Common Sports Injuries in Children and Adolescents

Common Injuries by Type in Adolescent and Preadolescent Athletes

Overuse injuries occur from the repetitive application of submaximal stresses to otherwise normal tissues.^[22] This type of injury is more prevalent in the setting of organized sports, compared with backyard or pick-up games or purely recreational activities, especially in elite child athlete programs. Overtraining and exposure to excessive levels of physical activity can present an increased risk of injury. If not managed properly and efficiently, overuse injuries can affect normal physical growth and maturation. Prevention is the key; gradual rather than sudden increases in stresses and intensity can usually avoid physical breakdown.

Early identification and modification of the training program can ensure successful return to sport and minimize time lost from sport. Certain intrinsic factors may predispose a young athlete to overuse injuries. Anatomic malalignments lead to abnormal stresses. Motor strength imbalance can result in muscular strains and overuse. As noted previously, skeletal growth leads to tight musculotendinous units, which are, in turn, associated with muscle strains. If identified early, the progressive inflexibility associated with growth can be overcome with a stretching program, which should reduce the risk of overuse injuries. Ultimately, as the child stops growing, the malalignment resolves naturally, and additional stretching is unnecessary.

Stress fractures are a form of overuse injury, and they occur most frequently in the tibia, fibula, and pars interarticularis in young athletes.^[23] Stress fracture occurs when the bone itself becomes overstressed and begins to fail. Pain with impact or activity is the primary complaint. A high index of suspicion is required to identify some of these injuries to be detected. Focal tenderness in a singular site on the bone is common. The vibration of a tuning fork at the stress fracture site frequently exacerbates the pain. Technetium Tc 99m bone scans may be required to confirm the diagnosis. Tomographic bone scans (single photon emission computed tomography) are even more sensitive and may offer advantages for diagnosing subtle fractures in athletes and fractures of the pars interarticularis. Treatment includes activity modification, immobilization with splinting or casting, and rest. Some athletes can continue play with a stress fracture of a long bone if splinting relieves their pain. However, stress fractures will not heal until the offending stresses are reduced, which is usually post season.

Periostitis, also known as "shin splints," is an overuse injury that occurs in athletes involved in ballistic activities and those that involve rapid deceleration.^[24] It may be caused by a strain of the anterior or posterior tibialis muscles at their tibial origin. Pain is usually diffuse and less focal than that of stress fracture. Bone scan may show diffuse uptake along the shin. The diagnosis should be made only after ruling out simple muscle-tendon strains, stress fractures, and chronic exertional compartment syndrome. Orthotics may be beneficial if the injury does not respond to activity modification, physical therapy, and rest. In rare cases, surgery may be indicated.

For young swimmers and throwing athletes, shoulder pain is a common complaint. The pain is exacerbated by repetitive overhead activities that cause stretching of the anterior capsule and musculature of the shoulder. Physical examination may show rotator cuff weakness, scapular motor weakness, and apprehension. Radiographs rarely reveal significant pathologic findings unless a traumatic injury occurred. But beware, the diagnosis in this age group is rarely rotator cuff disease! The most common diagnosis is instability. Motor imbalance, scapular weakness, and capsular laxity usually play a role. Treatment is physical therapy, including stretching the posterior capsule and strengthening the anterior musculature, rotator cuff, and the muscles of the scapula. In the rare case that impingement is truly occurring, surgical decompression may be attempted. However, resection of the acromioclavicular ligament in the presence of instability may exacerbate the instability.

Little League elbow is a term that describes a number of chronic overuse conditions associated with repetitive throwing that affect the skeletally immature elbow. Repetitive valgus extension forces can lead to irritation of the medial epicondyle secondary to traction and to overgrowth of the radial head, osteochondritis of the capitellum, and premature closure of the proximal radial epiphysis secondary to compression. The young athlete who presents with this condition is frequently a pitcher who has pain during the acceleration phase of throwing. Poor technique or side-arm style may be associated. Treatment begins with rest and is dependent on the radiographic findings. Loose bodies should be removed, and avulsed bone should be repaired. Intact osteochondrotic lesions should be left in place, since the prognosis for healing is good in skeletally immature athletes. When the pain is resolved, a careful progressive return to throwing can be instituted. Proper technique should be monitored by the child's coach. Total number of throws and innings pitched per week should be limited.

The extensor mechanism of the knee is the most common source of overuse complaints in the adolescent athlete. Increased stresses along the entire extensor mechanism occur with running, jumping, and squatting, which are key components of most sports. Osgood-Schlatter disease is a traction apophysitis of the tibial tubercle. It presents at about the age of 13 years in boys and 12 years in girls as a focal tenderness or prominence of the tibial tubercle. Radiographic studies may show ossification, sclerosis, prominence, or physeal irregularities of the tibial tubercle on the lateral aspect. Sinding-Larsen-Johansson is a similar syndrome that occurs at the distal pole of the patella. It is more commonly seen in male athletes between the ages of 11 to 13 years and presents as tenderness and mild swelling at the inferior pole of the patella.^[25] Both disorders are treated with rest, ice, hamstring stretching, and quadriceps strengthening. Patellar tendon taping or Chopart's straps have been helpful in some patients. Fortunately, both are usually self-limited and subside once the apophysis is closed.

Like Osgood-Schlatter and Sinding-Larsen-Johansson disease, Sever disease, or calcaneal apophysitis, is a traction apophysitis. Repetitive impact and Achilles tendon traction lead to complaints of heal pain exacerbated by running in boys and girls at about 11 or 12 years of age. Compression of the medial or lateral aspect of the calcaneus elicits tenderness. Radiographs show sclerosis of the calcaneal apophysis and irregularity of the physis. In the rare cases resistant to rest, ice, and Achilles and plantar fascia stretching, cast immobilization may be necessary.

