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Annotated Bibliography Alyssa Hamel 10/22/12This annotated bibliography analyzes an orthopedic injury common among young athletes, particularly runners. Hip apopysitis is a basic stress fracture that occurs in the growth plates of the hip. There are seven potential locations for the injury and concerns the muscle insertions within the hip. The focus for me is whether or not activities can continue once the injury is diagnosed, and if activities are continued, what the consequences would be. The discussion of whether or not activities can be continued is controversial. Some doctors suggest a 4-6 week period of rest whereas others suggest continuing activity but avoiding painful maneuvers. This topic is largely academic because not only are stress fractures common Orthopedically, but it also involves new options for treatment. This conversation covers a more recent time period because the injury is only more recently common. Due to the fact that this injury is occurring more frequently, it’s becoming more of a concern. Athletes are beginning to be diagnosed with this injury at a much younger age compared to previous years. There is no standard treatment for this injury and the research being done to find a definite rehabilitation is still in its early stages. More experienced doctors and researchers are included in this discussion. In this particular bibliography, medical doctors that are specifically involved in sports medicine wrote nearly every article I used. Rossi and Dragoni are the only doctors that truly stand out in this conversation due to the fact that they conducted the largest and most recent study to date with hip apophysitis. Besides these two, no one specifically stands out due to the fact that research and evidence for treatment in this injury is lacking. The topic was chosen because my intended career path would be to become an Orthopedic Physician Assistant. For two seasons of running I missed out on training due to the opinions of one doctor. The third time around, we sought a second opinion and were informed that I can run on the injury, that I just needed to avoid anything that caused pain. I personally don’t want future athletes to have to miss out on activities they love or to be confused by the opinions of doctors. The injury should have a standard form of rehabilitation so that the athlete can return to his activities as quickly as possible. The injury itself is important, and taken very seriously because it has an impact on the development of an adolescent’s skeleton as it matures. If it isn’t treated properly at early stages, the symptoms can get significantly worse and lead to an avulsion fracture. If the avulsion fracture isn’t properly treated, then it could potentially lead to problems in adult hood and limit an individual’s activities for life. This bibliography would be for anyone interested in becoming a PA, or even beneficial for young athletes that are active in high compact sports. Although the hips are common with growth plate issues, there are growth plates located all over the human skeleton and can cause problems in other limbs. Adirim, Terry A., Cheng, Tina L. “Overview of Injuries in the Young Athlete.” Sports Medicine. 33(1) (2003): 75-81.In this entry, both authors are medical doctors. Adirim is a director in the Office of Special Health Affairs. She received her medical degree from the University of Miami School of Medicine. Cheng received her medical degree from Brown University school of Medicine. Both women are particularly interested in injuries that involve children, therefore they both are extremely educated on the adolescent anatomy. Hip apopysitis is most commonly found in adolescence. The recommended treatments by these researchers include resting, icing and elevating. The women believe that the athlete can return to play when the pain subsides and the strength/range of motion is restored. They also included the fact that the type of equipment that the athlete is using, paired with the surface conditions play major roles in the injury. Specifically in high compact sports such as running, an ideal surface would be dirt or grass as opposed to the constant pounding on concrete. Supporting shoes are also incredibly recommended. When the shoes are worn out, a new pair is required. This contributes because my entire conversation revolves around the opinion of the doctors involving whether an athlete should rest or continue activities when they have hip apopysitis. These doctors believe that the athlete can return to play if the pain subsides. The first time that I was told to take a month and a half break the doctor reduced it to a month when I told him the pain was gone. I returned to my running by slowly getting back into it, and within days the pain returned just as it was. Stress fractures tend to take time to heal and ossify over compared to other injuries that can heal much quicker. I liked that this article mentioned something that majority of the others didn’t; the equipment and surfaces. Most high schools aren’t privileged with ideal surfaces that colleges have, obviously due to funding. Specifically in the case of running, majority of the high schools have concrete tracks and the runs off campus consists of concrete paths on the sidewalks. An eight-mile run on solid concrete five or six days a week can be extremely detrimental to an athletes body and is completely asking for an injury. It’s debatable whether or not a run like that can be tolerated with the proper equipment, but a recommended pair of shoes is required to. A run down pair of shoes with little support can also lead to serious injury. Carpenter, Clare E., Jones, Steve A., Richards, Huw. “Chronic Stress Injury of the Trochanteric Apophysis.” Clinical Journal of Sports Medicine. 