Chronic Apophyseal Injury

The apophysis is a secondary ossification center Secondary ossification center Development of the Limbs found on non-weight-bearing segments of bones. It is the site of ligament or tendon insertion and is involved in the peripheral growth of bones. These secondary growth centers are generally open during childhood and do not close until early adulthood. Chronic apophyseal injury (traction apophysitis Apophysitis Osgood-Schlatter Disease) almost always happens in adolescent athletes during periods of growth. Types of chronic apophyseal injury include Sever disease (posterior calcaneal apophysitis Calcaneal Apophysitis Ankle and Foot Pain), Osgood-Schlatter disease Osgood-Schlatter Disease Osgood-Schlatter disease, or apophysitis of the tibial tubercle, is a common orthopedic condition seen in children between 10 and 15 years of age. The disease is caused by the repetitive application of mechanical forces on the knee, leading to microtrauma on the ossification center at the site of insertion of the distal patellar ligament. Osgood-Schlatter Disease ( tibial tuberosity Tibial tuberosity Leg: Anatomy apophysitis Apophysitis Osgood-Schlatter Disease), little league elbow ( medial epicondyle Medial epicondyle Arm: Anatomy apophysitis Apophysitis Osgood-Schlatter Disease), and Sinding-Larsen-Johansson syndrome (inferior patella Patella The flat, triangular bone situated at the anterior part of the knee. Knee Joint: Anatomy apophysitis Apophysitis Osgood-Schlatter Disease). Diagnosis is generally made clinically. Chronic apophyseal injuries are generally treated with a conservative approach and rarely require surgical intervention.

Last updated: Mar 20, 2023

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Contents

Overview

Clinical Presentation

Diagnosis

Management, Prevention, and Prognosis

Differential Diagnosis

References

Overview

Etiology

The apophysis, a secondary ossification center Secondary ossification center Development of the Limbs, may be susceptible to repetitive or acute physical loading, which may lead to injury.

The apophysis, or traction epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types, is a secondary ossification center Secondary ossification center Development of the Limbs.
Most secondary ossification Ossification The process of bone formation. Histogenesis of bone including ossification. Bones: Development and Ossification centers fuse by one’s late teens; exceptions include the ischial apophysis and iliac crest, which may not close until the early 20s.
The apophysis is the weakest part of the musculotendinous junction; bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types growth and general inflexibility contribute to increased tension at the apophysis.
The apophysis, or traction epiphysis Epiphysis The head of a long bone that is separated from the shaft by the epiphyseal plate until bone growth stops. At that time, the plate disappears and the head and shaft are united. Bones: Structure and Types, is the site of tendon or ligament attachment.
Apophysitis Apophysitis Osgood-Schlatter Disease occurs from a traction injury to the apophysis.
The apophysis is subjected to tensile forces; apophyseal injury occurs when the apophysis is unable to meet the demands of physical activity.
Risk factors:
- Age: occur during periods of growth
- Training errors
- Poorly fitting equipment
- Muscle weakness and imbalance
- Repetitive shear forces

