Hello everyone. Thanks so much for coming to this Saturday morning session here. My name is Mary Dubon. I'm the session director for our Clinical Pearls in Pediatric Sports Medicine, Pediatric Sports Medicine and Pediatric Rehab Medicine in Boston. And we have our awesome team. We're so excited to be back together again in person. We've done this talk a couple of times now and just reviewing Clinical Pearls in Pediatric Sports Medicine by a bunch of docs that do this on a regular basis. So we have Dr. Aaron Carlin. We have Dr. Brian Kraback, Dr. Jonathan Napolitano and Dr. Amy Rabotin. So we're gonna start things off here with Salter-Harris fractures by Dr. Brian Kraback. Great and thank you and good morning. I'm really excited to be here as mentioned that for us to kind of go through. So it's gonna be a little you know a quick little talk here on Salter-Harris fractures and hopefully gain a little bit of a pearls so that we can maybe walk away with a couple of things in relation to our experience as well. We've got nothing to disclose. So we'll talk about the different types of fractures, look at the various different imaging and then kind of give you a basic treatment plan and hopefully some pearls related to that so as well. So when we think about the child and the growth plate we're going to remember that right that's their area of injury. The epiphyseal area is the weakest part for the child as they're growing. It varies where it is throughout the body obviously and in this picture we're looking at it at the knee in regards to this structure itself. As kids start to grow there's becomes damage to this area because it's in essence the weakest part of the growth and development in the child itself. So with that they can fracture it in different ways and that's why we're starting off. So as a child grows and as they move from preteen to teen right there's more likely to develop this area because there's alteration but as they become adults they're more likely to have trauma to the growth the ligaments itself. And we know as children grow right there's this area of change in peak velocity and their height and how that affects bone quality itself so we kind of run into trouble itself. So and it's also important which some of the other speakers will talk to is there's a difference between an apophysitis apophysitis right which is a secondary ossification center where you get overuse and then we want to think about areas with that are common for osteochondrosis. So these are kind of developmental areas that kids might get thinking like in the hip and the legs, calf, perithes. But for today's purpose we're talking really about Salter-Harris and when I teach this I think all of you kind of do that if you can say Salter you should know how how to grade all of these as well. So we kind of just work ourself along there with the S for Salter which has to do with separation or straight injury to the to the pivots itself so that's type 1. Type 2 is the A or above and above or as proximal as opposed to distal. L is for lower and the lower part and to the intra-articular area. T is through so it gets both of them and and type 5 which is quite common is a crush or erasure of the growth plate itself. So when we'll just walk through these real quickly so type 1 these these are actually are really sometimes hard to figure out right. You might think of the gymnast gymnast wrist or the little league elbow where there's this longitudinal force that happens across the growth plate itself and it's often an overuse in these kids come in and you kind of they get diagnosed with like hey you sprained your ankle or you know you're okay you're just a little kid just you kind of do a little bit too much here but the reality is is thinking about in the history in regards to the overuse type of injury that they have and for me because I visually kind of think of things I always think about the gymnast or their shoulder athlete or the throwing athlete that comes in itself and when we get x-rays you little pearl so that's I've had the little pearl there that they don't always show this but if you're palpating and you're along the area where the epiphysis is then you're gonna think about this as well and you might might consider if the history fits that they have a potential type 1 growth fracture until kind of proving otherwise because you would hate to send that kid back out there and then they get into trouble. My daughter's a gymnast like everybody's showing up with stuff as well and and and I don't hesitate to get an x-ray to figure that out and you can see on the top left there's some widening in that x-ray if we have concern from the history in the overuse then we might get an MRI that might show edema in the growth plate which you can see on the top right area but then you have to deal with the combination of trying to how to manage this as well and this is really where the sports medicine side comes in so as gymnasts or anyone takes care of gymnasts nobody wants to ever stop they always wind up being doing some conditioning but you do have to modify what's going on in regards to the overuse itself if you can you can see in this gymnast they have something sometimes they use something called tiger paws which are wrist splints to avoid kind of extension sort of modifying the load as well I don't really tend to put people in casts unless I really have to you're gonna utilize physical therapy look at the kinetic chain and kind of figure out why they got into trouble not only from the aspect of training but also in regards to how the kinetic chain played a role in regards to the how they injured themselves as well and then return to play is a good structured program and for the most part these do well the hardest part is just that sometimes they can't always see the fracture itself and that's frustrating for the parents type 2 Salter-Harris fracture so these are the above I always put the little thing in the corner so you could see but these are the most common type of Salter-Harris fracture this is what probably most of us see as as well as when we're in clinic usually it's in some type of collision they right they were in soccer and they fell skateboarding I don't know if you guys see a lot of skateboarders on the panel here but they seem to you know it stayed a little sunnier in Seattle it was almost like 90 degrees on Sunday and we're getting a lot of people just out skateboarding in the park and fall over itself these are the common type of fractures and you can see in the lower left the arrows pointing to the fracture that's above or proximal to the the epiphysis itself on the right you'll get the tibial type of fracture and there's a something called a Thurston Holland sign where the fracture itself there's a triangular portion you'll see in the metathesis that sort of stays intact while the rest of it kind of moves itself for the majority of these they don't typically displace if they do they're in the ER and get put back into place but you can manage these for most people we can manage these appropriately with with casting making sure things are relatively in good alignment and these actually do relatively well obviously if there's involvement of the growth plate you're going to be a little counsel the parents and the frack and the kids itself if they're young so if they're very young eight nine ten that that potentially there could be a problem with growth plate arrest long term so you just have to have to counsel them on that but I would say actually most of these do extremely well type 3 all right and we'll transition more to skateboard or at least this girl has a helmet and some things going on there but this is more of a impactful type of fracture itself that's very common in the distal tibia in here we have a it's a lower type of fracture here you can see it's intra articular the case on the right was really interesting so this was like an 11 year old kid who is like 6 foot 2 and like 200 and something pounds and he was actually playing basketball and he went up to dunk because he could dunk on everybody imaginable that was that and and you looked at this kid you look like a man you know an adult kind of coming in and when we took the x-ray I should have put actually put the AP and when you looked at the AP you're like okay this looks like pretty good but then when you look at the lateral you could see how we basically ripped this this off here and this guy had to go for surgery itself but it's amazing right here's that Mitch mismatch of this kid who was pretty young still had you know these growth plates yet he had this body that was just could have played in the NBA so unfortunately he had to go to do surgery and he did okay in that regards but the important part of this is is because there is disruption of the joint itself you're going to make sure you counsel the parents about the risk of future arthritis type for more traumatic we're just working our way down there so this is the one that's above and below and sometimes can be difficult to kind of see initially on the x-ray so as you go through the left you can kind of see how there's the the above and below the growth plate itself it's a little hard to appreciate perhaps here but if you look closely you can see the crack often for these we wind up getting extra imaging in regards to the growth plate and you can see here where there's evidence of a kind of multi-planar type of fracture these are often difficult to manage and this is what we'll get our orthopedic colleagues involved because the nature of the fracture itself through the between the the proximal disabled distal aspect of the growth plate they often need surgery and then there's a good conversation about growth plate arrest fortunately I don't see too many of these I don't know if anyone else probably not right as well and then type 5 actually these are pretty darn rare it's basically sort of a compression think think high collision type of fracture I've actually never seen one of these walk in the clinic most of them I think go in the ER and and they unfortunately do pretty poorly but it should be referred off to your orthopedic surgeon as well and there's a high probability