18(1) (2008): 100-101.This journal entry, written by researchers from the University Hospital of Wales in the United Kingdom, looks into what causes hip apopysitis and what they recommend for treatment. They also include a case report of a 14-year-old boy that was diagnosed with a chronic stress injury. They believe that the strength of the soft tissue combined with rapid bone growth in adolescents’ leads to a wider zone of injuries, making the growth plates more susceptible to fractures. These researchers also mentioned the importance of appropriate footwear and the ground surface. They also emphasized how important it is for the coaching to be up to par. The recommended period of treatment for the boy with the chronic injury would be a period of supervised rest. In his particular situation, it was six months. This was an extreme case due to the fact that he actually had his growth plate and muscles become unattached. The most powerful muscles in the human body are attached around the hip and pelvis, which makes the area more prone to injury. The first level of the injury, and least serious, would be a micro trauma. The next level would be a subsequent degeneration, and the most serious would be an avulsion fracture. The 14-year-old boy had an avulsion fracture. Biomedical studies show that there is no obvious difference in hip flexibility between the two sides. Therefore, even if an athlete is right handed, or values the right side, it won’t have an impact on the left side or make it more prone to injury. This contributes to the conversation because it provided an extreme case report of an athlete that experienced the worst possible level of this injury. It didn’t specify what caused his particular injury, but they explicitly state that rest from the activities is required. Another important factor to a quick recovery would be early detection of the injury in order to prevent a fracture. Therefore, if the injury is ignored or allowed to run on it could lead to a fracture in the growth plates and ultimately become an avulsion fracture. In other articles, the rest period is between 3-6 weeks. If an athlete just takes the recommended rest, it will take him out of athletics for approximately a month and a half as opposed to six months. Clearly, airing on the safe side would be more desirable for most serious athletes. This article stated that there are three main levels of this injury, which was something that none of the other articles mentioned. I like that they are able to be more specific with what category the degree of the injury can fall into. Davis, Kirkland W. “Imaging Pediatric Sports Injuries: Lower Extremity.” Sports Medicine Imaging. 48(6) (2010): 1213-1235.In this journal entry, Kirkland Davis, a doctor from the University of Wisconsin Hospital and Clinics, explained in thorough detail what exactly causes and results from hip apopysitis. Pelvic apopysitis could potentially relate to traction apopysitis, which just emphasizes the fact that it’s an overuse injury. The most common location for runners would be the iliac crest, and the attachment site of the muscles. When examining the x-rays, the physis, or growth plate, will have a “normal” appearance or be mildly widened but not displaced. The fact that the injury could have a “normal” appearance in the x-ray, doctors can use other tests such as MRI, CT, or ultrasound in order to be more efficient in diagnosing. Instead of using the x-ray, the other tests allow for the doctor to discover exactly what the injury is and to what extent it is (acute or chronic). The widening between the growth plates occurs because the apophysis hasn’t ossified yet. The osseous avulsions are the most common acute hip injury in adolescent athletes. In this case, the muscles may separate from the underlying bone and retract with the tendon. Apophyseal physis is the weakest link in the “muscle-tendon-bone” complex, which would make it more susceptible to injury. Chronic avulsions occur with repeated intensity and cause instant pain. In the largest study to date, two doctors looked at the cases of 203 avulsions in patient’s ages 11-17 and found that 45 of them were anterior inferior iliac spine, and 39 of them were anterior superior iliac spine. Therefore, nearly half of the injuries that occurred were located on the hip as opposed to other locations in the body. This study proved that the injury isn’t as rare as other researchers have made it out to be. This contributes to the conversation because it solidifies exactly what hip apopysitis is. It offers the opinion of a doctor who believes that this injury isn’t rare. It isn’t something that should be overlooked. The fact that the largest study to date occurred only in 2003 is upsetting, there should be more concern about an injury that can cause harm to the skeleton. I thought it was interesting to consider the fact that the x-rays make it hard to diagnose the injury. This factor could potentially lead to a misdiagnosis and cause farther pain or issues for the athlete. Luckily, in my x-ray the doctor was able to easily point out the widened space between my growth plates. It was very noticeable and he diagnosed it with complete certainty. I believe that for future references if an athlete has hip pain, an x-ray should be taken but if it comes back negative for hip apophysitis, I think an MRI should be mandatory. It’ll save confusion and possible issues with misdiagnosing the injury. Kivel, Courtney Grace, Charles Allou D'Hemecourt, and Lyle Joseph Micheli."Treatment of Iliac Crest Apophysitis in the Young Athlete With Bone Stimulation: Report of 2 Cases." Clinical Journal of Sport Medicine. 