Pediatricians and other PCPs can play a starring role in helping children avoid sports injuries and in managing the everyday types – from painful overuse conditions to sprains and simple fractures. Sports medicine specialist Celine de Borja, MD, discusses why developing bodies are prone to certain aches and pains; offers cases to illustrate the diagnostic process; and discusses how to educate youngsters so they don’t overtrain or specialize too soon. Includes tips on PT, imaging and referral.
Thank you Maria. Good afternoon everyone. I'm Selena devora, my pediatric primary care sports medicine physician here at UCSF. Um So my background is in primary care pediatrics and then I did a one year sports medicine fellowship um After that and then I'm part of the division of pediatric Orthopedics here at UCSF, where I see a lot of sports related injuries um and also non sports um M. S. K. Questions in the Children and adolescents. So today we'll talk about some lower extremities and kids, you know, growth plate injuries, fractures, um you know how to navigate these injuries in winter for um I'll go through a few cases today but again feel free to ask any questions as they arrive. You know, I think you know, it would be more useful for for us especially at this level, you know um you know on our clinical practices to you know discuss cases and you know, exchange ideas rather than me going through the entire um power point. So um no disclosure so um objectives for today would be to recognize common injuries that are specific to you know, growing athletes identify my indications for diagnostic imaging modalities and their urgency. Um and then discuss treatment options, especially because a lot of the options for these injuries could be managed by primary care um and may not need, you know, subspecialty referrals. So um when you know it's appropriate to you know, be managed in the primary care setting and when it would, you know, I need to see us sooner. So before we go through the different sports andrews, we'll just go through some numbers. Um And you know sports injuries are a top reason to see you know a primary care physician or you know come into the E. D. Or urgent care center. Um Pre pandemic data show that about 3.5 million Children under 14 received medical care for sports injuries. Um In that year more than half of these sports injuries are considered preventable. And that overuse injuries are responsible for nearly half of all sports injuries sustained by middle school and high school athletes. So young athletes are susceptible to sports injuries because they are skeletal lee immature. So they have increased bone plasticity. They have open growth plates, there ligaments relax, they have underdeveloped muscles which could all contribute to poor technique. Um And then certain variants of atomic alignment meaning you know things that are part of normal growth and development like knock knees or in towing or flat feet you can definitely contribute contribute to to them getting these injuries. Um and then extrinsic factors that put them at increased risk for overuse injuries include exposure. So rapid increase in training. So this is something that we saw you know sometime in spring of 2021 when you know Children eagerly returned to sports after a year long lockdown. Um and then um so that's what we would call you know too much too fast. And then other than that high training volume. So in high school athletes earlier studies show that those who trained more than 16 hours per week um were at significantly increased risk of overuse injuries. But nowadays we're seeing more and more studies especially because Children are participating in sports at younger ages. And so we're realizing that you know kids um especially those who participate in sports organized sports specifically in more number of hours per week in their agent years are also at risk for these injuries. So you know, a 10 year old boy, you know participating in baseball, 16 hours a week is definitely doing more than their body can handle. Um And then lastly early sports specialization um is a phenomenon that we see in these young athletes who specialize in just one sport and play it all year round um and exclude participating and all other sports. Um It has been it has been found to be an independent risk factor um for overuse injuries even if you account for your hours per week. So you know very important to have breaks throughout the year. And also very important to um diversify or play other sports um and uh and kind of develop other skills apophis itis again is like this umbrella term um that we use to describe overuse injuries to their growth plates. So um you know, important pieces here, it is overused, so not acute and then growth plates. So um these injuries happen um you know due to relative imbalance and strength and flexibility that happens during growth and development. What I usually tell them is that, you know, the bones are growing faster than the muscles and so as they're getting taller, their muscles are getting tighter. If you imagine, for example, you know, the extensive mechanism and we kind of take a look at this in a little bit. You know, if your muscles, you know, is our like this rope over here which are attached to like the bone, right, Which is this wall over here via a little ring or connection. And that would be the growth plate, right? So, you know, if the rope is tight and you're always like pulling and tugging on it when you're running and jumping, then definitely you're irritating the area of weakness over here, which is usually the growth plate where is usually wait, where they experience their symptoms. So rapid growth is something that, you know, definitely flares up these issues and then exacerbated um also by increased physical demands. So the thing about a prophecy, it is, it is an overuse injury. It waxes and wanes over time when they're in season, it