15.2 Scoliosis, Sports Injuries & Overuse Syndromes

Sports, spine, and overuse visits sit in musculoskeletal/orthopedic category #8. Domain II is the Adams bend you can describe, the apophysis you can name, and the athlete you pull from the field. Domain III is load reduction, heat safety, concussion return rules, and knowing a preparticipation physical is not a well-child visit. Pain scoring and analgesics are 15.3; hip emergencies and nursemaid's reduction are 15.1.

Quick Answer: Adams forward bend plus scoliometer; image and refer a progressive or obvious curve — commonly Cobb ≥20° or atypical (pain, left thoracic, neurologic findings). Overuse: Osgood-Schlatter, Sever, little-league elbow/shoulder. Concussion: remove same day, no same-day return, stepwise return. Screen female athlete triad/REDs. Heat illness ends in heat stroke (CNS change). Growing pains are bilateral, evening, normal exam — diagnosis of exclusion. A PPE is not a complete well visit.

Scoliosis: Adams, scoliometer, when to x-ray and refer

Adolescent idiopathic scoliosis (AIS) is a lateral spinal curvature with rotation, Cobb angle ≥10°, in an otherwise typical adolescent. Screening is inspection of shoulders, scapulae, waist, and pelvis, then the Adams forward-bend test: palms together, bend forward; a rib prominence or lumbar hump is rotational asymmetry. A scoliometer (inclinometer) quantifies the angle of trunk rotation. A reading around 5–7° commonly triggers standing PA spine radiographs (lateral as indicated) for a Cobb angle.

Do not invent a home-grown degree-by-degree algorithm you cannot defend if you are unsure of every cut. Teach the principle the exam wants: image and refer when the curve is obvious, progressive, or atypical. Commonly refer at Cobb ≥20°. Also refer any curve that is painful, rapidly progressive, associated with neurologic findings, left thoracic (more often non-idiopathic), or occurring in a very young child (infantile or juvenile scoliosis — higher chance of underlying pathology such as syrinx or tumor).

Risser staging (iliac apophysis ossification, 0 through 5) estimates remaining growth. Bracing conversations live with pediatric orthopedics/spine and typically involve skeletally immature patients with curves roughly in the mid-20s to 40s. Surgical discussion is for large curves (commonly around 45–50° and up), not for a 12° school-screen bump. Observation of small typical curves with documented measurements is appropriate. "Ignore until 40°" is not.

Do not obtain a scoliometer reading and then prescribe a Milwaukee brace from primary care. Do not tell a family that a 22° curve is nothing because it is under 40°. Do not skip the neurologic exam on a "school screen."

Clinic vignette. A 13-year-old has a visible thoracic prominence on Adams bend and a scoliometer that prompts films. Cobb is 22°, Risser is low, exam is neurologically normal, and there is no pain. That is a referral, not a two-year watch without measurements. A 6-year-old with a painful left thoracic curve is not AIS until orthopedics and sometimes MRI say so.

Overuse syndromes: Osgood-Schlatter, Sever, little league

Osgood-Schlatter disease is tibial tubercle apophysitis in a running or jumping early adolescent (often 9–14 years). Pain at the tibial tubercle, worse with sport, kneeling, and resisted extension; a prominent, tender tubercle; otherwise a stable knee. Management: relative rest (not necessarily zero activity forever), ice, quadriceps and hamstring flexibility, NSAIDs as needed, optional patellar strap. It is not a sarcoma. It is not SCFE — if the story is limp plus referred pain plus an externally rotated hip, go back to 15.1. Surgery is rare and not primary-care first-line care.

Sever disease (calcaneal apophysitis) is the 8–12-year-old athlete with activity-related heel pain, a positive squeeze test of the calcaneal apophysis, no fever, and no night-waking focal bone pain. Heel cups or lifts, calf stretching, load reduction, ice. Not a reflex MRI. Not a stress-fracture workup on day one of bilateral seasonal heel pain.

Little-league elbow is medial elbow overuse in throwers: repetitive valgus load on the medial epicondyle apophysis (and the ulnar collateral ligament in older adolescents). Pain with throwing, loss of velocity, tenderness over the medial epicondyle. Rest from throwing — not "ice and pitch the tournament." Pitch-count and rest-day counseling is prevention. Little-league shoulder is overuse proximal humeral physeal stress (epiphysiolysis): lateral shoulder pain in a thrower, decline in throwing; rest and sports-medicine or orthopedic input if it is not settling. Do not inject corticosteroids into an apophysis as office first-line care.

