Common Sports Injuries

A normal knee has three joint areas or compartments: a ligament on the inside of the knee (medial collateral ligament), a ligament on the outside of the knee (lateral collateral ligament), and 2 ligaments in the middle of the knee (anterior and posterior cruciate ligaments).

The ligaments keep the knee from bending or twisting further than it should and are even stronger than the growth plates in children. Because of this, children and adolescents who were still growing (skeletally immature) were historically thought to only be capable of sustaining a growth plate fracture and not a ligamentous injury.

Although knee ligament injuries were once thought to be rare in the growing children, they are now found with increasing frequency. The reasons for this are multiple: more and more children are participating in sports, physicians are becoming much more adept at identifying ligamentous injuries, and there is improved diagnostic equipment available to patients of all ages (such as MRI scanners).

ACL ruptures, or tears, in particular are more common in children as a result of a sports injury. ACL tears often happen from an abrupt stop or change in direction, a collision, or from landing in an odd position after a jump. ACL ruptures can be divided into those that have a bony avulsion (tibial spine fracture) and those with a complete intra-substance tear.

Bony avulsions can be repaired surgically with a traditional incision or arthroscopically (with a small camera). Treatment for a complete intra-substance rupture depends on the status of the other structures in the knee and the skeletal maturity of the patient (how close the child is to being done with their growth).

If the patient has a fixable meniscal tear (bucket-handle tear), in most circumstances it should be repaired and the ACL should be reconstructed. But, if the patient is skeletally immature, there are significant reconstruction risks that can alter the normal longitudinal and angular growth of the femur.

In the past, most patients were managed non-operatively with activity modification and then a reconstruction was performed once they were skeletally mature. Unfortunately, children do not limit their activities as they are directed and they permanently damage their knees when surgery is delayed.

Techniques that protect the growth plate but reconstruct the ACL have been developed. Although the procedure is risky, the benefits far outweigh the costs. Only a few orthopedic surgeons will perform this physeal-sparing procedure because most do not have the opportunity to treat this condition very often.

More Information:

• OrthoInfo (American Academy of Orthopaedic Surgeons)
• MedlinePlus
• Arthroscopy.com: Arthroscopic ACL Reconstruction

Apophysitis is inflammation of the growing areas of active young children’s bones. These problems are annoying, painful, and sometimes activity limiting, but not serious to the overall health of the child.

In the growing child, there are areas in their bones that are the sites of attachment for large muscle groups. These areas are called apophyses. When a child is very active, running and jumping will cause the muscles to contract, which then pulls on this specialized growth area.

With repetitive activity, the apophysis will become inflamed and painful. Initially, the pain will go away when the activity is stopped. If the child continues to play through the pain, the pain may continue after the activity is stopped or it may occur with all activities, even those as simple as walking.

Apophysitis is diagnosed by history and physical exam. The physical exam will reveal tenderness over the growth area itself without other abnormalities. Sometimes other diagnoses are considered and additional tests like an X-ray may be ordered.

Treatment may include anti-inflammatory medications, physical therapy, specialized equipment, ice, and sometimes rest. Fortunately, these maladies will go away once the growth area no longer exists; this happens when the child is done growing.

Common types and areas of apophysitis include:

• Osgood-Schlatter’s Disease: Knee, where the kneecap tendon attaches to the shin bone
• Sinding-Larsen-Johannson: Knee, at the lower tip of the patella
• Sever’s Calcaneoapophysitis: Heel bone, at the attachment of the Achilles tendon
• Iliac Crest: Where the abdominal muscles attach to the pelvis

Fractures in children and adolescents are very common and present in all ages. Many healthy and active children will have fractures in different locations during their childhood years. Broken bones in children differ significantly from adults.

First, because of their immense growth potential, children have a wonderful ability to heal and remodel a broken bone. Second, children have growth centers that may be injured and may require more aggressive treatment. If a child complains of pain, there is obvious deformity or an unwillingness of a child to move an extremity or walk, this may indicate a fracture and the child should be evaluated by a medical professional.

There are many different types and locations of fractures, the most common being fractures of the collarbone, elbow, forearm, wrist, fingers, ankle, and foot. The majority of fractures are related to falls, sports and minor trauma.

Once a fracture occurs, it is important to monitor for swelling, skin condition, sensation, and blood supply. A thorough physical examination is essential since there may be other associated injuries that may not be recognized.

X-rays are essential for evaluation and fracture management. They show the alignment, healing, growth plate, and joint architecture. Serial X-rays may be necessary to document final healing.

Treatment options include observation, casting with immobilization, and surgery.

• Observation may be indicated in partially healed fractures, avulsion fractures, and minor toe and finger fractures.
• Casting and splinting are frequently used to immobilize a fracture to allow healing and to mold a deformity. Molding is successful in children because of their immense growth and remodeling potential.
• Lastly, certain fractures require surgery to improve the fracture alignment and may require metal instrumentation to stabilize the fracture during the healing period.