**Table: Risk factors for common types of chronic apophyseal injury**
Disease	Risk factor
Osgood-Schlatter disease Osgood-Schlatter Disease Osgood-Schlatter disease, or apophysitis of the tibial tubercle, is a common orthopedic condition seen in children between 10 and 15 years of age. The disease is caused by the repetitive application of mechanical forces on the knee, leading to microtrauma on the ossification center at the site of insertion of the distal patellar ligament. Osgood-Schlatter Disease ( tibial tubercle Tibial Tubercle Osgood-Schlatter Disease apophysitis Apophysitis Osgood-Schlatter Disease)	Sports that involve running and jumping leading to repetitive tension or traction on the tibial tubercle Tibial Tubercle Osgood-Schlatter Disease (ex. basketball, soccer) Pre-teen and adolescents
Sinding-Larsen-Johansson disease ( Apophysitis Apophysitis Osgood-Schlatter Disease of the inferior pole of the patella Patella The flat, triangular bone situated at the anterior part of the knee. Knee Joint: Anatomy)	Sports that involve running and jumping place repetitive tension on the patellar ligament Patellar ligament A band of fibrous tissue that attaches the apex of the patella to the lower part of the tubercle of the tibia. The ligament is actually the caudal continuation of the common tendon of the quadriceps femoris. The patella is embedded in that tendon. As such, the patellar ligament can be thought of as connecting the quadriceps femoris tendon to the tibia, and therefore it is sometimes called the patellar tendon. Osgood-Schlatter Disease and can lead to irritation or even avulsion of the apophysis of the inferior pole of the patella Patella The flat, triangular bone situated at the anterior part of the knee. Knee Joint: Anatomy.
Pelvic apophysitis Apophysitis Osgood-Schlatter Disease (multiple sites)	Running/sprinting Kicking sports Dance
Little league elbow ( medial epicondyle Medial epicondyle Arm: Anatomy apophysitis Apophysitis Osgood-Schlatter Disease)	Repetitive throwing (pitching) places repetitive strain on the apophysis of the medial epicondyle Medial epicondyle Arm: Anatomy—a traction injury.
Sever disease ( calcaneal apophysitis Calcaneal Apophysitis Ankle and Foot Pain)	Participation in sports or activities with running and/or jumping Repetitive microtrauma Microtrauma Small injuries caused by external force applied to the body including bones, muscles, nerves and tendons. Osgood-Schlatter Disease Tight Achilles tendon
Iselin disease (5th metatarsal traction apophysitis Apophysitis Osgood-Schlatter Disease)	Activities that involve ankle inversion and stress Soccer Basketball Gymnastics Dance

Epidemiology

Injuries related to sports and activities in school-age children are the common presentation:

Typically presents to primary care physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship (PCPs) and orthopedic physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship
Apophysitis Apophysitis Osgood-Schlatter Disease accounts for a significant percentage of these visits.

**Table: Epidemiological data for common types of chronic apophyseal injury**
Disease	Epidemiology
Osgood-Schlatter disease Osgood-Schlatter Disease Osgood-Schlatter disease, or apophysitis of the tibial tubercle, is a common orthopedic condition seen in children between 10 and 15 years of age. The disease is caused by the repetitive application of mechanical forces on the knee, leading to microtrauma on the ossification center at the site of insertion of the distal patellar ligament. Osgood-Schlatter Disease	Boys 12–15 years of age Girls 11–13 years of age Occurs in 20% of adolescent athletes Occurs in 5% of adolescent non-athletes Bilateral in 25%–50% of cases Boys > girls Higher risk in girls with increased sports participation
Sinding-Larsen-Johansson disease	Similar to Osgood-Schlatter disease Osgood-Schlatter Disease Osgood-Schlatter disease, or apophysitis of the tibial tubercle, is a common orthopedic condition seen in children between 10 and 15 years of age. The disease is caused by the repetitive application of mechanical forces on the knee, leading to microtrauma on the ossification center at the site of insertion of the distal patellar ligament. Osgood-Schlatter Disease but commonly occurs in children slightly younger, between ages 10 and 13
Pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy apophysitis Apophysitis Osgood-Schlatter Disease	Age range is wide; related to variation in apophysis growth
Little league elbow	Commonly occurs in children between ages 9 and 12 Related to repetitive throwing
Sever disease	One of the most common causes of heel pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways in children Mean age of presentation is 8 to 12 Boys > girls Bilateral in up to ⅔ of cases
Iselin disease	Seen in physically active boys and girls Presents between the ages of 8 and 13

Pathophysiology

Apophyses Apophyses Apophyseal Avulsion Fracture contain fibrocartilage Fibrocartilage A type of cartilage whose matrix contains large bundles of collagen type I. Fibrocartilage is typically found in the intervertebral disk; pubic symphysis; tibial menisci; and articular discs in synovial joints. Cartilage: Histology instead of columnar cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology.
Occurs secondary to an overuse injury Overuse Injury Osgood-Schlatter Disease with repetitive strain of the apophysis (a secondary ossification center Secondary ossification center Development of the Limbs)
Age-related inflexibility and rapid bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types growth appear to contribute to the apophysis becoming susceptible to repeated forces.

