Move Well, Live Well, Perform Well

Growing Pains or Something More Serious? | Paediatric Orthopaedic Surgeon, Dr Claudia Maizen

• Simon Gilchrist

Share episode

Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.

0:00 | 1:11:33

Children’s bones, joints and muscles behave very differently from adults, yet many injuries and pains are still misunderstood or dismissed as “just growing pains.”

In this episode, we’re joined by Dr Claudia Maizen, Paediatric Orthopaedic Surgeon working at Barts Health and OS Clinic in London, to explore the unique challenges of diagnosing and managing musculoskeletal problems in children and growing athletes.

We discuss why children cannot simply be treated like smaller versions of adults, how to recognise early warning signs of serious conditions, and what parents, coaches and clinicians should know about supporting healthy growth and movement during childhood and adolescence.

Dr Maizen explains the “don’t miss” diagnoses that can present with symptoms such as limping, hip or knee pain, or refusal to weight-bear, including Perthes disease, slipped capital femoral epiphysis (SCFE) and growth plate injuries — and why early recognition is crucial for the best outcomes.

A major focus of the conversation is developmental dysplasia of the hip (DDH), Dr Maizen’s specialist area. We discuss how DDH is detected, why early screening matters, and how treatment approaches differ depending on a child’s age.

We also explore some of the most common issues seen in growing children today, from hypermobility and deconditioning to sports injuries and bone stress injuries in young athletes. Dr Maizen shares insights into how modern training patterns, growth spurts and early sport specialisation may be influencing injury risk.

Finally, we discuss practical advice for parents navigating childhood injuries: when pain is likely harmless, when to seek medical advice, and how to help children develop strength, movement confidence and long-term musculoskeletal resilience.

🎙️ In This Episode, We Cover

• Why children’s bones and joints behave differently from adults
• The key warning signs behind a child’s limp or refusal to weight-bear
• “Don’t miss” diagnoses including Perthes disease and SCFE
• Growth plate injuries and how they can mimic simple sprains
• Developmental dysplasia of the hip (DDH) and the importance of early detection
• The difference between growing pains and more serious pathology
• Hypermobility in children — when it’s normal and when it becomes problematic
• Modern movement challenges facing children today
• Bone stress injuries and pars fractures in young athletes
• How growth spurts influence injury risk
• Supporting children with neuromuscular conditions including cerebral palsy
• Practical advice for parents when a child develops pain or a limp

👨‍👩‍👧 Who This Episode Is For

• Parents concerned about pain, injuries or limping in their child
• Coaches and teachers working with young athletes
• Clinicians treating paediatric or adolescent musculoskeletal injuries
• Anyone interested in healthy growth, movement and resilience in children
• Families navigating diagnoses such as DDH, hypermobility or growth-related injuries

🎙️ Powered by Mayfair Health

At Mayfair Health, we specialise in recovery, performance and proactive wellness. If you’re navigating ongoing symptoms, rehabilitating from injury, or looking to optimise your long-term health, our multidisciplinary team is here to help.

🔗 Website: https://www.mayfairhealth.co.uk
📩 Contact: info@mayfairhealth.co.uk
📞 Phone: 020 3985 1500
📱Instagram: @mayfairhealth

SPEAKER_04

Welcome. I'm super excited today for our podcast, Move Well, Live Well, Perform Well. And today we have an amazing guest on, Dr. Claudia Maison. Now, Claudia is going to help us discuss about pediatric orthopedics and about all those injuries that we see with young children, be it Oskkood's ladders, be it severs, heel pain, knee pain, development type issues, and to just discuss an issue that I tend to see is that are we seeing more kids who aren't as strong as what they used to be? Are we seeing more hypermobile children that are lacking the physical resilience that they used to? Um, so I'm super excited to have Claudia here today.

SPEAKER_00

Thank you very much for having me. No problem.

SPEAKER_04

So Claudia is a pediatric orthopedic surgeon in London. She works at Bart's Health and also at the OS Clinic. She specializes in developmental dysplasia of the hip, DDH, and has extensive experience managing the full spectrum of pediatric orthopedic problems from everyday injuries and sports-related issues to complex trauma and neuromuscular conditions, including cerebral palsy. So Claudia brings a rare combination of deep specialist expertise and broad clinical experience, helping families and clinicians understand what's normal in growing bodies, what needs urgent attention, and how to support children to move well, build strength, and stay injury resilient through sport and adolescence. That's quite an impressive brief.

SPEAKER_03

It sounds like very impressive, isn't it?

SPEAKER_04

So, Claudia, you don't mind if we just dive in. Kids are not the same as adults, are they? No. We need to treat them a little bit differently in the context of uh medicine. Is that right?

SPEAKER_00

Absolutely. So uh kids are very different from adults. So they're not just small adults. They have to be treated uh differently, they have a different physiology. Uh from a sort of orthopedic point of view, uh they are growing. So we have a growing skeleton, so the whole bone turnover is different, the bones behave differently. We have growth plates, which we obviously don't have in in adults, and the growth plates are sort of the weak link uh in the sort of kinetic chain. Um so during movement or any injury is is uh usually um affecting the growth areas and the bones before they affect the ligaments. Yeah, in an adult, you typically with an injury uh get a ligament injury first before the bones start to break, unless you have a direct impact, obviously. Uh in children it's the other way around. The weak spot is the growth plate, and you get growth plate injuries before you get ligament injuries.

SPEAKER_04

And is that because tendons tend to attach to the bone, or they do attach to the bone, um, and we and we have multiple sort of growth plates around the body. Is that because these bones are just that little bit softer in in in kids?

SPEAKER_00

Yes, definitely. So um the the bones in adults were a bit more like hardwood, is maybe the best way to explain it, whereas in children they're more like greenwood. Yeah. So uh they're not as brittle. Uh so if they break, they don't shatter in the way that adult bones do. Okay. But uh because they're softer, they're more susceptible to sort of micro injuries. Yes. Uh and repeat micro injuries might then uh lead to fractures. Okay. Uh but it's it's not just that, it's the the growth plate is cartilage rather than bone. So it is it's much weaker. Yeah, and um sort of you have different um um areas and uh layers of this growth plate, and very typically uh fractures occur in in the weakest part of these uh layers. Um so it's it's not just the tanin attachment that is more related to um traction uh site, so these type of uh injuries or overuse injuries, uh whereas the sordoher is fractures, so the growth plate uh fractures or uh involving the growth plate, uh simply uh with twisting injuries, for example, uh that the um the force uh is transferred uh via uh the parts of the joint uh towards the growth plate, and that's where where it breaks. Yeah, so the ligaments are stronger than the growth plate.

SPEAKER_04

So the salta harris, just to um for anyone who ha isn't aware of that, salta harris is a type of fracture classification, isn't it?

SPEAKER_00

Exactly. So you have different types depending on um the involvement of the growth plate. It can be right through the growth plate, or it can involve the growth plate and the the metaphysis or epiphysis of different parts on either side of the growth plate, yeah, uh, in addition.

SPEAKER_04

Okay, cool. And the metaphysis or epiphysis and my Aussie accent and your Austrian accent might might might might sound a little bit different for people, but um, can you explain what they are? They're the areas of the bone adjacent to the growth plates.

SPEAKER_00

Exactly. So uh the epiphysis, uh they are at the end of the bones. Yep. Uh you then have the growth plate and then the metaphysis, uh, which uh is on that other side of the growth plate, uh, towards the shaft. Yeah. So in the middle uh bone.

SPEAKER_04

Okay, cool. So what are the biggest misconceptions you found that parents have about pain and injury in children?

SPEAKER_00

Um I'd say one is uh they will grow out of it. Okay. Yeah. They might grow out of the way.

