Semin Musculoskelet Radiol 2024; 28(02): 180-192
DOI: 10.1055/s-0043-1778029
Review Article

Return to Play in Youth Athletes: Role of the Radiologist with Focus on the Upper Extremity

1   Department of Radiology, Section of MSK, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
2   Drexel University College of Medicine, Philadelphia, Pennsylvania
3   Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
,
1   Department of Radiology, Section of MSK, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
2   Drexel University College of Medicine, Philadelphia, Pennsylvania
,
3   Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
4   Department of Pediatrics, Sports Medicine and Performance Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
5   Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
,
3   Division of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
5   Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
6   Division of Plastic, Reconstructive, and Oral Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
,
7   Division of Musculoskeletal Imaging and Interventions, Department of Radiology, Thomas Jefferson University Hospital, Sidney Kimmel Medical College at Jefferson, Philadelphia, Pennsylvania
,
Jie C. Nguyen
1   Department of Radiology, Section of MSK, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
5   Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
› Author Affiliations

Abstract

Increase in youth sports participation, longer duration of play, and earlier starting points have increased the prevalence of acute and repetitive overuse musculoskeletal injuries. This rise in injury rates has led to increased efforts to better understand the susceptible sites of injury that are unique to the growing immature skeleton. Upper extremity injuries are currently the best studied, particularly those that occur among pediatric baseball players and gymnasts. The weak link in skeletally immature athletes is the growth plate complex that includes those injuries located at the epiphyseal and apophyseal primary physes and the peripherally located secondary physes. This article reviews the anatomy and function of these growth plate complexes, followed by a discussion of the pathophysiologic mechanisms, spectrum of imaging findings, and existing evidence-based guidelines for injury prevention and return to play.



