Consideration for the adolescent athlete

Anatomical considerations for the adolescent athlete, which need to be considered in

Developing and execution of training programmes and competition schedules.

Everton Sorzano

Anatomy

Dr. Oba S. Gulston, RPT, DPT

March 24, 2009

 Introduction

When developing and hoping to execute a training programme for an adolescent athlete

there are certain aspects of the anatomical structure of the athlete that must be considered.

Adirim and Cheng (2003) stated that there are physical and physiological differences between

the adolescent and the mature adult athlete that may cause the adolescent athlete to be more

vulnerable to injury. In some of the joints of the adolescent athlete there are open physes (growth

plates) and there is the theoretical possibility of damage with certain activities such as

weightlifting which can lead to early closure. This is one of the factors that coaches should take

into consideration when developing training programmes for young athletes. Furthermore,

growing cartilage is more susceptible to stress, which may be a factor in overuse injuries. The

adolescent athlete, however, is more vulnerable to injury than the pre-pubescent child because

circulating androgens cause the development of mass and speed and therefore power.

Skeletal differences between adolescent and adult athlete in sport

Adirim et. al also concluded that the variability of anatomic development during the

adolescent years impact performance and injury significantly. Bone development continues

throughout adulthood. Even after adult stature is attained, bone development continues for repair

of fractures and for remodeling to meet changing lifestyles. Osteoblast, osteocytes and

osteoclasts are the three cell types involved in the development, growth and remodeling of bones.
Osteoblast are boneforming cells, osteocytes are mature bone cells and osteoclasts breakdown

and reabsorb bone.

SOURCE: file:///I:/bar.htm

Bones grow in length at the epiphyseal plate by a process that is similar to

endrochondral ossification. The cartilage in the region of the epiphyseal plate next to the

epiphyses continues to grow by mitosis. The chondrocytes, in the region next to the diaphysis,

age and degenerate. Osteoblast move in and ossify the matrix to form bone. This process

continues through childhood and the adolescent years until cartilage growth slows and finally

stops. When cartilage growth ceases, usually in the early twenties, the epiphyseal plate

completely ossifies so that only a thin epiphyseal line remains and the bones can no longer grow
in length. Bone growth is under the influence of growth hormone from the anterior pituitary

gland and sex hormones from the ovaries and testes.

Traction Apophysitis of 5th

Metatarsal base

SOURCE: International Sport

Med Journal, Vol.7 No.2, 2006, pp. 85-97 http://www.ismj.com

Certain anatomic variants can make adolescent athletes predisposed to certain injuries.

Adolescent athletes with a cavovarus foot are often prone to lateral foot injuries, including stress

fractures of the fifth metatarsal and ankle sprains. Adolescents who present with painful planus
or flatfeet must be carefully evaluated for tarsal coalition, tight gastroc-soleus muscle tendon, or

peroneal muscle spasm. The demands and expectations on an adolescent athlete make them

prone to injuries, particularly overuse injuries.

Sports injuries are particularly avoidable. For youth, this is especially salient since the

effects of childhood sports injuries can linger into adult years. Strategies should be considered

for sports related injuries specifically, Hergenroader outlined six potential mechanisms for

reducing injuries.

Epidemiology of injuries in adolescent athletes

Apophysitis is caused by micro-avulsions at the bone-cartilage junction. It is caused by

repetitive motion and overuse occurring during periods of rapid growth. The most common sites

for Apophysitis are the insertion of the patella tendon on the tibial tubercle (Osgood schlatter

disease), the insertion of the Achilles tendon and plantar fascia on the calcaneus (sever’s disease

or osteochondrosis of the calcaneus) and at the flexor/pronator origin on the medial epicondyle

of the elbow (little league elbow).

 Sever’s Apophysitis of calcaneus

SOURCE: International Sport Med Journal, Vol.7 No.2, 2006, pp. 85-97 http://www.ismj.com

Sever’s disease is seen in children who are contracted in the gastrocnemius-soleus

muscle complex and who are very physically active. On examination these, children have

tenderness over the posterior aspect of their heel and dorsiflexion at the ankle is limited.
 Growth plate of immature bone is still open.

SOURCE: Osgood schlatter disease pics.

Also known as osteochondritis of the tibial tubercle, Osgood-Schlatter disease is

commonly found in the active adolescent who participates in sports involving repetitive jumping
as well as excessive deep knee bending or squatting. It is characterized by tenderness and

swelling of the patella tendon and enlargement of the tibial tubercle’s proximal aspect. The

consensus is that this disease may be from trauma. This disease of adolescence, first described in

1903 by Osgood and later by Schlatter, involves an onset of symptoms usually prior to rapid

growth spurts. They believed that the disease is caused by trauma but disagree as to the nature of

the primary lesion. They also agreed that trauma causes a partial avulsion of the proximal tibial

tubercle. The primary lesion’s etiology remains controversial. The bony architecture of the

immature adolescent knee skeleton is not much different from that of an adult skeleton except for

the physis or growth plate of the long bones. In general, the secondary ossification centers

(epiphyses) of the long bones continue to expand dimensionally toward each other from birth

until midadolescence. The immature bone is separated by a cartilaginous remnant known as the

physis. The physes are primarily responsible for enchondral ossification, which results in

longitudinal growth. It is at this juncture of the immature proximal anterior tibia physis that we

encounter this disease. The knee’s structural bony support consists of the femur, with emphasis

on the femoral groove (trochlea); the tibia with particular attention to the proximal anterior

aspects; and the patella. The tendinous structures involved include the quadriceps and patella

tendons with their respective insertions. Familiarity with the knee’s extensor mechanism can

help the clinician appreciate the potential pathology. Scapinelli, in 1968, described the genicular

circulation.

