Evaluation and Management of Sports Injuries in Children

2019 Frontiers in Pediatrics

Sports Medicine Mini-Symposium Presented by MUSC Health Sports Medicine Sports Medicine Panel of Experts

Michael J. Barr, PT, DPT, MSR Sports Medicine Manager MUSC Health Sports Medicine

Alec DeCastro, MD Assistant Professor CAQ Sports Medicine Director, MUSC/Trident Family Medicine Residency MUSC Health Sports Medicine MUSC Department of Family Medicine

Harris S. Slone, MD Associate Professor Orthopaedic Surgery and Sports Medicine MUSC Health Sports Medicine MUSC Department of Orthopaedics Sports Medicine Breakout Group Leaders

Aaron Brown, ATC Athletic Trainer MUSC Health Sports Medicine

Amelia Brown, MS, ATC Athletic Trainer MUSC Health Sports Medicine

Brittney Lang, MS, ATC Athletic Trainer MUSC Health Sports Medicine

Bobby Weisenberger, MS, ATC, PES Athletic Trainer MUSC Health Sports Medicine Sports Medicine Schedule

Approximate Timeline: 2:00: Introduction – Michael Barr, PT, DPT, MSR – Sports Medicine Manager 2:05: Ankle Case Report – Harris Slone, MD 2:20: Knee Case Report – Harris Slone, MD 2:35: Shoulder Instability Case Report – Michael Barr, PT, DPT, MSR 2:50: Back Case Report – Alec DeCastro, MD 3:05: High BP Case Report – Alec DeCastro, MD 3:20: Hands On Practice of Exam Techniques – All + Athletic Trainers 3:50: Question/Answer Open Forum – All 4:00: End Sports Medicine Disclosers

No relevant financial disclosers Sports Medicine Learning Objectives

Learning Objectives: 1. Describe mechanisms of injury and clinical presentation for common pediatric sports related injuries of the ankle, knee, back and shoulder. 2. Demonstrate examination techniques to support the diagnosis of common pediatric sports related injuries of the ankle, knee, back and shoulder 3. Determine what imaging studies should be ordered and when to refer to a sports med/orthopaedic surgeon or to physical therapy 4. Through review of specific case reports, formulate an appropriate initial management and treatment plan for common pediatric sports related injuries of the ankle, knee, back and shoulder. 5. Discuss and review new clinical practice guidelines for high blood pressure in children and adolescent athletes, including applying guidelines to pre-participation sports physicals and well-child care

Disclosures

I have no relevant financial disclosures What are ankle sprains?

• Injuries to the ligament complex about the ankle • ATFL, CFL most common • More severe injuries involve other ligaments • High ankle sprains involve the syndesmosis (AITFL/PITFL/IO) • Most can be treated conservatively • Be wary of associated injuries

Images from orthobullets.com Case - Ankle

HPI- 16 year old male, presents with 5 days of ankle pain following an injury sustained playing football after being tackled from behind while running. Initially seen at an OSH ER, x-rays “negative” placed in splint and given crutches. Has been using RICE. Points medially when describing his worst pain.

No pertinent PMH, PSH, FH Case - Ankle

PE ankle: • Inspection • (hindfoot position, arch height) • Palpation • (anterolateral, posterior, lateral, syndesmosis, medial, 5th MT base, proximal fibula, 1-2 TMT joint) • ROM • Strength • (DF/PF/inversion/eversion) • Special Tests • (talar tilt, ankle drawer, resisted eversion or circumduction for peroneal instability, ER stress, syndesmotic squeeze) Case - Ankle

PE ankle: • Inspection • Medial and lateral ecchymosis, marked swelling, normal alignment • Palpation • Global TTP about the ankle • ROM • Limited due to pain • Strength • 5/5 with inversion, 4+/5 otherwise • Special Tests • +pain with talar tilt, ER stress. Increased translation with drawer vs other side, no peroneal instability Case - Ankle

• Ottawa Criteria • Inability to bear weight • Medial or lateral malleolus point tenderness • 5th MT base tenderness (or Proximal fibular tenderness) • Navicular tenderness

Images from orthobullets.com Case - Ankle Case - Ankle Case - Ankle Case - Ankle Case - Ankle

• Surgical treatment recommended for syndesmosis repair

• Treated with suture button construct

• Doing well post-op Case- Knee

A 16 year old female sustained a non-contact knee injury while playing basketball 72 hours ago. She reports feeling a pop, followed by knee swelling and pain.