of growth plate arrest all right so with that thank you I know that was quick and to the point hopefully a couple little pearls talk a little bit just remember Salter and you should be able to do this or if you're teaching it just tell your residents remember Salter if you can spell Salter you're probably gonna figure out how to type these out thank you awesome thank you so much for that excellent overview all right so I'm going to speak next about something that dr. Craibach did make mention of which is apophysitis and is different than than the growth plate fractures so learning objectives here I'm just going to review the basics of what an apophysis is what apophysitis is learn about some of the common ones unfortunately I can't go through all of them today just in the nature of time and there's actually a ton and then understand the management strategies for apophysial injuries they don't have any relevant financial disclosures so again just as we talked about growing bones have growth plates right they have to have a means of getting bigger how I explain this in clinic is usually I look at the parents and I say you know those like teacher pointers that are metal that went from small to big that probably nobody uses anymore and then I look at and and for a while I was doing that and then the kids had no idea what I was talking about so one of the patients once in clinic said to me oh you mean like a selfie stick and I'm like yes exactly like a selfie stick so I look at the the parents usually and I say think about those teacher pointers and I look at the kid and say you know like a selfie stick and then usually everyone kind of knows what I'm talking about and that's how I try to describe and imagine growing bones right so they have an easy way of getting bigger right but then we have our muscles and tendons that our muscles and tendons don't have growth plates right so to me the way I always ascribe it in clinic is you know imagine that stick whichever it is that's smaller and then take a rubber band cut it and attach it to the top and the bottom now expand your selfie stick or your or your teacher's pointer and what happens is you see those muscles and tendons are getting stretched out the issue is that most of our major muscles and tendons cross joints right so then you get tightness at your knees you get tightness at your ankles and so you see tight hamstrings you see tight Achilles so I usually try to describe that because I think that in sports medicine there has been this pendulum swing with stretching right stretching is good stretching is bad we should do dynamic we should do do static stretching we should do a combination kids are different right so kids have a different setup in a different situation because they are in this situation where their muscles are getting tighter because they're they're growing and so there's some other factors too where we have to think about kids a little bit differently in terms of that stretching piece so as I described as bones grow muscles and tendons become more tight right so what happens is there's actually then a pull at where those tendons insert where there's this little minor growth center right it's not like a major growth plate it's not helping you grow taller these little areas but what it is doing is it's an area where if you can look here where that and I don't know if I there we go where our tendon inserts here there's a little apophysis and you can look on the x-ray and see it right in here okay you see that little gap there so this is the growth plate that helps you grow taller this is that minor growth center the way I think about it is you know I tell my patients like the bumps on your heel bone and like your heel bone in general and all these other areas that don't help you grow taller they're not the same size and not the same shape and everything perfectly the same as when you were a baby right so all those things have to grow and develop and so we have these minor growth centers that are right where those tendons insert and then there's a little gap that's here which is also cartilage and what happens is with anything in sports medicine again I like to simplify things the weakest link is what's going to be injured right so for example like what Dr. Karibak was talking about somebody who has an open growth plate and sprains their ankle quote-unquote it's more likely to actually be a growth plate related injury because that's weaker than the ligaments but for those of us that don't have open growth plates we're gonna have a ligament strain right and it's the same thing happens here with an apophysis too is that that area that's open is getting tugged at because things are really tight right your muscles are tight your tendons are tight and as someone's running and jumping it's pulling a lot on that area and it's causing irritation right here so it's actually pretty common it's one of the most common things I see in my pediatric sports medicine clinic is apophysitis so what is it so again it's really just pain inflammation irritation because there's that constant pulling in that area right there's the risk factors because of the tightness that we talked about and then of course because it's open and it's the weakest link it's the weakest part there and pain is generally worse with activity right so if you're doing running and jumping if you guys have those models in your clinic I usually use those models to say look at what you're doing what are you're pulling out when you're running and jumping right and so where somebody would you know have a patellar tendinitis if you have those open growth centers those open apophyses you might have an apophysitis diagnosis is usually clinical so I don't often get x-rays there's certain times that I will get x-rays and I'll try to go over that and then really it's just going to be activity modification my rule generally is that if their pain is 5 out of 10 or above that I don't want them to push through that I also you know they're kids they're growing they're not in the Olympics and trying to push through this big you know competition I don't like my patients to take NSAIDs before their activity because I don't want them to be masking something pushing through and then causing an injury that's more severe ice to the area after activity and stretching there is you'll see there's not a whole lot of evidence for for the treatments but this is pretty bread-and-butter what we do in pediatric sports medicine so here we have one of the more common ones so severs apophysitis and so right in here is that area of the apophysis so it's traction of the Achilles tendon so again our Achilles tendon coming here and attaching their kids are growing right and so they get tight they get real tight in that Achilles and then they're pulling a lot as they're doing they're running their jumping sports it's usually it oftentimes prevents presents bilaterally but it can present unilaterally too I've definitely seen both and sometimes it's like more significant on one side so they come in and then actually on exam you realize well they kind of have irritation on both sides too right now we think it's male more than female prevalence but that's that's a gap that's closing and honestly there hasn't been a whole lot of updated prevalence literature and so I would expect over time as more and more girls are playing sports that's gonna be more even general age range it's big it's 6 to 15 years of age girls clothes growth plates and growth centers earlier so we usually see it younger an average age of 9 for girls average age of 12 for boys and your diagnosis again is going to be mostly your exam I rarely get x-rays for this diagnosis I'm gonna get x-rays if I'm worried about a stress fracture really my very I think was my second technically a clinic as an attending I had a 14 year old who looked a lot older than 14 years old and he had tenderness right to that area and he was real mad when I pressed on it like jumping off the table mad and I'm like that seems like that might be a little bit more than a severs and that that's what kind of gave me that sense and of course it was actually a calcaneal stress fracture his was so significant it actually showed up on the x-ray which it doesn't always but really you're gonna just squeeze the the sides of the heel along that area that the apophysis is and they usually have tenderness in that area you're also going to do your complete ankle and foot exam too right because sometimes you will have tenderness also where the Achilles where the Achilles attaches as well as along that apophysis and what do we do? We tell them to rest from painful activity. We want them to do stretching of their gastroxolias complex. Ice to the area. So, a tip I learned in fellowship was an ice cube and a Dixie cup will get to a lot of like those little apophysis areas, and it's less messy. And a lot of kids don't really like the idea of a big, cold ice pack over a whole area, so I'll often give people that tip. And then NSAIDs is needed usually after activity. I still do my rule of five out of ten or above. If they have pain of that scale that I don't want them to be pushing through. And then we can do heel cups. So, this is one example of heel cups. This is kind of the more traditional one. There are other options, too, that are more gel-like, so they're pretty cheap. I usually tell them, try this kind. If that one doesn't really work for you, there's the other gel kind that you can use. We see this a lot in soccer players because the cleats are so hard, and so that causes irritation, too, in combination with everything else. So, these do actually fit in cleats, so that can be helpful. And so, there was a systematic review done not too long ago, 2013, and they looked at all these interventions that we talk about, the heel cups and stretching, and the conclusion was, actually, we don't really have a whole lot of literature to support this. So, for those of you out there that are doing this on a regular basis, there's definitely a need for more research in the field to support all the things that I think is bread and butter for a lot of people doing pediatric sports medicine, but there's just