Growth Related Injuries in Juniors

Growth related injuries are always a concern for junior football coaches, medical staff and treating physiotherapists.

Participation by children in Australian Football is on the increase. Not only is there a larger number of children participating, but we are also seeing many individuals playing not just one sport, but a number of different sports at the same time. Add to this the fact that sport seems a lot more serious, even at junior level, (and as a consequence training sessions have an increased frequency and intensity) and, as a result, injuries in children are increasing.

The growing bones of children and adolescents have a number of differences to the fully developed mature bone structure of adult. The main structural components of an immature bone are:

  • Head of the bone (physis)
  • Growth plate (epiphysis)
  • Shaft of bone (metaphysis)

The main differences in childrens bone structure are as follows:

  1. The joint cartilage or cushioning is of greater depth (thicker) than that of an adult, and can be remodelled. This allows greater shock absorbing capabilities, as well as the possibility of cartilage repair after injury.
  2. There is a weak point at the junction of the growth plate and the shaft of the bone. This point is predisposed to shearing trauma which can result in movement of the head of the bone, and can be likened to the appearance of ice cream falling of the edge of a cone.
  3. Tendons attach muscle to bone. In children, the tendons attach via a section of cartilage (which is softer than the calcified attachment of adult tendon). This is a very vulnerable point that can result in avulsion (the tendon tearing away a piece of bone), or detachment of the tendon from the bone.
  4. The shaft of the bone is more elastic in children and therefore less likely to break or snap.
  5. Children tend to suffer “greenstick” or hairline/incomplete fractures.
  6. Children tend to grow in “spurts”, and during rapid growth periods, bone lengthens or grows quicker than the muscles and tendons that are attached to it. This results in the muscles and tendons being permanently on stretch, placing greater tension on these tissues and the bone, and resulting in less strength and co-ordination to control the bone. This contributes to the awkwardness that is commonly seen during these rapid growth periods.

So injury rates in children would appear to be related to three main factors:

  1. Many children are playing multiple sports, or the same sport with multiple teams.
  2. Training and competition frequency and intensity has increased.
  3. The growing bones and tissues of children are susceptible to injury.

Fortunately many conditions in adolescence are self-limiting, and full recovery does occur with the right management in most cases. However serious conditions can occur, and a missed diagnosis can have significant consequences, particularly if it has occurred during the rapid growth period.

It is no longer acceptable to simply put your childs pain down as being “growing pains”. Children generally have the ability to recover quickly from their injuries, therefore if their pain has not disappeared relatively quickly then you should seek a diagnosis for the pain.

The more common conditions we see in childhood and adolescence include:

Osteochondritis Dissecans

This is a splitting or fragmenting of a piece of cartilage and attached bone from a joint and is most common at the knee, elbow, ankle, and hip. It is more common in boys ( 3:1) and usually presents between the ages of 10 - 20 years. The child will complain of pain, swelling, catching, and often “locking” of the joint. The locking is caused when the fragment of bone and cartilage becomes jammed between the joint surfaces.

There is nearly always associated swelling of the joint. Xrays diagnose the problem. If an early diagnosis is made and activity is restricted, conservative treatment (physiotherapy) can settle the problem. However as most children present late, surgical intervention may be necessary. Surgery aims to either remove the fragment, or if possible, reattach it to the joint surface.

Osgood Schlatter’s Disease (OSD)

This condition is caused by the inferior portion of the patella tendon pulling on its attachment to the tibia (shin bone), causing an inflammatory response. Unfortunately this tendon attachment point is also part of the growth plate of the bone and as such is a vulnerable area. OSD is more common in boys and tends to occur between the ages of 10 and 16.

Symptoms are very specific, and include acute pain and often swelling over the upper shin. The pain is aggravated by jumping, squatting, running, stairs and especially kneeling. OSD is commonly seen in both knees. Diagnosis is made purely by symptoms that are reported and Xrays are only necessary in more severe cases. Surgery is rarely necessary. Rest and ice are indicated. OSD tends to naturally ease within one to two years.

Patella Tendinopathy (“Jumpers Knee”)

This is similar to OSD, but affects the bottom pole of the kneecap and upper attachment of the patella tendon. Symptoms are similar to OSD, but pain is particularly aggravated by jumping. It is common in the jumping sports ( basketball, high/long jump etc).

Severs Disease

Severs occurs in children generally between the ages of 10 and 12 and again is more common in boys. It is caused by the achilles tendon pulling on its attachment to the heel bone, creating an inflammatory response. It is common for both heels to be affected and pain is specific to the back of the heel but can radiate along the side of the heel area. Treatment involves rest and ice. XRays generally are not necessary. At times we prescribe a cushioned heel pad.

Advice for coaches

For coaches at junior football level, it is important to consider the following points:

  • Specialisation is discouraged before age 10 or puberty - encourage a wide variety of sports/activities
  • Ensure adequate adult supervision
  • Take injuries seriously - children tend to not complain of pain for more than a few days unless they have a definite problem
  • Strength training is safe but light weights must be encouraged along with adult supervision
  • Many sports have specific guidelines for training volumes in children to reduce the risk of overuse injuries (e.g. cricket, baseball, swimming, distance running )
  • Nutrition is critical for active children. Strict restriction of nutritional requirements can have detrimental results (e.g. gymnasts)
  • Children are at higher risk when exposed to heat/cold due to less ability to automatically regulate their own body temperature
  • Biomechanical problems should be referred to a physiotherapist, podiatrist or doctor for further assessment
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