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Overview of Sports Related Injuries in Children
Each year approximately 30 million children and teenagers participate in organized sports, including football, baseball, lacrosse, soccer, field hockey, rugby, cheerleading, and gymnastics.1 This does not take into consideration the multitude of unorganized activities that children participate in. In looking at injuries and ailments associated with sports, the musculoskeletal and dermatologic systems are the two bodily systems most commonly affected or injured.2 Many of these conditions are minor and are considered a normal part of growing up. Pharmacists need to have a basic understanding of these conditions and how they are best treated—both pharmacologically and nonpharmacologically.
The recent emphasis being placed on sports participation has resulted in an increase in overuse injuries. Adolescents may be prone to these chronic injuries for physiologic reasons (i.e., their bodies are still growing) or due to decreased recovery time from an injury. Competitive seasons are longer in duration and many programs institute year-round training.3,4
Many orthopedic problems that develop in the young athlete can be attributed to the inability of growth centers to meet the demands placed on them during physical activity. The apophysis is a prominent bony outgrowth projecting from the surface of a bone and often acts as an attachment site for tendons. Damage to this growth center, from overuse syndromes, may result in apophyseal injuries such as Osgood-Schlatter disease (tibia), Sever’s disease (heel), and little leaguer’s elbow (medial epicondyle).3 Initial treatment for many of these syndromes will employ the RICE method followed by pharmacologic modalities for both pain and inflammation.
RICE is an acronym for what has been described as the best nonpharmacologic treatment for many overuse injuries. RICE stands for Rest, Ice, Compression, and Elevation. Rest is best achieved by reducing or stopping activity for at least 48 hours.2 It is recommended that ice packs be placed on the injured area for 15 to 20 minutes at a time, between four and eight times per day. Ice packs may consist of a cold pack, an ice bag, or a plastic bag filled with ice that has been wrapped in a towel. Ice should only be used the first 72 hours, then heat applied thereafter. The use of compression on an injured ankle, knee, or wrist may be used to help reduce the swelling. Elastic wraps (e.g., Ace bandages), special boots, air casts, and splints are commonly used. Finally, keeping the injured area elevated above the level of the heart to reduce blood flow has been shown to provide improvements in healing times.
Overuse Injuries (Upper Extremities): Sports such as baseball, tennis, and volleyball put the shoulder at risk for overhead injury.3 Little leaguer’s shoulder is particularly common in the adolescent population, due to the mechanics of the throwing motion and the fact that many of these athletes still have open growth plates.3 The average age of onset for little leaguer’s shoulder is 14 years, with pain presenting over the proximal and lateral portion of the humerus.5 Radiographs can be used to confirm the diagnosis and can be visualized as widening of the proximal humeral physis.5 Treatment includes rest from the exacerbating activity (3 months), icing, and analgesics as needed for pain.5
The elbow is also susceptible to overuse injuries, particularly in adolescents playing baseball. Throwing puts significant stress on the elbow and results in a condition known as little leaguer’s elbow.6 This condition usually presents in athletes from 9 to 12 years of age and results from an apophysitis of the medial epicondyle, with pain typically presenting in the medial aspect of the elbow.6 The diagnosis of little leaguer’s elbow can be confirmed on radiograph as apophyseal widening or hypertrophy of the medial epicondyle.7 Treatment consists of complete rest from throwing or pitching (4-6 weeks), icing, and analgesics as needed for pain.8
Overuse Injuries (Lower Extremities): Knee pain and injuries are common in the adolescent athlete (TABLE 1). Osgood-Schlatter disease is one of the most common causes of knee pain and is encountered in children from 10 to 15 years of age. Osgood-Schlatter disease is due to an apophysitis of the tibial tuberosity and is often seen in children participating in activities that require jumping, such as soccer, basketball, and gymnastics.9 Patients often report anterior knee pain, and examination reveals tenderness and swelling of the tibial tubercle.9 Radiographs are rarely indicated unless there is suspicion of other injuries.9 Osgood-Schlatter disease is usually self-limited, and as the child stops growing, the pain and swelling should subside. Only rarely does this condition persist beyond the growing stage.9 Treatment consists of rest from the painful activity, icing, quadriceps stretching, and analgesics as needed for pain.10
Sinding-Larsen-Johansson disease commonly affects male athletes 11 to 13 years of age in jumping sports such as basketball and volleyball. Clinical diagnosis reveals point tenderness at the inferior pole of the patella.11 Treatment consists of rest, ice, analgesics as needed for pain, and strength and stretching exercises for both the quadriceps and hamstring muscles.11 Sinding-Larsen-Johansson disease is self-limited, and adolescents will grow out of it.
