APOPHYSITIS

 

Common Types of Apophysitis

Apophysitis can occur anywhere in the body where a growth plate is located. Here are the most common types of apophysitis, categorized by their anatomical location:

Pelvic Region

• Iliac Crest Apophysitis: This form occurs at the upper hip bone area near the waist, affecting the Iliac crest, a prominent ridge on the pelvic bone.
• ASIS Apophysitis: The Anterior Superior Iliac Spine is a critical site for muscle attachment and can be affected by apophysitis, leading to pain in the front of the hip.
• AIIS Apophysitis: Located at the Anterior Inferior Iliac Spine, this area is another pelvic site where growth-related inflammation can occur.

Lower Extremities

• Sinding-Larson-Johansson Syndrome: This affects the knee cap or the lower part of the patella, causing discomfort during activities like running or jumping.
• Iselin’s Disease: Occurs on the outside area of the mid part of the foot, often affecting active children during periods of rapid growth.
• Sever’s Disease: Found at the back or under the heel, this is a common condition in young athletes experiencing heel pain.
• Osgood Schlatter’s Disease: This condition targets the knee cap or the bony area under the patella, commonly seen in adolescents involved in sports.

Upper Extremities

• Little League Elbow: This type affects the bony part inside the elbow, frequently seen in young baseball pitchers due to repetitive throwing motions.
• Little League Shoulder: Occurs at the upper part of the arm that adjoins to the shoulder, often due to repetitive stress in overhead sports.

Understanding these anatomical classifications helps in diagnosing and managing apophysitis effectively, ensuring that young athletes receive appropriate treatment and care.

Causes and Symptoms of Apophysitis

The root of hip apophysitis often lies in activities that repeatedly strain the muscles and tendons. This constant pulling can lead to inflammation, marking the point where a tendon meets the bone. Symptoms typically include:

• Pain and tenderness in the hip area
• Swelling

These are often exacerbated by movement, significantly affecting the individual’s ability to walk or perform in sports.

Who are the Most Susectable of Getting Apophysitis

Hip apophysitis is most common among children and adolescents between the ages of 12 to 18. Factors that increase the likelihood include:

• Growth spurts, which can place additional stress on the muscles as bones lengthen
• Tightness in the hip and thigh muscles
• Extended periods of sports training or competition
• Conditions like knocked knees and foot pronation, where the foot rolls inward

Activities Frequently Linked to Hip Apophysitis

Certain sports and physical activities are more likely to lead to this condition due to the nature of their movements. Young athletes who are particularly susceptible include:

• Dancers, due to the rigorous stretching and use of hip muscles
• Hockey players, who frequently twist and turn on the ice
• Runners and sprinters, with repetitive, high-impact strides
• Soccer players, constantly engage their hip flexors and other related muscles

By understanding these factors, parents and young athletes can take preventative measures, such as proper stretching and strengthening exercises, to reduce the risk of developing hip apophysitis.

Apophysitis Risk Factors

The common risk factors are the phases when bones undergo rapid growth where muscles and tendons can become tight. Young athletes involved in sports are mainly at risk. However, also, less active adolescents may experience this problem, especially those who wear flat shoes.

Hip apophysitis is common in children and adolescents who have growth spurts, which can put stress on the muscle. This condition is usually associated with strenuous muscle overuse, often seen in athletes and those engaged in intense physical activities. When children have tight hips and thigh muscles or have been training or competing in sports for a long time, they are prone to getting hip apophysitis.

Activities Linked to Apophysitis:

• Running sports such as soccer and Australian Football League (AFL)
• Gymnastics
• Dancing

Additionally, kids with knocked knees and pronation can also experience this problem. Dancers, hockey players, runners, soccer players, and sprinters have a higher chance of developing a problem like this due to the repetitive stress placed on their growing bodies. By understanding these risk factors, parents and coaches can better support young athletes in preventing injuries.

Common Apophyses Hip Injuries 

Apophysitis of The Ischial Tuberosity

This is the part of the pelvis bone that we sit on. The hamstring muscles that help the hip extend backward start in this area. Avulsion fractures are common at this location.

Apophysitis of the ASIS

This is the front part of the pelvis bone and is the large area right under the iliac crest. It is also roughly in line with the kneecap. The sartorius muscle begins at this part and flexes the hip. When you repeatedly stretch out this muscle, ASIS apophysitis may develop. Also, an avulsion fracture commonly develops in this location.