21(2) (2011): 144-147.In this journal entry, Courtney Kivel, a researcher from Columbia University, considered two cases of hip apopysitis. Kivel initially introduced background information to present the injury and define what hip apophysitis is. Hip apophysitis is an overuse injury located within 7 different locations on the hip. It’s typically found in adolescents because it’s related to growth within the plates. Kivel explored two cases and included pictures, as well as a brief timeline of each patient’s recovery. This particular article will contribute to my conversation because it defines the injury first off. With the groundwork laid out, Kivel includes examples of recovery by providing two separate cases. The two are separate cases, but are easily comparable because they have differing ages and play sports. The article is set up perfectly to deliver both ample information about the injury as well as real world cases. Kivel specifically supported the bone stimulation rehabilitation technique. Meaning, electrical stimulation to the site of the injury. Using this technique in an attempt to heal the miniature fractures in the hip is a relatively new decision. They tested it on animals, and found that it works for nearly half of the patients they used it on. It proved itself to be a more favored rehab technique because it produced the best outcome just short of surgical intervention. In both cases, the girls continued their activities, but were instructed to avoid anything painful, to ice, and receive the stimulation. I’m curious to know what would happen if either girl discontinued their activities or “cross trained”, meaning swimming or biking to avoid impact. This injury is most common in running and dancing due to the repetition. Kong, Chae-Gwan., In, Yong., Kim, Seok-Jung., Sur, Yoo-Joon. “Avulsion Fracture of the Iliac Crest Apophysis Treated With Open Reduction and Internal Fixation.” Journal of Orthopedic Trauma. 25(6) (2011): 56-58.In this journal entry, each of the authors involved have all received medical degrees. They stated that apophyseal fractures of the pelvis and hip are not rare, they are more frequently reported now than ever before. The article also referenced the large study by Rossi and Dragoni involving the 203 cases. Apophyseal avulsion fractures of the iliac crest are very rare though, there are only 13 articles in existence in English Literature. All of the cases were treated non-operatively. They mentioned potential complications that could result from a non-operational approach to an avulsion fracture, which includes: nonunion, malunion, or inability to return to physical activity. This contributes to the conversation because it illicitly states what could result from not correctly treating an avulsion fracture. Hip apopysitis is the early stage of an avulsion fracture. If that stage isn’t treated correctly it could directly result in this fracture. From there the complications are listed as to what could result from not having an operation. It’s very similar to a domino effect, and ultimately if it isn’t taken care of appropriately then the athlete can face the possibility of never returning to his or her sport. Moeller, James L. “Pelvic and Hip Apophyseal Avulsion Injuries in Young Athletes.”Current Sports Medicine. 2(2) (2003): 110-115. In this article, Moeller, a sports medicine doctor with nearly 20 years of medical experience shared his knowledge dealing with hip apophysitis. He believes that the injury is worsened by activities and relieved by rest. Compared to other articles, he actually stated that stretching wouldn’t be recommended because it could cause discomfort. After the period of rest, Moeller supports a controlled return, meaning easing back into the activity. Similar to the other articles, he stated that this injury is becoming more common and more noticed among other injuries. Due to the increased number of cases, there has been an improved understanding of the entity in recent years. Since there has only been one major study in the history of reviewing this injury, Moeller also mentioned the case study by Rossi and Dragoni that involved 203 cases of hip apophysitis. He advocates a 6-8 week rest for hip apopysitis, and with an avulsion fracture 2-4 weeks on crutches followed by 6-8 weeks of recovery.This contributes to my conversation because Moeller supports rest, and disapproves of continued activity. Majority of the articles I found state that rest should be taken, and continued activity should only occur if the athlete can tolerate the pain and isn’t limping. An important point that Moeller included would be that stretching isn’t ideal because it could cause discomfort. Logically, that makes sense because if the fracture is between the muscle and tendon on the bone, then stretching that out farther would only stretch the muscle farther away. So although the no stretching opinion makes sense, I also think it would be important to strengthen the hip that is injured, with light workouts and increasing the range of motion. The initial doctor I went to suggested a 6-8 week break in order to recover, and although it didn’t work well for me the first time, the second time I took the 6 weeks off, I joined the swim team instead and found that within those 6 weeks the pain had completely subsided. After that period of rest I was able to return to my running regime pain free.Paluska, SA. “An Overview of Hip Injuries in Running.” Sports Medicine. 