This final blog of my 3-part blog series on the management of children/adolescents will cover common conditions seen in the clinic. At the end is a solid pragmatic case example as well. Check out part 1 and part 2 if you haven’t already, as they will lay the foundations prior to this final section.
Alright, let’s close this out!
Common Conditions: Diagnosis and Treatment
The most common group of conditions among children/adolescents.
Rapid long bone growth around peak velocity height (PVH) causes a traction stress on the proximal or distal tendon attachments of the overlying muscle.
The common treatment for apophysitis is relative rest from aggravating conditions, which are usually cyclical, moderate to high load muscular contractions at long muscle lengths. Often the treating medical practitioner will put the child on a short course of NSAIDs alongside the below conservative treatments. Maintenance of physical strength, fitness, and meaningful activity within pain free limits is also crucial.
In general most apophysitis prognosis is good, with acute resolution within weeks to 2 months but recurrence until the apophysis has fused is common. However, it must be stressed that continued ignoring of symptoms by “playing through the pain” is a risk factor for an acute avulsion fracture which comes with it a period of immobility and possible impacts on growth. Unfortunately, certain apophysitis such as Osgood Schlatter’s disease can still have symptoms years after initial presentation or closure of the apophysis (1,2,4). I will go deeper into the various apophysitis’ below.
Apophysitis of the 5th metatarsal caused by traction of the peroneal muscles (brevis and tertius). The use of a stiff soled shoe or moon boot is the common treatment along with what’s mentioned above. Pain free strengthening of the foot and calf should be the focus.
Apophysitis of the calcaneal tuberosity caused by traction from the achilles tendon insertion and/or the plantar aponeurosis. The use of taping, heel cups, heel raises have all been found to have varying levels of effectiveness in reducing pain post activity and should be trialled based on clinical reasoning to enable some continued activity participation. Orthosis may be required for serious cases. Progressive strengthening and lengthening of the calf complex within a pain free range is useful (1-3).
Osgood-Schlatter/Larsen Johansson Disease
Apophysitis of the tibial tuberosity or inferior patella pole due to traction of the patella tendon. This is commonly associated with jumping and/or overuse and treatment via strengthening and lengthening of the quadriceps is key. As stated above, in 50% of athletes this is not a self limiting condition with resolution not coinciding with apophysis closure. Therefore, a plan for progressive capacity maintenance and building is important, generally spanning the whole rehab continuum over time. For a deeper dive, Dr Teddy Willsey covered this topic in the November 2020 issue of the Physio Network Research Reviews, which you can find here (4,5).
Hip Related Apophysitis
There are 7 sites of possible apophyseal injury in the hip/pelvis. Ischial tuberosity (Hamstrings/Adductor magnus), Pubic symphysis (adductor group), Lesser trochanter (Iliopsoas), Greater trochanter and Iliac crest (Gluteal group), AIIS (Rectus femoris), and ASIS (Sartorius). These are most implicated in high speed running, dancing, kicking and change of direction overuse. Due to the high impulses in these sports, avulsions are of higher clinical suspicion (1).
Little Leaguer’s Elbow (Medial Epicondyle)
This condition is caused by the traction to the medial epicondyle during the rapid rotation motion of the forearm flexors and medial collateral ligament in throwing. It is very common in sports like baseball where specific recommendations around disincentivizing high pitch counts, high speed pitching and pitching and catching in combination are best practices. Again due to the high impulse involved in throwing, avulsions are of high clinical suspicion and progression through the plyometric continuum should be part of rehab (1,2,6,7).
This is quite rare and caused by temporary disruption to the blood supply to the joint rather than traction. It is always atraumatic and can often result after a period of overuse. Boys are 4-5 times more likely to be affected than girls. I will list the most commonly encountered below.
These usually require frequent and close monitoring, with repeated scans (X-ray or MRI) often necessary to ensure they don’t continue to an avascular necrosis.
These conditions generally self resolve over time. However, if symptoms haven’t resolved within 6 months, orthopaedic referral would be indicated.
Legg-Calves-Perthes Disease (LCPD)
Although this is rare, it is the most common osteochondrosis group we will see in the clinic. This condition is characterised by a disruption of vasculature supplying the chondral surface and sub chondral bone of the femoral head. It is generally a self resolving condition that must go through the following stages. The other osteochondroses will go through the same stages but often a shorter time course.
- Initial stage: Where the vascular insufficiency has created early sclerotic changes. Bony and labral edema in scans are indicative of this stage (Weeks – months).
- Fragmentation: Where the head of femur is attempting to heal by removing the damaged bone. This is often characterised by a flattening of the femoral head (6 months – 1 year).
- Reconstitution: Where all the dead bone has been cleared and the femoral head is beginning to reform (<3 years).
- Residual stage: The bone has now fully healed though often not perfectly shaped (3+ years). About 50% of patients will have osteoarthritis and progress to hip replacement surgeries currently in their 50’s.