The athlete with open physeal plates is less susceptible to ligament and muscle-tendon injuries than to avulsion fractures and growth plate injuries.^[18,22] Nevertheless, strains and sprains, and more commonly contusions, do occur in the young athlete.

Strains. A strain is an injury to the muscle, near the musculotendinous junction, as a result of a forceful contraction of the muscle. Strains are unusual in early and middle childhood and are more common after the growth spurt. There are 3 degrees of severity of strains. The first is characterized by mild tenderness, pain with passive stretch of the muscle, and no palpable defect within the muscle. The second degree is associated with spasm of the involved limb, and the third degree is marked by a complete tear of the musculotendinous junction with a palpable defect, in addition to pain and spasm. Animal research regarding the mechanics of a strain injury appears to show that stronger muscles can absorb more energy and are therefore less likely to be injured than fatigued muscles.^[26] Clinical experience has shown that acute muscle strain injury is highly associated with improper warm-up before sports, fatigue, and previous injury.^[27] These observations support the practice of preparticipation conditioning and stretching to reduce injury.

Contusions. Contact sports, such as soccer and football, are the cause of most clinically significant lower extremity contusions in the young athlete. Severe injuries with large hematomas and loss of motion are associated with an increased risk of short-term complications and long-term disability, such as myositis ossificans.^[28] For severe injuries, the best long-term results appear to be obtained when the affected muscle is initially immobilized under significant stretch for a short period (since stretch reduces the degree of bleeding and edema).^[29] Early mobilization after the injury, with passive range of motion within the pain-free tolerance, has been shown to reduce scar tissue formation and provide a more rapid recovery of tensile strength. Subsequently, the athlete can perform active range-of-motion exercises, with restriction from vigorous activity. Massage therapy, ultrasound, and heat may cause further bleeding and damage and are contraindicated.^[26,30]

Ligament Sprains in Skeletally Immature Athletes. Sprains are ligamentous injuries. They occur less frequently in children because of the higher degree of elasticity of ligaments in children and because the adjacent epiphyseal plates are "the weak link." In any child with a proposed or presenting diagnosis of ligamentous injury, serious consideration of the possibility of a nondisplaced physeal fracture should be made. Adolescents who are undergoing or have undergone the growth spurt are more prone to ligamentous injury. Stress radiographs are frequently helpful in identifying the site of instability, be it ligamentous or physeal. Treatment of low-grade sprains consists of icing and splinting. If no ligamentous laxity is noted on physical examination, progress in ambulation should be guided by pain. If laxity is noted on examination, the injury is more severe and a longer period of splinting or protected weight bearing may be indicated. Some ligaments, such as the ACL, do not heal well with conservative treatment. Surgical reconstruction can proceed in the near skeletally mature athlete who wishes to return to competitive athletics.

Joint dislocations are the most severe form of ligamentous failure and are emergent regardless of sports participation. Knee and elbow dislocations may be associated with arterial injury, which places the entire distal limb at risk. Most joint dislocations are managed by reduction and evaluation of the associated neurovascular structures. Intra-articular ligaments, such as the ACL of the knee, do poorly with conservative treatment. If the ACL-deficient patient is an athlete who wants to return to a twisting and cutting sport, such as basketball, surgical reconstruction is recommended. If the ACL is avulsed with bone, primary repair may be indicated. If not, intra-articular surgical reconstruction can be successful even in patients with open growth plates.

Shoulder dislocations can lead to long-term disability in the child athlete. Age is an important factor in this injury. Very few patients older than 50 years who sustain a shoulder dislocation will have recurrent instability. However, among young athletes, 90% will have an associated Bankart lesion (avulsion injury of the labrum-ligament complex), and 90% will have recurrent instability if treated nonsurgically.^[30a] Indeed, age also should influence the selection of surgical technique. Because arthroscopically repaired shoulder dislocations in athletes younger than 20 years have an increased failure rate, contact athletes, younger athletes, and dominant arm athletes younger than 20 years should undergo repair with open surgical techniques.

The physis is the weak link in the structural chain of the skeletally immature athlete. Indeed, physeal plate injuries may have serious implications on growth, potentially leading to deformity. Physeal injuries are usually a result of acute mechanical overload, and some studies have correlated a large proportion of the physeal injuries in the lower extremity to sports participation.^[31] The incidence of fractures is much greater in collision and contact sports. Plain radiographs, occasionally with stress views, establish the diagnosis. Displaced injuries require anatomical reduction, and intra-articular involvement correlates with a poorer prognosis (Table 5). Multiple attempts at closed reduction may further damage the epiphysis.

Some fractures and physeal injuries in child athletes are not acute in nature. Stress fractures are secondary to overuse. Female athletes, especially those involved in aesthetic sports such as figure skating, dance, or gymnastics, are at risk for stress fractures associated with the female athlete triad (amenorrhea, anorexia, osteoporosis). Female athletes who appear to be at risk for the triad should have a thorough nutritional and menstrual history performed to rule out the components of the triad. Another chronic overuse injury occurs in the physis of skeletally immature gymnasts. The gymnast presents with wrist pain secondary to repetitive hyperextension and overuse. Gymnast's wrist frequently shows physeal irregularities and bony sclerosis on radiographs. If untreated, radial deformity and shortening can occur and lead to permanent deformity at the wrist. Rest usually relieves the symptoms, and extension splints such as "tiger paws" can prevent recurrence.

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Cite this: Common Sports Injuries in Children and Adolescents - Medscape - Jul 19, 2000.