The Adolescent Athlete (eBook)

Lyle J. Micheli, MD, one of the world’s foremost authorities on sports medicine, is an associate clinical professor of orthopaedic surgery at Harvard Medical School and director and co-founder of the Sports Medicine Division at Children’s Hospital Boston, which is internationally recognized for clinical care and research in pediatric and adolescent sports medicine. Noted as an active clinician and teacher, Dr. Micheli presents at the AAOS, ACSM, and NATA. He has written more than 100 book chapters (contributor to Cole & Malek, Articular Cartilage Lesions) and has co-edited several titles, including the Oxford Textbook of Sports Medicine, 2/e (Oxford, 1998, ISBN 0192627171) and The Sports Medicine Bible for Young Athletes (SourceBooks, 2001, ISBN 1570717109). Dr. Micheli serves on the editorial and advisory boards of more than 20 journals, including Spine and the Clinical Journal of Sport Medicine, and he has published more than 200 articles. Laura Purcell, MD, received her medical doctorate from McMaster University, one of the world’s leading evidence-based practice centers, and completed her pediatric residency at Dalhousie University (Nova Scotia) and a sport medicine fellowship at Fowler Kennedy Sport Medicine Clinic (Ontario). She is currently a primary care sport medicine physician at Fowler Kennedy and an emergency department consultant at the Children’s Hospital of Western Ontario. Dr. Purcell is chair of the Pediatric Sport and Exercise Medicine Committee of the Canadian Academy of Sport Medicine and president of the Pediatric Sport and Exercise Medicine Section of the Canadian Pediatric Society. She has contributed to several publications, including Paediatrics & Child Health, Pediatric Emergency Care, and Paediatric Child Health. An active educator, Dr. Purcell has been invited to speak at symposiums held by the Canadian Paediatric Society and the Canadian Academy of Sport Medicine/Ontario Medical Association.