Little league elbow is a spectrum of disorders that are characterized by pain around the elbow in someone who typically plays baseball, but can also be involved in other throwing motion sports such as tennis and football.

At the one end of the spectrum are the youngest kids who present with pain on the inside of their elbow. This is usually from flexor tendonitis or a stress fracture of the medial epicondyle. If ignored, this can lead to an acute fracture of the medial epicondyle, which sometimes requires surgical intervention.

This usually occurs in the adolescent in association with an injury to the ulnar collateral ligament.

As the thrower becomes older, their pain will change and localize to the outside of the elbow. This can be extremely serious. This is usually osteochondritis dissecans (OCD) of the capitellum or the radial head. OCD can lead to loose bodies in the joint, arthritis, and permanent disability.

Pitchers have a higher incidence of elbow disorders because pitching places the most stress on the elbow during play, but all other positions may also develop elbow problems.

What are the physical exam findings?

Most patients will not be able to fully extend the elbow, they may or may not have swelling, and the location of the pain will vary.

Will X-rays be taken?

X-rays are usually taken when either acute or chronic pain exists in someone who throws repetitively. A CT scan or MRI may also be ordered.

What is the treatment?

Treatment depends on the age of the patient and the cause of the pain. Treatment can range from rest to casting to surgery, depending on the nature of the injury. It is extremely important that the physician’s instructions are followed regarding both the acute care of the elbow, as well as the instructions for return to play.

Elbow injuries in the adolescent are serious and can have long-term implications if treatment is ignored.

PITCH COUNTS

• Age Pitches/Game
• 7-8 50
• 9-10 75
• 11-12 85
• 13-16 95
• 17-18 105

REST PERIODS

Little league shoulder is a disorder that is characterized by repetitive microtrauma to the proximal growth plate of the humerus. Failure of the growth plate results in a stress fracture. This is most commonly seen in male pitchers ages 11-13 years.

The common finding on X-ray is widening of the growth plate. Fortunately, most pitchers respond to rest, rehabilitation, and then pre-season conditioning the following year.

Besides having chronic repetitive stresses, pitchers with poor pitching technique are more likely to become symptomatic. In the development of young pitchers, the emphasis should initially be on the development of skills and control. Then as they mature, emphasis can change to increasing the speed of pitching

PITCH COUNTS

• Age Pitches/Game
• 7-8 50
• 9-10 75
• 11-12 85
• 13-16 95
• 17-18 105

REST PERIODS

A normal knee has three joint areas (compartments) covered by articular cartilage (pearly white stuff seen on the ends of all bones), a ligament on the inside of the knee (medial collateral ligament), a ligament on the outside of the knee (lateral collateral ligament), and 2 ligaments in the middle of the knee (anterior and posterior cruciate ligaments). The ligaments stop the knee from moving in certain directions and give stability to the knee.

The knee also has a different type of cartilage, called menisci, one on the inside of the knee (medial meniscus) and one on the outside of the knee (lateral meniscus). The menisci serve several functions in regards to normal knee mechanics. Most importantly they act as shock absorbers to cushion the articular cartilage. They also provide stability to the knee and help with nutrition of the articular cartilage.

In the past, menisci were thought to be extra tissue found in the human body and they were removed at the first sign of problems. We now know that they are extremely important to the knee and meniscal preservation should be the goal of all orthopedists.

What is the incidence of meniscal tears in children and adolescents?

The incidence of meniscal tears in children is rising because of increased sports participation and physicians being better at diagnosing the problem. Football, basketball, and soccer seem to have the highest incidence of tears.

In the past, meniscal tears in children less than 12 years of age were thought to be due to a congenitally abnormal meniscus. In fact, meniscal tears do occur in children with normal knees. After age 12, the incidence dramatically increases because of more damaging physical activity and a change in the mechanical properties of the menisci.

How is a meniscal tear diagnosed?

Taking a history from a child or adolescent is very difficult because of their inability to communicate about the problem. They are usually very vague about how they injured their knee, the symptoms they are feeling, the location of the pain, and whether or not they have any mechanical symptoms like locking, catching, or giving way.

The physical examination can be difficult because of the fear that the child has about going to the doctor. Determining where the pain is located is very important to determining the cause.

Will X-rays be ordered?

Plain X-rays may be ordered depending on the onset of pain and injury. Sometimes an MRI will also be ordered to look at the structures on the inside of the knee that do not show up on regular X-rays.

What is the treatment of a meniscal tear?

Fortunately for children and adolescents, most meniscal injuries occur in a way that can be fixed. Younger individuals usually tear the back of the meniscus where there is good blood supply. Adults usually tear their menisci after a lot of wear and tear. The goal is always to preserve the meniscus in order to maximize long-term function of the knee.

