7/22/2016 Juvenile Osteochondroses Nathalie Gaulier, MD Sports Medicine Physician Cook Children’s Medical Center Definition . General term for disorders that affect one or more ossification centers in children . Encompasses traction apophysitis and avascular necrosis . Exact etiology unknown . Radiographic picture show pattern of fragmentation, collapse, sclerosis and reossification Apophysitis . Apophysis - secondary ossification center which acts as an insertion site for a tendon . Apophysitis usually develops due to chronic repetitive stress or traction . Usually occurs during growth spurts . Clinical diagnosis, though imaging may be helpful to rule out other conditions . General treatment includes rest, activity modifications, PT and play as symptoms tolerate 1 7/22/2016 Osgood-Schlatter’s . Affects tibial tubercle apophysis . Ages 10-14 . Up to 30% will have bilateral involvement . Usually due to repetitive traction of the patellar tendon . Insidious onset, though sometimes triggered by traumatic event . Self-limiting process. Treat with activity modification, stretching, NSAIDs Sinding-Larsen-Johannson . Affects inferior pole of patella . Ages 10-13 . Exacerbated by jumping or direct pressure . Treat similarly to Osgood-Schlatter’s. Can immobilize temporarily if symptoms severe enough 2 7/22/2016 Sever’s Disease . Affects calcaneal apophysis . Worse with activity, particularly at the beginning of the season or during growth spurts . Ages: 8-12, more common in males . Bilateral in 60% . Tenderness in calcaneus and at Achilles insertion site. Often with tight heel cords and weakness with dorsiflexion . Treatment with rest, ice, activity or shoe modification, heel cushions, heel stretches 3 7/22/2016 Iselin’s Disease . Affects base of the fifth metatarsal where the peroneus brevis attaches . Ages 8-14 . Usually insidious onset but may start after an ankle injury (inversion) . Point TTP at base, may be assoc with swelling, pain with resisted eversion or with passive plantarflexion/inversion . Self-limiting Traction Apophyses of the Hip . Hip and pelvis are sites of multiple apophyses . Ages: 9-15 . Apophysitis – more subacute presentation, localized pain worsened with activity . Avulsion injury – usually acute injury usually during forceful contraction during activities such as sprinting, kicking, hurdles, etc. Often athlete will report feeling a ‘pop’ and have immediate pain/difficulty walking 4 7/22/2016 Traction Apophyses of the Hip . Iliac Crest: abdominals (internal/external oblique and transversus) . ASIS: sartorius . AIIS: rectus femoris . Greater Trochanter: gluteals . Lesser Trochanter: iliopsoas . Ischial Tuberosity: hamstring . Inferior pubic ramus: adductors 5 7/22/2016 Little Leaguer Shoulder . Injury to the proximal humeral physis due to repetitive stress . Mimics a Salter Harris I fracture . Males ages 11-14 . Presents with pain with overhead throwing, decreased throwing velocity, accuracy and distance . Point TTP over humeral physis, painful ROM Risk Factors . Inadequate rest . Playing for multiple teams . Pitching while fatigued . Excessive throwing while not pitching . Throwing curveballs and sliders at a young age . Showcases . Use of radar guns 6 7/22/2016 Treatment . REST!!! . PT and progressive throwing program . Correction of pitching mechanics . Education on prevention Medial Epicondyle Apophysitis . “Little Leaguer Elbow” . Usually due to repeated valgus stress (pitchers) . Presents with pain, decreased velocity . Typically normal radiographs . Acute presentation may indicate avulsion fracture or UCL sprain . Treatment rest and PT, work on throwing mechanics 7 7/22/2016 Legg-Calvé-Perthes . AVN of femoral head . Usually occurs in children aged 4-10 . 4:1 male predilection and up to 20% bilateral . Unknown cause . Classic presentation is painless limp and limited ROM . Treatment usually involves rest, off- loading and PT to preserve ROM . Younger age of presentation correlates with better prognosis Panner Disease . Affects capitellum . Thought to be related to lateral compression overuse injury . Ages 5-12, more common in males . Presents with lateral elbow pain worsened with activity, may have stiffness/decreased ROM . Treatment: activity modification, NSAIDs 8 7/22/2016 Freiberg Disease . Affect the head of the second metatarsal . Causes pain in forefoot, exacerbated by weight-bearing and athletic activities . Often seen in adolescent females and dancers . Bilateral in <10% . Treatment: activity modification, metatarsal pads, and well-padded shoes Köhler’s Disease . Affects tarsal navicular . Uncommon. Affects children aged 5-10 . Can present with persistent mid-foot pain and antalgic gait . Conservative management References . Andrews JR, Fleisig GS. Preventing throwing injuries. J Orthop Sports Phys Ther. 1998;27:187-188 . Binek R, Levinsohn EM, Bersani F, Rubenstein H. Freiberg disease complicating unrelated trauma. Orthopedics. 1988;11(5):753. Greiwe RM, Saifi C, Ahmad CS. Pediatric sports elbow injuries. Clin Sports Med. 2010 Oct;29(4):677-703. Kraft DE. Chronic foot and ankle injuries. In: Care of the Young Athlete, 2nd ed, Harris SS, Anderson SJ (Eds), American Academy of Orthopedic Surgeons and American Academy of Pediatrics, Park Ridge 2010. p.457 . Lyman S, Fleisig GS, Andrews JR, Osinski ED. Effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers. Am J Sports Med. 2002 Jul-Aug;30(4):463-8. Madden, Putukian, et al. Netter’s Sports Medicine. Philadelphia: Saunders. 2010 . Weinstein SL. Legg-Calvé-Perthes syndrome. In: Lovell and Winter's Pediatric Orthopaedics, 6th ed, Morrisy RT, Weinstein SL (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1039. 9 .