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05/18/2015
Adolescent
Sports
Medicine
Update
Objectives
X
Understand unique diagnostic and management
considerations of concussions in adolescents.
X
Review diagnosis and management of
adolescent specific musculoskeletal conditions.
X
Discuss answers to common questions parents ask
about exercise and sports participation in
adolescents.
AARON GRAY, MD
DEPARTMENTS OF FAMILY MEDICINE & ORTHOPAEDICS
UNIVERSITY OF MISSOURI.
Concussions
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05/18/2015
Missouri State Law
X
3. A youth athlete who is suspected of
sustaining a concussion or brain injury in a
practice or game shall be removed from
competition at that time and for no less than
twenty-four hours.
X
4. A youth athlete who has been removed
from play shall not return to competition until
the athlete is evaluated by a licensed health
care provider trained in the evaluation and
management of concussions as defined in the
guidelines developed under subsection 1 of
this section and receives written clearance to
return to competition from that health care
provider
Features of Concussion
XDirect
blow to head or elsewhere
on the body with an “impulsive
force transmitted to the head”
XRapid onset of short lived
impairment of neurologic
function that resolves
spontaneously
3rd International Conference on Concussion in Sport (Zurich, 2008)
McCrory, et al 2009 Clin J Sport Med 2009; 19:185-200
Definition
X
“a complex pathophysiological process
affecting the brain, induced by traumatic
biomechanical forces”
3rd International Conference on Concussion in Sport (Zurich, 2008)
McCrory, et al 2009 Clin J Sport Med 2009; 19:185-200
Definition
XMay
result in neuropathologic
changes, but the acute clinical
symptoms largely reflect a
functional disturbance rather
than a structural injury
XMay or may not include loss of
consciousness
XNo abnormality is seen on
standard structural neuroimaging
3rd International Conference on Concussion in Sport (Zurich, 2008)
McCrory, et al 2009 Clin J Sport Med 2009; 19:185-200
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Epidemiology
X
Epidemiology
Estimated 207,000 emergency room visits per
year for sports related traumatic brain injury
(TBI).
X Children
X
X Football
age 5-18 account for 65% of these visits.
X Girls’
Centers for Disease Control MMWR. 2007; 56;733-7
X
High School Sports Concussions
1.6-3.8 million estimated sports related TBIs
occur each year
40.5%
soccer 21.5%
X Boys’
soccer 15.4%
X Girls’
basketball 9.5%
X Many
do not seek care or are not treated by a
physician
Langlois J. J Head Trauma Rehab 2006.
Epidemiology
X
High School
X
X
Estimated 136,000 concussions per academic
year
544 concussions recorded in online
surveillance system during 2008-2009
X
57% involved in football
X
84% resolution of symptoms in 1 week
X
94% experienced headache
X
24% had amnesia
X
4.6% lost consciousness
Meehan et al AJSM, published online Aug. 17, 2010
Gessel et al. J Athl Train, 2007
Pathophysiology of
Concussion
X
Concussion results in a temporary
neuronal dysfunction not cell death
X
Complex neurometabolic cascade
occurs immediately and abnormalities
are found for at least 7 days after a
concussion occurs
Giza and Hovda J of Athl Training, 2001.
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Pathophysiology of
Concussion
X
Immediate release of glutamate which
binds to NMDA receptor
X
Neuronal efflux of K+ and influx of Ca2+
X
Increased Na+-K+ pump activity which
increases demand of ATP
Pathophysiology of
Concussion
X
X
X
Giza and Hovda J of Athl Training, 2001.
Biochemical Response to
Concussive Blow
Giza and Hovda in Neurologic Athletic and Spine Injuries 2000
Increased glucose metabolism and
decreased cerebral blood flow lead to
energy mismatch
Decreased cerebral blood flow up to 50% is a
likely mechanism for increased vulnerability to
another concussion
After initial metabolic state the brain goes
in to hypometabolism, glycolysis, and
increased lactate accumulation
Giza and Hovda J of Athl Training, 2001.
Cerebral Blood Flow Response
to Concussive Blow
X
12 children ages 11-15 with sports related
concussion
X
Significant reduction in cerebral blood
flow compared to controls
X
Only 27% improved to control levels at 14
days
X
64% took greater than 30 days to return to
control levels
Maugans, et al. Pediatrics, 2012.
