Sports/Ortho Rehab

Does bone or soft tissue grow faster in children?

Bone grows faster than soft tissue can accommodate

- Decreased flexibility

- Coordination challenges

Moderate-Vigorous Physical Activity Recommendation

>60mins + 2 to 3 days of m strengthening a week

Younger pts: Organized sport to free play time ratio?

Should not exceed 2:1

Older pts: Organized sport recommendation?

Should not spend more hours per week in their sport than their age

Early Sport Specialization Definition

>8months per year in one single sport

- Exclusion of other sports/activities

- Prior to adolescence (12yrs)

Recommended age for sport specialization?

15-16yrs

3 Types of Growth Plate Injuries

1. Apophysitis

2. Avulsion fx

3. Salter Harrise fx

Apophysitis

Inflammation/irritation of an apophysis, which is a growth plate where a tendon attaches to bone

- Often caused by overuse

Avulsion Fx

A fx that occurs when a tendon or ligament pulls a small piece of bone away from the main bone

- Often during a sudden forceful movement

Salter Harris Fx

A fx involving a growth plate of a child's bone

- Classified into Types 1-4

Epiphysis

Primary growth plate

Apophysis

Secondary growth plate

- Site of tendon and ligament attachment

What is the weakest link in the chain of growth?

Apophysis

- Vs being the tendon in an adult

3 PT Ways to Decrease the Pull on Bone

1. Relative rest

2. Stretching tight m groups

3. Strengthening surrounding m groups

Salter-Harris Fx Types

Type 1. Straight across

Type 2. Above the physis (most common)

Type 3. Lower than the physis

Type 4. Through everything

Type 5. Erasure (crush injury) - at greatest risk for growth arrest

Instability

Excessive symptomatic translation

Laxity

Increased stretch of surrounding tissues (not always symptomatic)

Little League Shoulder

Proximal humeral epiphysitis

Little League Shoulder: MOI

- Microtrauma from rotational and distraction forces of throwing

- Poor throwing mechanics

Little League Shoulder: Common Age

11-16 years old

Little League Shoulder: Presentation

- Pain w throwing

- TTP proximal humerus

Little League Elbow

Generic term for medial elbow pain but commonly associated w medial epicondyle apophysitis

Little League Elbow: MOI

- Microtrauma d/t tensile forces from valgus overload

- Poor throwing mechanics

Little League Elbow: Common Age

9-12 years old

Lateral Elbow Pain

Pain over capitellum, stiffness, and decreased elbow extension d/t excessive valgus load

2 Main Causes of Lateral Elbow Pain

1. Osteochondritis dissecans

2. Panner's disease

Osteochondritis Dissencans

Isolated defect or loose body of subchondral bone

- Longer recovery timeline

- Risk of residual deformity

Osteochondritis Dissencans: Common Age

>10 years old (older kids)

Panner's Disease

Flattening and fragmentation of the entire capitellum

- No true separation

- Self limiting

- Excellent prognosis

Panner's Disease: Common Age

< 10 years old (younger kids)

Most common elbow fx seen in kids?

Supracondylar

What makes up 25% of all pediatric fractures?

Distal radius fxs

Gymnast's Wris

Overuse injury of the distal radial growth plate d/t repetitive WB

Thumb Splica

Indicated for radial hand and wrist injuries that include any part of the thumb/carpal bones

Wrist Cock Up

Indicated for simple distal radius fxs, wrist sprains, strains, and acute pain with ROM

Pediatric Trunk/Legs Growth Ratio

2:1

- Trunk grows faster than legs

Most rapid periods of pediatric growth?

- Birth to 5 years

- Puberty

Spondylolysis

Defect or abnormality of pars interarticularis and surrounding lamina and pedicle

Spondylolysis: MOI

Microtrauma associated w excessive and repetitive extension + combined rotation

Spondylolysis: More common in M or F?

Male

Spondylolysis Grading/Progression

1. Stress reaction

2. Stress fx (disruption of bone without gap)

3. Pars nonunion (complete disruption w gap)

4. Spondylolysis (translation of one vertebrae on adjacent)

What sport has the highest risk for spondy?

Baseball

Do spondys hurt at rest?

No

Does flexion or extension increase spondy symptoms?

Extension

Spondy Historical Approach: Return to sport time average

4-7 months

Spondy Historical Approach: Imaging or no?

Yes to imaging

Spondy New Approach: Reurn to sport average time

2.5 months

Spondy New Approach: Imaging or no?

No, referakk to PT

3 Phases of Spondy PT

1. Neutral spine work

2. Functional strengthening

3. Return to sport

Scoliosis: SP deviates towards the ___ side?

Concave

Scoliosis: Which side is he rib pushed posteriorly on?

Convex

Left Scoliosis

Levoconvexity

Right Scoliosis

Dextroconvexity

3 Pillars of the Scroth Method

1. Muscular symmetry

2. Diaphragmatic breathing

3. Postural awareness

Scoliosis curve degrees that indicate part-time bracing?