SPEAKER_04

We hear growing pains a lot. Yeah. And is that actually a thing?

SPEAKER_00

Yes, it is a thing. Yeah. Uh but you have to differentiate it from true pathology. Yeah. Uh so it's uh an exclusion diagnosis. Yeah. So it's you you have to look for other causes uh of pain. Uh growing pains are very specific. They're very typically uh both legs, yeah, usually located around the shin, the knee downwards, um, typically at night.

SPEAKER_04

I remember, I think I remember my mum and dad just classifying, oh Simon, just toughen up. You've just got growing pains, you know. And it was leg pain that I get, but probably early teenage years. Is that a common time frame or it doesn't matter?

SPEAKER_00

It's usually earlier, yeah. Okay. Uh so that the growing type pains are usually smaller children. Okay. Um typically they are absolutely fine during the day. Yeah. So there's no pain, there's no limp, uh no issues during the daytime. Uh they usually uh improve very quickly with a little bit of a massage at night time and some paracetamol, and they will truly grow out of those uh growing pains. Whereas uh if you have leg pain during the day, for example, or those teenagers, it's more likely to do with uh uh either overuse or with growth in a different way. Yeah, uh growing pain as such, you would uh just this is that benign uh uh nocturnal bone pain, right? Or limb pain. Whereas um the skeleton is truly growing. Exactly. It's sort of uh uh diffuse pain. Whereas uh Tinergias typically are the attachments of tendons on big bones, also associated with growth, but still different from growing pain, as we would call it.

SPEAKER_04

Okay. Okay, interesting. So okay, so the biggest misconceptions you feel are that okay, parents think they'll just grow out of it. Anything else?

SPEAKER_00

Um that it's just a sprain. Yeah. That's another one. Um is it rarely just a sprain? Well, that that's the difference, as we sort of already covered, isn't it? Sort of that very often in children it's actually not a sprain, it might be a gross plate injury.

SPEAKER_03

Yeah.

SPEAKER_00

Uh and they can very easily be mistaken for sprains because you don't necessarily see these injuries on x-rays. Yeah. Yeah. Uh they are often uh not as swollen, you know, there's not much hematoma there, not much bruising. Um, but the pain is uh exactly over the bone. Yeah, and you might do an x-ray, you might see something, but you might not uh it can be this sort of silent fracture when the the injury goes across the growth plate, which you can't see on x-rays.

SPEAKER_04

Yep. And is that where you're using other imaging like an MRI? Exactly.

SPEAKER_00

An MRI scan uh uh is the next option, but it will always depend on the age of the child, right? So if you have a very young child, you need an anesthetic for an MRI scan, in which case you will just treat it as as a fracture, take them back if they're fine after a couple of weeks, that was good, right? Uh but if if the pain continues, you keep uh immobilization or cast or something.

SPEAKER_04

Uh okay. Okay, so that growing pains do exist, but actually a lot of the time they're not gonna grow out of it, and that's a lot of the time it's not just a sprain. Anything else that's that's a big misconception, do you feel?

SPEAKER_00

Um there's sort of there's the two different um sort of aspects, right? So you have uh sometimes parents that are you know very much pushing for sport, right?

SPEAKER_04

Um maybe it's you mean like the tiger mum, if you like.

SPEAKER_00

Possibly, yeah.

SPEAKER_04

So or just the the parent who just wants their kid to succeed at sports. Absolutely.

SPEAKER_00

So there's a very clear goal with a specific sport, and maybe a misconception is um that early specialization, right? So it it's not like playing an instrument, right? Uh playing an instrument, you know, you need uh to start early, you know, you need certain um hours of of practice. Yeah, 10,000 hours, I think, are generally quoted. That's what has been start before the age of five, and if you start later, you're never going to quite catch up. So when they're looking at uh elite musicians, it's very opposite uh in sports, right?

SPEAKER_04

Yes. So okay, so you're suggesting that actually a broader development rather than early specialization, because I think this is the big thing that we see in very talented athletes when football academies or clubs are scouting them quite early, and they're like, drop your cricket, drop your rugby, drop your tennis. Okay, you've got to focus on football. Um, but actually, from a physical development point of view, um, that's actually about the worst thing that you can do. It might be useful from a skill point of view, but actually from a physical development point of view, you want a child to actually do multiple sports, play lateral sports, play with various directions for bone density, play, you know, do some strength work, hand eye coordination, all of that sort of thing.

SPEAKER_00

Yeah, yeah, absolutely. So you have to sort of build it's it's like a neuromuscular literacy, isn't it? That you build. Um so you need to build your strength symmetrically. Yeah, okay. So just um practicing one specific uh skill, yeah, um it is actually going to cause overuse problems, right? Okay. Um and the the studies that looked at uh elite athletes versus near elite athletes, right? Um the the practice hours in one specific sports uh under the age of 15, right, might be higher in the near athletes in comparison to the athletes, but then um to elite athletes, uh but then when it comes to the age 15 to 21, that's when the elite athletes will sort of catch up. Yes. So it's it's um sort of specialization after the age of 15 is issues.

SPEAKER_04

Is more appropriate, yeah. And you mentioned two par or two groups. So one is where parents might be pushing kids to specialise early. Yes.

SPEAKER_00

And then the other uh to um be too protective.

SPEAKER_04

Yeah.

SPEAKER_00

Yeah, uh, that's another thing. So the worry of the child injuring themselves, right? Uh you're trying to protect them.

SPEAKER_04

What do we call that? Is that the helicopter parent or something like that? Okay, so so someone not allowing their their child to I don't know, fall over, to learn how to protect themselves, as in run and take a kick. Exactly. Yeah. Okay, so those are the sort of camps. And and so anxiety and a parent's fear, worry can probably have quite a big impact on how a child recovers post-injury.

SPEAKER_00

Uh absolutely, with with everything, right? So the fear is transferred onto the child. Yeah, absolutely.

SPEAKER_04

Now that's maybe we'll just follow that pathway just for a second if you're okay with that. How does how do you manage those situations where you might identify that parents are really fearful that their child is going to have an injury or further damage themselves?

SPEAKER_00

Um, so you know again, so it will depend very much on on what the other activity levels at this point. Yeah. Uh but I generally um uh advise strength training, right? Um uh conditioning, yeah, appropriative training. Yeah, um, and also sort of directly address the maybe the fear uh that you you can't um sort of put them in cotton wool, right? So you can't wrap them and and and protect them.

SPEAKER_04

It's reassurance that they that they often need, isn't it?

SPEAKER_00

Yeah, absolutely. Um it's it's also the fear of um uh failing or making a mistake, right? Uh as a parent, um feeling guilty. Yeah. This is I think uh that's uh in my experience the the main issue.

SPEAKER_04

If a parent feels guilty, that their son has sprained an ankle or done something and they haven't been able to protect and sort of to just reassure them, look, you can't you can't.

SPEAKER_00

You can't protect them from everything, right? They need to learn, they need to also fall and things happen, and it's nobody's fault specifically, right?

SPEAKER_04

Yeah, yeah, yeah, yeah. Good point. How do you tackle the other parents? And is one easier than the other some of the time?

SPEAKER_00

Uh obviously it depends on the individual, but um uh it is hard, but also if the kids are very much into the sport, right? So um it's very hard to tell a child that is uh you know they're they're aiming for nationals or they have to have goals and they know if they are. I think we shared probably a couple of patients who are a little bit similar to that. Yes. Um but to actually understand that taking some time out is necessary to be able to succeed in the long term is very difficult for these these kids and the parents. Um there's a lot of ambition uh in there, and also I think the fear that they will then just, you know, lose uh lose their spot or lose their progression. Yeah. Exactly, especially in clubs.