actually not a lot of research out there to say one way or another. Prognosis is great. They go back to previous activity within two months. I would say that's what's reported. I would say it's even earlier most of the time. And I always warn people, this can still happen on and off while this apophysis is open. So, they might have flares that come and go, but usually there's power in knowing what it is. That gives families and patients peace of mind that, okay, maybe I need to up my stretching, I need to use my heel cups. And there's nothing ongoing as adults. For Osgood-Schlatter, that's the one that people tend to know that name. They've heard of it before. It's a pretty common one. So, that's an apophysis of the tibial tuberosity. So, that was that one that we just showed earlier when I was explaining what an apophysis is. So, it's traction of the quadricep muscle and patellar tendon. Again, running, jumping activities. Again, there's a pattern here for sure. It's bilateral in 25 to 50% of cases, which is a pretty big range. Like I said, there's not a whole lot of research to really support a lot of data for these injuries. And this slide used to say, when I used to give this lecture, male greater than female prevalence. But actually, the more recent systematic review actually showed that they are pretty similar now, which I think is more a matter of the fact that more girls are playing sports. And then the age range, 8 to 15 years. Boys, again, are gonna be a little older than girls, cuz those apophyses are gonna be open at different times. So, boys' average age, 10 to 15, and then girls' average age is 8 to 13. So, this is that prominence of that tibial tuberosity. So, you will see this when you're looking for and diagnosing Osgood's ladder. Oftentimes, you'll see a little bit more of a prominence, and that's exactly what we were describing, right? Those tendons are pulling, and it's actually kind of opening up that apophysis a little. And then it fills in, so you actually wind up with a permanent little reminder that you had Osgood's ladder as a child. Once that closes up, though, you have that prominence cuz it calcifies inside there, but then you don't have ongoing symptoms, typically, as an adult. Unless it closes up in a way that you have little ossicles, which happens rarely, but sometimes happens. And surgeons can just go in and smooth that out or remove floating pieces. You typically will have tenderness palpation in that area. So, I usually start my knee exam, I have a patient seated, and then I have them extend both of their knees. And then I test against resistance. So, that's to make sure that our quad and patellar tendon are intact, right? I usually tell them, I first wanna make sure that there's nothing major that I need to call one of my surgical friends for, which fortunately, I haven't run into that yet, but that would be a more major issue, right? But also, that exam also gives you some information for Osgood's ladder. Because if you're testing against resistance and they have pain to that area of the tibial tuberosity, that is another exam maneuver that you can do for Osgood's ladder. And then they'll have tenderness palpation of that area. Sometimes they could have a little bit of swelling. It's not like infusion of the knee, it's usually just like a little puffiness over that area. And this is another one I don't typically get x-rays on. I will say my rule of thumb, though, is if anyone comes to my clinic and they have unilateral pain for more than a month, even if I'm dead set, that this totally looks like severs, this very much looks like Osgood's ladder. I do still get an x-ray cuz there are things, as you'll hear about, that you don't wanna miss in pediatric sports medicine. So it's not really that I get it to diagnose this, but I get it sometimes to make sure it's not looking like that when it's actually something more serious. And so activity modification, again, is gonna be your key. But there's some other tips that can be really helpful here. So the Chopat strap or the patellar tendon strap can be really helpful. And it just basically adds a pulley to the system, right? So we talked about if you're tight and you're pulling on that area of the tibial tuberosity. If you add that component there with that strap, you're decreasing how much of an arm there is there that's pulling on that area. And so patients actually get a lot of good relief with that. So basketball's a really common sport we see this in, lots of jumping, lots of running, they tend to be really tight in their muscles but strong. And a lot of basketball players and other athletes will be able to put these on and they won't really have much pain while they're doing their activity for it. And if that's the case, I'm fine with them playing. Again, I still have that five out of ten rule. You can also do padding over the tibial tuberosity, which I don't run into as much. So you might run into if you're taking care of a baseball catcher. Where I thought it was unique, and this is a very physiatry thing, is I had a patient referred to me who has cerebral palsy. And he is a primary wheelchair user. He usually gets around in his power wheelchair, but he can actually do some crawling to get around in the house. And that's how he gets around at home. And he was at that perfect age for his apophysis to be open. And he actually was really tight cuz of his spasticity. And so he's crawling around at home and actually wasn't able to crawl at home anymore. Which was tough because that was a really important means of mobility at home for him. So what we did for him was I got him pads just like this. I got him pretty much identical to this brace that had padding over the tibial tuberosity to decrease the pressure that he put on that area. While, of course, also taking care of his tightness and spasticity as well. So again, stretching the quadriceps, the hamstrings, and then the same rule as before, avoidance of headsets before activity. Prognosis is great. They get back to their previous activity again in two months. But I tend to see a lot of the patients get back a lot earlier. And a lot of them are able to go right back into sport as long as they are wearing their show patch strap and doing their stretching. Again, there are people that have pain ongoing. It's not because they continue to have Osgut's Ladder. I've had parents of patients before be like, yeah, I had that Osgut's Ladder, it's awful. And I'm like, it's not Osgut's Ladder probably anymore. But they may have had it when they were younger and they may have had some ossicles that, in some cases, people do surgical treatment. I actually had someone who was mugged, unfortunately, and got hit to that area of their previous Osgut's Ladder and wound up having some shatter there. So had to go in for surgery to clean that up, too. And then SLJ, or Sidney Larson Johansson, three people's last names. We often call it SLJ for short. It's actually very similar, except it's an apotheosis to that bottom area, the inferior pole of the patella. We do the same thing. I don't do the padding piece, obviously. And the only other tip that I would say for this one is that on examination, if you're working with a pediatric sports medicine doc, ask them how they examine it. Because you want someone to have their leg at rest and laying flat supine. And you're just gonna gently press on the top of their patella to allow the bottom of the patella to come up a little bit so that you can actually touch that inferior pole. Otherwise, if you just press down, you're gonna miss this, because you're gonna wind up not being pressing on that exact insertion site area. And then there was a systematic review that was done of lower limb hypothesial injuries. Ashgood Slatter was the only one that had enough articles to actually look at. And one of the conclusions that they said was that there was a higher prevalence in those who played sports versus those who didn't. So that was helpful information, but we still don't have a lot of helpful information literature supporting the treatment. So thank you guys. And with that, I am going to pass it on to Dr. Jonathan Napolitano. Thank you. Thanks, Mary. Yes, my name's John Napolitano. I practice pediatric sports medicine at Nationwide Children's Hospital in Columbus, Ohio. Mary, when you're using this pointer here, I'm glad you didn't have one of those extension sticks to wag me here. But also, so this, if you guys were coming in thinking that we're gonna talk about OCDs in an extension of yesterday's mental health and sport lecture, that's not true. We're gonna talk about osteochondritis desiccans. So OCD is much easier to say. This is one of those things that, as Mary was alluding to, is a kind of deceptive injury that you, there's not a great exam, there's not a great history, but it is something that's really important that we can't miss. The proposed etiologies of this are really robust. First of all, in its name, like we have done throughout medicine, we have kind of misnomered this. Osteochondritis, hinting at the fact that there may be an inflammatory component. Similar models and histologic studies have been done in the same things. We've deceived a lot of epicondylitis as epicondylosis. And this is actually not inflammatory, but rather some form of degeneration or other deficit, as we'll talk about later on the slide. So osteochondrosis is really the more appropriate term, and that's what they use in the veterinary literature, actually. So not really an inflammatory process. Is there a genetic component? There have been various cases of showing description of various genes that alter collagen matrix or the extracellular matrix around that to make that scaffold that has been responsible or related to some certain cases. However, the overwhelming majority of cases of OCD do not have any familial component to it, they're the first diagnosis. So while there may be some genetics that we continue to study, it's not a primary factor. There's been a lot of study to look at the endocrine components of this. As we think about this as a juvenile etiology, and so what is happening during those hormonal changes as we are maturing our