COMMON

Victor Felix S. ACUTE AND

OVERUSE
Gaddi, MD
Orthopedic
Consultant
Philippine Sports INJURIES IN THE
Commission
PEDIATRIC
ATHLETE
•Introduction
•Risk factors
•Common Acute Injuries
•Common Overuse Injuries
•Head Injuries
•Cervical Spine Injuries
•Heat-induced Conditions
•Management
 INTRODUCTION
•Physical activity plays a
significant role in the well-being
of a child
•A well-designed exercise
programme enhances the
immediate physical,
psychomotoric and intellectual
attainments of a child
Shephard RJ (1984) Physical activity and child health. Sports Med, 1,
205–233.
• Last two decades - competitive
sports participation has become
an established feature of
childhood in Western countries
• The past decade - explosion in
the number of children
participating in team and solo
sports
INCIDENCE OF KIDS INTO SPORTS
• In the UK, 79% of children aged between 5 and
15 take part in organized sport
• 11% of whom are involved in intensive training
• In the USA, up to 50% of boys and 25% of girls
between 8 and 16 years take part in organized
competitive sport
• Approximately 3–11% of school children are
injured per year
• Twice as many boys as girls sustain sports related
injuries
Chezhiyan Shanmugam and Nicola Maffulli. British Medical Bulletin 2008;
86: 33–57
IN THE PHILIPPINES…
• PALARONG PAMBANSA
• annual multi-sport event involving
student-athletes from 17 regions of
the Philippines
• The event, started in 1948, is
organized and governed by the
Department of Education
 YOUTH SPORTS ACTIVITY AND YOUNG PEOPLE’S WELL-
BEING AFTER A DISASTER: A TRIAL WITH THE MASTERY
APPROACH TO COACHING (MAC) IN THE PHILIPPINES
TAKESHI AKIYAMA, ERNESTO R. GREGORIO JR. & JUN KOBAYASHI
BMC RESEARCH NOTES VOLUME 11, ARTICLE NUMBER: 747 (2018)

• The Mastery Approach to Coaching (MAC)

• a coaching-education program that has been reported to have a
positive effect on young people’s personal and social development
through sports activities – self-esteem
• The study was implemented in Leyte from January to February
2015, approximately a year after the onslaught of Typhoon Haiyan
in November 2013
• 10th grade students (3 public schools; n=293), mean age=16.6 yrs;
Sport: Volleyball
• Intervention group = 51; Control = 242
• the self-esteem score on the post-intervention evaluation was
higher in the intervention group than in the control group
(p < 0.05)
• The intervention group showed a significant change in the self-
esteem, with the average score increasing from 20.2 to 21.1
(p = 0.02)
• At a young age, sport is for enjoyment and for
health and personal development

• Changes – competitive element intervenes

• Subsequently, young athletes train harder and

longer and participate in sport throughout the
whole year significantly increased sports-
related injuries
• Schmidt and Hollwarth
• compared the frequency of sport injuries
according to their location
• 43.8% in the upper extremity
• 34.5% in the lower extremity
• 16% in the head
• peak at the age of 12

Schmidt B, Hollwarth ME (1989) [Sports accidents in children and

adolescents]. Z Kinderchir, 44, 357–362
 RISK FACTORS/ VULNERABILITY TO
INJURY
•Growth plate vulnerability
•Adolescent growth spurt
•Differences between
biological & chronological
age
•Differential growth
 GROWTH PLATE VULNERABILITY
• Vulnerability of growth plates to
shearing injury (at the
epiphyseal-metaphyseal
junction) growth plate
fractures
• Vulnerability of apophyses to
traction and strong muscle
contractions apophysitis
or avulsion injuries
Donna L. Merkel and Joseph T. Molony. The International Journal of
Sports Physical Therapy. Volume 7, Number 6 . December 2012. 691-704
ADOLESCENT GROWTH SPURT
• Increased bone
length, but not so
much bone
strength
• MSK imbalance
• Tight ligaments and joint
capsules
• Inadequate
neuromuscular control
• Awkward/ gangly
movements
DIFFERENCES BETWEEN BIOLOGICAL
AND CHRONOLOGICAL AGE
• Chronological age: the age in years between birth
and the evaluation of a subject;
• Bone age: the age expressed in years that
corresponds to the level of maturation of bones
• based on the presence of particular centers of bone
formation as well as the dimension and structure of
the bones
• Bone age may be affected by several factors,
including gender, ethnicity, nutrition, as well as
metabolic, genetic, and social factors and either
acute or chronic diseases, including endocrine
dysfunction
Cavallo et.al. Frontiers in Pediatrics 2021
RISSER
 DIFFERENTIAL GROWTH
• Differential growth of the body segments
(head, trunk, and lower extremities) occurs
throughout growth and influences body
proportions accordingly
Malina RM, Bouchard C, Bar-Or O: Growth, maturation and physical
activity. 2nd edition. Champaign: Human Kinetics; 2004

