Athletic kids often need care for pain in the knee, ankle or another part of the lower leg – but when is it worthy of imaging tests or referral? In this case-based presentation, pediatric sports medicine specialist Celina de Borja, MD, discusses common injuries and how to manage them.
Good afternoon everyone and thank you for joining us today and for allowing us to stay connected. Uh, despite these very unique times, we'll be talking about lower extremity overuse injuries in young athletes today, um, which I, you know, wasn't sure was uh as relevant initially, especially with all the sporting events being postponed this season. However, the combination of, you know, easing up of covid restrictions, some warmer weather and Children just, you know, being very excited to go back to physical activities have um caused a recent uptick in um, these uh consults and so hopefully at the end of this session, I'd be able to help primary care providers recognize these common complaints that may present as non specific aches and pains that seem to have come out of nowhere. And at the same time help individual providers apply principles and indications for obtaining diagnostic modalities and also assistance in formulating a treatment plan. So, um, in an attempt to respond or adapt to these uh very unique times of virtual learning. I've tried to incorporate some online polling um, activities during this talk. So please if you can log on to uh pull everywhere or P O L L E V dot com. Our user name today is Pete Sports MD. Or simply text peed Sports MD 222333 So that you can respond to some over clinical cases today. And so common. Uh, one of the common ovaries, injuries seen in young athletes are the apophis itis injuries or inflammation or irritation of the growth plates. And these are pretty uh unique to our pediatric population. So the way I explain it to families is that um during periods of growth, kids go through a relative imbalance of strength and flexibility. And the way I explain it to them is that their bones actually grow faster than their muscles. And so as these bones get longer, the muscles that are attached to these uh and are getting tighter. And if you compare it to um this cartoon over here, at the corner of a man pulling a rope that's attached to a wall, then um you may find chronic changes or um irritation at the area of weakness and in that um unique situation and Children and that is the growth plate. And these injuries are usually exacerbated by periods of increased physical demands. So we'll go through several clinical cases. And hopefully by the end of this lecture you'd be able to tease out certain features or clinical presentations that suggests or describes a different overuse injuries. And so our first patient is a 14 year old boy who presents with our right side of the pain for about two weeks. Um he doesn't remember any traumatic injury that preceded his symptoms, although he mentions that he recently um joined the basketball team. He says that his symptoms are intermittent, um they're worse with running and jumping um and they're improving the rest on physical exam. He points to the anterior aspect of his knee over that bony bump or that area, which he may refer to as swelling. Uh that is also very tender to palpitation. He has full range of motion, although if you ask him to do his range of motion with resistance, he says there's a little bit of discomfort um which is similar to what he feels during physical activities. And when you look at his flexibility through realize testing or by checking his pictorial angle, you may notice some tightness in his quadriceps or hamstrings. So given this clinical presentation, um what would your diagnosis? B and this may be a list of differentials that you'd like to consider. Um And so um feel free to let me know by putting your answers in. Mhm. Yeah. All right. So this is a classic case of osgood slaughter disease or apophis itis at via tibial tuber coal. As you can see on the diagram over here, the quad muscle is connected to your patella via the quad tendon. Uh And the patella is connected to your tibia via the patellar tendon. And in that kinetic chain, the area of weakness is usually the growth plate which is made up of hard village um which usually presents as pain or discomfort with these high impact activities um due to a chronic irritation. So Ash goods is uh is a clinical diagnosis. Radiographs are not usually necessary to make this diagnosis If you do. However, choose to obtain radiographs. You may see some irregularity or fragmentation at the table to brickell which could be a normal variant, the way we manage these cases is usually through activity modifications. And so instead of traditionally telling young kids to completely rest from all activities which usually uh they may not be able to comply with. You just try to talk them through some uh modifications. So if symptoms are worse than things like running and jumping, um you may be able to uh negotiate by you know, asking them to participate in biking or swimming instead, which are lower impact activities. Uh exercises that promote flexibility such as a quad or hamstring stretching are helpful in these cases as well um in events that you feel like they need a little bit of guidance. With these exercises, you may want to send them