35(11) (2005): 991-1014. This journal entry, Paluska, a researcher at the Department of Family Medicine with the University of Illinois, explored hip injuries that commonly result from running. Among the injuries was hip apopysitis. Paluska pointed out that majority of these injuries occur in adolescent females. The article had several sections that cover the separate injuries and include in depth information about each, as well as possible rehab options. In this article, there were several things that differed and lead way to possible controversy. The first would be that the iliac crest is a rare location for the apophysitis, yet in this article Paluska stated that it’s one of the most common locations for the injury. Another major difference would be the question of whether or not rest is a necessity for this injury, and if not what the possible outcome would be. Paluska stressed that 4-8 weeks of rest should occur before returning to activity. Potential outcomes of continuing activity include continuous aggravation at the site of the injury, or worse and avulsion of the muscle. If the muscle tears from the growth plate, extensive recovery will be required and surgical intervention may be needed. Paluska stated that stretching would make the injury less painful and lead to a quicker recovery.Pointinger, H., Munk, P., Poeschl, G.P. “Avulsion Fracture of the Anterior Superior Iliac Spine Following Apophysitis. (Case Report).” British Journal of Sports Medicine. 37(4) (2003): 361-362.In this entry, the authors, all doctors, perform a case study on an 18-year-old athlete that was diagnosed with hip apopysitis. He was a long distance runner and was experiencing pain in his right side. He was instructed to stop his activities for a week, and only took anti-inflammatories. Within two weeks he wasn’t experiencing pain so he returned to his running. Three weeks later he felt intense pain in his hip, and heard a pop. The athlete had an avulsion fracture of the anterior iliac crest. In this case, surgical intervention was necessary for the athlete and they inserted screws to reattach the muscles. After four weeks of no activities, he was healed and able to return to running without any pain.This aids my conversation because of the controversy behind whether or not a break is necessary. If an injury like this occurs within season, and the athlete is instructed to rest before returning to activities, they miss out on their season. If the athlete is permitted to continue the activities they can continue training, but if an injury like this occurs then they have to undergo surgery and it could take them out even longer than just taking the initial break. Plus, if the athlete continues to run through the pain, it could potentially prolong the injury and the athlete would endure pain for a longer amount of time. Injuries such as this one typically occur between the ages of 11 and 23. Pointinger et al. mentioned that in cases such as this one, stress fractures are typically misdiagnosed in the initial examination. These doctors explicitly stated that when an injury such as hip apophysitits is diagnosed, it needs to be treated immediately and taken care of appropriately. Ideal treatment consists of crutches the first week to alleviate the body weight off the injury, followed by 3-6 weeks of rest. The “take home message” is that this injury should be taken seriously and treated correctly to prevent damage to the juvenile skeleton. The fact that this injury occurs specifically in adolescents during their growth periods makes them more susceptible to serious damage within their growth plates. The articles above take the other approach and stated that the athlete can continue the activities. Rossi, F., Dragoni, S. “Acute avulsion Fractures of the Pelvis in Adolescent Competitive Athlete: Prevalence, Location and Sports Distribution of 203 Cases Collected.” Skeletal Radiol. 30(3) (2001): 127-131.This article, written by two medical doctors, would most likely be one of the most significant articles in this bibliography. The doctors conducted the largest study on this particular injury, to date. Rossi and Dragoni reviewed 1238 radiographs, and all of the x-rays were the standard view of the pelvis. From these x-rays, they found 203 acute apophyseal avulsion fractures. The average age among these cases was only 13.8 years. The breakdown of the 203 cases was 139 males and 64 females. The interesting thing about these numbers is the fact that some doctors state that this injury is more likely to occur in females due to the hip developments and the widening. This means there is more than double the amount of males with this injury compared to females. Of all the 203 cases, only three of the athletes had surgery, the rest of them took a period of rest from their activities. Rossi and Dragoni stressed the fact that this injury needs to be taken more seriously and is not as rare and some doctors make it out to be. It’s becoming increasingly more common and affecting more athletes, which makes it more important. This definitely adds to my conversation because the study done by Rossi and Dragoni is one of the most significant studies in the history of this injury. It’s the most recent study, and also the largest study done. I was surprised that majority of the cases occurred in males as opposed to females. In puberty, girls tend to develop wider hips in order to prepare for child bearing. Males don’t go through a period of developing wider hips. I figured that when this widening took place, the females would have significantly more injuries and have more trouble with the growth plates closing up and ossifying over. I was also surprised to find that only three cases had an operational recovery whereas the rest recovered without an operation. The study didn’t specify if the athletes had continued issues after returning to their activities, so I’m curious to know if the rest of the athletes that didn’t have surgery were able to fully recover due to the potential risk of nonunion. Smith, David V., Bernhardt, David T. “Hip Injuries in Young Athletes.” Current Sports Medicine Reports. 