Title Page 3
Copyright Page 4
Preface 5
Table of Contents 6
Contributors 8
Introduction 11
Benefits of Sports 11
Sport Readiness 12
Growth, Maturation, and Development 14
Sexual Maturity 14
Skeletal Maturity 16
Risk of Injury 17
Conclusion 17
References 18
Section I Rehabilitation and Diagnosis 20
1 Principles of Rehabilitation 21
Principles of Rehabilitation 22
Rehabilitation Program 22
Patient History 22
Systems Review 23
Establishment ofA Plan of Care 30
Rehabilitation Plan of Care 32
Immediate Care 32
Promote Healing 32
Restore Function 35
Muscle Length (Flexibility) 35
Joint Range of Motion 36
Restore and Improve Strength 37
Safe Return to Sport/Competition 40
Prevention of Future Injuries 42
Summary 44
References 44
2 Diagnostic Imaging 49
Imaging Techniques 49
Radiography 49
Computed Tomography 50
Magnetic Resonance Imaging 51
Nuclear Medicine 52
Ultrasound 52
Arthrography 53
Sites of Injury 53
Head and Face 53
Spine 54
Chest and Abdomen 58
Extremity Injuries 59
Fractures 59
Avulsion Injuries 59
Internal Derangement 59
Chronic Physeal Injury 60
Stress Injuries 62
Growth Arrest 62
Conclusion 65
References 65
Section II Anatomic Regions 67
3 Traumatic Head Injuries 68
Anatomy 68
Clinical Evaluation 70
History 70
Physical Examination 71
Diagnostic Tests 72
On Field/Office Assessment 72
Neuroimaging 72
Neuropsychological Testing 73
Head Injuries 74
Skull Fractures 74
Intracranial Hemorrhage 74
Epidural Hematoma 75
Subdural Hematoma 76
Intracerebral Hematoma 76
Subarachnoid Hematoma 76
Malignant Brain Edema Syndrome 76
Diffuse Axonal Injury 78
Concussion 79
Management 80
Stepwise Process (8,10,14,24): 81
Prevention 82
Return to Play 82
Clinical Pearls 83
References 84
4 Cervical and Thoracic Spine Injuries 87
Anatomy 87
Clinical Evaluation 90
History 90
Physical Examination 91
Imaging 93
Acute Injuries 96
Burners 96
Fractures and Traumatic Instability 97
Cervical and Thoracic Disc Disease 103
Other Causes of Acute Neck and Upper Back Pain 104
Chronic Injuries 104
Cervical Disc Degeneration 104
Cervical Facet Syndrome 105
Scheuermann's Kyphosis 105
Scoliosis 106
Congenital Anomalies 107
Klippel-Feil Syndrome 107
Os Odontoideum 108
Return to Play Guidelines 109
Prevention 110
Clinical Pearls 110
References 111
5 Lumbar Spine Injuries 116
Anatomy 117
Clinical Evaluation 118
History 118
Physical Examination 118
Risk Factors 120
Injuries of the Posterior Elements of the Spine 121
Spondylolysis and Spondylolisthesis 121
Risk Factors 122
Presentation 123
Clinical Examination 124
Investigations 125
Management 128
Cauda Equina Syndrome 129
Posterior Element Overuse Syndrome 130
Presentation and Clinical Examination 130
Management 130
Low Back Pain Related to Injuries of the Pelvis 131
Sacroiliac Joint Dysfunction 131
Presentation and Clinical Examination 131
Investigations 131
Management 132
Iliac Crest Apophysitis 133
Injuries of the Anterior Elements of the Spine 133
Lumbar (atypical) Scheuermann's 133
Presentation 133
Clinical Examination 133
Management 134
Vertebral Body Apophyseal Avulsion Fracture 134
Presentation 134
Clinical Evaluation 134
Investigations 134
Management 135
Disc Herniation 135
Presentation 135
Clinical Examination 135
Investigations 136
Management 136
Other Causes of Low Back Pain 137
Seronegative Spondyloanhropathies 137
Presentation 137
Clinical Examination 138
Investigations 138
Management 138
Discitis 139
Investigations 139
Management 139
Vertebral Osteomyelitis 139
Investigations 139
Management 140
Spinal Neoplasms 140
Investigations 140
Scoliosis 140
Prevention 141
Return to Play Guidelines 141
Clinical Pearls 143
References 143
6 Thoracoabdominal Injuries 148
Intrathoracic and Intraabdominal Injuries 148
Anatomy 148
Clinical Evaluation 149
Thoracic Injury 149
Abdominal Injury 149
Coexisting Injuries 150
Diagnostic Assessment 150
Treatment 150
Thoracic Injuries 151
Lung Injuries 151
Pneumothorax 151
Pulmonary Contusion 152
Hemothorax 153
Cardiac Injuries 153
Commotio Cordis 153
Myocardial Contusion 154
Chest Wall Injuries 154
Rib Fractures 154
Rib Stress Fractures 156
Rib Tip Syndrome 157
Costosternal Syndromes (Costochondritis) 158
Sternal Fractures 158
Scapular Fractures 159
Abdominal Injuries 159
Splenic Injury 161
Epstein-Barr Virus, Infectious Mononucleosis, and Splenomegaly 161
Hepatic Injury 162
Renal Injury 163
Pancreas 164
Bowel Injury 165
Groin Pain and Injuries 165
Prevention 165
Return to Play Guidelines 165
Clinical Pearls 166
References 166
7 Adolescent Shoulder Injuries 172
Functional Anatomy 173
Clinical Evaluation 175
History 175
Physical Examination 175
Range of Motion 175
Strength Testing 177
Special Tests 177
Scapulothoracic Region 179
Diagnostic Imaging 181
Acute Shoulder Injuries 182
Acromioclavicular and Sternoclavicular Separations and Dislocations 182
Clavicle Fractures 183
Proximal Humerus Fractures 183
Glenohumeral Dislocation 185
SLAP Lesions 187
Rotator Cuff Injury 188
Chronic Overuse Shoulder Injuries 189
Little Leaguer's Shoulder 189
Glenohumeral Instability 191
SLAP Lesions 192
Internal Impingement 192
"Secondary" Impingement Syndrome 193
Prevention 195
Return to Play Guidelines 196
Clinical Pearls 196
References 196
8 Elbow and Forearm Injuries 201
Anatomy 201
Bony Anatomy 201
Ossification Centers 202
Ligament Complexes 202
Muscle Tendon Units 204
Neurovascular Structures 204
Clinical Evaluation 205
History 205
Physical Examination 205
Observation, Palpation, and Range of Motion (Look, Feel, Move) 205
Stress Tests 206
Provocative tests 207
Looking Beyond the Elbow 209
Imaging 210
Acute/Traumatic Elbow Injuries 210
Elbow Dislocation 210
Posterolateral Rotatory Instability 212
Forearm fractures 212
Medial Epicondyle Avulsion 214
Chronic / Atraumatic Injuries 214
"Little League Elbow" 214
Osteochondritis Dissecans of the Capitellum 215
Panner's Disease 218
Medial Apophysitis 218
Ulnar Collateral Ligament Injury 219
