The Application of Osteopathic Treatments to Pediatric Sports Injuries

Use and complications with manual medicine

A 2008 survey investigated the use of complementary and alternative medicine (CAM) in patients 18 years or younger. The Department of Health and Human Services found that more than 2 million youths (2.8%) had used chiropractic or osteopathic manipulation in the previous year. It was the second most common CAM behind the use of vitamins or other natural remedy. The most common reason cited for seeking care was back or neck pain.¹ Children whose parents used CAM were twice as likely to be treated

Methods and barriers to sound research

A paucity of literature regarding manual treatments in pediatric patients exists. Pubmed searches were performed using key words mobilization, manipulation, osteopathic, chiropractic, pediatric, child, and adolescent as well as the specific condition to be examined. The vast majority of articles identified were of an anecdotal nature.

There are many barriers to conducting high-quality osteopathic research. Chief among these is poor research question design. Most reasonable efforts have centered

Barrier concepts in the evaluation of pediatric patients

The rationale for using biomechanical approaches to a specific injury is to restore motion. Conceptually, each joint or body region has a range of motion through which it can pass. There are physiologic and anatomic barriers (Fig. 1). As motion in either direction from midline proceeds, ligamentous tension develops. In the case of injury or dysfunction, a restrictive barrier may alter active and passive range of motion. These restrictive barriers are referred to as somatic dysfunctions.

Most

Pediatric considerations and specific osteopathic techniques

Although osteopathic techniques can be applied to infants and young children,² this discussion is limited to the application to pediatric patients between the ages of 6 and 18. With any use of manual medicine in the pediatric population, there are key differences between pediatric and adult patients. Joint mechanics are influenced by the maturation of the ossification centers. Pediatric patients with open growth plates are vulnerable to injury; techniques used must be gentle and carefully

Scoliosis

Idiopathic scoliosis is a rotational malalignment of the vertebrae that produces a partly fixed lateral curvature of the spine.² Usually thoracic spine and rib cage are involved and a compensatory curve is found in the lumbar spine. Girls between the ages of 10 and 16 years are nearly 4 times more likely to develop the condition.² The biomechanics of scoliosis and distant claims of cures with manipulation²⁹ have led to efforts to define the role of manual medicine and its effectiveness.

Low back pain

The sacroiliac (SI) joint and pelvis can be pain generators from the joint proper or its ligamentous attachments. Athletes involved in sports that necessitate unilateral loading of the SI joint, such as kicking or throwing, are at higher risk for SI injury and pain.³⁵ There are several historical features and physical examination maneuvers that are used by osteopathic practitioners to diagnose a 3-D position of the SI joint. A complete description of these is available from many sources.2, 6, 10

Upper extremity

Nursemaids' elbow is probably the best-known diagnosis for which manual treatment is thought curative. The mechanism is a pull usually from above a young child's arm, which subluxes the radial head through the annular ligament. The child usually experiences pain and a loss of function of the arm. Hyperpronation with mild dorsal pressure on the radial head is considered the superior method for reduction (evidence level B).³⁹

Older pediatric athletes are more likely to develop radial head symptoms

Lower extremity

The rationale for manual medicine in lower-extremity injuries may be best understood when looking at the alteration of normal biomechanics that occurs with the inversion ankle sprain. In the subacute evaluation of athletes with an ankle sprain, a subtle loss of range of motion, commonly dorsiflexion, may be observed. Ankle motion loss may arise from fibular or talar malposition.

The loss of motion can be explained by the effect of the inversion mechanism on ankle mechanics. The talus and fibula

Cuboid syndrome

Cuboid subluxation or syndrome refers to pain on the lateral, dorsal, or often plantar aspect of the foot over the cuboid thought to be due to ligamentous injury and loss of joint congruity of the calcaneocuboid joint.⁵⁰ The subject has recently had a thorough literature review.⁵⁰ The disorder is commonly seen after ankle inversion injury but is also seen as a result of overuse in dance.⁵¹ Diagnosis is usually clinical, with direct palpation of the cuboid eliciting pain. Radiography is

Summary

The use of manipulation for a variety of athletic injuries remains an alternative treatment. Conditions, such as nursemaids' elbow or cuboid syndrome, that clearly resolve after appropriate restoration of function by manipulation should suggest the validity of looking more closely at underlying biomechanics to understand dysfunction and injury. As part of standard examination, motion deficits and asymmetry should be actively sought. When identified, mobilizations may be of benefit. They need

Acknowledgments

The author thanks Quinton Nottingham, PhD of Virginia Tech's Department of Business Information Technology for the photography and photo-editing of the figures in this article and Jonathon Tait, DO for his critical reading of the manuscript.