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Pediatric Overuse Sports Injury and Injury Prevention
Pediatric Overuse Sports Injury and Injury Prevention Karen M. Myrick, DNP, APRN ABSTRACT
Participation in sports by the pediatric population has grown vastly over the years. Overuse injuries in the pediatric population signify a significant health care interest. Some reports and clinical observations designate 50% of all pediatric sport-related injuries as overuse or repetitive trauma. Furthermore, it is ventured that more than half of these injuries may be preventable with straightforward strategies. Nurse practitioners are well positioned to identify these injuries and implement injury prevention in their practices. Keywords: injury prevention, orthopedics, overuse, sports medicine Ó 2015 Elsevier, Inc. All rights reserved.
N
urse practitioners (NPs) have a solid foundation of health assessment, and this article will build on that foundation and provide the framework of the specialty focus of orthopedic and sports medicine to providing clinical pearls for improving care for athletes who present with overuse injuries. The emphasis is on the identification of risk factors, preparticipation physical examination best habits, proper supervision, suggestions for best practices in treatment and referral, sports alterations options, available training and conditioning programs, and an explanation of the concept of delayed specialization. Characterized as microtraumatic damage to bone or soft tissues, overuse injuries occur in structures that have been subjected to repetitive stress without sufficient recovery time.1 Soft tissue comprises the muscles, tendons, cartilage, and ligaments. In the pediatric population, the skeletally immature physeal and apophyseal growth cartilage is particularly vulnerable. Injuries can occur to healthy tissue as a result of repetitive force or the repeated application of lesser quantities of energy to pathologic or maturing tissue or bone.2 Overuse injuries of developing tissue include the growth-related disorders of Osgood-Schlatter disease (OSD), Sever disease and other apophyseal (growth plate) injuries such as little leaguer shoulder (humeral epiphysiolysis) and elbow (medial apophysitis), and radial epiphysiolysis (gymnast wrist). Overuse www.npjournal.org
injuries resulting from recurring microtrauma and chronic submaximal loading of tissues include stress fractures, osteochondral defects (OCDs), and tendinitis. Training errors, unsuitable technique, extreme sports training, insufficient rest, muscle weakness and imbalances, and early specialization in 1 sport are all viable mechanisms for overuse injuries to occur. Overuse injuries typically present with an insidious onset of pain and can worsen to be present at rest and prevent play. The Table represents a commonly used symptom-guided grading system of overuse injuries with a 1 to 5 scale. RISK FACTORS
Elements that are indicated in overuse injuries are typically multifactorial. These factors can occur as intrinsic or extrinsic to the athlete and can also have both overarching types of factors at the root of the overuse. At the level of the athlete, these factors include participation on multiple teams, participating in year-round involvement in sports without adequate rest, previous injury, core weakness including the hip and trunk, and specializing in 1 sport at an early age. Extrinsic factors that are indicated in overuse injuries include pressure on the young athlete in the form of the requirements of a weekend sports tournament, such as those common in the sports of swimming, soccer, lacrosse, and baseball. These tournaments may include 6 hours each day of play. The Journal for Nurse Practitioners - JNP
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Table. Symptom-guided Grading of Overuse Injuries Injury Severity
Symptom Characteristics
Grade 1
Symptoms occur at the end of the activity or only at the initiation and then diminish
Grade 2
Symptoms develop during activity, late onset, diminish after activity is completed
Grade 3
Symptoms develop during activity, early onset, and persist during the remainder of activity, diminish after activity has ended
Grade 4
Symptoms develop during activity and limit training frequency, intensity, or duration
Grade 5
Symptoms prevent training
Modified from Difiori.3
Over a full weekend, the athlete might be involved with playing for more than 12 hours. Other extrinsic factors indicated in overuse injuries may also be in the form of parental insistence, coaching pressure, and peer or sibling competition. Factors affecting child (younger than 11) and adolescent (age 12-18) athletes differ. The child athlete is at risk because of muscle imbalance and tissue immaturity, and the adolescent athlete is more likely to develop overuse injuries because of rapid periods of growth.3,4 EPIDEMIOLOGY
NPs are very likely to encounter pediatric patients who are actively participating in organized sports. In the United States, participating in sports is increasing steadily. Currently, there are an estimated 30 to 40 million children who participate in organized sports activities each year.5 Additionally, half of pediatric patients presenting for sports medicine chief complaints are not presenting with acute injuries but rather injuries that are chronic in nature.1 Furthermore, approximately 50% of all pediatric sport-related injuries ensue through overuse or repetitive trauma mechanisms.1
Typically, a combination of repetitive throwing, weak physeal cartilage at growth centers, muscle tightness associated with rapid long bone growth, increased laxity of soft tissue structures, and decreased development of neuromuscular movement patterns will foster an increased risk of injury to the athlete.5 The common age for little leaguer shoulder is 11 to 15 and is typical in the throwing athlete population. The diagnosis of humeral epiphysiolysis is made when the athlete presents with proximal shoulder pain with activity. When asked to try and “pinpoint” the discomfort, the athlete will typically point to the area of the humeral growth plate. Radiographs will show widening of the proximal humeral physis and changes in the appearance of the bone including sclerosis, fragmentation, and changes that appear cystic in nature.5 Figure 1 shows the findings that are typical for humeral epiphysiolysis. Treatment is geared toward rest, including cessation of all throwing activities. Follow-up with radiographs is indicated for the determination of healing and improvement. An important pearl, yet frequently overlooked, is that the pediatric patient needs to be reminded of what constitutes throwing. Some will take this literally to mean a baseball or a softball. However, playing catch, throwing a football or Frisbee, fetch with their dog, and even Figure 1. Radiograph of Little Leaguer Shoulder (Humeral Epiphysiolysis).
