S3.3 Seil Overuse injuries in the immature athlete · 2013. 6. 11. · lesion in a young athlete as it is in an elderly patient with joint degeneration and a typical sports injury

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Centre Hospitalierde Luxembourg

OrthopaedicSurgery

Sports Medicine Research Laboratory

Centre de RecherchePublic – Santé,

Luxembourg

IOC advanced team physician course, Saltsjöbaden, Sweden 05-2013

Overuse injuries in the immature athlete.

Prof. Romain Seil, MD, PhD

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Why sports at pediatric / adolescent age?

Should be fun !

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• Susceptibility of growth plate

• Direct mechanical stress

• Repetitive physical strain

• Growth spurt during puberty

• Mechanical (over-)loading

• Variation of biological maturity at same

age

• Skeletal development precedes muscle& tendon growth

• Permanent changes of lever arms,

imbalances of muscle chains

Youth sports: specificities

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Growth of upper & lower segment not proportional

Growth

♀ 13 y.♂ 15 y.

Growth velocity

Height

Upper segment

Lower extremity

Difference Trunk / lower extremity

Juvenile peak

Gicquel P, Rev Chir Orthop 2007

= peak of injuries !

(Watkins J,

Peabody P 1996)

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Skeletal age

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Kahl H Bundesgesundheitsbl - Gesundheitsforsch - Gesundheitsschutz 2007

1 lesion out of 3 results from sports !

N = 16706

schoolhome traffic

15-17 y

5-14 y

1-4 y

schoolhome traffic

home

Magnitude: general population

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sports

sports

sports

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Injury surveillance sports school

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2

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2013

Increase in training intensity week before injury

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2.853.41*

2.16*#

1.06

1.38

0.65*#

0

1

2

3

4

5

6

2008-2009 (1) 2009-2010 (2) 2010-2011 (3)

Inc

ide

nc

e (

inju

rie

s/1

00

0h

)

Overuse injuries

Traumatic injuries

* significantly different from 2008-2009 (p

3

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Always be prepared for the worst !

Differential diagnosis

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♀, 15 y., Synchronized swimming;

Knee pain

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♂, 14 y.; Football;

Knee pain

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Epiphysiolysis capitis femoris


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Epiphysiolysis capitis femoris

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01-2011

Septic arthritis

04-2011

+ 3 mo.

03-2012

+ 13 mo.


♂, 13 y., Football

Left hip pain

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Types of injuries

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• Differential diagnosis (worst case)

• Osteotendinous junction

• Alterations of growth plate

• Congenital

• Muscle & tendon

• Alterations of bone metabolism

• Alteration of joint mechanics

• Joint dysfunctions

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Traction apophysitis

M. Sinding - Larsen

M. Sever

M. Osgood-Schlatter

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♂ 15 y., football

♂ 15 y., football

Hip



♀, 14 y, Tennis

„Growth epicondylitis“

♂ 12 y., Kayak

Consequence of overloading !

Elbow

Baseball:

Little leaguer’s elbow

Brogdon BG, 1960

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• Prevalence: 8%

• 30-60% bilateral

• fusion @ 18-25 years

• start with nonoperative treatment

• screw fixation, bone graft & cerclage if possible

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Os acromiale

♂, 24 y., gymnast

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• the most frequent apophysitis

• microtraumas

• excentric contractions

• ♀ 10-11 y.; ♂ 13-14 y.

♂, 14 y.

Fragmentation tuberosity

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Osgood – Schlatter disease

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• Relative rest (several months)

• Static quadriceps training

• Stretching

• NO CORTISONE !!!

No strict contraindication for sports, BUT: avoid jumps, acute accelerations or decelerations,

inform coaches and parents

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Osgood – Schlatter disease

♂, 15 y., handball

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Avulsions

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♂ 15 y, football

Surgical treatment mandatory

♂ 15 y, football

Nonoperative

♂ 15 y, football

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Avulsions

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Surgical treatment optional

Extraarticular endoscopic resection


Traction apophysitis & avulsions

• Frequent after growth spurt (♀ 13 y.; ♂ 15 y.)

