Dr. Jeff Sellman, Younger Athletes

Particular talk this starts and talks about children our children are just small adults right. Of course every medical talk has to talk that way. But no they’re not. And that’s why we do this, it’s a pretty meaty. We’ll be whipping through it kind of quickly so look at these slides later for those of you in the field so that you know what you’re looking for and what are kind of unique to children themselves. Very important obviously topic because as kids get more and more involved in sports. And specifically, as kids get more and more involved in one sport all year round, we are seeing more and more chronic conditions or chronic injuries that used to exist only in the older population and happening more and more often in the younger population. In addition to the fact that kids are getting hurt younger and younger there are certain stages. Obviously, children and adolescents and we tend to go define them as up to win the growth play closes which certainly can be 16 or above for most people the average age. Like I said is early teens but it does get younger and younger. Not only collision sports but also most contact sports are the ones that are involved. Why is the child not. Just a small adult.
Well each child obviously is growing but each child grows at a different rate for different body parts such that the torso or the arms may grow before the legs and they do not grow symmetrically top and bottom. Also, if you have a group or a soccer team that is an eleven and under or 11-year-old group an 11 year old boy who is born in January probably is a little less mature than someone who was born later than that. So but they’re playing on the same team. And there could be a huge number of discrepancies between the physical characteristics associated with the child. Of course, growth spurts are very important to think about in our clinics as we as family medicine physicians especially we get so lucky because we get to see everybody from birth until death or cradled until death. So we have to be kind of aware of all of these particular topics.
That is one of the questions to always ask a child or their parents is has the child had a recent growth spurt and then that will help delineate what you’re working differential diagnoses are. And of course in the young skeleton. Do we have more associated cartilage and bone than the actual ligament itself. Because the injuries to Carl I mean the cartilage in the bones themselves are a little softer. All right we’re going to go by region. We’re going to go buy the most common ones and then hopefully a little bit of what they. Present as in how they are treated. So impingement is usually internal impingement in the child itself associated with the capsule and a deficit in internal or external rotation. You’re going to see a swimmer all the time. It’s like the bane of our existence right and sports medicine swimmer comes in with shoulder pain you want to go hide off in the break room moreover in your nursing station and they use their shoulders all the time. So of course, there’s a lot of talking about how to go combat it. It’s really a management issue for swimmers.
But not overhead athletes because they have more likelihood of an acute injury multi directional instability back in the day multiple substations or dislocations or even just overall general laxity was treated surgically but we now know that’s not the preferred option and physical therapy physical therapy physical therapy is always the option for some multi directional instability literally your shoulder is just the inflammation of the proximal growth plate or the impetus of the humerus it is something that we see quite often and it’s almost like I prejudge my patients here. Twelve-year-old baseball player who comes in with shoulder pain. I’m going to come in and already have the diagnosis in my head which unfortunately is not always a good idea. But more than likely as is the case. So what happens in this. And a lot of parents will ask why can’t I get an MRI. Once again back to the MRI I would be careful what we order because of the outcome or the results. Number One Number Two. Is it going to affect or change our treatment plan. You get an overhead athlete with shoulder pain you have someone below the age of 18 16 conservatively.
You always get bilateral films so that you can compare that growth point and then you can make a slam dunk diagnosis itself. So the pure the right a humorous is on your left and the left shoulder is on your right. And as you can see the carpet assists itself is slightly widened or greatly widens leading to certainly a tremendous amount of lateral deltoid pain and a lot of pain with throwing. So then comes the uncomfortable conversation of stopping the early Greg Maddox from throwing for a few weeks or months before he can start throwing again. All right elbow pain, another one little leaguers elbow same thing. It is a growth plate abnormality associated with a distal humerus off the medial elbow pain. Sometimes you can see on physical examination an actual difference between the EPI can dial between the contra laterals elbow pain directly over it.
Once again a slam dunk. But what we always do is get in of course bilateral films with machines just a second. Another thing to consider is an Oscar controlled defect which is another reason why we get x rays and musculoskeletal problems because you get to start seeing things that may you thought oh gosh I didn’t know that was going to be there. But as you can see a little bit of the lighter lighter shade in the distal humerus there right at the heat Radiohead a little lesion or a little defect in the the cartilage that covers the end of the bone usually affects the capital them. Also associated with medium I’m sorry lateral elbow joint.
Pain. So here are the x rays and a little leaguer elbow with the humerus and the medial ethicists or the medial condyle. As you can see here the right a little bit wider than the left. Once again it’s very soft tissue so that ligament of parents are gonna be like oh my god his knees. Tommy John surgery. Oh no it’s just the ligament. I mean it’s just the growth plate that is inflamed. It is an inflammatory process. You treat the symptoms and it is generally not a surgical problem unless it becomes wider certainly more than two centimeters or there are loose bodies that you see floating around in there.
All right. The how we rehab it there’s always a there’s no cookie cutter recipe book cookbook out there. But what I always tell patients is that we’re going to we’re an individualize it to you but there’s always a period of rest and if you want to say for foreign four that’s perfectly fine and that would be four weeks of rest four weeks of a return to throw protocol away four weeks of physical therapy and then a four weeks of return to throw a protocol that is not set in stone. And but it gives them an opportunity. OK I might be out for 12 weeks or three months. And then if they’re back before that they get a little happy and a little giggly because they get to go back to the showcase over in Orlando in December core strengthening the most important. I mean we tend to forget this.
