus bone –Vulnerable growth cartilage Articular cartilageArticular cartilage –Relative weakness of growth plates –Decrease in flexibility during growth spurts –Abnormal development

20. GeneralGeneral –Poor nutrition/hydration –Psychological stress –Poor fitness –Size/weight differences amongst same age –Inclement weather

21. Some activity specific factorsSome activity specific factors –Hyper extension of lumbar spine (gymnastics, dance, cricket, tennis) –Shoulder overuse (swimming, racket sports) –Wrist/distal radius overuse (gymnastics) –Lower extremity (Running, jumping sports) (Micheli et al 2000) (Micheli et al 2000)

22. Summary Address the Risk factors including:Address the Risk factors including: –Screening as appropriate –Fitness & conditioning (Inc strength, flexibility, balance & psychological) –Environment –Use of appropriate equipment –Enforce safety rules –Match & group children according to skill level, weight and physical maturity