No pertinent PMH or PSH. What is ACL function?

• Primary: • Resist anterior tibial translation • Resist internal tibial rotation

• Secondary: • Varus and Valgus Restraint Exam** ** Examine the normal knee first!

• Inspection/Alignment • Palpation • Range of Motion • Degree of motion • Patella tracking • Ligamentous Exam • Coronal Plane Stress • Lachman • Pivot Shift • Anterior/Posterior Drawer • Special Tests • McMurry’s • Thessaly Case- Knee Imaging

• Start with plan Xray • Segond fracture • Deep sulcus terminais (lateral femoral notch sign) • Anterior tibial translation (may be present in chronic setting) • Tibial eminence • Associated injuries • Evaluation of physis

• MRI Case- Knee Imaging (not this patient…) Imaging (not this patient…) Case- Knee MRI Case- Knee

Findings: Medial meniscal tear, ACL tear

Treated with medial meniscus repair and autograft ACL reconstruction Case- Knee

• Doing well post-op

• Has since returned to sports Thanks!

Harris Slone 843-792-8765 [email protected] Shoulder Instability: 11 Year-old Female Swimmer Michael J. Barr, PT, DPT, MSR Sports Medicine

Michael J. Barr, PT, DPT, MSR

• MUSC Health Sports Medicine Manger • Team Physical Therapist for: • Charleston Battery • Charleston RiverDogs • Volvo Car Open - WTA • Lowcountry High Rollers – Roller Derby • Number of Local High Schools and Club Teams Sports Medicine Definitions

• Anterior Shoulder instability refers to a shoulder in which soft-tissue or bony insult allows the humeral head to sublux or dislocate from the glenoid fossa where the humerus is displaced from its normal position in the center of the glenoid fossa to a more anterior position.

• Multidirectional Instability (MDI) refers to symptomatic laxity of the glenorhumeral joint (GHJ) where the athlete has consistent subluxations of their shoulder in multiple directions (anterior/inferior/posterior) usually due to a combination of hyperelasticity and overuse. Sports Medicine Chief Complaints of Patients with GHJ Instability • Shoulder pain with active movement • “Dull Ache” during rest • Weakness and sport limitations • Loss of “zip” when throwing • Decreased “pull” when swimming • Numbness or “pins and needles” into hand or scapular region • C/o muscular tightness through upper and middle traps and pec major • Recent/Acute or Chronic history of dislocation and/or subluxation Sports Medicine Clinical Presentation – General

• Excessive ROM in one or multiple directions with possible loss of ROM in the opposite direction • Muscular imbalance or deficits • Excessive humeral head translation • Scapular winging, instability, or dyskinesis • General ligamentous laxity or hypermobility – Beighton Scale Sports Medicine Clinical Presentation – General Excessive External Rotation and Loss of Internal Rotation • Anterior Capsular Laxity • Posterior Capsular Tightness • Soft Tissue Tightness • Osseous Adaptations – Humeral Head Retroversion Sports Medicine Clinical Presentation – General Scapular Winging Sports Medicine Treatment Philosophy – Scapular Winging

• Scapular instability and winging contributes to GHJ anterior instability • If proper scapular alignment and stability can be achieved initially along with moderate rotator cuff strength improvement – the scapula would rotate back into position creating a decreased tilt at the glenoid fossa Sports Medicine Case Report - Subjective

