Managing sports injuries in the GP surgery: children and adolescents

GPSI in sports medicine Dr Frank O’Leary advises on common sports injuries affecting children and adolescents 

Case 1: Osgood-Schlatter’s disease

You see a 14-year-old boy who plays tennis and rugby. He has been asked to attend an elite rugby academy, which involves two extra training sessions per week on top of his school rugby and tennis training. For the past six weeks he has been complaining of a pain just under his left knee at the front, and in the past week the right knee has also started to hurt. 

Osgood Schlatter’s disease is a traction apophysitis (see box) of the tibial tuberosity. It has no effect on child growth. It affects active adolescents more than those who are sedentary. 

Key history
Typical age of onset is 12-15 years, and one to two years earlier in girls. It is more common in boys, although the incidence in girls is increasing. It can be unilateral or bilateral.^3,4 It is typically worse during and after activity, especially after jumping and running, and tends to present with anterior knee pain. Risk factors include excessive physical activity, especially that involve sharp changes in direction, jumping and running (movements that involve repeated forced knee extension).  

Examination
Swelling (bony or soft tissue) can be noted over the tibial tuberosity. This is generally tender to touch.⁵ Pain tends to occur on passive knee flexion typically performed in prone position (stretching quadriceps). There is also pain on resisted knee extension from flexion (quadriceps activation). The quadriceps muscles may be tight at rest. The remainder of the knee examination is usually normal, but there may be excessive pronation of the ankle on the affected side. In this age group it is essential to examine the hip because of potential referred pain to the knee, and to avoid missing significant hip pathology – such as slipped upper femoral epiphysis or Perthes disease. 

Differential diagnosis

• Avulsion fracture tibial tuberosity – generally an acute injury.
• Patellar tendinopathy and Sinding-Larsen-Johannsen disease (see Case 3). 
• Inflammatory arthritis and bone malignancy are much rarer differentials.

Investigations
Although diagnosis can be made clinically, X-ray imaging can help exclude other causes such as avulsion fracture, inflammatory arthritis and bone malignancy. In Osgood Schlatter’s an X-ray (lateral view) may show overlying soft tissue swelling over the tibial tuberosity. There may be bone fraying.⁶

Management
The main goal of management is to allow activity to continue.⁷ Complete rest is not the answer. It may be necessary to avoid certain movements like kneeling, or alleviate pain if this cannot be avoided – for example, using protective knee pads. Ice over the affected area can help alleviate pain after activity.⁸ Advice (from NHS paediatric physiotherapy services) to promote quadriceps flexibility and strengthening is important. Osgood Schlatter’s generally resolves when the tibial growth plate fuses (at age 13-15 years in girls and 15-17 years in boys). Long-term prominence of the tibial tubercle may continue into adulthood. 

 Case 2:   Sever’s disease 

Alice is 10 years old. She has been involved in gymnastics since age six. She trains with her local team three times a week and has regular competitions over the summer. She has had pain in both her heels for the past two months. Initially it was only a slight ache after a session, but now the pain is stopping her finishing the session.  

Sever’s disease is a traction apophysitis of the calcaneum. The calcaneal apophysis is located at the posteroinferior aspect of the calcaneum. The injury occurs from bone remodelling in response to excessive load.⁹

History
This typically affects ages 8-12 years, with girls presenting earlier. A child may present with unilateral, or in two-thirds of cases bilateral heel pain typically associated with running or jumping, such as in basketball.^10,11 The pain can build gradually. It is usually worse when getting out of bed. It can be associated with hyperpronation of the feet, flat feet or high arches. The pain is made worse by wearing footwear with poor heel support. 

Examination
There is usually a point of tenderness where the Achilles tendon inserts into the calcaneus. Squeezing the upper portion of the heel with both hands is also provocative.¹² Heel walking is painful. There will usually be reduced ankle dorsiflexion, and poor flexibility of the calf muscles.¹³ 

Differential diagnosis

• A calcaneal fracture, which tends to be more acute, or stress fracture.
• Achilles tendinopathy or rupture.
• Plantar fasciitis.
• Retrocalcaneal bursitis.

Investigations for suspected Sever’s disease are generally not required. If an X-ray is performed (to rule out other conditions) it would show fragmentation of the calcaneal apophysis.¹⁴

Management
This involves modifying activities when the pain is very active, using pain as a guide on how much activity to do. A heel raise in the footwear can help. Applying ice to the heels after activity can help alleviate the pain. A calf and hamstring flexibility and strengthening programme (via paediatric physiotherapy) can improve symptoms as the condition runs its course.¹⁵ Note that stretching, although recommended, can be painful. There is no role for complete rest or steroid injections. Apophyseal closure occurs around 12 years of age, which resolves the condition. There are no long-term complications.¹⁶

Case 3:  Patellar tendinopathy (jumper’s knee)

James is 16. He plays basketball for his school and club. He noticed a pain at the front of his knee three months ago. It is now happening more often and becoming more painful, especially after basketball. He is worried about his future playing career.  