If a meniscal tear is identified, an arthroscopy will usually be performed. This is a surgical procedure where 2 small holes are made in the skin and a camera is placed into the knee. Using very small instruments and watching through the camera, a surgeon can repair the meniscus. If the meniscus cannot be repaired, then the torn part is trimmed back to an area that is not loose.

How soon can my child return to sports?

The answer to this question depends on whether the meniscus was partially resected (trimmed) or repaired. If a partial resection was performed, the patient can usually return to activities in a few weeks after they have progressed through the physical therapy criteria. If a repair was performed, the patient will be on crutches, then start physical therapy, and be out of all activities for 3-4 months.

Though a meniscal resection seems easier at the beginning, it is not the best answer for the long-term function of the patient and their knee.

Nursemaid’s elbow is also known as a “pulled elbow” or “partial dislocation of the radial head.” It is the most common traumatic elbow injury of children, accounting for 15-27% of all elbow injuries in children younger than 10 years of age. The average age of incidence is 2-4 years old.

Usually this occurs when the parent, walking with the child, pulls on the child’s arm to help them up onto a curb or pulls them from a sitting position. The radial head pops out of joint or the annular ligament becomes entrapped in the joint. The X-rays are usually normal. The child will hold the arm in a protected position and not use the upper extremity. They hold the elbow flexed (bent) with the palm turned downward.

The initial pain usually subsides and they will return to play. Younger children may hold the arm limp. The child needs to have the radial head popped back into place. This is usually done at the doctor’s office or emergency room. Afterwards, the child should begin using the arm fairly quickly. Casts are not routinely used in order to allow the bones to resume normal function, but casts may be necessary to relieve pain if there have been multiple episodes.

Osteochondritis dissecans (OCD) is a pathologic change seen in many joints but most commonly seen in the knee. The cause is thought to be due to trauma and a reduction in the blood supply to the bone.

The pathophysiology involves the loss of blood supply in an area of bone underlying cartilage. Without blood supply, the bone dies and the cartilage breaks loose and arthritis develops. OCD is the most common cause of loose bodies in the knee. There are two distinct subgroups of patients: the skeletally mature and the skeletally immature.

What are some of the symptoms seen in OCD?

The patient will complain of pain, catching, locking, swelling, and giving way. They may feel something moving inside their knee.

Will X-rays be taken?

X-rays will usually show an OCD lesion. This is typically seen on the medial femoral condyle (inside bump on the femur). A MRI is used to determine if the lesion is attached or not attached.

What is the treatment for an OCD?

The treatment of OCD depends entirely on the skeletal maturity of the patient and if the piece of cartilage is loose or not loose.

• If the lesion is loose in any age, an arthroscopy needs to be performed to evaluate the cartilage and either fix or remove the loose piece.
• If the patient is skeletally immature (still growing) and the OCD is attached, then activity modification for 3 months will usually allow the lesion to heal.
• If a patient is skeletally mature, arthroscopy is necessary because healing cannot occur without medical intervention.

The initial dislocation of a patella (kneecap) is usually a dramatic acute event that occurs during a knee-twisting event. The patella will jump laterally (to the outside of the knee) and either stay there or pop back into place. The knee will swell a great deal immediately and the patient may or may not be able to bear weight on that leg.

How is a patellar dislocation diagnosed?

The diagnosis is based on the history given by the patient and by the physical examination.

Will X-rays be taken?

If this is the first time that the patella has dislocated, then X-rays will usually be taken. Sometimes, an MRI will also be ordered to look for any other problems in the knee or if a piece of bone has broken loose with the patellar dislocation.

What is the treatment for an initial patellar dislocation?

This is a controversial area of sports medicine. Depending on the age, physical examination, X-rays, and the athletic level of the patient, a treatment protocol will be initiated.

Fortunately for adolescents, the treatment does not usually involve surgery. They will be maintained in a knee immobilizer or a cylinder cast. At a certain point in their rehabilitation, they will be sent to physical therapy to work on a stretching and strengthening program.

Some patients will need to have surgery. This is sometimes performed arthroscopically (through a small camera), but also may require a regular surgical incision.

Does the patella ever dislocate again in these patients?

Yes, the incidence of having another dislocation is dependent on the age at which the first dislocation occurred. Younger children are more likely to have a recurrence. Some patients will have one or two more dislocations and others will begin having dislocations all of the time (or chronically).

A patient that has had more than 6 dislocations may be a candidate for a surgical procedure to help keep the patella in place.

What are the long-term problems associated with a patellar dislocation?

A great deal of force is required to pop the patella out of joint. This force is transferred into the joint where the articular cartilage (pearly white stuff on the ends of all bones) may be damaged. This may lead to arthritis and other persistent problems.

