Acute and Chronic Youth Sports Injuries - Dr. Aaron Gray, University of Missouri

1. Aaron Gray, MD
Departments of Family Medicine & Orthopaedics
University of Missouri
@MizzouSportsDoc

2. About Me
 Family Physician
 Sports Medicine Physician
 Team Physician for University of
Missouri Athletics

3. www.bit.ly/sportsmedicin
e

4. Overview – Acute Injuries
 Ankle Sprain
 Acute Knee Injuries
 ACL Injuries
 Patellar Dislocation, MCL and Meniscus
Tears
 Avulsion Injuries of the Pelvis
 Scaphoid Fractures
 Mallet Finger
 AC joint sprain (shoulder separation)

5. Acute Knee Inuries

6. History of Injury
 Mechanism of Injury?
 Discuss immediate symptoms
 Did they hear/feel a pop?
 Did the knee immediately swell?
 Where was the location of initial pain?
 Were they able to bear weight or continue
playing?
 Chronological description of symptoms
up to the point of evaluation

7. Questions I Always Ask
 Current location of pain?
 Are they having TRUE “locking”?
 Meniscus tear, loose body
 Any instability, looseness or wobbly
feeling in the knee?
 Ligamentous injury, patellar dislocation
 Any swelling or effusion?
 Immediate effusion suggests ACL tear
 Slightly delayed effusion could be patellar
dislocation, fracture, meniscus tear

8. Physical Exam
• Inspection
• Bony Palpation
• Soft Tissue
Palpation
• Range of Motion
• Neuro and
Muscle Testing
• Tests for Joint
Stability
• Special Tests

10. Traumatic Effusion=Get a MRI
 2/3rds of the time the patient has suffered
an ACL injury if there is immediate
swelling after a twisting injury with a
pop.

11. “Epidemic” of Female ACL
Ruptures in US
 Female athletes have 4-6x increased risk
of ACL injuries than males in similar cutting
sports
 Since Title IX was passed in 1972
 10x increase in participation in girls HS athletics
 5x increase in female participation in collegiate
sports
Arendt, et al. J Athl Train, 1999.
NCAA (2002) and NFHS (2009) published data

12. ACL Injury Statistics
 Soccer was highest mechanism of injury (26.6%)
in Kaiser Permanente ACL registry
 Year-round female athletes who play soccer or
basketball have ACL tear rate of 5%
Maletis, et al. J Bone Joint Surg Am 2011.
Prodromos, et al. Arthroscopy 2007.
ACL tears peak at age 16 in
female athletes

13. Gender Disparity is Likely
Multifactorial
 Intrinsic variables with gender differences
 Anatomic
 Hormonal
 Neuromuscular

14. Neuromuscular Deficits in
Female Athletes
 4-6 inch growth spurt
around 10-11 years
old
 After growth spurt
female adolescents
do not gain
“neuromuscular
spurt” that males
achieve
 Center of mass rises
through puberty
Huston & Wojtys. AJSM 1996.

15. What Usually Happens in a
Non-contact ACL injury?
 60-80% of ACL injuries are non-contact
 Two common mechanisms
Landing Cutting
Krosshaug et al. AJSM 2007.

16. Characteristics of ACL tears in
Females
 Dynamic knee valgus on landing
 Knee is relatively straight on landing
 Most or all of weight is on one leg
 Trunk is tilted laterally (center of mass is
outside feet)

17. What usually happens in a non-
contact ACL injury?
S

18. What usually happens in a non-
contact ACL injury?

19. What usually happens in a non-
contact ACL injury?

20. What usually happens in a non-
contact ACL injury?

21. What usually happens in a non-
contact ACL injury?

22. What usually happens in a non-
contact ACL injury?
E

23. What usually happens in a non-
contact ACL injury?
S

24. What usually happens in a non-
contact ACL injury?

25. What usually happens in a non-
contact ACL injury?

26. What usually happens in a non-
contact ACL injury?

27. What usually happens in a non-
contact ACL injury?

28. What usually happens in a non-
contact ACL injury?
E

31. • Solely using sensitivity and specificity
values, the Lachman test is best overall
test at both ruling in and ruling out ACL
ruptures
• Anterior drawer test appears to be
inconclusive for drawing conclusions either
way
Scholten, R., et al. J Fam Pract 2003

