Sports-related injuries in young athletes are increasingly prevalent as participation in competitive sports programs becomes more popular. Roughly 7.9 million American high-school students participated in high-school sports in the 2016 to 2017 academic year, an increase of over 90 000 participants from the previous year.1 Including all pediatric athletes younger than 19 years old, the Center for Disease Control estimates 2.6 million children sustain a sports-related injury annually.2 Sprains, contusions, and fractures are the most common injury types, and injury location is often correlated with the sport.3 Younger athletes suffer more injuries to the upper extremities, and their injuries are often traumatic. Adolescents suffer more injuries to their lower extremities and are more likely to require surgery for their injuries.4 Adolescent female athletes are more likely to report overuse injuries while adolescent male athletes are more likely to report traumatic injuries.5,6 The overall incidence of pediatric patients requiring surgery for sports-related injuries has been reported in one study to be 7.1%,7 but athletes who sustain meniscal injuries require surgical intervention in 63.8% of cases.8 When compared with adults, adolescent athletes report higher pain levels, greater anxiety, and more frequent catastrophizing thoughts.9 However, achieving adequate pain control in children is important for early mobilization and prevention of behavior changes, unplanned hospital admissions, hyperalgesia, and fear of future medical personnel.10,11 Acute pain after both sports-related injuries and surgical correction of musculoskeletal injuries should be managed appropriately and effectively to avoid conversion into chronic pain and to avoid causing additional psychological burdens on pediatric athletes.
PubMed and the Cochrane Central Register of Controlled Trials were used to perform an extensive review of acute pain management options in pediatric and adolescent athletes presenting with acute sports-related musculoskeletal injuries or acute postoperative pain after sports-related surgeries. Four separate searches were conducted between January 2018 and March 2018 to evaluate acute pain management in children, postoperative pain management, complementary medical therapies, and indications for opioids. The first search used key words of “pediatric pain management of acute injuries,” “pediatric athlete sports pain,” “pediatric pain management topical,” and “pediatric orthopedic pain.” The second search investigated key words of “postoperative pain,” “pediatric orthopedic postoperative pain,” and “pediatric regional anesthesia.” The third search involved the key words “complementary medicine in pediatric acute pain” and “complementary alternative therapies postoperative pain.” The fourth search investigated “indications for the use of opioids in pediatric athletes.” Inclusion criteria included (1) meta-analyses and prospective studies evaluating (2) acute pain management in (3) pediatric patients with (4) sports-related or orthopedic injuries. Each citation was reviewed, and if it met inclusion criteria, the corresponding article's abstract was reviewed. If the abstract was considered relevant to the topic of our article, the article was read by the authors to make the final inclusion decision. Information involving year of publication, number of subjects, age of subjects, type of analgesic agents, and efficacy of analgesic agents were then recorded. Primary outcomes of interest were analgesic type, analgesic requirements, and pain scores. Secondary outcomes of interest were side effects from medications including nausea, vomiting, hemodynamic instability, respiratory depression, and analgesic duration.
Acute sports-related injuries may result in sprains, dislocations, fractures, or concussions.12 Children experience the most severe pain either at the time of injury or within the first 48 hours of sustaining the injury.13 Conservative management is often the first-line treatment for extremity sprains.14 Three studies (Table 1), published between 2006 and 2018, investigated conservative treatments using the acronyms RICE (rest, ice, compression, and elevation) or PRICE (protection, rest, ice, compression, and elevation). One study shows immobilization of acute orthopedic injuries reduces pain scores in children while application of ice to the injury may cause higher pain scores.15 A different study showed that RICE therapy produces no significant effect on pain relief in children with extremity fractures.13 Early mobilization produces similar pain scores compared with traditional PRICE management in children presenting with ankle sprains.14
