Having been a part of many youth related special interest groups in physiotherapy and strength and conditioning, I have seen some common trends and been involved in many interesting discussions around the management of adolescent injury/pain. The main mistake I see clinicians and coaches make is attempting to treat youth injury and pain the same way they would an adult with a similar condition. Therefore, the purpose of this blog is to provide a guideline for clinicians to follow when managing adolescent injuries/pain.
This blog will be split into 3 parts for ease of reading and to signpost clinicians to the most relevant information. These are:
Part 1 – Anatomy and physiology of growth and development along with unique paediatric red flags.
Part 2 – Considerations for creating an effective intervention with children / adolescence, and the implication for practice of the long term athletic development model (LTAD) implications.
Part 3 – Finally, we will tie it together with some common conditions we’ll see in the clinic. We’ll also give an example how management would change along the LTAD framework depending on the age of presenting conditions and goals.
Alright, let’s rip into part 1!
Growth/Maturation Phases
Childhood growth and development is characterised by both longitudinal bone growth as well as subsequent remodelling of that bone to deal with the forces that are applied to it. From approximately four years old until puberty, mass and length accumulates uniformly. From this time until mid adolescence, appendicular long bone growth outstrips skeletal density deposition, and axial bone growth. This can lead to some of the unique things like greenstick fractures seen in immature skeletons.
The most important event to highlight here is the phase of peak height velocity (PHV), a point during early puberty where long bone growth hits the accelerator. This is where the epiphyseal plate begins closing via ossification of the cartilage at the epiphyseal line and further calcification occurs at the epiphysis to form a longer bone. This time, traditionally known as ‘’the growth spurt’’, can be a potential area of vulnerability in an immature skeleton. Peak bone deposition rate usually occurs around 6-12 months after PHV. The individual’s hormonal, nutritional and physical activity status will all greatly impact bone development (1-4).
A quick question to determine the likelihood of PHV being associated with the clinical presentation is to ask about recent rapid change in shoe size (due to distal long bone growth). A failure to reach PHV (approximately 11.5 years for girls and 13.5 for boys) in physique sensitive sports like ballet and gymnastics must be noted as a possible sign of Relative Energy Deficiency in Sports (RED-S) and relevant referral discussions should be made.
Tendon/Ligaments:
Tendons and ligaments in childhood/adolescence are highly active tissue, laying down most of the framework from which we gradually modify in our adult years. Early in childhood the make-up of these tissues is biased towards a highly cellular environment with the extracellular matrix’s (ECM) functional force transmitting collagen proteins relatively sparse. In response to loading during growth, these cells signal greater composition of ECM proteins, especially in areas of high force (Musculotendinous Junction and Entheses/Apophysis). During growth the apophysis is another site of importance for pain and injury risk as the tendon tissue grows longitudinally much slower than the underlying bone placing a traction stress at this point (5).
Muscle/Neuromuscular Coordination:
The hypertrophic response to mechanical loading in the child/adolescent will be limited until puberty is reached and sex hormones are adequate. Strength and neuromuscular control of a joint segment can still be optimised via neurological mechanisms within the context of the repeated bout effect in training. This differs to the post pubertal period where greater emphasis can be put on hypertrophy in a periodised plan for joint stability. Furthermore, the period of PHV is often associated with negative changes in coordination as the athlete must adapt to their rapidly growing bodies. Management of training loads is required due to the increased risk of injury during this period (1,6).
The 5 “S’ of Paediatric Red Flags
Symptoms: Though common to have stress points during growth and development due to the different tissue development rates, symptoms presenting at any of these sites should at least be flagged.
Systemic: Anything not presenting as an isolated single joint, or showing signs of affecting more than just the musculoskeletal system. Septic arthritis is a common orthopaedic emergency in children. Therefore, think of signs of infection.
Symmetry: Though slight asymmetries in growth are completely normal, anything overly obvious should not be missed here. Think of large leg length and spinal alignment differences.
Skeletal Dysplasia: Abnormal bony growth patterns in young children need to be considered and referred appropriately.
Stiffness: Conditions like juvenile arthritis or other systemic conditions present as joint stiffness (7).
It is beyond the scope of this blog to outline all the types but for further learning I would direct you to here (8). The basic premise is that these fractures are either along or through the epiphyseal line and can impact bone growth and development. These are important not to miss as they can present as joint pain, but the consequences can be a lot higher for abnormal development of a child. Normal fracture related flags should prompt this investigation.
This is a paediatric orthopaedic emergency with either hip or knee pain or both, a limp and a lack of/and painful hip internal rotation (9).
Any paediatric back pain presentation coinciding with a change to training load, in a physique/weight based sport with dietary restrictions should be flagged. It’s also worth having a high index of suspicion of sports with repetitive lumbar extension and rotation (10).
Alright, that’s part 1 all wrapped up. I hope it’s been useful for you. You should now have a better understanding of the anatomy and physiology of adolescents and how to spot some paediatric red flags.
https://www.strengthandconditioning.org/jasc-24-2/8-adolescent-growth-and-maturation-assessments-injuries-and-strength-training
Luliano-Burns S, Mirwald RL, Bailey DA. Timing and magnitude of peak height velocity and peak tissue velocities for early, average, and late maturing boys and girls. Am J Hum Biol. 2001 Jan-Feb;13(1):1-8. doi: 10.1002/1520-6300(200101/02)13:1<1::AID-AJHB1000>3.0.CO;2-S. PMID: 11466961.
Stagi, S., Cavalli, L., Iurato, C., Seminara, S., Brandi, M. L., & de Martino, M. (2013). Bone metabolism in children and adolescents: main characteristics of the determinants of peak bone mass. Clinical Cases in Mineral and Bone Metabolism, 10(3), 172.
Beck B, Drysdale L. Risk Factors, Diagnosis and Management of Bone Stress Injuries in Adolescent Athletes: A Narrative Review. Sports. 2021; 9(4):52. https://doi.org/10.3390/sports9040052
Subramanian A, Schilling TF. Tendon development and musculoskeletal assembly: emerging roles for the extracellular matrix. Development. 2015 Dec 15;142(24):4191-204. doi: 10.1242/dev.114777. PMID: 26672092; PMCID: PMC4689213.
6- Lloyd, Rhodri S.1; Oliver, Jon L.1; Faigenbaum, Avery D.2; Myer, Gregory D.3,4,5; De Ste Croix, Mark B. A.7 Chronological Age vs. Biological Maturation, Journal of Strength and Conditioning Research: May 2014 – Volume 28 – Issue 5 – p 1454-1464 doi: 10.1519/JSC.0000000000000391
https://www.cambscommunityservices.nhs.uk/docs/default-source/leaflets—children’s-physiotherapy-services—april-2015/0405—guidelines-mskortho—april-2018-(v2).pdf?sfvrsn=2
https://www.rch.org.au/fracture-education/growth_plate_injuries/Physeal_growth_plate_injuries/
Tekmyster, G., Barbaria, V., & Lee, C. J. (2019). Diagnosis and Treatment of Spondylolysis in the Adolescent Athlete. Connecticut Medicine, 83(9).
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