33. Patellar Dislocation
 Often caused by twisting episode
 Patella usually spontaneously reduces
 Treatment includes immobilization for 1-
2 weeks followed by optional patellar
stabilization brace
 PT works to restore motion and improve
strength
 Recurrence after primary episode is
17%

35. Medial Collateral Ligament (MCL)
Tear
 Pain in medial aspect of knee
 Pain (+/- laxity) with stress testing at 30
degrees flexion
 Treatment
 Hinged knee brace
 RTP 4-6 wks for grade 1 up to 12 wks
for grade 3

37. Meniscus Tears
 Pain in joint line of knee after twisting
injury
 May have locking
 Children under 10 with a tear likely have
a discoid meniscus
 Meniscus repairs are often successful in
children

38. • Special Tests
o Meniscal tear
 McMurray Test (feel for a snap or click that is often
accompanied by pain)

39. Hip and Pelvis Injuries
 12 yo felt a painful pop in right groin
when kicking soccer ball
 What is your differential?

41. Hip & Pelvis Injuries
 Avulsion injuries to are possible at
multiple growth plates in the pelvis
 Anterior superior iliac spine (ASIS)
○ Sartorius origin
 Anterior inferior iliac spine (AIIS)
○ Rectus Femoris origin
 Ischial tuberosity
○ Hamstring origin
 Male athletes 14-17 yo, female athletes
12-15 yo

43. Wrist Injuries
 17 yo male who fell on out stretched
hand with pain in anatomic snuff box.
 What would you do next?
Phillips, et al. Am Fam Physician. 2004.

45. 1 year later…
 Only had cast
for 6 weeks
initially
 Still refused
treatment to
finish HS
basketball
season

46. 28 yo with Scaphoid Nonunion

47. Mallet Finger
 Forced extension of distal
interphalangeal joint (DIP) while in
active flexion.
Emedicinehealth.com

48. Mallet Finger
 Ruptures extensor digitorum at DIP joint
 Treatment
 Place DIP joint in slight hyperextension for
6-8 weeks
 Must avoid flexion 24 hours/day!

49. Acute Shoulder Injuries
 AC sprain
 Rotator cuff tears rarely happen in
pediatric patients

50. Acromioclavicular Sprains
(Separated Shoulder)

52. Rockwood &
Green’s
Fractures in
Adults
6th Edition

53. AC joint Crossover Test
• Patient forward
flexes affected arm
to 90°
• Actively adducts
arm across body
• Forces acromion
into distal end of
clavicle
• Suggests AC joint
pathology if
painful

55. Overview
 Upper Extremity
 Elbow and Shoulder
 Lower Extremity
 Foot to Pelvis

56. Elbow
 Little Leaguer Elbow
 OCD of capitellum

57. Phases of Pitching
 High valgus tension forces and high radial
head/capitellum compression forces occur

58. Little League Elbow (medial
apophyseal injury)
 Usually affects Little League age
pitchers 9-12 years old
 Repetitive valgus overload can lead to
microtrauma in the medial epicondyle
apophysis
 Older pitchers with closed growth plates
would stress their ulnar collateral
ligament instead

59. Little League Elbow (medial
apophyseal injury)
 Xrays of bilateral sides can show
apophysis widening
 Treatment is rest from throwing
 Focus on core and posterior shoulder
strengthening during rehab during
period of rest

60. Shoulder
 Rotator cuff impingement
 SLAP tear
 Rotator cuff strain/tendonitis
 Little Leaguers Shoulder

61. Subacromial Space
The area under the
acromion and above
the glenohumeral joint
Structures
• Supraspinatus muscle
• Subacromial/subdeltoid
bursa
Subacromial Bursa
Supraspinatus
Sobotta (2002)Small Space • Impingement

