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Musculoskeletal injury in children and skeletally immature adolescents: Overview of treatment principles for nonoperative injuries

Musculoskeletal injury in children and skeletally immature adolescents: Overview of treatment principles for nonoperative injuries
Literature review current through: Jan 2024.
This topic last updated: Mar 28, 2023.

INTRODUCTION — This topic provides an overview of the basic principles of and modalities used in the treatment of nonoperative musculoskeletal injuries in young athletes. Rehabilitation of musculoskeletal injuries, with an emphasis on the physical therapy program, is discussed separately. (See "Musculoskeletal injury in children and skeletally immature adolescents: Overview of rehabilitation for nonoperative injuries".)

The discussion that follows assumes that fractures and joint instability have been excluded. The evaluation of musculoskeletal trauma and the management of fractures and unstable joints are discussed separately (refer to UpToDate topics on the specific bone or joint in which fracture or dislocation is suspected).

EPIDEMIOLOGY — Approximately 60 million United States youth aged 6 through 18 years participate in organized sports each year [1]. Analysis of sports and recreation related injury episodes in the United States has shown an average annual estimate of 8.6 million injury episodes with an age-adjusted rate of 34.1 per 1000 population [2]. Overall, injury rates are higher among males and children between the ages of 5 to 14 years. Approximately 50 percent of injuries require medical attention. Injuries to the lower extremities are most common (42 percent) followed the upper extremities (30 percent), and head and neck (16 percent).

According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases report there are more than 2.6 million children younger than 19 years of age who were treated in emergency departments for musculoskeletal injuries due to sport participation [3]. Musculoskeletal injuries are also the most common reason for injury-related visits to primary care physicians. Sprains and strains, growth plate injuries, and repetitive motion injuries account for the majority of injuries.

Although most children and adolescents with musculoskeletal complaints can be managed by primary care providers with appropriate training, such children often are referred to specialists [4]. Primary care providers (including pediatricians, family physicians, and internists) and providers trained in other specialties see patients with these injuries and complaints and report a lack of confidence and/or training in the management of musculoskeletal problems [5-8]. The purpose of this discussion is to attempt to remedy this gap in care.

PHASES OF HEALING — The healing processes are divided into three phases:

Inflammatory phase (0 to 72 hours after injury)

Reparative/fibroblastic phase (72 hours to 3 weeks after injury)

Maturation/remodeling phase (3 weeks to 2 years after injury)

Inflammatory phase — The inflammatory phase of healing occurs immediately after trauma and lasts approximately 72 hours. During the inflammatory phase, local and systemic responses to injury lead to altered vascular permeability about the injury site. Homeostasis of fluid balance is disrupted, resulting in swelling [9]. Capillaries dilate and become more permeable, resulting in transmission of blood to the extravascular space and concentration of local inflammatory mediators. Plasma protein and fluid are deposited in the interstitium, and development of small pockets of fluid in tissues occurs [9].

If these processes and their sequelae are improperly managed, healing may be delayed, and chronic adverse tissue changes (eg, fluid stasis, aberrant deposition of fibrinogen, soft-tissue thickening, formation of adhesions) may occur [9]. Chronic changes may be associated with persistent pain, decreased function, decreased range of motion, decreased power, and increased risk of reinjury.

Reparative phase — The reparative/fibroblastic phase of healing takes place from approximately three days through three weeks after injury. During the reparative phase, collagen deposition and tissue healing occur.

Maturation phase — The maturation/remodeling phase takes place from approximately three weeks through two years after injury. During the maturation phase, new collagen and bone matrix fibers that were deposited during the reparative phase increase their strength and organization. The application of excessive force during the maturation phase will disrupt the immature tissue. On the other hand, if insufficient force is applied, the tissue will not organize along lines of stress and will fail during the application of strong force as the athlete returns to sports activity.

REHABILITATION PROGRAM — The phases of rehabilitation correspond to the phases of healing.

Goals — Each phase of rehabilitation has associated goals, although there is some overlap, particularly as the athlete makes the transition from the reparative to the maturation phase. The ultimate goal is to return the athlete to sports competition in a timely fashion while minimizing the risks of reinjury or a second injury. The rehabilitation program is discussed in detail separately. (See "Musculoskeletal injury in children and skeletally immature adolescents: Overview of rehabilitation for nonoperative injuries".)