SPEAKER_04

I don't know if you find this, but I've often found in the children that have treated where it feels like the parent is the real driver, they're actually the harder one. Whereas getting the child on side, if you can sit and explain with them, if they're the ones who are driving it, they seem to have a bigger picture vision a little bit more because they're the ones who've had the ambition to see the big picture, to drive it themselves. Um I don't know if you've found that, but often it's I've found it's harder to essentially say to the parents, look, you need to give them space. You need to give them some downtime. This injury is only going to get worse if you continue if you if you continue pushing or um not allowing some downtime.

SPEAKER_00

Um it it is definitely definitely hard. And the dynamics in in families are very difficult, you know, for for us as clinicians to always handle. Um and you also don't have the insight of what happens at home. You don't know the role of the the coach as well. So um the dynamics are very complex sometimes. Yeah. And you see just this sort of small you know uh time frame in clinic. You you coming in and saying, Yeah, you're making a snap judgment in that you have to reduce. Um, but I also think it's important to offer an alternative, yeah, for someone who's really into movement and sports to just say you're not allowed to do anything very difficult, right? Yeah, uh, but offer different types of sports.

SPEAKER_04

Because often it's a perfect time to work on you know their core strength or other forms of loading, or work on your cardio if you can't load, but you could might be able to do bike or swimming, or you know, it's always in athletes and and I think in kids, if the parents are willing, there's always other things I think generally they could be doing.

SPEAKER_00

Yeah, yeah. It's very rare that you sort of have a kidnapped one like that, like that, but it does happen.

SPEAKER_04

Maybe reds or red S, it might be a situation where you're like, okay, no, you need some rest. But yeah, red S for anyone who hasn't is is relative energy deficit syndrome or in sports.

SPEAKER_02

Yeah.

SPEAKER_04

Um we won't dive into that today though. But so the don't miss diagnosis. When a child presents with a limp or a hip or knee pain or refusal to weight bear, what are your diagnoses that you just we shouldn't miss?

SPEAKER_00

So there's several alarm bells uh going off. Um the first one is any septic joint, right? So uh the limp, painful limp um with uh systemic symptoms specifically, so uh fever, yeah, uh unable to move the joint, etc. So uh you have to always think about septic uh arthritis, uh septic joint.

SPEAKER_04

Why does that happen more commonly in children? Or does it happen more commonly in children?

SPEAKER_00

Again, depending on the age group. Yeah, so with septic arthritis, you're sort of you're talking uh different causes, uh uh different uh um uh also presentation, uh different age groups. So you have to sort of baby age, right? Uh so uh infancy. Uh when it comes into uh a later age group, so you know you you you coming near uh um uh sort of adult uh uh type of frequency. Um but it it is it has to be uh always a limitation of movement in a joint that is this is your first thing to rule out because it's uh it's dangerous, yeah, could potentially even be um uh life-threatening if you if you're missing septis. Um and how do you identify that?

SPEAKER_04

So fever?

SPEAKER_00

Yep, absolutely. So red-hot swollen uh joint, uh, no range of movement, very reduced range of movement. Uh you then do blood tests, right? And then you know you come to your diagnosis. Um differentials, uh less um you know severe, uh, but still very important and never uh to miss is Perth's disease and Sufi, yeah, slipped uh upper thermal epiphysis. So what's Perthes disease? So Perth's disease is uh essentially an avascular uh necrosis. So you have an interruption to the uh of the blood supply to the ball uh uh of the uh thigh bone, yeah, to the hip, um that is temporary, uh, but uh that specifically makes that uh ball.

SPEAKER_04

And we see we see that in all age groups at times.

SPEAKER_00

So is there is sort of uh between two and and ten is sort of the typical uh time, I'd say. And so why is that um so why um uh this happens? Nobody knows quite, yeah. There's sort of uh multifactorial uh uh uh reasons to it. Um but what what's sort of the important part is that um the pain is never really uh located in the hip joint, and that's why it very often can uh be misdiagnosed in the groin diagnosed. It's usually down the thigh and the knee. Yeah, so you sometimes see uh kids that have gone uh uh to see someone and there's uh x-rays of the knee, but nobody they actually examined or x-rayed the hip. And this is actually where the true problem lies. And Sufi is very similar to that, but in a different age group. And that's the slip capital uh femoral epiphysics. So you have essentially the ball slipping off the femoral neck in the area of the growth plate again. Um uh this is typically more in sort of teenage years, yeah, sort of that last growth spurt. Yeah. Uh so it's the the hormones, uh the change in hormones, it's all mechanical factors, uh, if the fice is a bit more vertical, so it's different, different from the And is that typically in uh teenagers who are more active. So um no, it's usually um it's it's higher weight, yeah. Uh it's as I say, sort of uh uh hormonal uh influences, um, and it's also mechanical uh issues with the direction of the growth plate. Yeah, so there's there's several inf uh um uh uh influences. Uh whereas the Perths, these are more the skinny, yeah, uh busy, yeah, very active kids.

SPEAKER_04

Yeah, okay. And what about I know you know my boys who are thirteen and fifteen and you know, we've had a synovitic hip for irritable hip. Like an irritable hip, which actually settles within a week or two weeks a lot of the time. We've had severs, we've had Oshkwood's ladders, we've had lots of lots of the spectrum, because they're very active and w what what's the synovitic hip, like the irritable hip? Is is that growth and movement? What is why does that happen?

SPEAKER_00

It's more like um um it's a reactive, yeah, yeah, uh arthritis. So you're saying you have a coat, a fluid, in the same way as um you know you have a runny nose, uh you get fluid building up in the in the joint. Okay. So that's the idea. So because there's fluid inside the joint uh that stretches the joint capsule, you have nerve endings in the joint capsule, and that's why it hurts.

SPEAKER_04

Yep, okay. And so okay, so the the Perthes and and slip capital ephemeral epiphysis, we've we've sort of discussed how do other growth plate injuries tend to occur? Like for me as as a sports physio, we see quite a lot of Oshkutz ladders, we see quite a lot of severs. And I used to think of severs as more of a traction apophysitis, but I think it's probably more the growth plate that is getting irritable because the we're using these new type of orthotics which offload the heel completely. Which seemed to be quite a game changer for things. But why are we seeing a lot more of the maybe we're not seeing a lot more, but but uh uh our cohort is we're seeing a lot more of them. So why are we seeing these in kids?

SPEAKER_00

So this is very much uh associated with growth. Yeah. Uh so you the bones are growing in length, yeah, the children are getting uh taller, um the muscles have to stretch out, muscles and tendons. Uh so you essentially have a scenario where uh the muscles and tendons are like a string on a bow. Yeah. Yeah. Uh so you get like a tug of wall in the areas of these growth plates where these uh tendons insert. Yeah, typically um muscles that crossing two joints. Yeah, so you have um uh your cordis attaching on your tibial tuberosity, which is also a growth plate, uh, area of growth. Uh in Sebus, you have your gastrocnemius uh yeah, uh attaching uh on the on the heel, again, area of growth. And what you get is it is a traction apophysitis, but you get these sort of inflammatory uh changes and because of this uh inflammation and increased blood flow in an area of inflammation, you can also get overgrowth. Yeah, so you can maybe get a lump that will persist uh later on, uh both on the heel or or uh on the shin on the dipotuberosity.

SPEAKER_04

Now are these injuries ones that generally people will grow out of?