feces and growing through there. And similarly to the genetic, there has been some findings suggesting that these hormonal alterations may alter the way that that ossification happens. And so in certain patients who may take growth hormone supplements or other things, that they can have some of these findings as well. But again, not an overwhelming cause of this or really a predominant risk of those medications, just more of a kind of finding in parallel rather than a causative effect. These last three points on this slide are really the combination of which as we assume to be the primary cause of these lesions. So the ossification deficit. So as Brian started out in talking about that physis or that layer between the epiphysis and the metaphysis where we are laying down new bone, this is cartilage to bone formation. And so somewhere in this epiphysis where the subchondral bone interfaces with the overlying cartilage, that there is an error or a deficit in that ossification. So sometimes there's been seen to be an accessory bone nucleus, and then with that, there's an incomplete connection, vascularly primarily, which leads to kind of this little island that doesn't really completely close or form, and so that's demonstrated in the slides over here. So this is normal subchondral bone is the gray area up above, and then the cartilage is the white cap below it. And so what you're starting to see in this area here, right there, is just kind of a fainter signal in the vascular area. And so because that doesn't happen, they're calling this osteochondrosis latans. And then over here, it becomes osteochondrosis manifesta. Once the bone formation kind of pushes down past this, you start to see this kind of gap or abnormality within this. And so this is manifested in this way. And this becomes where the split happens. Either this can be a normal finding, or this goes on to be an issue. So in a normal finding, remember that if you're gonna get an x-ray and you're gonna look at any joint, frankly, you're not seeing the cartilage. So in this picture, this latans area, it looks normal. In this area, where this latans area has come to kind of form a defect or a crater in the subchondral bone, that may be noted on a radiograph. However, you're still in this stage of we haven't deviated yet when you are nine, ten years old, because that process can continue down this pathway, where this can close off and be normal, and it just kind of pushes back up. However, it can also progress negatively. And so what are the things that happen there? They oversimplify this here as saying trauma. Is that a microtrauma? Is that a macrotrauma? Ultimately, there are mechanical forces that we'll talk about. But one of those forces, that force leads to necrosis or can lead to necrosis. So there's an ischemia in this area with that abnormal ossification. And so with that ischemia, it's seen in certain predilection sites of this endochondral, subchondral kind of interface through there. And then what's the mechanical component added to this? There can be macrotrauma that may be associated with this in rare cases. However, overwhelmingly, this is proposed to be a chronic underlying microtrauma. Is that just from repetitive injury or overuse to the area? There has been some proposed mechanism of, these predilection sites tend to be in the notch of the knee. So we'll go back to my last slide here. So this one is not specifically, but in the notch of the knee in the center. There we go. Over there, the tibial spine fits into there. And so the thought is, all right, well, if we are turning, twisting, and you have this prominent tibial spine, can that push the pressure on there? That alters that, so that's one proposed mechanism. The other proposed mechanism is that it's actually seen relatively higher in those patients with a discoid meniscus. And so by increasing that pressure on a unilateral side of the knee, does that extra load cause some more impaction, pressure leading to more of that ischemia? So it is not well determined as far as, is there a single ideology of this? And so it's a combination, really, is the conclusion from these number of systematic reviews on the citations below here that really continue to evaluate and discuss this. Regardless of what its cause is, we know that we see it, and we see it fairly well. So this talk here is talking about juvenile osteochondrosis, but adult osteochondrosis is well understood to be a unresolved juvenile OCD. And the fact that, hey, my knee would hurt on and off as a kid. It would swell up, and then it would go away. I wouldn't notice it. Never gotten an x-ray, never did anything. I was told I had Oshkosh Slaughter, so I did some stretches and was able to rest, and it felt fine. So in adults, we can see this at three and a half per 100,000 person years. The difference here in adults, however, is we see it more in the ankle than in the knee, where overwhelmingly in juvenile, it's much more commonly seen in the knee. So juvenile OCD of the knee, we see it from nine and a half to really 29, as high as 29, per every 100,000 knees. And a lot of that has to do with the fact of bilateral, which we'll see here in a little bit. But 2.2 out of 100,000 elbows, so definitely lower than the knee, but we do see it in the elbows primarily, in the lateral elbow at the capitellum. And then in the ankles, two to four and a half per 100,000, and that's seen on the talus. So on the talar dome, and as we'll describe later, more medially than laterally. So the highest risk of juvenile OCD is in those greater than the age of 12. So again, as I was saying, that 9, 10, 11 year old, that's someone who is forming this subchondroendochondral area. And those deviations, or those lumps and bumps, are more likely to kind of resolve with normal ossification as they mature, and more likely an incidental finding. Boys are at higher risk of having this in the knee as well as in the elbow. And that has to do with some of that older literature that Mary was referring to, is that we would see Oshkod slaughter higher in boys' knees. We would see OCDs higher in boys' knees because they were the ones playing basketball and soccer. Whereas we would see ankle and severs in girls because they were more commonly doing barefoot sports like dance or gymnastics. But now we're seeing those kind of level off or become more equal. So the association with high-level participation, you know, that's really interesting. And Mary pointed out again on the apophysitis stuff. It is very easy to see that and say, all right, well, is this causative and therefore is that at fault? So you can't look at that and say, well, because we are participating, then that's the cause of this and you need to stop and not do it. Because for apophysitis, for example, like if you continue to just rest and that's your only treatment, you're continuing to grow and grow your selfie stick taller and so your muscles get tighter. So you have to keep participating. Here, what we're seeing though, is this is higher in those high-level participations. So when we did this talk two years ago, we talked a lot about sports specialization and overuse injuries. And we specifically see more of these OCDs in those who are in that high-level year-round participation where they are less free play active and they're more pressured to do things and that's where we see these types of overuse injuries. We also see it significantly higher in those with obesity. Again, pushing towards some of that mechanical factor of more pressure through that subchondral, endochondral interface leading to some ischemia. So the locations of this, I hinted at these already, but in the knees, this is very commonly bilaterally. Really, some studies have shown it's as high as 30 or 29% where you would see that it's bilaterally. But the most common site for this, the predilection for this area of the abnormal vascular interface or whether it's the tibial spine or not is within that notch. So in my x-ray studies for every youth athlete who's coming in with knee pain or nonspecific knee pain is it's not an AP and lateral. It's a foreview where I'm looking at the AP lateral on notch view, which is in, that's the picture of the top right here, and that's in a little bit of flexion. So you're looking down, it's also called a tunnel view. You're looking down into that tunnel where you're gonna see that a lot more commonly where you may miss a lot of OCDs if you're just looking at a standard AP and lateral. And then I get that patellar view or sunrise view or merchant view or whatever your site does and they're all slightly different. But what that helps you see is there are some that are underneath the patella as well. And so you're gonna miss those on your APs and laterals as well. So between one and a half to 10% there. The elbow, we see this occasionally bilaterally as well, but the most common site that I see these in, or I'm sorry, the most common athlete I see these in are both gymnasts as well as pitchers. And so usually for the pitcher, this is a unilateral problem. They're overusing one aspect. They're giving that varus moment and then a valgus moment. And with that varus moment, we're compressing the capitellum over and over again, leading to some of that pressure and possible necrosis. So we see that much more commonly unilaterally in the baseball players, but bilaterally in a gymnast who's loading both elbows as they're going off a vault or their floor exercises. In the ankle, significantly most commonly seen medially. And this is if you think about the typical inversion ankle injury, right? You're opening up the lateral joint space and you're compressing the medial joint space. So this in the ankle we see is possibly the result of more of that macro trauma, right? Is there a big compression load on that aspect of it that leads to this pathology? You know, our previous presenters did a lot of talking about how do we educate our kids and parents. And that's what I love so much about practicing pediatric sports medicine. So the images that I try to explain, if I come into a room and talk to a kid about OCD or osteochondritis desiccans, they're already zoned out. So I start talking about apple