Children with sports-related injuries often present first to primary care clinicians or emergency department physicians for acute pain management. Ten studies, published between 2007 and 2017, involving children who presented with acute orthopedic or musculoskeletal injuries were found to evaluate enteral analgesic medications including ibuprofen, naproxen, acetaminophen, codeine, oxycodone, and morphine (Table 2). Although the FDA and Health Canada issued a warning in 2017 against the use of codeine and tramadol for pain relief in children younger than 12-year-old citing serious risks of difficulty breathing and death,16 we included studies involving codeine and tramadol in this article for inclusiveness and comparison purposes. No statistical difference in pain relief exists between acetaminophen and naproxen in children who presented with soft-tissue injuries of the ankle.17 However, ibuprofen provided faster and greater pain relief than either acetaminophen or codeine in children with musculoskeletal injuries.18 Ibuprofen was even as effective as acetaminophen with codeine for children with extremity injuries in analgesic efficacy,19,20 more effective in its ability to improve motor function outcomes, and associated with fewer incidences of nausea and vomiting.19 The addition of codeine to ibuprofen did not improve pain relief for children with musculoskeletal injuries when compared with ibuprofen and placebo.21 Oxycodone did not show increased efficacy at reducing pain scores compared with ibuprofen, and even ibuprofen plus oxycodone showed no reduction in pain scores when compared with oxycodone alone or ibuprofen alone in children with orthopedic injuries.15 Children with suspected fractures found radiography of the injury to be the most painful part of the initial examination and found analgesic relief from oxycodone superior to codeine.22 Oral morphine with sublingual midazolam provided no significant change in pain scores when compared with patients who received oral morphine and sublingual placebo, but the combination did lead to more drowsiness.23 Pain scores after ibuprofen administration for extremity fractures showed no significant difference in pain scores after oral morphine administration, but children who received morphine reported more drowsiness and nausea.24 For children with musculoskeletal injuries who received morphine and ibuprofen, no significant reduction in pain scores were noted when compared with those who received ibuprofen and placebo or morphine and placebo.25 No clinical trials were found to evaluate analgesic efficacy of enteral steroids, clonidine, gabapentin, or muscle relaxants in pediatric patients with acute sports-related injuries. Based on these studies, enteral opioids are not superior to ibuprofen in pain relief efficacy or side-effect profile and therefore have no place in the management of acute musculoskeletal injuries. Some clinicians are hesitant to prescribe ibuprofen in acute orthopedic injuries, given the fear of adverse effects on bone healing.26 However, a recent retrospective study in children with extremity fractures showed no association between ibuprofen and fracture nonunion, delayed union or redisplacement.27 We are not aware of any prospective randomized controlled trials that have examined the effect of ibuprofen on bone healing in children.
Fractures account for roughly 29% of sports-related injuries that present to the emergency department,28 and displaced fractures are associated with higher pain scores compared with nondisplaced fractures.15 Thus, nonenteral analgesic medications are sometimes required for adequate pain control. Eight studies, published between 2007 and 2017, were found to evaluate nonenteral medication administration for acute extremity injuries in children (Table 3). Intranasal fentanyl reduced pain scores in children with acute fractures within 10 minutes of administration.29 Two studies found that intranasal fentanyl was as effective as intravenous morphine for pain reduction and was associated with no increase in adverse effects.30,31 A similar study found that nebulized fentanyl was also as effective as intravenous morphine at reducing pain scores in children with acute fractures.32 Oral transmucosal fentanyl provided significantly superior analgesia compared with intravenous morphine for children with suspected fractures after 30 minutes of administration.33 Intranasal ketamine had similar analgesic effects as intranasal fentanyl but is associated with more dizziness.34,35 Sublingual ketorolac provided no more significant reduction in pain scores compared with sublingual tramadol.36 No clinical trials were found to evaluate topical lidocaine, topical NSAIDs, topical capsaicin, or transdermal opioids for pediatric athletes or acute sports-related injuries. Intravenous analgesic medications and regional anesthesia procedures, while nonenteral, are discussed below under the postoperative pain management section.
