Cogent Evidence
Folarin Babatunde PT PhD MScSEM MScPT BScPT
Sudden increases in youth competitive athletic activity among the youth, early specialization in sports, year-round training and competition, increased skill-based activities compared to strength and conditioning have led to a commensurate increase in the frequency of anterior cruciate ligament (ACL) tears in the skeletally immature. Young individuals have to live with their knee problem for the rest of their life and these may further compromise their quality of life, increase the risk for further injury, including meniscal tears and early onset osteoarthritis.
CLINICAL TIPS
Completing the FIFA 11+ for kids program should be incorporated early in the young athlete's developmental process. There is compelling evidence that ACL injury prevention programs work in skeletally mature patients and can reduce football-related lower limb injuries by 39% to 50%.
Clinical Tip 1 - The well-established injury prevention program, FIFA 11+, has recently been modified by adding falling techniques, making partner-based exercises more play-oriented to suit the training needs of the paediatric population (FIFA '11+ For Kids').
Clinicians need to combine information from the patient's history, examination and clinical assessment findings and imaging to inform a clear diagnosis and patient-centered treatment planning.
Clinical Tip 2 - Haemarthrosis (acute swelling in the knee within 24 hours after a trauma due bleeding in the joint) after acute knee injury is very big clue to that may suggest a structural injury to the knee.
Clinical Tip 3 - Diagnosing knee injuries in children is more challenging compared to adults because children may be poor historians, naturally have more joint laxity and imaging interpretation is more difficult due to the different stages of development in children
Clinical Tip 4 - Children may sustain different knee injuries such as sleeve fracture of the patella, epiphysiolysis, than adults due to the immaturity of their skeletal system.
Both high quality rehabilitation alone with a physiotherapists skilled in paedictric orthopedics and ACL reconstruction are both reasonable treatment options.
Clinical Tip 5 - Recommended functional tests and return to sport criteria for the child and adolescent with ACL injury. Rehabilitation for the child with an ACL injury is organised into four phases.
For athletes who choose ACL reconstruction
Prehabilitation
Full active extension and at least 120 degrees active knee flexion
Little to no effusion
Ability to hold terminal knee extension during single leg standing (Figure 1)
For adolescents: 90% limb symmetry on muscle strength tests
For athletes who choose ACL reconstruction OR non-surgical treatment
Phase I to phase II
Full active knee extension and 120 degrees active knee flexion
Little to no effusion
Ability to hold terminal knee extension during single leg standing
Phase II to phase III
Full knee range of motion
80% limb symmetry on single-leg hop tests, with adequate landing strategies
Ability to jog for 10 min with good form and no subsequent effusion
For adolescents: 80% limb symmetry on muscle strength tests
Phase III to phase IV: sport participation (return to sport criteria), and continued injury prevention
Single-leg hop tests: >90% of the contralateral limb (with adequate strategy and movement quality)
Performed gradual increase in sport-specific training without pain and effusion
Confident in knee function
Knowledge of high injury-risk knee positioning, and ability to maintain low-risk knee positioning in advanced sport-specific actions
Mentally ready to return to sport
For adolescents: 90% limb symmetry on muscle strength tests
Muscle strength testing should be performed using isokinetic dynamometry or handheld dynamometry/one repetition maximum. The type of test and experience of the tester are highly likely to influence the results. If using handheld dynamometry/one repetition maximum, consider increasing the limb symmetry criterion cut-off by 10% (ie, 90% limb symmetry becomes 100% limb symmetry). Clinicians who do not have access to appropriate strength assessment equipment should consider referring the patient elsewhere for strength evaluation.
Clinicians need to prioritize skeletal maturity, injuries to other knee structures and any potential adverse events after treatment when advising children and their parents or guardians.
Clinical Tip 6 - Five considerations for skeletal age assessment to better understand the difference between skeletal age and chronological age.
Use imaging of the knee to find out if the femoral and tibial physes, and the tibial tubercle apophysis are open. If the growth areas are closed, the child can be treated as an adult, independent of chronological age.
No specific methods for skeletal age determination is sufficient to accurately determine skeletal age.
A multifaceted clinical approach to determine skeletal age includes whether or not a child has had an adolescent growth spurt, the relative heights of the child’s parents and Tanner staging.
The most common method of skeletal age assessment is through posterior-anterior X-rays of the left hand and wrist. This can be compared with a skeletal atlas or using a smart-phone application (e.g., the Bone Age app for iPhone).
Children who are close to skeletal maturity may follow rehabilitation and return to sport guidelines intended for adults.
Clinical Tip 7 - There are five important considerations for the prepubescent child.
Consider a home-based program and emphasize playful exercises and variation to discourage boredom.
Use single-leg hop tests and isokinetic strength tests with caution due to their larger measurement errors in the prepubescent individuals.
Evaluate the quality of movements during single-leg hop testing, instead of leg symmetry index measures.
Develop skills and experience in using tests and criteria for assessing movement quality in children.
Use standard Return to sport criteria only for the child who is close to maturity because they were designed and scientifically tested in the skeletally mature patients.
Use generic health-related quality of life measure, a self-reported knee function measure and measure of activity level to monitor treatment outcomes in children and youth athletes.
Clinical Tip 7 - The Pediatric International Knee Documentation Committee Subjective Knee Form (Pedi-IKDC) and Hospital for Special Surgery Pediatric Functional Activity Brief Scale (Pedi-FABS) are two were specifically created and validated for use with pediatric patients for assessing outcomes following ACL injury.
FOR MORE INFORMATION
Book an appointment with one of our physiotherapists at Cogent Physical Rehabilitation Center for an assessment and discussion on how physiotherapy can help you find relief from plantar fasciitis.
Sources
Aarden et al. 2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries. Br J Sports Med 2018;52:422–438.
Fabricant PD et al. Development and validation of a pediatric sports activity rating scale: the Hospital for Special Surgery Pediatric Functional Activity Brief Scale (HSS Pedi-FABS). Am J Sports Med. 2013 Oct;41:2421-9.
Kocher MS et al. Reliability, validity, and responsiveness of a modified international knee documentation committee subjective knee form (Pedi-IKDC) in children with knee disorders. Am J Sports Med. 2011;39:933–939.
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