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Pediatrics
Why Do My
Legs Hurt
Treat The Cause Joseph Chorley MD
Associate Professor
Primary Care Sports Medicine
Fellowship Director
Page 1
xxx00ppt 9102013 25846 PM Pediatrics
Goals and Objectives
bullI have nothing to disclose
bullReview the most serious and most common
diagnoses for leg pain in the pediatric population
bullReview the etiologies of the overuse injury
‐to be able to take a adequate history
‐to be able to identify the musculoskeletal abnormalities
bullReview the principles of treatment of overuse
injuries
Page 2
xxx00ppt 9102013 25847 PM Pediatrics
MOST SERIOUS Always perform medical review of symptoms first
bullInflammatory
‐ JIA or transient synovitis
bullInfection
‐ Osteomyelitis septic arthritis
diskitis
bullTumor
‐ Osteoid osteoma
osteosarcoma Ewingrsquos
Leukemia
bullMSK Injury
‐ Occult injury or abuse
‐ SCFE or Perthes Disease
bullNeuromuscular etiology
‐ Ataxia MD weakness CBLM
peripheral neuropathy
bullAbdominal or testicular
etiology
Page 3
xxx00ppt 9102013 25847 PM Pediatrics
Red flags
bullSystemic symptoms
‐ Malaise Fatigue
‐ Fever
bullMorning symptoms or symptoms that awaken from sleep
bullMultiple joint complaints
bullLimp or NWB
bullAntecedent infection
bullSTI symptoms
bullSkin changes or joint swelling
Page 4
xxx00ppt 9102013 25848 PM Pediatrics
If there are red flags some helpful
considerations bullSubspecialty consultation
bullImaging
‐ Radiographs
‐ MRI
‐ Bone Scan
bullLabs-
‐ ESR
‐ CRP
‐ CBC with diff and plts
bullCultures
Page 5
xxx00ppt 9102013 25848 PM Pediatrics
Rheumatologic
bullMorning Stiffness gt 30rsquo
bullWarm up phenomenon
bullFamily history
bullLate adolescent (10-20 lt16)
bullEnthesitis
Page 6
xxx00ppt 9102013 25849 PM Pediatrics
Infection Osteomyelitis
bullSymptoms
‐gt 3 days or more- 44
‐gt 1 week- 22
‐Fever (40-80)
‐Localized pain (56-95)
‐Decreased mobility (50-
84)
bullLabs
‐Esr 90
‐Crp 98
‐WBC 25
‐Blood culture 30-50
Pediatrics 1994 Jan93(1)59-62 Serum C-reactive protein erythrocyte sedimentation rate and white blood cell count in acute hematogenous osteomyelitis of children Unkila-Kallio L Kallio MJ Eskola J Peltola H
Page 7
xxx00ppt 9102013 25849 PM Pediatrics
Diskitis and Paraspinal Abscess
bullLess systemic
symptoms but more
severe presentation in
pediatric patient
bullLocalized tenderness
bullRadicular pain and
paresthesias
bullWeakness altered
sensation loss of sphincter
bullParalysis
bullONLY 13 HAVE FEVER
Page 8
xxx00ppt 9102013 25850 PM Pediatrics
Septic arthritis
bullNWB
bullFever
bullESR
bullCRP
bullWBC gt12K
Page 9
xxx00ppt 9102013 25850 PM Pediatrics
Tumors
Page 10
xxx00ppt 9102013 25851 PM Pediatrics
Page 11
xxx00ppt 9102013 25851 PM Pediatrics
Osteosarcoma
bull Most common bone tumor in children
bull Prior irradiation or chemotherapy 12-16 years prior
bull Symptoms
‐ localized pain typically of several months duration Pain frequently begins after an injury and may wax and wane over time
‐ Systemic symptoms such as fever weight loss and malaise are generally absent
bull Most common location
‐ distal femur proximal tibia
bull Laboratory evaluation is usually normal
‐ Alkaline phosphatase (40)
‐ Lactate dehydrogenase (30)
Page 12
xxx00ppt 9102013 25852 PM Pediatrics
Ewing Sarcoma
bullSecond most common bone tumor in children
bullHighest frequency between 5-15 years
bullLocation
‐ pelvis 25
‐ femur 16
‐ fibula tibia 14
bullFrequent delay in diagnosis
‐ one report averaged over nine months
Page 13
xxx00ppt 9102013 25852 PM Pediatrics
Osteoid osteomas
bullIntense night pain relieved by NSAIDs
bullMost common
‐Proximal Femur
‐Tibia other parts of femur
spine
bull25 are not obvious on XR
Page 14
xxx00ppt 9102013 25853 PM Pediatrics
Child Abuse
bullFractures second most common injury (~55)
bull85 occurring in children lt3 yo
bullIf a single fracture the most common location is diaphyseal
femur (35) or humerus (29 )
bullNo particular fracture pattern location or morphology that is
absolutely pathognomonic of child abuse
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 1
xxx00ppt 9102013 25846 PM Pediatrics
Goals and Objectives
bullI have nothing to disclose
bullReview the most serious and most common
diagnoses for leg pain in the pediatric population
bullReview the etiologies of the overuse injury
‐to be able to take a adequate history
‐to be able to identify the musculoskeletal abnormalities
bullReview the principles of treatment of overuse
injuries
Page 2
xxx00ppt 9102013 25847 PM Pediatrics
MOST SERIOUS Always perform medical review of symptoms first
bullInflammatory
‐ JIA or transient synovitis
bullInfection
‐ Osteomyelitis septic arthritis
diskitis
bullTumor
‐ Osteoid osteoma
osteosarcoma Ewingrsquos
Leukemia
bullMSK Injury
‐ Occult injury or abuse
‐ SCFE or Perthes Disease
bullNeuromuscular etiology
‐ Ataxia MD weakness CBLM