• Child
• proportionately larger head and trunk, and
shorter legs compared with an adult.
• This “top-heavy” characteristic could predispose
the young athlete to increased risk of injuries
Maffulli N, Caine D: The Younger Athlete. In Clinical Sports Medicine. 4 th edition. Edited
by Brukner P, Khan K. McGraw-Hill: Sydney; 2012
 OTHER FACTORS
• A history of amenorrhea is a significant risk
factor for stress fractures
• Female athlete triad
• Higher training volumes/ Too much workload
have consistently been shown to increase
the risk of overuse injury in multiple sports
• Training more than 16 hours per week was
associated with a significantly increased risk of
injury requiring medical care

Rose MS, Emery CA, Meeuwisse WH. Sociodemographic predictors of

sports injury in adolescents. Med Sci Sports Exerc. 2008;40:444–450.
• Improper equipment
• Poor training facilities
• Previous injury
• Poor nutrition
 ACUTE VS OVERUSE
• Acute • Overuse
• Macrotraumatic event • Microtraumatic/
• Presentation NOT repetitive
delayed • Insidious onset
• Clear MOI • Exact identification of the
• Pain, swelling, deformity anatomical area injured
can be difficult
• TX: RICE, PT, Surgery
(possible) • TX: relative rest, referral
for specialist assessment is
advisable
Source: John P. DiFiori, MD et.al. Clin J Sport Med
2014;24:3–20
 COMMON ACUTE INJURIES
• Fractures (Salter - Harris): physeal fractures