bruises or potholes in the road. And they're actually pretty good analogies where if you think about this, what we're looking for is we're gonna judge stability of this. We wanna see what the cartilage is like over top. And then what we evaluate the bone underneath it because that x-ray is only showing the bone underneath. So that's a bruise of an apple, right? Where the cartilage is intact, but that's softened underneath there. Whereas if that is an unstable lesion, if that apple skin breaks, then you have a pothole and it's no longer a smooth surface of that road. So the history is really vague. So yeah, I get knee x-rays on really most of my patients who come in with knee pain. It's rare that I don't get an x-ray. So it's a vague, atraumatic history. Or they'll point out to one thing. You know, one time I slipped getting out of a canoe when I was eight years old or something. So they always will try to point it back to one specific injury, but it's very vague. Intermittent pain and effusion, you'll see mechanical symptoms. If it's an unstable lesion, if there's a loose part within there, it becomes unstable. I said there's not really great physical exam tests, but the Wilson test is one of those. It's kind of, just think about it as a modified McMurray's, where basically you're in this McMurray position, and then you're internally rotating the tibia, and then extending the knee. So instead of kind of varus and valgusly loading the knee when you're doing your McMurray's, you're basically just keeping the knee straight, internally rotating the tibia and extending, and that's kind of pushing the tibial spine against that notch, and then you're extending. And then if you open it back up, so you externally rotate, that should relieve it. So it's one of those tests like the O'Brien's. Not only is it painful, but is it not painful if you turn it the other way. I talked about the x-rays, and then MRIs are the standard of care for further characterization. I do not necessarily get an MRI in a nine- or a 10-year-old who has one of these little tiny bumps in here, but if I see a large lesion, if I see a weight-bearing lesion, if I see that other signs that this person is actually further along than being nine or 10 in skeletal maturity, then I'll further image it. There are four primary versus three secondary signs in lesions for stability. So how do we treat these? Non-operative treatment, if someone has open physis, if they have a stable lesion, and if they have minimal symptoms, you know, I add more to this. I'm gonna say this is non-operative not only if they have minimal symptoms, but these common thoughts, as everything in the literature, doesn't really talk about the location or the size. So, I mean, if this is a large lesion, I'm not gonna mess around with non-operative treatment. If this is a weight-bearing surface of the knee rather than deep in the notch or something, I'm not gonna even consider non-operative treatment. And so the question marks here are there's no consensus as to how to treat this non-operatively. You gotta activity restrict, but what does that mean? Does that mean that you're not running and jumping? Or does that mean that you're able to free play, but you're not gonna play on a team? What does activity restriction look like and for how long, what activities? Weight-bearing or not, the thought of healing of this is very opposite, right? If we're evaluating this as this is a cartilage lesion, we actually want to continue that knee motion, right? We wanna keep smoothing that cartilage back and forth. Think about the arthritis picture, right? You want non-impact, but motion of the knee. But if you're thinking about this as a bone lesion too, then you want that weight-bearing surface to stimulate new bone growth underneath it. So are you putting them on crutches? Are you bracing up, bracing, immobilizing, casting? Those kind of things would limit that knee flexion. And so it's really not clear how to do this. My standard of care is what I do if I evaluate that I'm not gonna treat this operatively. I don't put them on crutches. I don't put them in a brace. And I have them rest from organized activity. I have them rest from any free play on the playground. And it's really, really hard. And then I follow them. Operative treatment. So if they fail non-operative or these are the other characterizations. So if this is a stable lesion with retroarticular versus transarticular drilling. So that's, if it's stable, this is how you would treat it. So either transarticular, meaning that it's an arthroscopic procedure where you're drilling and scraping straight through the cartilage lesion versus retro where you're using like a K wire and following it and you're drilling into the knee. So that's basically like the picture on the top right here. Sorry, that actually doesn't look great. But basically that's transarticular. Retroarticular would be if you were to come from the outside of the joint. And if it's unstable, you can try to salvage it. If it looks like you can put that piece back on and use an anchor to put it in surgically. Or if it's unstable, then you clean out that area, drill into it and really try to hope for a new bone. And then there's a whole bunch of other alphabet soup of kind of cartilage plugs as ways to do it. So the outcomes here, this is old literature. And as I was talking to my colleagues here about this talk, we've not seen 100% success rates with non-operative treatment of this. And I think we've gotten more and more advanced that this is less consistently a non-operative intervention, but rather more of these we guide towards surgery if they're starting to show signs of failure. The ankle is also far less significant healing rate for operative interventions. So however, those operative interventions are good. They're returning to play. They're healed with fixation if they're salvageable. If they're unsalvageable, all this alphabet soup, as I said, the OATS procedure, the ACI, the autologous or the allografts, they really, those grafts do well. So as this is kind of updates in literature and where we are, the two different organizations, AAOS looked at this and put this whole paper together and concluded that none of our recommendations are, none of them are strong. Most of them are inclusive, some are weak, and they're following consensus statements. So I'm not even gonna go through the details of that. So after that paper came out in 2010, through PRISM, Pediatric Research and Sports Medicine, they started the ROCK group. So Research in Osteochondritis of the Knee. That is now evolving into the ROCKIT group. So of the knee, elbow, and talus. And so this is a group of most pediatric hospitals throughout the country. Their first eight years of organization was kind of finalizing classification and nomenclature. And then they did two different big studies where they're looking at a randomized control trial of transarticular versus retroarticular drilling. That's not yet been published, however it's been presented at various sites. And that data shows essentially equivalency that there's not a significant difference whether you're drilling through the lesion versus on the other side. And then they're tracking a cohort for really to answer some of those questions that we don't have answers to yet. This is a final slide, and I apologize, that's way too small to see, so I'll walk through it with you guys. But basically it's saying if this is a knee OCD, that's what the small print says, it's either juvenile or adult. If it's adult, we're looking at evidence of instability. If it's loose and unstable, then we send them to an arthroscopy. And if there's mechanical malalignment and joint instability, the whole knee is abnormal because of such a large lesion, they're talking about even joint arthroplasty and osteotomies and other things here in adults. But so over this way, if we're kids and this is stable, you're looking at non-operative. If it's unstable, then we're going into arthroscopy. And then it's either, as I said, you're either plugging it if it's salvageable, you're drilling it if it's not. And then out this way is the drilling, salvageable is fixation, and then unsalvageable is cleaning that all out and doing those OATs procedures or other things. We'll take questions at the end, but thank you. All right, I'm going to give you a whirlwind tour of Spondy. So because I'm between you and a really exciting concussion talk. I'm Amy Rabot, and I'm at Mayo Clinic in Rochester, Minnesota. I have no financial disclosures. So we're going to cover six pearls on Spondy's. And within that, we'll review what it is, how it occurs, how to evaluate it, how to treat it, and then what's returned to play. So I'd be remiss if I didn't remind you that back pain in young athletes is different than it is in adults, right? This is kind of a pinnacle paper from 1995 from Dr. McKayley out at Boston Children's. And what really is important here is seeing that Spondy's occur much more frequently in youth athletes than it does in adults. And that lumbosacral strains, for example, occur much more frequently in adults than they do in kids. Dysgogenic pain is very infrequent in the youth athlete. And osteoarthritis and spinal stenosis weren't even reported in these 100 kids. So really making sure that you keep that differential broad, but it's going to be different than it is in those adult athletes that you may see. So pearl number one, growth, muscle imbalance, and biomechanics are significant contributors to Spondy's. And I think you're hearing this throughout all of the talks today, that this rapid growth, your giant selfie stick or teacher pointer, you're growing, growing, growing, right? And like Mary said, those muscles don't keep up. So then what happens, and we're all sitting, so we're getting this gluteal amnesia. So you're getting tight hip flexors, a weak butt, a weak core, you're growing, and all of a sudden you just have these biomechanics where you've got hyperlordosis as a young athlete. So you've got this muscle imbalance and kind of an imbalance with the bones. You're growing so much faster than you're gaining weight. And so all of these, the growth cartilage