peripheral neuropathy
bullAbdominal or testicular
etiology
Page 3
xxx00ppt 9102013 25847 PM Pediatrics
Red flags
bullSystemic symptoms
‐ Malaise Fatigue
‐ Fever
bullMorning symptoms or symptoms that awaken from sleep
bullMultiple joint complaints
bullLimp or NWB
bullAntecedent infection
bullSTI symptoms
bullSkin changes or joint swelling
Page 4
xxx00ppt 9102013 25848 PM Pediatrics
If there are red flags some helpful
considerations bullSubspecialty consultation
bullImaging
‐ Radiographs
‐ MRI
‐ Bone Scan
bullLabs-
‐ ESR
‐ CRP
‐ CBC with diff and plts
bullCultures
Page 5
xxx00ppt 9102013 25848 PM Pediatrics
Rheumatologic
bullMorning Stiffness gt 30rsquo
bullWarm up phenomenon
bullFamily history
bullLate adolescent (10-20 lt16)
bullEnthesitis
Page 6
xxx00ppt 9102013 25849 PM Pediatrics
Infection Osteomyelitis
bullSymptoms
‐gt 3 days or more- 44
‐gt 1 week- 22
‐Fever (40-80)
‐Localized pain (56-95)
‐Decreased mobility (50-
84)
bullLabs
‐Esr 90
‐Crp 98
‐WBC 25
‐Blood culture 30-50
Pediatrics 1994 Jan93(1)59-62 Serum C-reactive protein erythrocyte sedimentation rate and white blood cell count in acute hematogenous osteomyelitis of children Unkila-Kallio L Kallio MJ Eskola J Peltola H
Page 7
xxx00ppt 9102013 25849 PM Pediatrics
Diskitis and Paraspinal Abscess
bullLess systemic
symptoms but more
severe presentation in
pediatric patient
bullLocalized tenderness
bullRadicular pain and
paresthesias
bullWeakness altered
sensation loss of sphincter
bullParalysis
bullONLY 13 HAVE FEVER
Page 8
xxx00ppt 9102013 25850 PM Pediatrics
Septic arthritis
bullNWB
bullFever
bullESR
bullCRP
bullWBC gt12K
Page 9
xxx00ppt 9102013 25850 PM Pediatrics
Tumors
Page 10
xxx00ppt 9102013 25851 PM Pediatrics
Page 11
xxx00ppt 9102013 25851 PM Pediatrics
Osteosarcoma
bull Most common bone tumor in children
bull Prior irradiation or chemotherapy 12-16 years prior
bull Symptoms
‐ localized pain typically of several months duration Pain frequently begins after an injury and may wax and wane over time
‐ Systemic symptoms such as fever weight loss and malaise are generally absent
bull Most common location
‐ distal femur proximal tibia
bull Laboratory evaluation is usually normal
‐ Alkaline phosphatase (40)
‐ Lactate dehydrogenase (30)
Page 12
xxx00ppt 9102013 25852 PM Pediatrics
Ewing Sarcoma
bullSecond most common bone tumor in children
bullHighest frequency between 5-15 years
bullLocation
‐ pelvis 25
‐ femur 16
‐ fibula tibia 14
bullFrequent delay in diagnosis
‐ one report averaged over nine months
Page 13
xxx00ppt 9102013 25852 PM Pediatrics
Osteoid osteomas
bullIntense night pain relieved by NSAIDs
bullMost common
‐Proximal Femur
‐Tibia other parts of femur
spine
bull25 are not obvious on XR
Page 14
xxx00ppt 9102013 25853 PM Pediatrics
Child Abuse
bullFractures second most common injury (~55)
bull85 occurring in children lt3 yo
bullIf a single fracture the most common location is diaphyseal
femur (35) or humerus (29 )
bullNo particular fracture pattern location or morphology that is
absolutely pathognomonic of child abuse
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 2
xxx00ppt 9102013 25847 PM Pediatrics
MOST SERIOUS Always perform medical review of symptoms first
bullInflammatory
‐ JIA or transient synovitis
bullInfection
‐ Osteomyelitis septic arthritis
diskitis
bullTumor
‐ Osteoid osteoma
osteosarcoma Ewingrsquos
Leukemia
bullMSK Injury
‐ Occult injury or abuse
‐ SCFE or Perthes Disease
bullNeuromuscular etiology
‐ Ataxia MD weakness CBLM
peripheral neuropathy
bullAbdominal or testicular
etiology
Page 3
xxx00ppt 9102013 25847 PM Pediatrics
Red flags
bullSystemic symptoms
‐ Malaise Fatigue
‐ Fever
bullMorning symptoms or symptoms that awaken from sleep
bullMultiple joint complaints
bullLimp or NWB
bullAntecedent infection
bullSTI symptoms
bullSkin changes or joint swelling
Page 4
xxx00ppt 9102013 25848 PM Pediatrics
If there are red flags some helpful
considerations bullSubspecialty consultation
bullImaging
‐ Radiographs
‐ MRI
‐ Bone Scan
bullLabs-
‐ ESR
‐ CRP
‐ CBC with diff and plts
bullCultures
Page 5
xxx00ppt 9102013 25848 PM Pediatrics
Rheumatologic
bullMorning Stiffness gt 30rsquo
bullWarm up phenomenon
bullFamily history
bullLate adolescent (10-20 lt16)
bullEnthesitis
Page 6
xxx00ppt 9102013 25849 PM Pediatrics
Infection Osteomyelitis
bullSymptoms
‐gt 3 days or more- 44
‐gt 1 week- 22
‐Fever (40-80)
‐Localized pain (56-95)
‐Decreased mobility (50-
84)
bullLabs
‐Esr 90
‐Crp 98
‐WBC 25
‐Blood culture 30-50
Pediatrics 1994 Jan93(1)59-62 Serum C-reactive protein erythrocyte sedimentation rate and white blood cell count in acute hematogenous osteomyelitis of children Unkila-Kallio L Kallio MJ Eskola J Peltola H
Page 7
xxx00ppt 9102013 25849 PM Pediatrics
Diskitis and Paraspinal Abscess
bullLess systemic
symptoms but more
severe presentation in
pediatric patient