*6-30 % of all childhood fractures

*Growth arrest occurs in 15% of those growth plate injuries
*Risk factors that impact growth arrest: severity of injury, age, skeletal
maturity, and anatomic site
Torus Fracture Avulsion Fracture
FOOSH: FALL ON OUT-STRETCHED
HAND
 Torus fractures
• Distal radius; most common
• 6-12 years old
• FOOSH injury
• TX: conservative
 UPPER EXTREMITY
• Supracondylar fractures
• most common elbow fracture sustained by children <10 y/o
• > 50% of all elbow fractures
• FOOSH injury; extension type
• swelling, localized pain, tenderness, and depression over
the triceps area
• Elbow dislocations
• more common among 13 and 14
year old athletes when the distal
physis begins to close
• MOI: FOOSH w/valgus positioning
• Non-Sx Tx
• Distal humeral lateral condyle
fractures
• second most common
fracture of the elbow region
• FOOSH injury
• most are treated surgically,
unless the degree of fracture
displacement is less than two
millimeters (< 2mm)
• Medial epicondyle avulsion
fracture
• often in teenage boys,
• during late cocking and
acceleration phases of
throwing
• Non-surgical treatment
parameters:
• are minimal to no
displacement
• Absence of valgus
instability
• no ulnar nerve
involvement
• Sx: >5mm displacement
• PT: Flexor-pronator
strengthening
 UPPER EXTREMITY
• Clavicle fractures
• 10–15% of all childhood fractures
• Midshaft
• Result of a direct blow to the lateral aspect of the
shoulder
• pain on shoulder elevation and horizontal
adduction
• “Figure 8” harness or arm sling for two to four
weeks
• Shoulder dislocations
• common in the
adolescent
• Mechanism of
injury: indirect
blow to the arm
positioned in
abduction,
external rotation
and extension
• High re-
occurrence rates
in athletes under
the age of 20
REDUCTION TECHNIQUES FOR
SHOULDER DISLOCATIONS
 LOWER EXTREMITIES
▪ ACL Tear
 MOI: valgus
deceleration, internal
rotation
 ligament fails in tension
 Femoral attachment
 Females: 4 to 10 fold
increased risk
 Poor landing mechanics
 Muscle balance
 Anatomy: narrow notch,
wider hips, genu valgus
• Immature sensory motor function
• Increased risk for ACL injury
• “...neuromuscular control of knee
motion and landing forces is
significantly worse in females than in
males during the transition from
prepubertal to pubertal stages...”
Ford KR, Myer GD, Hewett TE: Longitudinal effects of maturation on lower
extremity joint stiffness in adolescent athletes. Am J Sports Med 2010,
38:1829–1837.
Hewett TE, Myer GD, Ford KR: Decrease in neuromuscular control about
the knee with maturation in female athletes. J Bone Jt Surg Am 2004,
86-A:1601–1608.
Quatman CE, Ford KR, Myer GD, Hewett TE: Maturation leads to
gender differences in landing force and vertical jump performance:
a longitudinal study. Am J Sports Med 2006, 34:806–813.
 • ...study of high school athletes,
female soccer players were
found to have the highest rate
of ACL injury, with an incidence
of 14.08 per 100,000 exposures;
male football players had the
second highest rate, with 13.87
injuries per 100,000 exposures...
Comstock RD, Collins CL, McIlvain NM: Summary Report: National High School Sports-related Injury
Surveillance Study. 2009-2010 School Year. Available at: http://www.nationwidechildrens.org/
Document/Get/103353. Accessed November 9, 2012
LOWER EXTREMITIES
• Tibial spine avulsion
fractures
• in youth athletes
between the ages of
8 and 14 when the
incomplete ossified
tibial spine fails due
to excessive stress
placed on the ACL
• MOI: same as ACL
injury
 PATELLAR DISLOCATIONS
• Fithian et.al
• In athletically active, female adolescents
 MECHANISM OF INJURY
• Internal rotation of the femur on a fixed
externally rotated tibia
• Direct blow to the medial side of the
knee
• feeling or hearing a “pop” with
concurrent knee buckling

Spritzer et.al. AJR, 1997(168): pp 117-

122
 CONSIDERATIONS IN EVALUATION
OF PATIENTS WITH PATELLOFEMORAL
INSTABILITY
Dynamic Factors Static Factors

Quads/ VMO MPFL

Hip abductor strength Trochlear Groove

CORE stability Alignment (Q-angle; TT-TG distance)

Patella alta

Bollier, Fulkerson, Cosgarea &

Tanaka. Arthroscopy 2011
•PE
• Lateral
patellar
apprehension
test is positive
• tenderness
• swelling
• limitation of
motion
• Moving Patellar
Apprehension
Test
CLOSED REDUCTION OF PATELLAR
DISLOCATION
 TREATMENT
• Conservative treatment
• consists of two to four weeks of knee
immobilization
• PT: quadriceps (VMO) strengthening
and improved patellar tracking
• Surgery
• Failed conservative TX
 SH TYPE 1 OF LM VS
ANKLE SPRAIN
• SH Type 1 of LM
• Inversion injury
• Mistaken for a sprain
• (+) Tenderness 2cm
above the tip of lateral
malleolus
• most common acute
injury of the adolescent
foot and ankle
• TX: immobilization with a
short leg walking cast for
3 to 4 weeks
• Lateral ankle sprain
• 2nd most common/
predominant injury
in a child’s lateral
ankle
• tenderness over the
ATFL or the CFL
REHAB &
PREVENTION
Rehab Program
Grade

1 Brace 1-2 weeks, then with activity prn; ROM as

soon as pain allows; then strengthening and
proprioception exercises as soon as pt tolerates.
Key is appropriate follow up!