and the secondary ossification centers are, again, that weakest link that we've been talking about. And if you think about how athletes move, you think about the kind of the common extension-based athletes, but you also have to think about the athletes with rotation too. So your tennis server, right? So if they're going back and up, they're really putting a ton of stress on that back. So thinking about how people move is really important and looking at how they move in the clinic is important as well. So pearl number one continued. So what is this? What analogy do I use when explaining this to a young athlete? It's that defect in the pars interarticularis. Again, just like OCD, eyes will glaze over if you use these words. So I use a paperclip analogy. It's a paperclip that, and I always ask, have you ever done that? You're sitting there and you're studying or whatever. It's like the first fidget tool, maybe, is a paperclip. And so you're like, you're bending it and you're bending it and it kind of gets warm in there. And then all of a sudden, boop, it breaks, right? So that's kind of the analogy that I use. And I actually do say boop because I'm a pediatrics. So anyway, but it's typically sports with extension. So dance, gymnastics, football linemen, but don't forget about the rower. Don't forget about the tennis player. These can occur, again, because of that biomechanics. Level five is the most common. A theme, again, you're hearing, it used to be, yep, these happen a lot more in boys than they do in girls. That's not true anymore, but it also depends on where you're doing your evaluation. So here in the U.S., boys and girls are pretty much the same in Spondyland. So, but if you go somewhere else where girls don't play as much, play as many sports, that might not be the case. Bilateral is typically most common. And then spondylolisthesis, we're not gonna cover today, but that's that gradation of when you have that translation forward of the one vertebrae on top of the other. Pearl number two, primary complaint is low back pain with activity, especially lumbar extension. So get a good history, ask lots of questions, don't assume it's a spondy. I was in fellowship and had Friday afternoon rule out spondy, I'm like, got it. So ask her some questions. Yep, she's a gymnast, blah, blah, blah. When does it occur? Well, it's kind of like, I don't know, in these weird times, like when you're doing gymnastics? No. Okay, so you pooping and peeing okay? Well, I have blood in my urine. Okay, are you having your menses? No. So, well, it ended up, she had kidney stones. So, you know, like your rule out spondy isn't necessarily rule out spondy. You have to ask good questions. So, you know, and what's your alleviating factors? Have they already started rest? And yep, I'm getting better with rest. What are those good questions? What's their sport? How long have they participated? What's their level of competition? These are things you're already starting to ask because that's gonna give you some insight into whether they're gonna be compliant with the four letter word of rest. So, really understanding what they're doing there. So, what you would expect them to say is, you know, I'm coming in, it's worse with extension, I'm this kind of athlete, it's worse with extension, it might lateralize, it doesn't radiate, it gets better when I don't do that activity. Important to not forget about relative energy deficiency. You know, these athletes might have this as a component to the care that you need to consider. And then always those red flags. If their pain is at night, this is not a spondy. So really thinking about what those red flags can be to think about what other things you might have to have on your differential. Rule number three, perform inspection, palpation, in addition to your provocative maneuvers. And you need to see your patient, right? If you do your spondy exam with a sweatshirt on, you're not doing a spondy exam. So, you know, you need to see the back. Get them in a gown, whatever you need to do. Super important. Look for that hyperlordosis, right? Again, that weak core, weak butt, tight hip flexors. Thinking about what things look like. Looking for cafe au lait spots. This could be something very different. Palpation, thinking about is there a step off? I've never felt a step off, but, you know, they say they exist and maybe you guys have felt them. But where are they tender to palpation? What's their range of motion like? Do they have really tight hamstrings? So what's the popliteal angle? What's their bite and score? Athletes with a spondy that have a high bite and score have a higher risk of increased pain if they return to play too early. So it's something to pay attention to. They should have a normal strength exam and they should have a normal neuro exam. If those aren't true, then you need to think about something else. Look at their gait. My favorite part, always try to see them before they know you're watching. Because you will definitely, potentially, not see the doctor walk. And so kids who have back pain might actually posterior pelvic tilt to kind of compensate for that. So that might be something that they do as they're walking in. What's their single leg stance like? That can give you a really indicator of A, they don't want to do it, but B, also what their glute strength is. And then we have special tests that we need to think about, right, rule out hip pathology for all of this. What's their straight leg raise? That might give you some insight into what their spondy type symptoms. The Storks test, we all do it. It's not really super reliable, but we all do it. And that can be important, but not, again, pathognomonic for a spondy. And then thinking about testing for tight hip flexors and SI joints. So pearl number four, AP and lateral X-rays after rest, MRI if not improving. So typically, you don't have to image right away. You can wait two to four weeks, get them to rest if they will rest. But a lot of times, people are coming in and they've already tried resting a little bit, so you might get X-rays. AP and lateral are what you get. We do not get obliques anymore, so you don't get to see the little Scotty dog. But it just doesn't, the bang for the buck and the amount of radiation just isn't worth it. So the challenge with X-rays is it doesn't tell you about acuity or chronicity of this injury, but it can potentially tell you if it's there or not. In an MRI, again, this is where that paper clip analogy comes in. That, you know, if you see that bone marrow edema, that's where that paper clip's getting a little bit hotter. You might see edema in the pedicle or PARS region. MRI can be helpful to identify other soft tissue pathology that might be contributing to this. Again, as you know, no radiation, but it might be a little less sensitive than a spec scan, for example, which some would say is a gold standard. But again, the amount of radiation is that worth the bang for the buck. It's very sensitive for identifying a PARS defect, but compared to a plain film and also other pathology, but it's not necessarily worth the radiation. And finally, a CT. Some people, you know, like to get a CT for progression of healing, for, you know, acute versus chronic. But there's, again, a lot of radiation. So some people might just get a level or two. They might say, gosh, I'm pretty sure this is an L5, so I'm just going to get L5. But what happens, you're not looking above and below for things that actually might be contributing to the symptoms that they're having. So again, a challenge for that. Rule number five, step one in recovery is relative rest. And, you know, rest is so hard for these athletes and their parents. So in activity modification, so, you know, you have to have a heart-to-heart, like, you got it, you pay me now or pay me later. And so that's, you know, we have that conversation. And so depending on the severity and what kind of athlete they are and what level of competition, that's going to weigh into how long and their resting. Ice and warm showers might be helpful for symptom management, over-the-counter analgesics. Again, like Dr. DeBahn was saying, you know, not trying to take them before activity to cover up pain. Might use topicals. And if they're not improving or they're refusing rest, then that is when you might actually just advance, get your x-ray, and then if you have to, for insurance, and then advance to an MRI, so you really kind of know how, that can help lead that conversation and have that visual for the family to say, this is really what's going on in your back. And then follow-up throughout recovery. You know, you want to see these athletes pretty frequently to see how they're doing, to remind them about the relative rest. And check in, because that might push you into advanced imaging, for example, if they're really not getting better. Typically, you know, there isn't great data to say, gosh, it's two to four weeks, it's 90 days, it's this, it's that, for that relative rest. But a lot of people start with that two to four weeks and then over the course, if it is kind of an uncomplicated one, it'll be a 90-day kind of period out of resting for their sport. And it's really important, though, too, you know, this doesn't mean laying on the couch. And so, it'll be important to talk about what activity modification means. Physical therapy, many send to physical therapy for core strengthening, for glute strengthening, hip flexor and hamstring strengthening, and sometimes anti-lordotic exercises. I'm going to pick it up here because we need to get to our concussion talk. Bracing, bone stimulation surgery is rare. To brace or not to brace, it depends on where you practice. And so, some people use the BOB, which is, we'll use for acute stress fractures. It really takes away that lumbar lordosis, but can also be very stressful to the family and to the athlete. They work 23 hours a day. So, and there's debate on whether they actually do any improvement and kind of, in theory, aligning the PARs to heal better. Some places will use a non-rigid corset-type brace that has rigid back so that they'll get that tactile stimulation when participating in their sport. But