62. Shoulder Impingement
 Hx: Gradual onset of pain worsened with
overhead activities. Often with night pain
 PE: +impingement tests, weakness and
pain with resisted supraspinatous testing,
ROM usually NL
 Imaging: Xray – usually NL. Treatment: PT
for strengthening of scapula stabilizers and
rotator cuff
 Referral - Consider if not improved after 6
months of adequate rehab

63. Impingement Signs
Hawkins Test
• Patient’s arm
forward flexed to
90°
• Elbow flexed to
90°
• Shoulder forcibly
internally rotated
by examiner
• Pain suggests
Subacromial
Impingement

64. Glenoid Labrum Tear

65. Glenoid Labral Tear
 Hx: Multiple mechanisms
 Atraumatic
 Traction in overhead throwing athletes
 Sudden pull from catching oneself from
falling
 Compression from falling onto outstretched
arm
 Hx: Pain with overhead activities;
sometimes will have popping, clicking,
or catching with motion. Often will have
failed rehab with continued discomfort.

66. Glenoid Labral Tear
 PE: + O’Brien’s test
 Imaging: MR arthrogram
 Treatment: start with PT, however, most
patients will need surgical treatment to
resume full function

67. Labral signs
O’Brien Test
• Arm forward flexed to 90°
• Elbow fully extended
• Arm adducted 10° across
body with thumb down
• Apply downward pressure
against patient resistance
• Repeat with thumb up
• Suggestive of labral
tear if more pain with
thumb down

68. “Little Leaguer’s Shoulder”
 Widening of proximal humeral growth
plate
 Mild shoulder pain that increases with
pitching
 Xrays comparing bilateral sides can be
helpful

69. Little Leaguer Shoulder – 13 yo

70. “Little Leaguer’s Shoulder”
 Tx: No throwing for 6-8 weeks or until
all pain resolved
 Start core exercises immediately and start
rotator cuff exercises once pain improved

72. Wilk et al. “Advanced Throwers Ten.” Physician and Sports Medicine, 2011.

73. Advance Throwers Ten
Wilk et al. “Advanced Throwers Ten.” Physician and Sports Medicine, 2011.

74. .org

76. Foot and Ankle Overuse
Injuries

77. Sever’s Disease (calcaneal
apophysitis)
 #1 Cause of heel pain in 8-12 year olds
 Often occurs during/after rapid bone
growth leaving the muscle/tendon
complex tight
 Xrays not necessary
 Treatment includes ice, decreasing
volume of activity, CAM boot if severe
pain

78. Keep an eye out
for stress fractures!
• Secondary to overuse
• Can result from increasing
physical activity too quickly,
improper shoe wear or
technique
• Metatarsals (2nd or 3rd most
common), navicular, calcaneus
• Maximal point tenderness over
the bone at fracture site, hop
test +
• Xray often negative early on
• MRI is best.

79. Usually Not Achilles Tendonitis
or Plantar Fasciitis
 Pediatric patients usually don’t get
inflammatory tendon conditions
 Think of other possibilities first

80. Osgood Schlatter Disease

81. Osgood Schlatter Disease

82. Patellofemoral Pain Syndrome
 One of most common adolescent
musculoskeletal complaints
 Often complain of vague anterior knee
pain around patella
 Worse with stairs, squatting, hills
 Exam: Often quite normal.
 Single leg squats can illicit pain

83. Patellofemoral Pain Syndrome

84. Snapping Hip
Images from Dr. Thomas Byrd, Nashville, TN
Iliopsoas tendon
IT band

85. Foam Roller – for IT Band
stretching
Bicycling.com

86. 14 yo girl with left lateral hip
pain
 Pain at left iliac crest playing volleyball.
 Worse with twisting and jogging.
 Pain comes and goes, worse during and
after activity

87. Iliac crest apophysitisIliac Crest Apophysitis

88. Thanks!
 Email – grayad@missouri.edu
 Twitter- @MizzouSportsDoc