to a physical therapist, supportive measures such as ice or incense may be needed for pain relief. Um And these in these cases a trope pad or a counterforce trap may be helpful um when they go back to sports. Mhm. So kids with josh grids usually have pretty good prognosis. Um It's important however, to counsel families that these symptoms may wax and wane over time, but we'll completely resolved once they're done growing that bony bump over there as a result of chronic changes from there from repetitive um irritation and so that bump may never go away. In certain cases you may see someone who has a history of Osgood who presents with a an acute injury um in the case where they would describe this painful popping or snapping mechanism associated with a ballistic movement. So, if they went for a jump or kicked a soccer ball, um keep in mind an avulsion fracture is a possible um injury. And so if that were the case, um feel free to send them straight over to us as they may require a certain period of immobilization. Um An intensive rehab. In very rare cases, some individuals who are growing up may report some persistent um discomfort with kneeling due to that bony bump. And in very rare cases we may be able to um consider surgical removal of that residual hospital. All right, so our next patient is a nine year old girl. Um She also has similar complaints of right sided knee pain for two weeks. It's also a traumatic, she recently started participating in gymnastics where she does a lot of jumping and tumbling. Her symptoms are worse with jumping or running or other high impact activities and improve with the rest. So, very similar clinical history. However, on physical exam, um instead of pointing to the proximal aspect of her tibia, she points a little bit more approximately to that specifically the inferior pole of her patella. Um She is a little bit tight on her quads, but the rest of her exam is unremarkable. So, given this type of clinical picture, um please uh let me know what you think. Mhm. Okay. All right. Bit divided in here. Huh? All right. Um So this one is uh what we would call sending Larson joe Hanson syndrome, which is an apophis itis at the inferior pole of the patella. Just like in Oz goods. There is a growth plate over there which could be irritated. Um And individuals who have open growth plates, it is also diagnosed clinically. Um And so x rays aren't necessary if you happen to get x rays and see a little bit of uh sclerosis or irregularity or fragmentation at the inferior pole of the patella. That could be a normal variant, just like you would see in Ash Woods. They are treated very similarly with activity modifications, stretching of the quads and hamstrings, supportive measures. Um And use of a counterforce trap. Uh Kids with S. L. J. Also have pretty good prognosis. Um Feel free to feel free to manage them initially. Um and send them to you know, physical therapy if need be. Um And also consider sending them to us if there's persistence of symptoms despite these conservative measures. Or if they are having any symptoms with that fragment or obstacle at the distal pull of the patella. All right, so our next patient is a 16 year old female who presents with left sided knee pain for about two months now. Um it's also a traumatic, it's located uh auntie really. It's interment and just like the other kids. It's worse with activity. Um But sometimes it's also bothering them while they're sitting for a long time. Um measures used to improve symptoms include rest or stretching out. Uh Sometimes they experienced some non painful clicking and they may mention that in certain days their knee gives away on exam when you ask them to appoint specifically where their knee hurts. Uh They grabbed their knees just like that picture in front. So very very non specific hurts everywhere. Kind of in a situation. It may look a little puffy but not, you know, a real effusion. When you examine them, they're tender over their federal condos, specifically the area that is right underneath their kneecap. Um And if you kind of grind their kneecap towards their thigh bone, uh that elicits the kind of pain or discomfort that they've been describing. And so given this um kind of clinical presentation um please uh let me know what you would consider. Mhm. Mhm. All right. So, it looks like majority got it. Um This is a classic case of a patella femoral pain syndromes. So, uh this is usually do Patel ephemeral about tracking or the way I describe it to families, is the way the Annika rubs over the thigh bone during physical activities. Um As you can see in this diagram over here, you know what we think about when we think about the kneecap, we think that it goes um superior early and inferior lee during flexion and extension of the knee. However our knee cap is attached to the quad muscles um which may offer an upward outward vector or force or pull. Um due to the vastness lateral is muscle and also a an upward inward pull because of the vastness. Media Alice muscle, potato farmer. All syndrome is usually brought about by relative imbalances in strength and flexibility. And so because the fastest literalist muscle is a bigger, stronger and longer muscle oftentimes it overpowers the smaller VM. Oh muscle over here and causes patellar mall tracking. Um Which also