SELECT COMMON CLINICAL OVERUSE INJURY DIFFERENTIALS Upper Extremity
Child. Little Leaguer Shoulder (Humeral Epiphysiolysis) The pathophysiology of little leaguer’s shoulder is the result of the tension from repetitive throwing in overhead athletes, which can lead to a widening of the humeral growth plate or physis. 1024
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a good-natured snowball fight all include throwing and must be avoided. Suggestions for best practices include increased clinician suspicion based on the history of the athlete, and the history of the present illness will improve accurate diagnosis and treatment of humeral epiphysiolysis. Overhead athletes with complaints of aching and tenderness on physical examination over the growth plate of the humerus should be considered for this diagnosis and evaluated with radiographs. Taking comparison x-rays of the contralateral and noninvolved side may aid the less experienced clinician in seeing the difference in the growth plates. Typically, athletes present with mild to severe posterior tightness and may also show weakness in the midback, contralateral hip, and trunk in general when evaluated. These areas should all be a focus for a sound strength and conditioning program once symptoms reside, and a formalized physical therapy prescription is recommended. Panner Disease The pathophysiology behind Panner disease is a failure within the ossification center of the capitellum within the elbow.6 The problem is not known to be caused from reduced blood flow or from an infarction. There are many theorized mechanisms in the literature. Typically, the child is in the age range of 7 to 10 years old, and the presentation is a history of dull, aching elbow pain that is worsened with activity and improves with rest. The aggravating activity is generally throwing. Diagnosis is made with x-rays; in Figure 2, there is an area delineated with an arrow showing an irregular surface on the capitellum. Treatment is aimed at complete rest from throwing. Suggestions for best practices include referral to an orthopedic or sports medicine specialist once the disease is suspected. Recalling that this disease affects primarily the younger athlete, suspicion needs to be high on the radar of the practicing clinician in order to make an accurate diagnosis and prompt referral. There is a high chance of long-term consequences and progression of the disease.7 Certainly, to decrease incidence, adherence to pitch counts and adequate rest are prudent for the athlete and for those involved with the athletic population to enforce. Adolescent Patients. OCD Elbow The pathophysiology of OCD comes from throwing activities that involve strain across the elbow joint, www.npjournal.org
Figure 2. Radiograph of Panner Disease (OCD of the Capitellum).
stretching the ulnar side of the joint and compressing the radial-capitellar joint. It is theorized that there is a disruption in subchondral blood flow to the capitellum from repetitive compressive forces as the pathophysiology behind OCD.5,7 The age for patients with OCD is typically 12 to 16 years old. This is in comparison with Panner disease, which affects the younger athlete, but also presents with elbow pain with a similar symptomatology. OCD usually occurs when the bones have completed their growth phase. Throwing athletes often present with pain during throwing, and upper extremity weight-bearing athletes present with pain during weight bearing. A common clinical complaint is one of locking or catching of the joint caused by loose bodies from the OCD. Gymnasts are a common group of athletes in the upper extremity weight-bearing category. There is frequently a history of increased throwing activity, and on examination the athlete has pain at the lateral elbow with both extremes of motion (flexion and extension and occasionally supination and pronation). There may be changes on plain radiographic examination, showing a lucency in the area of OCD. However, diagnosis is confirmed with magnetic resonance imaging (MRI), which indicates signal changes around the lesion.7 Figure 3 shows the increased signal on T2-weighted images. MRI will not only confirm diagnosis but also will aid the orthopedic specialist in the treatment plan, determining the extent of the defect and the condition of the surrounding cartilage The Journal for Nurse Practitioners - JNP
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Figure 3. MRI of OCD of the Elbow (OCD of the Capitellum).
and bone. Treatment consists of relative rest with the stress of throwing removed and a gentle increase in range of motion and flexibility when pain has decreased. Relative rest means that the athlete may continue some strengthening and cardiovascular exercises but needs to remove the stress of throwing from the upper extremity. Suggestions for best practices include being aware of the high potential for long-term consequences; therefore, a referral to an orthopedic or sports medicine specialist is recommended. The symptoms of arm pain, fatigue, and decreased throwing performance need to be recognized by athletes, coaches, parents, and medical personnel as early warning signs of potential overuse injuries in pediatric athletes.1 If the athlete is in fact a pitcher, decreasing the volume of pitches is recommended along with early recognition of risk factors such as generalized laxity and hypermobility, which should be discovered during the preparticipation physical examination.1 Ulnar Collateral Ligament Tear The pathophysiology involved with ulnar collateral ligament (UCL) tears rests on activities that typically involve strain across the elbow joint, stretching the ulnar side of the joint and compressing the radial-capitellar side. In the 1026
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younger athlete, the potential for muscle imbalance is high; particularly upper/midback and core weakness, including trunk and hip weakness, may play a role in increasing the forces across the elbow when throwing. This relates to the periods of growth with bones typically growing at a faster rate than the supporting and surrounding soft tissues, including muscles, ligaments, and tendons. Additionally, athletes may pitch or throw when fatigued, and this increases the risk for injury. Throwing when fatigued decreases the power from other parts of the body, such as the trunk or core or lower extremities, and increases the strain across the elbow itself. The diagnosis of a UCL tear is made when the history and physical examination clearly show medial arm pain at the elbow, typically a low-grade ache, and possibly 1 traumatic throw when the athletes may perceive the injury occurring. Many athletes will know and painfully recall the 1 pitch or throw that culminated in the cessation of their play. The examination will show pain over the length of the UCL laxity with valgus stressing of the joint and a positive milking maneuver. Suggestions for best practices include obtaining MRI of the elbow joint and referral to an orthopedic and sports medicine expert. MRI will show discontinuity of the fibers of the UCL, as shown in Figure 4. The likelihood for surgical repair is high in a complete tear, and careful examination and followup are keys for healing. Medial Apophysitis (Little Leaguer Elbow) The medial epicondyle apophysis is under strain with overhead throwing motions.4 These biomechanics allow for increased strain across the apophysis of the skeletally immature athlete. Repetitive strain without adequate rest and muscle imbalance may lead to apophysitis. Pain that is worse with throwing activities and better with rest is typical in the history of the present illness for patients with medial epicondyle apophysitis. Diagnosis is typically made with clinical examination only. However, radiographs can be helpful to show hypertrophy, widening, and fragmentation of the apophysis, especially with a comparison view of the contralateral side.7 Figure 5 shows radiographic findings with widening noted of the medial epicondyle apophysis. Volume 11, Issue 10, November/December 2015
Figure 4. MRI of an Ulnar Collateral Elbow Tear.