POSTOPERATIVE ACUTE PAIN MANAGEMENT
Adequate postoperative pain control in children is challenging especially since children present in varying stages of emotional and cognitive development. There are differences in perioperative anxiety and self-reported pain between adolescent females and males, although gender does not influence postoperative opioid use.37 It has also been shown that younger children are less likely to receive analgesic medications when compared with older children presenting with the same injury.38 Six studies were found to evaluate nonopioid analgesic medications for postsurgical pediatric patients (Table 4). Oral morphine did not demonstrate superior analgesic efficacy compared with ibuprofen in children after outpatient orthopedic surgery and was associated with more drowsiness and nausea.39 Opioid requirements and pain scores were reduced postoperatively if patients had received both acetaminophen and ketoprofen perioperatively as opposed to either one alone.40 Intravenous ketorolac administration can lead to shorter hospital stay, fewer doses of morphine postoperatively, and fewer gastrointestinal side effects when compared with intravenous morphine.41 The addition of ketorolac to morphine patient-controlled analgesia (PCA) reduced morphine consumption and incidence of urinary retention.42 As with ibuprofen, multiple studies have shown that perioperative ketorolac use does not increase bleeding complications, nonunion or delayed union rates in children with fractures.41,43–45 In a study involving adolescent and adult patients with extremity fractures, intravenous lidocaine provided more pain relief at 15 and 30 minutes after administration than intravenous morphine.46 Although not for acute orthopedic injuries, oral gabapentin reduces the amount of morphine consumption during the first 2 postoperative days after pediatric spinal fusion surgeries.47 The use of other nonopioid analgesic medications have been used successfully in postoperative children including diazepam, dexamethasone, ketamine, clonidine, dexmedetomidine, and magnesium; however, none of the studies involved acute sports-related injuries in pediatric patients and therefore did not meet inclusion criteria.
Regional Anesthesia Procedures
Multiple studies have shown that regional anesthesia could successfully be used to treat acute pain, reduce opioid consumption, and prevent unanticipated hospital admissions in pediatric patients with acute extremity injuries.48,49 Eighteen studies investigate the analgesic benefits of regional anesthesia procedures in pediatric patients (Table 5). Individual forearm nerve blocks of the ulnar, median, and radial nerves or bier blocks with low-dose lidocaine can be performed in the emergency department to decrease pain, reduce fractures, and minimize opioid use.50–52 Intra-articular injection of bupivacaine reduces opioid consumption postoperatively after closed reduction and percutaneous pinning of supracondylar humeral fractures.53 Lower-extremity nerve blocks include femoral nerve blocks, adductor canal nerve blocks, fascia iliaca nerve blocks, sciatic nerve blocks, and epidurals. Adductor canal blocks with dexmedetomidine provide low postoperative pain levels in the saphenous nerve distribution without reducing quadriceps muscle strength.54 For children with femur fractures, the fascia iliaca block provides more effective and longer pain relief than intravenous morphine and femoral nerve blocks combined with lateral femoral cutaneous nerve blocks showed no difference in postoperative opioid requirements and time to first opioid administration when compared with intravenous opioids.55,56 Both femoral nerve blocks and fascia iliaca nerve blocks reduce pain after anterior cruciate ligament repair, but pain may still be reported postoperatively from harvesting the gracilis and semitendinosus tendons.57 Lumbar plexus blocks (also known as psoas compartment blocks) also reduce postoperative pain scores in children by numbing the iliohypogastric nerve, ilioinguinal nerve, genitofemoral nerve, lateral femoral cutaneous nerve, femoral nerve, and obturator nerve.58 Local anesthetics infused through catheters inserted under the fascia layer of the incision reduce postoperative opioid use after postoperative hour 4 when compared with catheters filled with placebo.59 Outpatient peripheral nerve block catheters after foot and ankle surgeries can provide efficient analgesia and shorten hospital stay for children with suitable family environments.60 Continuous popliteal sciatic nerve blocks are as effective in pain relief as continuous epidural blocks and carry lower risks of urinary retention, nausea, and vomiting.61 Pain relief from patient-controlled epidural nerve catheters can be augmented with dexmedetomidine, fentanyl, morphine, hydromorphone, or fentanyl plus epinephrine, but the solutions with opioids may be associated with more postoperative nausea and vomiting.62–66 Epidural solutions with bupivacaine, fentanyl, and epinephrine with rectal paracetamol is effective analgesia management for children after femur osteotomies.63 Epidural morphine, when compared with PCA morphine, is associated with comparable pain scores and less drowsiness but higher rates of pruritus and urinary retention.67 Although some clinicians have worried about the delayed diagnosis of compartment syndrome with regional anesthesia, multiple studies have demonstrated no delay in diagnosis if frequent clinical evaluations are performed for breakthrough pain despite a functional nerve block.68–70
