Apophysitis – Adolescent ankle, knee and hip pains explained

One of the most common categories of pain in sporty or active children is what is collectively known as apophysitis. Not a very catchy word, but you may know these better by their regional names: Sever’s Disease at the rear of the heel or ankle, Osgood-Schlatter Disease below the knee, Sinding-Larsen-Johansson Syndrome (SLJ) at the base of the kneecap and the one they forgot to name – Ilium Apophysitis –  at the front of the hip. Add to this Osteitis Pubis in the groin for a slightly older, but still youthful, population.

What is Apophysitis

Apophysitis refers to inflammation – itis – of the apophysis – the junction of the growth plate to the musculo-tendinous unit in growing skeletons. It is caused by repetitive stress on the apophysis from the musculo-tendinous unit, and therefore is more likely to affect very active children. I often like to explain to my patients that where kids will get apophysitis, adults will get tendinitis or tendon injury. This is because the growth plate hasn’t fused in children and the apophysis becomes the weak point for any stress or overload. Once it is fused, the attachment on the bone itself (think plantar fasciitis) or the tendon (think rotator cuff, Achilles or patella tendinopathy) becomes the weak point.

Apophysitis presents at first as a dull pain on or after activity at or around the bony site, with the absence of any obvious one-off cause or injury event. Sever’s will feel like ankle pain to most kids. As the severity progresses, pain will be more severe, the onset of pain will be quicker during activity, and the pain will last for longer after activity & often worse after rest (e.g. the next morning). 

There will be precipitating extrinsic factors – change of training surfaces, conditions or type; change of footwear, especially to lower heeled shoes like thongs or football/soccer boots – and intrinsic factors – growth spurts, tight calves or quadriceps, pronating feet, poor running biomechanics and poor core or other muscle strength.

The reported ages of occurrence for all apophysitis conditions vary slightly, but correspond to the ‘growing skeleton’ definition:

  • Sever’s: 8-14 years old
  • OSD & SLJ: 8-15 years old (females 8-13, males 12-15)
  • Ilium: 11-15 years old
  • Osteitis Pubis: 15-25 years old

What is the Treatment

All of these apophysitis conditions are relatively straightforward for a physiotherapist to diagnose and treat without imaging being required. A thorough history and physical examination will point to causative factors that should be addressed prior to or whilst returning to activity in order to reduce the high risk of recurrence.

The factor of repetitive stress cannot be understated. In the past, rest and occasional ice was the only treatment. The pain will often settle with 2-4 weeks rest and icing, however without addressing the underlying factors the pain will return until the growth plates fuse, often once training is ramped up again and coincides with the next growth spurt. And problems will persist for the patient in the musculo-tendinous or bony region as an adult once the growth plate is fused.

More recent knowledge has physios tackling the contributing factors, which is particularly helpful during the initial rest period, or the early stages if the condition has not progressed to the severity to require rest:

    • Foot posture – excessive rolling in or out during gait, rotated heel or forefoot in standing; treated with footwear advice, taping and orthotics
    • Reduced joint range of movement – particularly ankles, hips and lower back; treated with hands on treatment and home exercises
    • Increased muscle tension – calves for Sever’s, quadriceps, adductors, hamstrings, glutes; treated with massage and stretching, dry needling an option > 14 years old depending on the child
    • Muscle weakness – particularly core and hips for OSD, SLJ and Osteitis Pubis; treated with tailored core, pelvis and lower limb strengthening program, Pilates for the serious adolescent athlete >12 years
    • Education  – perhaps the most important, so that children and parents know the signs and how to manage the condition in the future before it gets bad enough to warrant resting from sport
    • Running Biomechanics – evaluating what is happening with each joint and major muscle groups during gait and running, and tailoring stretching, strengthening and running exercises to the individual

 

Each of our physiotherapists at Dandenong Ranges Physio are to assist with assessment, treatment and advice for Sever’s Disease, Osgood-Schlatter’s, SLJ, Ilium Apophysitis or Osteitis Pubis. To make an appointment please call us on 9751 0400.

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