January 2011 Newsletter

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Apophysitis
By Dr. Stephen A. Hunt

Apophysitis (a-pof-i-site-tis) is an injury that is commonly seen in children. Children have apophyses all over their body. They are areas of cartilage that connect tendons to bones. Usually there is a small cartilage bridge between the bone attached to the tendon and the main bone. These are not traditional growth plates in relation to what we get height from, but they are still important structures. Skeletally immature individuals are at risk for an apophyseal injury because of overuse (excessive training), traumatic events, and rapid growth. Injuries vary from inflammation and pain to avulsion fractures (where the tendon pulls off the bone). While they are usually injuries requiring no surgical intervention, they can be a source of angst for young athletes and families. Here are some common ones we see at our office.

The Pelvis
The pelvis injury is an injury to the iliac crest apophysis, which is the bony prominence above your hips on both sides of your body. Strong abdominal and thigh muscles share an origin here and can pull on the cartilage bridge during dance, running, skating, and cutting. The athlete may report dull achiness at the site during and sometimes after activities. Occasionally x-rays will show widening of the apophysis and sometimes the apophysis will fracture. These injuries can be treated with rest, activity restriction, stretching exercises, anti-inflammatory medication and gradual resumption of sports activities – usually after four to six weeks.

The Hip
There are three apophyseal injuries to the hip that are commonly presented after the apophysis has broken off the main bone. One is the anterior superior iliac spine, which is the attachment of the sartorius muscle. Another is the anterior inferior iliac spine, which is the attachment of the rectus femoris or quadricep muscle. The last is the lesser trochanter, where the hip flexor attaches to the thigh bone. Sometimes young athletes will have pain with activity prior to experiencing a “pop” in the groin region. It is often painful to walk and the hip may feel weak. Even when the apophysis is displaced, surgery is rarely indicated. Crutches, physical therapy, and anti-inflammatories are the mainstay of treatment. Return to play is around eight to ten weeks.

The Knee
Osgood-Schlatter Disease
This knee injury involves the patella tendons insertion on the tibial tubercle, which is the bony prominence at near the top of our shin bone. Sports that involve running and jumping tend to cause this injury. Pain is activity related and can be reproduced with direct pressure on the tibial tubercle, kneeling on the knee, or applying resistance while the patient tries to straighten their leg. X-rays may show some fragmentation of the apophysis, but avulsion fracture is uncommon. Activity modification (stopping the sport), anti-inflammatory medications, and a stretching program are the mainstays of treatment. Patients have tried using a patella strap with varying success on improving pain during activities. In severe cases, a knee immobilizer or cast may be applied. Most cases resolve within eight weeks, but this injury can plague an athlete until they reach skeletal maturity. Less than 10% of kids with this problem may have issues as an adult.

Sinding-Larson-Johansson Syndrome
This apophyseal injury is much less common than Osgood-Schlatter disease and involves the other end of the patella tendon at its origin, on the bottom of the patella (kneecap). Other than the location of the pain, the symptoms, risk factors, and treatment are very similar to Osgood-Schlatter disease.

The Foot and Ankle
Sever’s Disease
This injury involves the apophysis of the calcaneus or heel bone. The Achilles tendon inserts into this apophysis. It is said that tightness of the Achilles tendon and weakness of the front ankle muscles results in this injury to the cartilage and bone. Rapid growth and overuse (running and jumping sports) are risk factors for this. Pain is usually activity-related and the back of the heel bone is tender to the touch. X-rays may show sclerosis (increased density) or fragmentation of the apophysis. Treatment consists of activity modification, anti-inflammatory medication, an Achilles stretching program, and heel cup shoe inserts. In severe cases, casting may be performed. This usually resolves within two months and with skeletal maturity.

Iselin’s Disease
This is an injury to the apophysis of the outside aspect of the foot. The peroneal tendon inserts at the base of the fifth metatarsal and provides ankle stability for many activities. This rare injury requires activity modification, anti-inflammatory medication, and a stretching/strengthening/balance exercise program. It usually resolves in four weeks.

Summary
Overall, apophyseal injuries are very common in the young athlete. While the names of these injuries may suggest a grave situation, they are relatively benign injuries which do not require surgical intervention and cause mild pain and lost time in athletic activities. If you suspect that your child has one of these injuries, see a physician to confirm the diagnosis and rule out any more serious problems to ensure proper treatment.

REFERENCES:
Frank, JB et al. Lower Extremity injuries in the skeletally immature athlete. JAAOS 2007 (15): 356-66.