The occurrence of activity-induced shin pain or “shin splints” is a common complaint of the young athlete. Medial tibial stress syndrome is the most prevalent type of periostitis, particularly common in runners.12 The shin pain typically presents bilaterally and is characterized by tenderness over the posterior medial edge of the tibia.12 Initially, pain may only occur with activity, but over time it continues even when activity has stopped.12 Radiographs can be useful in differentiating between periostitis and stress fracture.12 Treatment includes rest, ice after activity, and nonsteroidal anti-inflammatory drugs (NSAIDs) for pain and inflammation. A program of strengthening and stretching exercises should be implemented as pain permits.12 It is also important to emphasize the use of running shoes with adequate support.
Sever’s disease (calcaneal apophysitis) typically presents in male athletes from 9 to 12 years of age. This traction apophysitis can be attributed to overuse of the heel.3 Sever’s disease is common in athletes participating in contact sports, particularly if cleats are worn. On physical examination, medial and lateral compression of the heel should reproduce the pain. Radiographs may demonstrate a sclerosis and fragmentation of the calcaneal apophysis.12 Treatment consists of activity modification, icing, analgesics as needed for pain, stretching of the gastrocnemius-soleus complex, and heel lifts or cushions.13 Persistent heel pain not responding to treatment may be due to calcaneal stress fractures.14 Stress fractures are an overuse injury resulting from excessive loading of the bone, frequently affecting the tibia, fibula, and metatarsals.15 The combination of load, repetition, and inadequate recovery time results in the injury.16 Additionally, training regimens, improper equipment, and nutritional habits may play a role.16 For the female athlete it is important to consider the role of the “female athlete triad” (i.e., amenorrhea, eating disorders, and osteoporosis) as risk factors for stress fractures.12
Epidemiologically, the highest incidence of stress fractures occurs in track and field.12,16 Pain may be noted during or immediately after exercise with progression to involve pain during times of rest and nonsport activities.12 On examination there is localized tenderness over the affected bone. Diagnosis may be confirmed radiographically two to three weeks after symptoms occur, and the fracture may show as a faint sclerotic line.12 MRI is being used more frequently to diagnose stress fractures due to the sensitivity and specificity of the test.12
Treatment for stress fractures primarily includes avoidance of painful activities until healing has occurred. Activity should be modified for at least one month. The athlete can gradually return to activities after being pain free for one month.12 Stress fractures may also require immobilization with splinting or casting.
Muscle injuries are often caused by excessive strain. Muscle strains typically occur at the myotendinous junction, but they may also involve the periphery of the muscle.17 Adolescent athletes are at greatest risk for apophyseal avulsion, as this junction biomechanically represents the weakest interface.17 Strains are often diagnosed on a three-point scale: 1 = mild, 2 = partial tear, and 3 = complete tear.17 Muscle strain injury is associated with improper warm-up, fatigue, and previous injury.17 To reduce the incidence of muscle strain, it is important to condition and stretch prior to activity.
Skin Ailments in Adolescent Athletes
Adolescent athletes are frequently affected by skin injuries because of the nature and the environmental conditions of their competitions. Cuts and scrapes are the most common types of injuries incurred by the dermatologic system by child and adolescent athletes.2 Minor cuts and scrapes do not usually require emergency or urgent care. Instead, the area should be cleaned well with mild soap (no fragrances added) and water.18 The use of a topical antibiotic such as Neosporin or Polysporin should be applied to keep the area moist. Although the antibiotic does not necessarily promote quicker healing, it prevents infection and allows the wound to close more quickly. Finally, covering the wound with a dressing such as a Band-Aid or Steri-Strip keeps pathogens out. Once the wound has healed enough that infection is not a risk (1-2 days), the dressing should be removed. Exposure to air will allow the wound to heal more quickly.
If the proper wound care is not performed, a dermatologic infection can develop. Although these infections often have low morbidity and are easily treated, they significantly impact individual and team athletic performance.19 The risk of developing and transmitting a cutaneous infection is particularly high in sports that involve skin-to-skin contact that results in injury, such as football, rugby, and wrestling.20 Although adolescent athletes can contract any skin infection observed in the general population, we will focus specifically on those infections that have been extensively studied and reported (TABLE 2). The most reported skin infections among athletes are dermatophyte (e.g., tinea) infections, herpes simplex virus (HSV) infections, and infections caused by Staphylococcus aureus.18 Other infections commonly transmitted among athletes include molluscum contagiosum and human papillomavirus.21 It is important to note that tinea and herpes infections caused by sports contact may occur in areas different from where they usually present.22
Why are skin infections common in athletes? The skin is the most accessible organ and is subject to several physical and environmental stressors. Excessive sweating during sport without evaporation can lead to skin maceration and also provides the ideal environment for growth of pathogenic organisms.23 Mechanical skin disorders such as chafing, abrasions, and friction blisters are often experienced among athletes and can precede infection because injury to the skin provides a port of entry to the pathogenic organism.24 Additionally, sharing and making contact with contaminated athletic equipment can promote transmission among team members and competitors. Exposure to one or a combination of the above factors predisposes athletes to developing and spreading skin infections.
