Apophysitis – The Growing Disease
What is it? Why does it Occur?
Apophysitis, also known as an apophyseal injury, is a condition that primarily affects children and adolescents, especially those who are involved in sports that involve repetitive movements, are high impact (running, jumping, landing, cutting, pivoting). Apophysitis is primarily seen in the younger population and is caused by overuse, creating inflammation and therefore pain at the site of attachment of tendons on areas of bone known as the growth plates or physis.
The reason this injury primarily occurs in children and adolescents is due to the nature of the bone, tendon and cartilage.
Muscles attach to tendons which then attach onto cartilage and bones. In certain areas of the body these tendons attach onto growth plates which are skeletally immature as they allow for growth of the bones.
This creates a weaker attachment site which means the tendon and bone complex is unable to resist stress (particularly shear and tension forces) compared to the cartilage and bone in adults.
What are the risk factors?
The most common risk factors for apophysitis are periods of rapid growth. During these periods there is a mismatch of the rate of growth between bone and muscle. Typically bone will start to grow first, followed by muscle growth. This mismatch creates tension and therefore traction on the soft attachment site which leads to pain, inflammation and swelling.
Combine the growing with sports, usually multiple sports nearly every day. Exercising and in particular running sprinting jumping will cause an increase in traction on the attachment site of the tendon, further causing pain swelling and inflammation.
What are the Symptoms?
Symptoms of apophysitis usually include;
- Pain, tenderness and often swelling at the affected area
- Pain worsens with physical activity
- Reduced range of motion and discomfort with movement at the affected muscle/tendon junction
Common Types
As there are multiple growth plates located across the body, the more common types are seen in the lower limb or legs in the young athlete, however, it is possible to have apophysitis in the upper limb.
Calcaneal Apophysitis (Sever’s Disease)
Calcaneal apophysitis, better known as Sever’s Disease, is considered one of the most common diagnoses of posterior heel pain in rapidly growing, physically active children aged between 8 and 15 years (Volpe et al., 2009; Howard, 2014)
Sever’s Disease is described as an ‘overuse injury’ with a gradual onset of pain with no specific traumatic event in the physically active growing children population (Ramponi et al., 2019)
Sever’s disease can present unilaterally or bilaterally, with an incidence of 60% of cases presenting bilaterally (Smith et al., 2021)
Risk factors for Sever’s Disease
- Considered an ‘overuse’ injury, an increase in sports activity and/or training volumes (particularly sports requiring repetitive running and jumping – Smith & Varacallo, 2022)
- Achilles tendon tightness
- Poor ankle dorsiflexion strength
- Inadequate shoes (including worn-out athletic shoes)
- Environmental (running on harder surfaces etc).
- Biomechanical factors that contribute to poor shock absorption (foot shape, proximal limb weakness etc)– James et al., 2016
- Obesity
- Gender (boys 3:1 ratio to girls)
Tibial Tuberosity Apophysitis (Osgood Schlatters Disease)
Considered one of the most common overuse injuries of the lower limb causing anterior knee pain in the young, skeletally immature athletic population – with basketball, volleyball, sprinters, gymnastics and football the most common sports associated with the condition (Smith & Varacallo, 2022; Corbi et al., 2022)
Osgood-Schlatters is atraumatic with a, gradual onset of pain that is increased with physical activity (Smith & Varacallo, 2022)
Risk factors for Osgood Schlatters Disease
- Gender (males have a higher likelihood of developing OSD)
- Adolescents aged 8-15 years
- A recent, rapid increase in growth
- Increased levels of physical activity
- Hamstring and Quadriceps tightness (particularly rectus femoris)
- As previously mentioned, adolescents participating in sports that require repetitive jumping and/or running (basketball, volleyball, athletics, gymnastics and football)
- Some studies have identified that reduced elasticity of the patella tendon can be associated with a greater risk of OSD (Enomoto et al., 2020)
Ischial Tuberosity / Hamstring Apophysitis
Like Sever’s and Osgood-Schlatter’s, hamstring apophysitis is an ‘overuse’ injury which results in inflammation of the apophysis that undergoes ossification to form the ischial tuberosity during adolescence.
The location of pain is situated at the proximal hamstring attachment to the ischial tuberosity apophysis and may produce pain in the gluteal region when performing physical activity (including sports with high physical plyometric demands such as running, football, rugby and tennis)
Risk factors for Hamstring Apophysitis
- Physically active young adolescents
- Increased training volumes (pre-season, competitions)
- Rapid growth spurt (with bones growing faster than muscle tissues and reducing flexibility)
- Linking to above, reduced flexibility of the hamstring muscles (biceps femoris, semitendinosus and semimembranosus)
- Type of sport (similar to Sever’s and Osgood-Schlatters with the young athletic population performing repetitive jumping and running at a higher risk of developing apophysitis)
- Hamstring to quadriceps strength ratio
So how do we prevent or treat Apophysitis?
Apophysitis can be debilitating in season and cause lots of pain and dysfunction in the active adolescent.
Prevention is always better than cure and there are many ways to prevent this common injury occurring.
- Strength training
- Biomechanical assesment retraining
- Proper Warm-up and Cool-down routine
- Appropriate Sports Equipment
- Training Techniques and Load management
- Cross-Training
- Regular Check-ups with a Physiotherapist
Physiotherapists are highly trained in all of the above prevention strategies and can be a crucial part of an adolescents active lifestyle. By improving overall lower limb strength with a specific tailored program has shown to have a significant reduction in pain, inflammation and swelling and decrease the overall prevalence of this overuse injury.
Treatment for Apophysitis varies from individual to individual however ultimately starts with a basic strength and biomechanical assessment to see whether any patterns in movement can be contributing factors to the progression of the injury. From this assessment a specific strengthening and loading programme can be created which is tailored to the individual. Without changing biomechanics or altering the amount of strength in certain muscle groups, the problem is not being addressed and will continue to cause issues as the adolescent goes through growth spurts.
References
Smith JM, Varacallo M. Sever Disease. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021
Volpe R. Keys to diagnosing and treating calcaneal apophysitis. Podiatry Today. 2009;22(11):60-66.
Lucenti L, Sapienza M, Caldaci A, Cristo C, Testa G, Pavone V. The Etiology and Risk Factors of Osgood-Schlatter Disease: A Systematic Review. Children (Basel). 2022 Jun 2;9(6):826. doi: 10.3390/children9060826. PMID: 35740763; PMCID: PMC9222097.
Vaishya R, Azizi AT, Agarwal AK, Vijay V. Apophysitis of the Tibial Tuberosity (Osgood-Schlatter Disease): A Review. Cureus. 2016 Sep 13;8(9):e780. doi: 10.7759/cureus.780. PMID: 27752406; PMCID: PMC5063719
Kujala UM, Orava S, Karpakka J, Leppävuori J, Mattila K. Ischial tuberosity apophysitis
and avulsion among athletes. Int J Sports Med. 1997 Feb;18(2):149-55. doi: 10.1055/s-2007-972611. PMID: 9081273.
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