• Pt is an 11 year-old, right hand dominant, female swimmer, who reports experiencing progressive onset of anterior left shoulder pain for ~2 months • Started when she returned to swimming after a 6 week period of rest. • Able to continue to swim at this time, but her pain starts ~1/2 way through practice and limits her ability to continue. • Denies any type of neurological or radicular symptoms • No specific episodes of instability but does state that she has a lot of "hyper mobility". Pt and her mom state • No previous assessments, imaging, or treatment – Pt’s mom contacted pediatrician and was provided a referral for PT • Normal practice includes a total of ~2500 yards, variety of distances and strokes • Pt is in the 6th grade, she also plays basketball but swimming is her main sport. Sports Medicine Case Report – Examination

Positive: Empty Can, Near’s Impingement, Hawkins-Kennedy, Sulcus, Load-and-Shift, Anterior/Posterior drawer – notable hypermobility

Negative: Spurling’s, Obrien’s, Speeds, Lift-off, Apprehension/Relocation

Beighton Scale = 6/9

ROM: ER@90: R = 95o, L = 96o IR@90: R = 81o, L = 82º Flex/Abd – Equal Bilatearlly

MMT – Grossly 5/5 B, except left: ER = 4/5 IR = 4+/5 Scaption in prone = 4/5 H.abd in prone = 4-/5 Ext in prone = 4+/5

* Notable scapular winging B (L >R) without signs of dyskinesis Sports Medicine Examination – ROM and Strength

Shoulder AROM and PROM: Strength: • Flexion • Flexion • Abduction • Abduction • External Rotation @ 0o of Abduction • External Rotation @0o of Abduction • External Rotation @90o of Abduction • External Rotation @90o of Abduction • Internal Rotation @90o of Abduction • Internal Rotation @0o of Abduction • Internal Rotation (behind back) • Internal Rotation @90o of Abduction • Assess Scapular Mobility during movements – • Prone H.Abduction, Scaption, Extension Look for Dyskinesis, Winging, Increased or Decreased Mobility Sports Medicine Range of Motion Sports Medicine Scapular Winging Sports Medicine Examination – Empty Can - Supraspinatus: Positive Origin: Supraspinous Fossa Supraspinatus – Posterior View Insertion: Greater Tubercle of the humerus Action: Shoulder Abduction and stabilization – presses humeral head into glenoid fossa. Test: 1. Patient abducts shoulder 60o (scapular plane), flexes to 60o, with full internal rotation (ie. thumbs pointing down). Supraspinatus (“Empty can”) Test 2. Provide downwards pressure 3. *Note: Deltoid is responsible for abduction beyond ~70o 4. Partial tear – pt will experience pain and some level of weakness. 5. Complete disruption of muscle prevention pt from achieving abduction. Sports Medicine Examination – Sulcus Sign – Inferior Instability: Positive Caudal traction is applied to the humerus in an attempt to displace the humerus inferiorly. If this test is positive, multidirectional instability may be present. Sports Medicine Examination – Load and Shift Test Positive The examiner pushes the humeral head against the glenoid fossa and then moves it anteriorly and posteriorly. The test is positive if there is anterior displacement of the joint. Sports Medicine Joint Mobility Sports Medicine Examination – Hawkin’s Test - Impingement: Positive Hawkin’s Test: 1. Raise patient's arm to 90 degrees forward flexion and neutral to 10 degrees of horizontal adduction. 2. Rotate internally (i.e. thumb pointed down) places greater tubercle humerus in position to further compromise space beneath acromion. 3. Pain = Impingement. Orthopaedics and Sports Medicine Examination – Neer’s Test - Impingement: Positive Neer’s Test: 1. Place 1 hand on patients scapular and hold the forearm with the other hand. With arm internally rotated (thumb pointed downward). 2. Passively flex the arm, positioning hand overhead, until endpoint is felt. 3. Pain = Impingement Sports Medicine Examination – Anterior Drawer Test - Instability: Positive - Hypermobility • Pt is positioned in supine • Examiner supports the arm through the bicondylar axis of the elbow • Examiner grasps the humeral head and gently translates the head anteriorly * Test is then repeated in multiple planes Sports Medicine Examination – Posterior Drawer Test – Instability: Positive - Hypermobility

