Sports-Related Acute Injuries
Monica Sifuentes, MD; Kier Maddox Blevins, MD; and Andrew K. Battenberg, MD
A 15-year-old female basketball player reports 6 months of intermittent pain in her left knee. Occasionally the knee gives out while she is playing ball. The patient denies any associated swelling or erythema over the joint. She can walk with no problem and reports no history of direct trauma to the area. She is otherwise healthy.
Physical examination shows the patient to be a well-developed, well-nourished adolescent girl in no acute distress. The examination is normal, with the exception of mild pain to direct palpation of the left patella. No swelling, erythema, or effusion of the knee joint is evident, and full range of motion is noted in the left hip, knee, and ankle. The back is straight.
1. What are some of the most common orthopedic findings in adolescent patients, and why do they occur in this age group?
2. What is the pathophysiology of overuse syndromes?
3. What is the purpose of the preparticipation physical evaluation?
4. What criteria help determine if an adolescent should be disqualified from participation in a competitive sport?
5. What are the current recommendations for the management and rehabilitation of acute soft tissue injuries?
Many adolescents with varying degrees of athletic ability participate in sports during their middle school/junior high school and high school years. Some participate in sports at the college level as well. Regardless of the reason for participating, team sports are an important means by which children and adolescents can experience both winning and losing. Individuals learn the importance of group participation and develop interactive skills with other team members. They are exposed to the concept of physical fitness, which can improve body image as well as self-esteem.
Participation in athletics carries significant risks, however. Injuries, inappropriate coaching, and aggressive training sessions are not uncommon occurrences that may have long-term sequelae for young athletes. Primary care physicians are responsible not only for the evaluation of children prior to their participation in sports but also for the prevention, diagnosis, and management of athletic injuries.
Recent estimates indicate that approximately 38 million young athletes participate in organized sports in the United States each year. Of these, 4 million athletes younger than age 14 years and 2 million high school–age athletes are treated for a sports injury. These numbers have increased dramatically in the past 20 years. This increase is thought to be multifactorial, including an increase in the number of female athletes in the United States following the passage of Title IX of the Education Amendments of 1972, a new emphasis on year-round competition, single-sport focus, and increased training intensity. Several studies have attempted to quantify the overall injury rate associated with athletic participation. In general, the rate of injury for individuals 13 through 19 years of age is 7% to 11%. Approximately 20% of those injured sustain a significant injury. For boys, the sports with the highest injury rate in all age groups are football, basketball, and soccer. In girls, gymnastics, cheerleading, and roller skating account for the most injuries. Sex-related differences have been found in some studies, depending on the sport. Overall, boys tend to have more shoulder-related injuries, whereas girls tend to have more knee and ankle injuries as well as more problems with overuse syndromes. Reports indicate that the severity of sports-related injuries increases with age. Along with the increased incidence of injuries, sports-related injuries previously thought to be rare in the pediatric population are on the rise. For example, anterior cruciate ligament (ACL) ruptures are occurring with increased frequency in this demographic, especially among high school–age females. Management of such injuries is complicated in skeletally immature individuals because of the need to preserve growth potential.
Preparticipation Physical Evaluation
The goal of the preparticipation physical evaluation (PPE) is to identify any physical conditions or abnormalities that may pre-dispose the young athlete to injury. Examples include a history of concussion with head trauma or an incompletely healed sprain.
The PPE consists of 2 parts: a review of the patient’s current health and medical history, including sports injuries and family history relating to participation in strenuous exercise, and a complete physical examination with a focus on the musculoskeletal system. Known as a “2-minute orthopedic examination,” the musculoskeletal examination is a detailed assessment of all muscle groups, assessing their strength, tone, and function. Congenital or acquired deformities should also be noted. The American Academy of Pediatrics has developed a form specifically for the PPE visit (see Chapter 38).
Disqualification from participation in specific sports is appropriate in certain situations. Competitive sports are classified according to their degree of contact or impact and their strenuousness. Recommendations differ depending on the adolescent’s medical condition and the type of sport the athlete desires to play. For details of these recommendations, see Selected References at the end of this chapter. Fortunately, many young athletes are healthy and rarely need to be restricted from sports participation.
Older children and adolescents with sports-related injuries usually present with specific reports of pain or swelling in a particular joint (Box 117.1). Additionally, they may report nonspecific musculoskeletal pain occurring in certain areas, such as the lower back or shoulder, or they may report a limp, decreased range of motion of an extremity, or an inability to participate in a desired activity without pain.
