Adolescence refers to the years between ages 13 and 19 and is considered the transitional stage from childhood to adulthood.
The telltale transformations that occur can start during the preteen or “tween” years (ages 9 through 12), and last through the end of puberty (typically around age 15 for girls and 17 for boys); the physical, emotional and hormonal shifts can have parents scratching their heads, remarking that their child has “become someone else.”
As parents and health care providers, we witness their mood swings, changes in the body and voice, changes in sleep patterns, and of course changes in attitude. Their musculoskeletal system is going through profound changes, too. Bone growth during adolescence is crucial.
Increased sex hormones lead to an increase in size and mass. This is both an exciting time and a daunting one; with limited cognitive ability when it comes to risk assessment and long-term thinking, teenagers tend to engage in risky behaviors and push themselves aggressively during activity and sports.
Common concerns
Road accidents, sports and recreational activities are common sources of adolescent musculoskeletal injury, and they often prompt visits to the chiropractor.1 Injuries or pain in or around the growth plates of the long bones and persistent pain around joints should never be ignored or dismissed as “growing pains.” Seemingly innocuous injuries during adolescence may lead to serious health problems down the road, including chronic posttraumatic osteoarthritis.2
Injury can also lead to a premature exit from sports and activity altogether, which invites a whole new set of health complications, immediately and in the future. According to the World Health Organization, the waning years of adolescence have become a “high-risk time period for physical inactivity.”
For adolescents ages 12 to 19, 50 percent of males and 75 percent of females fall short of activity targets set by the World Health Organization, according to a recent study. The most alarming finding? By age 19, “teenagers are as sedentary as 60-year olds.”3 This is all the more reason to keep adolescents active and on their feet.
Focus on the foundation
As a chiropractor, you are hyperaware of the importance of keeping the spine strong and aligned, but what about the feet and lower extremities? Most acute sports- and recreation-related injuries in children and adolescents involve the lower extremities.4
Moreover, healthy feet are critical in maintaining balance and promoting healthy biomechanics and proprioception, which in turn decrease an adolescent’s risk of injury. The feet are well-supplied with proprioceptive nerve endings with connective and articular tissues, and both intrinsic and extrinsic muscles. Mechanoreceptors in the joints along with the muscle spindles of the foot muscles are responsible for the positive support reflexes and a variety of automatic reflexive reactions.5
Generally speaking, adolescents and their parents have little understanding of the three arches of the foot and the role they play in supporting the ankles, knees, hips and spine. After age 7, the arches can either begin their collapse into some degree of foot pronation or roll out into excessive supination. More than 80 percent of individuals worldwide over-pronate, while only 3 to 5 percent of the population excessively supinate.
The pronation-supination phenomena are important because the resultant stress they create moves up the axial kinematic chain. These can cause numerous ailments that bring adolescent patients in for care. Most of the conditions involving the lower extremities have a link to the stability of the feet, which is why assessing, supporting and correcting the feet must play a role in any effective treatment plan for lower extremity injuries.
Typical adolescent injuries
You may find a wide range of problems in the lower extremities of your adolescent patients, but the following chronic conditions and syndromes are some of the more-common injuries likely to present in practice:
- Osgood-Schlatter’s disease
- Sinding-Larsen-Johansson disease
- Anterior knee pain
- Knee ligament issues
- MCL (medial collateral ligament) injuries
- ACL (anterior cruciate ligament) injuries
- Meniscal injuries
- Sever’s disease
- Ankle sprain
- Patellar tracking disorders
- Osteochondritis dissecans
- Growth plate fractures
Many of the more recent (and traditional) treatment approaches to musculoskeletal problems take advantage of proprioceptive concepts. Joint manipulation, especially of the spinal joints, has a direct and immediate effect in normalizing receptor responses.6-8 In most cases, adjusting the appropriate extremity and spinal bones will also be vital.
Restoring proper alignment is essential for any of the other ancillary therapies or treatments you perform to work more effectively. Use the appropriate modalities to address the presenting symptoms. Ultrasound, cold laser, EMS, interferential, heat, ice, etc., can all be appropriate depending on what situation you are dealing with.
Stretching and strengthening for the lower extremities and the spine can be recommended, and tailored to the particular injury and patient. Luckily, there is so much variation on the types of exercises that you can help the patient choose. A patient who is empowered to choose is more likely to be compliant.
You might start the patient on simple, basic stretches for the lower back (e.g., knees-to-chest, child’s pose, and cat or cow). Yoga and Pilates are also effective as the patient stretches and strengthens their body during the same session.
Orthotic support
I recommend three-arch, flexible, custom orthotics to nearly every patient who walks through my doors, especially those who are suffering a lower extremity injury. On the patient’s first visit, I begin with a digital foot scanner. The report of findings helps teach about the foot arches, foot structure, and how the integrity of these affects the rest of the body.
While waiting for the patient’s custom orthotics to arrive, you can rely on taping to stabilize the area, improve blood flow and aid the healing process. I use elastic tape to create a “pseudo-orthotic” for the patient. I use two pieces of tape to support the three arches so when the patient leaves my office, they leave the tape on and have support for the next few days until the orthotic arrives. There are plenty of seminars and videos online from the various taping companies that can help you tape the lower extremities.
It is important to discuss the quality and type of shoes the patient wears the most. Have them take their shoes off and look inside to examine the wear pattern. Most shoes have little to no arch support, or only at the instep.
Accordingly, people end up fitting their feet to their shoes rather than the other way around. Teach your patients how to choose healthy, supportive shoes and, better yet, recommend they fit every pair with arch-supporting custom orthotics. Proper foot support will go a long way toward preventing lower extremity injuries from worsening or reoccurring.
The adolescent patient presents in similar fashion to your adult patients, but their age creates special vulnerability. Keep a close eye on them as you treat them and consider the body’s foundation in your treatment plan. What is amazing about this young age range is how fast they heal compared to adults.
It takes a fraction of the time for adolescents to heal compared to your older patients. Use your clinical knowledge, apply your techniques for the feet and the extremities, and you will help get those tweens and teens back out engaging in healthy sport and play.
Kevin Wong, DC, is an expert on foot analysis, walking and standing postures, and orthotics. He discusses spinal and extremity adjusting at speaking engagements, and he can be contacted through orindachiropractic.com.
References:
1 Sleet DA, et al. A review of unintentional injuries in adolescents. Annu Rev Public Health. 2010;31:195-212.
2 Anderson DD, et al. Post-traumatic osteoarthritis: improved understanding and opportunities for early intervention. J Orthop Res. 2011;29(6):802-809.
3 Varma VR, et al. Re-evaluating the effect of age on physical activity over the lifespan. Prev Med. 2017 Aug;101:102-108.
4 LaBella CR. Common Acute Sports-Related Lower Extremity Injuries in Children and Adolescents. Clinical Pediatric Emergency Medicine. 2007;8(1):31-42.
5 Freeman MAR, Wyke B. Articular contributions to limb muscle reflexes. The effects of partial neurectomy of the knee-joint on postural reflexes. Br J Surg. 1966;53:61-69.
6 Slosberg M. Effects of altered afferent articular input on sensation, proprioception, muscle tone and sympathetic reflex responses. J Manip Physiol Ther. 1988;11:400-408.
7 Rogers RG. The effects of spinal manipulation on cervical kinesthesia in patients with chronic neck pain: a pilot study. J Manip Physiol Ther. 1997;20:80-85.
8 Fitz-Ritson D. Assessment of cervicogenic findings. J Manip Physiol Ther. 1991;14:194-198.