Clinical Presentation

The majority of traction apophysitis Apophysitis Osgood-Schlatter Disease presents with localized swelling Swelling Inflammation and pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways at the site of the apophysis that worsens with resisted motion or muscle activation of the associated muscle–tendon complex.

**Table: Clinical presentation of specific chronic apophyseal disorders**
Disease	Clinical presentation
Osgood-Schlatter disease Osgood-Schlatter Disease Osgood-Schlatter disease, or apophysitis of the tibial tubercle, is a common orthopedic condition seen in children between 10 and 15 years of age. The disease is caused by the repetitive application of mechanical forces on the knee, leading to microtrauma on the ossification center at the site of insertion of the distal patellar ligament. Osgood-Schlatter Disease	Anterior knee (anterior tibial tubercle Tibial Tubercle Osgood-Schlatter Disease) pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, swelling Swelling Inflammation, and localized tenderness to palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination that increases gradually with time Symptoms range from a low-grade ache to pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways that impairs activity. Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways exacerbated by: Direct trauma Direct Trauma Toddler’s Fractures Kneeling Running and jumping Walking uphill or climbing stairs May have quadriceps and/or hamstring tightness Evidence of an acute inflammatory reaction requires further evaluation to exclude more-serious diagnoses (infection, malignancy Malignancy Hemothorax).
Sinding-Larsen-Johansson disease	Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, swelling Swelling Inflammation, and localized tenderness to palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination at the inferior pole of the patella Patella The flat, triangular bone situated at the anterior part of the knee. Knee Joint: Anatomy Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways exacerbated by activity: Jumping Kneeling May have patellar tendon thickening and/or infrapatellar bursitis
Pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy apophysitis Apophysitis Osgood-Schlatter Disease (multiple locations)	Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and localized pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways to palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination over one of the pelvic apophyseal locations: Iliac crest Anterior superior iliac spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy Anterior inferior iliac spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy Greater trochanter Lesser trochanter Ischial tuberosity Pubic symphysis Pubic Symphysis A slightly movable cartilaginous joint which occurs between the pubic bones. Vagina, Vulva, and Pelvic Floor: Anatomy Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways increased with activation of the specific muscles related to each location
Little league elbow	Medial elbow pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways that is exacerbated by throwing Point tender over the medial epicondyle Medial epicondyle Arm: Anatomy, may have associated swelling Swelling Inflammation Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways increased with valgus stress test and resisted flexion Flexion Examination of the Upper Limbs/ supination Supination Applies to movements of the forearm in turning the palm forward or upward. When referring to the foot, a combination of adduction and inversion movements of the foot. Examination of the Upper Limbs of the wrist
Sever disease	Chronic heel pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with insidious onset that is related to activity Associated with poorly supportive footwear and athletic shoes with cleats Heel tenderness on palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination and a positive calcaneal compression Compression Blunt Chest Trauma test
Iselin disease	Insidious onset of pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways over the base of the 5th metatarsal (proximal, lateral 5th metatarsal) Discomfort with resisted eversion, passive inversion, or plantar flexion Flexion Examination of the Upper Limbs

Apophyseal disorders of the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy

There are specific apophyseal disorders of the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy with associated muscles. These disorders can present secondary to repetitive trauma, direct trauma Direct Trauma Toddler’s Fractures, or acute avulsion:

Iliac crest apophysitis Apophysitis Osgood-Schlatter Disease: insertion of external and internal abdominal oblique muscles
Anterior superior iliac spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy: sartorius Sartorius Thigh: Anatomy muscle (proximal tendon attachment)
Anterior inferior iliac spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy: rectus femoris Rectus femoris Thigh: Anatomy (proximal tendon attachment)
Greater trochanter: gluteus medius Gluteus medius Gluteal Region: Anatomy and gluteus minimus Gluteus minimus Gluteal Region: Anatomy muscle tendons attachment
Lesser trochanter: iliopsoas tendon attachment
Ischial tuberosity: proximal hamstring muscles attachment
Pubic symphysis Pubic Symphysis A slightly movable cartilaginous joint which occurs between the pubic bones. Vagina, Vulva, and Pelvic Floor: Anatomy: adductor muscles
The most commonly affected pelvic apophyses Apophyses Apophyseal Avulsion Fracture are the anterior superior iliac spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy and anterior inferior iliac spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy—sometimes referred to as “sprinter’s fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures.”