bullLocalized tenderness
bullRadicular pain and
paresthesias
bullWeakness altered
sensation loss of sphincter
bullParalysis
bullONLY 13 HAVE FEVER
Page 8
xxx00ppt 9102013 25850 PM Pediatrics
Septic arthritis
bullNWB
bullFever
bullESR
bullCRP
bullWBC gt12K
Page 9
xxx00ppt 9102013 25850 PM Pediatrics
Tumors
Page 10
xxx00ppt 9102013 25851 PM Pediatrics
Page 11
xxx00ppt 9102013 25851 PM Pediatrics
Osteosarcoma
bull Most common bone tumor in children
bull Prior irradiation or chemotherapy 12-16 years prior
bull Symptoms
‐ localized pain typically of several months duration Pain frequently begins after an injury and may wax and wane over time
‐ Systemic symptoms such as fever weight loss and malaise are generally absent
bull Most common location
‐ distal femur proximal tibia
bull Laboratory evaluation is usually normal
‐ Alkaline phosphatase (40)
‐ Lactate dehydrogenase (30)
Page 12
xxx00ppt 9102013 25852 PM Pediatrics
Ewing Sarcoma
bullSecond most common bone tumor in children
bullHighest frequency between 5-15 years
bullLocation
‐ pelvis 25
‐ femur 16
‐ fibula tibia 14
bullFrequent delay in diagnosis
‐ one report averaged over nine months
Page 13
xxx00ppt 9102013 25852 PM Pediatrics
Osteoid osteomas
bullIntense night pain relieved by NSAIDs
bullMost common
‐Proximal Femur
‐Tibia other parts of femur
spine
bull25 are not obvious on XR
Page 14
xxx00ppt 9102013 25853 PM Pediatrics
Child Abuse
bullFractures second most common injury (~55)
bull85 occurring in children lt3 yo
bullIf a single fracture the most common location is diaphyseal
femur (35) or humerus (29 )
bullNo particular fracture pattern location or morphology that is
absolutely pathognomonic of child abuse
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 3
xxx00ppt 9102013 25847 PM Pediatrics
Red flags
bullSystemic symptoms
‐ Malaise Fatigue
‐ Fever
bullMorning symptoms or symptoms that awaken from sleep
bullMultiple joint complaints
bullLimp or NWB
bullAntecedent infection
bullSTI symptoms
bullSkin changes or joint swelling
Page 4
xxx00ppt 9102013 25848 PM Pediatrics
If there are red flags some helpful
considerations bullSubspecialty consultation
bullImaging
‐ Radiographs
‐ MRI
‐ Bone Scan
bullLabs-
‐ ESR
‐ CRP
‐ CBC with diff and plts
bullCultures
Page 5
xxx00ppt 9102013 25848 PM Pediatrics
Rheumatologic
bullMorning Stiffness gt 30rsquo
bullWarm up phenomenon
bullFamily history
bullLate adolescent (10-20 lt16)
bullEnthesitis
Page 6
xxx00ppt 9102013 25849 PM Pediatrics
Infection Osteomyelitis
bullSymptoms
‐gt 3 days or more- 44
‐gt 1 week- 22
‐Fever (40-80)
‐Localized pain (56-95)
‐Decreased mobility (50-
84)
bullLabs
‐Esr 90
‐Crp 98
‐WBC 25
‐Blood culture 30-50
Pediatrics 1994 Jan93(1)59-62 Serum C-reactive protein erythrocyte sedimentation rate and white blood cell count in acute hematogenous osteomyelitis of children Unkila-Kallio L Kallio MJ Eskola J Peltola H
Page 7
xxx00ppt 9102013 25849 PM Pediatrics
Diskitis and Paraspinal Abscess
bullLess systemic
symptoms but more
severe presentation in
pediatric patient
bullLocalized tenderness
bullRadicular pain and
paresthesias
bullWeakness altered
sensation loss of sphincter
bullParalysis
bullONLY 13 HAVE FEVER
Page 8
xxx00ppt 9102013 25850 PM Pediatrics
Septic arthritis
bullNWB
bullFever
bullESR
bullCRP
bullWBC gt12K
Page 9
xxx00ppt 9102013 25850 PM Pediatrics
Tumors
Page 10
xxx00ppt 9102013 25851 PM Pediatrics
Page 11
xxx00ppt 9102013 25851 PM Pediatrics
Osteosarcoma
bull Most common bone tumor in children
bull Prior irradiation or chemotherapy 12-16 years prior
bull Symptoms
‐ localized pain typically of several months duration Pain frequently begins after an injury and may wax and wane over time
‐ Systemic symptoms such as fever weight loss and malaise are generally absent
bull Most common location
‐ distal femur proximal tibia
bull Laboratory evaluation is usually normal
‐ Alkaline phosphatase (40)
‐ Lactate dehydrogenase (30)
Page 12
xxx00ppt 9102013 25852 PM Pediatrics
Ewing Sarcoma
bullSecond most common bone tumor in children
bullHighest frequency between 5-15 years
bullLocation
‐ pelvis 25
‐ femur 16
‐ fibula tibia 14
bullFrequent delay in diagnosis
‐ one report averaged over nine months
Page 13
xxx00ppt 9102013 25852 PM Pediatrics
Osteoid osteomas
bullIntense night pain relieved by NSAIDs
bullMost common
‐Proximal Femur
‐Tibia other parts of femur
spine
bull25 are not obvious on XR
Page 14
xxx00ppt 9102013 25853 PM Pediatrics
Child Abuse
bullFractures second most common injury (~55)
bull85 occurring in children lt3 yo
bullIf a single fracture the most common location is diaphyseal
femur (35) or humerus (29 )
bullNo particular fracture pattern location or morphology that is
absolutely pathognomonic of child abuse
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 4
xxx00ppt 9102013 25848 PM Pediatrics
If there are red flags some helpful