hurts when their off season gets better. When they're more active, it hurts when they rest, it gets better. Um It's just the natural course of these injuries. So um first patient is a 14 year old boy who's been having right knee pain for two weeks, no trauma reported. He's active in basketball. He's saying that he's having pain on the front part of his knee. There is a bony bump that's somewhat swollen in the front of his knee. Um the symptoms again are intermittent, worse with running and jumping and approved with the rest on physical exam. You can see there's that Bonnie Bump over there um that is tender to palpitation. He has full range of motion, but if you asked him to um do resisted knee extension, it provokes that area over there. Um and then if you look at his flexibility, he shows some tightness in his quads and his hamstring. So um what does everyone think about this 14 year old boys knee pain? Any guesses chat chat is completely fine too. Yeah, I see some Osgood slaughter in there um And that is correct. Um There's patella femoral pain too, but this one is a classic case of Osgood slaughter will have a case of normal paint and a little bit and we'll be able to compare. Um So Osgood slaughters that apophis itis um Specifically traction apophis itis at the tibia to brickell again, remember that rope attached to that wall by the little connection over there with the rope is tight. Um And you're having increased physical demands, meaning your, you know running and jumping which contracts this muscle over here. It's like this pulley system that pulls over to the for your knee, other front of your knee. Kids have um growth plates which which are made up of cartilage. And so there's an area of weakness. And so usually um that's where the irritation happens again, it's an overuse injury. So no acute trauma is, there's something that's worsened with activity um and improves with some rest or modification. So slaughter being overused injury may not necessarily, you need x rays for diagnosis, you can diagnose it clinically. Um If you ever get x rays you may see sclerosis fragmentation, You see how this looks very regular over here. Um That's completely normal, does not mean there's an avulsion fracture um in there. Um And that's just how the you know the area Aasif eyes over time. Um We recommend activity modifications. So you know these kids when they have Oscar's daughter, it means they're super duper active. It's really hard to slow them down. Um It's very hard to convince them to completely rest. So I just say you know just modify your activities if running and jumping hurts you then you know we'll hold off on that. Maybe other activities like swimming or biking or you know something else might be better suited for you for the time being because we know that this is something that's provoked by rapid growth. We emphasize importance of quad and hamstring stretching. Um So they can do that on their own or they can do that through physical therapy. Um And then for symptomatic relief ice or insets are helpful, they want to start with ice because they're avoiding medicine that's completely fine. Um And then, you know, if they're like really flared up, you know, to the point that they're limping, I usually say, you know, help them out with a little bit of insects, I think that's completely reasonable. Um And then for sports, because it's something that is irritated by, you know, high impact sports or running and jumping this patellar strap or chou pat strap is a counterforce trap that could be helpful. It's available off the shelf, it's available on sporting goods stores. You know, the idea is it holds it down, you know, over here, it has that counterforce um purpose so that it's not always um tugging when when they're playing their sports and it doesn't hurt as much. So um for prevention, flexibility exercises are very important, especially around periods of growth. Um It is expected for this condition to wax and wane, but it will ultimately resolve over time. I think that's something that's very important to share with their um parents because a lot of times, you know, you give your recommendations, things get better. Um they're happy and then it comes back again the next season and then they're worried that your initial diagnosis was um you know, not correct or that our treatment options weren't, you know, the right um you know, move and so, you know, they start seeking out like second amendment and things like that. Um a lot of times they come, you know, to see us and we say the same exact thing that, you know, their primary care told them in the first place. So just kind of setting expectations I think is helpful um to to, you know, um to ease any any anxiety amounts of parents and then that bump that they see in the front of the knee, um it's it's from chronic, you know, changes um from chronic attraction um that just kind of is healing on its own, so because it's like getting pulled, its, you know, putting more kind of bony material in the area um and so that bump may never go away, that's just part of them until they grow up. Um there shouldn't cause any issues except for sometimes it causes some discomfort with kneeling and so in very, very rare cases, and I haven't seen this happen um during my stay here is is, you know, that residual obstacle can be um excites or surgically removed, but um if they can live without, you know, kneeling for long periods of time, then, you know, they can just leave it alone. Um Again, Osgood is an overuse injury, so no acute trauma. Um and even though the X ray looks, you know, sclerosis or regular, it doesn't mean that it's broken or revolved. Um an avulsion fracture is something that you should think of. There's an acute injury. So when you ask them how long their injury, their pain has been, if they say, you know, something chronic like two weeks to months, even two years but they can't recall an injury