Keeping the athlete from all throwing activities until there is no pain typically consists of a 4- to 6-week initial trial of rest. Upon completion of this rest period, a follow-up appointment is encouraged. Dependent on the history and physical examination findings at that follow-up visit, as with other overhead athlete overuse injuries, a solid strength program focusing on hip, trunk, and back musculature is paramount. Gymnast Wrist (Distal Radial Epiphysiolysis) In a gymnast, the dorsiflexed wrist position is a common position for many stunts and activities. This extreme position coupled with repeated weight-bearing activities cause progressive disruption in the ossification at the distal epiphysis of the radius in the wrist.4 www.npjournal.org
Figure 5. Radiograph of Little Leaguer Elbow (Medial Apophysitis).
Physical examination along with a thorough history will likely lead the clinician to the diagnosis. Radiographs may not be necessary for diagnosis but can be helpful in documenting progression or severity. In order to rule in epiphysiolysis and rule out tendinitis, a thorough evaluation of range of motion and a strict evaluation of tenderness to palpation are essential. The findings of normal range of motion and pain only with axial loading of the wrist are positive in epiphysiolysis and negative with tendinitis.4 Pain with axial loading is a common physical examination finding for fractures of most bones. Suggestions for best treatment include relative rest, specifically from any weight-bearing activities. Depending on the level of the athlete and the nature of their compliance, immobilization may be a necessary strategy to ensure rest and protection. Torso
Spondylolysis. Repetitive spine extension is common in sports such as basketball, volleyball, gymnastics, and figure skating. The pathophysiology of spondylolysis includes recurring loading of the vertebral bodies, especially with spine extension; in many sports, it may cause a defect in the posterior element, the pars interarticularis. The Journal for Nurse Practitioners - JNP
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The diagnosis of spondylolysis is made with direct visualization of the pars interarticularis on radiographs, observing the oblique images.8 The “Scotty dog” sign is shown on these radiographs when spondylolysis is present. Figure 6 represents this “Scotty dog” finding on radiographs. This finding is likened to the collar or a break in the dog’s neck.8 Treatment is relative rest of the spine, with elimination of extension activities. Bracing may be indicated, and eventual rehabilitation with a focus on core strengthening will be in the treatment plan. Suggestions for best practices include keeping the suspicion for spondylolysis among adolescent athletes with low back pain as a chief complaint high and even first on the differential diagnosis list. The incidence has been reported to be as high as 47% of athletes presenting with low back pain compared with an incidence of only 5% in adult controls.9 Of note is that spondylolysis may occur at any vertebral level, but 85% to 95% of pediatric lesions have been found to occur at the L5 vertebra.10
and it is earlier in females compared with their male counterparts because of growth spurt timing.4 Suggestions for best practices include treating the athlete bilaterally. Although the patient will generally complain of unilateral pain, bilateral findings are not uncommon. Findings on radiographs typically show widening of the calcaneal apophysis, as shown in Figure 7. Treatment should be considered for both lower extremities. Although not commonly performed, casting the athlete for a week or longer has been effective. Flexibility should be a focus, with a particular emphasis on gastrocnemius/soleus. OSD Traction on the tibial tubercle ossification center by the patellar tendon (part of the extensor mechanism) is the causative factor in OSD. This traction occurs at the physis and at the insertion of the extensor tendon. Pain that is worse with running and jumping activities and better at rest along with a painful bump over the tibial tubercle are the trademarks of OSD.
Lower Extremity
Figure 7. Radiograph of Sever Disease (Calcaneal Apophysitis).
Pediatric Patient. Calcaneal Apophysitis (Sever Disease) The cause of Sever disease is traction of the Achilles tendon on the calcaneal ossification center, and it is the most common apophysitis.11 The rapid bone growth, coupled with the slower growth of the soft tissues, places this area at high risk. Patients will generally complain of pain that is worse during running, and, commonly, the sport is soccer. The age of presentation is generally 9 to 13, Figure 6. Radiograph of Spondylolysis (“Scotty Dog Sign”).
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Radiographs demonstrate widening of the tibial tubercle physis, as shown in Figure 8. Comparison views may be helpful to either confirm the diagnosis or educate the patient and family but are not necessary. Suggestions for best practices, although not common treatment, include placing the athlete in a cylinder cast and allowing ambulation. This cast is the length of the proximal third of the upper leg to the distal two thirds of the lower leg. This allows for rest of the ossification center from the extensor mechanism traction. A caution is that only 1 week should be considered for the length of treatment, and the risk and benefits need to be carefully weighed. It is
Figure 8. Radiograph of OSD (Proximal Tibial Avulsion).