2 Brace 2-4 weeks; Exercises as above.

3 Pneumatic walker boot for up to 4-6 weeks, then

brace with activity. Exercises as above.
Consider casting especially with concomitant
fractures. Recovery may take 3 months or more.
 COMMON OVERUSE INJURIES
•Due to repetitive submaximal
loading/microtrauma of the
musculoskeletal system
•Rest is not adequate to allow
for structural adaptation to
take place
 OSGOOD-SCHLATTER DISEASE
• Stress fracture of apophyseal
cartilage of the tibial tubercle
• Traction forces – patellar tendon
• Tight hams, weak quads
• Girls: 8 -13 years ; Boys: 10 – 15
years
• M:F = 2:1
• In running &
jumping
athletes
• Tibial tubercles
may or may
not be
enlarged, but
are tender
• TX:
Immobilization,
PT, rest
 SEVER’S APOPHYSITIS
• Inflammation of the
calcaneal apophysis,
known as Sever’s
disease
• one of the most
common overuse
injuries in the young
athletic population
• Pain is at the heel,
particularly, with
running and jumping
 TREATMENT
• Stop offending activity
• Comprehensive heel cord stretching and
dorsiflexor strengthening program
• Ice and pain meds
• Avoid barefoot walking
• Heel insert or a heel lift
 LITTLE LEAGUER’S ELBOW
• Usually with sensitivity around
medial epicondyle
• Due to microinjuries at the
apophysis and ossification center
• Presents with medial epicondylar
fragmentation, and possibly
avulsion
 TREATMENT
• Rest
• PT
• Evaluate
throwing
technique
• Gradual return
to throwing
• ...SURGERY...
 LITTLE LEAGUE SHOULDER
• Shoulder pain
• Throwing more than 75 pitches in a game
• Throwing more than 600 pitches in a season
• Pitching with arm fatigue

Lyman S, Fleisig GS, Waterbor JW, et al. Longitudinal study of elbow

and shoulder pain in youth baseball pitchers. Med Sci Sports Exerc
2001;33:1803–10.

Olsen SJ II, Fleisig GS, Dun S, et al. Risk factors for shoulder and elbow
injuries in adolescent baseball pitchers. Am J Sports Med 2006;34:905–12

Lyman S, Fleisig GS, Andrews JR, et al. 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;30:463–8.
• Epiphysiolysis
• caused by the rotational
stress placed on the
proximal humeral
epiphysis during
overhead throwing
• Age: 13 - 16 years
• Diffuse shoulder pain
aggravated with throwing
(recent increase in throwing
regimen)
• PE
• tenderness and swelling over the
anterolateral aspect
• weakness to abduction and internal
rotation
• decreased external and internal range of
motion
 TREATMENT
• Protocol
• Refrain from throwing until symptoms
resolve
• 2–3 months
• Appropriate pitching mechanics
• Rotator cuff and periscapular
strengthening and capsular stretching
exercises
Kocher MS, Waters PM, Micheli LJ. Upper extremity injuries in the paediatric athlete. Sports Med
2000;30:117–35.
 SPONDYLOLYSIS
• Stress fracture
• Unilateral or bilateral defect
(separation) in the
• vertebral pars interarticularis
• Evident on radiograph as a crack or
‘collar’ on the neck of the “scotty dog”
(detects up to 30%)
Source: The Sports Medicine Core Curriculum Lecture Series Sponsored by an ACEP Section
Grant
Author(s): Timothy Rupp, MD FACEP, FAAEM and Jolie C. Holschen, MD FACEP
Editor: Jolie C. Holschen, MD FACEP
 SPONDYLOLYSIS
• 47% of young
athletes sports
clinic w/ Low
Back Pain
• Mechanism:
repetitive pars
overload in
extension
• Pain increases
with lumbar
extension
• TX:
• Bracing and
exercises
• Surgery – if
persistently
symptomatic
 PREVENTION
• From a practical point of view the most important
factor in preventing overuse injury is to correct training
errors. The general rules include the following:
• Only increase distance, intensity, surface, new equipment, or
types of training one at a time.
• Only increase one aspect of distance, time, or intensity by
10% a week
• Ensure adequate time for recovery within the training
schedule, for example, days off, light days, and cross training.
• Keep a training log and follow the training schedule
• Monitor heart rate, weight and sleep quality.
• An increase in resting heart rate more than 10% or a sudden
change in weight or sleep quality indicates that the body might
be stressed and need more recovery time.
 PREVENTION
• Limiting weekly and yearly participation time, limits on
sport-specific repetitive movements (eg, pitching limits),
and scheduled rest periods are recommended
• Careful monitoring of training workload during the
adolescent growth spurt
• Preseason conditioning programs can reduce injury
rates in young athletes
• Pre-practice neuromuscular training can reduce lower
extremity injuries
• Proper sizing and resizing of equipment
• Emphasize skill development more than competition