that's probably over user Osgood if they come in very acutely um you know, eagerly trying to see you same day or following day, be worried about an acute injury. So avulsion is happen when they happen. It's because the quad pulled off that piece of bone um with it with, with a forceful um contraction of the quad muscle. So it's usually there is a story of a painful pop or painful snap um that's followed by significant swelling and inability to move their name. They may or may not have prior history of Oscar. Um you'll see even more swelling of the proximal tibia more than the soft tissue swelling that I showed you earlier. Um and they're very, very, very tender over that tibia. To Bergdahl um fractures always say, especially when they're fresh, they're jump off the table tender. So this is a scenario um that you'll see in an avulsion. So, if you have an acute injury and suspect an avulsion fracture of the tibia Tabernacle, that would be an indication to get X rays as you can see over here, there's that kind of dark line over there and you see how the tibia to brickell is lifted off. So this is an example of a non displaced tibial avulsion fracture. Um if it's not displaced or minimally displaced, meaning it's less than two millimeters gap, We just keep them in knee extension. So what we want, what we wouldn't want to happen is them to bend their knee and like you know rip it off even further so we keep them in knee extension either through a castle or a hinge knee race. Um If you you see a pretty soon severe one like this one at the bottom or and it's like more than two millimeters displace, then definitely we have to put it back in place through um open reduction internal fixation because um you know that is this little segment of your extensive mechanism is very important in an ambulance. Ation walking, running jumping. Um And a lot of R. A. D. L. S. So if there is an acute injury get X rays. Um and you know depending on the degree of displacement um we may or may not have to operate on it. Um And the initial treatment would be just keep the entire leg and extension. Um So because that's how we would treat not displaced injury in the first place. Um Next case is a very similar history to Osgood's but the kid is pointing at a different location which is right underneath her kneecap. Um Does anyone have any ideas on on what this maybe is this the tell ephemeral finally or something else. So this is what we call S. L. J. Or sending Larsen Johansson syndrome. So sending Larsen Johansson syndrome um Same exact mechanism as Osgood Schlatter, just different locations. So it's also attraction apophis itis but instead of the you know proximal tibia it's at the inferior people the patella. Um So same deal same mechanism, same treatment but I just feel like it it doesn't get as much um um You know talked about as as as good but it is you know clinical entity can be diagnosed clinically um on x rays may show um you know some irregularity over there in the pool of the patella. Um So if anyone gets x rays and has that finding um that might just be from traction of prophecy itis um in the absence of an acute injury um that's unlikely. Um an acute fracture of aldrin fracture. Um And I wanted to share this because we do get you know, some referrals wherein you know, they get knee pain or knee injury, knee pain, I would say any pain, chronic knee pain um and then you know x rays um and then you know these findings are are kind of you know described by the radiologist but you know radiologists because they couldn't see the patient or examine the patient, they will say you know either overuse or avulsion fracture and then you you know families tend to get nervous or anxious about it but in the absence of an acute injury it's probably just um kind of a normal variant and from traction. So treatment again is very similar activity modifications and lots of stretching. Alright, next one is a 16 year old girl who's been having left knee pain for two months. Um a traumatic um it hurts in the front um It's worse with activity and it's you know, improving the rest. Um You know, sometimes prolonged sitting also bothers it. Sometimes she she has kneecapped clicking. Um but sometimes her knee gives way um when you ask her specifically to point, you know where her knee hurts, she'll do that because it kind of hurts everywhere in the front. Um And then if you're trying to um you know, find the area that's that's most tender. It's it's really right around the kneecap. So um what do you think is is her knee pain from? All right? Yes, this is patella femoral pain. So, you know, patella femoral pain is, you know, pretty common cause of anterior knee pain. Um You know, it's it's commonly known as runner's knee. Um You know, it has that, you know, that grab sign right when they say, yeah, the entire front of my knee hurts. You know, think patella femoral pain syndrome. So, you know, patella femoral pain is from patella femoral mount tracking. So again, you know, the quad muscles, you know, pull the kneecap up and down when we're bending and extending our knee, ideally the kneecap tracks, you know, straight up and down. However, because of um you know, relative imbalances and growth and development in terms of strength and flexibility. I mean you know sometimes some muscles are stronger and some muscles are tighter and so the kneecap doesn't always go up and down. Sometimes kind of mile tracks up and out like that. So what happens is it kind of over strains the fibers on the medial aspect. So a lot of people have knee pain um on the medial aspect of the patellar and sometimes the rubbing on top of the femur you know, causes that discomfort. Um Again um relative balances and strength and flexibility and then certain anatomical variants. So like thermal an aversion or in towing um or you know knock knees sometimes it kind of predisposes them to this kind of knee pain. So patella formal pain