20-25 degrees

Scoliosis curve degrees that indicate full time bracing?

>25 degrees

Scoliosis curve degrees that indicates surgery?

>45-50 degrees

Most Common Type of LBP

Mechanical Back Pain

- Characterized by pain that varies with physical activity and position

Chronic Pain

Pain that persists after tissue healing (3 months post injury)

SCFE

Slipped Capital Femoral Epiphysis

- Posterior/inferior slippage of the proximal head of the femur through the growth plate

SCFE: Common age and gender

8-15 yo males

SCFE: Clinical Presentation

Pt presents w a leg in ER and that appears shorter than the non-impaced limb

SCFE: Clinical Presentation ROM

Painful loss of flexion, abduction, and hip IR

SCFE: Drehmann's Sign

Do they have hip ER/abd during hip flexion?

- A positive sign is that they don't

SCFE: Where else will they present with pain?

Knees

Legg-Calve Perthes Disease

Avascular necrosis of he femoral head related to interrupted blood supply

Legg-Calve Perthes Disease: Common age and gender

4-10 yo males

Legg-Calve Perthes Disease: Clinical Presentation

Pt will typically complain of an insidious onset of a painless limp

- May also note a leg length discrepancy d/t femoral head collapse

Legg-Calve Perthes Disease: Clinical Presentation ROM

Noted decreased IR and hip abduction

Hip Apophysitis

Pain along the growth plate in children related to inflammation or stress to he open growth plate with passive stretch or active contraction

Hip Apophysitis: MOI

Commonly occurs with overuse activities such as running/jumping

- Can also occur with acute injury

Hip Apophysitis: Clinical Presentation

Presents similarly to tendinopathies but pain is more likely to be over bony landmarks

Hip Apophysitis: Common Sites (3)

- Sartoris attachment at the ASIS

- Rec fem at AIIS

- Hamstrings at ischial tuberosity

Hip Apophysitis: Common age to see in F vs M?

F: 10 yo

M: 12 yo

Patellofemoral Pain: Location

Around/behind the patella

Patellofemoral Pain: Movements that increase pain?

Aggravated by flexion activities

- Especially in WB

Knee Apophysitis

Excess stress at growth plate

Knee Apophysitis: 2 Common Types

1. Sinding-Larsen Johansson Syndrome (inferior pole of the patella)

2. Osgood-Schlatter's Disease (tibial tubercle)

Osteochondritis Dissecans (OCD)

Idiopathic alteration of subchondral bone with risk of instability and disruption of adjacent articular cartilage that may result in premature OA

Osteochondritis Dissecans (OCD): Most common age?

10-50

- Favorable outcomes in skeletally immature pts

Osteochondritis Dissecans (OCD): WB Status

0-4wks: FWB + brace locked in extension

4-6wks: FWB + brace unlocked, wean from brace pending quad control

Osteochondritis Dissecans (OCD): Quad Strengthening

0-4wks: NWB

ROM depends on lesion

Lateral Extra-Articular Tenodesis (LET)

Take part of the ITB to add extra lateral support to an ACL repair

Physeal Sparing Techniques

Techniques during ACL reconstruction to preserve growth plate in skeletally immature pts

PCL vs ACL Anatomy

PCL is 50% thicker and twice as strong as the ACL

- Isolated PCL injuries are rare

What ligament is commonly torn with the ACL?

MCL

Medial Patellofemoral Ligament (MPFL)

Medial patellar border to femur

- Between adductor tubercle and medial epicondyle

Medial Patellofemoral Ligament (MPFL): Function

Limits lateral motion of the patella

Medial Patellofemoral Ligament (MPFL): MOI

Lateral dislocation of patella

MPFL Reconstruction

Allograft or quad turndown technique

MPFL Reconstruction: Greatest strain on graft ___?

At 25-30 deg knee flexion

MPFL Reconstruction: How long for no max voluntary isometric activity?

Until 11 wks post-op

Anterior knee pain has been associated with decreased flexibility of ___ (3)?

1. Quad

2. Gastroc

3. Soleus

Anterior knee pain has been associated with decreased strength of ___ (3)?

1. Quad

2. Hip abductors

3. ERs

Sever's Disease (Calcaneal Apophysitis)

Stress/inflammation at open growth plate of the calcaneus

Sever's Disease (Calcaneal Apophysitis): MOI

Microtrauma d/t repetitive loading of the heel during dynamic activity

Sever's Disease (Calcaneal Apophysitis): Common during ___?

Rapid growth

- Especially 6-8 years old

Iselin's Disease

Apophysitis with pain at 5th met

Iselin's Disease: Common after ___?

Ankle inversion or direct trauma to lateral foot during sport

Iselin's Disease: Common during ___?

Rapid growth

- Especially children ages 9-13