SPEAKER_00

Yes, eventually. Yeah. Um so um I always warn patients, you know, it's obviously uh physiotherapy with a lot of stretching exercises, uh, but also coordination um and conditioning. Um and the the it will always bounce back. Yeah. Yeah. So it's it's sort of a coming and going. So the symptoms, you have the next growth spurts, the symptoms will come back unless you prophylactically continue with all the stretches, etc. Uh, but once the growth plates are closed, yeah, then they tend to not be able to get the big thing.

SPEAKER_04

Then the pain tends to settle, doesn't it? I mean, uh w we've had these new orthotic soul maids that I think we've discussed with you, and they really have r revolutionized how we've treated severs because we used to really just have to manage load a lot, but the way that the orthotic what it does, it it lifts up underneath the arch, and so you know the heel is not uh in contact, direct contact with so it's reducing that force. And it seems to allow people to just exercise through this, whereas Oshgood's ladders we are still managing a little bit more, you know. We're we're lengthening the quads, we're trying to free up the muscles, we're unloading, we're s having to somehow balance their their exercise through there. So we we we definitely need a a better solution for Oshgood's ladders, but I'm not sure what's out there.

SPEAKER_00

Yeah, I'm I'm not aware of anything either apart from just the exercise and the typical rice, right? Yeah.

SPEAKER_04

And look, generally those two anyway, there's various stages, but if pati if kids are able to play, if it's not that they're then generally sore for a day or two and then it settles a lot of the time, and then maybe three or four days later they can play again. Clearly, you would see some whereby you know they're almost on crutches. It's it's it's so painful. Yeah. Um, and and that's a cohort that you're not managing at all, they need sort of complete rest to settle.

SPEAKER_00

Yeah, absolutely. Um, so it's rare I have to say that they come so late, I may say, uh that it's so severe that they can't walk. Um but it does happen.

SPEAKER_04

Yeah. So the true red flags when someone's coming to you are if there's a you know redness and swelling around a particular area, an associated fever, any deformity, obviously.

SPEAKER_00

Yep.

SPEAKER_04

Anything else?

SPEAKER_00

Well, when you're thinking red flags, then you're thinking um infection and tumour, right? Um so um any uh loss of uh weight loss, uh um night sweats, yeah, pain at night and addressed uh more than uh uh with activity, these will also be your red flags. Yeah, yeah. Um kids are very pale, you know, very tired very quickly. So those systemic symptoms are sort of those red flags that make you think of something very severe. Uh but obviously deformity, uh you're thinking of any any uh injury, for example.

SPEAKER_04

Yeah, okay, cool. Okay, so you specialize in developmental dysplasia of the hip. Yes, DDH.

SPEAKER_00

Yeah, one of my favorites.

SPEAKER_04

Okay, cool. Can you explain what that is?

SPEAKER_00

Uh it's essentially a spectrum of pathology. Um so um d developmental dysplasia suggests it's a dysplastic acetabulum, right? Uh but the spectrum goes from what's dysplastic. Dysplastic is shallow, yeah. Uh so the socket is uh too shallow for the ball to sit in, uh uh, is best to explain. Uh but the spectrum goes from uh mild dysplasia, for example, which might not clinically be apparent until later in life.

SPEAKER_04

And we we see a lot of those in in in in adults.

SPEAKER_00

Yes, exactly. So they will only be symptomatic at a later stage uh because of uh the biomechanics and the uneven load uh on the cartilage, you get wear and tear earlier. Um and then you have the other end of the spectrum, which is a fully dislocated hip at birth, essentially.

SPEAKER_04

Yeah, okay. And so these are detected, they should be detected very, very early.

SPEAKER_00

Yes, ideally. Yeah. Um so the as we're talking about the spectrum, you can imagine you might be able to detect a dislocated hip with clinical examination. Uh so we have a pre uh screening program. Um there's different types of screening program. In the UK, we have a selective screening program or risk factor screening, which means uh every baby will have a clinical examination at birth, uh, and only babies that have either a risk factor, which is first degree family history or bridge presentation beyond 36 weeks, uh, or those babies that have an abnormal clinical examination, they will go for an ultrasound scan. In other countries, every baby might get an ultrasound scan, so you can't overlook these mild dysplasures, yeah, or any displasure. Whereas with clinical examination, you wouldn't be able to pick those up. So when we're looking at uh late presentations, it means those kids that then come with a dislocated hip later on, yeah, at uh at a much later age, when they start to walk, for example, delayed walking, they might walk with a waddling gaze, yeah. Um, exercise rotated uh leg length difference, etc. Yep, we can see that um the majority actually of those kids uh didn't have a risk factor. Yeah, that means they they weren't picked up by clinical examination, which is not a failure. We know from literature that about 50 percent uh cannot be packed picked up with clinical examination because they might still be clinically silent at this stage. Yeah, they are maybe not dislocated quite yet, or it's bilateral, more difficult to uh is there a question when okay, the clinical examination is deficient?

SPEAKER_04

But you're risk assessing based on a family history one other breach.

SPEAKER_00

Um that's sort of the mechanical factors. Uh but you have other risk factors, yeah, that are sort of uh packaging disorders, yeah. So if there's not enough space in the womb, so firstborn female, high birth weight, torticolis, uh food deformities, they're also associated with high risk of TDH.

SPEAKER_04

Okay, interesting. And so from a clinical examination, you are assessing range of motion motion within the hip.

SPEAKER_00

Exactly. So in the babies you have uh specific signs. Yeah. Uh so you have the balo otolani sign, which essentially where you're checking stability uh of the hip joint, as you can feel for uh the femoral heads, yeah, you you you're applying pressure, and you can feel if there's some telescoping, if there's movement of that, if that uh femoral head moves out of the uh joint or out of the socket. Uh the Ottolani sign, Ottolani click clunk, yeah, uh is something most people might have heard of. Uh it's actually the opposite where you have a hip that is dislocated and you're able to reduce the colour. Relocated almost, yeah. Yeah, so rather than a sort of a noise, yeah, rather than a click, it's actually a feeling. Yeah, you can almost see that it's gonna back into the joint, you're relocating um that hip joint. Galati sign is another sign where you're checking for leg length, yeah. And babies is very difficult because they have a little wiggle.

SPEAKER_04

The legs look different lengths, so it's uh where you're bending the hip and because they're not weight bearing early on, you you you could easily, more easily miss some of these more subtle presentations.

SPEAKER_00

Absolutely. Abduction is another one, so range of movement. Uh if that is reduced, uh then you certainly need uh an ultrasound scan to confirm.

SPEAKER_04

And so you so you you might do an ultrasound if you suspect and you identify something clinically. And so that's just looking at um okay, whether the and you're able to size.

SPEAKER_00

Yeah, absolutely. So uh there's different ultrasound uh techniques. So um the uh technique most commonly used, the graph method, um uh which we also teach. Yeah, that's my uh my favorite subject. And is that the standard diagnostic ultrasound with it? It's a linear probe, it's very important for musculoskeletal ultrasound. Uh linear probes are uh uh used.

SPEAKER_04

I mean that's what we use, but I definitely don't do any of this on on infants, that's for sure.

SPEAKER_00

Fair enough. But um yeah, it's very standardized. You're actually having a standard plane. Uh you go right through the middle of the acetabulum. Yeah, you have uh certain landmarks that have to be present to make sure that it doesn't matter who uh does the ultrasound, yeah, or who looks at it, everybody comes to the same conclusion, and you can measure, you can quantify uh the acetabular coverage, yeah. Um and the development of the acetabulum.

SPEAKER_04

Yep, okay, fascinating. And so if you s identify this, what does management look like?

SPEAKER_00

So depending on uh age and severity, yeah, uh very much age-dependent. So uh first line of treatment under the age of six months will be a public harness. Yeah, so a harness, a brace uh that just keeps that hip uh stable in stable condition and can even reduce it if the public um uh is used.