We always wonder why if my shoulder hurts my mom why it is my core gonna be strong. The biomechanics of the throwing motion of course is almost directly all directly related but the kinetic chain with the core itself. And that’s what supplies a lot of the torque associated with your upper extremity and the very unnatural throwing motion of a baseball player. So core strengthening I had I’ve had patients come back after you know the follow up after starting therapy and the like came and touched my shoulder but it’s a really great idea to start to start on the core itself. And there’s a return to throw program. Of course there’s a return to throw followed by return to mound. If you are a pitcher, if you’re just an overhead athlete, return to throw. We have those in our clinics if anybody was ever interested looking at those.
But the most important thing like Kevin alluded to in almost every musculoskeletal condition if you don’t take away or treat the underlying cause if there is a disassociation between how they’re pitching the bad biomechanics they’re going to come back with the same exact thing if they’re throwing something or throwing junk before they’re supposed to have a curve ball they’re going to come back with the same exact kind of injury itself. So a lot of times you stick suggests a pitching coach which they usually have one already which is already pitching them like a major league baseball player anyway but a pitching coach to really stress and reinforce proper mechanics associated with the pitching motion because a lot of times kids and they’re in their small musculature their youth they get tired easy when they throw too much tired a lot more quickly than an adult and then they’re mechanics really suffer.
And that’s when injury starts happening. All right. So hip pain once again once. Like our whole theme in this particular talk is we’re focusing mainly on the growth plates. So you have somebody who is sprinting suddenly pulls up and they had develop pain either anterior or posterior in the hip and you probably are a growth plate until proven otherwise. So when you have it involves an injury associated with the growth plate the anterior inferior iliac. Spide is the most common which I thought would actually be the issue to veracity associated with a hamstring. But the rectus femoris attaches to the eh eh I guess. And when they have tendered as directly to patient over that you just get an AP pelvis and you can compare each side once again when you see an elevation. If their point tender diagnosis of very mild when you see a difference in size you can diagnose obviously right then and then if it is certainly separated more than two centimeters sometimes that’s that is often when a surgeon becomes involved.
I had a patient last year who came to me for a second opinion because the surgeon said that you needed surgery and I took a picture I’m like yes you need surgery you probably would be more beneficial because in this particular case the issue tuberosity was pulled off three centimeters and it probably was not going to go back those very large put these disease is a year before pre-teen usually oftentimes a male but it’s where the flattening of the femoral head. Usually that surgery doesn’t happen until they become symptomatic which oftentimes is later in life in their late 30s I mean late 20s early 30s often but more we love saying the word SCFE Slipped capital femoral and that is the most common presenting or the most common person who presents this way as a pudgy dude. So a little kid who’s a little fat starts to develop being hip pain or all of a sudden had a pain in the hip itself.
You have this height differential but what is also very common is that it actually presents as knee pain or thigh pain. So don’t forget that things are actually related in the human body. And just because they have knee or hip pain doesn’t mean that another joint is affected. Don’t forget to examine and investigate the hip above. I mean the. Joint above and below. All right how do we rehab it. There’s a time of protected weight bearing. Put them on crutches if they have a limp so it’s usually crush them until they stop limping. They walk without pain. That’s when I have them start rehab with some stretching and once they have stretching then you start strengthening when they have an acute SCFE or with they skip you overall. It’s often a surgical management if it’s a progressive onset of pain they can just go and see the orthopedic surgeon in the next available but if it’s an acute injury that happened this morning, you’d probably have an emergent type issue with you.
All right knee pain knee pain. One of the things that is missing on here is another bane of these sports medicine physicians existence is teenage girl pain Patellofemoral syndrome which is so common and so is something that worth talking about off the slide a little bit in that you present most a lot of girls present with this and here knee pain once again unrelated to any injury and it doesn’t really have any mechanical symptoms associated with it. And what I have found it’s extremely difficult to treat. You’ll end up going down this path of a million-dollar workup and everything usually comes back normal. That then begs the question what is causing the pain. Well once again there’s a difference in structural and functional pain. So when she is moving likely is when she’s having the pain as opposed to a structural abnormality causing it.
So in this case you treat from the floor to the hip. And so oftentimes we’ll put somebody in arch supports which I rarely recommend actual orthotics that are custom made because those are four to six hundred dollars out of pocket. But really good over the counter arch supports and then hip abduction and hip strengthening with core strength thing oftentimes relieves knee pain 100 percent of the time. The two-apotheosis associated in the knee are the Oscars slaughter and the sending Larson Johansen which we most of us are all familiar with. All right once again rehab is symptomatic for most kind of knee injury and also the growth plates also symptomatic care ice heat topical anti inflammatory short term oral and go from there. Foot and ankle pain. Sievers disease is the most common. Most people think that when they come in that it certainly is an Achilles tendon issue when in fact it’s just the growth plate where the Achilles tendon is actually inserting.
Once again it is symptomatic relief and. Then a very aggressive stretching program for the calf. Musculature itself. Another topic that we don’t always talk about but very common in children most common thing associated with low back pain is just soft tissue and the very thing to stress is let them rest the relative rest is perfectly fine. But don’t let them have bed rest. Keep them moving some different modalities and go from there. The other thing that parents always ask about too is what if he has a herniated disk. Usually not the case is very rare in this age group but what is more. Common is the stress fracture of the past into particulars and that is commonly used to pop around different physicians too because it’s a very amenable to conservative treatment. All right we’re going gonna go through the rest of it because. It’s a long kind of a section and we are we’re out of time so we can get you out of here.