Inflammatory phase – The goals during the inflammatory phase include protection of the injured area, relative rest, and decreased swelling to prevent chronic tissue changes (eg, fluid stasis, aberrant deposition of fibrinogen, soft-tissue thickening, formation of adhesions) (table 1). (See "Musculoskeletal injury in children and skeletally immature adolescents: Overview of rehabilitation for nonoperative injuries", section on 'Inflammatory phase'.)

Reparative phase – The goals during the reparative phase include continued protection of the injured structures, achieving full range of motion (ROM) of the affected joints and soft tissues, reestablished proprioception, and progressing from voluntary muscular firing patterns to muscular strength, endurance, and power. (See "Musculoskeletal injury in children and skeletally immature adolescents: Overview of rehabilitation for nonoperative injuries", section on 'Reparative phase'.)

Maturation phase – The goals during the maturation phase overlap with those of the reparative phase and include maintenance of cardiovascular fitness, ROM, flexibility, and proprioception; increased muscular strength, endurance, and power; increased speed and agility; and achievement of sport-specific skills [10]. (See "Musculoskeletal injury in children and skeletally immature adolescents: Overview of rehabilitation for nonoperative injuries", section on 'Maturation phase'.)

General principles — General principles of sports rehabilitation are listed below [9-11]:

Establish the diagnosis.

Identify causative factors (eg, increasing the training load too rapidly, imbalance of strength or flexibility, biomechanical problems, equipment that is not properly fitted, inadequate endurance) and make modifications during the recovery period.

Formulate a rehabilitation program to address the specific injury; the program should be individualized to the athlete (eg, skeletal maturity, sport, position, skill level); list sport-specific skills and arrange them according to stress.

Provide adequate time for healing and provide information to the patient, family, and coach regarding the predicted healing time.

Maintain cardiovascular fitness.

Maintain strength in muscle groups that are not affected.

Avoid exercises that cause pain.

Reintroduce activities progressively after healing is complete.

Return to sports activities and competition gradually.

Physical therapy prescription — Proper prescription of physical therapy is vital to the completion of healing and a timely return to sports participation. Staged physical therapy treatment is based upon known tissue-healing properties and timelines. How and when a modality, manipulation, or exercise is deployed is guided by the type of injury and tissue response to physiologic demand and by the signs and symptoms of the stages of the healing process (table 2).

PHYSICAL AGENTS — Physical therapists use a variety of techniques to clinically evaluate and treat the athlete. Delivery of care ranges from conservative application of physical modalities (eg, cold therapy, heat therapy) to the application of high-velocity, low-amplitude manipulation of a hypomobile joint.

Cold therapy — Cold therapy (ice) is commonly used during the inflammatory phase to decrease swelling and pain; decreased swelling may result in increased range of motion and flexibility. It is also used during later stages of healing and rehabilitation if pain and swelling recur during or following therapeutic exercise [9,11]. (See "Musculoskeletal injury in children and skeletally immature adolescents: Overview of rehabilitation for nonoperative injuries", section on 'Range of motion and flexibility'.)

The physiologic effects of ice include decreased bleeding, swelling, inflammation, and pain [9]. These may in turn limit secondary injury, ischemia, and damage to other structures [10]. The effects of ice application on scar formation are unknown [10].

Neural effects of icing include [9]:

Cold sensation (0 to 3 minutes)

Burning, aching (2 to 7 minutes)

Local numbness, anesthesia, decreased reflexes, interruption of pain spasm cycle (5 to 12 minutes)

Deep-tissue vasodilation not accompanied by increased metabolism (12 to 15 minutes)

The neural effects of ice application are thought to be mediated through vasoconstriction, leading to decreased edema, decreased release of localized pain mediators, and a slowing of nerve conduction velocity of peripheral nerve fibers [12].

How to apply ice — Correct usage of cold therapy includes [13]: Ice application should begin immediately postinjury. Ice packs should be applied for 20 to 30 minutes (either continuously or in 10-minute sessions with 10-minute breaks between sessions) directly on the skin. Three to four times per day is considered sufficient, but cold therapy can be performed every hour; the more frequent the application, the greater the chance of effectively reducing the inflammatory process.

