Childhood and Adolescent Sports-Related Overuse Injuries KYLE J. CASSAS, M.D., and AMELIA CASSETTARI-WAYHS, M.D., Methodist Health System, Dallas, Texas Youth sports participation carries an inherent risk of injury, includ- ing overuse injuries. Little leaguer’s shoulder, a stress fracture of the proximal humerus that presents as lateral shoulder pain, usually is self- limited. Little leaguer’s elbow is a medial stress injury; treatment con- sists of complete rest from throwing for four to six weeks followed by rehabilitation and a gradual throwing program. Spondylolysis is a stress fracture of the pars interarticularis. Diagnostic modalities include plain film radiography, bone scan, computed tomography, single photon emission computed tomography, and magnetic resonance imaging. Treatment usually is conservative. Spondylolisthesis is the forward or anterior displacement of one vertebral body over another and may be related to a history of spondylolysis. Diagnosis is made with plain film radiography and graded according to the amount of displacement. Osgood-Schlatter disease presents as anterior knee pain localized to the tibial tubercle. Diagnosis is made clinically, and most patients respond to conservative measures. Calcaneal apophysitis (or Sever’s disease) is a common cause of heel pain in young athletes, presenting as pain in the posterior aspect of the calcaneus. (Am Fam Physician 2006;73:1014-22. Copyright © 2006 American Academy of Family Physicians.) SCOTT BY ILLUSTRATION BODELL S Patient information: ach year in the United States, develop in young athletes when this growth A handout on Osgood- approximately 30 million children center is unable to meet the demands placed Schlatter disease is available online at http:// and teenagers participate in orga- on it during activity. Some sites of apophyseal familydoctor.org/135.xml. nized sports.1 Sports are the lead- injury include the knee (Osgood-Schlatter Eing cause of injury in adolescents,2 and the disease), heel (Sever’s disease), and medial This article exem- plifies the AAFP 2006 Centers for Disease Control and Prevention epicondyle (little leaguer’s elbow). Annual Clinical Focus on estimates that one half of all sports injuries caring for children and in children are preventable2,3 with proper Shoulder Pain in Overhead Sports adolescents. education and use of protective equipment. The demands of overhead sports (e.g., base- Children and adolescents may be particularly ball, racquet sports, volleyball) put the shoul- at risk for sports-related overuse injuries as a der at risk of injury. The etiology of shoulder result of improper technique, poorly fitting pain may be varied and often is difficult to protective equipment, training errors, and diagnose (Table 1). Rotator cuff syndrome is muscle weakness and imbalance. Most of uncommon in children. However, conditions these injuries can be managed conservatively such as little leaguer’s shoulder (i.e., gradual with proper and timely diagnosis. Increas- onset of pain in the proximal humerus dur- ing numbers of chronic overuse injuries in ing throwing6) are unique to overhead sports young athletes may be related to limited athletes with open growth plates. Little leagu- recovery time from longer competitive sea- er’s shoulder is thought to be an overuse or sons and year-round training.2,4 stress injury of the proximal humeral physis The apophysis is a secondary center of and is not limited to baseball players; it also ossification and a location for the insertion can be encountered in athletes involved in of a muscle tendon into bone.4,5 Overuse swimming, gymnastics, volleyball, and ten- syndromes such as traction apophysitis may nis.7 Parents and coaches must be aware that Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright© 2006 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References Patients with little leaguer’s shoulder should abstain from C6 throwing for an average of three months. Plain radiographs should be obtained when evaluating athletes C7,19 with back pain of greater than three weeks’ duration. Single photon emission computed tomography should be used C20 to diagnose acute spondylolysis, and computed tomography should be used to help stage and determine proper treatment. Plain radiographs are rarely necessary for the diagnosis of C 26,30 Osgood-Schlatter disease or calcaneal apophysitis. