Musculoskeletal complaints in children are usually related to activity. Different injury patterns occur at different ages, probably reflecting relative strengths of adjacent structures at the particular skeletal age.
The immature musculoskeletal system differs significantly from that of the mature individual. Open growth plates are vulnerable to different types of injury, the nature of which varies with age, growth rate and in the presence of a disease process. The characteristics of periosteum and articular cartilage are also different from those of adults.
Additional factors also can play significant roles. Flexibility is usually greater in the child, and there is a greater incidence of hypermobility, which is associated with a higher risk of injury and a longer healing time. On the other hand, growth spurts can lead to muscle-tendon imbalances across joints leading to local injury or to non-specific pain (previously termed ‘growing pains’). Growth spurts also result in reduced flexibility, with lengthening of the musculotendinous unit lagging behind elongation of bone, with resulting stresses applied in particular to the musculotendinous attachments. Biomechanical problems are also common in young people and can increase the stresses upon these tissues and commonly contribute to shin and/or anterior knee pain. Growth spurts and weight gain can alterations in co-ordination and centre of gravity, all of which make the child more susceptible to injury.
Lack of supervision or inadequate matching in contact sports, when matching is performed by age rather than height, weight, development and maturity are further contributing factors to injury. Psychological factors, motivation and parental/peer pressure may be positive or negative influences.
Injuries in children and adolescents can affect the growth plate and these injuries require serious attention.
Injuries can be acute or related to overuse. Where acute injuries occur in the prepubescent child, ligamentous injuries are more likely, as the bone is usually stronger than soft tissues. At the time of the adolescent growth spurt, however, growth plate injuries may occur, as the ligaments may be stronger during this period. At all ages, however, the possibility of a fracture must be considered; and note that x-rays can be inconclusive in this group.
Overuse injuries in relation to repetitive microtrauma are increasingly recognised, often in relation to heavy training in sports. Injuries include tendinitis, bursitis, physeal and osteochondral injuries. Apophyseal injuries (apophysitides) include small avulsions at the weaker bone –cartilage junction due to repetitive traction stresses, with subsequent repair. These include Osgood Schlatters disease at the knee, Severs disease at the heel and iliac crest apophysitis disease at the pelvis. Patients differ in how they respond to these complaints and so no one single approach suits all.
Management of injuries in Children & Adolescents
Although the principles of management are the same, the treatment of soft tissue complaints in children differs from that in adults in several respects. The use of drugs is generally discouraged, although may be necessary in severe cases or where rehabilitation is being inhibited; the use of injections is· strongly discouraged; the use of modalities such as ultrasound should be avoided near open growth plates, but the use of electromuscular stimulation is allowed.
Rehabilitation, as with adults, forms the core of the management regime, but must be modified to suit the child. Those children going through growth spurts also need much explanation and reassurance that, for example, the sudden changes in co-ordination that has occurred is temporary. If strength training is considered, the child must adhere to light weights, and move through a limited range of motion. Those children with hypermobility need much counseling, reassurance and supervised rehabilitation.
Some of Professor Speed’s publications on Children + Adolescents:
- Bones before 50: children and adolescents
- Vitamin D
- Speed CA, Fordham JN, Cunningham JL.Simultaneous bilateral tibial stress fractures in a 15-year-old milkman–a case report. Br J Rheumatol. 1996 Sep;35(9):905-7.
- Speed CA. Sports Injuries. In: ABC of Rheumatology. Adebajo A (ed). BMJ Books. 2003. 2007 (4th edition).
- SPECIAL GROUPS: IN: The Oxford Textbook of Soft Tissue Rheumatology. BL Hazleman, GP Riley, CA Speed (eds). Oxford University Press. Oxford, 2004.