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Dr Andrew Newton – Grass Roots Paediatric Sports Medical Issues – Injury Rehab Network

The June event of the Injury Rehab Network from Sterosport and BASRaT proved to be extremely popular as the online event attracted over 110 sports rehabilitation professionals from the UK and across the globe.

The expert guest speaker was Dr Andrew Newton, who kindly shared his expertise and fascinating insights from his 30-year career in the NHS and latterly as a Consultant in Emergency Medicine.

 

Dr Andrew Newton – Consultant in Emergency Medicine

Dr Andrew Newton graduated from Nottingham University Medical School in 1985. Andrew served a medium career commission in the Royal Navy as a Medical Officer, with active service experience in the Middle East and the Adriatic.

Dr Newton completed General Practitioner training and then worked as a Principal in General Practice, both in the military and the NHS, for a total of 5 years. He moved into Emergency Medicine as a Staff Grade in 1996 and Progressed from a Staff Grade to an Associate Specialist in 2000. Dr Newton completed Article 14 (CESR) application and was awarded ‘Specialist Register’ status in Emergency Medicine in 2006.

Andrew was appointed as a Consultant in Emergency Medicine at Weston General Hospital in 2007 and completed ten years in the post there. Andrew was subsequently appointed as a Consultant in Emergency Medicine at Yeovil District Hospital at the end of 2017.

Dr Newton is a Life Support Instructor in ALS (Course Director), HMIMMS (Course Director), EAPLS, ETC and GIC.

Andrew’s specialist interests include Global Health, Sports Medicine, and Major Incident Planning / Emergency Preparedness. His interests outside medicine include travel, ancient and medieval history, rugby, and diving. Andrew is a longstanding volunteer with Future Hope India (a charity for street/ slum children in Kolkata).

Grass Roots Paediatric Sports Medical Issues

Dr Newton’s presentation, “Grass Roots Paediatric Sports Medical Issues”, provided a fascinating review of the common sports injuries that are encountered in ‘Grass Roots’ children’s sports. The focus of Andrew’s presentation was common problems and their remedies, rather than looking at the medical issues encountered by the ‘Young Elite Athlete’. The Talk followed the structure of “Heads, Shoulders, Knees and ….”

Andrew has completed research into several areas of paediatric sports medical issues, and his presentation referenced some of his research findings.

Dr Newton started his presentation with advice for any practitioners who are presented with an injured child, stating that history is especially important as factors associated with a child’s life outside of sport can contribute to pain during sport.

Child Head Injury

Heads

The injuries first considered in Dr Newton’s presentation were head injuries, with Andrew stating that most (90% +) children’s head injuries that are seen in an emergency department are minor and get discharged after a medical assessment. Children’s brains are tighter in their skulls, so any potential head injuries should be carefully examined due to the limited space for swelling.

Andrew described that whilst advice about rest and return to play is commonly given to children who present with sporting head injuries, the same advice is often not given to children who suffer a non-sporting head injury even though recovery and rehabilitation protocols should be the same.

Dr Newton’s practical advice for children’s head injuries is as follows:

  1. Manage all head injuries in accordance with local and national guidelines.
  2. Follow sport-specific guidelines. For example, The HEADCASE training and resources produced by the rugby union are excellent. Medical professionals can also use the Child SCAT5 sport concussion assessment tool (for children aged 5-12) and SCAT5 for athletes aged thirteen and older.
  3. Give verbal and written advice, which states that there should be a period of complete cognitive rest for two days and relative physical rest for 14 days.
  4. Modify school studies and computer use.
  5. Followed by a slow and graded return to exercise before returning to sport.

Child Playing Tennis

Shoulders

Dr Newton presented a case study of a young tennis player suffering from pain at rest, morning stiffness, clicking and worse pain after sport. An examination showed that there was shoulder instability. Core stability exercises were prescribed to enable the back, abdominal and pelvic floor muscles to work together and improve the patient’s posture.

Andrew also discussed how children participating in a lot of swimming could suffer from shoulder instability and injuries.

Child Knee Injury

Knees (+ Hips)

Case study 1

Dr Newton discussed a case study of a teenage footballer with discomfort in their knee and thigh, which was worse after sport. The GP has diagnosed quadriceps muscle strain. The pain was particularly bad after football one evening, so his parents brought him to the emergency department in desperation.

On examination, it was clear that the knee function was normal, so the focus moved to the hip. This young person was at the prime age for hip disease in children with an x-ray showing a Slipped Upper Femoral Epiphysis. Andrew stated that this injury can present acutely following minor trauma and can also have an insidious onset with pain often referred to the knee. Dr Newton described how presentation could be stable, unstable, chronic, or acute.

Andrew described how the unstable variety of Slipped Upper Femoral Epiphysis could be more common in overweight or inactive young people with less core strength. Treatment is for the patient to be non-weight bearing from diagnosis and then surgery with a cannulated screw into the top of the femur. Moderate and severe cases may require a corrective osteotomy or open reduction. Complications may include osteoarthritis, avascular necrosis and chondrolysis.

Case study 2

The second case study that Dr Newton discussed in the knees and hips category was a teenage footballer who took a free kick and developed acute discomfort around his right hip. An x-ray showed that the injury was a Rectus Femoris Avulsion Fracture (AIIS). Treatment included core stability exercises where Andrew advised that return to play should not be rushed as time should be taken to ensure full rehabilitation.

Case study 3

Andrew presented a third case study about a 12-year-old football player who, after kicking a long ball downfield felt instant pain in the region around his right hip. On initial presentation to the emergency department, the x-ray showed that the hip was normal, and the patient was referred to physiotherapy. There was no improvement after four weeks of therapy, with the physios reporting a potential upper hamstring injury.