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possible to have a stiffness result, which typically is overcome quickly in the pediatric population. Adolescent Patient. Shin Splints (Medial Tibial Stress Syndrome) The actual pathophysiology at the root cause of shin splints is not well understood. It is thought that discomfort arises from repetitive strain on muscles that are weak in the lower extremity, with bending forces of the tibia.12 Frequently, female runners who are inexperienced, have a higher body mass index, and have flat feet are common presenting risk factors. Diagnosis is made by clinical history and examination, with tenderness to palpation over the posteromedial tibia being the hallmark. Suggestions for athletes include slow increases in activities, generally no more than 10% a week. Appropriate and well-fitted shoe wear is extremely important for support. Strengthening should also be a focus with an emphasis on the hip and upper leg. Stress Fracture When the forces applied to a bone are not sufficiently coupled with adequate rest and/or nutrition, a stress fracture may occur. It is typical for a combination of these 2 factors to be present in the patient’s history of the present illness. Common sites for a stress fracture include the fibula, the distal tibia, and the metatarsals. The diagnosis for stress fracture will be made by high clinical suspicion from the athlete’s history of the present illness coupled with imaging. Imaging should begin with radiographs, but stress fractures often are not visualized without MRI.13 Treatment for stress fractures includes rest until pain has resolved and may include follow-up imaging. Immobilization may be required for cure, and each individual case will need to be considered, with risks and benefits weighed. Jumper’s Knee (Patellar Tendinitis) Patellar tendinitis includes a spectrum of pathology from chronic degeneration to partial tearing.14 Repetitive stress on the patellar tendon from running, jumping, and kicking coupled with decreased flexibility and rapidly growing tissues place athletes at a higher risk for patellar tendinitis. The diagnosis of patellar tendinitis is made in the jumping, kicking, or running athlete when the chief complaint is anterior knee pain over the tendon, The Journal for Nurse Practitioners - JNP
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worse with activity and better with rest. The treatment is relative rest and avoidance of the aggravation of the tendon with activities that exacerbate the condition. Improving flexibility, especially of the quadriceps, will help to prevent recurrence. Suggestions for best practices include keeping a high suspicion for patellar tendinitis in patients who are athletes who tend to jump, kick, and run. Patellar tendinitis should be considered early and heavily weighted in the differential diagnosis possibilities. Evaluation of the athlete for overuse and flexibility imbalances will assist in early recognition or prevention. Heat-related Illness As a condition of overactivity, heat-related illness may occur in the pediatric population. Heat-related illnesses are a result of the inability of the body to respond to the elevation of body temperature. There is an imbalance in the body temperature elevation and the increased need for the circulatory system to adapt appropriately to exercise and therefore regulate internal temperatures.15 Heatrelated illnesses occur on a continuum from heat cramps to heat exhaustion to heat stroke. Tightening and muscle spasms characterize heat cramps. Commonly, heat cramps are preceded by heavy perspiration and large electrolyte losses.16 Treatment for most variations of heat-related illness is geared toward cooling the athlete, gentle stretching, and electrolyte replacement with sports drinks or other easily and quickly digested sources of sodium. Heat exhaustion presents as profuse sweating, dehydration, fatigue, lightheadedness, rapid pulse, and low blood pressure.15,16 Treatment should include cooling the athlete with legs elevated; application of cool, wet towels; drinking cool fluids; and monitoring of vital signs.15 With heat stroke, the athlete will have an elevated body temperature (104 F or higher). They may have red, hot, dry, or moist skin. Vomiting can occur, and athletes may be incoherent or lose consciousness, have bradypnea, and possibly have a weak pulse.15 Because shock, convulsions, coma, or death are possible consequences, treatment consists of life support, rapid cooling by any means possible, and involving the emergency medical system.15,16 Prevention is of extreme importance in heatrelated illness. Heat stroke has been found to be even 1030
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more preventable in high school athletes than the general population.15 With athlete evaluation with adequate preparticipation physical examination, preparation for sports with acclimatization protocols, and avoidance of excess exercise in hot environments, the number of heat-related illnesses could be largely eliminated in the US.15 DISCUSSION
Preventing pediatric sports injuries includes the assessment of several variables and the education and implementation of practices that have been proven to be effective. Recommendations for prevention on the individual level include using a strategy of wellrounded training and conditioning, including cross training and adequate time off from the sport (1-2 days a week and 2-3 months a year). Furthermore, delaying specialization in any one sport has been recommended, emphasizing instead on a focus of seeking lifelong fitness. From a coaching perspective, recommendations for prevention include a focus on wellness and learning skills, not just the competition of the sport and a focus on winning. Proper supervision would include adhering to pitch counts and providing accurate and astute injury prevention through proper mechanics and surveillance of their young athletes. NPs can play a large role in prevention through performing an adequate preparticipation physical examination and taking every opportunity to identify overuse and through education. An adequate preparticipation physical should include obtaining a physical activity history and a thorough physical examination and taking the opportunity to promote health participation and preventive measures. The opportunity to educate on all levels (ie, parents, athletes, and coaches) is well within the scope of NP practice. NPs are also uniquely positioned for a role in advocating for advisory board oversight of weekend athletic tournaments, the development of educational opportunities, and policy making. References 1. Valovich T, Decoster L, Loud K, et al. National Athletic Trainers’ Association position statement: prevention of pediatric overuse injuries. J Athl Train. 2011;46(2):206-220.
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2. Paterno M, Taylor-Haas J, Myer G, Hewett T. Prevention of overuse sorts injuries in the young athlete. Orthop Clin North Am. 2013;44(4):553-564. 3. DiFiori J. Evaluation of overuse injuries in children and adolescents. Curr Sports Med Rep. 2010;9(6):372-378. 4. Pengel B. Common overuse injuries in the young athlete. Pediatric Ann. 2014;43(12):297-308. 5. Shanley E, Thigpen C. Throwing injuries in the adolescent athlete. Int J Sports Phys Ther. 2013;8(5):630-640. 6. Delee J, Drez D. Adolescent athlete considerations. In: Orthopedic Sports Medicine. Philadelphia, PA: WB Saunders Company Publishing; 2003: 1758-1771. 7. Greiwe R, Comron S, Ahmad C. Pediatric sports elbow injuries. Clin Sports Med. 2010;29:677-699. 8. Maxfield B. Sports-related injury of the pediatric spine. Radiol Clin North Am. 2010;48:1237-1248. 9. Gilepsie H. Osteochondroses and apophyseal injuries of the foot in the young athlete. Curr Sports Med Rep. 2010;9(5):265-268. 10. Micheli L, Wood R. Back pain in young athletes. Significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med. 1995;149(1):15-18. 11. Lomasney L, Lim-Duncan J, Cappello T, Annes J. Imaging of the pediatric athlete: use and overuse. Radiol Clin North Am. 2013;51(2):215-226. 12. Reshef N, Guelich DR. Medial tibial stress syndrome. Clin Sports Med. 2012;31(2):273-290. 13. DiFiori J, Benjamin H, Luke A, et al. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Br J Sports Med. 2014;48(4):1-15.
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14. Tuong B, White J, Louis L, Cairns R, Andrews G, Forster B. Get a kick out of this: the spectrum of knee extensor mechanism injuries. Br J Sports Med. 2011;45:140-146. 15. Allen S, Cross K. Out of the frying pan, into the fire: a case of heat shock and its fatal complications. Pediatr Emerg Care. 2014;30(12):904-910. 16. Centers for Disease Control and Prevention. Beat the Heat: A Guide to Heat Related Illnesses. http://www.cdc.gov/learning/archive/hri.html. Accessed May 10, 2015.
