When children go through a growth spurt, an increase in bone length creates tension in the muscles and nerves which may cause a traction effect on either the origin or insertion of the muscle. In the growing athlete, the growth plate is the weakest link in the adolescent bone and is the most common site of an injury. Tendons and ligaments attach to the bone mostly via an apophysis. The apophysis is a secondary centre of ossification that gives shape to the bone rather than length. They are the sticky out bits such as the AIIS, tibial tubercle and 5th metatarsal head.
Until they ossify, in late adolescence, the immature bony attachment tends to be weaker than that of the tendon/muscle unit and injuries are therefore more likely to occur to the bone rather than tendon, unlike adults who tend to experience injuries to the tendon and muscle. So, a similar set of symptoms in the adult might be diagnosed as a tendinopathy versus pain at a teno-osseous junction in the adolescent is much more likely to be a traction or overuse apophysitis. Osgood-Schlatter Disease (OSD) and Sever’s are the most-common apophyseal injuries. Although not written in stone, Sever’s around 11 years of age, OSD average age 13 years old and rarely result in an avulsion injury.
As muscles get stronger post the adolescent peak growth spurt, the risk of an avulsion injury around the pelvis increases when the muscle strength becomes greater than the integrity of the immature skeleton often resulting in the forceful detachment of a bony fragment at the insertion of a tendon or ligament. Accurate diagnosis and early intervention are essential to ensure that these injuries do not progress and create an increasing widening of the gap that may result in surgery being required.
The patient can usually point to the site of pain, there may be swelling and is usually made worse by activity and settles with rest. The history will almost always be related to a combination of a growth spurt and a sudden spike in volume and or intensity of sport such as the crossover of new seasons and sports camps. It is important to highlight the cause of the injury to the patient and parents as simply resting and strength work without adequate education around calorie and protein intake, sleep, recovery and monitoring load will usually lead to the frustration of a cycle of pain, rest, pain rest….
X-rays usually are not required but may be needed with a scan in younger active patients presenting with pain in the hip and pelvis. Careful screening for red flags is still key in this population group as bone tumours, bone infections and stress fractures do occur in younger patients but are thankfully rare at the tendon origin and insertions so the key is in the precise location of the pain.
Recommended treatment involves education. Often cutting back on the volume and intensity during growth spurts and temporarily adding a greater number of rests days (avoid back-to-back days). In the lower limb reducing jumping and sprinting and in the upper limb overhead and throwing activities may help and then follow it up with a graduated and phased return to sport avoiding sudden spikes in activity such as after the summer and Christmas holidays. Most cycle through a rapid return to sport as the pain settles then follow it with a return of pain. Some patients find ice helpful but if they need pain relief they are probably doing too much too soon and not allowing the body to adapt to the load applied. Sorbothane heel pads can help with heel pain.
Stretching in these patients is contentious. In essence, we are saying that these injuries are caused by traction created by a growing bone and tightness in muscles. If we stretch, do we then add greater traction or alleviate the problem? My approach is more around load management, strength-based exercises, soft tissue massage to the tight groups from a roller (or Mum!), greater cushioning for injuries like Severs and slowly stretching the muscle out if required.
If you want more information about how to stop these injuries from progressing or how to do a comprehensive return to sport and play in the active child, then visit https://angelajacksonphysio.thinkific.com/courses/Activekids
