Children have spines, muscles, joints and tendons like adults and are not immune to having muscle and joint pain. One of the most common presentations in my office when treating children, is knee pain. There are many causes of knee pain in kids, from growing pains, growth plate pain, sports injuries and even bone cancer. It is important to pay attention to your child when they complain of knee pain. Most conditions can be easily treated with conservative care.
True growing pains are not well understood and the main theory is that the pain is originating from the muscles. The muscles are thought to be adapting to their increased length and growth. The sensory receptors, that measure stretch, are effected more when the child is in a growth phase. This is most common around the ages of 3-4 and 8-12. Growing pains are felt in both legs, especially in the back of the legs(calves) and in the front of the thighs.
These pains are more common after sport activities and mostly present later in the day and evenings. The pain can also sometimes present in the middle of the night. Growing pains disappear in the morning and usually don't interfere with the child's ability to play sports or be active. When it comes to knee pain and growing pains, the pain is usually located at the top of the knee in the front or around the back of the knee.
Treatment for growing pains is using heat and massage to the leg muscles.
Osgood- Schlatter Disease
There are growth plates located at the ends of all growing bones. In Osgood-Schlatter Disease, the tendon from the quad muscle pulls on the growth plate at the top of the shin bone, just under the knee cap. The growing bone and short/tight muscle causes extra force to be placed over this growth plate area.
The signs and symptoms are point tenderness over the Tibial Plateau (end of the shin bone close to the knee cap), a bump found at the Tibial Plateau, and pain after activities involving running and jumping. An x-ray can also show if the growth plate has been disturbed.
Pain from Osgood Schlatter's is aggravated by activity and relieved by rest with ice and is most common during excelled growth periods. It can affect both knees or just one.
Treatments for Osgood-Schlatter's Disease includes rest, bracing, stretching, and muscle strength balance.
Bone Cancer in children is very rare and makes up roughly 30% of all childhood cancers and the most common malignant one is called Osteosarcoma. This tumor is most often located in the femur,(thigh bone) around the knee area. Osteosarcoma affects approximately 400 children younger than age 20 every year in the United States. Osteosarcoma occurs most often in children and young adults between the ages of 10 and 20 and often during a growth spurt. It occurs more frequently in boys than girls.
Signs and symptoms include one sided pain around the tumor area, secondary fracture due to bone weakening, decreased appetite, night pain, loss of energy, and swelling around the tumor area.
Osteosarcoma presents with a gradual onset often not related to any explained trauma or injury. Progressive pain occurs over time along with progressive symptoms.
Treatment includes surgery to remove the tumor and also chemotherapy.
Sports injuries are the most common presentation of childhood knee pain in my office. Like adults, one of the most common areas for kids to get a sports injury is to their knees. When obvious trauma is placed onto the knee it is very easy to diagnose a sprain, strain, or muscle injury. Sometimes sports injuries can be a repetitive strain type injury that develops slowly over time. One of these injuries is patellofemoral syndrome, also called runners knee. It is characterized by pain around the knee cap and aggravated with running and jumping exercises. Swelling can be present and pain is worse when squatting, climbing/descending stairs, and kneeling. It can be present in one leg or both.
This condition is common in active children that are growing fast and their leg muscles are not balanced in strength and length.
A thorough exam by a practitioner that treats muscle and joint problems is the first step with this type of knee pain. A treatment plan of therapy, exercises, and stretches will be implemented.
Knee pain is a common presentation in children. A lot of knee pain can be related to kids growing fast and the muscle balance is affecting the joints. Examples of this are growing pains, Osgood Schlatters and Patellofemoral Syndrome. These problems are all aggravated with activity and relieved with rest. They can also all be one leg or both with growing pains being more common in both legs.
Be concerned of an underlying bone tumor when your child has one knee that hurts, rest doesn't relieve it, the knee is swollen all the time and they are having night pain.
Activity Fact: Full bone growth is achieved at around the age of 21 but our body continues to make bone tissue throughout our life. Physical activity helps keep this process ocurring and helps prevent osteoporosis.
Children are not immune to back pain. According to a review of the epidemiology of low back pain in children in the British Medical Journal, children on average have a 15% to 26% chance of having back pain. Similar in adults, childhood back pain varies widely depending on their age, sex, and socioeconomic status.
Almost all back pain in children is related to muscle/joint pain and is self-limiting and resolves without complications. There are times though when you should pay close attention to your child's complaints.
1. Pain For More Than a Month
Prolonged pain is not normal. Children have an amazing ability to heal fast. If your child hasn't had a re-injury and still has symptoms that are not healing, you should seek care. Conditions, such as a stress fracture, can be the underlying cause. The most common type of spinal stress fracture is called a spondylolysis, an injury to the bone in the back of the spinal column. This injury occurs most often in adolescents who do sports involving repetitive hyperextension (bending backwards) of the spine, such as gymnasts and divers. If the stress fracture occurs on both sides of the spinal column, this can cause instability of the spinal column, or a condition called spondylolisthesis. This condition, also called a spinal "slip," can lead to the vertebral column alignment to shift.