considerations bullSubspecialty consultation
bullImaging
‐ Radiographs
‐ MRI
‐ Bone Scan
bullLabs-
‐ ESR
‐ CRP
‐ CBC with diff and plts
bullCultures
Page 5
xxx00ppt 9102013 25848 PM Pediatrics
Rheumatologic
bullMorning Stiffness gt 30rsquo
bullWarm up phenomenon
bullFamily history
bullLate adolescent (10-20 lt16)
bullEnthesitis
Page 6
xxx00ppt 9102013 25849 PM Pediatrics
Infection Osteomyelitis
bullSymptoms
‐gt 3 days or more- 44
‐gt 1 week- 22
‐Fever (40-80)
‐Localized pain (56-95)
‐Decreased mobility (50-
84)
bullLabs
‐Esr 90
‐Crp 98
‐WBC 25
‐Blood culture 30-50
Pediatrics 1994 Jan93(1)59-62 Serum C-reactive protein erythrocyte sedimentation rate and white blood cell count in acute hematogenous osteomyelitis of children Unkila-Kallio L Kallio MJ Eskola J Peltola H
Page 7
xxx00ppt 9102013 25849 PM Pediatrics
Diskitis and Paraspinal Abscess
bullLess systemic
symptoms but more
severe presentation in
pediatric patient
bullLocalized tenderness
bullRadicular pain and
paresthesias
bullWeakness altered
sensation loss of sphincter
bullParalysis
bullONLY 13 HAVE FEVER
Page 8
xxx00ppt 9102013 25850 PM Pediatrics
Septic arthritis
bullNWB
bullFever
bullESR
bullCRP
bullWBC gt12K
Page 9
xxx00ppt 9102013 25850 PM Pediatrics
Tumors
Page 10
xxx00ppt 9102013 25851 PM Pediatrics
Page 11
xxx00ppt 9102013 25851 PM Pediatrics
Osteosarcoma
bull Most common bone tumor in children
bull Prior irradiation or chemotherapy 12-16 years prior
bull Symptoms
‐ localized pain typically of several months duration Pain frequently begins after an injury and may wax and wane over time
‐ Systemic symptoms such as fever weight loss and malaise are generally absent
bull Most common location
‐ distal femur proximal tibia
bull Laboratory evaluation is usually normal
‐ Alkaline phosphatase (40)
‐ Lactate dehydrogenase (30)
Page 12
xxx00ppt 9102013 25852 PM Pediatrics
Ewing Sarcoma
bullSecond most common bone tumor in children
bullHighest frequency between 5-15 years
bullLocation
‐ pelvis 25
‐ femur 16
‐ fibula tibia 14
bullFrequent delay in diagnosis
‐ one report averaged over nine months
Page 13
xxx00ppt 9102013 25852 PM Pediatrics
Osteoid osteomas
bullIntense night pain relieved by NSAIDs
bullMost common
‐Proximal Femur
‐Tibia other parts of femur
spine
bull25 are not obvious on XR
Page 14
xxx00ppt 9102013 25853 PM Pediatrics
Child Abuse
bullFractures second most common injury (~55)
bull85 occurring in children lt3 yo
bullIf a single fracture the most common location is diaphyseal
femur (35) or humerus (29 )
bullNo particular fracture pattern location or morphology that is
absolutely pathognomonic of child abuse
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 5
xxx00ppt 9102013 25848 PM Pediatrics
Rheumatologic
bullMorning Stiffness gt 30rsquo
bullWarm up phenomenon
bullFamily history
bullLate adolescent (10-20 lt16)
bullEnthesitis
Page 6
xxx00ppt 9102013 25849 PM Pediatrics
Infection Osteomyelitis
bullSymptoms
‐gt 3 days or more- 44
‐gt 1 week- 22
‐Fever (40-80)
‐Localized pain (56-95)
‐Decreased mobility (50-
84)
bullLabs
‐Esr 90
‐Crp 98
‐WBC 25
‐Blood culture 30-50
Pediatrics 1994 Jan93(1)59-62 Serum C-reactive protein erythrocyte sedimentation rate and white blood cell count in acute hematogenous osteomyelitis of children Unkila-Kallio L Kallio MJ Eskola J Peltola H
Page 7
xxx00ppt 9102013 25849 PM Pediatrics
Diskitis and Paraspinal Abscess
bullLess systemic
symptoms but more
severe presentation in
pediatric patient
bullLocalized tenderness
bullRadicular pain and
paresthesias
bullWeakness altered
sensation loss of sphincter
bullParalysis
bullONLY 13 HAVE FEVER
Page 8
xxx00ppt 9102013 25850 PM Pediatrics
Septic arthritis
bullNWB
bullFever
bullESR
bullCRP
bullWBC gt12K
Page 9
xxx00ppt 9102013 25850 PM Pediatrics
Tumors
Page 10
xxx00ppt 9102013 25851 PM Pediatrics
Page 11
xxx00ppt 9102013 25851 PM Pediatrics
Osteosarcoma
bull Most common bone tumor in children
bull Prior irradiation or chemotherapy 12-16 years prior
bull Symptoms
‐ localized pain typically of several months duration Pain frequently begins after an injury and may wax and wane over time
‐ Systemic symptoms such as fever weight loss and malaise are generally absent
bull Most common location
‐ distal femur proximal tibia
bull Laboratory evaluation is usually normal
‐ Alkaline phosphatase (40)
‐ Lactate dehydrogenase (30)
Page 12
xxx00ppt 9102013 25852 PM Pediatrics
Ewing Sarcoma
bullSecond most common bone tumor in children
bullHighest frequency between 5-15 years
bullLocation
‐ pelvis 25
‐ femur 16
‐ fibula tibia 14
bullFrequent delay in diagnosis
‐ one report averaged over nine months
Page 13
xxx00ppt 9102013 25852 PM Pediatrics
Osteoid osteomas
bullIntense night pain relieved by NSAIDs
bullMost common
‐Proximal Femur
‐Tibia other parts of femur
spine
bull25 are not obvious on XR
Page 14
