Know the best treatment plan for your adolescent patients’ sports-related extremity injuries
Many children participate in organized sports programs that involve regimented, year-round repetitive training. With more than 30 million participants in organized youth sports and many more who participate in unorganized sports, the inherent potential for injury is very large. Sports injuries have, in fact, increased considerably over the past 15 years with a minimal change in population.1 The main reason for the increase is due to an increase in participation. Of the data collected, most of the available information comes from interscholastic high school sports. Among high schoolers it has been estimated that organized sports account for 25% to 30% of the total injuries in that age group, while unorganized sports account for 40%.2
There is an increased likelihood of injury during the first month of participation in organized recreational sports.3 The most common way to measure the severity of an injury is by the amount of time lost from participation in the activity. The National Athletic Injury Reporting System uses the following categories when classifying athletic injuries: nonreportable, no time lost; minor, 1 to 7 days lost; moderate, 8 to 21 days lost; major, more than 21 days lost; and severe, resulting in permanent impairment.
Injured Parties
In high school, the injury rates for boys and girls are similar. Boys are most likely to be injured in football, while soccer accounts for the most injuries in girls. The location of the injury varies by what sport the person was participating in at the time of injury.
Soft-tissue injuries are the most common type of injury, which includes sprains, strains, and contusions. More acute injuries occur during a practice session than during a game.
Thirty percent to 50% of adolescent injuries are due to overuse, and more time is lost from sports due to overuse injuries than acute trauma. When looking at all injuries to adolescents 17 years of age and younger, researchers analyzing national data show that sports and recreational injuries account for 59% of sprains, 48% of fractures and dislocations and 25% of lacerations. With athletic injuries, 50% occur to the lower extremity, 30% to the upper extremity, and 20% to the axial skeleton.2
Most of the skeleton’s bone mineral density is acquired during the adolescent years. For that reason, nutrition is very important. Bone mass may fail to accrue optimally if the child is dieting or trying to lose weight. Ligament and tendon strength normally develop faster than bone strength, which is why there is a greater risk for avulsions at the insertion sites of bones than for muscle and ligament tears.
Know by Site
One of the most common sites for this type of injury is the insertion of the patellar tendon over the tibial tuberosity. The condition is commonly called Osgood-Schlatter’s disease and is far more common in athletes involved in jumping activities such as basketball. Patients may complain of anterior knee pain, which is aggravated by jumping, squatting, or kneeling. X-rays may show fragmentation of the tibial tubercle and possibly an ossicle in the patellar tendon. Treatment should include ice, flexibility exercises for the quadriceps and hamstrings, and a stabilizing strap. Taking a break from sports activities for several months will usually allow the injury to heal.
In adolescents, growth cartilage is present at the epiphyseal plate, joint surface, and epiphysis. This cartilage is the weakest link and more prone to injury than the ligaments.
The risk of growth-plate injuries is high in contact sports especially during times when they are going through a rapid growth spurt. Acute growth plate injuries are twice as common in the upper extremity than the lower extremity.2
Stress injuries can occur to the growth plate because chronic repetitive microtrauma associated with intense training, which occurs with pitchers, runners, and gymnasts. Heavy weight training in adolescents, before the growth plate closes, is not advisable, as it may cause growth-plate injuries.
When there is localized tenderness on palpation over the growth plate, injury to the adjacent ligaments, or in more severe injuries displacement or deformity, athletes should be referred to an orthopedic surgeon for consultation. With these injuries, there is potential for serious complications, such as limb length inequality or deformity.
The articular cartilage is extremely susceptible to repetitive microtrauma, and overuse could potentially be a contributing factor in osteochondritis dissecans type of lesions. Osteochondritis dissecans is a disorder that occurs during adolescence in which a small segment of subchondral bone undergoes ischemic necrosis secondary to trauma or vascular occlusion. The lesion may heal spontaneously or it may separate and become displaced into the joint cavity forming an intra-articular loose body.4 The most common sites of occurrence are the knee, ankle, foot, shoulder, elbow, wrist, and temporomandibular joint (TMJ). Some patients are asymptomatic, while others will have acute pain. Findings on examination may include joint effusion, painful joint motion, clicking, locking, and localized tenderness over the site of the osteochondrosis.