Iliac Apophysitis

It is located on the iliac crest on the upper pelvis and connects muscles of the abdomen, back, and sides of the torso. Athletes participating in activities with repetitive twisting, bending, etc. are at higher risk for iliac apophysis. Common symptoms of Apophysitis of the iliac are pain and tenderness over the iliac crest.

Apophysitis of the lesser trochanter

It is located on the top, inside the femur. It has a strong muscle the iliopsoas which is the most powerful flexor of the hip. Injury in this part may occur while doing activities such as sprinting, kicking, and jumping. It is because during these activities the muscle is repeatedly overstretched.

Symptoms of Apophysitis

Apophysitis symptoms can vary but there are a few key factors to check for:

• Worsening pain during or after repetitive sports or activities such as jumping, running, and throwing
• Pain, swelling, and/or tenderness at the growth plate areas at the elbow, shoulder, heel, knee, hip, or foot
•  A “bump” may appear at the knee, heel, elbow, hip, and pelvis areas. And it does not go away.
• Pain that worsens with activity and improves with rest.
• Pain with activity, sometimes causing problems in walking.

Apophysitis Diagnosis

If you think your child may have apophysitis, you must immediately consult an orthopedic doctor. They perform a detailed musculoskeletal examination. Also, they perform x-rays of the affected area to confirm any injuries, fractures, or apophysitis. Apophysitis on an X-ray can present in a couple of different ways. Often, the X-ray might appear normal without any distinct abnormalities. However, in some cases, there could be a noticeable alteration at the site where the muscle attaches to the bone. This change often appears as a hazy or cloud-like pattern, which suggests inflammation or mild swelling in the area. It’s important to note that while X-rays can sometimes help in identifying apophysitis, they are not always definitive, and further clinical evaluation might be necessary.

Thus, the typical clinical diagnosis of apophysitis is based on history and examination.

• A thorough examination is done to find local swelling and pain in the problem area.
• Doctors often do Radiography to check the severity of the injury. Also, it helps find other possible causes of pain. For example, stress fractures, avulsion, malignancy, fragmentation of the ossification center, etc.
• Ultrasonography can show an expanded and fragmented apophysis. It also provides a contralateral comparison. Ultrasonography involves no radiation risk and is more sensitive than plain radiography. This method confirms the absence of a tendon and muscle injury.

Usual Emergency Department Management for Apophysitis

Managing apophysitis in the emergency department focuses on minimizing pain and preventing further injury. Here’s a step-by-step guide:

1. Encourage Relative Rest: Advise patients to engage in activities that don’t induce pain. If walking is painful, consider recommending crutches. Rest from pain-inducing activities is crucial for about 1-2 weeks.
2. Cold Therapy: Applying ice intermittently to the affected area can help reduce inflammation and provide relief, especially in the initial stages.
3. Pain Management: Utilize non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen for short-term relief, typically not exceeding a week, to manage swelling and discomfort.
4. Gradual Return to Activity: Stress the importance of a gradual return to sporting activities. Advise patients to avoid rushing back to full activity as it could exacerbate the injury and lead to chronic discomfort.

By following these steps, patients can effectively manage their symptoms and work towards recovery. It’s essential to tailor the advice based on individual circumstances and monitor the progress over time.

Treatment Options for Hip Apophysitis: A Comprehensive Guide

Apophysis is a self-restricting disorder that heals by enhancing a patient’s flexibility. Also, when the patient stops developing, the apophyseal centers fuse automatically. In most cases, patients recover well with traditional therapy. And, only a small minority needs surgeries.

Doctors treat apophysitis in various ways depending on the location and severity of the injury. However, the basic recommendation is always to rest. Other treatments that doctors recommend are:

• NSAIDs or other medications that control pain and relieve inflammation
• Ice massage to control pain and soothe inflammation of the affected area
• Braces or any other medical equipment often help alleviate pain while protecting the area.
• Rehabilitation including stretching, strengthening, and treatments help relieve pain and prevent future complications.
• Sometimes, doctors recommend periods of non-weight bearing and/or immobilization by using a non-weight bearing, walking boot, crutches, and or cast.

Hip apophysitis is an overuse injury affecting the growth plates (apophyses) in children and adolescents, typically caused by repetitive stress from sports or intense physical activity. Proper treatment is essential to relieve pain, promote healing, and prevent long-term complications. Below is a detailed, step-by-step guide on how to effectively manage and treat hip apophysitis.

1. Activity Modification and Rest

Why It’s Important:

Overuse is the primary cause of hip apophysitis, so reducing repetitive stress is the first step in healing.