John P. DiFiori, MD et.al. Clin J Sport Med

2014;24:3–20
 STRENGTH TRAINING
• Development and maintenance of muscle strength
and endurance
• important in attaining peak bone mineral density and
bone mass,
• improving body composition, cardiorespiratory fitness,
blood lipids, performance of daily living activities, and
physical performance in recreational or competitive
activities

• Key: Individualization
 HOW STRENGTH TRAINING
DEVELOPS STRENGTH IN
CHILDREN
• In children, neural factors such as the coordinated
recruitment of motor units, increased number of motor
units recruited, improved firing rate or firing pattern of
activated motor neurons, and improved coordination
are responsible for strength gains resulting from strength
training (6, 10, 16).
• Increased neural response also may prevent or
decrease the severity of injury in activities of daily living
and other sports
• Increase in muscle mass – dependent on circulating
testosterone levels (higher in adolescent males)
• A well designed, 8 to 12 week strength training program
can produce significant (30% to 50%) gains in strength
 DOES STRENGTH TRAINING
CAUSE INJURIES IN
CHILDREN
• Possible
• Overloaded with load and number of reps
• Growth plate fractures that have occurred during
strength training have been attributed to misuse of
equipment, improper lifting technique, lifting
inappropriately heavy weight, or training in unsupervised
settings
Faigenbaum A.D, W.J. Kraemer, B. Cahill, et al. Youth resistance training: Position statement
paper and literature review. Strength and Conditioning 18:62–75, 1996.

Pearson, D., A. Faigenbaum, M. Conley, and W.J. Kraemer. The National Strength and
Conditioning Association’s basic guidelines for the resistance training of athletes. Strength
and Conditioning Journal 22(4):14–27, 2000.
POTENTIAL BENEFITS
OF STRENGTH
TRAINING

Vehrs. ACSM Health & Fitness Journal 2005

STRENGTH TRAINING
 STRENGTH TRAINING

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Injury Prevention
The FIFA 11+ warm-up has been
shown to substantially reduce
major injuries, particularly in
females between the ages of 13-
18 who have a high risk of knee
and ACL injury, by 50% and a
reduction of 39% of overall injury
incidence in recreational/sub-
elite football.

The program is only effective

when the warm-up exercises are
performed regularly, at least
twice a week.

Compliance is of utmost
importance—injury risk is lowest in
those players with higher
adherence to the program.
 HEAD INJURIES
• Loss or alteration of consciousness
• Confusion, disorientation
• In children: 30 % sports related
• MOI
• Acceleration of the brain in a closed
space from sudden contact
compressive, shearing, tensile forces
 HEAD INJURIES
• Concussion
• Most common head injury encountered by team MDs
• “..trauma induced alteration of mental status that may or
may not involve loss of consciousness..”

• Hallmarks: Amnesia & Confusion

• Retrograde, anterograde

Kelly et.al. Concussion in Sports: Guidelines for the prevention of

catastrophic outcome. JAMA 266: 2867-2869, 1991
CEREBRAL CONCUSSION
GLASGOW COMA SCALE
• Interpretation:
• Severe TBI: score
of 3-8
• Moderate TBI:
score of 9-12
• Mild TBI: score of
13-15

TBI: Traumatic Brain Injury

 CONCUSSION SEVERITY GRADING

Source: Luke A and Micheli L. Sports Injuries: Emergency Assessment and Field-side Care. Pediatrics in
Review 20(9):291-302, 1999
 NUMBER AND SEVERITY OF CONCUSSIONS IN
SINGLE SEASON PRECLUDE FUTURE
PARTICIPATION THAT SEASON