LCPD is most common in 4-8 year olds with males more affected (5:1) and presents as hip and knee pain with a noticeable limp. A child in this age group may also present with femoral internal rotation or a functional leg length discrepancy and should be treated conservatively as having LCPD until proven otherwise. Early conservative treatment results in less bone sclerotic changes and better resolution of the condition through the stages. Importantly, continued loading will worsen the outcome of the final bone healing after resolution of all stages of the condition (1,8).
Freiberg disease (metatarsal head), Köhler bone disease (navicular), and Panner disease (capitulum of humerus).
Bone Stress Injuries (BSI)
These injuries are often a result of increased training loads with repetitive tasks, relative energy deficiency, and biomechanical/neuromuscular changes due to reaching PHV (8). The occurrence is as high as 21% in the lower limb and lumbar spine. This is most prevalent in high performance sports that select for the above risk factors. Examples of this include tall height, high bowling load and high rotational forces in cricket fast bowlers, or low body weight along with high lumbar extension frequency and intensity in gymnastics, or the same anthropometric factors with high volumes of weight bearing through the metatarsals as seen in ballet dancers (9,10).
Gradual onset, pain on weight bearing often lasting post cessation of activity, joint range of motion, tenderness on palpation and to vibration, and in more superficial joints signs and symptoms of the inflammatory response will be notable.
BSI always requires relative rest/load reduction from the aggravating activity to allow bony healing and union. Due to the nature of BSI being inadequate recovery/remodelling of bone after loading events, both sides of the stress and recovery cycle need to be considered to allow for desired adaptation. This will include biomechanical interventions such as load management, technique modification and strengthening on the stressor side. The recovery side of the equation should be considered in a multidisciplinary team where dietary, and sleep/stress management also are considered (9).
The average time of return to play after a BSI is 12-13 weeks with a range of 6-30 being normal depending on location and severity. In general, the younger the child is from epiphyseal closure (average 14 girls 16 boys) the quicker the fracture healing times (9,11)
The most commonly affected areas are:
- Lower leg (40.3%) – Tibial stress injuries
- Foot (34.9%) – Metatarsals stress injuries
- Lumbar Spine / Pelvis (15.2%) – Pars stress injuries, pubic symphysis (9)
Soft Tissue and Non-Specific
I have lumped together all soft tissue (muscle, ligament, tendon etc) and non specific conditions (patellofemoral pain, subacromial pain, etc) as the management has relatively few paediatric considerations. PHV must still be considered along with its impact on biomechanics and neuromuscular control. It is likely your interventions will mostly be guided by helping the child regain strength and control of their rapidly growing body while temporarily modifying their sport involvement. It should be noted again that anterior knee pain in adolescent athletes isn’t as innocuous and self limiting as expected, with many adolescents still experiencing nonspecific anterior knee pain for up to 5 years post initial diagnosis (12,13).
In general, a good age appropriate strength and conditioning program, that lasts for 10-15 minutes, 2-3 times per week, doubles as an effective preventative intervention, for such issues as shown over multiple sports (14,15).
Ok, let’s hit this home with a case study!
- Condition – Osgood Schlatter Disease/Tibial Tuberosity Enthesopathy
- Age – 9 years old, Pre PHV
- Training Stage – FUNdamentals
A couple of weeks out of sports training will be useful, I want you to continue playing with friends/family anything else that doesn’t hurt.
- Wall sits with no prescribed volume load
- Make it a game (e.g. how many footy passes, basketball shots, balloon keep ups, can you get till you fall. Involve family/friends)
- Teach squat movement pattern with body weight
Sport-Specific / Neuromuscular Control
- Play based landing technique drills (e.g. child sitting on seat with beanbags pretending to be a chicken hatching eggs, throw a ball above them to be caught but then they have to quickly but gently sit back to their eggs.
- Continue some low volume, low load sport specific running / ball passing drills.
How would this advice differ if the patient was 16 years old (post PHV) with Osgood Schlatter Disease?
Train to compete
- Modified specific training
- Limited high intensity/volume lower limb work
- Use other cross training modalities (swim, bike, etc) to maintain conditioning
- Consider high tempo strength training protocols for quads
- Modify training volume loads to greater focus on hip hinges
- Consider readiness to implement eccentric loading (e.g. reverse Nordics)
Sport-Specific / Neuromuscular Control
- Work on sport-specific positions and plyometrics continuum
- Gamify specific undesired biomechanics targeted drills (e.g. ball drills or perturbation drills based on desired athletic position)
Well, that concludes part 3! This 3-part series has taken us on a journey that outlines all the critical differences when treating a child/adolescent patient. In part 1 we covered growth development and paediatric red flags; part 2 covered unique considerations with developing a treatment plan; and then we rounded it off with applying them to common conditions we see in the clinic along with a case study.
I hope this series has been useful for you!