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Concussion Management
X
Three aspects of management
X Starts
exam
with the pre-participation physical
X Sideline
X Return
assessment
to play decisions
On Field & Sideline
Evaluation
Symptoms may
be delayed
X Exercise high
suspicion
because
athletes often
will deny
symptoms
X
Diagnosis
X
Concussion should be suspected in the
presence of any one or more of the
following:
X Symptoms
X Physical
(headache, etc.)
signs (unsteadiness, etc.)
X Impaired
brain function (e.g. confusion)
X Abnormal
behavior
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Concussion Symptoms
Concussion should be suspected in the presence
of any one or more of the following:
X
Feeling “in a fog”
X
Difficulty
concentrating
X
Difficulty
remembering
X
“Pressure in head”
Feeling slowed
down
Dizziness
X Blurred vision
Amnesia
X Headache
X
Sensitivity to noise
or light
X
X
X
X
Neck pain
X Nausea or vomiting
Loss of consciousness
X Seizure or convulsion
X
Concussion Symptoms
X
Balance Problems
X
Fatigue or low energy
Percentage of Players with Concussion
Reporting Moderate to Severe
Symptoms at Time of Injury
X
Headache 85%
X
Dizziness/balance difficulties 77%
X
“Slowed Down” 69%
X
Decreased Concentration 60%
X
Sensitivity to Noise or Light 60%
X
Fatigue 55%
X
Memory Problems 45%
X
Confusion
X
Drowsiness
X
More emotional
X
Irritability
X
Sadness
X
Nervous or anxious
Now that a Concussion is
Suspected…
X
Remove from practice/game
X
Take the helmet or other required equipment
X
Monitor for deterioration
X
X
Seizures
X
Impaired consciousness
X
Focal neurologic signs
X
Vomiting or worsening of headache
X
Increasing confusion or slurring of speech
If these occur get athlete to ER ASAP!
Guskiewicz, McCrea, et al. JAMA 2003; 290:2549-255
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Does a Suspected Concussion
Need a Head CT?
Recurrent Concussions
X
In a prospective cohort study of 4251 player
seasons, 6.3% NCAA football players had a
concussion
X
X
6.5% of these players had a repeat concussion the
same season
Players reporting a history of ≥3 concussions
were 3x more likely to suffer a concussion than
those with no history
Guskiewicz K et al. JAMA 2003, 290: 2549-2555
Return to Play
X
Safety concerns for returning an athlete
to play too soon
X
Current return to play guidelines
Recurrent Concussions
X
30% of those with history of ≥3 concussions had
symptoms >1 week compared to 14.6% to
those with 1 previous concussion
X
11/12 who suffered a same season concussion
occurred with 10 days of first injury
X
9/12 occurred within first 7 days
Guskiewicz K et al. JAMA 2003, 290: 2549-2555
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Special Considerations for
Children
Special Considerations for
Children
X
A child’s brain is still developing in multiple ways
X
Children take longer to recover than older
adolescents and adults
X
Physical activity
X
Recovery patterns have not been studied well
in children <15 years old
X
Computer and video games
X
Television
Recommend to hold out of activity until
asymptomatic for a few days
X
Texting
X
Reading
X
School related activities
X
Special Considerations for
Children
X
90% of college athletes recover within 7 days
but only 50% of high school athletes had
completely symptom free at 7 days
X
Counsel on activities that can worsen
symptoms
Stepwise Return to Play
X
Each stage should take at least 24 hours
X
If symptoms return the patient should drop back
to the previous level and rest for 24 hours before
resuming progression
McCrea et al. JAMA 2003.
X
Cognitive rest
X
Communication with teachers & school
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Stepwise Return to Play
X
X
X
Stage 1
Stepwise Return to Play
X
Stage 4
X
No activity
X
Non-contact drills
X
Complete physical and mental rest until
asymptomatic
X
May start resistance training
X
*Consider Neuropsych testing
Stage 2
X
Light aerobic exercise
X
Walking, swimming, stationary bike
Stage 3
X
Sport specific exercise which adds movement
X
Stage 5
X
Stage 6
X
X
Full contact practice
Return to competition
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05/18/2015
Acute Knee Injuries
History of Injury
X
Mechanism of Injury?
X
Discuss immediate symptoms
X
X
Did they hear/feel a pop?
