Younger athletes are more likely to experience injury of the apophysis, where the tendon inserts into bone. Apophysitis, produced by chronic repetitive traction at the apophysis, “is unique to the developing skeleton,” Dr. Harris emphasized. Although most of these injuries have a self-limited course, some may take years to resolve, and others can predispose young athletes to more serious injury, such as avulsion fractures. Using 10 case studies, Dr. Harris enumerated common sites of overuse injury (elbow, tibia, metatarsal, pelvis) leading to apophysitis.
In general, most children and teenagers who experience overuse injuries do not have to give up sports participation altogether, although decreased or alternative activities are usually employed as part of management. Other treatments include icing, NSAIDs to control pain and inflammation, correcting biomechanical abnormalities, and correcting errors in training or equipment. Some injuries, such as apophysitis at the base of the 5th metatarsal (Iselin’s syndrome) may be helped by use of an ankle brace; arch support can be beneficial to help heal an apophysitis of the tarsal navicular bone. Apophysitis at the medial humeral epicondyle of the elbow (often seen in Little Leaguers) requires careful management, since there can be long-term consequences for elbow function.
With these injuries, and with apophysitis of the pelvis, it’s important to emphasize that the young athlete should not play through escalating pain. Dr. Harris also included cases, such as an avulsion fracture at the elbow, which did require a surgical pinning. Knowledge of the developing skeleton, coupled with a robust referral network between rheumatologists and their pediatric sports medicine colleagues, can result in healthy outcomes for these young patients, said Dr. Harris. “Once their conditions are properly addressed, these young athletes may be able to ease back in to full participation.”
Young Athletes with Rheumatic Pain
The last presenter of the afternoon session was Alison P. Toth, MD, an assistant professor of orthopedic surgery and director, Women’s Sports Medicine Clinic, at Duke University Medical Center, who discussed the special considerations in treating young athletes with juvenile arthritis and other rheumatic conditions.
Certain precautions should be followed for kids with juvenile arthritis, since they may be more prone to injury. In those with C-spine arthritis, for instance, Dr. Toth recommends a baseline preparticipation X-ray to rule out ligamentous laxity. A baseline neurological exam may also be warranted, and physicians should counsel these students to avoid collision/contact sports and sports with the potential for catastrophic neck injury, such as diving or gymnastics. Some risks can be mediated with preventive measures, such as wearing eye protection to prevent further eye damage in those with uveitis or applying sports sunscreen for those taking hydroxychloroquine to treat lupus. During periods of moderate to severe disease activity, young athletes with arthritis should limit weight-bearing sports to avoid further structural damage. Gradual return to play after flare-ups can be attained, said Dr. Toth, if pain and swelling have subsided and range of motion, strength, and balance are regained.