An ultrasound scan also showed that the hip appeared to be normal, but an MRI scan uncovered the injury as an Ischial Tuberosity Avulsion. Treatment included surgery with screws into the hip.

Dr Newton’s advice for hip injuries is that more than an x-ray or scan may be required with a thorough examination necessary to assess the injury.

Case study 4

Moving on to knee injuries, Andrew discussed a case study of knee pain in a young gymnast. Symptoms included pain in both knees, pain worse when knees bent, pain worse after exercise, pain worse on going downstairs and some clicking. An examination showed an abnormal Q angle of the knee joint with patellar shift and damage to the articular cartilage. Injuries can include Chondromalacia Patella and Osteo-Chondritis Desicans. Treatment focused on improving patella alignment.

Case study 5

In this case study, Andrew described the symptoms of a young runner with knee pain. The runner felt a pop in his knee on starting from the blocks and could not finish the 100m race. After rest and ice, the pain was worse after exercise and bending the knee with some clicking. An MRI scan showed a tear in the Medial Retinaculum of the Joint Capsule.

Case study 6

Dr Newton discussed a case study of a mid-teenage football player who presented with aching anteromedial knee pain after sport. The knee had been intermittently swollen. The examination found a lax effusion with discomfort when the medial compartment is loaded. The diagnosis was for Osteo-Chondritis Desicans requiring surgery. Surgical techniques for this condition include drilling, internal fixation, fragment removal and chondral resurfacing.

Children Playing Football

Ankles

Ankle and knee pains in young soccer players

Andrew described some common presentations for ankle and knee pain in young soccer players, including Osgood-Schlatter Disease and Sever’s Disease. In an online survey as part of Dr Newton’s research in North Somerset, children were asked to report any symptoms experienced that season as well as any previous problems.

Sever’s was reported in up to 40% of under 12’s, and Osgood Schlatter’s was reported in up to 50% of under 13’s. Prevalence was higher for children who played more than 5 hours of football per week. Prevalence of symptoms was found in 70% of players who just played football and one other sport, whereas less than 15% of players who participated in football and three other sports had a prevalence of symptoms. Andrew discussed how these findings demonstrate how important it is for children to participate in a range of sports and to develop multi-skills which will improve their performance and reduce the risk of injury.

Case study – shin pain

Dr Newton presented a case study about a young runner who was running around 30 miles per week and had developed a burning pain in the shin which was worse after exercise. Andrew described how shin splints are a diagnostic bucket with many options to explore. Shin splints can also take the form of various conditions, including stress fracture and tendonitis. Stress fractures may not always show on an early x-ray, and it may be necessary to review and re x-ray, do an MRI scan and potentially a bone scan if required.

Children Stretching

Hypermobility

Andrew discussed issues associated with hypermobility in some children and tests that can be performed.

Finally

Dr Newton presented two important final points for practitioners to consider.

Case study

Andrew discussed a case study about a 12-year boy who was a keen rugby and football player. The boy had developed an aching pain below the knee for six weeks and was now limping. The pain was worse at night, and the player had developed a sudden increase in pain whilst kicking the ball around the garden. The patient was now not weight-bearing. Andrew described how Nocturnal Pain is a red flag and explained that following an x-ray, bone cancer was diagnosed.

  • Final point 1: Sports injuries should not have pain present at night and when resting. These can be symptoms of bone malignancy in childhood and should be assessed urgently.
  • Final point 2: Never forget the potential for infection. Andrew described how young bones and joints are well vascularized by the epiphyseal plate vessels and are therefore more susceptible to infection. Joint pain caused by an infection should therefore not be ruled out.

Q&A

Dr Newton kindly answered several questions put forward by the practitioners who attended the session.

Q1. In pitch side care, some practitioners monitor the growth spurts of players. What would you advise regarding participation in sports during growth spurts?
A1. There is an increased risk of injury during growth spurts. A thorough warm-up is essential to reduce the risk of injury. Children should be encouraged to participate in a diverse range of sports to develop good core stability and skills.

Q2. It can be challenging to get an x-ray or scan. How can practitioners influence radiologists and doctors when an x-ray is required for a child’s injury?
A2. Present the facts from a position of strength and knowledge and communicate understanding with the medical team. Be persistent and don’t take no for an answer. Asking for an MRI may persuade practitioners that an x-ray could be worthwhile.

Q3. Is rectus femoris avulsion common in sprinters?
A3. Yes, this condition is common in sprinters, football, and rugby players.

Q4. Should young players do more core stability exercises?
A4. This is particularly important during growth spurts. Core stability can be incorporated into training and provided as homework for players to complete in addition to training and matches.

Q5. What is the best treatment for lumbar stress fractures in gymnastics?
A5. Lumbar injuries are complex, and accurate diagnosis is tricky. Core strengthening exercises should help reduce the risk of injuries of this type. There are protocols for investigation which should be followed. A healthy diet is important for gymnasts to reduce the risk of fractures and ensure good bone strength. In girls with a reduced BMI, it is important to establish that they are not anovulatory because if their menstrual cycle has been suppressed, they can be at risk of hormonal-induced osteoporosis.

Q6. Is an MRI scan recommended for avulsion fractures?
A6. An MRI scan may be required as x-rays aren’t completely reliable for this condition – But X-Rays are usually the investigation of first choice.

The recording of Andrew’s presentation is available to watch on YouTube here https://youtu.be/kLJmL05yg1c

The next event of the Injury Rehab Network

The next Injury Rehab Network event is taking place on the 7th of July and features a presentation from expert guest speaker Dr Carl Todd (Consultant Osteopath in Sport & Exercise Medicine). To reserve a place, sign up with BASRaT – click here to register.


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