Diane Ryding – Tackling Paediatric Injuries – Injury Rehab Network

Tackling Paediatric Sports Injuries

The latest event of the Injury Rehab Network with BASRaT, welcomed guest speaker Diane Ryding from Manchester United Academy. Diane’s presentation at the Injury Rehab Network was the most popular event to date with over 500 sports rehabilitation professionals joining the online event.

Diane is Head Physiotherapist for the Foundation and Youth Development Phases at Manchester United Football Club. Diane received her BSc (Hons) Physiotherapy from Manchester University in 2000 and worked in the NHS for the next decade. In 2010 she received her MSc in Musculoskeletal Physiotherapy from Manchester Metropolitan University.

Diane has been involved in academy football since 2004 initially working as a Casual Academy Physiotherapist at MUFC, progressing to her current role in 2010. During her time with MUFC, Diane has seen a significant expansion in the Academy system, managing the increasing medical requirements of an evolving Academy programme. Her role is to ensure that paediatric injuries are managed appropriately whilst considering growth and maturation and ensuring that the long-term athletic development of the player takes precedent over short-term gains.

Diane is a Visiting Senior Lecturer at Manchester Metropolitan University. She is an FA Affiliate Medical Tutor for the English Football Association and has taught on international sports trauma management courses for SPORTS ER. Diane has recently had three chapters published in ‘A Comprehensive Guide to Sports Physiology and Injury Management’. These chapters introduce concepts around working in an elite football academy along with diagnosing and managing paediatric injuries. Diane is currently involved in supporting research around Cardiac Profiling in Academy footballers.

Diane’s presentation ‘Tackling paediatric injuries’, focused on paediatric sports injuries, both the common presentations and those that are not to be missed! Diane discussed the importance of clinical reasoning skills to accurately diagnose and treat injuries.

Introduction to Paediatric Sports Injuries

Diane commenced her presentation with some key points about paediatric sports injuries, noting that paediatric injuries are unique with specific terminology and problems linked to growth.

Growth & Maturation

Diane provided insight into the three types of the age of children:

Chronological age
Biological age
Psychological age

The maturation status of children can vary from their chronological age and this can be most apparent during peak high-velocity stages of growth. It is important for coaches and medical teams to consider each child’s maturation status.

Child-Centred Assessment

Diane described a child-centred approach to physiotherapy assessment and how this involves the child, parents, and interdisciplinary team (IDT). Subjective assessment can be used with pain scales which support an evidence-based approach to injury assessment.

Communication

Diane described the importance of effective communication with children to ensure they can express their feelings and discuss their injuries effectively. Therapists should ask children for questions they have about their injuries and encourage them to think, “What can I ask?”

Osteochondroses

These injuries affect bone growth in children and adolescents and include Osgood-Schlatter’s, apophysitis and osteochondritis. Injuries may include Severs, Kholers and Freiberg’s. Osteochondroses are managed through education, physiotherapy, strengthening, podiatry, home exercises, modified sport, phased return to play and rest. The physios provide reassurance that with correct management, children can make a full recovery.

Fractures

Diane referenced the Ottawa rules for the assessment of the foot, ankle, and knee injuries. Fracture types may include Greenstick, Torus (buckle), Bow and Avulsion fractures. X-rays are particularly important for children to assess growth plates.

Serious and Sinister Paediatric Sports Injuries

Whilst rare, these injuries should not be discounted. Diane described some of the more serious and sinister injuries that those working in sports rehabilitation should be aware of.

Pars defect/ spondylolysis is a stress fracture of the lower spine and can be a cause of lower back pain in children and adolescents.

Slipped upper femoral epiphysis is when the head of the upper femur slips off the joint in a backwards direction.

The following types of the tumour should be considered during injury assessment:

Osteosarcoma – bone cancer, found at the end of long bones.
Ewing sarcoma – affects bones and tissue around bones.
Rhabdomyosarcoma – forms in soft tissue, including skeletal muscle tissue.
Testicular cancer – symptoms often include a painless swelling or lump.

Inflammatory arthropeses can include:

Ankylosing Spondylitis – long term inflammation of joints of the spine.
Juvenile Idiopathic Arthritis – causes joint pain and inflammation. The specific cause is unknown.

Diane described some of the serious infections that should be considered including septic arthritis which is caused by synovial joint infection and osteomyelitis which is a bone infection.

Diane also explained the importance of being aware of safeguarding concerns linked to non-accidental injury. This could be linked to repeated visits to the medical room where a child may be anxious to disclose an issue.

Whilst serious injuries are rare, Diane noted that professionals have a duty not to over-medicalise sports rehabilitation and to avoid excessive investigations. Sports rehabilitators should ensure that treatments such as sports taping are only utilised to support rehabilitation and return to play and that these treatments should not become long term requirements for players.

Paediatric Sports Injury Rehabilitation

Diane provided her top tips for evidence-based rehabilitation of paediatric sports injuries:

Rehabilitation should be phased.
Load should be graduated.
Exercise rehab should be criteria-based.
Exercises should be functional, starting simple and working towards more complex and dynamic movements.
Training volume, intensity and duration all need to be considered.
Activity should be appropriate.
Make it fun! Use teamwork, challenges, rewards, incentives, consequences, and games.

Kids Will be Kids!

When working with children, Diane provided a reminder that kids will be kids. Despite guidance for rest and recovery, children will often go out and play with their friends anyway!

Q&A

Some great questions were put forward during the presentation which Diane kindly took the time to answer as follows:

Question 1 – What would your advice be in relation to Relative Energy Deficiency in Sport (RED-S)?
Answer – Please join the Injury Rehab Network event with Angela Jackson in June where Angela will be discussing the management of overloaded younger athletes.

Question 2 – Which tests would you use for Pars?
Answer – Subjective tests are recommended but back extension and side flexion tests may provide a pain response.

Question 3 – How would you increase loading with young players?
Answer – During peak high-velocity growth it is particularly important to continually assess players ability to cope. Education for parents is also important. More research is being developed in this area.

Question 4 – How would you manage rehab when only outdoor space is available?
Answer – Get back to basics with simple equipment and make sure young people have ownership/ choice over their rehab programme.

Question 5 – Do you use kinesiology tape?
Answer – This is not used in the academy and the principle with any sports taping is to ensure it is only used for a medical purpose. Players should not become reliant on the use of tape.

Question 6 – Does osteochondrosis usually occur bi-laterally or uni-laterally?
Answer – Can be unilateral or bilateral but commonly is worse on one side.

Question 7 – Do you communicate differently with children and parents?
Answer – Try to be consistent and open but sometimes there needs to be a balance to keep children motivated and to ensure parents are informed.

Learn More

Diane has contributed to the book, ‘A Comprehensive Guide to Sports Physiology and Injury Management.’ Diane recommends the book as a useful resource for anyone working in sports rehabilitation.

Follow Diane Ryding

Keep up to date with the latest from Diane Ryding on Twitter https://twitter.com/dryding

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