xxx00ppt 9102013 25853 PM Pediatrics
Child Abuse
bullFractures second most common injury (~55)
bull85 occurring in children lt3 yo
bullIf a single fracture the most common location is diaphyseal
femur (35) or humerus (29 )
bullNo particular fracture pattern location or morphology that is
absolutely pathognomonic of child abuse
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 6
xxx00ppt 9102013 25849 PM Pediatrics
Infection Osteomyelitis
bullSymptoms
‐gt 3 days or more- 44
‐gt 1 week- 22
‐Fever (40-80)
‐Localized pain (56-95)
‐Decreased mobility (50-
84)
bullLabs
‐Esr 90
‐Crp 98
‐WBC 25
‐Blood culture 30-50
Pediatrics 1994 Jan93(1)59-62 Serum C-reactive protein erythrocyte sedimentation rate and white blood cell count in acute hematogenous osteomyelitis of children Unkila-Kallio L Kallio MJ Eskola J Peltola H
Page 7
xxx00ppt 9102013 25849 PM Pediatrics
Diskitis and Paraspinal Abscess
bullLess systemic
symptoms but more
severe presentation in
pediatric patient
bullLocalized tenderness
bullRadicular pain and
paresthesias
bullWeakness altered
sensation loss of sphincter
bullParalysis
bullONLY 13 HAVE FEVER
Page 8
xxx00ppt 9102013 25850 PM Pediatrics
Septic arthritis
bullNWB
bullFever
bullESR
bullCRP
bullWBC gt12K
Page 9
xxx00ppt 9102013 25850 PM Pediatrics
Tumors
Page 10
xxx00ppt 9102013 25851 PM Pediatrics
Page 11
xxx00ppt 9102013 25851 PM Pediatrics
Osteosarcoma
bull Most common bone tumor in children
bull Prior irradiation or chemotherapy 12-16 years prior
bull Symptoms
‐ localized pain typically of several months duration Pain frequently begins after an injury and may wax and wane over time
‐ Systemic symptoms such as fever weight loss and malaise are generally absent
bull Most common location
‐ distal femur proximal tibia
bull Laboratory evaluation is usually normal
‐ Alkaline phosphatase (40)
‐ Lactate dehydrogenase (30)
Page 12
xxx00ppt 9102013 25852 PM Pediatrics
Ewing Sarcoma
bullSecond most common bone tumor in children
bullHighest frequency between 5-15 years
bullLocation
‐ pelvis 25
‐ femur 16
‐ fibula tibia 14
bullFrequent delay in diagnosis
‐ one report averaged over nine months
Page 13
xxx00ppt 9102013 25852 PM Pediatrics
Osteoid osteomas
bullIntense night pain relieved by NSAIDs
bullMost common
‐Proximal Femur
‐Tibia other parts of femur
spine
bull25 are not obvious on XR
Page 14
xxx00ppt 9102013 25853 PM Pediatrics
Child Abuse
bullFractures second most common injury (~55)
bull85 occurring in children lt3 yo
bullIf a single fracture the most common location is diaphyseal
femur (35) or humerus (29 )
bullNo particular fracture pattern location or morphology that is
absolutely pathognomonic of child abuse
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 7
xxx00ppt 9102013 25849 PM Pediatrics
Diskitis and Paraspinal Abscess
bullLess systemic
symptoms but more
severe presentation in
pediatric patient
bullLocalized tenderness
bullRadicular pain and
paresthesias
bullWeakness altered
sensation loss of sphincter
bullParalysis
bullONLY 13 HAVE FEVER
Page 8
xxx00ppt 9102013 25850 PM Pediatrics
Septic arthritis
bullNWB
bullFever
bullESR
bullCRP
bullWBC gt12K
Page 9
xxx00ppt 9102013 25850 PM Pediatrics
Tumors
Page 10
xxx00ppt 9102013 25851 PM Pediatrics
Page 11
xxx00ppt 9102013 25851 PM Pediatrics
Osteosarcoma
bull Most common bone tumor in children
bull Prior irradiation or chemotherapy 12-16 years prior
bull Symptoms
‐ localized pain typically of several months duration Pain frequently begins after an injury and may wax and wane over time
‐ Systemic symptoms such as fever weight loss and malaise are generally absent
bull Most common location
‐ distal femur proximal tibia
bull Laboratory evaluation is usually normal
‐ Alkaline phosphatase (40)
‐ Lactate dehydrogenase (30)
Page 12
xxx00ppt 9102013 25852 PM Pediatrics
Ewing Sarcoma
bullSecond most common bone tumor in children
bullHighest frequency between 5-15 years
bullLocation
‐ pelvis 25
‐ femur 16
‐ fibula tibia 14
bullFrequent delay in diagnosis
‐ one report averaged over nine months
Page 13
xxx00ppt 9102013 25852 PM Pediatrics
Osteoid osteomas
bullIntense night pain relieved by NSAIDs
bullMost common
‐Proximal Femur
‐Tibia other parts of femur
spine
bull25 are not obvious on XR
Page 14
xxx00ppt 9102013 25853 PM Pediatrics
Child Abuse
bullFractures second most common injury (~55)
bull85 occurring in children lt3 yo
bullIf a single fracture the most common location is diaphyseal
femur (35) or humerus (29 )
bullNo particular fracture pattern location or morphology that is
absolutely pathognomonic of child abuse
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 8
xxx00ppt 9102013 25850 PM Pediatrics
Septic arthritis
bullNWB
bullFever
bullESR
bullCRP
bullWBC gt12K
Page 9
xxx00ppt 9102013 25850 PM Pediatrics
Tumors
Page 10
xxx00ppt 9102013 25851 PM Pediatrics
Page 11
xxx00ppt 9102013 25851 PM Pediatrics
