Primary Periphyseal Stress Injuries in Young Athletes: A Systematic Review.

BACKGROUND: Overuse injuries are common in sporting children and adolescents. These injuries are a particular concern when they involve the epiphyseal-physeal-metaphyseal (EPM) complex given their potential to disturb skeletal growth. Specifically, the limits of mechanical tolerance of the EPM complex to repetitive stress may be exceeded by the intense and continuous training characteristic of many youth sports today. OBJECTIVE: This article describes the present status of knowledge on the occurrence and outcome of primary periphyseal stress injuries (PPSIs) affecting the EPM complex in the extremities of children and adolescents involved in youth sports. METHODS: A comprehensive review of the sports medicine literature was conducted to determine the nature and extent of PPSIs affecting the EPM complex of the extremities among youth sports participants and the potential for consequent skeletal growth disturbance and resultant limb deformity associated with these injuries. RESULTS: Our initial search uncovered 128 original published scientific articles reporting relevant data on PPSIs. There were 101 case reports/series, 19 cross-sectional, 1 case-control, and 7 cohort studies with relevant data. The case reports/series studies reported 448 patients with PPSIs involving the extremities. Children and adolescents representing a variety of high impact repetitive youth sports activities-including baseball, badminton, climbing, cricket, dance, gymnastics, rugby, soccer, swimming, tennis, and volleyball-may sustain PPSIs involving the shoulder, elbow, hand and wrist, knee, and ankle and foot. Although incidence data from prospective cohort studies are lacking, data arising from cross-sectional studies suggest that PPSIs may be common in select groups of youth athletes-including the shoulder in baseball players (0-36.6%), wrist in gymnasts (10-83%) and platform divers (52.6%), and fingers in rock climbers (5-58%). Notably, not all stress-related skeletal changes detected on imaging were symptomatic in these studies. When diagnosed and treated with an appropriate period of rest and rehabilitation, most patients studied were able to return to their sport activities. However, our data also show that 57/448 PPSIs (12.7%) produced growth disturbance, and that 28/448 patients (6.2%) underwent surgery for their injuries. Absence of treatment, delayed presentation and diagnosis, and non-compliance with a rest regimen were common in cases that produced growth disturbance. CONCLUSIONS: PPSIs may affect the extremities of children and adolescents engaged in a variety of youth sports, especially at advanced levels of training and competition. Most skeletally immature patients with PPSIs respond well to timely treatment; however, in extreme cases, PPSIs can progress to produce skeletal growth disruption which may necessitate surgical intervention. Clearly, establishing the early diagnosis of PPSIs and providing timely treatment of these injuries are needed to ensure the skeletal health of youth sports participants. Rigorous prospective longitudinal epidemiological and imaging studies designed to provide incidence rates of PPSIs and to determine the effect of PPSIs on long-term skeletal health are also necessary.

Does Functional Bracing of the Unstable Shoulder Improve Return to Play in Scholastic Athletes? Returning the Unstable Shoulder to Play.

BACKGROUND: Functional bracing is often used as an adjunct to nonoperative treatment of anterior shoulder instability, but no study has evaluated the effectiveness of in-season bracing. The purpose of this study was to examine successful return to play in a nonoperative cohort of adolescent athletes with in-season shoulder instability and compare those athletes treated with bracing to those who were not. HYPOTHESIS: The use of functional bracing will improve success rates in a cohort of athletes treated nonoperatively for in-season shoulder instability. STUDY DESIGN: Cohort study. LEVEL OF EVIDENCE: Level 3. METHODS: A total of 97 athletes with anterior shoulder instability were followed for a minimum of 1 year. The mean age was 15.8 ± 1.4 years (range, 12.0-18.0 years). All athletes were treated with initial nonoperative management. Twenty athletes (21%) were also treated with bracing while 77 (79%) were not. The athlete completing the current season and 1 subsequent season without surgery or time lost from shoulder injury was defined as a successful outcome. RESULTS: There was no statistical difference in nonoperative success rates between the braced and nonbraced athletes (P = 0.33). Braced athletes (n = 20) returned to play 80% of the time, while nonbraced athletes (n = 77) returned at a rate of 88%. Of the braced athletes, 85% were football players (n = 17). A football-only comparison demonstrated no difference between braced failures (26%) and nonbraced failures (16%) (P = 0.47). CONCLUSION: This is the first study to evaluate the utility of functional bracing in returning an athlete to sport and completing a full subsequent season without surgery or time loss due to injury of the shoulder. In adolescent athletes with shoulder instability treated nonoperatively, functional bracing did not result in increased success rates when compared with no bracing. CLINICAL RELEVANCE: The data from this study indicate that functional bracing may not improve success rates for athletes with shoulder instability.

Sport specialization is associated with upper-extremity overuse injury in high school baseball players.