Similar to Anterior Drawer Test except humeral head is translated posteriorly Sports Medicine Physical Examination – Spurling’s Negative • Remember the cervical spine! • Flexion • Extension • Rotation • Spurling’s maneuver • Neurologic exam Sports Medicine Examination – O’Brien’s Test: Negative O’Brien’s test › Forward flexion to 90° › Adduction 10° across body › Thumbs down vs. thumbs up › Thought to be indicative of labral tear Sports Medicine Examination – Speed’s Test – Biceps Tendonitis: Negative Speeds test 1. Patients Arm is flexed to 90 degrees with elbow straight and in supination (palm-up) 2. While lightly palpating proximal biceps tendon a down ward force is applied and patient is instructed to resist 3. Maneuver is then repeated with arm in pronation (palm-down) 4. Positive Test: pain/tenderness elicited in the bicipital grove/over proximal biceps tendon in supination, relieved in pronated position Sports Medicine Examination – Apprehension/Relocation Test Negative Apprehension test › Supine › 90°-90° position › Feeling like the shoulder will “pop out” Relocation test › In 90°-90° position, posteriorly -directed force is applied, with relief of symptoms Sports Medicine

Examination – Beighton Scale = 6/9

LEFT RIGHT 1. Passive dorsiflexion and hyperextension of the fifth MCP joint beyond 90° 1 1 2. Passive apposition of the thumb to the flexor aspect of the forearm 1 1 3. Passive hyperextension of the elbow beyond 10° 1 1 4. Passive hyperextension of the knee beyond 10° 1 1 5. Active forward flexion of the trunk with the knees fully extended so that the palms of the hands rest flat on 1 the floor TOTAL / 9 Sports Medicine Beighton Scale Sports Medicine Case Report – Clinical Assessment

Pt is an 11 year-old, female, swimmer with general upper extremity hypermobility who presents to PT for the evaluation and treatment of her left shoulder. Upon examination pt demonstrates signs and symptoms consistent with internal impingement secondary to MDI of her left shoulder with associated bilateral scapular winging (L>R) and strength deficits. Pt has a good rehab potential and should benefit from skilled PT. Sports Medicine Treatment Options: Following Primary Assessment (ED, Primary Care MD, Pediatrician) Acute phase: Goal – control pain and inflammation: Rest, Ice, NSAIDs, Activity Modification

Subacute Phase: Goal: Restore range of motion, strength and stability – HEP or PT

Extended Acute/Subacute Phase or Chronic: • If not showing improvements with inflammation management and HEP, consider referral to PT • If not showing improvements with PT or instability is worsening (additional events) consider referral to Sports Med/Ortho and/or advanced imaging * Note if ordering MRI for instability – usually an MR Arthrogram is indicated Orthopaedics and Sports Medicine Treatment Options: Home Exercise Program - Strengthening Orthopaedics and Sports Medicine ** Important ** • All strengthening exercises should be completed in a slow and controlled manner • Goal is to create stability, strength and muscular endurance through use of low resistance, high repetition exercises. Orthopaedics and Sports Medicine The Throwers Paradox

