MIAMI — In young children, think apophysitis instead of tendonitis, Dr. Teri McCambridge said at a meeting on pediatric sports medicine sponsored by the American Academy of Pediatrics.
Apophysitis is a traction injury that can occur wherever a tendon attaches to bone in an open apophyseal center. Even though these are growth-related injuries, they usually occur on only one side, and stem from differences in the use of each limb in many sports.
Dr. McCambridge of Johns Hopkins University, Baltimore, emphasized that excessive participation in a single sport is often a culprit. “When you do year-round sports of the same thing, you're stressing the same growth plate over and over, and that's why they are breaking down.”
The American Academy of Pediatrics recommends restricting organized sports participation to children at least 6 years of age, while specialization in one sport should be reserved for adolescents.
The way a young tennis player grips her racket or the placement of cleats on a soccer player's shoes can contribute to an overuse injury such as apophysitis. Dr. McCambridge advised looking for fixable causes and consulting with a coach or if it's not clear what to look for in a particular sport.
Although apophyseal centers close in a distal-to-proximal fashion, the exact timing of their appearance and disappearance varies by joint and by individual. The last apophyseal centers to close in the lower extremity are those in the hips, and, therefore, clinicians should watch for apophysitis of the hip in older adolescent athletes.
Calcaneal apophysitis, or Sever's disease, tends to occur early in the growth spurt, at age 8–12 in girls or age 10–14 in boys. It is most common in sports in which children wear cleats, such as lacrosse and soccer, or do not wear shoes, as in gymnastics or dance.
Children with calcaneal apophysitis often complain of ankle pain, although upon closer examination the source of the pain turns out to be the heel. Dr. McCambridge said that x-rays are generally not warranted except in certain instances, such as children with atypical features or nighttime pain, those on the extremes of the expected age range, and those who do not improve after treatment.
Other potential causes of joint pain in children, including tendonitis and, rarely, stress fractures, osteomas, tumors, or rheumatologic conditions.
Rest is a critical treatment for apophysitis. Children with calcaneal apophysitis also can use ice and should avoid walking barefoot. Dr. McCambridge suggested that when the child has no pain with daily living, he can return to sport with modifications such as the use of heel cups and supportive shoes and the removal of cleats, especially for practice.
Another common traction apophysitis is Osgood-Schlatter disease (OSD), which occurs at the tibial tuberosity in children aged 11–15 years. Children often present with pain over the anterior tibia, pain with activity, and pain with full flexion. They also tend to have swelling and palpable tenderness at the tibial tuberosity.
Chronic OSD carries the risk of long-term problems due to the formation of painful, nonunited ossicles resulting from fragmentation of the tibial tuberosity. Because of this risk, Dr. McCambridge tends to radiograph OSD more than any other apophyseal injury to try to prevent the condition from getting to that point.
For children with significant fragmentation, she recommends using a knee immobilizer for 2 weeks, followed by rehabilitation. These athletes tend to remain out of activity for 4–6 weeks.
Fracture extension into the epiphyseal plate is another potential risk of OSD, although it only occurs rarely. Rest is the most important treatment measure for OSD. Children can benefit from stretching and strengthening exercises and the use of a patellar strap.
The way a young tennis player grips her racket can contribute to an overuse injury such as apophysitis. DR. MCCAMBRIDGE