can irritate the fibers. Media lee and cost is you know, very vague non specific uh knee pain. So diagnosing a patella femoral pain syndrome is uh via clinical presentation. Um If for example symptoms are persistent or presentation is unclear. Um You may want to obtain radiographs. If you were to obtain radiographs, I would suggest adding two more views or traditional ap and lateral views. So as the differential for this non specific knee pain may include osteoarthritis dissidents or an O. C. D. If you've ever ever heard that uh mentioned. So this is the tunnel view which is similar to an ap view with a knee that's slightly flexed. It gives us a better visualization of the articular surface of the distal femur where OECD's usually present. Uh And this is the uh sunrise view which looks at the articular surface of the patella where cities can also be seen. We'll talk a little bit about O. C. D. S in a little bit but just finishing up on patella femoral pain syndrome. Um These are managed by activity modifications, strengthening exercises that focus on your quads and your hips supportive measures are used for pain relief. A patellar stabilizing brace or Katie taping can help alleviate the patellar mel tracking issue. Um And in certain cases where there's a valve, goose or mild vargas, lower extremity alignment. As you can see over here we're in this individual may look a little bit not need um And primarily from the ankles. You know collapsing in uh you know which we may see an individuals who have flexible flat feet. Um In these cases cases over the counter shoe inserts may be helpful in improving their overall alignment. Yeah so patella femoral pain usually resolves spontaneously over time with these conservative measures. Um Treatment is mainly non operative in very rare cases where in uh individuals have what we would call miserable man alignment. Um Where in there is severe you know valdas, lower extremity alignment because of the way the the hip is rotated or which we would call femoral and aversion. Or you know certain findings within the tibia or tibial torsion. Um They may benefit from realignment procedures. However these are very uh uncommon. Um And only reserved in cases that present a severe pain that lead to functional limitations And so since treatment of patella femoral pain syndrome is mainly not operative, feel free to manage them conservatively if they need a little bit of assistance or guidance with exercises or physical uh you know send them to physical therapy um And and then you know consider sending them to us uh if these things don't work. So because I mentioned O. C. D. S earlier or osteoarthritis desiccant I just wanted to give a brief overview um about it just uh since I introduced the topic so it's uh considered an injury to the sub control bone which may cause secondary effects to the cartilage. So as you can see over here there's a defect of the medial aspect of the lateral aspect of this. So uh femur and so um ideology is still under debate. There are certain studies that suggest inflammatory processes. On the other hand there's also studies to suggest repetitive micro trauma to an area with poor vascular supply causes necrosis of the bone and then eventually degeneration of the cartilage around it. If you happen to get the tunnel views this is what it would look like on X rays as you can see here um on the lateral aspect of the media ephemeral condo it looks like a piece of bone. Um Got bitten off that would be the classic presentation or location of your O. C. D. Uh Some O. C. D. S. Are stable and some are not. Um And so the best way to address it is to obtain an M. R. I. To look at its stability. So in this Emerald over here you would see the O. C. D. At the distal femur. The bright white line over here represents fluid would suggest which suggests that um this O. C. D. Is an unstable um lesion. So basically the lesion has completely separated from the parent bone. There's two treatment arms for uh these conditions. So there's a nonsurgical treatment arm that's appropriate for stable O. C. D. S. Um They may include activity restrictions or avoidance of high impact activities such as running or jumping for about three months. Um And uh pain free weight bearing through the use of crutches or braces. We may also institute some non impact range of motion or strengthening exercises during this period. And the main goal of the nonsurgical approaches to promote healing and prevent further displacement. In certain cases were in a individuals fail conservative treatment or if they have an unstable O. C. D. On their MRI uh These are managed surgically through arthroscopic procedures which aim to salvage the native cartilage and restore the bone. Mhm. So moving a little bit further uh we have a 12 year old boy who presents with bilateral ankle pain over the past four weeks. When asked about the history of trauma. He doesn't remember anything specific although he recently joined the soccer team. He points to his post syria ankle. Um As the area that's bothering him the most. Uh more specifically, it is his heels. His symptoms are worse with activities like running or jumping, especially when he's wearing those hard cleats or whenever he's walking on really tough surfaces. And his symptoms are improved of the rest on physical