“Loose enough to throw but stable enough to prevent symptoms” - Kevin E. Wilk, PT, DPT Sports Medicine References Chapus V., Rochcongar G., Pineau V., Salle de Chou E., Hulet C. Ten-year follow-up of acute arthroscopic Bankart repair for initial anterior shoulder dislocation in young patients. Orthopaedics & Traumatology: Surgery & Research. 2015; 101 (8): 889-893. Longo U. et al. Mangement of Primary Acute Anterior Shoulder Dislocation: Systematic Review and Quantitative Synthesis of the Literature. The Journal of Arthroscopic & Related Surgery. 2014; 30 (4): 506-522. Kirkley A., Werstine R., Ratjek A., Griffin S. Prospective randomized clinical trial comparing the effectiveness of immediate arthroscopic stabilization versus immobilization and rehabilitation in first traumatic anterior dislocations of the shoulder: Long-term evaluation. The Journal of Arthroscopic & Related Surgery. 2005; 21 (1): 55-63. Geier C., Paletta G. Shoulder Instability in the Skeletally Immature Athlete. Operative Techniques in Sports Medicine. 2006; 14 (3): 159-164. Khiami F., Gerometta A., Loriaut P. Mangement of the recent first-time anterior shoulder dislocations. Orthopaedics & Traumatology: Surgery & Research. 2015; 101: 551-557. Kavaja L. et al. Treatment after traumatic shoulder dislocation: a systematic review with a network meta-analysis. British Journal of Sports Medicine. 2018; 0: 1- 11. Reinold, M., Wilk, K., and Andrews J. Interval Sport Programs: Guidelines for baseball, tennis, and golf. Journal of Orthopaedic Sports Physical Therapy. 2002; 32: 293-298. Burkhead W., Rockwood C. Treatment of instability of the shoulder with an exercise program. American Journal of Bone and Joint Surgery. 1992; 74 (6): 890-896. Sciascia, A., and Kibler, W. The Pediatric Overhead Athlete: What is the Real Problem? Clin J Sports Med. 2006; 16: 471-477. Terry, G. and Gaunt, B. Activity Levels as a Guide for Shoulder Girdle Exercise Progression. Sports Medicine and Arthroscopy Review. 2001; 9: 61-68. Vidal, L. and Bradley, J. Management of Posterior Shoulder Instability in the Athlete. Current Opinion in Orthopaedics. 2006; 17: 164-171. Voight M. et al. The effects of muscle fatigue on and the relationship of arm dominance to shoulder proprioception. Journal of Orthopaedic and Sports Physical Therapy. 1996; 23: 348-352. Wilk, K., Andrews, J., Arrigo, C. et al. The strength characteristics of internal and external rotator muscles in professional baseball pitchers. Am J Sports Med. 1993; 21: 61-69. Wilk K., Meister, K., and Andrews, J. Current Concepts in the Rehabilitation of the Overhead Athlete. Am J Sports Med. 2002; 30: 156-161. Wilk, K., Reinold, M., and Andrews, J. Rehabilitation of the Thrower’s Elbow. Techniques in Hand and Upper Extremity Surgery. 2003; 7(4): 197-216. Back Pain in Children Case

• 13 yo F presents to your office for 6 months of worsening low back pain. She does admit to carrying a very heavy backpack to her classes. • Her sport is gymnastics, which she has been doing since she was 8 yo but denies any specific injury or trauma. • She describes the pain in her lower back as sharp, hurts with movement but better with rest. Epidemiology of back pain

• Nonspecific musculoskeletal pain accounts for at least 50% of cases • Mechanical problems from computer use, physical activity, or heavy backpacks do not appear to be associated with back pain in school-age children • More common in school-age children with high levels of psychosocial difficulties, conduct problems, or other somatic disorders • General well-being and self-perception may be important associated variables • AAP guideline - Backpacks not exceed 10 to 20 percent of the child's body weight (not an evidence-based recommendation) History

• Injury vs overuse • Severity • Where located? • Radiation? Location of Pain

• Lumbar pain • SI Pathology • Pain around PSIS or radiating into hip/groin • Piriformis • Muscle spasm may imitate sciatica • Pain radiating into extremities • Peripheral paresthesia or numbness: • Result of impingement or pressure on nerve root exiting intervertebral foramen or dural irritation proximal to pain site “Red Flags” in back pain

• Nighttime pain • Tumors or infection • Pain with generalized sx • Fever, anorexia, malaise • S/sx of infection • Abnormal neuro findings • Hx of repetitive trauma • Morning Stiffness • Hx of exposure to TB • Young age (< 4yo) Physical Examination

• Inspection • Palpation • Bony • Soft Tissue • Range of Motion • Neurologic Examination • Special Tests Landmarks Landmarks Inspection

• Observe for areas of erythema • Infection • Long-term use of heating element • Unusual skin markings • Café-au-lait spots (Neurofibromatosis) • Hairy patches (spina bifida) • Gait Inspection

• Posture • Shoulders and pelvis should be level • Bony and soft-tissue structures should appear symmetrical • Normal lumbar lordosis • Exaggerated lumbar lordosis is common characteristic of weakened abdominal wall