Karen M. Myrick, DNP, is an assistant professor of nursing and a nurse practitioner at the Quinnipiac University School of Nursing in Hamden, CT. She can be reached at karen. [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/15/$ see front matter © 2015 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2015.08.028
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Participation in sports by the pediatric population has grown vastly over the years. Overuse injuries in the pediatric population signify a significant health care interest. Some reports and clinical observations designate 50% of all pediatric sport-related injuries as overuse or repetitive trauma. Furthermore, it is ventured that more than half of these injuries may be preventable with straightforward strategies. Nurse practitioners are well positioned to identify these injuries and implement injury prevention in their practices. Keywords: injury prevention, orthopedics, overuse, sports medicine Ó 2015 Elsevier, Inc. All rights reserved.
N
urse practitioners (NPs) have a solid foundation of health assessment, and this article will build on that foundation and provide the framework of the specialty focus of orthopedic and sports medicine to providing clinical pearls for improving care for athletes who present with overuse injuries. The emphasis is on the identification of risk factors, preparticipation physical examination best habits, proper supervision, suggestions for best practices in treatment and referral, sports alterations options, available training and conditioning programs, and an explanation of the concept of delayed specialization. Characterized as microtraumatic damage to bone or soft tissues, overuse injuries occur in structures that have been subjected to repetitive stress without sufficient recovery time.1 Soft tissue comprises the muscles, tendons, cartilage, and ligaments. In the pediatric population, the skeletally immature physeal and apophyseal growth cartilage is particularly vulnerable. Injuries can occur to healthy tissue as a result of repetitive force or the repeated application of lesser quantities of energy to pathologic or maturing tissue or bone.2 Overuse injuries of developing tissue include the growth-related disorders of Osgood-Schlatter disease (OSD), Sever disease and other apophyseal (growth plate) injuries such as little leaguer shoulder (humeral epiphysiolysis) and elbow (medial apophysitis), and radial epiphysiolysis (gymnast wrist). Overuse www.npjournal.org
injuries resulting from recurring microtrauma and chronic submaximal loading of tissues include stress fractures, osteochondral defects (OCDs), and tendinitis. Training errors, unsuitable technique, extreme sports training, insufficient rest, muscle weakness and imbalances, and early specialization in 1 sport are all viable mechanisms for overuse injuries to occur. Overuse injuries typically present with an insidious onset of pain and can worsen to be present at rest and prevent play. The Table represents a commonly used symptom-guided grading system of overuse injuries with a 1 to 5 scale. RISK FACTORS
Elements that are indicated in overuse injuries are typically multifactorial. These factors can occur as intrinsic or extrinsic to the athlete and can also have both overarching types of factors at the root of the overuse. At the level of the athlete, these factors include participation on multiple teams, participating in year-round involvement in sports without adequate rest, previous injury, core weakness including the hip and trunk, and specializing in 1 sport at an early age. Extrinsic factors that are indicated in overuse injuries include pressure on the young athlete in the form of the requirements of a weekend sports tournament, such as those common in the sports of swimming, soccer, lacrosse, and baseball. These tournaments may include 6 hours each day of play. The Journal for Nurse Practitioners - JNP
1023
Table. Symptom-guided Grading of Overuse Injuries Injury Severity
Symptom Characteristics
Grade 1
Symptoms occur at the end of the activity or only at the initiation and then diminish
Grade 2
Symptoms develop during activity, late onset, diminish after activity is completed
Grade 3
Symptoms develop during activity, early onset, and persist during the remainder of activity, diminish after activity has ended
Grade 4
Symptoms develop during activity and limit training frequency, intensity, or duration
Grade 5
Symptoms prevent training
Modified from Difiori.3
Over a full weekend, the athlete might be involved with playing for more than 12 hours. Other extrinsic factors indicated in overuse injuries may also be in the form of parental insistence, coaching pressure, and peer or sibling competition. Factors affecting child (younger than 11) and adolescent (age 12-18) athletes differ. The child athlete is at risk because of muscle imbalance and tissue immaturity, and the adolescent athlete is more likely to develop overuse injuries because of rapid periods of growth.3,4 EPIDEMIOLOGY
NPs are very likely to encounter pediatric patients who are actively participating in organized sports. In the United States, participating in sports is increasing steadily. Currently, there are an estimated 30 to 40 million children who participate in organized sports activities each year.5 Additionally, half of pediatric patients presenting for sports medicine chief complaints are not presenting with acute injuries but rather injuries that are chronic in nature.1 Furthermore, approximately 50% of all pediatric sport-related injuries ensue through overuse or repetitive trauma mechanisms.1
Typically, a combination of repetitive throwing, weak physeal cartilage at growth centers, muscle tightness associated with rapid long bone growth, increased laxity of soft tissue structures, and decreased development of neuromuscular movement patterns will foster an increased risk of injury to the athlete.5 The common age for little leaguer shoulder is 11 to 15 and is typical in the throwing athlete population. The diagnosis of humeral epiphysiolysis is made when the athlete presents with proximal shoulder pain with activity. When asked to try and “pinpoint” the discomfort, the athlete will typically point to the area of the humeral growth plate. Radiographs will show widening of the proximal humeral physis and changes in the appearance of the bone including sclerosis, fragmentation, and changes that appear cystic in nature.5 Figure 1 shows the findings that are typical for humeral epiphysiolysis. Treatment is geared toward rest, including cessation of all throwing activities. Follow-up with radiographs is indicated for the determination of healing and improvement. An important pearl, yet frequently overlooked, is that the pediatric patient needs to be reminded of what constitutes throwing. Some will take this literally to mean a baseball or a softball. However, playing catch, throwing a football or Frisbee, fetch with their dog, and even Figure 1. Radiograph of Little Leaguer Shoulder (Humeral Epiphysiolysis).