Osteosarcoma
bull Most common bone tumor in children
bull Prior irradiation or chemotherapy 12-16 years prior
bull Symptoms
‐ localized pain typically of several months duration Pain frequently begins after an injury and may wax and wane over time
‐ Systemic symptoms such as fever weight loss and malaise are generally absent
bull Most common location
‐ distal femur proximal tibia
bull Laboratory evaluation is usually normal
‐ Alkaline phosphatase (40)
‐ Lactate dehydrogenase (30)
Page 12
xxx00ppt 9102013 25852 PM Pediatrics
Ewing Sarcoma
bullSecond most common bone tumor in children
bullHighest frequency between 5-15 years
bullLocation
‐ pelvis 25
‐ femur 16
‐ fibula tibia 14
bullFrequent delay in diagnosis
‐ one report averaged over nine months
Page 13
xxx00ppt 9102013 25852 PM Pediatrics
Osteoid osteomas
bullIntense night pain relieved by NSAIDs
bullMost common
‐Proximal Femur
‐Tibia other parts of femur
spine
bull25 are not obvious on XR
Page 14
xxx00ppt 9102013 25853 PM Pediatrics
Child Abuse
bullFractures second most common injury (~55)
bull85 occurring in children lt3 yo
bullIf a single fracture the most common location is diaphyseal
femur (35) or humerus (29 )
bullNo particular fracture pattern location or morphology that is
absolutely pathognomonic of child abuse
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 9
xxx00ppt 9102013 25850 PM Pediatrics
Tumors
Page 10
xxx00ppt 9102013 25851 PM Pediatrics
Page 11
xxx00ppt 9102013 25851 PM Pediatrics
Osteosarcoma
bull Most common bone tumor in children
bull Prior irradiation or chemotherapy 12-16 years prior
bull Symptoms
‐ localized pain typically of several months duration Pain frequently begins after an injury and may wax and wane over time
‐ Systemic symptoms such as fever weight loss and malaise are generally absent
bull Most common location
‐ distal femur proximal tibia
bull Laboratory evaluation is usually normal
‐ Alkaline phosphatase (40)
‐ Lactate dehydrogenase (30)
Page 12
xxx00ppt 9102013 25852 PM Pediatrics
Ewing Sarcoma
bullSecond most common bone tumor in children
bullHighest frequency between 5-15 years
bullLocation
‐ pelvis 25
‐ femur 16
‐ fibula tibia 14
bullFrequent delay in diagnosis
‐ one report averaged over nine months
Page 13
xxx00ppt 9102013 25852 PM Pediatrics
Osteoid osteomas
bullIntense night pain relieved by NSAIDs
bullMost common
‐Proximal Femur
‐Tibia other parts of femur
spine
bull25 are not obvious on XR
Page 14
xxx00ppt 9102013 25853 PM Pediatrics
Child Abuse
bullFractures second most common injury (~55)
bull85 occurring in children lt3 yo
bullIf a single fracture the most common location is diaphyseal
femur (35) or humerus (29 )
bullNo particular fracture pattern location or morphology that is
absolutely pathognomonic of child abuse
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 10
xxx00ppt 9102013 25851 PM Pediatrics
Page 11
xxx00ppt 9102013 25851 PM Pediatrics
Osteosarcoma
bull Most common bone tumor in children
bull Prior irradiation or chemotherapy 12-16 years prior
bull Symptoms
‐ localized pain typically of several months duration Pain frequently begins after an injury and may wax and wane over time
‐ Systemic symptoms such as fever weight loss and malaise are generally absent
bull Most common location
‐ distal femur proximal tibia
bull Laboratory evaluation is usually normal
‐ Alkaline phosphatase (40)
‐ Lactate dehydrogenase (30)
Page 12
xxx00ppt 9102013 25852 PM Pediatrics
Ewing Sarcoma
bullSecond most common bone tumor in children
bullHighest frequency between 5-15 years
bullLocation
‐ pelvis 25
‐ femur 16
‐ fibula tibia 14
bullFrequent delay in diagnosis
‐ one report averaged over nine months
Page 13
xxx00ppt 9102013 25852 PM Pediatrics
Osteoid osteomas
bullIntense night pain relieved by NSAIDs
bullMost common
‐Proximal Femur
‐Tibia other parts of femur
spine
bull25 are not obvious on XR
Page 14
xxx00ppt 9102013 25853 PM Pediatrics
Child Abuse
bullFractures second most common injury (~55)
bull85 occurring in children lt3 yo
bullIf a single fracture the most common location is diaphyseal
femur (35) or humerus (29 )
bullNo particular fracture pattern location or morphology that is
absolutely pathognomonic of child abuse
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 11
xxx00ppt 9102013 25851 PM Pediatrics
Osteosarcoma
bull Most common bone tumor in children
bull Prior irradiation or chemotherapy 12-16 years prior
bull Symptoms
‐ localized pain typically of several months duration Pain frequently begins after an injury and may wax and wane over time
‐ Systemic symptoms such as fever weight loss and malaise are generally absent
bull Most common location
‐ distal femur proximal tibia
bull Laboratory evaluation is usually normal
‐ Alkaline phosphatase (40)
‐ Lactate dehydrogenase (30)
Page 12
xxx00ppt 9102013 25852 PM Pediatrics