SPEAKER_04

Um six months is a long time.

SPEAKER_00

So under the age of six months. Sorry, under the age of six months. The length of harness is usually somewhere between six and twelve weeks, depending again on age and severity. The smaller the kids, the more remodeling, the faster the pathology will resolve. Yeah um so sort of the cutoff is a little bit three months, yeah. Um so you have a remodeling curve in those uh hips. So uh remodeling means that how quickly um they can reshape. Reshapes, absolutely. So uh under the age of six weeks, you have a very steep uh remodeling curve. Yeah, so there's a lot of you know uh bone formation and um uh transfer going on. Yes.

SPEAKER_04

If you and are there's specific excuse my ignorance because I haven't worked in this field, but you uh that pelvic harnesses, do they do they really approximate the ball into the socket? So you're getting some type of input into the tissue?

SPEAKER_00

Yeah, exactly. So it's it's always action, counteraction, right? Yeah. So what the harness does, it it brings the hip back into that fetal position essentially. Yeah, so it's flexion uh to about 100-110 degrees and abduction. You want to be in a safe zone, you don't want too much abduction, about 45 degrees abduction.

SPEAKER_04

Yeah, you don't want to be doing what I'm doing and crossing your legs like that. Yeah.

SPEAKER_00

But it's essentially what it does, it sort of brings the forces down deep into the socket.

SPEAKER_04

And that's why you're getting the remodeling. Exactly. Well then, because there's exactly that.

SPEAKER_00

There's an opposed hand that actually deepens, yeah. So the the acetabulum can then develop on top of that ball. Yeah. Yeah. Okay. Whereas if the other way around, if you have a hip that pushes constantly up on the acetabulum, then it will get shallower and shallower and eventually dislocated.

SPEAKER_04

Yes. And how often are you needing to progress to surgical input in any of these particular patients?

SPEAKER_00

Um depends on when we catch them. Yeah I'd say. So um if you uh if you diagnose and treat early before the age of three months, yeah, let's put it this way. Let's put it six weeks, right? Under the age of six weeks, um it's it's 97% success rate with the mandacarness, right? Yeah. Coming beyond four months. Which is very good. Which is very good. Yeah. Uh if you're coming beyond four months, then the success rate goes down to about 37%. Wow. Yeah. So um that remodeling curve eventually plateaus, yeah, uh, but also the the disease progresses. Yeah. So if the hip is constantly pushing, as just demonstrated, against that socket and it will eventually highly dislocate. Yeah, the longer it's been out, the more likely you have um uh other tissues in the way and and that uh prevent uh reduction, but also the socket remodels in an incorrect way, right? So the socket then uh uh displaces to below that femol head, yeah, which is then in itself uh uh you know barrier to reduction.

SPEAKER_04

I imagine in this country we're quite lucky and fortunate in that we have relatively good screening programs compared to some other countries.

SPEAKER_00

Um I'd say. So um I think um so we looked into this a lot, is is clinical examination, yeah, um, is is not always done by an expert. Yeah, but very often So a midwives doing their uh yes, so it's it's an IP practitioners, but it can also be junior doctors, yeah. So it it varies uh hugely uh across the country. Uh but then we already said that clinical examination is actually not that useful. It might pick up those uh that are very obviously dislocated, but definitely doesn't pick up any any uh dysplastic hip, right? Um but also with screening, so um sort of one of the things that I'm sort of um yeah fighting a little bit for T3, that's why I'm also um involved in education, yeah, in in organizing courses, uh, is standard of ultrasound. Yeah, so um because it's a uh dynamic investigation, right? Uh you it's it's user dependent. Yes. Yeah, so you want to minimize this uh user dependency and standardize it as as much as possible. Um and um getting more quality control in uh would be my wish, I think.

SPEAKER_04

Okay.

SPEAKER_00

Yeah.

SPEAKER_04

Okay, so how many do we miss? How many do we do not get picked up within that first four-month period and need to go on to a higher level of intervention?

SPEAKER_00

So um the so the way that you're trying to um work out how many late presentations you have is a tricky one, right? Because you know you don't know that you've missed them. Yeah, yeah, yeah. Uh so they might be able to do that. But the late presentation. So the latent. Yeah. Yeah. So what you measure it by is the um operation rate beyond the age of five. Yeah.

SPEAKER_04

And that's when you need to wait till uh no, no, no.

SPEAKER_00

Uh this is just a sort of indicator of whether uh the diagnosis was made made very late, right? Because you also have those hips that you catch but then you treat, but the public harness treatment might fail, and then they go on to have surgery, right? So that's why there's sort of uh certain criteria that you use um uh for uh you know what you consider late or what is likely due to late presentation. That's something you can measure uh in a population. Um so that's in the UK somewhere around 1.6% per thousand. Okay. Um when you're coming to countries that have uh universal screening, you're coming down to 0.04%. Oh wow, so quite a difference.

SPEAKER_04

Yeah, okay. Okay, fascinating. And so how many of the how many children might you have to operate on for DDH per year, for example?

SPEAKER_00

Yeah. Far too many, I'd say still. Um so we looked at at our numbers roughly, yeah, um, and uh keeping in mind the more you operate, the more you you have to consider your screening system, right? Yep. So um we've come when we looked at it uh a few years ago, we had about maybe 20 per year uh that we had to operate on, yeah, that uh required open surgery uh that has come down, which is good. Yeah, uh so with lots of uh uh teaching, yeah, and uh getting more involved in the screening, uh teaching also uh on the uh neonatal wood, midwaves, etc. Uh, but also a high quality ultrasound uh uh screening uh within uh the trust uh is something that has definitely brought the uh the late presentations down.

SPEAKER_04

So the screening and the education aspect is making a big difference.

SPEAKER_00

Also um empowering parents, right, to know that one of your children had DDH. Yes. You definitely need an outrasound together. Yes, get that screened.

SPEAKER_04

Yeah, okay. Fascinating. So the modern child. And underdeveloped from a movement pattern perspective that can't do a basic squat, that can't stand on one leg very well, that just don't have the inherent levels of strength and stability that we need for not only daily function, but to be highly functioning kids to run around and play a bit of sport. Is that do you see a similar pattern?

SPEAKER_00

Um yes, definitely. Yeah, so it's it's some people call it a deconditioning crisis, isn't it? Um where you certainly have uh uh undermuscled uh uh children, uh which you know is it's like the muscles are like the motor, right? Yeah, of your you know car. Um so if you have a uh car that is massively underpowered, are you more likely to you know just not reach uh uh uh the goal or not go up the hill or uh or whatever you're trying to do. Um so um under muscled uh children are more likely to have these uh growth-related injuries, right? Fraction apophysitis uh or uh stress fractures. Um you have the problem that um um there is some sort of dynamic malalignment there, yeah. Yes. Um what I find, what you find, but very often, especially around the hips, right? Hippopductus, yeah, often very, very weak. Yeah, very, very weak. And they often are actually quite sporty kids, right? They're often so there's also this misconception my child does lots of sports, right? Yeah, and they're actually quite strong, yeah, but but they're still sort of weak in certain areas uh exactly. So core specifically, uh so even very very masculine, and that's again where the specialization comes into it, isn't it? Um so weak core, yeah, weak central core, uh we have very poor posture, uh hyperladosis, yeah, uh the cantor plank, yeah, for example. Yeah, uh, or when you ask them to lift the arms forward within seconds, they start to go into this sort of uh very arched back, uh tummy, pot tummy uh uh coming out. Um also when you're letting them uh stand on one leg, yeah, pale with drops on the other side, trend book sign, uh or as you mentioned, sort of doing a single-leg squat or jump, they go into that vulgus posture.