Scoliosis

• Signs and symptoms › Uneven shoulders - one shoulder blade appears more prominent › Uneven waist / 1 hip higher vs. other › Leaning to one side › Back pain and difficulty breathing (severe) • Causes › Idiopathic (85% of cases) › Underlying neuromuscular disease, leg-length discrepancy, birth defect, fetal development (congenital) › Not caused by poor posture, diet, exercise, or the use of backpacks Bony Palpation

Sacrum and Pelvis › Median sacral crests › Iliac crests: › Palpate laterally from PSIS to find iliac crests (L4-5) and anteriorly to locate ASIS (level of symmetry) › Posterior superior iliac spine (S2 spinous process) › Ischial tuberosity › Greater trochanter › Pubic symphysis

Soft Tissue Palpation

4 clinical zones › Midline raphe › Paraspinal muscles › Gluteal muscles › Anterior abdominal wall and inguinal area

Sciatic notch

› Sciatic area › Place thumb on ischial tuberosity and 3rd finger on the PSIS. 2nd finger will fall into sciatic notch (nerve most superficial as it passes by ischial tuberosity)

Range of Motion

Flexion 80º Extension 35º Rotation 3-18º Lateral Bending 40º each side Neurologic Examination

Special Tests

• Tests to stretch spinal cord/sciatic nerve • SLR, Cross leg SLR • Kernig's test •Tests to increase intrathecal pressure •Tests to stress the SI joint

Slump Test

Positive Findings: › Sciatic pain or reproduction of other neurological symptoms Implications: › Impingement of the dural lining, spinal cord, or nerve roots

Note: Patient performs ACTIVE knee extension and dorsiflexion Tests to Increase Intrathecal Pressure

• Vasalva Maneuver • Reproduction of pain suggestive of lesion pressing on thecal sac Tests to stress the Sacroiliac Joint

Pelvic Rock Test Flexion AB-duction External Rotation Clearing up the terms

•Spondylosis – Degenerative joint disease affecting the vertebrae and intervertebral disc •Spondylolysis – Fracture in pars interarticularis

•Spondylolisthesis – Displacement of one vertebra on another Disc rupture and herniation

Scheuermann's kyphosis

• Osteochondrosis • abnormality of the vertebral epiphyseal growth plates. • Onset occurs in early adolescence (boys>girls) • should be distinguished from postural kyphosis  limited correction on extension xrays) • Get standing lateral spine XR (anterior wedging > 5 degrees) • Rigid, and the pain is generally gradual, located over the deformity, and worst at the end of the day Inflammatory Joint Disorders

• JRA or ankylosing spondylitis • Morning stiffness is common, and mobility may improve with moist heat such as from a hot bath or shower • SI joint tenderness may be present, although nighttime pain is uncommon with inflammatory joint disorders • Sacroiliac joint changes with limited chest expansion may occur with juvenile ankylosing spondylitis. • FABER test of the hip may detect joint problems HTN in the Pediatric Athlete Case

• 12 year old male comes in during a mass participation sports physical screening event at the local high school. He plans to play football for the local middle school team and has not played football in the past. He has no significant PMHx or FHx reported on his PPE form. He also has no symptoms reported. • Vital signs: BP 130/88 (repeat manual 130/80), Ht 55 in, Wt 155 lbs.

• Do you clear him to play football? AAP Guidelines 2017

• Significant increase in interest in childhood hypertension (HTN) since 2004 Fourth Report • 3.5% of children have HTN; another 10%–11% have elevated blood pressure (BP) • Increase in prevalence due to obesity • High BP in childhood increases the risk for adult HTN and cardiovascular disease. • Even youth with HTN have evidence of accelerated vascular aging AAP Guidelines 2017

• New normative BP tables based on BPs from normal- weight children • Simplified screening table • Emphasis on use of 24-hour ambulatory blood pressure monitoring (ABPM) to confirm HTN diagnosis • Revised recommendations for performance of echocardiography • Lower treatment goals for primary HTN; ABPM goal for chronic kidney disease (CKD) Definition of HTN age 1-18