GRADE 1 GRADE 2 GRADE 3

3 2 or 3 1 or 2
 SCAT 5 (SPORT CONCUSSION
ASSESSMENT TOOL 5TH EDITION)
Source: Neidecker J, et al. Concussion management in combat sports: consensus statement from the
Association of Ringside PhysiciansBr J Sports Med 2019;53:328–333
 RETURN TO PLAY GUIDELINES

Grade 1 (mild)

Source: Luke A and Micheli L. Sports Injuries: Emergency Assessment and Field-side Care. Pediatrics in
Review 20(9):291-302, 1999
 WHY CHILDREN ARE AT
RISK?
• Second Impact
Syndrome
• Primarily < 21 years old
• Severe brain swelling
W/O intracranial mass
lesion (vascular
engorgement) after
repetitive head
trauma
• Cerebellar herniation
then Respiratory
failure
• Rapid: 2-5 minutes
 Neck Injuries
• More than half of catastrophic injuries in
sports are cervical spine injuries

• Most contact sports: football, hockey,

rugby, and wrestling

• Several noncontact sports: skiing, track

and field, diving, surfing, power lifting, and
equestrian events
 DIFFERENCE
BETWEEN ADULTS
AND CHILDREN

• Fulcrum of C-spine is higher in kids:

C2-C3
• Higher levels of C-spine
fractures
• SCIWORA (Spinal Cord Injury
without Radiographic
Abnormality)
• Ligamentous laxity and
numerous ossification centers
• 15-20 %
• More odontoid fxs in kids due to
incomplete ossification
MANAGEMENT
HEAT ILLNESSES
• More common
in summer
months/ warm
climates
• Children: at risk
even when
adequately
conditioned
 PHYSIOLOGY OF TEMPERATURE
REGULATION
Exercise:
metabolic
activity &
muscle
contraction

Dissipation of
heat to
environment Heat: stored in
via deep tissues
convection
and radiation

Vasodilation:
Increased
Increased Core Body
blood flow to Temperature
skin

Increased heart rate to increase cardiac output

(CO)
 DIFFERENCE BETWEEN ADULTS &
CHILDREN
• Exercising children are • Smaller respiratory &
more vulnerable to heat circulatory systems, hence
injury less efficient and less able
• Produce more metabolic to adapt to exercise
heat mass per unit when • Smaller mass-to-surface
walking/ running area ratio, thus more heat
• Core temperature rises transfer during hot weather
faster during dehydration • Do not instinctively or
• Rate of acclimatization is voluntarily drink enough
slower liquids
• Dehydration insufficient circulatory
volumes increases risk of heat
related problems

• Elevated humidity + increased

environmental temperature
decreased heat loss Fatal heat injury
in 20 min.
 ON FIELD MANAGEMENT
• ABCDE
• Vital signs
• Assess skin for perspiration
• Heat exhaustion: moist skin
• Heat stroke: dry skin
• ???ecchymosis or epistaxis: may
suggest DIC
SIDELINES MANAGEMENT
• Rehydration
• Cool shady area
• Elevate legs
• Spray with mist of
water
• Heat cramps:
massage and
stretching
•IV access if unable to drink
•Ice packs: axilla, groin, nape
•Heat stroke
• Rapid cooling
• Ice bath
• Evaporative cooling
• Intubate if comatose
 PREVENTION
• Acclimatization training for at least 2 weeks
• Assess temperature and humidity
• Appropriate clothing
• WATER available
• Drink before the event
• Water breaks every 20-30 mins
• 150 ml q 30 min = 40kg child
• Weigh after practice
• Each 0.45 kg weight lost, replaced by 473 ml of fluid
 TAKE HOME MESSAGE
• Weaker bones
• “Weakest Link”
• Stronger joint ligaments
• Gangly movements/ “Lampa”
• Nutrition is important
• Proper conditioning, strength training, technique,
equipment
• “Drink, Drink, Drink”
• “WATCH YOUR HEAD AND NECK”
• Second Impact Syndrome
• SCIWORA
 L TS
D U
L A
AL
S M
O T
E N
A R
E N
DR
HIL
C