SPEAKER_04

Uh and flat feet, uh you know, that whole miserable malalignment type sort of syndrome, I think maybe gets set up in childhood a lot of the time. Um because no one sort of pointed out that they seem to run around okay, but actually they're not effective in their movement patterns.

SPEAKER_00

Yes. So flat foot is an interesting one, right? Because you have sort of this physiological, um, you know, just uh flexible flat feet that are in itself not a problem. So what is also sort of maybe a sign for this weakness, yeah, the conditioning is this sort of um this slapping type of gait, right? Sort of this very early fatigue and um yeah, the pre-conditioning of those muscles before the foot actually lands on the floor, right? Um isn't happening. So it's sort of this uh cushioning isn't there, and that's when you get this sort of flat-footed slapping type of landing in a good thing.

SPEAKER_04

So almost like a lazy, uh lazy sort of walking pattern, yeah. And so why are we seeing that? Because you know, we see a uh like you pointed out, we see a lot of kids who do play a fair bit of sport, but actually they don't do any strength work.

SPEAKER_01

Yeah.

SPEAKER_04

So, you know, the ones who are generally in academies or or are doing very well in their sport, they will have done some s movement pattern work and strength work. But the ones who might do a bit of sport, but they tend not to do the same strength type stuff. I mean, I remember when I was at school, part of PE was right, learn how to climb that rope. Learn how to do some push ups.

SPEAKER_01

Yeah.

SPEAKER_04

That's squat. You've got to hold that wall squat. And they do proper just strength training, but with body weight. And I I think you know, I've got kids who are boys who are thirteen and fifteen, and they don't Seem to do as much of that within schools these days. And is that a failing of the curriculum? Is it a failing of our modern life in that we're on iPads and playing games a lot more?

SPEAKER_00

I think certainly it's a more sedentary lifestyle, right? Um maybe the protection comes into this as well, right? Because we used to also climb trees. Yeah, yeah. Yeah, completely. Hang off. I had this big tree out the front that was about 30 meters.

SPEAKER_04

And I look back and go, would I have let would I let my kids do that now?

SPEAKER_00

But also sort of think back, right? So I think sports was always a bit scary, right? The sports teachers, and it was sort of maybe sort of bordering on you know um cruelty.

SPEAKER_04

Yes, I mean I can remember a few. I'll I'll they'll remain nameless, but I can remember a few. They were tough individuals and scary.

SPEAKER_00

Yes, exactly. Yeah, but um, and I think it's something it's probably you can't you can't do that anymore, right? Yeah, like kids climb up the ramp. Yeah, that's true. That's very true, and actually in a woke society. Um it would have to probably be more in a guided way rather than how we experienced it, isn't it? Um uh specifically with an emphasis on on strength training. And I suppose, you know, the certain day from from um my daughter, yeah, um I I know they are she's 17 now. Yeah. Um I think the the the teachers are really trying their best, right? Yeah, but um there's lots of excuses. So the overprotection comes into it, right? Uh kids taken out of of of swimming because they're my deal. You know, there's there's there's just uh a lot of protection which is um counterproductive though, yeah. Uh even if you're just academic, it's still important, right? Mensana incorporates an alright to be strong.

SPEAKER_04

Uh you're of the and and I might be stereotyping here, but Austrians, Germans, they're pretty hardy characters generally, and they're like, just go and do it. Just get out there. Just go and do it.

SPEAKER_00

Is that your you know, I wasn't, you know, I I was more one of those, you know, sitting uh at home reading a book type of kids, right? So I I was very much sort of into you know this. You're an intellectual. Yeah, you could say so. Yeah. Um saying it in a nice way. So I understand, right, that you know, you might this might not be your favorite thing, but that there is something out for out there for everyone. Completely. Finding something that is fun. And it doesn't have to be a team sport, it doesn't, you know, it doesn't have to be anything where you have to succeed in. Just finding something, some movement.

SPEAKER_04

Because if you're not moving, you're not achieving your development milestones essentially, and you're not gonna build like we know because we run a bone health clinic, and I strongly believe that osteoporosis is a childhood injury or a childhood disease. Because if you're not exercising a lot and doing a lot of lateral type sports like basketball or football or rugby or tennis, in during that teenage period, you're not gonna achieve your peak bone density. And if you're not encouraging kids to move, they're not gonna build one good movement patterns, but also the basic strength.

SPEAKER_00

Yes, yeah, you need the loading of those bones.

SPEAKER_04

All of that.

SPEAKER_00

I think it's sort of multifactorial as well, right? It's less outdoor activities, right? Thinking of your vitamin D and uh bone, yeah, you know, because that's critical for for for bone health.

SPEAKER_04

Yeah, it's also musculoskeletal health.

SPEAKER_00

Yeah, yeah.

SPEAKER_04

So maybe this is a you know, I've got a qu uh question down here saying, Do kids need structured strength training now? Um, my view as uh as a physio is that actually yes they do. Like uh my kids, you know, my youngest has just recovered after a re a recfem traction apophysitis. So he's just returning because he good goalkeeper, lots of big kicking, he's had severs before, not that long ago, and you know, we're we've he's got a strength program. Yeah my eldest is growing, and I tell patients, well, you your bones probably are 12 months ahead of your whole muscle system. I don't know if that's right, but your your your muscles and tendons tend to lag in that development, don't they?

SPEAKER_00

Absolutely. So especially in that sort of uh peak peak height velocity, right? When you have these really uh massive growth spurts and these sort of teenage, um your bones are suddenly, you know, you're shooting up in in in height and and and length, and the muscles are just staying behind, right? They have to stretch out. But it's not just um bones versus muscles, it's also the brain has to be able to get to the case.

SPEAKER_04

Yeah, it's the it's the neuro neuromuscular development.

SPEAKER_00

Yeah, so it's it's your your brain has to uh adapt to the new lever arms, yeah. The muscles have to stretch out. Uh so you you have to give the body and the brain. Yeah, absolutely, yeah. Uh to catch up, yeah, and adapt to to this new the new system.

SPEAKER_04

So so so the take-home from this is that kids should be doing more specific movement work and strength work.

SPEAKER_00

Um so I think uh strength work in general uh is important absolutely. Uh and as we're sort of more lacking those activities, yeah, that sort of traditionally maybe children were able to do outside climbing and and all those sort of things. Um having a more structured strength training built into a curriculum curriculum, certainly for uh the athletes, yeah. Yeah, I think this it's not enough. Yeah. Um, so a lot of it is still uh skill training and general, you know, uh load and and and practice. Um there is of course that strength and conditioning in there as well, yeah, but I don't think it's enough. And it's uh it's very often optional. Yes. Yeah, rather than mandatory.

SPEAKER_04

So we should be advocating more specific strength work for children. Um but uh on that note, and and I know there's and I'd love to get your opinion on this, that there's parents often worry about strength work and using load, external load with children and that might gram damage growth plates. And my philosophy, um, and the research and evidence that I've read, and we would always look at we tend to really get people doing a lot of bodyweight work. We optimize movement patterns, and then from 13, 14, we're very happy to start adding external load only when they're good movers.

SPEAKER_00

Yes. Um, yes, so I would I would um generally agree with that, but it will also depend where they are in their gross spat, right? Because your chronological age and uh bone age.

SPEAKER_04

So if their bony age is appears similar to their chronological age, you would be okay with that.

SPEAKER_00

Yes. Um so you you often have kids that can sometimes be two years behind, right? So when you typically in sports, you know, you have them lined up, uh the little ones eventually catch up, yeah. Uh and and um they're all closer together in terms of their uh end height, but uh you have uh some kids that are behind in their in their bone color.

