BMJ 1994;308:1556-1559 (11 June)

Education and debate

ABC of Sports Medicine: Musculoskeletal Injuries in Child Athletes

L Klenerman 

The growing skeletons of children may be injured more easily than the mature skeletons of adults because the bones are more porous and the long bones are further weakened by the epiphysical plates at their proximal and distal ends. Children and young teenagers nevertheless have a lower injury rate from participation in sport than fully mature adolescents.

Children's v adults' skeletons

More vulnerable because:

* Still growing

* More porous

* Long bones weakened by epiphysial plates at each end

Lower injury rate because:

* More flexible



Osteochondroses are a loose grouping of conditions affecting the growing epiphysis. They all show healing in radiographs. Common examples that occur in growing children at traction epiphyses are Osgood-Schlatter disease (at tibial tuberosity), Sever's disease (at insertion of Achilles tendon), and Larsen-Johansson disease (at lower pole of patella). Others that affect articular surfaces are Freiberg's disease (head of second or third metatarsal) and Panner's disease (capitellum). These disorders result because physical activity in vigorous growing children produces stresses at the bone-ligament junction or on articular surfaces.

Osgood-Schlatter disease is caused by a traumatic avulsion of the patellar tendon from the tibial tuberosity and occurs commonly in children aged 11-13. There is pain and discomfort over the tibial tuberosity after exercise. Examination shows local tenderness and prominence of the tuberosity. The best treatment is to ignore the symptoms. Parents should be advised that symptoms usually last for 12-18 months. Rest will relieve the pain. If the children wish to be active they will aggravate their symptoms but come to no harm. Surgery is rarely required but may be necessary for excision of unfused ossicles deep in the ligamentum patellae. These cause pain on kneeling in adulthood.

Larsen-Johansson disease has a similar pattern of symptoms to Osgood- Schlatter disease but occurs at the lower pole of the patella owing to traction by the ligamentum patellae.

Severs' disease is similar to the two previous diseases but occurs in the heel just below the insertion of the Achilles tendon. There is traction on the growth centre by both the Achilles tendon and the plantar aponeurosis. There is no specific radiological appearance diagnostic to the disorder. The transverse and translucent zones seen on the radiograph are due to tension on the epiphysis.

Freiberg's disease entails collapse of the articular surface of the second or third metatarsal heads and is commonest in girls aged 12-15. There is pain on weight bearing, which results in reduced physical activity. Examination shows local tenderness and swelling, with pain on extension of the affected toe. Non-surgical measures, rest, and a metatarsal pad are often effective in relieving symptoms. Surgical treatment primarily entails removal of loose fragments of articular cartilage and should include resection of a small part of the dorsal aspect of the metatarsal head to allow free dorsiflexion at the metatarsophalangeal joint.

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Freiberg's disease. Note the collapse of the metatarsal head.

Stress Fractures

Stress fractures occur in children less often than in adolescents or adults. Common sites are the upper third of the tibia (51%), the lower third of the fibula (20%), and the pars interarticularis of the lower lumbar vertebrae (15%). The primary training error that leads to stress fractures is doing too much too soon. Plain radiographs will provide the diagnosis in about 50% of cases. Scintigraphy misses few lesions and is invaluable when the diagnosis is in doubt. Stress fractures in the tibia have occasionally been mistaken for osteosarcomas. They occur most commonly in running and gymnastics.

Stress fracture diagnostic aids

* History of training

* Pain on ultrasound treatment

* Plain radiography

* Technetium bone scanning

* Computed tomography

* Scintigraphy

Lesions of the pars interarticularis of the lower lumbar vertebrae occur in those subjected to hyperextension and high axial loading as occurs in gymnastics. In a study of 100 young female gymnasts the incidence of defects was 11%, which is about four times the incidence in the general female population (2.3%). If treatment is started early immobilisation in a plastic jacket will allow healing to occur.

Shear stress and compressive loads have an important influence on physical growth. Obvious changes have been noted in the distal radial epiphyses of high level gymnasts. The extent of change is directly related to the intensity of training, and a reduction of workload will cause the changes to disappear.

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Changes in distal radial epiphyses of gymnast caused by shear stress and compressive loads.

Injuries of anatomical regions.

Head, neck, and spine

The incidence of major head or spinal cord injury in children under 15 is low. Damage is most likely to be in the neck. Rugby and diviing are the commonest causes. Schoolboy rugby teams should be matched for size and weight rather than simply by age as this policy reduces injuries. Scrum engagement still requires careful supervision and crash tackling is illegal.

Shoulder girdle and elbow

Anterior dislocation of the shoulder is rare before the skeleton is mature. Occasionally, recurrent dislocation may occur and treatment is similar to that in adults by a Bankart or Putti-Platt repair. Impingement of the supraspinatus tendon beneath the coracoacromial arch is common in butterfly swimmers and in throwing and racket sports. The primary problem lies in the tendons of the rotator cuff and not in the coracoacromial arch. Impingement in young athletes is often secondary to shoulder instability.


