1
Centre Hospitalierde Luxembourg
OrthopaedicSurgery
Sports Medicine Research Laboratory
Centre de RecherchePublic – Santé,
Luxembourg
IOC advanced team physician course, Saltsjöbaden, Sweden 05-2013
Overuse injuries in the immature athlete.
Prof. Romain Seil, MD, PhD
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Why sports at pediatric / adolescent age?
Should be fun !
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• Susceptibility of growth plate
• Direct mechanical stress
• Repetitive physical strain
• Growth spurt during puberty
• Mechanical (over-)loading
• Variation of biological maturity at same
age
• Skeletal development precedes muscle& tendon growth
• Permanent changes of lever arms,
imbalances of muscle chains
Youth sports: specificities
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Growth of upper & lower segment not proportional
Growth
♀ 13 y.♂ 15 y.
Growth velocity
Height
Upper segment
Lower extremity
Difference Trunk / lower extremity
Juvenile peak
Gicquel P, Rev Chir Orthop 2007
= peak of injuries !
(Watkins J,
Peabody P 1996)
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Skeletal age
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Kahl H Bundesgesundheitsbl - Gesundheitsforsch - Gesundheitsschutz 2007
1 lesion out of 3 results from sports !
N = 16706
schoolhome traffic
15-17 y
5-14 y
1-4 y
schoolhome traffic
home
Magnitude: general population
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sports
sports
sports
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Injury surveillance sports school
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2
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Injury surveillance sports school
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2013
Increase in training intensity week before injury
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2.853.41*
2.16*#
1.06
1.38
0.65*#
0
1
2
3
4
5
6
2008-2009 (1) 2009-2010 (2) 2010-2011 (3)
Inc
ide
nc
e (
inju
rie
s/1
00
0h
)
Overuse injuries
Traumatic injuries
* significantly different from 2008-2009 (p
3
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Always be prepared for the worst !
Differential diagnosis
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♀, 15 y., Synchronized swimming;
Knee pain
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♂, 14 y.; Football;
Knee pain
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Differential diagnosis
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Epiphysiolysis capitis femoris
Differential diagnosis
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Epiphysiolysis capitis femoris
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Differential diagnosis
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01-2011
Septic arthritis
04-2011
+ 3 mo.
03-2012
+ 13 mo.
Differential diagnosis
♂, 13 y., Football
Left hip pain
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Types of injuries
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• Differential diagnosis (worst case)
• Osteotendinous junction
• Alterations of growth plate
• Congenital
• Muscle & tendon
• Alterations of bone metabolism
• Alteration of joint mechanics
• Joint dysfunctions
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Traction apophysitis
M. Sinding - Larsen
M. Sever
M. Osgood-Schlatter
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Traction apophysitis
♂ 15 y., football
♂ 15 y., football
Hip
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Traction apophysitis
♀, 14 y, Tennis
„Growth epicondylitis“
♂ 12 y., Kayak
Consequence of overloading !
Elbow
Baseball:
Little leaguer’s elbow
Brogdon BG, 1960
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• Prevalence: 8%
• 30-60% bilateral
• fusion @ 18-25 years
• start with nonoperative treatment
• screw fixation, bone graft & cerclage if possible
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Os acromiale
♂, 24 y., gymnast
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• the most frequent apophysitis
• microtraumas
• excentric contractions
• ♀ 10-11 y.; ♂ 13-14 y.
♂, 14 y.
Fragmentation tuberosity
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Osgood – Schlatter disease
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• Relative rest (several months)
• Static quadriceps training
• Stretching
• NO CORTISONE !!!
No strict contraindication for sports, BUT: avoid jumps, acute accelerations or decelerations,
inform coaches and parents
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Osgood – Schlatter disease
♂, 15 y., handball
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Avulsions
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♂ 15 y, football
Surgical treatment mandatory
♂ 15 y, football
Nonoperative
♂ 15 y, football
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Avulsions
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Surgical treatment optional
Extraarticular endoscopic resection
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Traction apophysitis & avulsions
• Frequent after growth spurt (♀ 13 y.; ♂ 15 y.)
• More frequent in boys
•Treatment: (relative) rest, immobilization (+ 4 weeks),
physiotherapy
• Sometimes specific diagnostic steps and
therapeutic procedures necessary
•Anticipate muscle imbalances
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Types of injuries
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• Differential diagnosis (worst case)
• Osteotendinous junction
• Alterations of growth plate
• Muscle & tendon
• Congenital
• Alterations of bone metabolism
• Alteration of joint mechanics
• Joint dysfunctions
crp-sante.lu 2929Netter FH
Growth plate
Epiphysis
Metaphysis
Germinal layer
Calcification
Chronic injury:
Impaired vascularisation
↓Decreased calcification
of hypertrophic zone
↓Physeal widening
Acute injury:Salter 3+4
=
vertical section of
germinal layer
↓Bone bridge formation
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Gymnast‘s wrist
Repetitive hyperextensions
Load: 2-16 x body weight
→ Pain after training, swelling
Wrist pain in up to 50% of young gymnasts
DiFiori JP, 2006
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Widening of distal radius physis
=
Fatigue fracture
Premature physeal arrest&
Relative ulnar elongation
Caine D, 2003
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Gymnast‘s wrist
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Prevention
• Wrist protectors
• Growth control / 3 mo.