Publication History

Article published online:
14 March 2024

© 2024. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 
  • References

  • 1 Caine DJ. Are kids having a rough time of it in sports?. Br J Sports Med 2010; 44 (01) 1-3
  • 2 Luke A, Lazaro RM, Bergeron MF. et al. Sports-related injuries in youth athletes: is overscheduling a risk factor?. Clin J Sport Med 2011; 21 (04) 307-314
  • 3 DiFiori JP, Benjamin HJ, Brenner JS. et al. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Br J Sports Med 2014; 48 (04) 287-288
  • 4 Post EG, Rosenthal MD, Pennock AT, Rauh MJ. Prevalence and consequences of sport specialization among Little League baseball players. Sports Health 2021; 13 (03) 223-229
  • 5 Ritzer EE, Yang J, Kistamgari S, Collins CL, Smith GA. An epidemiologic comparison of acute and overuse injuries in high school sports. Inj Epidemiol 2021; 8 (01) 51
  • 6 Makhni EC, Lee RW, Nwosu EO, Steinhaus ME, Ahmad CS. Return to competition, re-injury, and impact on performance of preseason shoulder injuries in Major League Baseball pitchers. Phys Sportsmed 2015; 43 (03) 300-306
  • 7 Trofa DP, Obana KK, Swindell HW. et al. Increasing burden of youth baseball elbow injuries in US emergency departments. Orthop J Sports Med 2019; 7 (05) 23 25967119845636
  • 8 Bullock GS, Nicholson KF, Waterman BR. et al. Persistent joint pain and arm function in former baseball players. JSES Int 2021; 5 (05) 912-919
  • 9 Tisano B, Zynda AJ, Ellis HB, Wilson PL. Epidemiology of pediatric gymnastics injuries reported in US emergency departments: sex- and age-based injury patterns. Orthop J Sports Med 2022; 10 (06) 23 259671221102478
  • 10 Trikha R, Greig DE, Shi BY. et al. Multicenter analysis of the epidemiology of injury patterns and return to sport in collegiate gymnasts. Orthop J Sports Med 2023; 11 (02) 23 259671231154618
  • 11 Mauck B, Kelly D, Sheffer B, Rambo A, Calandruccio JH. Gymnast's wrist (distal radial physeal stress syndrome). Orthop Clin North Am 2020; 51 (04) 493-497
  • 12 Aoyama JT, Maier P, Servaes S. et al. MR imaging of the shoulder in youth baseball players: anatomy, pathophysiology, and treatment. Clin Imaging 2019; 57: 99-109
  • 13 Nguyen JC, Lin B, Potter HG. Maturation-dependent findings in the shoulders of pediatric baseball players on magnetic resonance imaging. Skeletal Radiol 2019; 48 (07) 1087-1094
  • 14 Schnitzler CM, Mesquita JM. Cortical porosity in children is determined by age-dependent osteonal morphology. Bone 2013; 55 (02) 476-486
  • 15 Cottrell JA, Turner JC, Arinzeh TL, O'Connor JP. The biology of bone and ligament healing. Foot Ankle Clin 2016; 21 (04) 739-761
  • 16 Caine D, Meyers R, Nguyen J, Schöffl V, Maffulli N. Primary periphyseal stress injuries in young athletes: a systematic review. Sports Med 2022; 52 (04) 741-772
  • 17 Caine D, Maffulli N, Meyers R, Schöffl V, Nguyen J. Inconsistencies and Imprecision in the nomenclature used to describe primary periphyseal stress injuries: towards a better understanding. Sports Med 2022; 52 (04) 685-707
  • 18 Nguyen JC, Markhardt BK, Merrow AC, Dwek JR. Imaging of pediatric growth plate disturbances. Radiographics 2017; 37 (06) 1791-1812
  • 19 Rogers LF, Poznanski AK. Imaging of epiphyseal injuries. Radiology 1994; 191 (02) 297-308
  • 20 Jaramillo D, Hoffer FA, Shapiro F, Rand F. MR imaging of fractures of the growth plate. AJR Am J Roentgenol 1990; 155 (06) 1261-1265
  • 21 Nguyen JC, Degnan AJ, Barrera CA, Hee TP, Ganley TJ, Kijowski R. Osteochondritis dissecans of the elbow in children: MRI findings of instability. AJR Am J Roentgenol 2019; 213 (05) 1145-1151
  • 22 Laor T, Zbojniewicz AM, Eismann EA, Wall EJ. Juvenile osteochondritis dissecans: is it a growth disturbance of the secondary physis of the epiphysis?. AJR Am J Roentgenol 2012; 199 (05) 1121-1128
  • 23 Kwong S, Kothary S, Poncinelli LL. Skeletal development of the proximal humerus in the pediatric population: MRI features. AJR Am J Roentgenol 2014; 202 (02) 418-425
  • 24 Leonard J, Hutchinson MR. Shoulder injuries in skeletally immature throwers: review and current thoughts. Br J Sports Med 2010; 44 (05) 306-310
  • 25 Hannonen J, Hyvönen H, Korhonen L, Serlo W, Sinikumpu JJ. The incidence and treatment trends of pediatric proximal humerus fractures. BMC Musculoskelet Disord 2019; 20 (01) 571
  • 26 Singh A, Mahajan P, Ruffin J, Galwankar S, Kirkland C. Approach to suspected physeal fractures in the emergency department. J Emerg Trauma Shock 2021; 14 (04) 222-226