Prolonged pain can also be a sign that there is a more serious injury to the joints or muscles involving damage to these structures.
2. Back Pain with Generalized Illness
Prolonged back pain with flue like symptoms, including fever, loss of appetite, fatigue, and weakness, can be a red flag for infection. Infection of the spine is a very rare, but is a very serious condition. Infection of the urinary tract can be another reason for back pain and generalized illness as it can mimic back pain and can often be ignored. Children will also complain of stiffness in the back accompanied with a flu or various viral infections. This pain is self-limiting with the flu symptoms. If the pain and fever persist you should visit your doctor.
3. Night Pain
You should be concerned if your child is woken up in the night due to their pain. This can be a concern if your child hasn't had a significant injury to their back but is waking up with dull achy pain. The concern is a spinal tumor in this case. Tumors of the spine are very rare but need to be taken seriously. Night pain associated with weight loss, pain that isn't aggravated by movement, and loss of appetite, all lead to a concern of a spinal tumor.
4. Back Pain and a Change in Posture
Back pain with a change in the posture, can indicate an underlying structural problem. The two most common conditions to cause this is Scheuermann's Disease and scoliosis.
Scheuermann's Disease is characterized by a decrease height in the front of the vertebral bodies in the mid back spine, causing an increased forward curve or hump back. It is unknown why it occurs, starts in adolescence and has less than an 8% prevalence in both girls and boys. The condition can cause tension in the entire spine due to the forward positioned change of posture. Some studies show that it can be triggered by a flexion injury, (excessive forward bending), to the mid back.
Scoliosis is again found in adolescence, more common in girls, and you will observe a change in your child's posture. A low shoulder, a curved spine, a high rib cage on one side when bent forward, can all be an indication of scoliosis. Scoliosis is rarely painful but can cause spinal fatigue and chronic back tightness.
5. Numbness and Other Symptoms in the Arms or Legs
Arm or leg symptoms in a child are a good reason to bring your child to a health care provider. The nerves of the cervical, (neck) spine travel out of the neck to the arms and the nerves from the lumbar spine travel into the legs. Sometimes these nerves can be aggravated and even impinged by the structures around the spine including the joints, muscles and more commonly the discs.
It is rare for a child to have a disc protrusion but it can happen in older adolescents who participate in sports. Sciatica is the name of a condition where the low back nerve roots are irritated and symptoms such as numbness, pain, weakness, pins/needles, and burning pain radiate down the leg. In more emergent cases, the nerve roots can be irritated causing changes in bowel and bladder control. This is a definite reason to get your child checked ASAP.
A numb arm(s) can also be due to a disc irritating the nerve roots but in the neck. Contact sport athletes can also get a nerve stretch, or stinger, when a hit causes excess lateral flexion of the neck, pulling on the nerve root.
To summarize, be concerned when your child is complaining of constant pain that is not relieved by rest and can't be reproduced with movement. Get to the doctor if there is back pain associated with fever or other flu like symptoms that has your child not eating or being their usual active self. Watch a change in your child's posture or if they complain of any arm or leg numbness.
Activity fact: The number one cause of back pain in children is due to a weak core musculature due to inactivity. Get out and get active with your kids!
After twenty years of practice I think I have almost heard everything when it comes to people describing how they injured their back and also what they think the diagnosis is. These include "I threw my back out", "I have a rib out", or "I slipped a disc". There is no doubt that when someone says these things that they have a legitimate problem, but often it is not what the person thinks. This weeks blog will help uncover what really is going on behind these phrases:
Meet the Spine:
The back is made up of the vertebrae, the discs between the vertebrae, the ligaments that hold everything together and then four different layers of muscles. Throw in a whole bunch of sensory nerves to help the brain to know what is going on and to contract the muscle, and you have the wonderful structure of the spinal column.
The nervous system controls the movement of the spine by receiving sensory information from receptors in the muscles, ligaments, and joints. The brain then relays back a signal to contract the muscles which causes either movement or stabilization. When you combine millions of signals from the muscles and joints, and then a response back to them from the brain, you have a movement pattern. These movement patterns allow us to do everything from walking to hitting a baseball.
The Injury Response
Low back pain will affect 8 out of 10 Canadians at sometime in their lives. Low back injuries can occur slowly over time, such as prolonged sitting, or by a trauma, such as a slip and fall.
The small, (first two layers), of muscles of the back can be injured when excess force is placed on them. This can occur when the larger muscles of the core do not support the load placed on them and extra force is transmitted into the deeper muscles. This is common when the back muscles are fatigued and then a heavier lift or an unexpected movement causes the smaller muscles to fail.
Another mechanism is if the muscles of the spine can't handle the force put on them and the spinal joints take the brunt of the trauma, casing a sprained joint. Again, in this case the body will naturally tighten up around the area to protect that joint.
Often a short term inflammatory response also occurs, causing swelling, pain, and more muscle guarding.
Is My Back Out of Place?