• Load reduction
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Gymnast‘s wrist
DiFiori JP, 2006
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Little leaguer‘s shoulder
Dotter WE, 1953
Adams JE, 1966
Widening of proximal humeral physis,
Local pain & tenderness
Control of no. of throws;relative rest
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Types of injuries
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• Differential diagnosis (worst case)
• Osteotendinous junction
• Alterations of growth plate
• Muscle & tendon
• Congenital
• Alterations of bone metabolism
• Alteration of joint mechanics
• Joint dysfunctions
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Overuse injury proximal patellar tendon
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Patellar tendinitis (jumper‘s knee)
♂ 17 y., football
Blazina classification:
Phase I: pain after activity only. No functional impairment
Phase II: pain during and after activity. Still able to
perform at a satisfactory level.
Phase III: pain during and after activity and more
prolonged. Increasingly difficult to perform at a
satisfactory level.
Blazina ME, Orthop Clin North Am 1973
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Beware tendon necrosis !
• Pain for 3 years
• Multiple cortisone injections !
Achilles tendinitis
♂ 20 y., football
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Types of injuries
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• Differential diagnosis (worst case)
• Osteotendinous junction
• Alterations of growth plate
• Muscle & tendon
• Congenital
• Alterations of bone metabolism
• Alteration of joint mechanics
• Joint dysfunctions
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• Prevalence: 2-3 / 10.000 children
• 2nd decade• 10 % bilateral• Genetic / Microtrauma ??
• Pain during activities
♀, 17 y.
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Juvenile osteochondritis dissecans
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The younger the patient, the higher the probability of spontaneous resorption !
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Juvenile osteochondritis dissecans
4-2010 11-2011
♀, 13 y. ♀, 15 y.
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Bruns J, 1997
SurgeryDrilling +/- refixation,
Cartilage surgery
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Juvenile osteochondritis dissecans
Conservativetreatment
Rest, no sports6 – 12 weeks unloading
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Juvenile osteochondritis dissecans
Repairable OD
♂, 15 y., basketball
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Juvenile osteochondritis dissecans
Non-repairable OD
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♂, 18 y., swimming
Chondrocyte transplantation
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Juvenile osteochondritis dissecans
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Watanabe M, Takeda S, Ikeuchi H. Atlas of
arthroscopy. Tokyo: Igaku-Shoin, 1978;88.
Lateral discoid meniscus
Complete (70-80%)
Incomplete (10-25%)
Wrisberg type (< 10 %)
Lateral condyle
ACL
Complete discoid
meniscus
• ♀ 12 y, ballet
• blocking, extension deficit, crepitations
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Foot & ankle
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Accessory navicular bone
♀, 12 years, running ♂, 14 y., badminton
Os trigonum
1. Injections
2. Posterior ankle arthroscopy
1. Cons. treatment (insoles)
2. Open resection & tendon refixation
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Types of injuries
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• Differential diagnosis (worst case)
• Osteotendinous junction
• Alterations of growth plate
• Muscle & tendon
• Congenital
• Alterations of bone metabolism
• Alteration of joint mechanics
• Joint dysfunctions
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• High mechanical stress, low vascularization
• Diagnosis often delayed
• Here: Mechanical pain after intense training
period
• Therapy: Immobilisation (> 10 weeks !)
Sometimes surgery
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Stress fractures
Navicular bone
♀ 13-y., track and field
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Types of injuries
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• Differential diagnosis (worst case)
• Osteotendinous junction
• Alterations of growth plate
• Muscle & tendon
• Congenital
• Alterations of bone metabolism
• Alteration of joint mechanics (i.a. structural lesion)
• Joint dysfunctions
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Osteochondritis
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OD of the capitellum♀, 13 y., gymnast
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• “Overuse” if associated with chronic
instability
• Unrecognized, isolated lesions in stable
knees:
- bucket handle, flap
- radial tears lateral meniscus
- isolated root tears
- meniscal ossicle
- instabilities lateral meniscus
- meniscal cysts
- early horizontal degenerative tears
♀, 16 y.
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Meniscus
♀ 14 y., high-level gymnast
• Always try to repair !
♂ 17 y., handball
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It is sometimes as difficult to find the
right treatment of a degenerative
lesion in a young athlete as it is in an
elderly patient with joint degeneration
and a typical sports injury.