exam. Uh He has tenderness pa patient over his uh cal kenya's more specifically if you squeeze it, that usually elicits the pain or discomfort that he's experiencing. Um he has pretty good range of motion, but if you passively Dorsey flex him uh with an extended knee or stretched out me, Children should be able to Passively Dorsey flex to about 20°. However, this child is pretty tight. Um he's only able to Dorsey flexed about neutral or sometimes not even close. So it suggests tightness in his tank, in his calves or in his achilles. So when this kind of a situation comes in, what are your top picks? Let me know. Mhm. All right, so looks like most people got it. This is classic Seaver's disease, which is a calculation real apophis itis also diagnosed clinically. Um But if you do happen to uh obtain x rays, um the heel bone looks very irregular, especially around the growth play. It could be fragmented, there could be sclerosis or even widening of the hypothesis, which can all be considered as normal. You manage this very similarly with activity modifications, um exercises focusing on hamstring and calf stretching, um supportive measures. And in certain cases, Hill cups may be beneficial for when they're just walking around. Um And not participating in sports. So um just like the other overused injuries. These symptoms may wax and wane over time but usually have no complications into adulthood. Um In certain cases were in there pretty flared up or are in severe pain or discomfort because they didn't tell their parents you know soon enough about their um emerging symptoms. Um You know feel free to send them to us. Um Sometimes they may benefit from a period of um using crutches or using a walking boot to help them move around right. Um Moving on is an eight year old female who presents with right sided foot pain for about four weeks. Um Just like the other kids can't remember anything that led to her symptoms. Um She is active in the L. A. And she loves to dance. She points to the lateral border of her foot. Her symptoms are worse with activities especially those that um have a lot of four ft movements. Sometimes it rubs inside her shoes um And their improved with the rest or walking in the medial aspect of her foot. Um Physical exam she's tender to palpitation on the lateral aspect of her foot, specifically over the base of her fifth metatarsal. She has pretty good range of motion but she does report some discomfort with passive inversion and resisted ankle E. Version. So what do you think is going on with this little dancer? Let me know, mm. Mhm. All right. So, this would be a case of Iceland's disease um Which is an apophis itis at the base of the fifth metatarsal. So, as you can see on this diagram over here, the Perot nia's breakfast tendon actually attached to the base of your fifth metatarsal where a growth plate is located. And so constant four ft motion will cause um tugging to that area, which can irritate the growth plate and lead to an apophis itis injury. So, um because an actual fracture maybe a possibility or a natural differential for these kinds of cases, you may want to get an X ray if you were to do one, um you may want to get it in three views so that we have, you know, good visualization of the fracture pattern, although in certain cases where there really isn't any traumatic history and symptoms are very mild. Um You know, diagnosis can be made clinically. So just to let you know the different ways that the fifth metatarsal can appear on X rays, are these uh images over here on the right side. So the growth plate is um situated longitudinal E. Over here. Um So if you see a straight line going now and it could look jagged or fragmented. Um but that represents a growth plate. If you see a jagged line that's more diagonal, you may want to consider an avulsion fracture in that situation. Um Or if you see a line that goes transfers, uh you may want to think about a stress fracture. Uh you know, there is a a special kind of transfers fracture that's seen in the fifth metatarsal and that is the jones fracture. Um It is uh in similar fashion transfers. However, it's located a little bit um distill e um and is significant for um ah historically, you know, poor healing or even Mallya union because it is a vascular watershed area. So as you can see here, um injuries or fractures um are, you know, sharpen jagged if you happen to see um in an area of loosen, see that is well circumscribed in a little bit around it um in the absence of, you know, history of acute trauma or you know, even any symptoms. It's it's possibly an accessory obstacle. So that's also a possible uh one of the possibilities um if you ever get X rays, so these are managed with activity or footwear modifications, um stretching exercises that work on your pre meals or your calves, um supportive measures for pain relief and then uh taping techniques as needed. So just like other overuse injuries, symptoms, maybe vaccine wane over time. The fifth metatarsal um may not close until 18, 18 years of age though. So just kinda, you know, let the families know that it may take a while for um uh you know, these individuals have complete resolution symptoms um if they ever develop a bony prominence from chronic repetitive irritation, um They're usually symptomatic um and just like the other