When the back is injured, the body always wants to protect itself and does this by shutting down movement in the injured area. This allows the body to save any further damage to injured tissue and to prevent injury to the surrounding nervous system. Protective muscle spasms cause the joints to loose movement and then the connective tissues around the joint also loose flexibility causing joint stiffness and pain. The results of this is that the body recruits other muscles to achieve the movement needed. This change in muscle recruitment can cause a change in the position of the pelvis, often resulting in a higher side and a change in leg lengths. It very much feels like your back is out when you are walking like and "S" and you have a leg short leg but it would be more accurate to say my back is "locked up" rather than "out". The body will also unconsciously off load injured joints and discs by causing you to bend out of your normal form.
Rib pain in the mid back also feels like the rib is sticking up and out of place. This is because the muscles around the rib head, the part that attaches onto the spine, are inflamed and swollen. When the rib is aggravating the exiting spinal nerve it can cause a deep breath to be painful and for you to compensate with this spasm.
What Do You Do?
When your body is responding to injury by tightening up, the best thing to do is to manage the inflammation and then work on getting the area moving. Research shows that range of motion exercises and stretches along with short term use of anti-inflammatory medications help with acute spinal pain. Chiropractic care is a great modality for getting joints moving and helping muscles relax. An adjustment to the spine has a direct effect on soft tissues by stretching the ligaments and joint capsules. This frees up restrictions at this level as well as directly effects the tight muscles of the spine. The smaller muscles of the spine relax in tone when they are quickly stretched with an adjustment. Overall the adjustment frees up the joint and muscles rather than "putting it back into place".
Activity Fact: Low back pain is the leading cause of lost work days and activity limitation (WHO), and is responsible for about 40% of missed work days.
Sports drinks are everywhere. The bright coloured and well marketed drinks are seen on the benches of most professional teams and the coaches even get a Gatorade shower after a big win. The commercials promote better performance and endurance with every sip. Here is a look at the good and the bad of sports drinks:
Our body looses fluid throughout the day and we need to keep hydrated. The average intake of fluid for an adult women is 2.7 liters/day and 3.7 liters/day for the average adult male. This of course changes with the amount of activity one is doing and how hot vs cold it is. Everyone has to keep hydrated and when we are perspiring we obviously need more fluids, but we also need electrolytes. Electrolytes are composed of the essential nutrients that we need to keep hydrated, they help our nervous system function, help repair damaged cells, and to have our body in Ph balance. We normally get these electrolytes from food but when we endure strenuous exercise and sweat them out, we need to supplement these. Sports drinks are mainly made up water and also include electrolytes (mainly Potassium and Sodium), carbohydrates and sometimes vitamins. They are essential for athletes who are enduring long periods of exercise that causes a lot of fluid loss. Sport drinks can also help the body better recover after strenuous exercise. The American College of Sports Medicine recommends drinking 3-8 fluid ounces of water every 15-20 minutes when exercising for less than one hour. When exercising for longer than one hour, they recommend 3-8 fluid ounces of a carbohydrate/electrolyte beverage every 15-20 minutes. They note the need for a sports drink increases with increased duration workouts.
Research shows that sport drinks do help performance and endurance compared to just drinking water when athletes are performing strenuous long duration type exercises. A lot of these studies are performed on professional athletes that compete in endurance type sports like running or cycling. An example of this is Currell, & Jeukendrup in the Journal of Medicine & Science in Sports & Exercise found that when cyclist ingested multiple transportable carbohydrates (found in sports drinks) they where 18% faster in a 120 minute time trial.
A 32-ounce sports drink contains between 56 and 76 grams of sugar – equal to about 14 to 19 teaspoons – and four to six times the recommended daily amount for kids and teenagers. The higher sugar content can be easily taken up as fuel for the athlete that has been exercising for over an hour and sweating a lot. The body will not use up these carbohydrates if you are simply drinking a sports drink to "keep hydrated". For this reason the American Pediatric Society does not recommend kids consume sports drinks unless they are doing strenuous exercising over an hour. Sports drinks have a little over half the sugar as soft drinks but are still a source of extra sugar in our diet. Excess sugar intake is linked to many health problems including: diabetes, obesity, mental health issues, and cardiovascular disease. Some sports drinks are marketed to be sugar free but contain artificial sweeteners which have also been linked to weight gain and health problems.
Another problem is when athletes ingest too many electrolytes from sports drinks it cause excess water to be absorbed into the gut and diarrhea and/or gut irritation occurs.
Some sports drinks are also marketed to have caffeine in them that will help with performance. This can be a dangerous thing, especially for children. Excess caffeine can cause an increased heart rate, anxiety, high blood pressure, diarrhea, and headaches.
Research shows that the average athlete does not need to use sports drinks. A good rule of thumb is that a sports drink is a good option if you are doing intense exercise for over an hour. If you are doing less intense exercises or a short duration of exercise, water is a much better option. Sports drinks are also not appropriate for children to take in most cases unless they are performing at a high level and sweating a lot during their sport. Stay away from caffeinated sports drinks.
Activity fact:- you can easily loose one liter of fluid with an hour of high intensity exercise!