What to Do:

• Immediately stop or reduce activities that cause pain, especially high-impact sports like soccer, basketball, gymnastics, and running.
• Encourage relative rest rather than complete immobilization—light activities such as walking may still be allowed if they don’t worsen symptoms.
• Avoid sudden movements like jumping, sprinting, or cutting motions, which can further irritate the apophysis.
• Monitor symptoms: If pain persists even during daily activities, further rest is needed.

2. Ice Therapy (Cryotherapy)

Why It’s Important:

Ice reduces pain, swelling, and inflammation in the affected area.

How to Apply:

• Use an ice pack or a bag of frozen peas wrapped in a thin towel to prevent frostbite.
• Apply for 15 to 20 minutes every three hours during the first 48 to 72 hours after symptoms begin.
• Never place ice directly on the skin to avoid irritation or burns.
• Continue icing after activity as needed to prevent flare-ups.

3. Pain Management with Medications

Why It’s Important:

Pain and inflammation can hinder healing and make daily activities difficult.

Recommended Medications:

• Acetaminophen (Tylenol): Best for pain relief without reducing inflammation.
• Non-steroidal anti-inflammatory Drugs (NSAIDs) such as Ibuprofen (Advil, Motrin) or Naproxen (Aleve): Help reduce both pain and inflammation.
• Always follow proper dosage recommendations based on age and weight.
• Consult a doctor before prolonged NSAID use, especially in children.

4. Gentle Stretching and Physical Therapy

Why It’s Important:

Tight muscles can contribute to apophysitis by increasing stress on the hip growth plate. Stretching and strengthening help improve flexibility and prevent future injuries.

Effective Stretching and Strengthening Exercises:

• Hip flexor stretches: Stand in a lunge position with the back knee on the ground and push your hips forward slightly. Hold for 20-30 seconds per side.
• Quadriceps stretch: Pull one foot toward the buttocks while standing, keeping the knees together. Hold for 20-30 seconds per leg.
• Hamstring stretch: Sit on the floor with one leg extended and reach toward the toes, holding for 20-30 seconds.
• Core strengthening: Exercises like planks and bridges support hip stability and reduce strain.
• Physical therapy guidance: A professional therapist can create a customized rehab plan to restore strength and mobility.

5. Gradual Return to Sports and Activity

Why It’s Important:

Returning to sports too soon increases the risk of re-injury and prolonged recovery.

Guidelines for Safe Return:

• Wait until the pain has completely subsided before resuming intense activity.
• Start with low-impact activities like swimming or cycling before returning to running and jumping.
• Gradually increase activity over 2-4 weeks rather than jumping back into full training.
• Monitor for signs of pain or limping—if a limp is still present, the child is not ready to return.
• Use proper warm-up and cooldown routines to reduce future injury risk.

6. Long-Term Management and Monitoring

Why It’s Important:

Hip apophysitis symptoms can fluctuate as a child grows, so ongoing care is essential.

Key Considerations:

• Growth spurts may cause symptoms to come and go, requiring periodic treatment.
• Maintain a strong and flexible core and hip musculature to reduce stress on the apophysis.
• Encourage proper biomechanics and posture during sports to avoid excessive strain.
• In rare cases, if symptoms persist despite conservative treatments, a sports medicine specialist or orthopedic doctor should evaluate for additional interventions.

Conclusion

Treating hip apophysitis involves a combination of rest, pain management, physical therapy, and a gradual return to activity to ensure proper healing. Recognizing symptoms early and following a structured recovery plan can prevent long-term complications and allow young athletes to resume their favorite activities safely.

By following these targeted treatment strategies, both parents and athletes can effectively manage hip apophysitis and ensure a smooth recovery.

Prevention of Apophysitis

Coaches, parents, and young athletes can help prevent apophysitis. All that is needed is awareness. Your child needs to advise his parents of any activity-related pain. Also, children should recognize the symptoms of apophysitis in an early stage. This is how they can prevent the problem from getting worse.

• When a child is having pain because of an activity, he/she should rest until the pain completely resolves. Once the complications are gone, patients can again return to those activities.
• One thing that contributes a lot to prevention is maintaining and improving the flexibility of muscles as your child develops. Make sure they never avoid doing proper warmups and stretching before doing strenuous activities.
• Avoiding single sport specialization will let your child’s body take rest from strenuous and repetitive sports activities such as throwing or jumping. Thus, it will prevent overuse injuries.

