Injuries in the Growing Athlete

Many young sports athletes are tripped up by their own skeletal system. Traumatic and overuse injuries affecting the physes (growth plates) can result in permanent deformity. Undiagnosed, untreated, and neglected injuries to the physes can put an end to a budding career. These are the findings of a study from the Cincinnati Sports Medicine Research Foundation in Ohio.

Who is affected most often? The young, skeletally immature athlete. Skeletally immature means the bones are still growing. And as long as the bones are still growing, there are growth plates at the ends of the bones to allow for the bone to get longer until growth stops.

Girls usually stop growing sooner than boys. Therefore, boys are at greater risk for injury longer than girls. The exception to this is gymnasts and ballet dancers. They seem to experience full growth later so can be older when they are injured.

The seriousness of physeal (growth plate) and epiphyseal (areas adjacent to the growth plate) injuries can't be emphasized enough. The repeated stress of sports is the major cause. Unknown or unrecognized trauma is a secondary cause.

The severity of the condition (or more likely the consequences of the injury) is directly linked to delayed diagnosis and treatment. The longer the athlete plays with an injury to the open growth plate, the greater the risk of permanent, disabling results. That's why we must pay attention anytime an athlete reports tenderness at the joint that is brought on or made worse with palpation (pressure) or stretch of a muscle that attaches to the joint.

Sports doctors must watch out for the following overuse injuries in young athletes: radial epiphysitis, elbow overuse injuries, humeral epiphysitis (Little Leaguer's Shoulder), and overuse injuries of the skeletally immature spine and pelvis. Other common problems in this age group include Osgood-Schlatter disease, Sever's disease, and Iselin's disease.

Each of these conditions is discussed at length in this article. Most common age and sports athletes affected by each problem are presented. Diagnostic findings, time to heal, and standard treatment protocols are also provided. Here's a brief summary of each one.

Distal radial epiphysitis. Radial refers to the radius is one of two bones in the forearm. The distal end is the bottom of the bone where it attaches to the wrist. Epiphysitis is a compression or shear injury most common in gymnasts.

Wrist pain associated with distal radial epiphysitis comes on gradually. It is made worse by any activity that requires weight through the extended wrist. For a gymnast, that can mean putting a stop to tumbling routines, vaulting, and back walkovers.

Permanent bone changes with shortening of the radius can occur when athletes continue to practice and compete with this condition. Early intervention with casting and rest for four weeks is the minimum time to heal. This problem can take up to six months to recover from if involvement is severe.

Elbow overuse injuries. Repetitive throwing and putting weight through the elbows can cause microtrauma in baseball players, gymnasts, and weight lifters. Shearing stresses at the elbow damage the cartilage around the growth plates. The location of the pain (medial or lateral elbow) depends on the activity and type of load placed on the elbow. Baseball pitchers develop medial pain. Gymnasts are more likely to have lateral pain.

The athlete notices it is difficult to throw or lift as much as before. Elbow pain gets their attention. If caught early, treatment doesn't have to be complete immobilization. The athlete can rest for four to six weeks.

Throwing athletes can avoid aggravating pitches. Daily stress on the elbow (whether from throwing or weight-bearing) causes damage to get worse quickly. Rest and recovery may take longer for children and young teens who have closed physes. The still growing elbow (open physes) tends to bounce back after repetitive stress better than more mature bone.

Humeral Epiphysitis. Little Leaguer's shoulder affects more than just young kids in Little League. It is very common in pitchers older than 12. To understand this condition, think about the round top of the humerus (upper arm bone) as it attaches to the shaft of the main bone. The bone at this meeting place isn't fully mature until the athlete is around 20 years old.

The force of a pitched ball distracting and twisting the bone can be strong enough to pull the growth plate away from the bone. Bone fracture or local inflammation is a natural response to fatigue in this area from repetitive overuse. Using any means of immobilization will only make it worse. The shoulder and elbow can get too stiff. Instead, a very gentle program of rest, range of motion, and strengthening with gradual return to sports is indicated. This can take up to a full year.

Spine and Pelvis. Overuse of the immature spine and pelvis can lead to low back pain from small fractures of the vertebra or hip pain from repetitive muscle pull on the unfused iliac (pelvic bone) apophysis.

The apophysis is a bony outgrowth that has not fully joined the rest of the bone. The iliac apophysis forms the curved crest along the upper portion of the pelvic bone. Once again, gymnasts are at risk for either of these injuries. Long distance runners, wrestlers, dancers, and football players develop pelvic overuse injuries. If the traction of the muscle pull is strong enough, it can pull a piece of bone along with the tendon away from the iliac (pelvic) bone. This injury is called an avulsion fracture.

Treatment for spine or pelvis problems begins with restricted activities, especially anything involving weight-bearing. With rest and activity modification, symptoms can go away in about three to four weeks. With avulsion fractures of the hamstring muscle (pulling away from the ischial apophyses), crutches are needed during walking activities. Return to sports with spine or pelvic injuries must be monitored carefully. Retiring too soon (before full healing and recovery) can result in reinjury.

Each of the other common apophyseal injuries occur in the same way: either traction or compression/shearing forces. Osgood-Schlatter disease affects the knee and is caused by repeated knee extension. Usually there is an underlying anatomic reason why this develops -- either the athlete has flat feet, knock knees, or a slight torsion of the lower leg.

Sever's disease occurs in the foot at the back of the heel. The Achilles tendon or the plantar fascia pulls away from the bone. The affected individual reports heel pain that's worse when walking or putting weight on the heel. Sometimes there is pain in the midfoot and/or discomfort in the ankle. Athletes who develop this problem usually have a pronated (flat) foot.

Athletes are usually frustrated with the recommended treatment approach. They must stop all running and rest the affected foot for at least a month. Some experts recommend the use of a cast to help ensure the patient's cooperation and give the fastest road to recovery.

And finally, Iselin's disease affects the base of the little toe. The tendon attachment of the peroneus brevis muscle in the lower leg becomes inflamed from repetitive use. The weak apophyseal cartilage can't hold up under the traction stress. Inflammation of the apophysis occurs when the athlete enters a rapid growth spurt. Anyone with an ankle sprain affecting the soft tissues of the lateral ankle (outside along the little toe side) is at risk for Iselin's disease.

With any of these overuse injuries, sports participation with repetitive motions during a growth spurt seem to be the major risk factors. Anatomic variations from the norm may add to the risk. The actions required by certain sports seem to be a part of the equation as well. Knowing that the growing athlete has an increased risk for these types of injuries should alert all who work with them to pay attention to any reports of joint or bone tenderness or pain.

Early referral to a sports physician or orthopedic surgeon is always advised. The diagnosis isn't always so easy. There are many sports injuries that can present with the same (or similar) kinds of pain patterns. A history, physical exam, and clinical tests along with X-rays or other more advanced imaging give the physician clues as to the real problem. The sooner an accurate diagnosis is made and treatment is started, the faster the athlete can recover. Delays in diagnosis extend out the treatment time and can result in further injury and/or deformity.

Reference: 

Todd J. Frush, MD, and Thomas N. Lindenfeld, MD. Peri-epiphysial and Overuse Injuries in Adolescent Athletes. In Sports Health. May/June 2009. Vol. 1. No. 3. Pp. 201-211.

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