SELECT COMMON CLINICAL OVERUSE INJURY DIFFERENTIALS Upper Extremity
Child. Little Leaguer Shoulder (Humeral Epiphysiolysis) The pathophysiology of little leaguer’s shoulder is the result of the tension from repetitive throwing in overhead athletes, which can lead to a widening of the humeral growth plate or physis. 1024
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a good-natured snowball fight all include throwing and must be avoided. Suggestions for best practices include increased clinician suspicion based on the history of the athlete, and the history of the present illness will improve accurate diagnosis and treatment of humeral epiphysiolysis. Overhead athletes with complaints of aching and tenderness on physical examination over the growth plate of the humerus should be considered for this diagnosis and evaluated with radiographs. Taking comparison x-rays of the contralateral and noninvolved side may aid the less experienced clinician in seeing the difference in the growth plates. Typically, athletes present with mild to severe posterior tightness and may also show weakness in the midback, contralateral hip, and trunk in general when evaluated. These areas should all be a focus for a sound strength and conditioning program once symptoms reside, and a formalized physical therapy prescription is recommended. Panner Disease The pathophysiology behind Panner disease is a failure within the ossification center of the capitellum within the elbow.6 The problem is not known to be caused from reduced blood flow or from an infarction. There are many theorized mechanisms in the literature. Typically, the child is in the age range of 7 to 10 years old, and the presentation is a history of dull, aching elbow pain that is worsened with activity and improves with rest. The aggravating activity is generally throwing. Diagnosis is made with x-rays; in Figure 2, there is an area delineated with an arrow showing an irregular surface on the capitellum. Treatment is aimed at complete rest from throwing. Suggestions for best practices include referral to an orthopedic or sports medicine specialist once the disease is suspected. Recalling that this disease affects primarily the younger athlete, suspicion needs to be high on the radar of the practicing clinician in order to make an accurate diagnosis and prompt referral. There is a high chance of long-term consequences and progression of the disease.7 Certainly, to decrease incidence, adherence to pitch counts and adequate rest are prudent for the athlete and for those involved with the athletic population to enforce. Adolescent Patients. OCD Elbow The pathophysiology of OCD comes from throwing activities that involve strain across the elbow joint, www.npjournal.org
Figure 2. Radiograph of Panner Disease (OCD of the Capitellum).
stretching the ulnar side of the joint and compressing the radial-capitellar joint. It is theorized that there is a disruption in subchondral blood flow to the capitellum from repetitive compressive forces as the pathophysiology behind OCD.5,7 The age for patients with OCD is typically 12 to 16 years old. This is in comparison with Panner disease, which affects the younger athlete, but also presents with elbow pain with a similar symptomatology. OCD usually occurs when the bones have completed their growth phase. Throwing athletes often present with pain during throwing, and upper extremity weight-bearing athletes present with pain during weight bearing. A common clinical complaint is one of locking or catching of the joint caused by loose bodies from the OCD. Gymnasts are a common group of athletes in the upper extremity weight-bearing category. There is frequently a history of increased throwing activity, and on examination the athlete has pain at the lateral elbow with both extremes of motion (flexion and extension and occasionally supination and pronation). There may be changes on plain radiographic examination, showing a lucency in the area of OCD. However, diagnosis is confirmed with magnetic resonance imaging (MRI), which indicates signal changes around the lesion.7 Figure 3 shows the increased signal on T2-weighted images. MRI will not only confirm diagnosis but also will aid the orthopedic specialist in the treatment plan, determining the extent of the defect and the condition of the surrounding cartilage The Journal for Nurse Practitioners - JNP
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Figure 3. MRI of OCD of the Elbow (OCD of the Capitellum).
and bone. Treatment consists of relative rest with the stress of throwing removed and a gentle increase in range of motion and flexibility when pain has decreased. Relative rest means that the athlete may continue some strengthening and cardiovascular exercises but needs to remove the stress of throwing from the upper extremity. Suggestions for best practices include being aware of the high potential for long-term consequences; therefore, a referral to an orthopedic or sports medicine specialist is recommended. The symptoms of arm pain, fatigue, and decreased throwing performance need to be recognized by athletes, coaches, parents, and medical personnel as early warning signs of potential overuse injuries in pediatric athletes.1 If the athlete is in fact a pitcher, decreasing the volume of pitches is recommended along with early recognition of risk factors such as generalized laxity and hypermobility, which should be discovered during the preparticipation physical examination.1 Ulnar Collateral Ligament Tear The pathophysiology involved with ulnar collateral ligament (UCL) tears rests on activities that typically involve strain across the elbow joint, stretching the ulnar side of the joint and compressing the radial-capitellar side. In the 1026
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younger athlete, the potential for muscle imbalance is high; particularly upper/midback and core weakness, including trunk and hip weakness, may play a role in increasing the forces across the elbow when throwing. This relates to the periods of growth with bones typically growing at a faster rate than the supporting and surrounding soft tissues, including muscles, ligaments, and tendons. Additionally, athletes may pitch or throw when fatigued, and this increases the risk for injury. Throwing when fatigued decreases the power from other parts of the body, such as the trunk or core or lower extremities, and increases the strain across the elbow itself. The diagnosis of a UCL tear is made when the history and physical examination clearly show medial arm pain at the elbow, typically a low-grade ache, and possibly 1 traumatic throw when the athletes may perceive the injury occurring. Many athletes will know and painfully recall the 1 pitch or throw that culminated in the cessation of their play. The examination will show pain over the length of the UCL laxity with valgus stressing of the joint and a positive milking maneuver. Suggestions for best practices include obtaining MRI of the elbow joint and referral to an orthopedic and sports medicine expert. MRI will show discontinuity of the fibers of the UCL, as shown in Figure 4. The likelihood for surgical repair is high in a complete tear, and careful examination and followup are keys for healing. Medial Apophysitis (Little Leaguer Elbow) The medial epicondyle apophysis is under strain with overhead throwing motions.4 These biomechanics allow for increased strain across the apophysis of the skeletally immature athlete. Repetitive strain without adequate rest and muscle imbalance may lead to apophysitis. Pain that is worse with throwing activities and better with rest is typical in the history of the present illness for patients with medial epicondyle apophysitis. Diagnosis is typically made with clinical examination only. However, radiographs can be helpful to show hypertrophy, widening, and fragmentation of the apophysis, especially with a comparison view of the contralateral side.7 Figure 5 shows radiographic findings with widening noted of the medial epicondyle apophysis. Volume 11, Issue 10, November/December 2015
Figure 4. MRI of an Ulnar Collateral Elbow Tear.
