"Hip Pain in Teens"-Issue 4

"What is Slipped Capital Femoral Epiphysis?"
       To understand SCFE, you first have to know a little bit about the hip joint. As you can see pictured to the right, the hip joint consists of the rounded “ball” shaped end of the thigh bone, called the femoral head, and the “socket” shaped hole of the hip bone. In growing kids and teens, the growth center/growth plate is located just under the “ball” portion of the thigh bone, which is pictured in red.
        The job of this particular growth center is to keep the femoral head connected to the thigh bone while still allowing the bone to lengthen and grow. As discussed in our previous blogs, the growth center is made up of a soft cartilage, which is weaker than the bone, making it more susceptible to injury.
       Slipped capital femoral epiphysis (SCFE) occurs when the “ball” portion of the thigh bone slips out of place. In mild cases of SCFE a child may experience groin pain, knee pain, hip stiffness and a noticeable limp. In more severe cases, a child may have significant loss of motion in the affected leg, difficulty walking, significant pain, and an outward turned leg. The reason why this injury occurs is misunderstood. It often begins seemingly for no reason with no injury to associate with the pain.

       SCFE typically affects kids ages 11 to 16 and is much more common in boys. Several other factors can contribute to a child’s chances for developing SCFE including: family history of SCFE, kidney failure, endocrine disorders and being overweight.

      Catching SCFE early can make a big difference in how easily it can be treated. The longer a child walks on the unstable joint, the greater the chance that more slipping will occur. In cases of severe slippage, blood flow to the thigh bone may be impaired, requiring immediate medical attention.

      A child suspected of having SCFE will need to be evaluated by a trained orthopedic physician, and an x-ray should ALWAYS be requested. Often times a child will be misdiagnosed with a “muscle strain”, resulting in wasted time and placing the child at greater risk. An x-ray is of utmost importance to ensure an accurate diagnosis.
     SCFE is typically treated with surgery to stabilize the hip joint and prevent further slippage. When SCFE is detected and treated early, most kids do very well. They will likely receive physical therapy to strengthen the hip and leg muscles after surgery and will continue to have follow-up x-rays to monitor the condition.
      There is no guaranteed protocol to prevent SCFE. Parents can reduce the risk by encouraging kids to keep their weight within a healthy range. Maintaining a healthy weight can spare a child’s bones and joints from excess wear and tear that can weakens and damages them.
      If you would like more details about this condition please contact your physician or physical therapist for more information.

References:

1. http://www.seattlechildrens.org/

2. http://www.kidshealth.org/

"Growing Pains In The Knee"-Issue 3

    
If you can recall from last month’s issue, the tissues most at risk for injury in a growing athlete are the soft, cartilaginous growth centers or growth plates. During a growth spurt, bones grow faster than muscles. This places increased stress on the growth centers where they attach. When a growth spurt is combined with increased physical activity, the repetitive stress on the growth center can result in injury. In fact, it has been reported that at least 15% of all youth sport injuries occur along these delicate growth centers.
       Osgood Schlatter’s Disease is the most common overuse injury in children and it involves the growth center at the knee. It is estimated that 20% of young athletes ages 8 to 15 suffer from this diagnosis.       
        Osgood Schlatter’s involves irritation of the growth plate at a location called the tibial tubercle. This is the bump on the front of the shin bone where the patellar tendon attaches. If the tension of the muscle tendon across the bone becomes great enough, the growth center will start to pull away from the bone. This results in pain, swelling, and often times a large bump that occurs a few inches below the knee cap.
       These symptoms usually begin gradually over time with no real mechanism of injury. Occasionally, initial symptoms can be tied to a sudden increase in activity or direct trauma to the knee.
       Typically, your child will complain of pain that worsens with running, jumping and kneeling activities and that decreases with rest.
       Generally, treatment for Osgood Schlatter’s includes a combination of relative rest, stretching for the muscles on the front of the thigh and hip, strengthening for the muscles on the back of the thigh and hip, and use of ice and NSAIDs to manage pain and inflammation.
      Occasionally, physicians will recommend a patellar tendon strap/brace to provide additional pain relief. This helps to decrease the tension of the patellar tendon across the tibial tubercle, but will not resolve the underlying muscle tightness that should be addressed with stretching.
       If you would like more details on specific stretches and exercises to prevent or treat Osgood Schlatter’s Disease, contact your physician or physical therapist for more information.


  

References:

1.Watkins J, Peabody P. Sports Injuries in Children and Adolescents Treated at a Sports Injury Clinic. J Sports Med Phys Fitness 1996;36(1):43-48.
2. Phil SG, Flynn JM, Ganley TJ. Managing and Preventing Overuse Injuries in Young Athletes. J Musculoskel Med 2003;20:434-442.
3. Krause BL, Williams JP, Catterall A. Natural History of Osgood Schlatter Disease. J Pediatr Orthop 1990;10(1):65-68.

