Ritalin and bony healing

[phunphysio]

I have a 9 year old boy 5 months post ACL reconstruction who has developed Sever's Calcaneal Apophysitis. He has had the heel pain for 14 weeks now, (just started with me) has been recieving physio (calf stretches, night splints, heel raise, new shoes) and it is just getting worse. I am attempting to find any information/studies or professional opinions on Ritalin slowing bone healing. I know it can cause growth retardation, he is very small for 9, however, is it affecting his bony healing of the Sever's and ACL recon or not? What is the mechanism that Ritalin slows the growth. MIMS online doesnt help and our pharmacy department was not helpful.
Appreciate any assistance
Thanks

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[estherderu]

dear phunphysio,

sorry for my ignorance but by saying ACL reconstruction do you mean a anterior cruciate ligament recon?
Could you also tell me more about his history... why did the he need a recon in the first place... trauma? and why is he using Ritalin and for how long? Is his blood monitered because of this usage? How is his health status? is he hypermobile? etc etc
That will make my understanding complete and because I find your question very interesting, I will start looking things up as well.

esther de ru

[phunphysio]

Yes, Anterior cruciate ligament reconstruction. His fathers hamstring was used as the graft, a new technique here is Australia. His heel pain seems secondary to biomechanical faults from changed gait post reconstruction. I have found 2 articles ragarding bone mineral density and ritalin, one small one on humans, and one or rats, both reported no significant difference but I still question the mechanism by which the Ritalin slows growth (and whether or not it then influences the healing of bone). Very difficult to find.

[phunphysio]

To answer the other questions-he ruptured the ACL in the playground, soccer tackle. He is using Ritalin for ADHD and was diagnosed 3 years ago, tried elimination diets, councilling but none worked, Ritalin has set him back on the straight and narrrow and he is doing well at school. He does not have hypermobility issues, in fact he is quite tight both ligamentous and muscle. His health is fine, nothing apart from the Ritalin and children must be monitored by a paediatrician here when on Ritalin, growth and weight calculate dose. Hope this helps?

[fisiofriend]

Hi there! I think there are a few theories about Ritalin and growth. But I emphasise, they are speculation.

i) Ritalin is an amphetamine and hence reduces appetite. If a child is not meeting his daily calorie intake, he will not thrive as well. When nutritionally deprived, a child does not grow as well.

ii) Ritalin causes a disruption in sleep pattern. Doctors advise not to take Ritalin in the late afternoon as it will cause difficulty in falling asleep. Growth hormone ( somatotrophin) is released during sleep. If an individual is sleep deprived, they do not release as much growth hormone. Children on Ritalin may have disrupted sleep and growth hormone may not be released in sufficient amounts to ensure optimal growth.

It has been observed that some children seem more prone to the growth retardation effects of ADHD drugs than others. Ritalin and other drugs like Strattera (atomoxetine) have been observed to cause slowed growth in only some individuals. Ritalin and Strattera improve the uptake of brain chemicals such as dopamine and boost the levels of norepinephrine in the brain.

I would very much like to know if Ritalin might slow bone healing. I believe this may be worthy of further research.

For example research has shown that alcoholics demonstrate poor bone healing. Alcohol causes an increased turnover of norepinephrine and dopamine in the brain. Alcoholics are often poorly nourished. Alcohol has an adverse effect on osteoblast activity, thus suppressing new bone formation.

Diabetes, poor weight bearing, steroids, malnutrition, poor blood supply...there is a long list of other causes of poor bone and tissue healing.

NSAIDs ( non steroidal anti-inflammatories) also delay or modify healing of bones.
The significant component at work appears to be the cox-2 enzyme (associated with inflammation and pain) that is blocked by these drugs. Is it possible your patient is taking NSAIDs and these are responsible for the poor bone healing?

Regards
fisiofriend

[estherderu]

dear phunfisio and fisiofriend, love your names!

Fisiofriend has a good and interesting point here.
Phunfisio, I didn´t find more literature concerning bonegrowth and Ritalin, only the two mentioned by you before.

Now a bit of old fashioned practiced based evidence from my side....
I have seen many (> 100) kids "diagnosed" with ADHD and using Ritalin or other medication...
In the past (Holland) teachers and parents will tend to diagnose on gut feeling, heresay and observation. It was fasionable to go to your GP and "get a prescription" for your childs´/ this problem.
Nowadays children will be diagnosed properly first by paediatricians or psychiatrists and put on medication if necessary.

Parents organisations are often well informed (sometimes more so than GP´s) and the Dutch Society called Balans has a network of health professionals and specialists giving up-to-date information.
This results in parents sometimes knowing more than their own healthprofessionals.

During these last 30 yrs I have been seeing more and more of these children. Many of them correctly diagnosed and maybe just as many not.
It goes without saying that proper physiotherapeutic assessment and proper treatment was initiated if necessary BUT.....
One of the most rewarding "therapies" was teaching the parents how to massage.....especially the feet. These children (with and without medication) often have difficulties in going to sleep. They love to play rough just before bedtime and watch TV etc. and that might not be that good for them.
I taught the parents to take a little time to talk with their child (go over the day, read a book, the Bible etc) and subsequently either massage their whole body, (back and legs), or their feet(the older child).

I have often heard parents tell me that they were really happy with this advice. They heard a lot more about what was going on in their childs life´and mind, the child would relax and go to sleep more easily. It made them especially happy because they got the feeling they were helping their child. It was Quality Time.

On a personal note: massaging my sons´feet was one of the only ways to hear anything from them at all at a certain age. They would actually ask me to do so.

I have hear parents tell me likewise.....

Now for your patient, I would strongly suggest you try massaging (classic) his back and not affected leg. We know this has a benificiary effect on the circulation. Connective tissue massage of his back only if you know the technique but be constantely very aware of the signals his body gives. They are your guideline and if he where my patient I would only use the superficial technique and for a few minutes only.

Hope this helps and if not I would certainly suggest he consult a good acupuncturist/chinese medice to try to find the reason behind the bad healing process.

kind regards
Esther