The optimum temperature range for reduction of cell metabolism without causing cell damage is 10 to 15°C [14]. In human subjects, a standard ice pack (0.6 to 1 kg ice in a plastic bag [15]) applied for 25 minutes cools to 2 cm deep in the target muscle by 4.63°C, 6.65°C, or 8.03°C when using no compression, flexi-wrap, or elastic wrap, respectively [16]. At 30 minutes of ice application, surface temperatures have been demonstrated to be 14.95°C, 11.55°C, and 9.49°C when an ice bag was applied with no external compression, flexi-wrap, and elastic wrap, respectively [16].

The magnitude of temperature reduction is affected by the placement of a barrier between the ice and the skin (table 3), the amount of ice in the ice pack, the depth of adipose tissue, the method and duration of application, and the depth of the injured tissue [14,15,17,18]. Ice massage may cool muscle tissue more rapidly than the application of ice packs [19]. The combination of ice and compression is more effective in reducing temperature and controlling edema than either ice or compression alone [20-22]. Compression increases contact between ice and skin and may limit rewarming [14,16]. (See 'Cold therapy methods' below.)

Cold therapy methods — Cold therapy may be applied with ice packs, ice massage, ice baths, or vapocoolant sprays.

Ice packs – Standard application of melting iced water ensures a constant temperature of 0°C, whereas ice directly from the freezer may be below freezing point [14]. Commercial ice packs and flexible, reusable gel cold pack temperatures may be lower than those achieved with ice (-5 to -15°C) [9]. They may cause tissue damage and frostbite if the patient is not adequately monitored. (See 'Adverse effects' below.) With proper use, ice packs can achieve significantly decreased temperature in both the surface and target intramuscular tissue for up to 50 minutes following removal of the ice pack.

Ice massage – Ice massage consists of rubbing the injured area with an ice cube (eg, water frozen in a small paper cup) for approximately 10 minutes per session [9,23]. Ice massage is a safe, inexpensive way to use cold therapy for superficial lesions and areas with low tissue volume. Ice massage is dose dependent, with deeper tissues cooling more at 10 minutes than with 5 minutes of ice application [24].

In a controlled study of ice massage, skin temperature decreased most rapidly during the first two minutes of ice massage (14.8 and 5.7°C decrease in the first and second minutes, respectively) [23]. The lowest mean temperature was 5.8°C in the 10th minute. Cooling occurred at an average of 2.7°C per minute and rewarming at an average of 1.9°C per minute. The analgesic effect began when the skin temperature reached 13.6°C during cooling (after a mean of 1 minute, 45 seconds) and ended when skin temperature reached 15.6°C during warming (2 minutes, 57 seconds after the ice was removed).

Ice baths – Ice baths may be more suitable than ice packs or ice massage for cooling large areas or body parts with an irregularly shaped surface (eg, hands and feet). Although ice baths require the limb to be in a dependent position, the effects of dependency on swelling are offset by the water pressure and the overall improvement in decreasing the tissue temperature and nerve conduction velocity of the target tissue compared with ice massage and ice packs [9,25]. Ice baths at a temperature of 4.4 to 10°C (40 to 50°F) may be used for cryokinetics (ROM during cold treatment).

Vapocoolant sprays – Vapocoolant (eg, ethyl chloride) sprays may be used for rapid cooling after direct contusion, as part of "spray and stretch" techniques, and for injection of trigger points within aberrant muscles [9].

Adverse effects — Adverse effects of cold therapy include frostbite and nerve damage [26]. Areas particularly vulnerable to ice injury include the peroneal nerve at fibular neck and the ulnar nerve at elbow. There are case reports of neurapraxia and axonotmesis from prolonged icing over subcutaneous nerves; most patients completely recovered within hours to days, but one patient remained symptomatic at 18 months [26]. Application of cold therapy should be limited to 20 to 30 minutes with frequent skin checks and sensation evaluation.

The application of ice may have implications for return to play due to its effect on, muscle performance and position sense [14,27-29]. When applied to the lower extremities of uninjured athletes, cold therapy resulting in temperatures less than approximately 18°C reduced the strength of plantar flexion and impaired functional and motor performance [28]. Sensory nerve conduction velocity can decrease by 1.4 to 2.6 m/s for every °C of skin temperature reduction, whereas motor nerve conduction velocity can decrease by 1.1 to 1.5 m/s per °C. There are other factors that affect the relationship between skin temperature and nerve conduction velocity, such as the depth of the nerve, the amount of surrounding subcutaneous tissue, age, range of temperature variation, and possibly the type of modality used to alter skin temperature [25]. Observations that cold therapy affects position sense are inconsistent and conflicting; the clinical implications of potential impaired position sense with respect to return to play after icing are controversial [14,27,29-34].