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 956 or http://www.aafp.org/afpsort.xml. any shoulder or elbow pain that persists in a activities.6 Most patients report insidious young athlete may be a sign of an overuse or onset of symptoms that have been present for stress injury. Some evidence supports certain months and often delay seeking consultation measures to reduce throwing and overuse until the pain increases or until there is a injuries (i.e., adequate rest periods, icing decrease in throwing velocity or control.7 after activity, evaluation for proper throwing Up to 70 percent of patients with little mechanics, enforcement of proper pitch type leaguer’s shoulder have tenderness over the and number for age, immediate reporting of proximal and lateral portion of 6,7 pain during throwing or of persistent arm or the humerus. Radiographs Little leaguer’s shoulder shoulder pain).8-10 should be ordered to confirm should be suspected in Little leaguer’s shoulder should be sus- the diagnosis: anteroposterior in young pitchers who throw pected in young pitchers who throw break- internal and external rotation, breaking pitches such as ing pitches (e.g., curveballs, sliders), which lateral Y-view or axillary view, curveballs and sliders. put increased demands on the shoulder and and comparison views of the elbow.8 The average age of onset is 14 years; uninvolved side. Classic findings these patients typically present with lateral include widening of the proximal humeral shoulder pain during throwing or overhead physis with or without physeal fragmentation, sclerosis, and demineralization (Figure 1).6,7 Bone scan and magnetic resonance imaging TABLE 1 (MRI) usually are unnecessary but may be Causes of Shoulder Pain in Athletes considered if initial radiographs are negative and suspicion for the diagnosis is high, or if Acromioclavicular sprain or injury there is clinical suspicion for other pathology. Biceps tendonitis Treatment consists of relative rest from Bone tumor throwing for an average of three months, Brachial plexus injury icing, and analgesic medications as needed Distal clavicle osteolysis for pain.6 Athletes are encouraged to main- Fracture tain cardiovascular conditioning.6 Patients Glenohumeral instability should begin strengthening exercises when Impingement syndrome they are comfortable and an interval throw- Labral pathology/SLAP tear ing program when they are pain free. Evalu- Proximal humerus stress injury (little leaguer’s shoulder) ation of throwing mechanics also should be Referred pain considered. Rotator cuff tendonitis or bursitis Elbow Pain in the Thrower Thoracic outlet syndrome The elbow is the most common site of SLAP = superior labrum anterior to posterior. injury in young baseball players, and many of these injuries are preventable.4,11 Throwing March 15, 2006 U Volume 73, Number 6 www.aafp.org/afp American Family Physician 1015 Childhood Sports Injuries TABLE 2 Differential Diagnosis of Elbow Pain Site Possible diagnoses puts significant tension forces on the medial Lateral Avascular necrosis of the elbow and compression forces on the lateral capitellum (Panner’s disease; radiocapitellar joint, leading to a spectrum of in children seven to 12 years conditions that may include little leaguer’s of age) elbow (Table 2).9,12-14 Osteochondritis dissecans (in Little leaguer’s elbow has been described as children 12 to 16 years of age) an apophysitis of the medial epicondyle in ath- Medial Flexor/pronator strain letes between nine and 12 years of age.4 Most Medial apophysitis (little leaguer’s patients experience pain in the medial aspect elbow, in children nine to 12 years of age) of the elbow during throwing, and they may Medial collateral ligament injury have decreased pitch velocity or control.9,15 Medial epicondyle avulsion The history should address hand Ulnar neuritis dominance, position played, The diagnosis of little Posterior Olecranon apophysitis previous arm or elbow injuries, leaguer’s elbow is made Olecranon (posterior) number and type of pitches per clinically and should be con- impingement week, loss of control or veloc- sidered in throwers with Olecranon osteochondrosis ity during throwing, decreased Triceps/olecranon tip avulsion medial elbow pain, even if range of motion, numbness, and symptoms are minimal. Other Fracture paresthesias. It also is impor- Loose cartilaginous bodies tant to ask about the number of Synovitis teams on which the athlete plays (club and/or school teams) and whether he or she has taken any time off from throwing during the year. Radiographs may be normal or may reveal Examination may reveal swelling, loss of hypertrophy of the medial epicondyle,