Ewing Sarcoma
bullSecond most common bone tumor in children
bullHighest frequency between 5-15 years
bullLocation
‐ pelvis 25
‐ femur 16
‐ fibula tibia 14
bullFrequent delay in diagnosis
‐ one report averaged over nine months
Page 13
xxx00ppt 9102013 25852 PM Pediatrics
Osteoid osteomas
bullIntense night pain relieved by NSAIDs
bullMost common
‐Proximal Femur
‐Tibia other parts of femur
spine
bull25 are not obvious on XR
Page 14
xxx00ppt 9102013 25853 PM Pediatrics
Child Abuse
bullFractures second most common injury (~55)
bull85 occurring in children lt3 yo
bullIf a single fracture the most common location is diaphyseal
femur (35) or humerus (29 )
bullNo particular fracture pattern location or morphology that is
absolutely pathognomonic of child abuse
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 12
xxx00ppt 9102013 25852 PM Pediatrics
Ewing Sarcoma
bullSecond most common bone tumor in children
bullHighest frequency between 5-15 years
bullLocation
‐ pelvis 25
‐ femur 16
‐ fibula tibia 14
bullFrequent delay in diagnosis
‐ one report averaged over nine months
Page 13
xxx00ppt 9102013 25852 PM Pediatrics
Osteoid osteomas
bullIntense night pain relieved by NSAIDs
bullMost common
‐Proximal Femur
‐Tibia other parts of femur
spine
bull25 are not obvious on XR
Page 14
xxx00ppt 9102013 25853 PM Pediatrics
Child Abuse
bullFractures second most common injury (~55)
bull85 occurring in children lt3 yo
bullIf a single fracture the most common location is diaphyseal
femur (35) or humerus (29 )
bullNo particular fracture pattern location or morphology that is
absolutely pathognomonic of child abuse
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 13
xxx00ppt 9102013 25852 PM Pediatrics
Osteoid osteomas
bullIntense night pain relieved by NSAIDs
bullMost common
‐Proximal Femur
‐Tibia other parts of femur
spine
bull25 are not obvious on XR
Page 14
xxx00ppt 9102013 25853 PM Pediatrics
Child Abuse
bullFractures second most common injury (~55)
bull85 occurring in children lt3 yo
bullIf a single fracture the most common location is diaphyseal
femur (35) or humerus (29 )
bullNo particular fracture pattern location or morphology that is
absolutely pathognomonic of child abuse
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 14
xxx00ppt 9102013 25853 PM Pediatrics
Child Abuse
bullFractures second most common injury (~55)
bull85 occurring in children lt3 yo
bullIf a single fracture the most common location is diaphyseal
femur (35) or humerus (29 )
bullNo particular fracture pattern location or morphology that is
absolutely pathognomonic of child abuse
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 15
xxx00ppt 9102013 25853 PM Pediatrics
Fractures that are highly suggestive
of intentional injury
bullMetaphyseal corner
bullRib fractures
bullFractures of the sternum scapula or spinous processes
bullMultiple fractures in various stages of healing
bullBilateral acute long-bone fractures
bullSkull fractures in children younger than 18 months of age particularly
without a corresponding history
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 16
xxx00ppt 9102013 25854 PM Pediatrics
Slipped Capital Femoral Epiphysis
(SCIFE)
bullAge 12-15 usually growth spurt Obese
More males than females
‐ It will be bilateral in 50 of the time but often not simultaneously
Physical Exam
‐ Pain and or abnormal gait
‐ Decreased internal rotation of hip
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 17
xxx00ppt 9102013 25854 PM Pediatrics
Ice cream falls of the cone
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 18
xxx00ppt 9102013 25855 PM Pediatrics
Legg- Calve-Perthes disease
(osteochondrosis)
bullTemporary interruption of blood supply to the
proximal femoral epiphysis
‐Leads to impaired epiphyseal growth and flattening of the
femoral head by dense bone deposition
‐Remodeling occurs as the bone develops and matures
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 19
xxx00ppt 9102013 25856 PM Pediatrics
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 20
xxx00ppt 9102013 25856 PM Pediatrics
Clinical features
bullAge 4-12 years old
bullGender MF 41
bullCC limp and intermittent pain + trauma
bullPE decreased abduction and internal rotation
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 21
xxx00ppt 9102013 25857 PM Pediatrics
Other sites of osteochondrosis
bullFreibergrsquos disease Metatarsal heads
bullKienboumlckrsquos disease Lunate
bullKohlerrsquos disease Navicular
bullPannerrsquos disease Capitellum
bullScheuermannrsquos disease Wedging anterior vertebral bodies
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 22
xxx00ppt 9102013 25857 PM Pediatrics
Sports Medicine Diagnoses
bullPatellofemoral Dysfunction
bullMedial Tibial Stress Syndrome
bullOsteochondritis Dissecans
bullTarsal Coalition
bullApophysitis
‐Knee Heel