outcomes are no different. I'll skip over bone stimulators in the interest of time. Many return to play. So again, with this conservative treatment, so this rest and activity modification, 80% to 90% return to their sport at some level. They must be pain-free. They must have full range of motion, normal strength, no more neuro exam, and then go through some sports activities to get back to their activities, back to their sport. Typically, you don't have to get follow-up imaging. You know, many are like, well, is it healed? Well, actually, you don't have to have complete bony union, and many don't get complete bony union and get back to their sports just fine. It's important to spend time with the team during recovery. You know, again, the mental health aspect of their sport. And again, I can't stress enough this core and glute strengthening. It will benefit them ongoing and kind of have that lecture of this is something you need to do all the time for your sport. So those are the main pearls, and I'm gonna get off the stage here. Thank you. Morning. All right. So I was tasked to communicate to you guys an update on the management of pediatric and adolescent concussion management. And so, you know, the last time we did this talk was the virtual one right after the beginnings of COVID. I should say the only disclosure I have is that I unfortunately don't have any financial disclosures. It would be nice if I did. And so I was tasked with coming up with an update since our last talk. And so I did the lit searches that we all do when we give these talks. And I went to our resources that we all have. You know, we went to this, I looked at the CDC, say, hey, what's new there? How about Hockey Canada, which if you're not familiar with is a phenomenal resource for concussions. Looked there. And, you know, of course, we know our summary and agreement statements from the consensus in sports. And realized that, dang, over the last two to three years, not a whole lot to report in terms of updates. Now, as you can see, next weekend there's kind of a big meeting in Amsterdam. And I think some, from what I've been hearing from my sources, there's going to be some new stuff being dropped. But nothing that I can present here. So I said to myself, okay, what the heck am I going to do? I can't just get up here and tell jokes for like 10 minutes. So I thought to myself that, you know, when we come to these meetings, you know, I decided to go a different route. We attend these meetings. It's a lot of data download, right? We get a lot of information given to us on different topics. And we did a great job. Our crew did that earlier with the topics that they covered. But we don't get a lot of insight into how we communicate that to our patients. And really as physicians, I think that that's at least 50%, if not more, of our job. So I kind of asked myself, so what exactly is our role? Yeah, we're diagnosticians and we're guides. We're guiding our patients through treatment and return to play, return to school, return to work, for sure. Hopefully not return to that bottom right in terms of attitude. So we want to stay away from that. But really we're educators. We want to help people, but we also love educating, right? So we need to take this complex concept, really, of a concussion and make it accessible. We need to make it understandable. We need to talk about the what, the how, the when, and then really what they want to know, the why. Why do I have to do this? Because buy-in. We need that buy-in. You cannot underestimate, or excuse me, I shouldn't say, you can't overstate the importance of buy-in. And not just the patient but the parent. And, you know, we need to establish that connection, especially in that pediatric and adolescent population when we have that 16-year-old that's just this vapid kid that wants to get out there and play again. And then the dad or the mom wants them back as soon as possible. And they need to be really directly involved with understanding their care so that there's good carryover. When we have good carryover, and again I should say this needs to be done at the front end. This needs to be done right at that first visit, that first interface, or else you're just going to lose them. You need to set that tone. You need to set expectations and have that transparency with what the course of care oftentimes is, but why we're doing it. The why, the why, the why. Better compliance equals better outcomes. Quicker recovery, quicker return to play. So, what am I going to do? We're going to talk more about how we communicate rather than what we communicate. And this is just one study that I threw out. There's a number of other ones that I could list but in the interest of time I just didn't. That really shows that if you give good discharge instructions, if you have that good interface, you have quicker resolution of symptoms, you have quicker return to play. So, instead of the first slide, we're not giving an update. What I'm giving you is the talk. And for those, I see a few of my medical students or former residents or former med students, I will get you counseling for the PTSD you're about to go through because we are literally going to do the 10 minute canned talk that I force upon my new patients and their parents when they come in. And I know that we're running a little bit behind on time, so I'm going to try to go as quickly as possible. So, these are the AA PM&R Pediatric Rehab players. And we have, I'm going to go grab a, you guys have a, great. Alright. And this is Mark Green, Pediatric Rehab from Kansas City. And this is Steph DeLuca, Sports Medicine Fellow that works with... Is your mic working? Yeah. All right. All right, good morning. So we're going to talk a little bit about concussion. Because if you don't understand what a concussion is, it's not really going to make any sense to you why Dr. Johnson even sent you here in the first place. So we've learned a lot about concussions in the last 10, 15, 20 years, so that we treat them very different than, say, you and I were kids. So one of the things we know is that a concussion is a type of traumatic brain injury. So it's an injury to your brain. It's induced from a trauma, either from a direct hit to your head that's covered with blood. We've also learned that you don't have to be knocked out to get a So most people, when they get concussions, they remember everything and they're not knocked out. We don't say mild, moderate, or severe concussion anymore. That's something that you might have heard, grade one, grade two, or grade three. Because those grading systems were based on how much loss of conscience or how much loss of memory you had. We found that actually doesn't matter. You only know how severe a concussion really is based on how long it takes for your symptoms to go away. And the only person who knows that isn't really talking. The analogy that I like to use frequently about what a concussion is, Okay, you ever played battleship. Yeah. Yeah, so it's like someone came to your back So you can imagine, no two concussions are going to be alike, it depends on what pegs... The next group of symptoms are cognitive or thinking symptoms. Trouble with word fun, trouble with math, trouble with memory, slowed reaction time, slowed processing speed. more than what is a normance, feeling mentally foggy. Next group of symptoms are gonna be sleep-related symptoms, trouble falling asleep, trouble staying asleep, or being overly tired, sleeping 12, 14 hours a day, taking daytime naps when you normally wouldn't. And the last group of symptoms are gonna be emotional symptoms, because your brain's in charge of your emotions. So these are kids that are normally pretty even keel, all of a sudden happy, sad, angry, glad, crying for no reason, excessively irritable, short fuse, snapping at people that they normally wouldn't. Even though you're four to five days out and doing better, but you've had your share and it certainly Now, we know in the pediatric and adolescent population, which you're in, John, it seems to take a little bit longer, more like three to four weeks, but by five to six weeks, pretty much everybody's back. Now, it doesn't mean that it couldn't happen earlier, but by that period of time, most TV, computer, video games. Nice ad-lib, love it. Give me that. Yeah, thank you. I charge a dollar to each patient who uses a phone each time they do that. Things like TV, computer, video games, texting, telephone, homework, movies, music, iPod, iPhone. You'd have normal balance tests. You had some trouble on that today when we were doing that test. Yeah, I know everybody's got bad balance, but it was a little bit more than what's normal. You need to have a normal neurologic exam, and you did fine. So there you go, we're one for three. And you need to have normal cognitive testing. And so today we had a baseline test that you did pre-season. We were able to compare how you did today to that, and you had some struggles. So we showed some statistically significant declines. So one for four. So one for four isn't what? Well, it's not good, but it's also not four for four. You need to be four for four, pretty much. Because if you're not, if your brain isn't healed from a concussion at rest, and you go back to sports before your brain's fully healed, you're at risk of four things. Number one, just like if you have a bum ankle. You go back to sports too soon, what are you at risk of? Yeah, you got it. So if you have a concussion, and he goes back too soon before his brain's fully healed, he's at an increased risk of getting another concussion. Tends to take less of an impact to do it. The symptoms tend to be more severe. They tend to last long, months instead of weeks. So we don't. We also know in kids who get concussions, or anyone who gets concussions, even if your symptoms are gone in the first 24 hours, even if they're gone in the first three or four hours, what we used to call getting your bell rung, getting dinged, we don't use that terminology anymore, because we found out that that brain is actually abnormal for at least a week. It's a neurometabolism. The way that it makes decisions, it sends signals to your body, is actually