SAN FRANCISCO—It’s healthy—physically and socially—for children and adolescents to participate in sports. But engaging in athletic pursuits also can entail risks, especially for developing young bodies.
Physicians have a window of opportunity to make a difference in the future health and quality of life of young female athletes, emphasized Aurelia Nattiv, MD, a professor in the UCLA department of family medicine, and division of sports medicine in the department of orthopedics at UCLA. Dr. Nattiv, the first of three presenters at the October 2008 ACR/ARHP Annual Scientific Meeting presentation, “Treating the Young Athlete,” served as chair of the American College of Sports Medicine’s Revised Position Stand on the Female Athlete Triad.1 In her presentation, Dr. Nattiv outlined the current science underpinning the revised position stand, and also touched on common musculoskeletal injuries seen in female athletes.
The female athlete triad is currently defined as energy availability, menstrual function, and bone strength, three interrelated items that exist on continuums from health to disease, Dr. Nattiv explained. She noted that “energy availability” has replaced the term “eating disorder,” and is defined as the amount of dietary energy remaining for all other physiological functions after energy has been expended in exercise.
While clinicians may be more familiar with the frank clinical manifestations of the triad (e.g., eating disorders, functional hypothalamic amenorrhea, and osteoporosis), Dr. Nattiv said, “A large group of female athletes don’t have an eating disorder [and therefore do not fall within the DSM-IV eating disorder diagnoses]. But, these athletes still need education about meeting their energy needs.” Negative energy availability is now considered key to the triggering of pathologic processes. For example, recent research is showing that reduced energy availability is a co-risk factor for lowered bone density, along with menstrual dysfunction.
Building bone density is of crucial importance between ages 10 and 14, with 90% of peak bone mass being reached at around age 18. “It’s hard to gain bone back,” Dr. Nattiv reminded her audience, and showed slides of severe osteoporosis in young women. She urged session participants to be proactive and screen all girls and women in sports and regular exercise programs for the triad disorders. This screening should include a menstrual history and nutritional habits, among other elements. A baseline bone density may be indicated if a girl has experienced prolonged amenorrhea or oligomenorrhea for over six to 12 months and has a lower body weight and/or pathologic stress fractures. Because building bone in younger women does not respond to boosting estrogen with oral contraceptives (a different mechanism is at work than in postmenopausal bone mineral loss), Dr. Nattiv argues for a nutritionally based approach to boost body weight while ensuring adequate vitamin C and D intake.
Think Apophysitis, Not Tendonitis
Next, Sally S. Harris, MD, MPH, a clinical instructor of pediatrics at Stanford University School of Medicine and a pediatric sports medicine specialist at Palo Alto Medical Foundation in Portola Valley, CA, described a series of common overuse injuries, which can mimic rheumatologic conditions. Because they develop insidiously and tend to be chronic, overuse injuries may be referred to the rheumatologist for diagnosis. In these situations, it’s important to understand the structure of the immature skeleton so that patients can be properly referred and treated, noted Dr. Harris. For example, she cautioned: “Beware of the diagnosis of tendonitis,” because it is rare in children. “By definition,” she explained, “tendonitis refers to degenerative changes, and tissues of kids and adolescents are too healthy to exhibit such changes—although they can be seen in rare cases.”
Younger athletes are more likely to experience injury of the apophysis, where the tendon inserts into bone. Apophysitis, produced by chronic repetitive traction at the apophysis, “is unique to the developing skeleton,” Dr. Harris emphasized. Although most of these injuries have a self-limited course, some may take years to resolve, and others can predispose young athletes to more serious injury, such as avulsion fractures. Using 10 case studies, Dr. Harris enumerated common sites of overuse injury (elbow, tibia, metatarsal, pelvis) leading to apophysitis.