The Joint Commission established standards for pain assessment and treatment in 2001, which encouraged clinicians to provide adequate pain management for all patients. The WHO 3-step analgesic ladder for adults and the WHO guidelines on persisting pain in children supports the use of nonopioid medications such as acetaminophen and ibuprofen for mild pain. However, the second step in the guidelines for pain in children suggest low doses of a strong opioid such as morphine on a regular schedule for moderate to severe pain instead of a weak opioid such as codeine or tramadol.71 Several studies have shown that outpatient fracture management with ibuprofen alone, ibuprofen with codeine, or ibuprofen with morphine is not effective enough to reduce pain scores into an acceptable mild range.18,20,21,39 The most common opioids prescribed postoperatively are hydrocodone, oxycodone, and acetaminophen with codeine followed by oral morphine, hydromorphone, and tramadol.72 A different study found that oxycodone was the most commonly prescribed opioid on hospital discharge, that girls consumed more opioid doses compared with boys, and that nonspine orthopedic patients required more opioid medications compared with patients recovering from other types of surgery.73 If intravenous opioids are needed, patients can be given intravenous PCA pumps or as needed doses administered by nurses (Table 6). Morphine PCA provides better analgesia than meperidine PCA for children after orthopedic surgery.74 The addition of an opioid infusion to opioid boluses through PCA produces no significant reduction in reported pain scores or opioid consumption.75,76 Studies vary in the reporting of postoperative opioid requirements after orthopedic surgery from a median of 4 doses to a median of 24 doses and a median duration of 3 days to greater than 10 days.13,19,73
Addressing the Opioid Epidemic
A survey of high-school seniors found that 12.9% admit to nonmedical use of prescription opioids and 80% of those teenagers started with a legitimate prescription but then began using the leftover pills recreationally.72,77 Even among seventh and eighth graders, 5% report recreational use of opioids.78 Studies have found that up to 58% of all opioids prescribed to children remained unconsumed,72,73 and adolescents participating in high injury sports, especially football and wrestling athletes, are at highest risk of abusing prescription opioids.77,79 Because reductions in perceived pain have been observed after initiating proper preoperative education, emotional support, and realistic postoperative pain expectations to patients before surgery,72,80–82 all clinicians should use these strategies for all athletes who have sustained an acute injury. Roughly 13% of postsurgical patients will develop chronic postoperative pain, and the median pain duration in one study is 4.1 months.83 When pain is more severe with a longer duration than expected, expert consultation with a pain specialist is recommended.
Complementary and Alternative Medicine Therapies
Approximately 8.7 million children and adolescents in the United States use complementary and alternative medicine therapies for acute and chronic medical conditions.84 These therapies include biochemical-based therapies (ie, herbal supplements and diets), mind–body therapies (ie, yoga, hypnosis, or biofeedback), body-based therapies (ie, chiropractic manipulation or massages), and bioenergetic therapies (ie, acupuncture). Several clinical studies have investigated complementary therapies, cognitive training, or mindfulness techniques to reduce pain in children for chronic diseases, cancer pain, or short procedures such as lumbar punctures or venipuncture; however, only 3 studies met the inclusion criteria of conducting prospective clinical trials on complementary medicine therapies in pediatric patients for acute injuries (Table 7). Acupuncture combined with low-frequency electric stimulation successfully provided better pain relief for the treatment of sprains compared to athletes without the same treatment.85 Hypnosis has been demonstrated to reduce anxiety, lower postoperative pain, and decrease hospital stay compared with children without hypnosis.86 Imagery-induced relaxation reduced children's perception of postoperative pain, although it did not reduce their nurses' perception of pain levels.87 Research in adult patients for glucosamine, chondroitin, yoga, transcutaneous electrical stimulation, and osteopathic manipulation exists, but the lack of articles investigating complementary and alternative medicine therapies for young athletes with acute injuries indicates the need for further research into this topic.
Adequate pain management is important in children for emotional and physical healing, but a balance must be achieved to provide acceptable pain relief while minimizing opioid use and side effects from analgesic medications. A multimodal pain management strategy that includes nonopioid strategies and discussions of pain expectations can help provide adequate analgesia and reduce the need of opioid medications. Being cognizant of opioid doses and quantity dispensed can prevent recreational use and abuse of opioid medications. Pain management in pediatric and adolescent athletes is an area of focus that still needs more evidence from clinical trials, especially in nonopioid pharmacologic therapies and complementary therapies.
The authors are grateful for the assistance of Meaghan Muir, MLIS, Manager, Library Services at Boston Children's Hospital, who provided help with the literature search.
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