abnormally jacked up for at least a week. Well, does it make sense if I feel fine or should be fine, doc? Well, if you think about it like this, it makes perfect sense. When you get a cut on your skin, it forms a scab, right? First couple of days, you press that scab, the scab hurts. It's our body's way of saying I'm not healed, leave me alone. Couple more days go by, though, press that scab, what do we all do to that scab, John? You got it, and what does it start doing? Yeah, so even though it felt like it was fully healed, it wasn't, right? Your skin takes a certain number of days to heal, no matter what, guess what's just like that? Your brain. Your brain, so you could be in a situation that you're feeling fine and you go back too soon. Or even worse, you're still having symptoms and you go back too soon. It's like picking, picking, picking at that scab. And does it take longer or shorter for it to heal? Longer. It's bright, longer. So why do I care about that? Because at number three, most kids are back, doing everything by that five to six weeks, right? A lot even earlier. Those who aren't, though, are getting close to what we're talking, or what we're calling post-concussion syndrome. And for every week and for every month that you continue to have symptoms, beyond that period of time, it can become harder and harder for that operator to put those pegs back in, and the risk becomes higher and higher that whatever symptoms you're having can become permanent. Permanent headaches, academic declines. Good news is, it's exceedingly rare. 1.7 to 3.8 million sports-related concussions a year in the United States. Congratulations on adding to the 2022 totals. One to three cases of second impacts. So really, one in a million, super rare. Problem is, if it's your kiddo who has a concussion and goes back to sports before their brain's fully healed from a concussion and gets another hit to the head, a helmet-to-helmet like you had, or you slip on a banana peel, hit your head on a countertop, whatever reason, and get another concussion before that first one's fully healed and your brain rolls that dice, rolls those dice, and you roll that one in a million, 50% of the time they can die. Five, 10, 15 minutes on the field. 100% of the time, generally some form of disability. Not going back to Brother Martin High School, not gonna become president, not going to the NFL, whatever. So what is it? You got that telephone switchboard operating inside your head, right? He or she's in charge of a lot of things. One of the things is blood flow. So when you get a sprained ankle, you get a lot of blood sent down to your ankle. We've all had that, right? We've got skin that can stretch and accommodate this. Think about your brain. And that operator is kind of woozy, not making good decisions, gets hit again in the head, says, oh, I've got another traumatic brain injury, I've got another concussion, I know what I want. concerned about the potential long-term problems. And I'm not too concerned about that in your son's case and your case, John, because you're doing a lot better. So what do we do here in concussion management? Well, you get forced to listen to that boring 10-minute talk so you can understand what a concussion is. And we take a look at each kid, and we ask ourselves, did you meet those four criteria? Because if you did, I don't want you in my office. I want you out there being a kid. But you didn't. So you're on what's called relative activity restrictions. I do not need you, John, in a dark room with noise-canceling headphones, laying on your back, blinds shut, doing nothing. It actually slows down brain pain. So it's regular activities of daily living. I do want you, at least right now, going for a 30-minute walk every day. I do, right now, want you to go back to school. But we are going to write for some academic accommodations, untimed tests, extended time for homework and projects, sitting in the front of class, things like that, because you've been complaining about some of the cognitive or thinking difficulties. Other things that you can do to help yourself, you need to stay hydrated. One of the number one causes of headaches in anybody is dehydration, right, mom? So we want you to drink, when you've had a concussion or a traumatic brain injury, you're more sensitive. We want you aiming for a half to a full gallon of fluids per day, which sounds like a lot, but that's what you're supposed to be drinking annually. No caffeine, no coffee, no tea, no pop, no monster energy drinks. Caffeine is a stimulant. We don't need to be necessarily stimulating your brain, but it's also a diuretic, which means it's going to make you pee a bunch. It can dehydrate you. We don't want that. We're going to do the 30 minutes on, 30 minutes off with those cognitive stressors until you're symptom free. Tylenol, ibuprofen, Aleve. Yeah, you can take those as needed, but we want to try not to be taking that more than four or five doses per week. You do it more than four or five doses. 7-10 days you're going to be doing a whole lot better. We can get you moving a whole lot quicker. We've talked about the 30 minutes on, 30 minutes off. You also need to get 8 hours of sleep, 7-8 hours of sleep every night. That's not 1am to 9am, okay? It's regular sleep hours to maintain sleep, yeah. So I'm going to give you guys a few things. Oh, and I left it over there. So I'm going to give you my card. I'm going to give you my information on the concussion program here at Osher. This is a recap of everything that I just told you because I'm sure some of that went a little bit in one ear and out of the other. Not yours, his. And here's a handout also on concussions from the CDC for both parents and kids. I want you guys to take a look at that together later on today. I'm writing up the academic accommodations for you. I'm writing up the note to give to your coach and the athletic trainer at your school. This is where I say to you, I know that is a lot of information to take in. Do you have any questions for me? Did that all make sense? This weekend's homecoming, can I play? What's that? This weekend's homecoming, can I play? Okay, so that's a great question, John. That's a great question. So you have two things going against you, okay? You're a teenager and you have a Y chromosome. Do you know what that makes you? An idiot, okay? And yes, I do say that. The people here can vouch for it. So the issue is, I don't have a problem with you going to the game. You're not going to dress out. But here's the thing, I don't have a problem with you going to the dance, but we need to use common sense. And that's where that Y chromosome can kind of get in the way. If when you're at the game, the juxtaposition between the dark sky and the lights or the band or whatever, even just watching the game makes your symptoms worse, or you're at the dance and the noise makes your symptoms worse, what do you need to do? You can do it. You can answer it. Yeah, you need to go. But other than that, I don't have a problem with you going. Absolutely. What other questions can I answer? So I think I know the answer to this, but his dad's going to want to know, CT scan was normal. Why does he have this? Yeah, it's always the dad. Yeah, it's always the dad. Never the moms. Yeah. So that's a great question. So the analogy that I use about, so CAT scans and MRIs don't show you concussions. The analogy I use is still that telephone switchboard operator that we were talking about. That CAT scan and that MRI takes a picture of the switchboard itself, but not the wiring. So you can imagine that with the concussion being an injury to the wiring, unless there was damage to that switchboard, like a bruise or a contusion on the brain or a bleed, I'm not going to see it. There are tests, some specialized tests called fMRIs and some PET scans that we can use to look for injury to the wiring, but unless we really have a picture of him before and after the repair, not super helpful. Great question. Great question. What other questions do you guys have? Can I drive? Can you drive? That's another good question. So what I would say to you is based on your balance testing, that you had a lot of difficulty with today, I probably wouldn't do that. Plus his reaction time on the computer test that we had him take showed decline from what's normal for him. So I would say no for right now. I don't know that that's super safe for you or super safe to those around him, but when those improve, what I'll usually say to my patients is I'll say, well, I want you to go for a ride with him once during the day, once at night. And if you're holding onto the oh, you know what bars a little bit more than you normally would with him driving, then the answer is still no. But otherwise, yeah, you probably would. What other questions do you guys have? And in terms of school, he can go back to school? Yeah, actually I want him to go back to school. Believe it or not, there's a lot of good nerdy studies that show, I know you probably don't want to, but you're going. There's a lot of good studies that show that holding kids out from school and the socialization that's there actually prolongs symptoms. But we'll set you up with those accommodations. And scene. Sorry for running over, guys. Yeah, thank you. Thank you so much for that. Yeah, I think, yeah. I recognize that there was a multitude of hyperbole in that talk that I gave to these patients, but it's purposeful hyperbole. You need to do that with teens and adolescents to get through that big skull, especially the white ones. So thank you guys for staying. I know we did go a little over time. We'll have the speakers up here if people have any questions. And then at 1130 in the Camden Lobby, so not too long from now, the Pediatric Sports Medicine Community, which includes this group here, is going to be meeting, so we'd love to meet some of you guys there, too. Thank you so much. Thank you so much. Thank you.

Salter-Harris fractures

apophysitis

osteochondritis dissecans

fractures

imaging techniques

treatment

pediatric sports medicine

concussions

brain injuries

head trauma

recovery

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