9(5) (2010): 278-283.In this article, Smith and Berhardt are both medical doctors. Both Smith and Bernhardt graduated from the University of Wisconsin and work in sports medicine. They stated that hips are becoming more commonly injured. Hip injuries are receiving increasing amounts of attention because more children are getting active in sports. With new attention come newer surgical techniques. Children as opposed to adults are more important with hip injuries because the open apophyses are very weak. The injury is caused by a sudden forceful contraction of the muscles. They also supported the fact that the MRI should be used more frequently because it’s more accurate. As far as recovery is concerned, they believe that there should be a period of rest from activities, and in the case of an avulsion fracture crutches should be used. Repeat x-rays should be taken to track the healing process of the injury. Strengthening exercises should be done as well as gentle range of motion exercises. More and more children are becoming active in sports in the recent years, and majority of them get involved in higher intensity sports. A major thing that Smith mentioned was the fact that repeat x-rays should be taken. Even if the pain seems to be subsiding, some athletes are able to begin to ignore the pain and develop a tolerance to it. If the growth plate is still vulnerable after controlled rest and the athlete attempts to continue his or her activities it could easily result in an avulsion fracture and take the athlete out of his activities for even longer. It’s also important because in some cases if one side of the growth plate is widened, there is a chance that the other side may also have issues not closing completely. When I had hip apophysitis, I initially had extreme pain in my left hip but after resting and then returning to my activities that right side began feeling the same pain the left had. In my case, both of my growth plates closed much later on than normal growth plates causing inflammation and irritation in both of my hips. Sundar, Manthravadi, Carty, Helen. “Avulsion Fractures of the Pelvis in Children: A Report of 32 Fractures and Their Outcome.” Skeletal Radiol. 23(2) (1994): 85-90.In this article, Sundar, an orthopedic surgeon, and Carty, from the department of radiology, are both medical doctors from the United Kingdom. They explored issues related to hip apophysitis. These injuries, although considered trivial, have left disability persisting into adulthood limiting their activities. Sundar specifically does not advise an operation to recover. Instead, he suggests just strict bed rest and a break from the activity. A significant point Sundar made was that the average age for this injury has gone down significantly in recent years. As opposed to the later teens being the average, it’s now down to 13.8 years of age. The earlier teen years is when the child’s skeleton is most vulnerable and therefore more susceptible to injury. This contributes because compared to the other articles, Sundar mentioned the fact that this injury can lead to issues in adulthood, and cause disability in future activities. This raises an entirely new factor making the injury more important and serious. If this injury cannot only affect childhood activities, but also continue to have an impact on adult life, that’s scary. I wouldn’t want to have difficulty staying in shape and being active later in life.Wilson, Julie C., Rodenberg Jr, Richard E. “’Growing’ Pains: Apophysitis of the Lower Extremities.” Contemporary Pediatrics. 28(6) (2011): 38-46.In this journal entry, both Wilson and Rodenberg are medical doctors. Hip apophysitis is more common in the year round sports, and is also more frequent in the athletes that do multiple sports at once. Both of these factors lead to increased training demands. This injury specifically comprises a significant proportion of musculoskeletal complaints in this population, meaning it being talked about more, more injuries are coming to the surface. It’s an extremely painful injury with persistent and worsening symptoms if not taken care of appropriately. An acute avulsion fracture according to these doctors, is ground for immediate disability. Meaning they suggest rest from activities. The pain only ceases when the growth plate at the apophysis is completely closed. This article specifically mentions that evidence based reports of treatments are lacking. The open growth plate is more vulnerable to injury and inadequate protection during rest period could lead to an avulsion fracture. Activity may be modified to allow continued participation, but require complete rest depending on the level of pain. Rule of thumb revolves around whether or not the athlete is limping. They recommend stretching and strengthening the hip and abdominal muscles, as well as a 4-6 week resting period. If an avulsion fracture occurs then 4 weeks on crutches and 8-12 weeks following that until they return to the sport. This contributes to the conversation because similar to the other articles, it points out that if the injury isn’t taken care of appropriately it’ll lead to worsening symptoms, or an avulsion fracture. I like that they set a limitation so that if an athlete is limping, rest isn’t an option it’s mandatory. I’ve seen plenty of fellow runners believe that they can run through an injury and limp with every step, but when the pain becomes unbearable they realize that instead of the one stress fracture they had, the absence of rest has turned it into two stress fractures. They mentioned that evidence based reports are lacking, which is concerning granted that this article was only written in 2011. But at the same time that makes perfect sense because the most recent and most significant study only happened in 2003. That’s nearly a decade ago, and the fact that in recent years it’s becoming increasingly more common, more studies and research needs to be done. ................
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