Fungal Infections: Dermatophyte fungi, especially members of the genus Trichophyton, cause several superficial infections. Dermatophytes invade and proliferate in tissues that are high in keratin, such as the top layer of dead skin, the hair, and the nails. These infections are collectively called tinea and are individually named according to the Latin word for the site of infection. Common infection sites include the body (tinea corporis), the feet (tinea pedis), the groin (tinea cruris), and the toenails (tinea unguium). Tinea infections occur frequently in adolescents and are more prevalent in males than in females.25 Tinea corporis infections among wrestlers are well documented and have been described specifically as tinea corporis gladiatorum.23
Transmission of dermatophyte infections can occur from fungal spores in the environment (e.g., pool decks and showers) or from direct skin-to-skin contact. Warm, moist environments encourage rapid dermatophyte growth; therefore, areas of the body covered by tight clothing are especially prone to tinea infections. It is important to note that self-transmission is very common with superficial fungal infections. For example, fungal spores can be carried to the groin area from the feet or toenails by pulling underwear over feet. Transmission may also occur via shared equipment or mats; however, no study has confirmed this theory.26
The body responds to a dermatophyte infection by increasing the thickness of the epidermis and forming scales on the lesion.27 The clinical appearance of dermatophyte infections varies depending on the pathogenic organism and the site of infection (TABLE 3). However, in most cases the lesion is well defined, scaly, and erythematous. Tinea pedis can occur in three clinical forms: the interdigital, moccasin-like, and vesiculobullous forms. The interdigital and moccasin-like forms are caused by Trichophyton rubrum and the vesiculobullous form is caused by Trichophyton mentagrophytes.26 The interdigital type is the most common presentation and is characterized by redness, maceration, scale, and fissures in the webbed spaces between the toes.28 Tinea corporis is also often caused by T. rubrum and can occur on the trunk or the extremities. It causes the formation of scaly, erythematous, circular plaques with a central clearing and a raised border. Tinea corporis gladiatorum infections are differentiated from other tinea corporis infections because they are primarily caused by Trichophyton tonsurans and not T. rubrum.26 T. tonsurans likely resides asymptomatically in the scalps of wrestlers. The starting position of wrestlers facilitates the transmission of this organism to the opponent.
In most cases, treatment of tinea infections involves prolonged applications of topical antifungal medications such as the allylamines and the imidazoles (TABLE 4). Depending on the agent, the medication may need to be applied every day for one to four weeks in order to eradicate the infection and prevent reoccurrence. In addition, it is recommended that treatment continue for two weeks after disappearance of physical signs.21 Given the long duration of treatment, it is advisable to recommend products with a once-daily application. Such recommendations may increase patient compliance and lead to better outcomes.29 In the instance of a widespread or recalcitrant case of tinea corporis and in all cases of tinea unguium, treatment with an oral antifungal agent such as griseofulvin, itraconazole, fluconazole, or terbinafine may be warranted.21,26
Viral Infections: HSV infection in wrestlers (herpes gladiatorum) and rugby players (herpes rugbeiorum) is the most common infection transmitted person-to-person in sports.21 Contracting HSV is particularly detrimental to the athlete because it cannot be cured and often recurs. The majority of nongenital herpes infections are caused by the HSV-1 strain.30 Herpes is acquired via direct exposure to lesions of an individual with an active infection. Close contact with an athlete with broken skin is necessary for transmission because in most cases, normal, healthy skin is usually an adequate barrier.31 HSV may also be transmitted via fomites, because the virus can remain viable on clothing and plastic for brief periods of time.30
A herpes simplex infection begins with a prodromal syndrome characterized by burning or tingling at the site of inoculation. This tingling is followed by the formation of grouped vesicles on a red base. In the case of a primary infection, fever, chills, and myalgias may also occur.28 The fluid within the vesicles contains a high concentration of HSV; therefore, there is a risk of transmission whenever vesicles are present and/or become ruptured.21 Eventually the vesicles rupture and crust over; however, viral shedding can continue three to five days after lesions resolve.30 Herpes gladiatorum is seen on the head, neck, ears, torso, and upper extremities in wrestlers.31