Contraindications — There are few contraindications to cold therapy. They include [9]:

Raynaud phenomenon (see "Clinical manifestations and diagnosis of Raynaud phenomenon")

Peripheral vascular disease (eg, diabetes)

Impaired sensation

Cold allergy/hypersensitivity

Severe cold-induced urticaria (see "Cold urticaria")

Cryoglobulinemia

Paroxysmal cold hemoglobinuria (see "Paroxysmal cold hemoglobinuria")

Heat therapy — Heat therapy may reduce pain and spasm and increase blood flow and compliance of soft-tissue structures [9]. Heat therapy may be achieved through warm-up exercises or passive heating modalities (eg, hot packs, hydrotherapy, ultrasound) [11]. Heat therapy may be used before exercise or in chronic conditions where recovery is slowed by restricted muscle or joint motion. Heat therapy should not be applied during the inflammatory phase of injury. (See "Musculoskeletal injury in children and skeletally immature adolescents: Overview of rehabilitation for nonoperative injuries", section on 'Heat'.)

Therapeutic exercise — Therapeutic exercise is used to stretch and strengthen muscles, improve joint mobility, maintain cardiovascular endurance, and to increase strength, power, endurance, speed, agility, and sport-specific skills (table 4) [9,11]. The use of therapeutic exercise in rehabilitation of nonoperative musculoskeletal injuries in young athletes is discussed separately. (See "Musculoskeletal injury in children and skeletally immature adolescents: Overview of rehabilitation for nonoperative injuries".)

Other modalities — Other modalities that may be indicated during rehabilitation of musculoskeletal injuries include ultrasound and electrical stimulation. These modalities require an understanding of injury physiology that is beyond the scope of this review. They should be undertaken in consultation with experts in sports medicine and rehabilitation.

Manual therapy — Dysfunction of a joint complex can include arthrokinematic hypomobility. Abnormal joint mobility precludes normal motor control and sport performance. The physical therapist may use manipulation to restore normal joint mobility. Observational studies have demonstrated improved mobility following joint manipulation by physical therapists [35-38].

SUMMARY

Epidemiology – Most musculoskeletal injuries among young athletes are nonoperative and can be managed by primary care providers with appropriate training. (See 'Epidemiology' above.)

Phases of healing – The healing processes are divided into three phases (see 'Phases of healing' above):

Inflammatory (0 to 72 hours after injury)

Reparative/fibroblastic (72 hours to 3 weeks after injury)

Maturation/remodeling (3 weeks to 2 years after injury)

Rehabilitation – The phases of rehabilitation correspond to the phases of healing. Each phase of rehabilitation has associated goals, although there is some overlap. The ultimate goal is to return the athlete to sports competition in a timely fashion while minimizing the risks of reinjury or a second injury. (See 'Rehabilitation program' above.)

The rehabilitation program is individualized and focuses on protection of the injured tissue and maintaining cardiovascular fitness and strength in muscle groups that are not affected while progressively restoring function, strength, power, and endurance of the injured muscle groups, followed by gradual reintroduction of sport-specific activities. (See 'General principles' above and "Musculoskeletal injury in children and skeletally immature adolescents: Overview of rehabilitation for nonoperative injuries".)

Physical therapy – Proper prescription of physical therapy is vital to the completion of healing and a timely return to sports participation. Physical therapists use a variety of techniques to clinically evaluate and treat the athlete:

Cold therapy is used to decrease pain and swelling; decreased swelling may result in increased range of motion and flexibility. (See 'Cold therapy' above.)

Heat therapy may reduce pain and spasm and increase blood flow and compliance of soft-tissue structures. (See 'Heat therapy' above.)

Therapeutic exercise is used to stretch and strengthen muscles, to improve joint mobility, maintain cardiovascular endurance, and to increase strength, power, endurance, speed, agility, and sport-specific skills (table 4). (See 'Therapeutic exercise' above.)

Staged physical therapy treatment is based upon known tissue-healing properties and timelines. How and when a modality, manipulation, or exercise is deployed is guided by the type of injury and tissue response to physiologic demand and by the signs and symptoms of the stages of the healing process (table 2).

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Dana Fitzgerald, MD, who contributed to earlier versions of this topic review.

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