In general, most children and teenagers who experience overuse injuries do not have to give up sports participation altogether, although decreased or alternative activities are usually employed as part of management. Other treatments include icing, NSAIDs to control pain and inflammation, correcting biomechanical abnormalities, and correcting errors in training or equipment. Some injuries, such as apophysitis at the base of the 5th metatarsal (Iselin’s syndrome) may be helped by use of an ankle brace; arch support can be beneficial to help heal an apophysitis of the tarsal navicular bone. Apophysitis at the medial humeral epicondyle of the elbow (often seen in Little Leaguers) requires careful management, since there can be long-term consequences for elbow function.
With these injuries, and with apophysitis of the pelvis, it’s important to emphasize that the young athlete should not play through escalating pain. Dr. Harris also included cases, such as an avulsion fracture at the elbow, which did require a surgical pinning. Knowledge of the developing skeleton, coupled with a robust referral network between rheumatologists and their pediatric sports medicine colleagues, can result in healthy outcomes for these young patients, said Dr. Harris. “Once their conditions are properly addressed, these young athletes may be able to ease back in to full participation.”
Young Athletes with Rheumatic Pain
The last presenter of the afternoon session was Alison P. Toth, MD, an assistant professor of orthopedic surgery and director, Women’s Sports Medicine Clinic, at Duke University Medical Center, who discussed the special considerations in treating young athletes with juvenile arthritis and other rheumatic conditions.
Certain precautions should be followed for kids with juvenile arthritis, since they may be more prone to injury. In those with C-spine arthritis, for instance, Dr. Toth recommends a baseline preparticipation X-ray to rule out ligamentous laxity. A baseline neurological exam may also be warranted, and physicians should counsel these students to avoid collision/contact sports and sports with the potential for catastrophic neck injury, such as diving or gymnastics. Some risks can be mediated with preventive measures, such as wearing eye protection to prevent further eye damage in those with uveitis or applying sports sunscreen for those taking hydroxychloroquine to treat lupus. During periods of moderate to severe disease activity, young athletes with arthritis should limit weight-bearing sports to avoid further structural damage. Gradual return to play after flare-ups can be attained, said Dr. Toth, if pain and swelling have subsided and range of motion, strength, and balance are regained.
The remainder of Dr. Toth’s talk was devoted to eight case studies, which demonstrated the collaboration between sports medicine and pediatric rheumatology at Duke. For instance, a 14-year-old basketball player with a history of bilateral anterior uveitis and morning joint stiffness, taking methotrexate 25 mg SQ weekly, presented with a 3rd metatarsal stress fracture. The dominant philosophy, said Dr. Toth, is that “inactivity is not good, even in someone with inflammatory arthritis.” Thus, using a custom “clamshell” brace of fiberglass and ethyl vinyl acetate, a modified orthotic, and a carbon fiber shank in the shoe, the treatment team was able to unload the metatarsal and allow the young man to continue to play.
In one cautionary case, Dr. Toth and her team performed a revision tibial tubercle osteotomy in a girl with juvenile spondyloarthritis. The first surgery had resulted in a nonunion and wound infection when the girl returned to soccer practice and to her immunosuppressant medications too soon after surgery. After the revision surgery, physicians held off on restarting her adalimumab and MTX. The case points out, said Dr. Toth, that rheumatologists should make sure their orthopedic colleagues are aware of their patients’ special issues, since they differ from those of the general orthopedist’s population.
Rheumatologists can access the expertise of their sports medicine colleagues to devise strategies for treating their patients, either through appropriate bracing and orthotics or with timely and expert surgical repairs. Surgical consultations should be considered for refractory synovitis, mechanical entrapment (such as “hourglass biceps”), AVN (the joint can be salvaged before resorting to total knee replacement), joint malalignment, and chondral pathology. These young people need not be denied the positive benefits of sports participation, believes Dr. Toth.
If you want to view this session, download it (and more than 70 other sessions) from the ACR/ARHP Annual Scientific Meeting via ACR SessionSelect at www.rheumatology.org/SessionSelect.