Unlike adults, adolescents are particularly susceptible to injury because their bones and joints are not fully mature. Most injuries that occur during adolescence involve the epiphysis, which is the weakest point of the musculoskeletal system. Additionally, the presence of congenital anomalies, such as leg length discrepancy and hip rotation abnormalities, puts the young athlete at further risk for injury. Biomechanical and neuromuscular factors, hormonal influences, and anatomic differences have also been proposed as reasons for higher rates of some injuries in young female athletes compared with young male athletes. For example, patellofemoral pain syndrome, which presents as knee pain exacerbated by activity, is a common problem in adolescent females, affecting nearly 1 in 10 of those who are active. Contributing biomechanical factors include tight iliotibial bands, weak gluteal strength, and a relative genu valgum resulting from increased hip width in female individuals. This combination causes valgus stresses at the knee, internal femoral rotation, and abnormal patellar tracking, which places the athlete at increased risk for patellofemoral syndrome.
Most orthopedic injuries are the result of either macrotrauma or microtrauma. Sprains are an example of macrotrauma, whereas overuse syndromes can be considered microtrauma. Macrotrauma is the result of complete or partial tearing of muscle, ligaments, or tendons and often is associated with acute injuries. In contrast, microtrauma usually is caused by chronic repetitive trauma to a particular area, resulting in inflammation and ultimately, pain. Such injury most commonly occurs in soft tissues, such as muscle and tendon, but can occur in bone as well.
Box 117.1. Diagnosis of Orthopedic Injury in the Older Child or Adolescent Patient
•Joint pain or swelling
•Tenderness to palpation of the affected joint
•Decreased range of motion of the affected joint or extremity
•May or may not have associated bruising of the skin overlying the injury
A sprain is a stretching injury of a ligament or the connective tissue that attaches bone to bone. A strain is a stretching injury of a muscle or its tendon, which is the connective tissue that attaches muscle to bone. Tendinitis is an inflammation of the tendon. Apophysitis is an inflammation of the apophysis, which is the site of ligamentous or tendinous attachment to growth cartilage (eg, Osgood-Schlatter disease [ie, apophysitis of the tibial tubercle], Sever disease [ie, calcaneal apophysitis]). A stress fracture is an incomplete fracture often occurring in the bones of the legs and feet from repetitive trauma to the area. It is believed that the pain associated with shin splints may result in part from atypical stress fractures of the distal tibia.
Overuse syndromes occur from repetitive microtrauma to the musculoskeletal system secondary to excessive or biomechanically incorrect activity. Typically, they are the result of training errors in which athletes are “trying to do too much too fast.” Common syndromes in adolescents include Osgood-Schlatter disease, shin splints (ie, medial tibial stress syndrome), and patellofemoral syndrome (ie, chondromalacia patellae).
Grading of Sports Injuries
Sprains most commonly occur in the knee or ankle, and they can be classified according to the degree of injury. Assigning a grade that describes the injury is useful when considering the prognosis of a particular injury. Grading an injury is helpful when referring patients to sports medicine specialists (eg, orthopedists). Typically, sprains are classified as grade I, II, or III (Table 117.1). Grade I generally refers to stretching of the ligament, grade II is a partial tear of the ligament, and grade III is a complete tear of the ligament. Joint stability, range of motion, and degree of pain and swelling determine the grade of the sprain. The grading system for strains, however, is based on an assessment of strength. Because strains typically do not cause joint instability, criteria for grading strains are different from those for sprains and may be more subjective (Table 117.2).
Abbreviations: ↓, reduced; ↓↓, markedly reduced; +, mild; ++, moderate; +++, severe.
Abbreviations: −, none; ±, variable; +, mild; ++, moderate; +++, severe.
The differential diagnosis of orthopedic conditions depends on the anatomic site of the injury or symptom and the mechanism of injury. Box 117.2 lists some of the more common orthopedic conditions by location. Anomalies of skeletal development, such as congenital angular deformities of long bones, and soft tissue abnormalities, such as Ehlers-Danlos syndrome, should be considered as possible etiologies for overuse syndromes. Other nonorthopedic conditions, such as collagen vascular diseases, infections, and tumors, may present with joint or bone symptomatology.
The history should focus on the musculoskeletal system and the mechanism of injury (Box 117.3). Other pertinent information about the activity level and competition level of the sport should be ascertained as well, because it can help the physician determine any underlying factors that may have precipitated the injury, such as a chronic overuse mechanism. It is also important to note the increased numbers of children engaging in early single-sport specialization, because these children may be prone to overuse injury and should be evaluated for signs of burnout.
Box 117.2. Differential Diagnosis Based on the Site of Injury
•Acute elbow injury
•Anterior cruciate ligament sprain
•Femoral stress fracture
•Iliac crest contusion
•Medial/lateral ligament sprain
•Patellofemoral stress syndrome
•Posterior cruciate ligament sprain
•Shin splint syndrome