  • 27 Binder H, Schurz M, Aldrian S, Fialka C, Vécsei V. Physeal injuries of the proximal humerus: long-term results in seventy two patients. Int Orthop 2011; 35 (10) 1497-1502
  • 28 Kim HHR, Menashe SJ, Ngo AV. et al. Uniquely pediatric upper extremity injuries. Clin Imaging 2021; 80: 249-261
  • 29 Allen H, Davis KW, Noonan K, Endo Y, Nguyen JC. Orthopaedic fixation devices used in children: a radiologist's guide. Semin Musculoskelet Radiol 2018; 22 (01) 12-24
  • 30 Dotter WE. Little leaguer's shoulder: a fracture of the proximal epiphysial cartilage of the humerus due to baseball pitching. Guthrie Clin Bull 1953; 23 (01) 68-72
  • 31 Heyworth BE, Kramer DE, Martin DJ, Micheli LJ, Kocher MS, Bae DS. Trends in the presentation, management, and outcomes of Little League shoulder. Am J Sports Med 2016; 44 (06) 1431-1438
  • 32 Hatem SF, Recht MP, Profitt B. MRI of Little Leaguer's shoulder. Skeletal Radiol 2006; 35 (02) 103-106
  • 33 Arnold A, Thigpen CA, Beattie PF, Kissenberth MJ, Shanley E. Overuse physeal injuries in youth athletes. Sports Health 2017; 9 (02) 139-147
  • 34 Kanematsu Y, Matsuura T, Kashiwaguchi S. et al. Epidemiology of shoulder injuries in young baseball players and grading of radiologic findings of Little Leaguer's shoulder. J Med Invest 2015; 62 (3-4): 123-125
  • 35 Bednar ED, Kay J, Memon M, Simunovic N, Purcell L, Ayeni OR. Diagnosis and management of Little League shoulder: a systematic review. Orthop J Sports Med 2021; 9 (07) 23 259671211017563
  • 36 Zaremski JL, Zeppieri Jr G, Tripp BL. Sport specialization and overuse injuries in adolescent throwing athletes: a narrative review. J Athl Train 2019; 54 (10) 1030-1039
  • 37 Ogden JA, Beall JK, Conlogue GJ, Light TR. Radiology of postnatal skeletal development. IV. Distal radius and ulna. Skeletal Radiol 1981; 6 (04) 255-266
  • 38 Kallini JR, Fu EC, Shah AS, Waters PM, Bae DS. Growth disturbance following intra-articular distal radius fractures in the skeletally immature patient. J Pediatr Orthop 2020; 40 (10) e910-e915
  • 39 Cannata G, De Maio F, Mancini F, Ippolito E. Physeal fractures of the distal radius and ulna: long-term prognosis. J Orthop Trauma 2003; 17 (03) 172-179 , discussion 179–180
  • 40 Shah AS, Guzek RH, Miller ML, Willey MC, Mahan ST, Bae DS. Pediatric Distal Radius Fracture (PDRF) Study Group. Descriptive epidemiology of isolated distal radius fractures in children: results from a prospective multicenter registry. J Pediatr Orthop 2023; 43 (01) e1-e8
  • 41 Bae DS, Waters PM. Pediatric distal radius fractures and triangular fibrocartilage complex injuries. Hand Clin 2006; 22 (01) 43-53
  • 42 Greig D, Silva M. Management of distal radius fractures in adolescent patients. J Pediatr Orthop 2021; 41 (Suppl 1): S1-S5
  • 43 Syurahbil AH, Munajat I, Mohd EF, Hadizie D, Salim AA. Displaced physeal and metaphyseal fractures of distal radius in children. can wire fixation achieve better outcome at skeletal maturity than cast alone?. Malays Orthop J 2020; 14 (02) 28-38
  • 44 Abzug JM, Little K, Kozin SH. Physeal arrest of the distal radius. J Am Acad Orthop Surg 2014; 22 (06) 381-389
  • 45 Bhanushali A, Bright R, Xu L, Cundy P, Williams N. Return to sport after forearm fractures in children: a scoping review and survey. J Child Orthop 2023; 17 (02) 164-172
  • 46 Kox LS, Kuijer PP, Kerkhoffs GM, Maas M, Frings-Dresen MH. Prevalence, incidence and risk factors for overuse injuries of the wrist in young athletes: a systematic review. Br J Sports Med 2015; 49 (18) 1189-1196
  • 47 Kox LS, Kuijer PPFM, Thijssen DAJ. et al. Health effects of wrist-loading sports during youth: a systematic literature review. J Phys Act Health 2018; 15 (09) 708-720
  • 48 Kraan RBJ, Kox LS, Oostra RJ, Kuijer PPFM, Maas M. The distal radial physis: exploring normal anatomy on MRI enables interpretation of stress related changes in young gymnasts. Eur J Sport Sci 2020; 20 (09) 1197-1205
  • 49 Benjamin HJ, Engel SC, Chudzik D. Wrist pain in gymnasts: a review of common overuse wrist pathology in the gymnastics athlete. Curr Sports Med Rep 2017; 16 (05) 322-329
  • 50 Mariscalco MW, Saluan P. Upper extremity injuries in the adolescent athlete. Sports Med Arthrosc Rev 2011; 19 (01) 17-26
  • 51 Dwek JR, Chung CB. A systematic method for evaluation of pediatric sports injuries of the elbow. Pediatr Radiol 2013; 43 (Suppl 1): S120-S128
  • 52 Delgado J, Jaramillo D, Chauvin NA. Imaging the injured pediatric athlete: upper extremity. Radiographics 2016; 36 (06) 1672-1687