Other overuse patterns to name: patellofemoral pain, spondylolysis in gymnasts and football players (extension-related back pain), gymnast wrist, and stress fracture when pain is focal, progressive, and not "growing pains."

Concussion: out the same day

A sport-related concussion is a traumatic brain injury from a blow to the head or body with transmitted force. Diagnosis is clinical. You do not need a positive CT. CT is for red-flag suspected intracranial injury (falling GCS, focal neurologic signs, worsening severe headache, repeated vomiting, seizure, suspected skull fracture) — not for proving concussion so the athlete can return in the second half.

Remove from play the same day. No same-day return. This is non-negotiable AAP/CDC teaching. A second hit in the same contest is the danger. After removal: rest from sport, relative cognitive rest as needed for symptoms (not mandatory days of dark-room isolation as a default), then a stepwise return-to-learn and return-to-play progression. Advance a step only if symptoms stay controlled. Written clearance before contact. "He looks fine, let him finish" is the item the exam writes on purpose.

Female athlete triad / REDs and heat illness

The female athlete triad is low energy availability (with or without frank disordered eating), menstrual dysfunction, and low bone mineral density. REDs (relative energy deficiency in sport) is the broader IOC construct: impaired physiologic function in multiple systems, in any sex, when energy intake does not match expenditure. Screen the thin distance runner with recurrent stress fractures, relative bradycardia, amenorrhea, or "sport weight" talk. Plan: restore energy availability, involve sports medicine, nutrition, and mental health as needed, and do not clear unrestricted impact sport while the energy deficit and bone risk are ignored. Combined oral contraceptives are not a complete bone-protection plan if the athlete is still under-fueled.

Heat illness is a spectrum. Exercise-associated cramps are painful muscle contractions in the heat. Heat exhaustion is heavy sweating, weakness, dizziness, headache, still relatively intact mentation — remove from heat, oral or IV fluids, stop the event. Heat stroke is CNS dysfunction (confusion, collapse, seizure), often with a very high core temperature — emergency cooling and EMS, not a cool towel and a return to the third quarter. Prevention belongs in the PPE and in August two-a-day counseling: acclimatization, hydration, rest breaks, never work through altered mentation.

PPE versus well visit; growing pains

A preparticipation physical evaluation (PPE) screens for sport risk: cardiac history using AHA 14-element-style questions, concussion history, musculoskeletal screening, female-athlete energy and menstrual history, heat-illness history, and clearance decisions. It is not a substitute for a Bright Futures well visit. Immunizations, development, SDOH, confidential adolescent care, and anticipatory guidance still belong on the periodicity schedule. Combining PPE and well care in one appointment is good primary care. Completing a five-minute clearance form and skipping vaccines is not.

Growing pains are real and over-called. Typical: bilateral limb aches, evening or night, preschool or early school age, normal exam, full activity by morning, no limp, no fever, no swelling, no morning stiffness. They are a diagnosis of exclusion. Unilateral pain, a limp, focal bony tenderness, night pain that progressively wakes the child with systemic signs, back pain in a young child, or morning stiffness is not growing pains — that list is infection, SCFE, JIA, or malignancy (15.1 and 15.3).

Exam traps. Bracing a 12° curve from the primary-care drawer. Missing atypical scoliosis because the school screen said idiopathic. Treating Osgood-Schlatter as sarcoma — or missing SCFE because you stared at the tibial tubercle. Same-day concussion return because the CT was normal or was never indicated. Clearing amenorrheic runners without asking about intake. Calling unilateral febrile limp growing pains. Using a PPE as the only health-supervision visit of the year.

Clinic close. Asymmetric Adams bend: scoliometer, x-ray when indicated, refer ≥20° or atypical. Tibial tubercle in a jumper: Osgood-Schlatter, load down. Heel squeeze in a 10-year-old soccer player: Sever. Medial elbow in a pitcher: stop throwing. Dazed soccer player: out for the day, stepwise return. Thin miler with amenorrhea: triad/REDs. Hot, confused football player: heat stroke — cool and EMS. Bilateral evening aches, normal exam: growing pains only after you exclude the rest. PPE plus immunizations, not PPE instead of well care.