Common sites of apophyseal disorders of the pelvis
Image by Lecturio.

Diagnosis

The diagnosis of apophysis-related disorders is based on the history and physical exam.
Physical exam findings:
- Point tenderness
- Swelling Swelling Inflammation and pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways at the apophysis
- Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways with resisted activation of the associated muscle group
Radiography:
- Radiographs are often inconclusive in apophyseal disorders.
- Often not indicated; may be ordered to exclude other disorders or lack of clinical improvement
- Other possible indications for radiographic studies:
  - Evaluate for apophyseal avulsion fracture Avulsion fracture Tearing away of the cortical bone fragment at the location of a strong ligament or tendon attachment. The bone fragment detachment site often occurs near a soft site (e.g., growth plate) at the base where ligaments; tendons; or joint capsules attach. Overview of Bone Fractures
  - Stress fractures
  - Infection
  - Malignancy Malignancy Hemothorax
- Ultrasound: An office-based ultrasound may show widened apophysis or fragmentation and support diagnosis.

**Table: Common findings based on specific chronic apophyseal disorder**
Disease	Radiographic findings
Osgood-Schlatter disease Osgood-Schlatter Disease Osgood-Schlatter disease, or apophysitis of the tibial tubercle, is a common orthopedic condition seen in children between 10 and 15 years of age. The disease is caused by the repetitive application of mechanical forces on the knee, leading to microtrauma on the ossification center at the site of insertion of the distal patellar ligament. Osgood-Schlatter Disease	Soft-tissue swelling Swelling Inflammation and fragmentation of the tibial tubercle Tibial Tubercle Osgood-Schlatter Disease
Sinding-Larsen-Johansson disease	Soft-tissue swelling Swelling Inflammation and calcification or fragmentation of the inferior pole of the patella Patella The flat, triangular bone situated at the anterior part of the knee. Knee Joint: Anatomy
Pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy/hip apophysitis Apophysitis Osgood-Schlatter Disease	Normal or widened apophysis when compared to opposite pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 “hip” bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis: Anatomy/hip Ischial tuberosity injuries may appear as heterotopic Heterotopic Transplantation of tissue typical of one area to a different recipient site. The tissue may be autologous, heterologous, or homologous. Organ Transplantation bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types, which may be mistaken for a tumor Tumor Inflammation.
Little league elbow	Can show fragmentation or widening of the medial epicondyle Medial epicondyle Arm: Anatomy apophysis
Sever disease	Frequently normal on plain radiography
Iselin disease	Normal or widened apophysis of the proximal 5th metatarsal

Osgood-schlatter disease — Lateral radiograph demonstrating fragmentation of the tibial tubercle, indicating Osgood-Schlatter disease
Image: “Osgood-Schlatter disease X-ray” by Kristin M Houghton; Radiograph courtesy of BC Children’s Hospital. License: CC BY 2.0

Sever disease — Lateral radiograph demonstrating fragmentation of the tibial tubercle, indicating Osgood-Schlatter disease
Image: “Osgood-Schlatter disease X-ray” by Kristin M Houghton; Radiograph courtesy of BC Children’s Hospital. License: CC BY 2.0

Management, Prevention, and Prognosis

Management

1st-line treatment involves modifying activities as tolerated, relative rest, and starting a stretching and strengthening program.
Education: self-limited problem that generally resolves with modifying activity and ultimately with closure of the apophysis

