Injuries to pediatric athletes have increased in number over the years as children are being pushed to specialize in one sport year-round. It is no longer unusual for kids to play in club sports and travel teams, and attend camps during the summer and winter breaks. Playing at these elite levels puts them at risk for overuse injuries.

      When children play different sports throughout the year, they use different body parts and movements, which reduces the risk of injuries, especially from overuse. Overuse injuries account for upwards of 90% of adolescent sports related injuries, according to some studies.

      Whether involved in one sport year-round or multiple sports throughout the year, an off season is necessary to allow the body to recover. Rest and recovery is important for all athletes, but especially for young athletes going through growth spurts. Injuries can interfere significantly with growth and development, as can caloric restriction (gymnastics, wrestling) and heavy weightlifting.

      Overuse injuries are also coming from poor coaching, “win at all costs” attitude, and trying to play through an injury. Parents and coaches seem to forget that sports-especially for children-should be fun, not work. Too often, the “play” is left out of playing sports.

     Injuries can affect children much differently than adults-both physically and emotionally. In part II of our pediatric athlete series, we will discuss pediatric injuries from a medical viewpoint. 

A stress fracture is a “crack” in the bone, and it’s a relatively common condition in the foot of an athlete who does a lot of running and jumping.
Fractures can be categorized in many ways, but it is important to differentiate between an acute fracture and a stress fracture.
An acute fracture is caused by a sudden trauma, that can be either from a direct force (like falling out of a tree and landing on your leg), or an indirect force (like falling from the same tree, but this time getting your leg caught between two branches and twisting the bone). Unlike an acute fracture, a stress fracture is not the result of one specific trauma or force. Instead, a stress fracture is the result from repeatedly loading or stressing a bone. Our bones are constantly being remodeled. This normal process of our cells breaking down old bone and building up new bone is called remodeling and it is a cycle that goes on throughout our lives. If you increase the amount of “loading” or stress on the bones, it results in microtrauma, and speeds up, or accelerates the remodeling process. During this phase, there is usually no pain or symptoms, and X-rays will not show any significant changes. If this “overloading” of the bone continues, you will begin to have pain during your training session or run. As this mirotrauma accumulates, you may notice pain starting earlier and earlier into your run. If you continue to train, you may progress into the stress-reaction phase. This phase is characterized by progressively worsening pain. You may now have pain immediately upon running, and the pain may remain even after you stop. The pain you used to have only at the end your run is now present when you are just walking. At this stage you may also have night pain. (1). Although a MRI or bone scan may be positive at this phase, most likely an X-ray will be negative (no signs of fracture). As microtrauma continues to weaken the bone, it will eventually lead to a completed fracture. It is usually not until this phase, that an X-ray will show positive for a stress fracture.

Stress fractures of the foot are almost always related to a sudden increase in amount or intensity of an activity. “Doing too much, too soon, too often, and with too little rest.” (2). Other factors that contribute to stress fractures of the foot are exercising on a hard surface, shoes that have poor support and shock absorption and structural problems of the foot. “Menstrual and eating disorders can also cause reduced bone mineral density and increase the risk of stress fractures.” (2)

Some common sites in the foot for stress fractures are the navicular bone (found on the inside of your arch) the metatarsals (known as “March fractures”) and the sesamoid bones (beneath the head of the first metatarsal and the base of the fifth).

Treatment of a stress fracture will most importantly mean decreasing the load on the bone, preferably making it non-weight bearing. This usually means crutches, possibly casted for 4-8 weeks. The amount of time depends on where the fracture is located. The areas that have the poorest blood supply will take longer to heal. In certain cases, surgery will be indicated to stabilize the fracture site. Alternative exercises may be indicated during this time. Activities such as swimming, stationary cycling and strength training may be prescribed. Resuming activity and training must be done gradually and cautiously. All activity must remain pain free. A physical therapist will be able to treat and guide you through this important phase of recovery. It is also beneficial to evaluate the foot structurally (do you need orthotics?), assess footwear (get good shoes), modify your training program (more rest, cross training, slower progression, vary running surface, limit miles…etc). After your initial rehab, you may want to work with a personal trainer who has education and experience working with runners.

Stress fractures of the foot usually heal well if they are properly and early diagnosed and treatment protocol is followed. Addressing the above concerns will help to prevent another stress fracture.

Bibliography
1. Magee, D.: Orthopedic Physical Assessment (3rd Edition). W.B.
Saunders Company. Philadelphia. 1997.
2. Bahr, R. & Maehlum, S.: Clinical Guide to Sports Injuries. Gazette bok.
Oslo. 2004.

The best way to treat an injury is to prevent it from happening in the first place. Two significant contributing factors to a hamstring injury are:
1. Hamstring to quad (quadricep) strength ratio
2. Flexibility
Athletes and coaches tend to emphasize quad strengthening (which is very important to protect the knee and optimize performance), but may overlook the hamstrings. The hamstrings should fall between 60-70% of the quad strength. To insure sufficient hamstring strength, it is recommended that athletes perform a series of exercises that isolate the hamstrings and are specific to their sport. For example, a football player might incorporate lunges into their workout routine.

