1

What is apophysitis?

Apophysitis is an injury secondary to overuse, seen in young, skeletally immature athletes. It is believed to result from repetitive microtrauma from forceful contractions by surrounding musculature. In the immature athlete, the area surrounding the growth plate, or apophysis, is relatively weak compared to attached tendons. Chronic tension from these attachments causes bony disruption and may lead to avulsion of the secondary ossification centers. As this area continues to grow, ossify, and enlarge, it may result in fibrous nonunion or union with bony enlargement. These areas of bony disruption may become painful and persist during an athlete’s growing years. Pain will generally resolve after athletes complete their growth; however occasional individuals may complain of chronic pain into adulthood.

The aim of this chapter is to educate on the presentation of various apophysitides, offer guidance that can be provided to patients, and provide some structure and ideas for treatment. The following chapter is limited to overuse apophyseal injuries.

2

In patients with Osgood-Schlatter disease, will continued play result in long-term knee problems?

Background: Osgood-Schlatter disease (OSD), sometimes referred to as Osgood-Schlatter syndrome, is one cause of anterior knee pain in young athletes. OSD was first described by Robert Osgood and Carl Schlatter in 1903. Due to chronic tension from the quadriceps muscle and patellar tendon, the apophyseal cartilage of the tibial tuberosity becomes separated from the anterior aspect of the tibia.

Presentation: The age of presentation is 12–15 years in boys, and 8–12 years in girls, with boys more commonly affected. History of pain is generally vague and progressive and located over the area of the tibial tuberosity. Pain typically worsens with activities, including running, jumping, squatting, kicking, and kneeling, and is relieved with rest. Risk factors for developing OSD include increased sporting activity in young individuals, family history of OSD, and quadricep and hamstring muscle tightness.

Physical examination: On physical examination, patients will have tenderness to palpation over the tibial tuberosity and a bony enlargement may be visualized. Pain with resisted knee extension may also be noted. The diagnosis of OSD is best made clinically.

Imaging: Radiographic imaging can be used for unilateral cases to rule out diagnoses such as fracture, infections, or tumor. Radiographs may demonstrate separation of the apophysis from the tibial tuberosity; however, this will not alter management. Magnetic resonance imaging (MRI) or computed tomography (CT) offer little in terms of establishing the diagnosis or treatment and should be reserved for refractory cases that do not respond to conservative management. Ultrasound is an inexpensive and safe option to assess the tibial tuberosity and may distinguish stages of disease; however, more research is needed.

Treatment: OSD is generally a self-limiting condition and will resolve after the patient has completed growth. Approximately 90% will improve with conservative treatment. Patients may be treated with ice, nonsteroidal antiinflammatory drugs (NSAIDs), and knee padding. Physical therapy may be beneficial for strengthening and improving flexibility of the quadriceps, hamstring, and gastrocnemius muscles and iliotibial band. High-intensity quadriceps strengthening should be avoided in early rehabilitation. If an athlete complains of mild pain and no weakness, activity may continue as tolerated. The patient may initially require modification of activity to continue pain-free participation. If the athlete continues to have pain despite modifying activities, then complete rest is necessary, which can be guided by individual pain levels. The importance of rest should not be underestimated as nonadherence may increase the risk of pain continuing into adulthood. Time of rest is variable and may require anywhere from 2 to 10 months. Surgical intervention is the last line of treatment and should be reserved for only those who are skeletally mature and continue to have symptoms despite appropriate conservative therapy. Corticosteroid use for this condition should be avoided due to risk of subcutaneous atrophy and tendon damage.

3

Are radiographic images necessary to diagnose Sever disease?

Background: Another location of pain seen in young athletes from apophysitis is in the posterior heel. This was first described by Haglund in 1907and then Sever in 1912. This condition is believed to result from traction of the Achilles tendon on the secondary ossification center of the calcaneus.

Presentation: The average age of onset is 11–15 years in boys and 8–13 years in girls. Boys are more commonly affected. Risk factors include high levels of athletic activity, obesity, increased height, and decreased ankle dorsiflexion. Pain is routinely described as “non-specific” and aggravated by activity.

Physical examination: The diagnosis of Sever disease is best made clinically. Edema, erythema, and warmth will be absent. There will be tenderness at the posteroplantar aspect of the calcaneus. Research demonstrates the most reliable physical examination findings are positive squeeze test (lateral compression over the calcaneal tubercle) and barefoot one-leg heel standing. These have the highest sensitivity (97% and 100%, respectively) and specificity (each 100%) for making the diagnosis.

Imaging: Imaging for suspected Sever disease is low yield. Abnormalities over the calcaneus in a young athlete are neither sensitive nor specific. No radiographic sign has been found to be pathognomonic, and changes can be seen in asymptomatic, healthy individuals. For these reasons, radiographs should be reserved for ruling out pathologic abnormalities in recalcitrant cases. A lateral view provides the highest benefit. Ultrasound has also been investigated with some promise; however, further studies are needed.

Treatment: Calcaneal apophysitis is self-limited. Treatment options include rest, orthotics, physical therapy, ice, and NSAIDs. Although several treatment options are available, it does not appear they have a large impact on time to resolution, as pain improves within 3 months. Heel lifts may be recommended as those patients admitted to improved satisfaction with treatment; however, this comes with financial implications. Over-the-counter heel lifts would be desirable over custom orthotics, as their use should be short term.