BACKGROUND AND HYPOTHESIS: Sport specialization is increasingly common in youth sports and is a risk factor for lower-extremity overuse injuries. However, limited data exist on whether specialization is associated with upper-extremity (UE) overuse injuries, specifically in youth baseball players. We hypothesized that specialization in baseball and being a pitcher would be associated with poorer arm health and UE overuse injury history in the previous year. METHODS: During the 2019 spring baseball season, 551 high school baseball athletes (aged 15.9 ± 1.3 years) from 3 states (Alabama, n = 200; California, n = 188; and Michigan, n = 163) completed an anonymous questionnaire. Athletes were recruited from 5 high schools in each state, with schools matched based on factors that influence specialization rates. The questionnaire consisted of (1) demographic characteristics, (2) baseball participation information (including sport specialization status), and (3) throwing-arm health and UE injury history in the previous 12 months. Throwing-arm health was assessed using the Youth Throwing Score (YTS), a validated and reliable outcome measure for youth baseball players. Multivariate regression analyses were used to examine the association between variables of interest and the YTS or UE overuse injury history, adjusting for covariates. RESULTS: After adjustment for covariates, highly specialized athletes were more likely to report a UE overuse injury in the previous year compared with low-specialization athletes (odds ratio [OR], 3.77; 95% confidence interval [CI], 1.39-10.2, P = .009). Both athletes who reported playing baseball for more than 8 months per year (OR, 2.03; 95% CI, 1.12-3.65; P = .019) and athletes who reported being a pitcher (OR, 2.11; 95% CI, 1.20-3.72; P = .010) were more likely to report a history of UE overuse injury. Highly specialized players reported lower (worse) YTS values compared with low-specialization players (least-squares mean estimate ± standard error, 56.5 ± 1.1 vs. 53.3 ± 0.7; P = .034). Players who reported pitching as one of their positions scored worse on the YTS than non-pitchers (least-squares mean estimate ± standard error, 51.6 ± 0.8 vs. 57.2 ± 0.6; P < .001). CONCLUSION: Although baseball recommendations that discourage sport specialization are widely available for parents, athletes, and coaches, high rates of sport specialization were reported in our sample. We found that being highly specialized in baseball was associated with UE overuse injury history and worse throwing-arm health in high school baseball athletes. Continued education for baseball parents, athletes, and coaches is necessary to raise awareness of the risks associated with high specialization.

Ulnar Collateral Ligament Reconstruction.

Ulnar collateral ligament (UCL) injuries can significantly impair the overhead athlete. Reconstruction of the anterior bundle of the UCL (UCL-R) has allowed a high proportion of these individuals to return to their previous level of play. Several techniques for UCL-R are described that produce acceptable results with an overall low complication rate. Transient ulnar neuritis is the most common complication following UCL-R. The rate of UCL injury in young athletes is rising with increased youth involvement and year-round participation in overhead sports. The sports medicine community must broaden its focus to not only treat UCL injuries but also prevent them.

Outcome Metrics in Pediatric Sports Medicine: Do PROMIS Computer-adaptive Testing Metrics Correlate With Pedi-IKDC?

BACKGROUND: A modified version of the International Knee Documentation Committee (IKDC), the Pedi-IKDC, is a validated patient-reported outcome measure in pediatric patients with knee pain. However, this questionnaire is lengthy and can fatigue patients, leading to inconsistent outcome collection. Thus, we sought to compare more easily attainable Patient-Reported Outcomes Measurement Information System (PROMIS) computer adaptive testing patient reported outcomes to the gold standard Pedi-IKDC. METHODS: We prospectively collected PROMIS scores and Pedi-IKDC scores in 100 new, consecutive patients presenting with knee pain to a pediatric sports medicine practice. Patients were excluded if they provided an incomplete Pedi-IKDC, had prior ipsilateral lower extremity surgery, or significant associated medical comorbidities. PROMIS domains including Mobility, Pain Interference, and Upper Extremity (control) were compared with the Pedi-IKDC with Pearson correlations. The number of questions in each metric was analyzed. Floor and ceiling effects of each test were also assessed. RESULTS: The average age of the study cohort was 14 years (range, 7 to 18 y) with 53% female and 47% male. 70% of patients completed the Pedi-IKDC questionnaire, compared with 100% with PROMIS tests. The average Pedi-IKDC score was 48.8±22.3 (range, 5.4 to 100). Mean scores for Mobility, Pain Interference, and Upper Extremity domains were 38.4±10.1, 53.5±10.3, and 49.7±8.7, respectively. All tests demonstrated similar and acceptable floor and ceiling effects (<15%). The length of the Pedi-IKDC (22 questions) was roughly double that of combined PROMIS Pain Interference and Mobility tests (11.9±2.3 questions). Pedi-IKDC scores correlated with tested PROMIS measures (Mobility/Pain Interference, r=0.42/-0.49). When 7 highly functional patients with significant pain symptoms were removed for a secondary analysis, Mobility and Pain correlations improved to 0.69 and -0.67, respectively. CONCLUSIONS: PROMIS Mobility and Pain scores demonstrate moderate correlations with the Pedi-IKDC, highlighting these tests are not capturing the same patient experiences. These correlations are weakened by a small group of painful yet highly functioning patients. The Pedi-IKDC was significantly longer and had a much lower completion rate than PROMIS tests, highlighting a need for a validated computer adaptive testing in evaluating pediatric patients with knee pain. LEVELS OF EVIDENCE: Level II.