SPEAKER_04

And so the ones that you would worry about doing external sort of weight programs might be the ones who are lagging behind in their bone development. Yeah. Yep. Um yeah, okay, cool. Because, you know, my both my children or boys now are thankfully at schools where they they have SNC, they have sort of performance training, and they they're they're now, you know, starting to push some interesting load, and we're always very hot on them with form, but actually it's helping them uh uh to develop. That they're starting to get stronger, they can now do push-ups, they can now do a uh a chin up, they can squat better. Their single leg movement pattern is is is much better.

SPEAKER_00

Yeah, I agree, as long as it's not done too early and it's guided, isn't it?

SPEAKER_04

Yes, yeah, and it does need to be guided and and and structured. Um touching on the weakness or under muscled, I wonder whether we're seeing more hypermobile children. Now, is that just our cohort that we're seeing? I don't know any stats on this, but do hypermobile children who are under muscled do they tend to run into a bit more trouble?

SPEAKER_00

I think that's exactly the point, right? I don't think we have more hypermobility. Um we may be diagnosing it more often for exactly those reasons, right? So we're talking about uh any kid, right, uh that that is under muscles, yes, uh uh uh will have problems with the joints. Yeah. If you're then hypermobile, uh that means that there's the joints are loose, right? So loose mechanics in a way.

SPEAKER_04

So there's a slight different way of testing children with hypermobility. And so there's a baiton scale that's commonly used. I think adults have to score five and above, and children need to score six and above.

SPEAKER_00

To be called hypermobile.

SPEAKER_04

To be called hypermobile. However, a lot of people would argue, well, aren't all children sort of hypermobile to some extent in you know, have bendier joints?

SPEAKER_00

In general, yes. Uh uh in comparison uh to adults for sure. Yeah, we all get, you know, our joints get stiffer the older we get. Um but um you know, with those scoring, you know, because there it's a difference between sort of you know being a little bit lax, right? And and the true hypermobility, right? So you're talking about uh a knee or an elbow being able to bend it back more than 10 degrees, right? So it's not real hyperextension, which I can't do on my elbow. Exactly, or the the thumb touching, you know. I'm a bit hypermobile, but I can't touch uh the my arm. Uh so you know the score is you know quite quite solid in in that way. But um it doesn't it doesn't matter as long as you're strong enough and you don't have symptoms, right? Exactly. It can actually be an advantage for certain sports. Completely because you know, swimmers, yeah.

SPEAKER_04

Yeah, I mean we see you know being hypermobile actually there's there's a high percentage of athletes, elite athletes who are hypermobile. So it can be incredibly advantage uh advantageous, but the one thing when we identify and explain to some of our patients that they're hypermobile, I will always stress, you know, the only thing about this is that you need to remain strong.

SPEAKER_00

Yes.

SPEAKER_04

It's the best thing you can possibly do to help your body is just be strong. Would you agree?

SPEAKER_00

I fully agree. So you don't want to rest or protect. Um you actually need to make uh uh those kids stronger because the the muscles is like uh muscle armor, right? Yeah. Yeah, you essentially uh you have loose bolts, you can't tighten them because you can't make ligaments tighter. So you need um to train the structure that you can actually uh address uh to to take over and give the joint stability.

SPEAKER_04

Yep. Okay. So trauma and overuse injuries. We've touched a little bit on overuse injuries. Are you seeing a particular trend in some of the kids' sports injuries? I know we are with sort of a lot more pars injuries, which are sort of stress fractures of the parse portion of the uh of the vertebrae in the lumbar spine. Are you seeing more trauma, more of a particular type of sporting injury?

SPEAKER_00

Um so I think these sort of stress fractures um are exactly the results again of all those things, right? Single sport, yeah. Um not enough. Specialization too early. Yeah, so this sort of arching type of sports, cricket, um long jump, yeah, uh, gymnastics again, dancing. Uh this would be um the typical uh um um patients that come with these past uh injuries are uh stress fractures.

SPEAKER_04

Um are you seeing more of those, do you think? Um or are we getting better at identifying them?

SPEAKER_00

Probably well, I think it's usually those high-level athl athletes, right, that uh that get them. And I think it's um lack of rest, yeah. Um too unilateral type of exercise, too much repetition, too high volume. Yeah, you you already um touched on red S, yeah. Yep. So certainly not actually giving the body enough energy.

SPEAKER_04

Uh so red S is essentially an imbalance between your energy input and the energy they're expending. So most of the time it's undercalorieing and or underproteining someone.

SPEAKER_00

So you essentially don't have uh the body doesn't have enough energy to to to repair uh these little micro uh injuries. Um and you know, if if given uh the option, right, it will go survival over uh bone uh uh uh repair. Yeah. Um so I think it's it's it's a combination of of all those things. Uh whether we may be more likely to diagnose possibly because maybe more people are sensitive to better imaging, better more awareness, maybe what I you I we used to see more, you know, the the the end result, like sponulolystesis, right? After it's already fractured, uh then you get you know problems uh with where one of the vertebrae uh slips on the other and you get neurological symptoms, etc. That's something the spinal surgeons might see, right? But uh that they don't come across uh that often anymore, right? So you you're diagnosing early, I think, before you're getting to that stage happens.

SPEAKER_04

Yeah. Which is good because you know we need to minimize that. But it does seem that we're seeing, you know, a push in a lot of sports, particularly football, where it's almost year-round training and these athletes are perhaps not doing the enough strength work as well, with a lot of growth and they're just overloading, they're overstressing specific movement patterns, you know, whether not enough rest as well, right?

SPEAKER_00

Um because if sort of if your if your your load is is is um you know higher then then the ch the body doesn't have the chance to repair, right? Uh uh or adapt. That's when you get the stress fractures.

SPEAKER_04

Loads. You know, you jump up and down 20 times, you've loaded your bones. Your receptors actually have probably that's enough to sort of almost switch them off. And then they need four plus hours. This is adults, so kids are probably a little bit different, to um be able to tolerate bone loading again. You load them again too many times, then they're not allowed that sort of rest time for those cells to actually repair.

SPEAKER_00

Absolutely. So um, you know, you sort of that that age rule, yeah. You shouldn't uh uh practice or you shouldn't do uh more activity than uh age, yeah, in hours per week. 14-year-old shouldn't do more than 14 hours per week overall uh activity. Um so if you if you exceed that, you have a more than 70 percent.

SPEAKER_04

So you're telling me that I have permission to go and do 49 hours of exercise per week.

SPEAKER_03

Yeah, okay, great.

SPEAKER_04

Yeah, okay, cool. So that's a good sort of rule of thumb for for parents, and you know I sort of assumed that when we're younger that kids need to go around and do about an hour a day of just running around, though.

SPEAKER_00

Yes.

SPEAKER_04

But you're talking specialist higher level sports.

SPEAKER_00

Absolutely, yeah. So that's sort of 60-minute rule, as you're saying, yeah, an hour of uh heart rate elevating activity every day.

SPEAKER_04

Climbing the play frame, running around, climbing trees. Yeah, yeah.

SPEAKER_00

And three days a week, you would say it is sort of more sort of uh a body weight, load, uh, and and strengthening type of exercises like climbing and uh um PE, this this type of uh exercises.

SPEAKER_04

Okay, fascinating. So we're gonna touch on another one of your favorite areas, which is neuromuscular conditions, um including cerebral cerebral pausy. So what uh what should people understand about the orthopedic management in cerebral pausy?

SPEAKER_00

Um so the way I see management is you're accompanying the children throughout growth. Yeah, you you are dealing with the same issues, just more severe. Okay. It's it's you're ca you're essentially fighting against growth.

SPEAKER_03

Yeah.