Returning to Play

• Before getting back to a normal activity schedule children should feel minimal pain while squatting and jumping. Thereafter, a progression through sports-specific movements should occur before a full return to sport.
• If an athlete is limping or experiencing pain during activities, he/she should continue treatment and return to sports only after consulting the orthopedic doctor.

Follow-Up

After treatment, you must visit your doctor for regular follow-up. They can help you know the right time to return to sports or activities. They can advise you on a step-by-step return to exercise program over a couple of weeks. Also, they will advise on stretching exercises to prevent the chance of re-injury.

Advice to Parents

Proper rest, not rushing back to sports, and being in touch with regular physiotherapy/exercise programs is crucial. Returning to sports before complete recovery increases the chances of problems coming back and delayed recovery.

When to Consider an Orthopaedic Referral for Apophysitis

Determining the right time to refer a patient with apophysitis to an orthopaedic specialist can be crucial for effective treatment. Here are some factors to consider:

• Uncertain Diagnosis: If the diagnosis isn’t clear or if the condition does not respond to initial treatment, an orthopaedic referral may be warranted.
• Severe or Persistent Symptoms: Cases where pain or dysfunction persists despite conservative management should be evaluated by an orthopaedic expert.
• Complicated Cases: If apophysitis is accompanied by other complications that could affect the treatment plan, involving an orthopaedic specialist might be beneficial.
• Specialized Opinion: When the standard protocol needs adjustment or a multi-disciplinary approach, guidance from an orthopaedic surgeon could provide valuable insights.

Typically, follow-up care involves collaboration with a physiotherapist or a sports physician for additional support and rehabilitation.

Sources Supporting Information on Apophysitis

A range of academic resources offer insight into apophysitis and its impact, particularly among athletes. Here are some key references:

• Clancy and Foltz’s Study: This research, appearing in the American Journal of Sports Medicine, details iliac apophysitis and stress fractures observed in adolescent runners from 1976. It provides foundational understanding of the condition’s effects in young athletes.
• Frush and Lindenfeld’s Overview: Published in Sports Health in 2009, this paper delves into both peri-epiphyseal and overuse injuries, shedding light on how these issues manifest in adolescent athletes.
• Pointinger’s Case Study: Featured in the British Journal of Sports Medicine in 2003, this report examines avulsion fractures of the anterior superior iliac spine, a result of apophysitis, enriching the understanding of its clinical implications.
• Read’s Imagery Resource: The website provides accessible imagery related to sports medicine, including topics on pubic apophysitis. This visual guide is critical for grasping the physical manifestations of the condition.
• Sailly et al.’s Clinical Entity: Published in the British Journal of Sports Medicine in 2015, this paper introduces pubic apophysitis as a newly recognized source of groin pain in athletes, expanding current diagnostic considerations.

These references collectively enhance the comprehension of apophysitis, emphasizing the condition’s relevance in sports medicine and adolescent health.

Final Words

When returning to activity after any injury, any pain should call for an immediate stop of the activity. Children should never try to push through because it can make the condition even worse. Remember, for complete and fast recovery from Apophysitis, having patience is important. However, for the best treatment available parents should bring their child to the Medical City Children’s Orthopedics Spine Specialists which have offices in Arlington, Dallas,  Flower Mound, Frisco, and McKinney, TX.   The practice is led by a team of highly qualified, experienced orthopedic surgeons. Our doctors are recognized as leaders in diagnosing and treating children for orthopedic and sports medicine injuries. Furthermore, the practice is well recognized for the scope of services it offers, as well as its doctors’ medical expertise.

The orthopedic surgeons at The Medical City Children’s Orthopedics Spine Specialists are board-certified, having completed rigorous training at the finest medical institutions in the country. Additionally, they specialize in all aspects of orthopedic care for children, including disorders of the knee, shoulder, elbow, hip, spine, foot, and ankle; trauma; and arthritis.

Each patient’s treatment program is tailored to the patient’s specific needs. Also, we continue to monitor patients with ongoing reevaluations and adjustments as the recovery progresses. Whether your child plays sports, just runs around with friends like kids do, or suffers an injury, The Medical City Children’s Orthopedics Spine Specialists is here to help. Furthermore, the team offers the most advanced treatment, which combines the latest in cutting-edge technology.  The surgeons prioritize minimally invasive techniques.  However, when necessary the surgeons will use sophisticated surgery to treat children and get them back to normal.

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Footnote:

Sports Medicine Today: Apophysitis