Current Evidence for Acute Pain Management of Musculoskeletal Injuries and Postoperative Pain in Pediatric and Adolescent Athletes.

OBJECTIVE: Sports-related injuries in young athletes are increasingly prevalent with an estimated 2.6 million children and adolescents sustaining a sports-related injury annually. Acute sports-related injuries and surgical correction of sports-related injuries cause physical pain and psychological burdens on pediatric athletes and their families. This article aims to evaluate current acute pain management options in pediatric athletes and acute pain management strategies for postoperative pain after sports-related injuries. This article will also elucidate which areas of pain management for pediatric athletes are lacking evidence and help direct future clinical trials. DATA SOURCES: We conducted a literature search through PubMed and the Cochrane Central Register of Controlled Trials to provide an extensive review of initial and postoperative pain management strategies for pediatric sports-related musculoskeletal injuries. MAIN RESULTS: The current knowledge of acute pain management for initial sports-related injuries, postoperative pain management for orthopedic surgeries, as well as complementary and alternative medical therapies in pediatric sports-related injuries is presented. Studies evaluating conservative management, enteral and nonenteral medications, regional anesthesia, and complementary medical therapies are included. CONCLUSIONS: Adequate pain management is important for sports injuries in children and adolescents for emotional as well as physical healing, but a balance must be achieved to provide acceptable pain relief while minimizing opioid use and side effects from analgesic medications. More studies are needed to evaluate the efficacy of nonopioid analgesic medications and complementary therapies in pediatric patients with acute sports-related injuries.

Rotator Cuff Repair in Adolescent Athletes.

BACKGROUND: Rotator cuff tears are rare injuries in adolescents but cause significant morbidity if unrecognized. Previous literature on rotator cuff repairs in adolescents is limited to small case series, with few data to guide treatment. HYPOTHESIS: Adolescent patients would have excellent functional outcome scores and return to the same level of sports participation after rotator cuff repair but would have some difficulty with returning to overhead sports. STUDY DESIGN: Case series; Level of evidence 4. METHODS: A retrospective search of the practice's billing records identified all patients participating in at least 1 sport who underwent rotator cuff repair between 2006 and 2014 with an age <18 years at the time of surgery and a minimum follow-up of 2 years. Clinical records were evaluated for demographic information, and telephone follow-up was obtained regarding return to play, performance, other surgery and complications, a numeric pain rating scale (0-10) for current shoulder pain, American Shoulder and Elbow Surgeons (ASES) Shoulder Assessment Form, and the Western Ontario Rotator Cuff Index. RESULTS: Thirty-two consecutive adolescent athletes (28 boys and 4 girls) with a mean age of 16.1 years (range, 13.2-17.9 years) met inclusion criteria. Twenty-nine patients (91%) had a traumatic event, and 27 of these patients (93%) had no symptoms before the trauma. The most common single tendon injury was to the supraspinatus (21 patients, 66%), of which 2 were complete tendon tears, 1 was a bony avulsion of the tendon, and 18 were high-grade partial tears. Fourteen patients (56%) underwent single-row repair of their rotator cuff tear, and 11 (44%) underwent double-row repair. All subscapularis injuries were repaired in open fashion, while all other tears were repaired arthroscopically. Twenty-seven patients (84%) completed the outcome questionnaires at a mean 6.2 years after surgery (range, 2-10 years). The mean ASES score was 93 (range, 65-100; SD = 9); mean Western Ontario Rotator Cuff Index, 89% (range, 60%-100%; SD = 13%); and mean numeric pain rating, 0.3 (range, 0-3; SD = 0.8). Overall, 25 patients (93%) returned to the same level of play or higher. Among overhead athletes, 13 (93%) were able to return to the same level of play, but 8 (57%) were forced to change positions. There were no surgical complications, but 2 patients did undergo a subsequent operation. CONCLUSION: Surgical repair of high-grade partial-thickness and complete rotator cuff tears yielded successful outcomes among adolescents, with excellent functional outcomes at midterm follow-up. However, overhead athletes may have difficulty playing the same position after surgery.