• More frequent in boys

•Treatment: (relative) rest, immobilization (+ 4 weeks),

physiotherapy

• Sometimes specific diagnostic steps and

therapeutic procedures necessary

•Anticipate muscle imbalances

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Types of injuries

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• Muscle & tendon

• Congenital




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Growth plate

Epiphysis

Metaphysis

Germinal layer

Calcification

Chronic injury:

Impaired vascularisation

↓Decreased calcification

of hypertrophic zone

↓Physeal widening

Acute injury:Salter 3+4

=

vertical section of

germinal layer

↓Bone bridge formation

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Gymnast‘s wrist

Repetitive hyperextensions

Load: 2-16 x body weight

→ Pain after training, swelling

Wrist pain in up to 50% of young gymnasts

DiFiori JP, 2006

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Widening of distal radius physis

=

Fatigue fracture

Premature physeal arrest&

Relative ulnar elongation

Caine D, 2003

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Gymnast‘s wrist

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Prevention

• Wrist protectors

• Growth control / 3 mo.

• Load reduction

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Gymnast‘s wrist

DiFiori JP, 2006


Little leaguer‘s shoulder

Dotter WE, 1953

Adams JE, 1966

Widening of proximal humeral physis,

Local pain & tenderness

Control of no. of throws;relative rest

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Types of injuries

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• Muscle & tendon

• Congenital




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Overuse injury proximal patellar tendon

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Patellar tendinitis (jumper‘s knee)

♂ 17 y., football

Blazina classification:

Phase I: pain after activity only. No functional impairment

Phase II: pain during and after activity. Still able to

perform at a satisfactory level.

Phase III: pain during and after activity and more

prolonged. Increasingly difficult to perform at a

satisfactory level.

Blazina ME, Orthop Clin North Am 1973

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Beware tendon necrosis !

• Pain for 3 years

• Multiple cortisone injections !

Achilles tendinitis

♂ 20 y., football

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Types of injuries

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• Muscle & tendon

• Congenital




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• Prevalence: 2-3 / 10.000 children

• 2nd decade• 10 % bilateral• Genetic / Microtrauma ??

• Pain during activities

♀, 17 y.

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Juvenile osteochondritis dissecans

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The younger the patient, the higher the probability of spontaneous resorption !

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4-2010 11-2011

♀, 13 y. ♀, 15 y.

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Bruns J, 1997

SurgeryDrilling +/- refixation,

Cartilage surgery

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Conservativetreatment

Rest, no sports6 – 12 weeks unloading



Repairable OD

♂, 15 y., basketball



Non-repairable OD

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♂, 18 y., swimming

Chondrocyte transplantation

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Watanabe M, Takeda S, Ikeuchi H. Atlas of

arthroscopy. Tokyo: Igaku-Shoin, 1978;88.

Lateral discoid meniscus

Complete (70-80%)

Incomplete (10-25%)

Wrisberg type (< 10 %)

Lateral condyle

ACL

Complete discoid

meniscus

• ♀ 12 y, ballet

• blocking, extension deficit, crepitations

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Foot & ankle

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Accessory navicular bone

♀, 12 years, running ♂, 14 y., badminton

Os trigonum

1. Injections

2. Posterior ankle arthroscopy

1. Cons. treatment (insoles)

2. Open resection & tendon refixation

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Types of injuries

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• Muscle & tendon

• Congenital




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• High mechanical stress, low vascularization

• Diagnosis often delayed

• Here: Mechanical pain after intense training

period

• Therapy: Immobilisation (> 10 weeks !)

Sometimes surgery

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Stress fractures

Navicular bone

♀ 13-y., track and field

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Types of injuries

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• Muscle & tendon

• Congenital


• Alteration of joint mechanics (i.a. structural lesion)


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Osteochondritis

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OD of the capitellum♀, 13 y., gymnast

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• “Overuse” if associated with chronic

instability

• Unrecognized, isolated lesions in stable

knees:

- bucket handle, flap

- radial tears lateral meniscus

- isolated root tears

- meniscal ossicle

- instabilities lateral meniscus

- meniscal cysts

- early horizontal degenerative tears

♀, 16 y.

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Meniscus

♀ 14 y., high-level gymnast

• Always try to repair !

♂ 17 y., handball

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It is sometimes as difficult to find the

right treatment of a degenerative

lesion in a young athlete as it is in an

elderly patient with joint degeneration

and a typical sports injury.

Recommendation to stop sports

sometimes necessary !

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Cartilage lesions

♀ 14 y., karate

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Types of injuries

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• Muscle & tendon

• Congenital



• Joint dysfunctions (no structural lesions)

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• Physiotherapy

• Functional evaluations

No surgery without

structural lesion !