For Children Aged 1–13 y For Children Aged ≥13 y Normal BP: <90th percentile Normal BP: <120/<80 mm Hg Elevated BP: ≥90th percentile to <95th Elevated BP: 120/<80 to 129/<80 percentile or 120/80 mm Hg to <95th mm Hg percentile (whichever is lower) Stage 1 HTN: ≥95th percentile to Stage 1 HTN: 130/80 to 139/89 mm Hg <95th percentile + 12 mmHg, or 130/80 to 139/89 mm Hg (whichever is lower) Stage 2 HTN: ≥95th percentile + 12 Stage 2 HTN: ≥140/90 mm Hg mm Hg, or ≥140/90 mm Hg (whichever is lower) New BP tables New BP tables New BP Tables Simplified Table BP Measurement technique

• Seated in a quiet room for 3–5 min before measurement, with the back supported and feet uncrossed on the floor. • BP should be measured in the right arm for consistency • Arm should be at heart level, supported, and uncovered above the cuff • Patient and observer should not speak while the measurement is being taken. • Correct cuff size • To measure BP in the legs, the patient should be in the prone position, if possible. An appropriately sized cuff should be placed midthigh and the stethoscope placed over the popliteal artery. The SBP in the legs is usually 10%–20% higher than the brachial artery pressure. Evaluation and Management of Elevated BP or HTN • No evidence that exercising while hypertensive increases sudden death risk • Physical activity and improved physical fitness are treatments for HTN • Treatment of HTN improves sports performance HTN and the • LVH or other target organ damage is present, should withhold from competition until BP is controlled athlete • Children and adolescents with HTN may participate in competitive sports once hypertensive target organ effects and CV risk have been assessed • Children and adolescents with HTN should receive treatment to lower BP below Stage 2 thresholds before participation in competitive sports Secondary Causes of HTN

• Coarctation of the aorta • Cushing syndrome • Drug induced • Hyperthyroidism • Mineralocorticoid excess • OSA • Primary HTN • RAS • Renal parenchymal disease • Rheumatologic disorder Secondary Causes of HTN

Clinical features Primary HTN Secondary HTN Age: Secondary HTN is more likely in Prepubertal younger children, especially those less than six years of age. Older children and adolescents are Postpubertal more likely to have primary HTN. Diastolic HTN is more likely to be Diastolic HTN* associated with secondary HTN. Nocturnal HTN is more likely to be Nocturnal HTN* associated with secondary HTN. Overweight or obese Overweight/obesity children/adolescents are more likely to have primary HTN. Children with a positive family history Family history may be positive in some Family history of HTN of primary HTN are more likely to have cases of secondary HTN due to a primary HTN. monogenic cause (eg, APKD)

Patients with secondary HTN often Patients with primary HTN are typically Symptoms of underlying disorder have other symptoms related to the asymptomatic. underlying cause PPE 5th edition Cleared? Sports Medicine Practice Exam Techniques Ankle: Shoulder: Back: • Talar Tilt • ROM: ER@90, IR@90 • SLR • Ankle Drawer • Empty Can • Cross Leg SLR • Resisted Eversion • Sulcus Sign • Kernig’s Test • Circumduction for Peroneal • Load and Shift • Slump Test Instability • O’Brien’s • Pelcic Rock Test • ER Stress • Hawkin’s • FABERs • Syndesmotic Squeeze • Apprehension/Relocation Knee: • Anterior Drawer • ROM • Posterior Drawer • Patellar Tracking • Beighton Scale • Valgus Stress – MCL • Varus Stress – LCL • Lachman’s • Pivot Shift • Anterior Drawer • Posterior Drawer • McMurry’s • Thessaly Sports Medicine Sports Medicine Sport Specialization – Play More Sports Professional baseball players who participated in multiple sports in high school played in more major league games and experienced lower rates of upper and lower extremity injuries than players who played only baseball in high school. Orthopaedic Journal of Sports Medicine. July 2019: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6661792/ Sports Medicine Discussion/Questions???