Another contributing factor to hamstring injury is a lack of flexibility. This can easily be prevented with a good stretching program. Remember that a muscle stretches best (and most safely) when it is warmed up. Try a low intensity exercise for 10-15 minutes just before stretching to get the most effective results. Also, try “slowing down” your stretches. Spend three minutes stretching your hamstring, ON EACH LEG. Stretches should also be slow and gentle, never forcing and never bouncing. Stretches should also be comfortable and never painful. Don’t forget to also stretch again after the game, as part of your cool down. One great way to stretch the hamstrings is called the “Doorway Stretch”. Lie down on the floor in a doorway and put one leg up on the doorjamb. Your heel should be resting on the wall and your knee should be straight. If you can’t get your knee all the way straight or it is too much of a pull (uncomfortable), scoot your buttocks farther away from the wall until the stretch is comfortable. If you don’t feel enough of a stretch, try scooting closer to the wall, or putting a belt up over your toes an gently pull your toes towards your nose. Hold for 3 minutes, then scoot over to the other side of the doorway and stretch the other leg.

If you have had a hamstring injury in the past or are trying to get over one, it is important to realize that the main problem with recovering from this injury is, returning too soon to play. The potential for reinjury is high if the muscle is not yet healed. The second injury to the hamstring is often more severe than the initial injury.

You may want to consider seeing a physical therapist if you have, or have had, a hamstring injury and are uncertain how to treat it, when to return to your sport or how to prevent it from happening again. If you have never had an injury and would like to keep it that way, you might choose to work with a certified personal trainer who can teach you specific exercises for strengthening and flexibility.

If you have any questions, please feel free to contact a staff member at COAST rehab, or drop by the clinic. We not only have physical therapy, but also a supervised fitness program and certified personal trainers. We’re here to help.

Early movement is the key to rehab. Since modern surgical techniques provide very good fixation (anchoring), bending (flexion) and straightening (extension) the knee can begin immediately after surgery. A constant passive motion (CPM) machine is recommended if the patient won’t be starting physical therapy immediately. The initial range of motion (ROM) goal is full extension and 110 degrees of flexion. Early movement helps strengthen the graft and reduces the formation of deleterious scar tissue. It also helps prevent breakdown of healthy tissue such as the joint surfaces (cartilage). ROM can also be improved by use of a stationary bike and/or swimming pool.

Controlling fluid (edema) build up in the knee early is very important. Our goal (before full weight bearing is allowed) is 1cm or less. Edema interferes with muscle activation and ROM. Compression via a bandage or sleeve, along with ice/cryotherapy machine are commonly used after surgery. Massage, ultrasound, and various forms of electrical stimulation can be utilized during physical therapy.

Keeping pain low is also key. Pain interferes with healing and motivation. Medications, cryotherapy, massage all can help reduce pain.

Achieving good quad muscle activation early is also important. Weight bearing should not be allowed until the patient can perform a straight leg raise with full extension, otherwise the patient is at increased risk of developing patellar-femoral pain. The body shuts down the muscles around the knee (primarily the quads) after a traumatic event (surgery). Getting the muscles to work properly again, is the focus of rehab once ROM goals have been met and edema is under control. Patients that are instructed in quad exercises prior to surgery usually can achieve good quad muscle activation within a day or so of the operation.

Exercises are designed to improve strength, endurance, flexibility, and balance. The measure of a good rehab program is how quickly a patient is able to return to full functional status. A patient should be progressed when the tissue is ready, instead of waiting a predetermined amount of time. All people heal at different rates. Everyone should be progressed as quickly as their tissues will allow it. In general, our goal is for patients to resume sport specific training within 2-3 months after surgery…that means they have normal strength, ROM, and endurance, no pain or edema, and can run and jump without problems. Often, our patients return to their sports in better condition than prior to their injury due to the comprehensive and intensive rehab program.

If you or anyone you know has questions regarding ACL rehab, please contact us at COAST Rehab via e-mail or by phone.

What is the ACL?

The ACL is a band of fibrous tissue that provides support to the knee. It is the primary restraint to limit forward movement of the lower leg (tibia) relative to the thigh (femur), and it also helps restrain lower leg rotation (pivoting). The function of the ACL is to stabilize the knee joint, prevent abnormal movements, and help guide the movement of the knee.

What are the signs and symptoms of the injury?

Often a pop is heard or felt at the time of the injury. A sensation of instability or knee buckling, especially with pivoting or jumping, is common, as is rapid swelling of the knee. An inability to fully straighten out the knee and significant pain may be present since 75% of ACL injuries include bone contusions and/or meniscal damage.

What are the causes of the injury?

70-80% of ACL injuries occur in non-contact situations. Usually the athlete is planting and cutting, or landing on one leg. In addition, the foot is firmly planted on the ground and is outside the (vertical plane) of the knee, which is slightly bent or straight.
In contact situations, the knee is usually impacted from the side or front (hyperextension), with the foot firmly planted on the ground and the knee slightly bent or straight.

Can this injury be prevented?

Studies have shown that ACL injuries can be reduced via specific exercises that includes perturbation training, jump landings on two feet with the knee over the toe, and strengthening of the lower extremity muscles. Also by avoiding surfaces and shoes that produce a high amount of friction.

What is the role of physical therapy?

ACL injuries in the adult do not heal themselves. The old ligament cannot be fixed, so a new one needs to be constructed. Whether or not a person decides to have surgery (and 70% of untreated knees develop arthritis and/or meniscal tears within 10 years), all patients will benefit from physical therapy. Decreasing pain and swelling, re-establishing normal range of motion and strength, improving balance, agility, and ambulation skills are essential components of a good physical therapy program.
One of the most important things to consider when deciding about treatment is—how long will recovery take?

At COAST Rehab, patients that have ACL surgery (reconstruction) typically return to all normal activities safely within 2-3 months, and sports activities in 3-5 months, which is 2-6 months earlier than typical physical therapy programs.