Overuse Injuries


Sports-related Overuse Injuries in school-aged children

Stephanie J. Klee
Samuel Merritt University           

  Children frequently participate in multiple after school sports. Engaging in extended periods of exercise places these children at a greater risk for overuse injuries. Overuse injuries, also known as cumulative trauma or repetitive stress injuries, are the result of repetitive use, (Quinn, 2008, p. tab: Sport Injury). Overuse injuries have an insidious onset and thus can be difficult to diagnose, children may not complain of pain immediately but over time. It is this slow onset of symptoms that prompts parents to seek medical treatment either at the primary care office or at the ED. Educating both advanced practice nurses in primary care and in the ED setting about assessment, diagnosis, and treatment of sports-related overuse injuries may reduce the number of visits to the local ED.

  The incidence of young athletes presenting to the emergency department seeking treatment for sports-related injuries may be as high as 8-10 % (Lau, Mahadev, & Hui, 2008, p. 315). Early adolescence is the time for major growth spurts to occur. The apophysis is the secondary center of ossification and the location of tendon insertion into the bone. The rapid gains in height and weight that take place during a growth period happen at an increased speed.  It is this differential in growth between the skeletal system and the musculotendious unit that results in disproportional length, which subjects the apophysis to pronounced tensile force during this growth spurt. Apophysitis refers to inflammation, irritation, and micro trauma to the apophysis. Early diagnosis of lower limb overuse injuries such as Osgood-Schlatter Disease (OSD), Sever’s disease, and Sinding-Larson-Johansson syndrome (SLJS) can be conservatively treated without long-term sequelae. Treating sports-injuries in School-aged children presents a unique challenge to the Family Nurse Practitioner. The purpose of this paper is to describe how an intervention which includes an educational program on overuse injuries, its diagnostic findings, and specific treatments given to advance practice nurses within the coastside community, will decrease the numbers of visits to the ED for overuse injuries from school-aged children.

Literature Review

  According to Adirim and Cheng, 2003, Sever’s disease typically occurs between ages 7-10 years while Osgood-Schlatter disease occurs between ages 11-15 years. In a retrospective review study of 506 pediatric cases diagnosed with overuse injuries, the knee joint was the most commonly affected joint. Osgood-Schlatter disease was the most prevalent overuse injury in both females and males, while Sinding-Larson-Johansson disease was most prevalent in males (Lau, et al., 2008).  Both OSD and SLJS will frequently complain of anterior knee pain with localized tenderness and swelling to the tibia tubercle. However, OSD occurs at the distal insertion of the patella tendon and the tibial tuberosity as opposed to SLJS, which effects the proximal insertion of the patella tendon to the inferior pole of the patella (Lau, et al., 2008). Radiography of lateral knee in OSD will have varying results depending on stage of disease and age of child. In the acute stage, visible edema of the skin and tissues anterior to the tibial tuberosity are identifiable, and the edges of the patellar tendon may be blurred. If the tibial tuberosity is cartilaginous, no change is seen initially; however by 3-4 weeks, fragmented ossification can be visualized within the tendon (Aparna, Wood, Coombs, Hernanz-Schulman, & Krasny, n.d.).  In SLJS, or frequently referred to as “Jumper’s knee ” in pediatrics, the radiographic results may show varying amounts of calcification or ossification at the junction of the patella and ligament (Wheeless, Nunley, & Urbaniak, 2011, p. tab: Joints-knee).

  In a prospective study of risk factors for Sever’s disease, Scharbillig, R., Jones, S., & Scutter, S., 2011, described the clinical picture presenting at the beginning of a sport season, generally male, active sport playing child, in the midst of a growth spurt. Sever’s can present with bilateral complaints of a gradual onset increasing in pain with exercise, especially running.  Physical features found on examination were pain over the apophyseal area of one or both heels, limited joint dorsiflexion, an underlying biomechanical deformity of variable nature. Radiography of lateral calcaneum will demonstrate increased radiopacity over apophysis of the calcaneum (Lau, et al., 2008).

Treatment

  Treatment for all three conditions consist of a long course of conservative therapies including cessation of aggravating activities, ice, nonsteroidal anti-inflammatory drugs, and physical therapy. The acronym RICE is the regime rest, ice, compression, and elevationthat should be used in all overuse injuries within the first 72 hours of symptoms. Although ice and bandage compression can be used regularly to decrease local inflammation and ease discomfort. In both OSD and SLJS crutches may be needed to provide complete rest of the joint. In OSD the physical therapy is focused on stretching of the quadriceps, hamstrings, and heel cords with progressive strengthening of the hamstrings (Kodali, Islam, & Andrish, 2011). Quadriceps strengthening must be avoided initially because this can cause increased stress across the tibial tuberosity apophysis and aggravate symptoms(Kodali et al., 2011). SLJS physiotherapy focuses on quadriceps stretches and static quadriceps contractions. Both of these should be done frequently throughout the day but not to elicit pain. Sever’s disease treatment includes heel cups, taping, soft tissue massage, and regular stretching of the gastrocnemiussoleus complex. These exercises are straight leg raises with ankle dorsiflexion and single ankle heel raise with ankle plantar flexion (Achilles stretch). Although these common overuse injuries are self-limiting, they can persist for 6-12 months and both SLJS and OSD may continue for up to 2 years.


References
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Wheeless, III, C. R., Nunley, II, J. A., & Urbaniak, J. R. (Eds.). (2011). SINDING-LARSON-JOHANSSON SYNDROME.Wheeless’ Textbook of Orthopaedics (Sec. Knee Joint Menu). Retrieved from http://www.wheelessonline.com/