The vascular supply of the patella tendon’s insertion site consists of branches from the

descending genicular, which come directly from the femoral artery. Medially, specific branches

such as the saphenous and articular branches of the descending genicular artery provide

nourishment. Anteriorly, branches from the anterior tibial recurrent artery and inframedial
genicular artery provide branches to the patella tendon and its insertion. Also, inferior to the joint

line is a subdivision from the popliteal artery, which parallels the above-mentioned

vessels. The physis anatomically is surrounded by blood supplies: epiphyseal vessels that

penetrate the Subchondral bone to the epiphysis, vessels of the perichondral ring (periosteal

vasculature), and the nutrient artery from the metaphysial side. Innervation of the adolescent

knee (tibial tubercle) consists of branches from the anterior group of afferent nerves. The main

contributor of the patella tendon region consists of the infrapatellar branch of the saphenous

nerve. Descending from the saphenous nerve, this wraps around and penetrates the patella

tendon’s medial aspect. Fortunately, Osgood-Schlatter disease is self-limiting and the pain

resolves when the tibial tuberosity matures and fuses with the tibial diaphysis. Quadriceps,

vastus, medialis, obliquus strengthening exercises may provide some relief from tenderness.

However, avoid stressing the extensor mechanism in hyperextension or flexion of the

knee beyond 90º because these 2 extremes may aggravate existing patella tendinitis. Advise the

patient to perform daily progressive stretching of the hamstring, quadriceps, and heel cord, and

to temporarily modify activities such as competitive jumping. Rarely is surgical intervention

necessary. Try all conservative means of treatment before surgery to excise ossicles from the

inferior pole of the patella or tibial tubercle.

 Conclusion

After careful research and analyzation I have come to the conclusion that the adolescent

athlete is the most vulnerable to athletic injury and this project has attempted to provide the

reader with an update of the growing concerns for today's young athletes based upon their

uniqueness and predisposing factors which need to be considered in developing and executing

training programmes and competition schedules. The continued expansion of sport activity in

young age groups necessitates asking some critical questions regarding their effects in order that

we can hope to insure that young athletes might participate and benefit from sport without undue

risk of injury. An ever increasing number of children are participating in organized sports and

recreational programmes. Sports participation provides many benefits including increased

fitness, improved motor coordination and improved socialization skills. However, the risk of

injury will always be present. Over a third of young athletes will sustain an injury that will bring

them to medical attention. Physicians who treat these children should be aware of the

physiological and developmental differences between young and the more mature athlete, both

for diagnostic purposes and to give anticipatory guidance on injury prevention. Advocating for

injury prevention practices, such as proper coaching, medical coverage and adequate hydration,

should be a goal of coaches caring for young athletes.

 References

Adirim TA, Cheng TL. Overview of injuries in the young athlete. Sports Medicine 2003; 33: 75-

81.

Apperly. Kate. Sever’s disease sorts media, edition 24, summer/spring 2008.

Bach BR. (2009, march 17) Acute injuries. Physician sports medicine. Retrieved from

http://www.physsportsmed.com/issues/1997/05may/bach.htm.

Benthien RA, Sullivan RJ, Aronow MS. Adolescent osteochondral lesion of the talus, ankle

arthroscopy in pediatric patients. Foot and Ankle Clinic 2002: 7; 651-667.

Chambers HG. Ankle and foot disorders in skeletally immature athletes, orthopedic clinic North

America 2003; 34: 445-459.

Collins HR Evarts CM: injuries to the adolescent athlete. Post grad med 49: 72-78, 1971.

Crosby LA, MC Mullen ST. Heel pain in an adolescent: consider calcaneal.

Hawkins D, Metheny J. overuse injuries in youth sports: biomechanical considerations. Med sci

sports exec 2001; 33 (10) 1701-07.

Kann L, kinchen SA, Williams BI. Youth risk behavior surveillance: United States 1999.

MMWRCDC survey sum 2000 Jun 9: 49(55-5): 1-32.

Lazerte GD, Rapp IH pathogenesis of Osgood schlatter’s disease. American J. pathology. 1958:

34: 803
Michelli LJ, Ireland ML. Prevention and management of calcaneal apophysitis in children: An

overuse syndrome. Journal of Pediatric Orthopedics 1987; 7:34- 38.

Scapinelli R studies on the vasculature of the human knee joint. Acta anat. 1968: 70: 305-331.