Physiotherapy in Pediatric Orthopedics III: School Age and

Adolescence

Kristy Brundage, B.Sc. P.T., M.Sc.

• Skeletal Changes and Growth

• Disorders– Scoliosis– Disorders of the Hip– Disorders of the Knee– Other: Fractures, Trauma

• Sports and Recreation

Skeletal Changes and Growth

Continued longitudinal and appositional bone growth dependent on:– Hormones– Nutrition– Mechanical factors

• growth spurts• proportions change at puberty

Development

• Mature patterns of running, jumping, throwing

• Increased coordination, eye-hand coordination, balance, endurance, attention span

• Develop sense of competitiveness

Disorders

• Scoliosis

• Hip

• Knee

• Fractures and Trauma

Scoliosis

Scoliosis

• Etiology: idiopathic, congenital, neuromuscular

• Plane of deformity: coronal, sagittal

• Levels of spine involved: cervical, thoracic, lumbar

Scoliosis - etiological subtypes

• Congenital: secondary to bony abnormality

• Neuromuscular: secondary to muscular weakness, imbalance

• Idiopathic: most common type; precise etiology unknown

Adolescent idiopathic scoliosis

• Asymptomatic

• Most common age presentation (10+ years)

• Not associated with back pain

• May have positive (extended) family hx

• Forward bend test – screening important

• Careful neurological exam mandatory

AdolescentIdiopathic Scoliosis -forward bendtest

Adolescent idiopathic scoliosis

• Goal of treatment is to prevent progression of curve

• Risk of progression related to growth remaining and curve magnitude

Adolescent idiopathic scoliosistreatment options

• < 20o: observation, serial x-rays

• 20-29o: brace if progression noted on follow-up x-rays

• 30-45o: brace immediately

• larger curves: surgical correction and fusion

Physiotherapy Treatment

• Historically

• Maintain mobility and strength in brace

• Post op

Disorders of the Hip

• Common

• Conditions unique to childhood

• Most have potential for early osteoarthritis

• Important to know what conditions are likely at various ages

Disorders of the HIP

• Legg Calve Perthes

• Slipped Capital Femoral Epiphysis

Legg-Perthes disease

• Initial presentation: pain, limp, normal x-rays (synovitis phase)

• More common (later) presentation: painless limp, abnormal x-rays

• Age 2-8 years• M>F

Legg-Perthes disease

• Etiology unknown

• Femoral head dies, resorbs, reforms over 18-24 months

• Treatment principle: maintain range, containment

• Observation, physio, bracing, surgery (osteotomy of femur or pelvis)

PT Management of LCP

• Crutch walking

• ROM: – With or without traction– all movements, BID– Passive, by parents– Within pain limits– Close monitoring

Slipped Capital Femoral Epiphysis

• Fracture through upper femoral growth plate

• Usually no identified trauma

• Pre-adolescent age group

Slipped Capital Femoral Epiphysis

• Usually obese

• Presentation: hip (groin) or knee pain (referred); acute or chronic

• Up to 40% are bilateral—monitor other hip

Slipped Capital Femoral Epiphysis: Treatment

• Surgical: Stabilize with insertion of screw across growth plate (encourage fusion of plate)

• Physio:– Post op care– Abductor strengthening

Disorders of the Knee

• Osgood Schlatter

• Patella femoral

• Discoid meniscus

• Osteochondritis dessicans

Osgood-Schlatter’s Disease

• Inflammation of the patellar tendon insertion (apophysitis) on the tibial tubercle

• ?from rapid growth of long bone, microavulsion, repetitive stress

• Presents as pain, swelling, prominence of tibial tubercle, occasionally limp

Osgood-Schlatter Disease: Treatment

• Analgesics/anti-inflammatories• Ice (massage)• Rest, activity modification (no jumping, squatting)• ?stretching and strengthening• ?ultrasound• **self limiting

ALSO: Sinding Larsen Johansson, Sever’s

Patella Femoral Syndrome

• Most common complaint of young athlete

• SPECTRUM

• Malalignment and maltracking

• Causes:– anatomical factors– acquired factors

PFS: Treatment

• PHYSIO:– Rest/activity modification– strengthening– Stretching– Other: orthotics, bracing, taping

• SURGICAL:– Lateral release– Patellar realignment

Discoid Lateral Meniscus

• Uncommon, but important diagnostically• Lateral meniscus undeveloped, remains

thick, disc shaped• Presents as joint line tenderness, decreased

ROM, swelling and snap on flexion-extension

• Rx is surgical removal with post op rehab (ROM, quads)

Osteochondritis Dessicans• Usually medial femoral condyle

• Necrosis of segment of articular bone and its overlying cartilage, often resulting in separation of fragment—intrarticular loose body.

• Presents as pain, swelling, giving way

Osteochondritis Dessicans: Treatment

• Rest +/- cast

• Surgical:– removal of loose fragment– resorbing pin

• Physio:– Post op– ROM, strengthening, retraining

Trauma and Fractures• Upper Extremity:

– Acromioclavicular

– Clavicle fracture

– # upper humerus

– Subluxation of G-H joint

– Elbow fractures: supracondylar

– Pulled elbow

– Wrists fractures: torus, both bones

– Hand: scaphoid, gamekeepers

Trauma and Fractures

• Lower Extremity:– Stress fractures– Snapping hip– #’s of femur, tibia– Ligamentous injury– Jumper’s knee– Growth plate #’s of distal tibia and fibula

Sports and Recreation

1. Team/competitive: school or community, coach +/-trainer, demanding, may involve contact,

2. Individual: recreational or training, with or without coach, protective equipment inconsistent

3. Family/community recreational: no trained supervision

*relate to types of injuries

Risk Factors for Injury

• Training

• Muscle tendon imbalance

• Anatomic malalignment

• Equipment, footwear and playing surface

• Associated disease states

• growth

Competition

• Young: learn to compete against other teams and individually

• Older: also learn to compete against themselves to better performance

• Injuries from: – Children– Parents– safety

Training

• Fitness statsTraining program:1. Energy: aerobic,anaerobic2. Muscle:

A. StrengthB. EnduranceC. FlexibilityD. Power

3. Speed

Strength Training

Ages 9-11 12-14 15-16 17+

Exercises per body part

1 1 2 >2

Sets 2 3 3-4 4-6

Repetitions 12-15 10-12 7-11 6-10

Max Weight

(resistance)V. Light Light Moderate Heavy

Return to Sport

• No swelling

• ROM: full, normal, pain free

• Strength: objective and functional testing

• Use of braces

• GRADUAL!