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Age Considerations in Therapeutic Exercise

This is an excerpt from Therapeutic Exercise for Musculoskeletal Injuries 4th Edition With Online Video by Peggy Houglum.

The prepubescent, midpubescent, and postpubescent age groups vary greatly in physical and psychological maturity. Rehabilitation clinicians must be aware of these variations in order to provide the best possible rehabilitation programs for people in all age groups. Given the brief discussion in the preceding sections, it is apparent that many changes occur in the body between the beginning of middle school and the end of high school, the time when we often see these patients' first-time injuries. How we treat these patients and their injuries may have a profound impact on them both physically and emotionally.

Sport Injuries in School-Aged Patients

More than two-thirds of boys and one-third of girls in the United States engage in organized sport.32 Most of the musculoskeletal injuries seen in pediatric patients in emergency departments in the United States occur as a result of sport participation.33 With the profound increase in organized sport for younger athletes, it is likely that rehabilitation clinicians will treat younger patients with athletic injuries since more injuries occur during organized sport than in free-play activities.8 More schools are employing certified athletic trainers who not only will treat these young patients but also will likely see the injuries occur.34

Anyone participating in sports is at risk for injury. Youngsters whose bones are not yet mature and whose skill levels are not fully developed are at even greater risk of injury.35 Each year 3.5 million children who are 14 years old and younger receive medical care from emergency departments for sport-related injuries.35 Many other injuries go unreported because the child's injury is managed without intervention from a medical provider.36

Sever's disease, stress fractures, Osgood-Schlatter disease, jumper's knee, apophysitis, and tendinopathies are common repetitive-induced conditions.37 Often, these injuries occur when bones or soft tissues are stressed excessively during growth spurts,37 or because of poor technique,38 or both. Most fractures occur in the 13- to 16-year-old age group and are Salter-Harris type II fractures; these occur primarily from a combination of rapid growth and physis weakness.39

Regardless of the cause, the young patient's injury complaints are similar to those of an adult. Treatment progression, however, is complicated by the fact that the youngster may still be growing and the injury site is not mature, so it cannot tolerate the same level of stresses as its adult counterpart can or receive the same treatments to manage it.

Acute sprains may be severe enough to indicate surgical repair. Anterior cruciate ligament ruptures are occurring with more regularity in teens and preteens.40 ,41 These skeletally immature patients require unique considerations. One of the primary concerns with this injury is avoiding the epiphyseal growth plate during the surgical graft implantation. The surgeon must know the patient's physiological age to prevent growth plate damage. As indicated in figure 15.3, Kocher and Tucker41 vary their anterior cruciate ligament (ACL) reconstruction procedure according to the patient's physiological age, classified into one of three groups:

  • Prepubescent: Either no surgery is performed and a functional brace is used for protection, or a physeal-sparing and combined intra-articular and extra-articular reconstruction is performed using an autogenous iliotibial band graft.
  • Adolescent with significant growth remaining: Surgery features a transphyseal ACL reconstruction using autogenous hamstrings tendons with fixation away from the physes.
  • Older adolescent approaching skeletal maturity: Surgery is a conventional adult ACL reconstruction with interference screw fixation using either autogenous central-third patellar tendon or autogenous hamstrings.

Figure 15.3 Surgical decision making for anterior cruciate ligament injuries in skeletally immature patients.
Surgical decision making for anterior cruciate ligament injuries in skeletally immature patients.

Rehabilitation Considerations for Sport Injuries of School-Aged Patients

Just as surgeons must adapt their surgical techniques to accommodate growth and developmental stages, rehabilitation clinicians must make adjustments in their rehabilitation programs. Not only do we have the physiological and physical immaturity issues to consider, but it also can be challenging to maintain a young patient's interest in and focus on rehabilitation exercises. Young patients often do not realize the importance of performing exercises correctly; instead their priority is completing them as quickly as possible. With these patients, clinicians need to use their imaginations to make exercises fun while accomplishing the program's goals. Exercises must be carefully monitored throughout the entire program for correct execution and proper compliance.

Proper care provided as soon as possible is a key factor in successful treatment and future good health. It is during the school-age years that genetic and acquired postural deviations are often discovered. Sometimes these deviations result in an athletic injury. The rehabilitation clinician should assess each young patient for postural deviations as part of a routine rehabilitation examination. Immediate care involves the use of modalities such as ice and electrical stimulation to relieve inflammation, pain, and edema. Several modalities are contraindicated for this age group, especially when applied over immature bones; the clinician must be aware of these contraindications and avoid them. Range-of-motion exercises to restore flexibility begin after reduction of pain and swelling. Strengthening exercises with primary emphasis on endurance activities are the next part of the progression. The final phase in a youngster's rehabilitation program involves the restoration of proprioception, balance, and agility before sport-specific activities.

Preparation and planning for a youth's rehabilitation program must account for the physical variations between younger patients and adults. Those factors have already been outlined; next we see how they need to be considered in relation to rehabilitation.


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