Keeping the athlete from all throwing activities until there is no pain typically consists of a 4- to 6-week initial trial of rest. Upon completion of this rest period, a follow-up appointment is encouraged. Dependent on the history and physical examination findings at that follow-up visit, as with other overhead athlete overuse injuries, a solid strength program focusing on hip, trunk, and back musculature is paramount. Gymnast Wrist (Distal Radial Epiphysiolysis) In a gymnast, the dorsiflexed wrist position is a common position for many stunts and activities. This extreme position coupled with repeated weight-bearing activities cause progressive disruption in the ossification at the distal epiphysis of the radius in the wrist.4 www.npjournal.org
Figure 5. Radiograph of Little Leaguer Elbow (Medial Apophysitis).
Physical examination along with a thorough history will likely lead the clinician to the diagnosis. Radiographs may not be necessary for diagnosis but can be helpful in documenting progression or severity. In order to rule in epiphysiolysis and rule out tendinitis, a thorough evaluation of range of motion and a strict evaluation of tenderness to palpation are essential. The findings of normal range of motion and pain only with axial loading of the wrist are positive in epiphysiolysis and negative with tendinitis.4 Pain with axial loading is a common physical examination finding for fractures of most bones. Suggestions for best treatment include relative rest, specifically from any weight-bearing activities. Depending on the level of the athlete and the nature of their compliance, immobilization may be a necessary strategy to ensure rest and protection. Torso
Spondylolysis. Repetitive spine extension is common in sports such as basketball, volleyball, gymnastics, and figure skating. The pathophysiology of spondylolysis includes recurring loading of the vertebral bodies, especially with spine extension; in many sports, it may cause a defect in the posterior element, the pars interarticularis. The Journal for Nurse Practitioners - JNP
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The diagnosis of spondylolysis is made with direct visualization of the pars interarticularis on radiographs, observing the oblique images.8 The “Scotty dog” sign is shown on these radiographs when spondylolysis is present. Figure 6 represents this “Scotty dog” finding on radiographs. This finding is likened to the collar or a break in the dog’s neck.8 Treatment is relative rest of the spine, with elimination of extension activities. Bracing may be indicated, and eventual rehabilitation with a focus on core strengthening will be in the treatment plan. Suggestions for best practices include keeping the suspicion for spondylolysis among adolescent athletes with low back pain as a chief complaint high and even first on the differential diagnosis list. The incidence has been reported to be as high as 47% of athletes presenting with low back pain compared with an incidence of only 5% in adult controls.9 Of note is that spondylolysis may occur at any vertebral level, but 85% to 95% of pediatric lesions have been found to occur at the L5 vertebra.10
and it is earlier in females compared with their male counterparts because of growth spurt timing.4 Suggestions for best practices include treating the athlete bilaterally. Although the patient will generally complain of unilateral pain, bilateral findings are not uncommon. Findings on radiographs typically show widening of the calcaneal apophysis, as shown in Figure 7. Treatment should be considered for both lower extremities. Although not commonly performed, casting the athlete for a week or longer has been effective. Flexibility should be a focus, with a particular emphasis on gastrocnemius/soleus. OSD Traction on the tibial tubercle ossification center by the patellar tendon (part of the extensor mechanism) is the causative factor in OSD. This traction occurs at the physis and at the insertion of the extensor tendon. Pain that is worse with running and jumping activities and better at rest along with a painful bump over the tibial tubercle are the trademarks of OSD.
Lower Extremity
Figure 7. Radiograph of Sever Disease (Calcaneal Apophysitis).
Pediatric Patient. Calcaneal Apophysitis (Sever Disease) The cause of Sever disease is traction of the Achilles tendon on the calcaneal ossification center, and it is the most common apophysitis.11 The rapid bone growth, coupled with the slower growth of the soft tissues, places this area at high risk. Patients will generally complain of pain that is worse during running, and, commonly, the sport is soccer. The age of presentation is generally 9 to 13, Figure 6. Radiograph of Spondylolysis (“Scotty Dog Sign”).
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Radiographs demonstrate widening of the tibial tubercle physis, as shown in Figure 8. Comparison views may be helpful to either confirm the diagnosis or educate the patient and family but are not necessary. Suggestions for best practices, although not common treatment, include placing the athlete in a cylinder cast and allowing ambulation. This cast is the length of the proximal third of the upper leg to the distal two thirds of the lower leg. This allows for rest of the ossification center from the extensor mechanism traction. A caution is that only 1 week should be considered for the length of treatment, and the risk and benefits need to be carefully weighed. It is
Figure 8. Radiograph of OSD (Proximal Tibial Avulsion).
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possible to have a stiffness result, which typically is overcome quickly in the pediatric population. Adolescent Patient. Shin Splints (Medial Tibial Stress Syndrome) The actual pathophysiology at the root cause of shin splints is not well understood. It is thought that discomfort arises from repetitive strain on muscles that are weak in the lower extremity, with bending forces of the tibia.12 Frequently, female runners who are inexperienced, have a higher body mass index, and have flat feet are common presenting risk factors. Diagnosis is made by clinical history and examination, with tenderness to palpation over the posteromedial tibia being the hallmark. Suggestions for athletes include slow increases in activities, generally no more than 10% a week. Appropriate and well-fitted shoe wear is extremely important for support. Strengthening should also be a focus with an emphasis on the hip and upper leg. Stress Fracture When the forces applied to a bone are not sufficiently coupled with adequate rest and/or nutrition, a stress fracture may occur. It is typical for a combination of these 2 factors to be present in the patient’s history of the present illness. Common sites for a stress fracture include the fibula, the distal tibia, and the metatarsals. The diagnosis for stress fracture will be made by high clinical suspicion from the athlete’s history of the present illness coupled with imaging. Imaging should begin with radiographs, but stress fractures often are not visualized without MRI.13 Treatment for stress fractures includes rest until pain has resolved and may include follow-up imaging. Immobilization may be required for cure, and each individual case will need to be considered, with risks and benefits weighed. Jumper’s Knee (Patellar Tendinitis) Patellar tendinitis includes a spectrum of pathology from chronic degeneration to partial tearing.14 Repetitive stress on the patellar tendon from running, jumping, and kicking coupled with decreased flexibility and rapidly growing tissues place athletes at a higher risk for patellar tendinitis. The diagnosis of patellar tendinitis is made in the jumping, kicking, or running athlete when the chief complaint is anterior knee pain over the tendon, The Journal for Nurse Practitioners - JNP