Recommendation to stop sports
sometimes necessary !
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Cartilage lesions
♀ 14 y., karate
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Types of injuries
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• Differential diagnosis (worst case)
• Osteotendinous junction
• Alterations of growth plate
• Muscle & tendon
• Congenital
• Alterations of bone metabolism
• Alteration of joint mechanics
• Joint dysfunctions (no structural lesions)
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• Physiotherapy
• Functional evaluations
No surgery without
structural lesion !
♀ 19 y.
Patellofemoral pain syndrome
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Diagnoses shoulder consultation
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Atraumatic
Instability
Traumatic
Instability
13 - 30 y.
Matsen RF, 1994
♂, 17 y., swimming
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Shoulder pain
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SICK scapula
S: Scapular malposition
I: Inferior medial border winging (trapezius muscle)
C: Coracoid pain (tight Pectoralis minor muscle)
K: Scapular dyskinesisKibler WB, J Shoulder Elbow Surg. 2002
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Multidisciplinary approach
Understanding of:
• Growth & maturation
• Specific anatomy
Need for:
• Fun (no pressure) !
• Rest !
• Interdisciplinary care
• Adherence to natural selection
process (performance)
• Professionalisation of sports
medical coverage in youth sports
Coaches / teachers
Physiotherapists
Parents
crp-sante.lu 5757
76 rue d’Eich, 1460 Luxembourg
www.crp-sante.lu
www.sportsmedicine-chl.lu
HélèneAgostinis
ThierryWindal
AnneFrisch
JoakimGenin
RomanBrunner
RomainSeil
AxelUrhausen
DietrichPape
RobertMann
DanielTheisen
Cyrille Hardy
Thank you !
CarolineMouton
LaurentMalisoux
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Christian Nührenbörger
Roland Krecké
Louis Wennig
Laurent Radrizzi
Daniele Schaack
Thomas Thünenkötter
NicolienVanGiffen
José Azzolin
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• ♂ 15 y. football• closed physes
• ACL & lateral meniscus repair
Association with ACL tears
• Push indications for repair
• Never repair without stabilization
• Exception: acute bucket handle
& inflammation
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• Proximal patellar tendon:
Sinding-Larsen
“Jumper’s knee“
• Cartilage lesion
• Instability (acute / chronic)
• Patellofemoral pain syndrome
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Patella & extensor mechanism
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Anterior knee pain
• during or after sports
• sitting with flexed knees (cinema)
• stairs
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Patellofemoral pain syndrome
Evaluation of :
• intraarticular soft tissues and bony
structures
• muscle contractures / imbalances (thigh /
hip / pelvis)
• malrotations / malalignment
• Pelvis posture / foot posture
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Avulsions
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Lesions of the acetabular labrum
17 y., handball
Arthroscopy
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Hip & pelvis
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SICK scapula
Shoulder pain
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Kibler WB, J Shoulder Elbow Surg. 2002
♀, 16 y.
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Instabilities of the lateral meniscus
Garofalo R, KSSTA 2005
• ♂ 15 y. football• painful locking in full flexion
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Simonian PT, Arthroscopy 1997 George M, Arthroscopy 2003
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• DD inflammation, bipartite sesamoid
• High mechanical stress, low vascularization
• Here: Mechanical pain after intense training
period
• Therapy: Insoles
(Immobilisation)
(Rarely surgery)
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Stress fractures
Sesamoid bone
♂, 17 y., running
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Risk factors
Extrinsic factors Intrinsic factors
Non-modifiable
• Type of sport• Weather• Level of play
• Time of season• Sport context• Playing position
Non-modifiable
• Maturity level• Previous injury• Age
• Gender
Modifiable
• Rules and regulations• Coaching education/training• Playing time
• Playing surface• Equipment
Modifiable
• Fitness level• Sport-specific training/warm-up• Muscle strength
• Flexibility• Joint stability• Biomechanical factors
• Balance and proprioception• Psychosocial factors
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• toe fracture 6 months before
• Pain
• Arthroscopic removal of loosefragment
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Fractures
Posttraumatic « overuse » sequelae
♀ 11-y., gymnastics
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• Genetic factor ?
♀, 17 y.
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Juvenile osteochondritis dissecans
♂, 15 y.
Mother & son bilateral OD
Brothers, right knee
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Traction apophysitis
Foot5th metatarsalIselin’s disease
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N = 16706
Overuse injury definition
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• Repetitive micro-trauma• Gradual onset
Bahr, 2009
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Magnitude: general population
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Malisoux L, KSSTA 2012
Injury surveillance sports school
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• Swelling
• Fever
• Weight loss
• Rest pain
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Osteosarcoma
Differential diagnosis
♀, 14 y.;Riding
Knee pain
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