The main cause of elbow problems in athletes who throw objects are the valgus forces that are generated and which produced distraction on the medial side of the joint and compression on the lateral side. Osteochondritis dissecans may occur in the capitellum or radial head. Loose fragments require removal.


Fractures and ligamentous injuries of the carpal bones are less common in children than in adults. The scaphoid is most commonly affected, most injuries occuring in children over 10.

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Stress fracture, upper third of tibia, lateral view.

Hip and pelvis

Overuse injuries from repetitive trauma occur around the pelvis. Pain may occur at any of the apophyses around the pelvis, on the iliac crest, the ischial tuberosity, or the anterior, superior, or inferior iliac spines. Frank avulsion injuries sometimes occur at the surface of iliac spines; if wide separation results they may need open reduction and fixation. Sometimes late diagnosis of an avulsion of the ischial tuberosity is mistaken for an osteosarcoma. The lesser trochanter is sometimes affected and causes considerable pain and swelling. Treatment consists of rest, crutches, and physiotherapy.

Slips of the upper femoral epiphysis may present as either an acute or chronic condition. By definition only slips seen within three weeks of the onset of symptoms after trauma should be considered to be acute. This injury may occur in children aged 12-16 who have pre-existent mild chronic slips. An acute injury may precipitate displacement in a vulnerable capital epiphysis. Affected children are commonly either of the tall, thin, rapidly growing type (greyhound type) or of the large and obese, hypogonadal type. The symptoms are severe pain, limited movement, inability to bear weight, and an external rotation deformity of the leg. In chronic disease the child may complain of persistent knee pain and have no symptoms specifically related to the hip until a clinically noticeable slip has occurred. Early treatment is important before slips occur as it is difficult to fix the capital epiphysis by cannulated screws once moderate displacement has occurred.

Traumatic dislocation of the hip is not a common injury. Dislocations may result from athletic injury. Posterior dislocation of the hip has occurred in accidents during mini-rugby in which players kneeling on the ground have had someone fall on top of them. The incidence of complications of traumatic dislocation of the hip in children is lower than that in adults as the dislocation occurs with less force. Avascular necrosis may occur in about 10% of cases.

Sports causing injuries of specific anatomical areas

Sport                         Area at risk
Rugby                         Neck (spinal cord)
Diving                        Neck (spinal cord)
Mini-rugby                    Hip (dislocation)
Swimming (butterfly stroke)   Shoulder
Throwing sports               Shoulder and elbow
Racket sports                 Shoulder and elbow
General repetitive movements  Pelvis (overuse injury)


Ligament and meniscal injury in children is rare but becomes more common as adolescence proceeds. Patellar instability and anterior knee pain are common. Osteochondritis dissecans is common in physically active adolescents. The lateral side of the medical femoral condyle is most commonly affected. Symptoms vary from discomfort on exercise to typical locking. In growing children the lesions may spontaneously reincorporate and disappear, whereas in older adolescents loose bodies may need to be removed.

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Osteochondritis dissecans on lateral aspect of medial femoral condyle.

Ankle and foot

So called sprains around the ankle are more likely to be epiphysial injuries than to arise from ligaments. Tarsal coalitions - that is, calcaneonavicular or talocalcaneal bars - should always be considered in young athletes with persistent pain in the hindfoot. Examination will show rigidity of the subtalar joint. About 40% of tarsal coalitions present after injury.

Calcaneonavicular bars are best seen in an oblique view (45°) of the hindfoot, but computed tomography is required to show talocalcaneal bars. Rest and reduction of activities may allow the symptoms to settle. If, however, pain and discomfort persist then excision of the bony bridge is indicated. Pain may arise from the sesamoids, which can be affected by traumatic fractures, stress fractures, and chondromalacia. Conservative measures to remove pressure from the painful area by means of a metatarsal pad are usually effective.

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Bilateral calcaneonavicular bars not yet completely ossified, 45° oblique views of hindfeet.



Children who actively participate in sport should not be treated as miniature adults: they need careful assessment in relation to the common problems that affect a growing skeleton. Overuse syndromes can be avoided by careful supervision from coaches and sensible parents. General practitioners should refer children who are keen athletes to orthopaedic surgeons as soon as possible to allow early treatment and to avoid a long interruption of sporting activities.

Preventing overuse injury in children

* Careful supervision by coaches and parents

* Equipment checked regularly for fit and wear

* Practice intensity and duration increased only gradually

* Poor techinique or posture recognised and corrected

* Warm up and stretch exercise before and after sport

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Related Article

Musculoskeletal injuries in child athletes
J G P Williams
BMJ 1994 309: 341. [Extract] [Full Text]

This article has been cited by other articles:

  • Shanmugam, C., Maffulli, N. (2008). Sports injuries in children. Br Med Bull 86: 33-57 [Abstract] [Full text]  
  • Sharma, P, Luscombe, K., Maffulli, N (2003). Sports injuries in children. Trauma 5: 245-259 [Abstract]  
  • Williams, J G P (1994). Musculoskeletal injuries in child athletes. BMJ 309: 341-341 [Full text]  

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