Overuse It and Lose It
The most common injuries seen in adolescent athletes are musculoskeletal overuse injuries. Contributing factors include subluxation, poor equipment, adverse environmental conditions, and training errors. It is important to have the spine and extremities of athletes checked for misalignments that could put greater stress on a joint that then may lead to injury.
The equipment and training machines should be adjusted to the athletes’s size. Shoes should be the proper ones for the environment in which they are competing and should have proper shock absorption. Custom, flexible orthotics that support the arches, absorb shock, and enhance performance are recommended.
When in training, young athletes should not increase intensity, duration, or frequency of activities faster than their bodies’ ability to adapt. A good coach or trainer will help make the most of workouts and correct subtle errors in technique to protect them from injury and allow them to perform to their maximum potential.
There are many other injuries to be aware of in young athletes. Shoulder impingement syndrome or rotator cuff syndrome is a common cause of shoulder pain in overhead throwing sports, tennis, and swimming. Repetitive overuse of the rotator cuff muscles leads to swelling and inflammation, which can progress to scarring and tendonitis that can lead to rotator cuff tears if not properly cared for.
Conservative treatment should include modification of activity, decrease of the inflammation, and rehabilitation of the injured or weakened muscles. One of the most effective ways to rehabilitate these muscles is with a low-tech rehabilitation system (such as one which utilizes surgical tubing stretching exercises). Other upper extremity syndromes include Little League shoulder, which is an injury of the proximal humeral physis. Gymnast’s wrist covers a host of injuries involving the wrist, from carpal tunnel syndrome to ganglion cysts. And do not forget medial and lateral epicondylitis, which affects young athletes to a lesser degree than adult athletes.5
The Game Plan
When treating young athletes, it is important to understand the unique characteristics of adolescent growth and development. Doctors also need to have a good understanding of the sport, the body mechanics necessary to play it, and knowledge of common injuries participants encounter . By understanding this and then performing a thorough examination, chiropractors will have a better grasp of the causes of many of the common injuries affecting young people and with that knowledge will do a better job of treating those injuries.
The best plan involves educating participants in ways to avoid injuries. This starts with making observations of their posture and gait. Look for abnormal shoe wear and check the spine from the front, back, and side. If imbalances are found, make the proper chiropractic adjustments or recommend rehab to aid in correcting imbalances. Do some muscle tests and look for a weak muscle that could cause an injury in the future. Check ranges of motion of the spine and extremities. If deficits are found work to correct them through adjustments, rehab, and muscle work. CP
Kim D. Christensen, DC, CCSP, DACRB, CSCS, founded the SportsMedicine & Rehab Clinics of Washington. He is a team doctor to high school and university athletic programs, a postgraduate faculty member at numerous chiropractic colleges, president of the ACA Rehab Council, and a lecturer and the author of many musculoskeletal rehabilitation and nutrition texts. He can be reached at PeaceHealth Hospital via email: kchristensen@peacehealth.org.
References
1. Jones SJ, Lyons RA, Sibert J, Evans R, Palmer SR. Changes in sports injuries to children between 1983 and 1998: comparison of case series. J Public Health Med. 2001;23(4):268–271.
2. Patel DR, Nelson TL. Sports injuries in adolescents. Med Clin North Am. 2000;84(4):983-1007.
3. Stevenson MR, Hamer P, Finch CF, Elliot B, Kresnow M. Sport, age, and sex specific incidence of sports injuries in Western Australia. Br J Sports Med. 2000;34(3):188-194.
4. Yochum TR, Rowe LJ. Essentials of Skeletal Radiology. Vol. 2. Baltimore: Williams & Wilkins; 1987:1009.
5. Bylak J, Hutchinson MR. Common sports injuries in young tennis players. Sports Med. 1998;26(2):119-132.
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