Posterior Impingement, Olecranon Stress Injury, and Apophysitis 220
Treatment 220
Initial Management 220
Physical Therapy 221
Surgery 221
Prevention 222
Return to Play Guidelines 223
Clinical Pearls 223
References 224
9 Injuries to the Wrist, Hand, and Fingers 230
Epidemiology 230
The Athlete's Wrist and Hand 231
Anatomy 231
Clinical Evaluation 233
History 233
Physical Exam 233
Wrist Injuries 234
Distal Radius Fractures 234
Anatomy 235
Clinical and Radiographic Evaluation 236
Management 236
Scaphoid Fractures 238
Anatomy 238
Clinical Evaluation 238
Radiographs 239
Nonoperative Treatment 240
Surgical Treatment 243
Other Carpal Fractures 244
Hook of Hamate Fractures 244
Dorsal Triquetrum A vulsion Fractures 245
Triangular Fibrocartilage Injuries 245
Anatomy 246
Clinical Presentation 246
Surgical Management 248
The Gymnast's Wrist and Ulnocarpal Impaction 248
Hand Injuries 249
Metacarpal Fractures 249
Metacarpal Shaft Fractures 250
Metacarpal Neck Fractures 251
Metacarpal Head Fractures 252
Phalangeal Fractures 252
Proximal Interphalangeal Joint Dislocations 253
Gamekeeper's Thumb 256
Mallet Finger 258
Jersey Finger 260
Prevention 262
Return to Play Guidelines 263
Clinical Pearls 264
References 265
10 Pelvic, Hip, and Thigh Injuries 271
Anatomy 271
Clinical Evaluation 272
History 272
Physical Examination 273
Acute Injuries of the Pelvis, Hip, and Thigh 273
Iliac Crest Contusion 273
A vulsion Injuries of the Pelvis 274
Chondral Injury of the Hip 275
Adductor Injuries 276
Hamstring Injuries 276
Quadriceps Strain 278
Quadriceps Contusions and Myositis Ossificans Traumatica 278
Overuse Injuries 279
Stress Fractures 279
Pelvic Stress Fractures 279
Femoral Neck (Hip) Stress Fractures 280
Femoral Stress Fractures 281
Labral Tears 283
Osteitis Pubis 284
Sacroiliitis 285
Snapping Hip 286
Proximal Hamstring Syndrome 287
Piriformis Syndrome 287
Trochanteric Bursitis 287
Acquired Conditions 288
Slipped Capital Femoral Epiphysis 288
Nerve Entrapments 288
Obturator Nerve Entrapment 288
Lateral Femoral Cutaneous Nerve Entrapment 289
Prevention 290
Return to Play 290
Clinical Pearls 290
References 291
11 Knee Injuries 296
Anatomy 296
Clinical Evaluation 299
History 299
Physical Exam 299
Acute Injuries 306
Patellar Dislocation 306
Clinical Examination 306
Management 306
Anterior Cruciate Ligament Tear 307
Clinical Examination 307
Management 308
Meniscal Tears 309
Clinical Examination 309
Management 310
Collateral Ligament Injuries 310
Clinical Examination 310
Management 311
Tibial Tubercle A vulsion Fracture 311
Clinical Examination 312
Management 312
Chronic Injuries 313
Patellofemoral Pain Syndrome 313
Clinical Examination 313
Management 313
Subluxing Patella 314
Clinical Examination 314
Management 314
Iliotibial Band Friction Syndrome 315
Clinical Examination 316
Management 316
Sindig-Larsen-Johansson Disease 316
Clinical Examination 316
Management 317
Osgood-Schlatter Disease 318
Clinical Examination 318
Management 318
Juvenile Osteochondritis Dissecans 319
Clinical Examination 320
Management 322
Plicae 323
Clinical Examination 323
Management 323
Congenital 323
Discoid meniscus 323
Clinical Examination 324
Management 324
Prevention 326
Return to Play Guidelines 326
Clinical Pearls 326
References 327
12 Lower Leg Injuries 331
Anatomy 331
Clinical Evaluation 333
History 333
Physical Examination 334
Acute Injuries 335
Acute Fracture 335
Muscle Strain/Peroneal Tendon Subluxation 336
Triceps Surae 336
Peroneals (with Ankle Sprain) 337
Achilles Tendon Rupture 337
Contusions 337
Bone Bruise 337
Saphenous Vein Hematoma/Occlusion 338
Chronic Injuries 338
Recurrent Exertional Compartment Syndrome 339
Stress Fracture/Stress Reaction 342
Posteromedial Tibial Stress Syndrome 346
Tendon Injury 347
Achilles 347
Peroneal 348
Flexor Hallucis Longus 348
Ankle and Toe Dorsiflexors at the Distal Tibia 349
Other Causes of Lower Leg Pain 350
Osteoid Osteoma 350
Ewing's Sarcoma 350
Brodie's Abscess 350
Osteogenesis Imperfecta or Other Metabolic Bone Disease 350
Reflex Sympathetic Dystrophy 350
Management of Difficult Lower Leg Injuries 351
Prevention 352
Return to Play Guidelines 352
Clinical Pearls 353
References 353
13 Foot and Ankle Injuries 355
Anatomy 355
Clinical Evaluation 362
History 362
Physical Exam 363
Acute Injuries 367
Ankle Fractures 367
Ankle Sprains 370
Metatarsal Fractures 371
Toe Fractures 375
Midfoot Sprains and Turf Toe 375
Overuse Injuries and Chronic Pain 376
The Unstable Ankle 376
Osteochondritis Dissecans of the Talus 377
Tendonitis 379
Stress Fractures 381
Apophysitis 383
Anterior and Posterior Impingement 384
Sesamoiditis 385
Reflex Sympathetic Dystrophy 385
Developmental and Related Conditions 386
Osteochondroses 386
Flat Feet 388
Tarsal Coalition 390
Accessory Bones of the Foot 392
Adolescent Bunion 394
Prevention of Foot and Ankle Injuries 395
Return to Play 396
Clinical Pearls 396
References 399
Appendices 403
Appendix 1 Sports and Children: Consensus Statement on Organized Sports for Children 404
Benefits of Organized Sports for Children 404
Risks of Organized Sports for Children 405
Recommendations 406
Sports Governing Bodies 406
Youth Sports Coaches 406
Health Professionals 406
Sports Training 407
Parents 407
Research 407
Members of the Ad Hoc Committee 407
Appendix 2 Position Statement on Girls and Women in Sport 409
Benefits of Sports Participation 410
Physical Benefits 410
Psvchosocial Benefits 410
Risks of Sports Participation 410
"Female" Injuries? 411
More Injuries? 411
Recommendations to Minimize Injury Risk and Enhance Participation 412
Sports Governing Bodies 413
Physical Educators, Coaches, and Other Exercise and Health Professionals 413
Parents 413
Research 413
Sources 413
Appendix 3 IOC Consensus Statement on Training the Elite Child Athlete 415
Scientific Basis of Training the Elite Child Athlete 415
Special Issues in the Elite Child Athlete 416
Recommendations for Training the Elite Child Athlete 417
Index 419

