Eric Small, M.D, dicusses growth related musculoskeletal issues in children

1. ERIC SMALL, MD, FAAP
Medical Director of Sports Medicine
Apophyseal Injuries:
Growth Related Musculoskeletal Issues
March 31, 2016

2. ERIC SMALL, MD, FAAP
Former Chair, Council on Sports
Medicine and Fitness
American Academy of Pediatrics
Westchester Health Associates
Assistant Clinical Professor of Pediatrics, Orthopedics,
and Rehabilitation Medicine
Mount Sinai School of Medicine, NY, NY
914-666-7900
email: drericsmall@gmail.com
website: www.drericsmall.com

3. Outline
• Definition/Background
• Case Studies
• Prevention

4. Differential Diagnosis
• Benign Musculoskeletal Pain of Childhood
• Hypermobility Syndrome
• Apophysitis/Apophyseal Injuries

5. Benign Musculoskeletal Pain of Childhood
• Pain does not occur with activity
• Pain usually occurs at night
• Pain of the thighs, knees, or calves
• Pain is relieved with massage and OTC
• Active child/PE is normal

6. Hypermobility syndrome
• 5-10% of population
• Females greater than males
• Genu Recurvatum/Elbow
hyperextension/Marshall
stage V for thumb
opposition

7. Apophyseal Injuries
• Muscle/tendon/bone friction/inflammation
• Severity of pain related to muscle imbalances,
tightness, and specific sports and movement
patterns
• Extremely common but not often talked about

8. Benign
Musculoskeletal
Pain/Growing Pains
Apophysitis/Apophyse
al Injury
Hypermobility
Syndrome
At night During/After Activity During activity and at rest
Less than 10 years of age 10-16 6-18
No swelling Swelling and pinpoint
tenderness
No swelling, diffuse
tenderness
Massage and NSAID’s Decrease Impact
activity/Flexibility/Core
strength
Core strength/Postural
training

9. Examples
• Sever’s Disease
• Iselin’s Disease
• Osgood Schlatter
• Sinding Larsen
Johanssen Syndrome
• Hip Apophysitis

10. 11 year old boy presents with 2 week history of
bilateral heel pain (right greater than left).
He is now limping every day toward the end of
the day.

11. Sever’s Disease
• Calcaneal Apophysitis
• Boys/Girls 9-12
• Tight hamstrings/calves
• Running especially in
cleats
• Tanner I-II

12. Teaching Points
• 1/3 of patients will develop hip pain in 2-3 years
• If stretching/strengthening is not instituted pain may
persist for up to two years
• With proper exercise pain becomes minimal 1
month into treatment.

13. Sever’s Disease Other Points
• 1/3 will develop Osgood Schlatter in 1-2 years
• 1/3 will develop Hip Avulsion Injury/hip apophysitis
in 2-3 years

14. Physical Exam
• Pain at distal 1/3 of
Achilles
• Check out you tube
video

15. Management
• Decrease running by 50%
• Calf/hamstring stretches 3-
4 times per day
• Introduce biking/elliptical

16. Teaching Points
If pain/stiffness occurs at rest or upon
awakening then think of rheumatologic
problems, lyme.

17. 12 year old figure skater presents with lateral
foot pain.
Her foot hurts her with inversion/eversion.

18. Iselin’s Disease
• 5th metatarsal apophysitis
• Peroneus Brevis inserts into the 5th metatarsal
(responsible for foot eversion)

19. Iselin’s Disease
• 5th metatarsal
apophysitis
• Boys/Girls 9-12
• Strong ankle
inversion/weak eversion

20. Iselin’s Syndrome

21. Management
• Taping
• Walking boot
• Eversion strengthening
• Balance training
• Dorsiflexion
stretching/strengthening

22. 13 year old boy presents with a painful bump
below his knee.
It hurts him when he runs, jumps, and squats.
He is limping toward the end of the day.

23. Osgood Schlatter Disease
• In peak growth spurt (9-12 girls, 12-15 boys)
• First described in 1903
• Tanner III-IV
• Related to how much running, jumping, and
squatting

24. • Mild-minimal widening
• Moderate
• Severe
Severity of Tibial Tubercle Separation

25. OSD Physical
• Pain at anterior tibia
tubercle
• Tight in hamstrings (SLR 30
degrees)
• Check out YouTube video

26. OSD MANAGEMENT
• Hamstring/Quad Stretches 3 - 4 times per day
• Cho-pat Osgood Schlatter Band
• Neoprene Knee sleeve with patella cut-out
• Do not immobilize
• Biking and swimming encouraged

28. 10 year old with anterior knee pain
Has pain with running and jumping
At times no pain
At other times severe pain

29. • Ages 10-13
• Jumper’s Knee
• Pain at inferior pole of patella
• Basketball, soccer, gymnastics, figure skating
• Tanner I-II
Sinding Larsen Johanssen Syndrome

30. Management
• Make sure there is no avulsed fragment
• Neoprene knee sleeve
• Eliminate Jumping/Decrease running by 50%

32. 15 year old girl with anterior hip pain
Pain with running
Pain with kicking

33. Hip Apophysitis
• Ages 13-16
• Tanner IV-V
• Sprinting Sports
• Soccer, lacrosse, running to first base in baseball,
hurdles

34. Physical Exam
• Tenderness at iliac crest
• Tenderness at anterior superior iliac spine
• Tenderness at anterior inferior iliac spine
• Tight in hamstrings/hip flexion
• Weak in core, weak in hip abduction, adduction

35. Iliac Crest Avulsion Fracture

36. Hip Avulsion Fracture
• Anterior inferior iliac
spine
• Origin of rectus femoris
muscle

37. Interesting cases
Appendectomy
Exploratory Laparoscopy

38. Management
• No sprinting or kicking for 2-4 weeks
• Bike 3 times per day, hip flexor, hamstring, quad
stretching, core stability
• Ice afterwards

39. Other Teaching Points
• If have “Osgood Schlatter and Sever’s
at same time, think of JRA or spondyloarthropathy
• About 1% may morph into complex regional pain
syndrome.

40. Prevention Strategies
• Do not play two sports teams in the same season
(especially soccer, lacrosse)
• Avoid excessive running in cleats
• Allow 2-3 days off from sport per week
• Consider taking 1 week off

41. Prevention Strategies II
• Consider switching positions: ie. Catcher to
outfield-midfield to defense
• Do not premedicate with antiinflammatories
• Do not play with a limp

42. Thank you and good
luck!!!
Have a good season!!!

43. ERIC SMALL, MD, FAAP
Former Chair, Council on Sports
Medicine and Fitness
American Academy of Pediatrics
Westchester Health Associates
Assistant Clinical Professor of Pediatrics, Orthopedics,
and Rehabilitation Medicine
Mount Sinai School of Medicine, NY, NY
914-666-7900
email: drericsmall@gmail.com
website: www.drericsmall.com

44. Eric Small, MD
Pediatric Sports Medicine
666 Lexington Ave
Mount Kisco, NY
Email: drericsmall@gmail.com
914-666-7900