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Evaluation and Management of Sports Injuries in Children

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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
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