syndrome um does not necessarily need x rays because it will um yield you know completely normal in the x rays. However we we tend to get x rays from them um You know I guess more often than we need to um And and mainly because you know this is usually a really chronic knee pain and you know really bothers families, you know it's been going on for months, you know, doesn't want to go away or it just keeps on coming back um if you were to get x rays I think to to make it most worthwhile um In addition to your usual ap and lateral views I think adding a tunnel and a sunrise view would be helpful. So this is a tunnel view. It's like an ap view that's taken in slight knee flexion. So it just looks at your particular surface um better than your ap view. And then this is your sunrise view which looks at how your kneecap sits on your femur thigh bone. Um And the reason is because sometimes you see lesions in these views um that may mimic patella femoral pain and I think I'm gonna describe that in a little bit. Um So but before we move forward patella femoral pain is mainly treated non operatively activity modifications. It will eventually you know go away and get better over the time and a lot of exercises physical therapy or home program. And the focus is not just on quads and hamstrings stretching and strengthening. You know we also take a look at for the I. T. Band. So on the lateral aspect and hip stabilizers and that's because if you have weak core and weak glutes or hip stabilizers there's a lot of times if you have them do squats or especially single leg squats they collapse like this which worsens the mile tracking issues. So you know focusing on core and hip stabilizer is very important for that overall alignment. Um And resolution of the patella femoral mount tracking. Um Ice and insides are helpful for symptom management. Um And then in terms of bracing a patellar stabilizing brace. Like this may be helpful. It has this gel donut hole in the middle that keeps your kneecap in place. Um no hindrance for this race. So nothing nothing stiff or or limiting really just keeping the kneecap in the middle. Um And then for others who have access to like physical therapist or athletic trainers, Katie taping and also help um against sometimes you know normal variants in an atomic alignment. Um You know we see in the growing child sometimes um you know flat feet where in the kind of pro nater collapse immediately on their ankles. Sometimes that contributes to their lower extremity alignment. So um you know if if that's the case using some off the shelf inserts or more supportive shoes sometimes helps out um if they're having you know symptoms with just prolonged walking um prevention. Um We recommend you know gradually increasing activities um avoiding the too much too fast um phenomenon and making sure they have good core lower extremity strength and flexibility. So focus on hips external rotate ear's and in I. T. Band in addition to your quads and hamstrings. Um Usually these will resolve over time. Um and we'll just completely go away unless if there's hard, you know an atomic um you know issues like what we would call miserable alignment syndrome wherein they have female an aversion. So their thigh bones are twisted in and then their shin bones are twisted out. Um And um because of that severe um angle that the kneecap goes through it, you know can persist this fighter or efforts. So um and so sometimes, you know surgical intervention might be discussed um for these patients um when I refer again since self harm, all pain is something that um is mainly managed um Not operatively or through physical therapy. I think it would be okay to you know, have them go through a course of P. T. Um and you know, see how it goes before sending them to us. Um Alrighty. Um I mentioned earlier osteo arthritis desiccant um as uh as a condition that can mimic the tell ephemeral pain. So it is an injury to the sub Condra bone. So this is a tunnel view. Um When you see that kind of you know piece that looks like it's it's been off like that. Um It may present, you know, very vaguely anti irony pain. Non specific. Um A lot of times it's like medial and to your knee pain that's worse with running and improve the rest. Um So I think you know, if you have a cell ephemeral pain and you're like, well it's probably patella femoral pain, but I'm getting x rays to check for anything else. I think adding the tunnel view would be important um or or helpful at least. And the reason is because usually these lesions are in the back over here and so that slight bend will show this lesion better than your regular ap view um it's it's a it's an injury to the sub control bone. So you know, sometimes I describe it to families is you know, imagine if you like drop an apple, you know the outside may look intact but the inside is is hurt. Um And you know, we might see that on X ray or you know, M. R. I. Um Usually if we see it, you know on extra we would get an M. R. I. To to see um the stability of that lesion meaning, you know, is that apple still intact or is it like completely bitten off or separated Because that kind of direct or management terms of you know, leaving it not operatively or you know, referring it to surgical colleagues. So nonsurgical is usually to promote healing. Um No high impact activities. Sometimes even up to three months um to to allow that bone to heal. Um However, if it doesn't work then, you know, that's when we start consulting with our surgical colleagues for um arthroscopic options. Let me skip um Seaver's or like go to receivers disease real quickly. Um But it's essentially heel pain. Um Usually like the 8 to 12 age group. Um It is the same traction of prophecy Itis at the cal kenya's if you get X rays of that foot or ankle, you'll see very jagged um You know, very regular borders. That's just the normal appearance um of the Calla kenya's when it's growing um