Having multiple episodes of dislocations increases the damage to the articular cartilage and puts the patient at increased risk for arthritis in the future.

Patellofemoral pain syndrome (PFPS) is anterior knee pain seen most commonly in two age groups: teenagers and those in their 30s and 40s.

In the adolescent, there are two distinct groups that get PFPS:

• Active athletes – especially those involved in jumping and kneeling activities
• Non-athletic, inactive, often overweight adolescents, most commonly girls

The cause of this non-traumatic knee pain is unknown, but appears to be multifactorial.

What are some of the symptoms that go along with PFPS?

During the history, the patient will complain of poorly localized anterior knee pain that moves around the patella (kneecap). They will complain of increased pain with sitting (theater sign), going up and down stairs, and with increased activity. They will sometimes complain of giving way and swelling, which is more “puffiness” than really being very swollen. The pain can be waxing and waning, and as such, this pain has usually been present for a long time before the patient seeks medical care.

What is the physical examination like?

The physical examination may involve the entire limb of the patient from the hip to the ankle. It is necessary that the patient be appropriately clothed in shorts – not pants with the leg rolled up – so that the physician can accurately assess the entire lower extremity.

Will X-rays be taken?

Depending on the history and the physical examination, X-rays may be taken. Other tests like a CT scan or MRI are usually not necessary.

What is the treatment?

The treatment for PFPS involves a course of non-steroidal anti-inflammatory medicine and physical therapy specifically geared toward PFPS. This means that the patient has to go to physical therapy and do the exercises reliably. The patient must be an active participant in the treatment program.

In order to successfully treat PFPS, an aggressive daily home exercise program, in addition to outpatient physical therapy 1-2 times a week, is required. The longer the pain has been present, the longer it will take to get rid of the pain.

Sometimes your doctor will prescribe a brace that may make physical therapy and some activities easier. Also, specific orthotics may be necessary in some patients. Continuing to be active in sports and physical education is encouraged, but coaches and PE instructors must be aware of the ongoing therapy program and the patient’s limits.

Shin splints are exercise-related pain found along the posteromedial border (inside) of the distal tibia (shin bone). It is most often caused by a stress reaction of the bone and the attached muscles in response to repetitive overuse. Shin splints account for 13% of all injuries in runners.

Patients typically present with pain, initially upon exertion, that may be relieved by continued activity. The pain may recur toward the end of the workout or after running. Over time the pain goes from being dull or sore to sharp, penetrating, and severe. With time, the pain may be present with activities of daily living.

Shin splints usually occur when there has been a significant change in activity. It is not restricted to the unconditioned or ill-prepared athlete. Changes in footwear, running surface, terrain, or intensity may precipitate shin splints.

Will X-rays be taken?

Many times, X-rays will be taken to rule out a stress fracture. Sometimes a bone scan or an MRI is advised to aid in the evaluation of this problem.

What are the treatment options?

Patients are usually sent to physical therapy to work on a stretching and strengthening program. Orthotics may be ordered and the running shoes may need to be evaluated. Your doctor may also recommend taking a non-steroidal anti-inflammatory medication.

How long will it take for the problem to go away?

Usually it takes about 7-10 days for the pain to decrease enough that the patient can resume some training. If it is important to maintain cardiovascular fitness, then cross-training with an exercise bicycle or water running have been found to be excellent alternatives.

Relative rest means that the patient is allowed to do activities that can be performed comfortably. Once the patient is comfortable, then the activity level can be gradually increased in response to the patient’s symptoms.

A stress fracture is most commonly seen in the tibia but can occur in many other bones. The majority of stress fractures are seen in runners, with females being 12 times more likely to develop stress fractures. This is thought to be secondary to the smaller size of the bone, their menstrual irregularities, and the higher incidence of eating disorders.

The development of a stress fracture is multifactorial. They can occur in the highly trained athlete or a recreational novice. The cause is typically a change in training, whether it is an increase in intensity or duration, change in footwear or surface, or an anatomical abnormality. Prior to puberty, stress fractures are thought to be uncommon, but after puberty, the incidence is the same as in the adult population.

Will X-rays be taken?

Usually X-rays are taken to identify a stress fracture. Not all stress fractures will show up on plain X-rays and then a bone scan or an MRI may be ordered.

How are stress fractures treated?

Relative rest is the treatment of choice, meaning that any activity that causes pain should be avoided. Walking with crutches helps to reduce stress on the bone.

When the patient can walk comfortably, they can come off of the crutches. When they can run, they can begin weight-bearing training. Until they are able to go back to regular activities, they may perform non-weight bearing exercises like bicycling and swimming.

What are the complications of a stress fracture?

A stress fracture that does not heal may become a true fracture that requires casting or surgery to heal. It is very important to allow a stress fracture to heal appropriately so additional time away from the patient’s sport is not required.