um You know cases if if they are symptomatic, then we may talk about surgically excising them. Um uh If you ever see any avulsion or stress fractures feel free to send them over to us as they may need a period of immobilization via cast or walking boot depending on the stability of the fracture. Um And then again, you know, the jones fractures are associated with prolonged healing or even mall union. And so um we take special attention to these things because sometimes um they may be candidates for surgical intervention. Mhm. So um moving along to stress fractures which are also a common um form of uh overuse injury and athletic population and also non athletic population. Um These are caused by abnormal response to repetitive loading to our bones. So the way you explain it to families is in contrast to the usual falling on your outstretched hand and then bone bends and kind of breaks or snaps in half, this is more of a chronic progressive entity. And so I usually compare it to bending a paperclip back and forth. So um if you do it um multiple times right before the paper clip snaps in half, you would actually see some chronic changes to the quality of the paper clips material and that's kind of how um stress fractures involved. These are very common in our endurance athletes. So runners as well as our dancers. And there's usually two main risk factors that will increase your suspicion for these stress injuries. And so one of them is the biomechanical risk factors. And so anyone represents with a recent increase in frequency intensity or duration of their training or their sport over the last 2 to 3 week period usually um you may want to think about stress fractures. So um the times that I think about it are you know usually um pre season training. So especially in the spring. So a lot of kids take a break during the winter and then they go from 0 to 100 once the sun comes out Um and they're ready to go back to their sport. So usually um you know someone who you know starts training again within 2-3 weeks, they'll um if they don't do the appropriate rest or recovery, they'll usually presented a stress injury. Um The other kinds of risk factors that I also keep in mind if you think that there wasn't really any bad mechanical risk factors but it does um you know clinically present like a stress fracture. You know, think about any reasons for them to have low bone mineral density. So exposure to any medications, especially steroids, um anti epileptics, antidepressants may interfere with your bone mineral density and hormonal issues that interfere with your um calcium and vitamin D. Um absorption. Um You know any nutritional deficiencies or any chronic disease involving the liver or kidneys uh that may interfere with, you know, the overall um equilibrium of bone health would definitely um you know, suggest a stress injury. And so uh stress fractures can pretty much present in, you know, different parts of the body. But I'll talk about the top three locations where we, you know, see them the most. So we'll start off with metatarsal stress fractures. Um These usually present with very localized pain. So we see these usually in runners or dancers who complain of dorsal foot pain. Most common locations would be, you know, second or third metatarsals. So in addition to um you know focal pain and you know tenderness of how patient you may check by a hop test or a single leg hop to see if that elicits their symptoms and um if it does, you know, work if impact or hopping or jumping um worsen their symptoms that really consider uh metatarsal stress fractures. Um if you get radio radiographs or for these cases um uh be aware that they may present in several different ways. So, um in certain cases, if the uh injury is is still new or if the injury is not as bad X rays may look normal. Um In certain cases, uh you may see that, you know, area of lucinschi which you see on this picture over here. Or if you take x rays um four weeks out or further from the onset of symptoms, you may see callous formation or signs of healing, like you would see over here on this x ray um if x rays are normal and the uh but there's high clinical index of suspicion. Um you know, the fracture maybe a cult. So in that situation you may want to get an M. R. I. To look for bone oedema mm hmm. Right. So um metatarsal stress fracture management are pretty simple and straightforward. You want to achieve a pain free weight bearing through the use of a walking boot. Um And maybe crutches. Usually they return activities in about 4-6 weeks. Um and in the meantime that they're not allowed to do high impact activities such as running or jumping. You may want to recommend other conditioning exercises such as biking or swimming, which may not affect their recovery. So these individuals have treated appropriately which you have complete recovery and of course if left untreated may maybe progressive. Um Just wanted to mention again any uh concerns over the base of the fifth metatarsal, which is located a little bit more distantly. Think about jones fractures because like I said, they are associated with poor healing. Um or even non union and in certain cases may be treated surgically through a screw uh tibial stress fractures in similar fashion, present with localized or focal bone pain. So they may say