You know some people are told they have a fracture. Um but in the absence of trauma, especially high velocity trauma, um it's probably Savers apophis itis, which is um similar to Osgood's and the other entities um don't need to get X rays, but if you do just so you know, the X rays might look um you know, widened um growth weights and we treat these with activity modifications. Um lots and lots and lots of caf stretching and then gel heel cups. So besides the traction issue, the impact on the ground. So this is something that's pretty common in those who use cleats, for example, soccer. So using these gel heel cups um might also be helpful for them. Um prevention, just like the other entities. Um calf flexibility is very important. Again may wax and wane but will ultimately resolve over time. And then if, you know, they have difficulty slowing them down. Sometimes they're like tiptoe, walk walking or limping. Sometimes I shut those down um by using a cam boot for like a few weeks just to let the area um you know, calm down a little bit. Um so if you have any doubts, you know, feel free to refer that to us and then um Iceland disease again is um an entity that's also attraction of prophecy itis, but the pain is on the outside part of the foot. So um on the base of your fifth metatarsal is one of your is where one of your pretty nails attached to and there's a growth plate in there that can also get irritated. And so this is another area where in some adult radiologists may read it um as a free fracture, but the growth weight is vertical like this. And so if you see something like that and there's no there's pain but there's no acute trauma, then it's probably just a regular growth weight. Um Now if there's trauma especially you know get X rays if it looks like this or like these um then it might be real fractures where we would need to immobilize them but similar to the other attraction of prophecy itis injuries, Iceland diseases um You know, prevented by um stretching and strengthening the ankles. So the ankle does not go just go up and down also goes kind of side to side. So making sure um that they exercise them that way as well. Um So that they don't get flared up. Um I think this is the last case that I wanted to share just because it's very p specific. This is a 10 year old girl who rolled her ankle. Um And you know, has swelling on the over the lateral Malia list. Um And tenderness of patient directly over the lateral Malia was over here. Um X rays show that you know, it looks like normal ankle skeletal immature, maybe a little bit of soft tissue swelling? Um What do you think? Um Does this kid have? Is it um ankle sprain or a distal fibula fracture? Yes. So um this is a growth plate fractures. So Salter Harris fracture. So this is from up to date. Um It goes through different types of Salter Harris fracture. Salter Harris one can be invisible on X rays because it's just through and through. Um Two is above three is below um T would be through both sides and then um five would be um you know crush injury. Um Salter Harris type one. Distal fibula factors are the most common um You know injuries and the skull totally immature. Um Children. Um It is mostly a clinical diagnosis again because X rays are gonna look normal if this is a if the patient is tender directly over here where the growth plate is. Think about a Salter Harris type one. To sell fibula fracture versus an ankle sprain. Usually an ankle sprain is not tender over the bone, an ankle sprain is tender over the ligament. This one this one or this one but not over the bone. And the thing is for kids, their growth plates are weaker than the ligaments. Usually the ligaments are real nice and strong and so it's it's the growth rate that gets injured. So even though X rays are normal um You know just are on the side of caution if they're tender over the bow and and just treat them presumptively? Um They are allowed to wait there um With this kind of diesel fibula fracture. They can use a cam boot or a walking cast for about 3 to 4 weeks. Um and then they're allowed to return to their sports or activities um Once the area is no longer tender and there's no pain with running and jumping. Um we expect complete healing and full return to previous level of activity for all patients. Although it is a growth plate injury. Growth disturbance is pretty rare for this type of diesel fibula fracture um and usually does not affect function. Um if you see a fracture in that area, that's more the type one, especially if there's some displacement I um that would be an indication to send to us urgently because we may have to put it back in place, you know, reduction um you know, might have to be performed or if it's you know, really unstable um surgical management might be recommended. So um yeah, before I always like to share some resources. So this pediatric orthopedic sports injuries is a book that's from the ap um it's written for primary care providers. Um not for orthopedic surgeons. So it's very very helpful. It has, you know, went to X ray and when to refer. Um and a lot of our pediatric trainees um And family practice trainees love it. Ap also has um you know, online resources for sports injuries as well as american medical society for sports medicine and it has you know, head to toe biomedical condition by by part by sport. Um You can have educational handouts that you can share with your patients that may help them understand their injuries. Um And lastly, thank you so much for having me today. Um This is our pediatric orthopedic group here at UCSF. We have different subspecialties. I'm from sports but we have spine, hip, you know lim um specialist um and we serve several locations in the bay Area. We continue to expand. So um I believe Maria will be sharing you know, any um referral information, but again thanks for having me. And I'm um I think we still have a minute or two for for questions.