Patellar tendinopathy is an overuse injury. It particularly affects adolescents who participate in sports involving jumping and running. The patella tendon itself is not inflamed. It is believed to occur when an injured patella tendon fails to heal, weakening it and impairing its function. Loading this tendon can therefore be painful.¹⁷

History
The patient will complain of chronic, anterior knee pain made worse by running and jumping, sometimes worse going up or down stairs or after sitting for prolonged periods. Risk factors include excessive training or an increase in training load. 

Examination
There tends to be localised tenderness along the patella tendon especially the inferior pole of the patella bone. This is tested by applying pressure to the superior pole of the patella (thus lifting the inferior pole) and palpating with a finger at the tendon origin. Eccentric contraction of the patella tendon (its contraction as the knees are bent, ready to jump) will make the symptoms worse. The differential diagnosis includes conditions that can cause anterior knee pain such as quadriceps tendinopathy, Osgood Schlatter’s disease, patellofemoral pain, fat pad impingement, prepatellar bursitis, osteochondral defects and referred pain from the back or hip. In most cases, this can be differentiated with appropriate history and examination. In this age group it is worth considering Sinding-Larsen-Johansson disease (patellar apophysitis) which can occur with patellar tendinopathy. This is traction apophysitis of the inferior pole of the patella. It can be aggravated by similar activities to those that aggravate patellar tendinopathy. Ultrasound can help if the diagnosis is in doubt and may show a thickened mixed echogenic patella tendon, sometimes with increased vascularity.¹⁸

Management
There is a paucity of evidence on how to manage the condition in the adolescent age group.¹⁹ Initial management involves controlling the pain and reducing load. Risk factors should be addressed. Correcting any biomechanical abnormalities is also key. After the acute phase, rehabilitation involves strength training with a gradual progressive load through the knee. Strength progression starts with isometric strength exercises, progressing to dynamic exercises that increase in intensity (along with functional movements) and finally sports-specific exercises.¹⁹ Progression is limited by the limits of pain. It is important to discuss with the patient and parents that although recovery tends to be quicker than in adults, it can still take months, and requires patience. Taping can help with pain in the short term. Extracorporeal shockwave therapy has limited evidence for reducing pain and helping progression. Other treatments such as glyceryl trinitrate patches, glucocorticoid injections and platelet-rich plasma injections have no supporting evidence in the adolescent population.

Dr Frank O’Leary is a GPSI in sports medicine and a sports and exercise medicine registrar at University College London

References

1. Achar S, Yamanaka J. Apophysitis and osteochondrosis: common causes of pain in growing bones. Am Fam Physician 2019;99:610-618
2. DiFiori J. Overuse injuries in children and adolescents. Phys Sportsmed 1999;27:75-89
3. Haines M, Pirlo L, Bowles K et al. Describing frequencies of lower-limb apophyseal injuries in children and adolescents: a systematic review. Clin J Sport Med 2022;32:433
4. Duri Z, Patel D, Aichroth P. The immature athlete. Clin Sports Med 2002;21:461
5. Clark M, Iwinski H. The limping child: the challenges of an accurate assessment and diagnosis. Pediatr Emerg Med 1997;2:123.
6. Willis R. Sports medicine in the growing child. In: Morrissey R, Weinstein S (eds). Lovell and Winter’s Pediatric Orthopaedics Lippincott Williams & Wilkins 2006
7. Wall E. Osgood-Schlatter disease: practical treatment for a self-limiting condition. Phys Sportsmed 1998;26:29
8. Bloom O, Mackler L, Barbee J. Clinical inquiries. What is the best treatment for Osgood-Schlatter disease? J Fam Pract 2004;53:153
9. Ogden J, Ganey T, Hill J et al. Sever’s injury: a stress fracture of the immature calcaneal metaphysis. J Pediatr Orthop 2004;24:488-92 
10. Cook J, Kiss Z, Khan K et al. Anthropometry, physical performance, and ultrasound patellar tendon abnormality in elite junior basketball players: a cross-sectional study. BJSM 2004;38:206-9 
11. Rachel J, Williams J, Sawyer J et al. Is radiographic evaluation necessary in children with a clinical diagnosis of calcaneal apophysitis (sever disease)? J Pediatr Orthop 2011;31:548
12. Perhamre S, Lazowska D, Papageorgiou S et al. Sever’s injury: a clinical diagnosis. J Am Podiatr Med Assoc 2013;103:361
13. Circi E, Atalay Y, Beyzadeoglu T. Treatment of Osgood–Schlatter disease: review of the literature. Musculoskelet Surg 2017;101:195-200
14. Kose O. Do we really need radiographic assessment for the diagnosis of non-specific heel pain (calcaneal apophysitis) in children? Skeletal Radiol 2010;39:359
15. James A, Williams C, Haines T. Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever’s disease): a systematic review. J Foot Ankle Res 2013;6:16
16. Howard R. Diagnosing and treating Sever’s disease in children. Emerg Nurse 2014;22:28-30
17. MacAuley D. Oxford Handbook of Sports and Exercise Medicine 2nd Edition. Oxford University Press. 2006. 693
18. Brukner P, Khan K. Clinical Sports Medicine 4th Edition. McGraw-Hill. 2012. 700-9
19. Cairns G, Owen T, Kluzek S et al. Therapeutic interventions in children and adolescents with patellar tendon related pain: a systematic review. BMJ Open SEM 2018;4:e000383