Injury & Rehab
Managing injuries in younger clients
While sedentary behaviour is a blight to the health of many young Australians, others are incredibly active – and consequently suffer overuse and trauma injuries. With correct identification and management they will soon be back out on the field, says Adam Floyd.
For most physiotherapists the onset of the winter months sees a flood of winter sports injuries through the clinic doors. Last year I treated what felt like a much larger number of young people, aged eight to 16 years, with both overuse and traumatic injuries. Overuse injuries were particularly prevalent.
We’re bombarded by news and statistics about kids spending too many hours in front of computer and video game screens, but I also see lots of kids at the other end of the spectrum – sporty kids, like my two older boys (aged eight and 10), who seem to have something on every day of the week, as well as weekends, leaving little recovery time for young bones, tendons and muscles.
There also seems to be an Australia-wide trend of young people training with personal trainers, particularly among those who are less involved in sport (see Key considerations when training kids). There are kids as young as 13 exercising with trainers in our gym. While young people are certainly more resilient than adults, there are some common conditions and injuries that every personal trainer should be aware of.
Overuse injuries unique to children
By far the most common complaint among sporty 10 to 16-year-old kids (boys more often than girls) is tractional apophositis. An apophosis is a bony projection, and in tractional apophositis is where the tendon attaches. Repeated stress (running and jumping) during a growth spurt causes this area to become inflamed and, sometimes, quite swollen. In adults this would result in a tendonitis, but in adolescents the problem develops in the tendon/bone junction, which is the softer/weaker area. The two most common areas at which this occurs are the attachment of the patella tendon to the tibial tuberosity below the knee, called Osgood-Schlatters disease, and where the Achilles meets the calcaneus (heel bone), known as Severs disease.
These conditions are defined as ‘self limiting’. The theory is that the restrictive nature of the injury will force the child to reduce the amount of sport they undertake by enough to not cause any permanent damage to the area. In other words, the pain will force them to reduce the load. In practice, I usually find myself negotiating with the sporty child about giving up one of the two or even three sports they currently play. Rarely do they need to cease all activity, and indeed it is not reasonable to expect an active child to do so. What they do need to do is manage the condition for around one to two years, after which time they seem to essentially grow out of it (possibly when the growth plate fuses). On occasion I have encountered cases where the condition continued into the client’s late teens, but this is rare.
Treatment often involves ice after activity, use of an anti-inflammatory gel or medication and patient education. The use of a patella tendon strap or taping for Osgood-Schlatters is often very helpful. The provision of gel shock-absorbing inserts into the shoes of those with Severs can also provide pain relief during activity. Correction of any obvious biomechanical issues, such as severely pronated feet, should also be addressed.
With regard to stretching or strengthening, a thorough exploration of the literature failed to uncover a single article examining these in regard to Osgood-Schlatters or Severs. I personally do not prescribe any stretching, as doing so would simply traction the area even further. I also don’t load them with any strengthening exercises in the acute phase, but have done so later on toward the resolution of the condition. Treatment is on a case-by-case basis as there is no gold standard other than education and activity modification. Diagnosis should be made by a qualified health professional.
Traumatic injuries unique to children
Besides the usual broken bones, sprained ankles and numerous unexplained bruises, there are some injuries unique to children that fitness professionals should be aware of. The most common of these are avulsion fractures.
Avulsion fractures are more common in children than adults. In adults, the ligaments and tendons tend to be injured, whereas in children the bone may fail before the ligament or tendon is injured. Children have a particularly weak point in their skeleton called the growth plate. This is the area of bone that is actively growing. In children, tendons or ligaments near a growth plate can pull hard enough to cause the growth plate to fracture. Avulsion fractures occur as a result of a forceful muscular contraction.
In young athletes it is not uncommon to avulse the hamstring tendon off the ischial tuberosity, or the rectus femoris tendon off the anterior inferior iliac spine (AIIS). Also fairly common are the sartorius from the anterior superior iliac spine (ASIS) and the ilio-psoas off the lessor tuberosity of the femur. If you suspect an avulsion fracture (client complains of a sharp pulling pain which occurred during a forceful activity and is limping) you should refer immediately to an appropriate health professional. Diagnosis is usually made via X-ray. Most are treated conservatively, and will take six to eight weeks to heal and return to full activity, but in some cases, where the bone has separated too far from its origin, surgical re-attachment may be considered.
Another condition to be aware of in children is a slipped capital femoral epiphysis, in which the growth plate slips off the top of the femur. The child will present complaining of groin and/or pain in the anterior upper leg extending as far as the knee, and they will be limping. Any child with suspected hip issues should be referred on immediately. Surgery to pin the growth plate is the usual outcome in this condition.
One of my son’s 9-year-old friends was also diagnosed recently with irritable hip syndrome. This condition is one of those medical anomalies that we really don’t know much about, but it is not dissimilar to frozen shoulder syndrome in adults in which the synovial lining of the joint becomes inflamed and restricted.
When it comes to managing pain in young people, it is worth remembering that kids will only complain of pain when there is an issue. So, if a younger client is complaining of a new pain which doesn’t resolve quickly, take it seriously and refer onto a physiotherapist as soon as practical.
Adam Floyd, BSc (Physio) BPE (Hons)
Adam is a Perth-based physiotherapist and exercise physiologist who runs the GymED series of seminars for fitness professionals. He produces a monthly injury management e-newsletter for fitness professionals which you can register for at www.adamfloyd.com.au