2010 Sports Medicine Conference - Dell Children`s Medical Center

2010 Sports Medicine Conference
Children’s Bone, Joint and Spine Center
John J. Williams, M.D.
Central Texas Pediatric Orthopedics
Background
• Back pain in adolescent athletes is common
Second most frequent cause of a visit to the
doctor
• 5-10 percent of all sports injuries are related to
the lower back
• Weight lifting, track and field events, skiing,
soccer, running, golf, skating, lacrosse, football,
baseball, tennis , and gymnastics all have high
rates of back injuries
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Causes
• Back pain in adolescence can be broken down
into acute injuries, and chronic overuse injuries.
• Acute injuries are usually caused by a muscle
strain or ligament sprain.
• Bruising, stretching or mild tearing of soft tissues
can cause pain and moderate to severe muscle
spasm
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Causes
• Repetitive hyperextension and twisting are
responsible for the chronic overuse injuries.
• The combination of weak abdominal muscles and
tight hamstrings predisposes growing children to
back injuries.
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Types of Injuries
• Mechanical Back Strain and Sprains
• Spondylolysis/Spondylolysthesis
• Disc Herniation
• Compression Fractures
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Mechanical Back Strain
• Strains occur by disruption of muscle fibers
within the muscle belly or musculotendinous
junction.
• Acute pain is most intense 24-48 hours after
injury, and is associated with intense muscle
spasm.
• Recurrent strains occur when muscle is reinjured
before healing can occur.
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Sprains
• Sprains occur by stretching or partially tearing
spinal ligaments.
• Interspinous process ligaments are most
commonly affected.
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Treatment for Strains and Sprains
• Short periods of rest
• Icing in the acute phase
• NSAIDs and muscle relaxers
• Guided gentle physical therapy program
• Athlete should be pain-free with normal flexibility
before returning to activity
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Spndylolysis/Spondylolysthesis
• Spondylolysis is a defect within the bone of
posterior part of the neural arch
• Usually occurs at the pars interarticularis
• L5 is most common level (85-95%)
• L4 is next most common level (5-15%)
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Spondylolysis/Spondylolysthesis
Etiology is a stress fracture caused by repetitive loading.
Unstable bilateral pars defects can lead to a “slip” or spondylolysthesis
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Spondylolysis/Spondylolysthesis
• Prevalence of spondylolysis in general population
is 3-6%. Most are asymptomatic.
• Very high incidence in adolescent athletes with
back pain (47%)
• Higher prevalence in certain sports: 43% divers,
30% wrestlers, 23% weight lifters, 27% throwing
athletes, 17% gymnasts, 17% rowers
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Spondylolysis/Spondylolysthesis
• This is an chronic overuse injury!
• Pain is confined to the low back and may radiate
to the buttock or back of the thigh
• Hamstring tightness on straight leg raising test
• Pain is exagerated with extension (single leg
extension test)
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Spondylolysis/Spondylolysthesis
• Imaging begins with plain radiographs (85% of
pars defects seen)
• Spondylolysthesis or splipping is graded by
percentage of slip (grade 1 <25, etc)
• For symptomatic patients with negative x-rays:
CT scan, bone scan, or MRI can be diagnostic
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Spondy Treatment
• Majority of athletes with pars stress fractures can
be treated non-operatively, and most will be able
to return to play
• Treatment involves a brief period of rest (6
weeks) followed by a period of physical rehab (6
weeks)
• Athletes can return to play when they are painfree regardless of whether or not there is
radiographic evidenced of pars healing
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Spondy Treatment
• Bracing can be used to “slow down” overzealous
athletes, or treat pain that is not relieved after 6
weeks of rest
• 75-80% of athletes will have an excellent result
and will be able to return to play with
conservative treatment
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Spondy Treatment
• Surgery is indicated for patients with neurologic
deficits related to spondylolysthesis, or
progressive, unstable slips (Grade III, IV)
• Surgery (posterolateral fusion) also used for
recalcitrant back pain associated with
spondylolysis or mild spondylolysthesis
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Spondy Treatment
• Direct pars repair in athletes is controversial
• Indicated for persistent pain that has failed to
resolve after 6 months of conservative care
• Smaller operation than fusion with faster return
to athletics. Results are comparable to fusion
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Disc Herniation
While degenerative disc disease in adult athletes is common, it it rare in
children.
Herniated Discs occasionally occur in adolescents and cause acute back
pain and sciatica
Annulus ruptures and allows disc material to compress a nerve root.
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Disc Herniation
• Discs in children are separated from the vertebra
by a growth plate (ring apophysis)
• Acute stress on the end-plate can cause a tear of
the apophysis with posterior protrusion of the
disc and end-plate material
• Rare cause of back pain and sciatica in
adolescent athletes (weight lifters).
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Treatment of Disc/End plate Herniation
• Non-operative: Extension and Abdominal
Exercise. Return to sports when full, painless
ROM
• Operative Rx: Free fragments compressing nerve
roots
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Compression Fractures
• Rare in children because of strong bone density
and cushioning effects of healthy discs.
• Can occur with high energy injuries (football, falls
from cheerleading, gymnastics, pole vaulting,
etc.)
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
3 Column system of classification
• Compression: failure of anterior column with
intact middle column
• Burst: failure of anterior and middle columns
• Flexion-Distraction: compression of anterior
column with distraction of middle and posterior
columns
• Fracture-Dislocation: caused by rotary forces
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Treatment of Compression Fractures
• Less than 10 %, rest then hyperextension
exercises
• Greater than 10%, hyperextension brace
• Two or more columns involved, surgical
stabilization my be necessary.
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Summary
• Back Injuries in Adolescent athletes are common
• Muscle Strains and Sprains are the most common
• High percentage of adolescent athletes will have
a spondylolysis. Overuse injury - Usually
treated conservatively
• Disc herniations and compression fractures are
rare high energy acute injuries.
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference
Thank-you
Dell Children’s Bone, Joint and Spine Center
2010 Sports Medicine Conference