  • 53 Gottschalk HP, Eisner E, Hosalkar HS. Medial epicondyle fractures in the pediatric population. J Am Acad Orthop Surg 2012; 20 (04) 223-232
  • 54 Tomsan H, Grady MF, Ganley TJ, Nguyen JC. Pediatric elbow: development, common pathologies, and imaging considerations. Semin Roentgenol 2021; 56 (03) 245-265
  • 55 Gregory B, Nyland J. Medial elbow injury in young throwing athletes. Muscles Ligaments Tendons J 2013; 3 (02) 91-100
  • 56 Kijowski R, De Smet AA. MRI findings of osteochondritis dissecans of the capitellum with surgical correlation. AJR Am J Roentgenol 2005; 185 (06) 1453-1459
  • 57 DeFroda SF, Hansen H, Gil JA, Hawari AH, Cruz Jr AI. Radiographic evaluation of common pediatric elbow injuries. Orthop Rev (Pavia) 2017; 9 (01) 7030
  • 58 Jaramillo D, Waters PM. MR imaging of the normal developmental anatomy of the elbow. Magn Reson Imaging Clin N Am 1997; 5 (03) 501-513
  • 59 Holme TJ, Karbowiak M, Arnander M, Gelfer Y. Paediatric olecranon fractures: a systematic review. EFORT Open Rev 2020; 5 (05) 280-288
  • 60 Frush TJ, Lindenfeld TN. Peri-epiphyseal and overuse injuries in adolescent athletes. Sports Health 2009; 1 (03) 201-211
  • 61 Matsuura T, Kashiwaguchi S, Iwase T, Enishi T, Yasui N. The value of using radiographic criteria for the treatment of persistent symptomatic olecranon physis in adolescent throwing athletes. Am J Sports Med 2010; 38 (01) 141-145
  • 62 Schickendantz MS. Diagnosis and treatment of elbow disorders in the overhead athlete. Hand Clin 2002; 18 (01) 65-75
  • 63 Wong TT, Lin DJ, Ayyala RS, Kazam JK. Elbow injuries in pediatric overhead athletes. AJR Am J Roentgenol 2017; 209 (04) 849-859
  • 64 Ahmad CS, ElAttrache NS. Valgus extension overload syndrome and stress injury of the olecranon. Clin Sports Med 2004; 23 (04) 665-676 , x x.
  • 65 Oestreich AE. The acrophysis: a unifying concept for understanding enchondral bone growth and its disorders. II. Abnormal growth. Skeletal Radiol 2004; 33 (03) 119-128
  • 66 Ellermann J, Johnson CP, Wang L, Macalena JA, Nelson BJ, LaPrade RF. Insights into the epiphyseal cartilage origin and subsequent osseous manifestation of juvenile osteochondritis dissecans with a modified clinical MR imaging protocol: a pilot study. Radiology 2017; 282 (03) 798-806
  • 67 Uozumi H, Sugita T, Aizawa T, Takahashi A, Ohnuma M, Itoi E. Histologic findings and possible causes of osteochondritis dissecans of the knee. Am J Sports Med 2009; 37 (10) 2003-2008
  • 68 Chau MM, Klimstra MA, Wise KL. et al. Osteochondritis dissecans: current understanding of epidemiology, etiology, management, and outcomes. J Bone Joint Surg Am 2021; 103 (12) 1132-1151
  • 69 Kida Y, Morihara T, Kotoura Y. et al. Prevalence and clinical characteristics of osteochondritis dissecans of the humeral capitellum among adolescent baseball players. Am J Sports Med 2014; 42 (08) 1963-1971
  • 70 Takahara M, Ogino T, Sasaki I, Kato H, Minami A, Kaneda K. Long term outcome of osteochondritis dissecans of the humeral capitellum. Clin Orthop Relat Res 1999; (363) 108-115
  • 71 Fader LM, Laor T, Eismann EA, Cornwall R, Little KJ. MR imaging of capitellar ossification: a study in children of different ages. Pediatr Radiol 2014; 44 (08) 963-970
  • 72 Takahara M, Mura N, Sasaki J, Harada M, Ogino T. Classification, treatment, and outcome of osteochondritis dissecans of the humeral capitellum. J Bone Joint Surg Am 2007; 89 (06) 1205-1214
  • 73 Takahara M, Ogino T, Fukushima S, Tsuchida H, Kaneda K. Nonoperative treatment of osteochondritis dissecans of the humeral capitellum. Am J Sports Med 1999; 27 (06) 728-732
  • 74 Westermann RW, Hancock KJ, Buckwalter JA, Kopp B, Glass N, Wolf BR. Return to sport after operative management of osteochondritis dissecans of the capitellum: a systematic review and meta-analysis. Orthop J Sports Med 2016; 4 (06) 23 25967116654651
  • 75 Brenner JS. Council on Sports Medicine and Fitness. Sports specialization and intensive training in young athletes. Pediatrics 2016; 138 (03) e20162148
  • 76 Jayanthi NA, LaBella CR, Fischer D, Pasulka J, Dugas LR. Sports-specialized intensive training and the risk of injury in young athletes: a clinical case-control study. Am J Sports Med 2015; 43 (04) 794-801
  • 77 Kliethermes SA, Nagle K, Côté J. et al. Impact of youth sports specialisation on career and task-specific athletic performance: a systematic review following the American Medical Society for Sports Medicine (AMSSM) Collaborative Research Network's 2019 Youth Early Sport Specialisation Summit. Br J Sports Med 2020; 54 (04) 221-230