Table: Specific management and indications for orthopedic referral based on location of apophysitis Apophysitis Osgood-Schlatter Disease
Disease	Treatment	Indication for orthopedic referral
Osgood-Schlatter disease Osgood-Schlatter Disease Osgood-Schlatter disease, or apophysitis of the tibial tubercle, is a common orthopedic condition seen in children between 10 and 15 years of age. The disease is caused by the repetitive application of mechanical forces on the knee, leading to microtrauma on the ossification center at the site of insertion of the distal patellar ligament. Osgood-Schlatter Disease	Activity modification Control of pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation Assessment of alignment and mechanics Effective rehabilitation program with flexibility and strengthening Return to activity based on symptoms Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship often can participate if they are able to maintain rehabilitation and manage symptoms without risking further injury.	Acute avulsion of apophysis Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship not responding to activity modifications and initial therapy
Sinding-Larsen-Johansson disease	Activity modification Control of pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation Assessment of alignment and mechanics Effective rehabilitation program with flexibility and strengthening Return to activity based on symptoms Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship often can participate if they are able to maintain rehabilitation and manage symptoms without risking further injury.	Acute avulsion of apophysis Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship not responding to activity modifications and initial therapy
Little league elbow	Throwing cessation for up to 6–8 weeks Proper conditioning and strengthening prior to return to throwing Progression through a graduated age-appropriate throwing program on return	Acute avulsions of the medial epicondyle Medial epicondyle Arm: Anatomy Widening of the medial epicondyle Medial epicondyle Arm: Anatomy apophysis on X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests Persistent symptoms despite rest
Hip apophysitis Apophysitis Osgood-Schlatter Disease	Rest from painful sports or activities Strengthening and stretching program for the core muscles, hip flexors, quadriceps, and hamstring muscle complex	Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with persistent pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways despite conservative management Significant avulsion of the apophysis Ununited or poorly united fragments
Sever disease	Activity modification Shoe modification/over-the-counter inserts Heel cups Calf stretching and strengthening exercises	Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship not responding to activity modifications and initial therapy
Iselin disease	Activity modifications Stiff-soled shoe for protected weight-bearing	Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship not responding to activity modifications and initial therapy Acute avulsions Persistent symptoms despite rest

Prevention

Reduce early sports specialization.
Reduce overtraining.

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

Self-limiting Self-Limiting Meningitis in Children disorder that usually resolves with modification of activity and PT and eventually with closure of the apophyseal centers
Most patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship do well with conservative therapy.
Only a very small minority will require surgery.

Differential Diagnosis

Osteochondrosis: less common than apophysitis Apophysitis Osgood-Schlatter Disease, osteochondrosis is due to temporary disruption of blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure at the bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types– cartilage Cartilage Cartilage is a type of connective tissue derived from embryonic mesenchyme that is responsible for structural support, resilience, and the smoothness of physical actions. Perichondrium (connective tissue membrane surrounding cartilage) compensates for the absence of vasculature in cartilage by providing nutrition and support. Cartilage: Histology complex of the growing bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types. Osteochondrosis is a rare disease with an uncertain etiology, and it is usually a transient disorder that resolves spontaneously but requires vigilance to avoid long-term morbidity Morbidity The proportion of patients with a particular disease during a given year per given unit of population. Measures of Health Status.
- Examples include:
  - Freiberg disease: avascular necrosis Avascular Necrosis Hip Fractures of the 2nd metatarsal head
  - Legg-Calvé-Perthes disease Legg-Calvé-Perthes Disease Legg-Calvé-Perthes disease (LCPD) is characterized by idiopathic avascular necrosis of the femoral head. The disease presents as a limp with an insidious onset and associated hip pain. Legg-Calvé-Perthes disease primarily affects school-age children and has a male predominance. Legg-Calvé-Perthes Disease: avascular necrosis Avascular Necrosis Hip Fractures of the femoral head
  - Köhler disease: avascular necrosis Avascular Necrosis Hip Fractures of the navicular Navicular Foot: Anatomy bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types of the foot Foot The foot is the terminal portion of the lower limb, whose primary function is to bear weight and facilitate locomotion. The foot comprises 26 bones, including the tarsal bones, metatarsal bones, and phalanges. The bones of the foot form longitudinal and transverse arches and are supported by various muscles, ligaments, and tendons. Foot: Anatomy
  - Scheuermann disease: osteochondrosis of the secondary ossification Ossification The process of bone formation. Histogenesis of bone including ossification. Bones: Development and Ossification centers of the vertebral bodies; may develop kyphotic deformity Deformity Examination of the Upper Limbs
  - Panner disease: osteochondrosis of the capitellum of the elbow
Apophyseal avulsion fracture Avulsion fracture Tearing away of the cortical bone fragment at the location of a strong ligament or tendon attachment. The bone fragment detachment site often occurs near a soft site (e.g., growth plate) at the base where ligaments; tendons; or joint capsules attach. Overview of Bone Fractures: an apophyseal avulsion fracture Avulsion fracture Tearing away of the cortical bone fragment at the location of a strong ligament or tendon attachment. The bone fragment detachment site often occurs near a soft site (e.g., growth plate) at the base where ligaments; tendons; or joint capsules attach. Overview of Bone Fractures is an acute injury in which a portion of the apophysis is avulsed, usually secondary to explosive movements or eccentric muscular contractions. Symptoms include severe pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, swelling Swelling Inflammation, point tenderness, and ecchymosis Ecchymosis Extravasation of blood into the skin, resulting in a nonelevated, rounded or irregular, blue or purplish patch, larger than a petechia. Orbital Fractures. The majority of apophyseal avulsion fractures are treated conservatively, but some may require surgery if the avulsed fragment is large or significantly displaced (although there is a lack of consensus, > 2 cm displacement Displacement The process by which an emotional or behavioral response that is appropriate for one situation appears in another situation for which it is inappropriate. Defense Mechanisms is often recommended for surgical intervention).