Herpes simplex infections are usually self-limited. However, oral therapy with acyclovir, valacyclovir, or famciclovir will shorten the duration of infection and reduce the risk of transmission by inhibiting viral replication.28 Acyclovir is the only agent approved for patients younger than 18 years, and it can be given in several different regimens. For example, it can be given as 200 mg orally five times daily for five days, 400 mg orally three times daily for five days, or 800 mg twice daily for five days.32
Antivirals are most effective at the first sign of clinical lesions and have no efficacy after the vesicles have ruptured. Suppressive therapy may be indicated in cases of recurrent HSV outbreaks in athletes who participate in sports with a high level of skin-to-skin contact.31 The use of 500 mg to 1,000 mg of valacyclovir once or twice daily was shown to prevent recurrence of herpes gladiatorum.33
Bacterial Infections: Bacterial skin infections in athletes are often caused by Staphylococcus aureus (including the methicillin-resistant type, MRSA) and group A beta-hemolytic streptococci (GABHS). They can include impetigo, folliculitis, furuncles, carbuncles, abscesses, and cellulitis. These infections can be highly contagious (e.g., impetigo) or can have a minimal risk of transmission (e.g., folliculitis).21 As with fungi, bacteria thrive in the warm, moist conditions that are prevalent in athletic competition and are spread primarily by contact with infected individuals. Although self-medication of bacterial infections is not ideal, in most cases these infections are relatively easy to treat. However, there has been a recent rise in the incidence of MRSA infections.34,35
Impetigo is one of the most common and highly contagious bacterial infections among adolescent athletes.34,35 It is transmitted via skin-to-skin contact and can present in bullous or nonbullous forms. Nonbullous impetigo is characterized by the formation of pustular lesions that progress into honey-colored crusted plaques. The bullous form presents as thin-roofed blisters.34,35 Treatment of impetigo usually consists of topical application of mupirocin ointment in combination with the frequent application of warm compresses to remove the crusted areas and improve absorption of the antibiotic.28,31,34 If the infection covers a large area of the body or if there is an outbreak involving multiple individuals, systemic therapy with antistaphylococcal antibiotics such as cephalexin, azithromycin, or trimethoprim-sulfamethoxazole may be indicated.28
Folliculitis is a superficial infection of the hair follicles that typically appears as clusters of small, red, itchy papules or pustules. Two types of folliculitis are common among athletes: Staphylococcus folliculitis and Pseudomonas folliculitis (“hot tub” folliculitis). Hot tub folliculitis is not passed by skin-to-skin contact, but instead through contact with contaminated hot tubs and swimming pools. Neither form of folliculitis is easily transmitted, and management includes daily washing with antibacterial soap and application of topical antibiotics. Depending on the causative agent, treatment with oral antibiotics may be warranted. However, Pseudomonas folliculitis is self-limiting in five to seven days and does not respond to antibiotics.34
In some cases, Staphylococcus folliculitis can spread to involve deeper layers of the skin and cause cellulitis, furuncles (boils), and carbuncles. Cellulitis is a diffuse inflammation of soft tissue, a furuncle is a painful single-chambered follicular-based inflammatory nodule, and a carbuncle results from the fusion of multiple boils and is usually accompanied by fever and malaise.28 Furuncles and carbuncles are often seen in areas of the body exposed to friction and excessive perspiration such as the axillae, the groin, the buttocks, and the thighs. A simple boil is treated with warm, moist compresses to promote drainage. However, more extensive cases may require incision, drainage, and, in instances where surrounding cellulitis is present, systemic antibiotics.28,31
Prevention of Skin Infections: Skin infections in athletes can easily be prevented. Proper hygiene is of utmost importance and should include frequent showering and hand washing, wearing breathable clothing and shower sandals, and not sharing towels or athletic equipment.34 Daily skin surveillance by athletes, trainers, and physicians is also important because it will allow for initiation of treatment during the early stages of the infection and for taking the appropriate measures to prevent future transmission.20 Additionally, disinfecting shared equipment, covering lesions, and restricting the contact activities of infected athletes can prevent an infectious outbreak among teammates.
Participation in sports is a rite of passage for children and adolescents alike. Most ailments and injuries associated with athletic activities involve minor dermatologic and musculoskeletal anomalies, which can usually be treated by nonpharmacologic or OTC products. It is important for the pharmacist to have an understanding of both minor ailments and the more complicated ones. Pharmacists are in the opportune position to counsel patients and their parents as to which conditions require medical follow-up.
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