"Section II Anatomic Regions (p. 60-63)

3 Traumatic Head Injuries

Laura Purcell

Head injuries are common among children, and they result in a significant number of visits to emergency departments and physicians offices each year. In children 15yr old and under, the estimated incidence of traumatic brain injury is 180 per 100,000children per year, totaling more than 1 million injuries annually in the United States and accounting for more than 10% of all visits to emergency departments (1). A recent study conducted in emergency departments in Canada demonstrated that 3% of all sport-related injuries were head injuries (2). The majority of sport-related head injuries occurred in individuals less than 20yr of age. Head injuries represented 2.8% of all sport injuries in children less than 10yr old, 3.7% in 10-14yr olds, and 4.20/0 in 15-19yr olds (2). Head injuries as a result of sport participation include minor injuries such as contusions, lacerations, and superficial hematomas, as well as more serious injuries, including concussions, skull fractures, and intracranial hemorrhages. Head injuries can occur in both organized sports, such as football, hockey, basketball, and soccer, as well as recreational activities, including biking, skiing, skateboarding, and rollerblading.

Anatomy

The brain is enclosed in the bony skull or cranium (Figure 3.1 A). Below the skull, there are three layers of meninges between the skull and the brain. The meninges, or mater, include the outer dura mater, enclosing the venous sinuses; the arachnoid mater, which bridges the sulci on the cortical surface of the brain; and the pia mater, which is a delicate vascular membrane lining the cerebral cortex.

There are three potential meningeal spaces: the epidural space between the cranium and the dura; the subdural space between the dura and arachnoid; and the subarachnoid space between the arachnoid and pia, which contains cerebrospinal fluid. The brain consists of right and left cerebral hemispheres, which are divided into lobes corresponding to the overlying cranial bones: frontal, parietal, occipital, and temporal (Figure 3.1 B). The cerebral cortex consists of gyri (folds) and sulci (grooves).

Posterior and inferior to the cerebral cortex are the cerebellum and the brainstem, consisting of the medulla oblongata, pons, and midbrain. Clinical Evaluation The athletes level of consciousness should guide management priorities (3,4). In an unconscious athlete, a cervical spine injury should be assumed, and appropriate immobilization of the cervical spine should be immediately instituted to protect against potential catastrophic spinal injury (4-6). Management then proceeds through the ABCs (airway, breathing, and circulation) (3-6). A patent airway must be established and protected.

If the patient is unable to protect the airway, or if there are signs of neurological deterioration, such as posturing or pupillary abnormalities, the athlete should be intubated and hyperventilated (4-7). If the airway is patent, adequate ventilation must be ensured. Circulation should be monitored and supported as necessary. The athlete should be transported on a spinal board by ambulance to the nearest trauma center as quickly as possible (Table 3.1) (3-7)."