♀ 19 y.

Patellofemoral pain syndrome


Diagnoses shoulder consultation

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Atraumatic

Instability

Traumatic

Instability

13 - 30 y.

Matsen RF, 1994

♂, 17 y., swimming

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Shoulder pain

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SICK scapula

S: Scapular malposition

I: Inferior medial border winging (trapezius muscle)

C: Coracoid pain (tight Pectoralis minor muscle)

K: Scapular dyskinesisKibler WB, J Shoulder Elbow Surg. 2002

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Multidisciplinary approach

Understanding of:

• Growth & maturation

• Specific anatomy

Need for:

• Fun (no pressure) !

• Rest !

• Interdisciplinary care

• Adherence to natural selection

process (performance)

• Professionalisation of sports

medical coverage in youth sports

Coaches / teachers

Physiotherapists

Parents

crp-sante.lu 5757

76 rue d’Eich, 1460 Luxembourg

www.crp-sante.lu

www.sportsmedicine-chl.lu

HélèneAgostinis

ThierryWindal

AnneFrisch

JoakimGenin

RomanBrunner

RomainSeil

AxelUrhausen

DietrichPape

RobertMann

DanielTheisen

Cyrille Hardy

Thank you !

CarolineMouton

LaurentMalisoux

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Christian Nührenbörger

Roland Krecké

Louis Wennig

Laurent Radrizzi

Daniele Schaack

Thomas Thünenkötter

NicolienVanGiffen

José Azzolin

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• ♂ 15 y. football• closed physes

• ACL & lateral meniscus repair

Association with ACL tears

• Push indications for repair

• Never repair without stabilization

• Exception: acute bucket handle

& inflammation

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• Proximal patellar tendon:

Sinding-Larsen

“Jumper’s knee“

• Cartilage lesion

• Instability (acute / chronic)

• Patellofemoral pain syndrome

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Patella & extensor mechanism

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Anterior knee pain

• during or after sports

• sitting with flexed knees (cinema)

• stairs

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Patellofemoral pain syndrome

Evaluation of :

• intraarticular soft tissues and bony

structures

• muscle contractures / imbalances (thigh /

hip / pelvis)

• malrotations / malalignment

• Pelvis posture / foot posture

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Avulsions

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Lesions of the acetabular labrum

17 y., handball

Arthroscopy

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Hip & pelvis

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SICK scapula

Shoulder pain

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Kibler WB, J Shoulder Elbow Surg. 2002

♀, 16 y.

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Instabilities of the lateral meniscus

Garofalo R, KSSTA 2005

• ♂ 15 y. football• painful locking in full flexion

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Simonian PT, Arthroscopy 1997 George M, Arthroscopy 2003

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• DD inflammation, bipartite sesamoid

• High mechanical stress, low vascularization

• Here: Mechanical pain after intense training

period

• Therapy: Insoles

(Immobilisation)

(Rarely surgery)

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Stress fractures

Sesamoid bone

♂, 17 y., running

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Risk factors

Extrinsic factors Intrinsic factors

Non-modifiable

• Type of sport• Weather• Level of play

• Time of season• Sport context• Playing position

Non-modifiable

• Maturity level• Previous injury• Age

• Gender

Modifiable

• Rules and regulations• Coaching education/training• Playing time

• Playing surface• Equipment

Modifiable

• Fitness level• Sport-specific training/warm-up• Muscle strength

• Flexibility• Joint stability• Biomechanical factors

• Balance and proprioception• Psychosocial factors

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• toe fracture 6 months before

• Pain

• Arthroscopic removal of loosefragment

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Fractures

Posttraumatic « overuse » sequelae

♀ 11-y., gymnastics

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• Genetic factor ?

♀, 17 y.

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♂, 15 y.

Mother & son bilateral OD

Brothers, right knee



Foot5th metatarsalIselin’s disease

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N = 16706

Overuse injury definition

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• Repetitive micro-trauma• Gradual onset

Bahr, 2009

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Magnitude: general population


Malisoux L, KSSTA 2012


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• Swelling

• Fever

• Weight loss

• Rest pain

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Osteosarcoma


♀, 14 y.;Riding

Knee pain

Documents

S3.3 Seil Overuse injuries in the immature athlete · 2013. 6. 11. · lesion in a young athlete as it is in an elderly patient with joint degeneration and a typical sports injury