References

Achar, S, & Yamanaka, J. (2019). Apophysitis and osteochondrosis: Common causes of pain in growing bones. American Family Physician, 99(10), 610–618.
Cassas, KJ, & Cassettari-Wayhs, A. (2006). Childhood and adolescent sports-related overuse injuries. American Family Physician, 73(6), 1014–1022.
Chorley, J. (2021). Elbow injuries in active children or skeletally immature adolescents: Approach. UpToDate. Retrieved March 29, 2021, from https://www.uptodate.com/contents/elbow-injuries-in-active-children-or-skeletally-immature-adolescents-approach
Chorley, J. (2020). Forefoot and midfoot pain in the active child or skeletally immature adolescent: Overview of causes. UpToDate. Retrieved March 29, 2021, from https://www.uptodate.com/contents/forefoot-and-midfoot-pain-in-the-active-child-or-skeletally-immature-adolescent-overview-of-causes#H481180180
Chorley, J, & Molina, D. (2020). Heel pain in the active child or skeletally immature adolescent: Overview of causes. UpToDate. Retrieved March 29, 2021, from https://www.uptodate.com/contents/heel-pain-in-the-active-child-or-skeletally-immature-adolescent-overview-of-causes
Hergenroeder, AC. (2021). Approach to chronic knee pain or injury in children or skeletally immature adolescents. UpToDate. Retrieved March 29, 2021, from https://www.uptodate.com/contents/approach-to-chronic-knee-pain-or-injury-in-children-or-skeletally-immature-adolescents
Hoang, QB, & Mortazavi, M. (2012). Pediatric overuse injuries in sports. Advances in Pediatrics, 59(1), 359–383. https://doi.org/10.1016/j.yapd.2012.04.005
Kienstra, AJ, & Macias CG. (2021). Osgood-Schlatter disease (Tibial tuberosity avulsion). UpToDate. Retrieved March 29, 2021, from https://www.uptodate.com/contents/osgood-schlatter-disease-tibial-tuberosity-avulsion
Peck, DM. (1995). Apophyseal injuries in the young athlete. American Family Physician, 51(8), 1891–1898.

Achieve Mastery of Medical Concepts

Study for medical school and boards with Lecturio

Chronic Apophyseal Injury

Overview

Etiology

Epidemiology

Pathophysiology

Clinical Presentation

Related videos

Diagnosis

Management, Prevention, and Prognosis

Management

Prevention

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

Differential Diagnosis

References

Lecturio

Support

Institutions

Resources

Follow Us

Create your free account or log in to continue reading!

User Reviews

Details

Get Premium to test your knowledge

Get Premium to watch all videos

Create a free account to test your knowledge