X
Did the knee immediately swell?
X
Where was the location of initial pain?
X
Were they able to bear weight or continue playing?
Chronological description of symptoms up to the
point of evaluation
Questions I Always Ask
X
Current location of pain?
X
Are they having TRUE “locking”?
X
Any instability, looseness or wobbly feeling in
the knee?
X
Any swelling or effusion?
X
X
Meniscus tear, loose body
Ligamentous injury, patellar dislocation
X
Immediate effusion suggests ACL tear
X
Slightly delayed effusion could be patellar dislocation,
fracture, meniscus tear
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05/18/2015
Effusion
Traumatic Effusion=Get a
MRI
X
Patellar Dislocation
2/3rds of the time the patient has suffered
an ACL injury if there is immediate
swelling after a twisting injury with a pop.
Patellar Dislocation
X
Often caused by twisting episode
X
Patella usually spontaneously reduces
X
Treatment includes immobilization for 1-2
weeks followed by optional patellar
stabilization brace
X
PT works to restore motion and improve
strength
X
Recurrence after primary episode is 17%
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05/18/2015
Hip and Pelvis Injuries
X 12
yo felt a painful pop in right
groin when kicking soccer ball
X What
Hip & Pelvis Injuries
X
Avulsion injuries to are possible at multiple
growth plates in the pelvis
X
Anterior superior iliac spine (ASIS)
X
Anterior inferior iliac spine (AIIS)
X
Ischial tuberosity
X
X
X
X
Sartorius origin
is your differential?
Treatment
X
Ice, NSAIDS, crutches, gentle stretching and range of
motion
X
Return to sport 4-8 weeks when strength back to 90% of
opposite side
Rectus Femoris origin
Hamstring origin
Male athletes 14-17 yo, female athletes
12-15 yo
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Phases of Pitching
X
High valgus tension forces and high radial head/capitellum
compression forces occur
Little League Elbow
(medial apophyseal injury)
X
Usually affects Little League age pitchers 9-12 years old
X
Repetitive valgus overload can lead to microtrauma in
the medial epicondyle apophysis
X
Older pitchers with closed growth plates would stress their
ulnar collateral ligament instead
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Little League Elbow
(medial apophyseal injury)
X
Xrays of bilateral sides can show apophysis
widening
X
Treatment is rest from throwing
X
Focus on core and posterior shoulder
strengthening during rehab during period of rest
Little Leaguer Shoulder –
13 yo
“Little Leaguer’s Shoulder”
X
Widening of proximal humeral growth plate
X
Mild shoulder pain that increases with pitching
X
Xrays comparing bilateral sides can be helpful
“Little Leaguer’s Shoulder”
X
Tx: No throwing for 6-8 weeks or until all
pain resolved
X Start
core exercises immediately and start
rotator cuff exercises once pain improved
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05/18/2015
11 yo with heel pain
Osgood Schlatter Disease
Sever’s Disease
(calcaneal apophysitis)
X
#1 Cause of heel pain in 8-12 year olds
X
Often occurs during/after rapid bone growth
leaving the muscle/tendon complex tight
X
Xrays not necessary
X
Treatment includes ice, decreasing volume of
activity, CAM boot if severe pain
Osgood Schlatter Disease
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Patellofemoral Pain
Syndrome
Snapping Hip
Iliopsoas tendon
X
One of most common adolescent
musculoskeletal complaints
X
Often complain of vague anterior knee pain
around patella
X
Worse with stairs, squatting, hills
X
Exam: Often quite normal.
X
IT band
Single leg squats can illicit pain
Images from Dr. Thomas Byrd, Nashville, TN
14 yo girl with left lateral hip
pain
Foam Roller – for IT Band
stretching
X
Pain at left iliac crest playing volleyball.
X
Worse with twisting and jogging.
X
Pain comes and goes, worse during and
after activity
Bicycling.com
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05/18/2015
Iliac crest apophysitis
Iliac Crest Apophysitis
Pitch Counts
“When Can My Child
Throw a Curveball?”
www.stopsportsinjuries.org
Jodieotte.com
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05/18/2015
“When Can My Child
Throw a Curveball?”
Thanks!
X
Please email with questions at any time
X [email protected]
X
Twitter - @MizzouSportsDoc
www.stopsportsinjuries.org
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