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 23
xxx00ppt 9102013 25858 PM Pediatrics
What are the diagnoses for leg pain
bullGrowing pains
bullStress fracture
bullPes planus
bullApophysitis
bullHallux valgus
bullSacroiliac dysfunction
bullHip impingement
bullMedial Tibial Stress Syndrome
bullAchilles tendonitis
bullAnkle impingement
bullPatellofemoral dysfunction
bull ITband syndrome
bullPlica syndrome
bullAvulsion Fracture
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 24
xxx00ppt 9102013 25858 PM Pediatrics
Etiologies of Lower extremity pain
bullAnatomic alignment and biomechanics
bull Imbalance (may be related to peak height velocity)
‐ Flexibility
‐ Strength
bullEndurance
bullProprioception
bullEquipment and Technique errors
bullOveruse
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 25
xxx00ppt 9102013 25859 PM Pediatrics
Inspection
TARSAL COALITION BLOUNTrsquoS DISEASE
HYPERMOBILITY
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 26
xxx00ppt 9102013 25859 PM Pediatrics
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 27
xxx00ppt 9102013 25900 PM Pediatrics
Passive Range of Motion
bullGastroc soleus
bullHamstrings
bullIliopsoas
bullIliotibial Band
bullQuads
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 28
xxx00ppt 9102013 25900 PM Pediatrics
Strength and Propriocpetion
bullStrong quads and calfs
‐21 quad to hamstrings
bullWeak all over
bullSingle leg squat
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 29
xxx00ppt 9102013 25901 PM Pediatrics
Functional Testing
bullGait
‐ walking and running
bull5 hop test
bullSingle leg triple jump
bullPlank
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 30
xxx00ppt 9102013 25902 PM Pediatrics
bullYour physical exam is much less demanding than
sports
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 31
xxx00ppt 9102013 25902 PM Pediatrics
Equipment or Training Errors
bullShoes
bullAsymmetric sport or strength training
bullSquatsPower cleans Knee extensionsLunges
bullOverstriding
bullSpeedwork
bullToo rapid progression
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 32
xxx00ppt 9102013 25902 PM Pediatrics
All that is normal What now
bullConcept of Overuse Injuries
bullTraining is based on progressive overload with body response to a build it back stronger for the next assault
bull If workload is too much for the repair crew
‐Workload problems include too much too often too intense
‐Repair crew problems include not enough rest poor nutrition poor baseline conditioning genetic healing potential
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 33
xxx00ppt 9102013 25903 PM Pediatrics
Classification of Overuse Injuries
bullMild
‐pain during activity but able to perform without decreased
effectiveness
bullModerate
‐performance is affected
bullSevere
‐activities of daily living are affected
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 34
xxx00ppt 9102013 25903 PM Pediatrics
Etiologies of overuse injuries
bullToo much workload
‐ total amount
‐ intensity
‐progression
‐ frequency
bullToo specific training
bullPerforming increased risk training techniques
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 35
xxx00ppt 9102013 25904 PM Pediatrics
Factors that contribute to overuse
bullPoor nutrition
bullAmenorrhea
bullObesity
bullChronic medical problems that may cause early
fatigue
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 36
xxx00ppt 9102013 25904 PM Pediatrics
Early signs and symptoms
bullSleep changes
bullFatigue
bullProlonged muscles soreness or ldquoheavyrdquo feeling
bullMood swings apathy
bullWeight loss- increased appetite or thirst
bullVital signs alteration
bullFlu-like symptoms
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 37
xxx00ppt 9102013 25905 PM Pediatrics
Psychological aspects-
etiology of and reaction to injury
bullBurnout
bullPost injury depression
bullSomatization syndromes
bullStress anxiety state
bullDevelopmental stress
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 38
xxx00ppt 9102013 25905 PM Pediatrics
Treatment Principles
bullGod gave us pain to tell us when we have a problem
bullOK to treat the symptom so that you can treat the etiology
but remember the definition of stupidity
bullParticipation does not equal rehabilitation
bullRehabilitation must be translated into their activity
bullDecreasing training load by 50 is a good compromise
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 39
xxx00ppt 9102013 25906 PM Pediatrics
Summary
bullAlways consider bad things first
bullBe sure to identify the etiology of the diagnosis
bullTreat the most significant etiology to focus rehab
bullTechnique is extremely important
bullTreat your patient with progressive function in mind
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
Page 40
xxx00ppt 9102013 25906 PM Pediatrics
Thanks
bullAny questions