that they have a specific spot on their shin um that's that's hurting. It's something that's you know chronic and progressive um And in addition to being tender over that area of the bone um asking them to hop on that bone are applying impact will cause exactly short of symptoms. Um differentials for to build stress fractures of course includes shin splints which are a little bit more vague, they're more diffuse lee distributed over the uh lower extremity. Um It's not as specific as the uh to be all stress fracture but definitely part of the differential and then another would be exertion, all compartment syndrome where you can get paid in paris, these asia's feelings of increased pressure or even weakness in the lower extremity in the setting of intense exercises. So um for diagnosis you can start with getting x rays for these cases. However, um just like in metatarsal stress fractures, where radiographs can be normal or fractures can be a cult. Um For tibial stress fractures, they may actually be normal even after the four week mark. So if you have very high clinical suspicion, especially if there's any of the bio mechanical or biological risk factors, um you may want to get an MRI to look for the bone oedema, which is what you would see over here Management of these. Tibial stress fractures are similarly trying to achieve, you know pain free weight bearing through a walking boot or crutches um for about 6-8 weeks during that time. You may also wanna send them to physical therapy to work on you know, some flexibility and non impact strengthening exercises and then once they're cleared or once their symptoms are better, you may wanna um have them go through a gradual progression or return to sport protocol um Which starts with low impact activities like biking um which may then be advanced to use the elliptical and then light jogging if they tolerate. And so um these uh injuries usually um you know achieve a complete recovery of treated appropriately. Um in certain cases um if you do see that, you know, dreaded black line on the anterior cortex, um they may be associated with you know, poor healing because they're on the tension barry hearing science so um feel free to send them to us so that we can monitor them closely and you know, talk to them about the options of non operative or surgical treatment. And then lastly is um ephemeral, next stress fractures. So in contrast to our metatarsal or to build stress fractures because of its location presentation can be vague and so you really have to have your high index of a clinical suspicion for these cases. Um as they may present with very vague symptoms such as hip pain or growing pain um or pain that radiates to the thigh or the knee. Um Look for your biomechanical or biologic risk factors. When you're trying to assess these individuals on physical exam, you may see them with an anti logic gate because of the pain. They may have decreased range of motion and we'll definitely have symptoms when if you ask them to hop. Um X rays may or may not show the actual defect, but if you have high clinical suspicion, get an MRI to see if there's bony oedema. Um So these types of fractures are treated differently based off of their stability. Um One type or in the injury is on the inferior aspect of the femoral neck is called a compression type. Federal Next stress fracture can be treated non operatively through a 6 to 8 week period of non weight bearing. Uh And these usually um have good prognosis and can return to sports have treated appropriately. Um The other kind of injury that you should be aware of is, you know, something that looks like this where in the defect is on the superior aspect of the femoral neck, which is what we would call a tension type um Federal next stress fracture because of its location. The pull of gravity tends to counteract, you know, the force of healing. And so these are actually treated surgically through um screw fixation. What we don't want to happen is, you know, something like this or and it goes through and through which can um lead to displacement. So any time you have a confirmed or really high suspicion for federal Next stress fracture. Um You know, send them to us. Some complications may include, you know, if these are treated um lay may include displacement of the injury, um, a vascular necrosis, nonunion or even um deformity. So, um, just very important to know. So that's the last of it. Um, I usually end with some resources for providers. So this handbook is um from the American Academy of Pediatrics. It's written by pediatricians for pediatricians. It's a very practical uh manual that you can use in your clinics or in the urgent care setting is very helpful. I usually encourage trainees to use these as it, you know, walks them through the different physical exam maneuvers. So someone who is learning at SK would benefit from that. Um, the healthy Children dot org through the ap also provides a lot of resources that are sports specific and are easy to understand for our patients and their families. Um, and then lastly stop sports injuries dot org is a website that is created in partnership with the A. O. S. S. M. Or american orthopedic Society for Sports Medicine. Um that also has a lot of resources um for young athletes. So thank you very much for your time. Mm hmm mm