SPEAKER_00

Um so we're talking about you know athletes and about kids that don't have the problem of uh um spastic muscles, yeah. So they are struggling, right, with growth uh of bones and the muscles having to catch up. So if your muscles are not loaded in a normal way, yeah, in a usual way, and if they are spastic to start with, so they're shorter from the beginning, they don't stretch out as well, that multiplies that problem. Yeah, but the types of problems are very similar, yeah. So you get contractures of those muscles that are crossing two joints with time. Um there's a bit of a quadriceps, and hamstring specifically, gastronomius, uh psoas as well, yeah. So all those muscles are uh affected the ductus as well. Yeah, um and and depending on your mobility level to start with, yeah. So again, seropaus is a spectrum, right? So uh depending on uh how much of the motocortex is involved or what parts of the brain uh are involved, you have different uh mobility, right? You you're classifying those into uh gross motor function levels one to five. Uh one being normal activity, uh normal movement, um uh independent uh ambulators, uh, to uh completely unable to move or even have head and echo control, for example. Uh so wheelchair bar on children. So you have a completely different um uh goal setting in terms of the treatment, uh, but also the the concerns you might have and what you have to monitor for. Uh in kids that are not walking, you're mainly worried about scoliosis and about hip dislocation, right? Whereas uh in those kids that are walking, you're more worried about uh walking pattern, yeah, energy consumption during date, um and and sort of being able to to walk and mobilize uh um as as um easily uh and and naturally as possible.

SPEAKER_04

So I'm sure it depends on the classification, but uh what are your main goals? Is it more about okay, trying to optimize function? Is it more reduction of pain? Is it more on maintaining as much mobility as possible?

SPEAKER_00

Um so as you said, it will depend on on uh the the function you start off with, right? So um for for you know kids that are not walking, it's it's pain management, but also postural management. So symmetry is key. Yeah, uh because it's important to have a good sitting posture, right? Um for the hips to to uh stay in joint, so prevent uh pain later on in life, prevent asymmetry, which will then cause scoliosis, right? So it's a sort of a knock on effect on different parts of the body. Um whereas uh children that um have dye bleacher, so there's uh legs involved but not upper limb and not uh not the trunk. Uh you might look at uh more functional goals, right? Or hemiplechia, where also uh one side of the body and one arm is uh involved. Um so your your your goals are very um depending on that very specific patient, and they vary hugely, yeah, because it's not just uh the goal in terms of what what is uh realistic to achieve, yeah. It also um involves motivation, right, for rehabilitation. Yeah.

SPEAKER_04

The parents need to be very motivated, motivated and also the and and the and the the kid, yeah.

SPEAKER_00

Uh treatment.

SPEAKER_04

So physio is we tend not to we don't specialize in this area, but physiotherapy's got to be incredibly important for this.

SPEAKER_00

Yeah, so that that's the baseline, right? So uh regular physiotherapy and postural management, right? So that might be splinting splinting. Exactly, stretches.

SPEAKER_04

Uh do you use Botox very often?

SPEAKER_00

Yeah, so I do use Botox. So Botox um is used for uh spasticity management, yeah, sort of tone control. Um in orthopedics, uh I use it to get overgrowth periods, right? So when I see a muscle is starting to get tight, right, and we can't catch up with all the stretches, then Botox can be an authority.

SPEAKER_04

Because their skeleton has grown and the muscles aren't going to stretch out sufficiently enough or quick enough.

SPEAKER_00

If you relax those muscles for a few months, that gives you a sort of a window of opportunity to get a muscle length by stretching, yeah. Casting is sort of different uh ways of getting uh catch for getting the muscle to catch up. Uh to try and delay any need for surgery for as long as possible. So you want to avoid um uh fixed contractures, yeah, deformities of joints, uh sort of uh uh the lever arm disease. Um and and if you operate Too early and you have a lot of growth still to go, you're very nicely having to repeat it. And each time um uh you lengthen tendons uh and muscles, you lose power permanently. Yeah, so weakness is the main enemy. Yeah, so the tightness is something I can treat. Yeah, weakness and selective muscle control and balance, we can't treat it.

SPEAKER_04

We can't treat, yeah. Yeah, that makes sense. So we're I'm mindful that we've we've had a great chat, super interesting, and hopefully um our listeners have found that yeah, lots of insights into uh various aspects of you know orthopedic management of children. But what are your practical take-home bits of advice for parents? Um is it that you know a limp, be it a small, or you should watch and observe, or what what are your simple simple bits of advice for parents?

SPEAKER_00

Um so with with with any aches or pains, yeah, it's just you know, has there been an obvious injury? Yeah um has it sort of sort of suddenly appeared? Is it one-sided, both uh legs involved? Uh is there limp during the day? Is there any any reduction in function? Yeah, it's a sort of maybe the red flags to to seek medical opinion. Uh if you know they've just fallen over and they're still able to weight bear, is sort of these four steps, right? Uh of continuous uh weight bearing without uh uh issues, um, then you can wait, yeah, 48 hours maximum, I'd say. Okay. Uh if it hasn't resolved, then definitely seek medical uh advice again. Look, is the joint swollen? You know, is there any limitation of movement? Go and see a doctor, right? So it's it it yeah.

SPEAKER_04

Who would you so you know if there's obvious swelling, if there's obvious been an obvious injury, okay. If it's not better within 48 hours, consult someone. Yes. Is that your GP first? Is that seeing someone like yourself? Is that seeing a physio who sees enough children to be able to recognize?

SPEAKER_00

Uh yeah, so I suppose you know if you have um a limp that is beyond 48, it's probably good to get an X-ray done. Um and to sort of that for step role, etc. So it's it's you know, whoever is able to, you know, request that x-ray, uh, do that assessment uh and make a diagnosis and act on it. Uh um that that doesn't matter who it is, right? Yep. Um as long as you you know find someone who can actually investigate and manage it.

SPEAKER_04

Yeah, okay, excellent. And how do we build resilient physical children? I mean, I know the answer to this based on what we've probably discussed, but how what in your view, what helps a child's long-term musculoskeletal development?

SPEAKER_00

Um so it's essentially summarizing, isn't it? That everything we we spoke about. I think it's um multi-sports up to the age of 15. Maybe that's sort of a a big message. Yeah. Um strength is not optional. Strength training is is is a requirement. Um listen to your body is another advice I'd give. Um so you know, your your alarm signs, pain is not don't ignore it. Yeah, uh, but because it, you know, if you if you do, you might uh encounter stress injury, stress fracture, and um respect that uh peak height velocity, yeah, that sort of uh uh time of massive growth.

SPEAKER_04

Um allow rest at the 11 to 13-ish for girls versus boys, yeah, versus boys a little bit. 12 to 15 or something like that.

SPEAKER_00

Yeah, so 11-13 girls, 12-15 boys is sort of usually, but you can actually, you know, if you have asked it can be different uh between children, measuring height, looking at you know, when are their trousers getting shorts, uh this sort of clumsiness, yeah, and they're starting to get really tired, it's usually a good sign.

SPEAKER_04

Yeah, yeah. And so respecting that and giving them a little bit of rest at times and you know, pulling them back from exercise during for a couple of weeks.

SPEAKER_00

Yeah. Um sometimes can help you. And rest. Yeah.

SPEAKER_04

Yep. Super interesting. And I mean, we haven't even we've you've touched, you've mentioned a couple of times scoliosis. We haven't even sort of dived into sort of scoliosis. Um, but so maybe we're gonna have to get you back on um for another sort of discussion about sort of different spinal scoliosis, all of those sort of postural things. But um, Cladia, that's been super fascinating and super interesting. And um I've loved having you here to thank you very much. Um have a chat. Thank you.