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worse with activity and better with rest. The treatment is relative rest and avoidance of the aggravation of the tendon with activities that exacerbate the condition. Improving flexibility, especially of the quadriceps, will help to prevent recurrence. Suggestions for best practices include keeping a high suspicion for patellar tendinitis in patients who are athletes who tend to jump, kick, and run. Patellar tendinitis should be considered early and heavily weighted in the differential diagnosis possibilities. Evaluation of the athlete for overuse and flexibility imbalances will assist in early recognition or prevention. Heat-related Illness As a condition of overactivity, heat-related illness may occur in the pediatric population. Heat-related illnesses are a result of the inability of the body to respond to the elevation of body temperature. There is an imbalance in the body temperature elevation and the increased need for the circulatory system to adapt appropriately to exercise and therefore regulate internal temperatures.15 Heatrelated illnesses occur on a continuum from heat cramps to heat exhaustion to heat stroke. Tightening and muscle spasms characterize heat cramps. Commonly, heat cramps are preceded by heavy perspiration and large electrolyte losses.16 Treatment for most variations of heat-related illness is geared toward cooling the athlete, gentle stretching, and electrolyte replacement with sports drinks or other easily and quickly digested sources of sodium. Heat exhaustion presents as profuse sweating, dehydration, fatigue, lightheadedness, rapid pulse, and low blood pressure.15,16 Treatment should include cooling the athlete with legs elevated; application of cool, wet towels; drinking cool fluids; and monitoring of vital signs.15 With heat stroke, the athlete will have an elevated body temperature (104 F or higher). They may have red, hot, dry, or moist skin. Vomiting can occur, and athletes may be incoherent or lose consciousness, have bradypnea, and possibly have a weak pulse.15 Because shock, convulsions, coma, or death are possible consequences, treatment consists of life support, rapid cooling by any means possible, and involving the emergency medical system.15,16 Prevention is of extreme importance in heatrelated illness. Heat stroke has been found to be even 1030
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more preventable in high school athletes than the general population.15 With athlete evaluation with adequate preparticipation physical examination, preparation for sports with acclimatization protocols, and avoidance of excess exercise in hot environments, the number of heat-related illnesses could be largely eliminated in the US.15 DISCUSSION
Preventing pediatric sports injuries includes the assessment of several variables and the education and implementation of practices that have been proven to be effective. Recommendations for prevention on the individual level include using a strategy of wellrounded training and conditioning, including cross training and adequate time off from the sport (1-2 days a week and 2-3 months a year). Furthermore, delaying specialization in any one sport has been recommended, emphasizing instead on a focus of seeking lifelong fitness. From a coaching perspective, recommendations for prevention include a focus on wellness and learning skills, not just the competition of the sport and a focus on winning. Proper supervision would include adhering to pitch counts and providing accurate and astute injury prevention through proper mechanics and surveillance of their young athletes. NPs can play a large role in prevention through performing an adequate preparticipation physical examination and taking every opportunity to identify overuse and through education. An adequate preparticipation physical should include obtaining a physical activity history and a thorough physical examination and taking the opportunity to promote health participation and preventive measures. The opportunity to educate on all levels (ie, parents, athletes, and coaches) is well within the scope of NP practice. NPs are also uniquely positioned for a role in advocating for advisory board oversight of weekend athletic tournaments, the development of educational opportunities, and policy making. References 1. Valovich T, Decoster L, Loud K, et al. National Athletic Trainers’ Association position statement: prevention of pediatric overuse injuries. J Athl Train. 2011;46(2):206-220.
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2. Paterno M, Taylor-Haas J, Myer G, Hewett T. Prevention of overuse sorts injuries in the young athlete. Orthop Clin North Am. 2013;44(4):553-564. 3. DiFiori J. Evaluation of overuse injuries in children and adolescents. Curr Sports Med Rep. 2010;9(6):372-378. 4. Pengel B. Common overuse injuries in the young athlete. Pediatric Ann. 2014;43(12):297-308. 5. Shanley E, Thigpen C. Throwing injuries in the adolescent athlete. Int J Sports Phys Ther. 2013;8(5):630-640. 6. Delee J, Drez D. Adolescent athlete considerations. In: Orthopedic Sports Medicine. Philadelphia, PA: WB Saunders Company Publishing; 2003: 1758-1771. 7. Greiwe R, Comron S, Ahmad C. Pediatric sports elbow injuries. Clin Sports Med. 2010;29:677-699. 8. Maxfield B. Sports-related injury of the pediatric spine. Radiol Clin North Am. 2010;48:1237-1248. 9. Gilepsie H. Osteochondroses and apophyseal injuries of the foot in the young athlete. Curr Sports Med Rep. 2010;9(5):265-268. 10. Micheli L, Wood R. Back pain in young athletes. Significant differences from adults in causes and patterns. Arch Pediatr Adolesc Med. 1995;149(1):15-18. 11. Lomasney L, Lim-Duncan J, Cappello T, Annes J. Imaging of the pediatric athlete: use and overuse. Radiol Clin North Am. 2013;51(2):215-226. 12. Reshef N, Guelich DR. Medial tibial stress syndrome. Clin Sports Med. 2012;31(2):273-290. 13. DiFiori J, Benjamin H, Luke A, et al. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Br J Sports Med. 2014;48(4):1-15.
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14. Tuong B, White J, Louis L, Cairns R, Andrews G, Forster B. Get a kick out of this: the spectrum of knee extensor mechanism injuries. Br J Sports Med. 2011;45:140-146. 15. Allen S, Cross K. Out of the frying pan, into the fire: a case of heat shock and its fatal complications. Pediatr Emerg Care. 2014;30(12):904-910. 16. Centers for Disease Control and Prevention. Beat the Heat: A Guide to Heat Related Illnesses. http://www.cdc.gov/learning/archive/hri.html. Accessed May 10, 2015.
Karen M. Myrick, DNP, is an assistant professor of nursing and a nurse practitioner at the Quinnipiac University School of Nursing in Hamden, CT. She can be reached at karen. [email protected]. In compliance with national ethical guidelines, the author reports no relationships with business or industry that would pose a conflict of interest. 1555-4155/15/$ see front matter © 2015 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2015.08.028
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