"Heel Pain in the Young Athlete"-Issue 2

      

In a child, bones grow from areas called growth plates. The growth plate is made up of cartilage, and is the weakest part of the growing skeleton. Due to their soft nature, these parts of the bone are vulnerable to injury during a child’s development. Therefore, they often fail before the surrounding tissues and ligaments. Consequently, symptoms that may present as tendonitis in adults could present entirely differntly in the young athlete.
Sever’s disease, or calcaneal apophysitis, is the painful irritation and inflammation of the growth plate at the back of the heel. It generally presents in physically active girls and boys ages 8 to 13. The most common complaint is pain at one or both heels, particularly with activities such as running or jumping.
Tight calf muscles are a large risk factor for Sever’s disease. As the taut muscle is pulled across an actively growing bone, tension is created along the growth center causing inflammation and pain to occur.

Often, children are placed in a cast, walking boot or heel lifts to help decrease pain occurring at the heel. While this can quickly resolve pain and inflammation surrounding the growth center, if used for extended periods the problem may persist.

Casts, walking boots and heel lifts will place the child’s foot in a neutral position or with the toes pointed down, keeping the calf muscles tight. If these muscles remain tight, inflammation and pain are likely to return as the child returns to normal activity or sport.

To prevent risk of re-injury or returning pain, the child should be placed on a regular stretching regimen to address the muscles involved.

The goal is to return your child to sport or activity as quickly and safely as possible. If the child returns to activities too soon, or continues to play with pain, the injury may worsen.

Severe pain may result in compensatory patterns that put a child at risk for additional injury. This may require a short period of rest from painful activities to decrease pain and inflammation and return normal gait patterns.

 Consult your physician or physical therapist regarding when it is safe to return to sport.

The goal is to return your child to sport or activity as quickly and safely as possible. If the child returns to activities too soon or continues to play with pain, the injury may worsen.

Severe pain may result in compensatory patterns that put a child at risk for additional injury. Therefore, a short period of rest from painful activities wil decrease pain and inflammation and return normal gait patterns.

Consult your physician or physical therapist regarding when it is safe to return to sport.

Follow our blog next month to learn about a similar problem that occurs at the knee: Osgood Schlatter Disease.

References:

1. http://www.childrensmemorial.com/

2. Scharfbillig R. Sever's Disease: What does the literature really tell us. Journal of the Amer Pod Med Assoc. May-June 2008; 212-223.

3. http://www.dellchildrens.net/

"The Growing Athlete"-Issue 1

According to a recent study by the CDC, approximately 38% of children ages 9 to 13 participate in some form of organized sport. In many instances, these young athletes are now "specializing" in a single sport year round. Today’s media does not help to discourage this mindset. Tiger Woods started putting on late night TV as early as 2. More recently, European soccer teams have been battling over the rights to sign a seven year old phenom, Madin Mohammad, to play on their team in the future.
The American Academy of Pediatrics poses some legitimate concerns about both the short and long term consequences of this type of sport specialization at an early age. By specializing, these athletes are exposing repetitive stress and fatigue on specific areas of the body required by their sport. As a result, more than 3.5 million children under the age of 14 receive medical treatment for sports injuries annually. According to the National Center for Sports Safety, nearly half of these athletic injuries in middle and high school students have resulted from overuse.

Immature bones, insufficient post-injury rest, and poor training and conditioning contribute to these overuse injuries.

The largest contributing factor that separates these young athletes from their adult counter parts is the fact that their bones are still growing. Regardless of their talent, young athletes are simply not "little adults", and their medical care and rehabilitation process should take that factor into account.
One of the most important factors to address in the pediatric and adolescent athletic population is the growth plate.

In adults, ligaments usually fail before bone when a bending stress is applied across a joint. However, in an immature skeleton, the “physis” or growth plate will fail under stress first. Because of this factor, children and adolescents often incur injuries entirely different than adults.

What may appear to be an ankle sprain, tendonitis or a muscle strain, might in fact be an overuse injury or fracture of the growth plate. Often these injuries are missed under normal examinations. Request an x-ray to rule out growth plate injuries. Early and accurate diagnosis can prevent long-term injuries and will allow the young athlete to return safely to the sport. Remember, young athletes deserve specialized care for their growing bones. For more information, contact you local physician or physical therapist.

References:

1. Wojciechowski, Michele. "Working with Kids: Physical Therapy and the Pediatric Athlete." PTmagizine (2007). 3 Sept. 2007 .

2. McHorse, Kevin. "Pediatric and Orthopedic Sports Medicine." The Dogwood Institute (2009). Nov. 2009