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Apophysitis

Apophysitis - Teenagers still need treatment

Relative rest isn’t always the best way to handle the growing pains of Osgood-Schlatter’s and Sever’s. By Sean Fyfe

Over the years I have become used to seeing promising young sports enthusiasts forced to significantly decrease their participation levels and play at far less then 100 % because a doctor – or even a sports injury professional – has told them that they have Osgood- Schlatter’s or Sever’s disease and must there-fore adhere to a regime of ‘relative rest’ until bone growth ceases.

In my experience some relative rest may be necessary at certain stages, but as a sole prescription this advice is nearly always bad. With the appropriate treatment it is rare that a child can’t completely remedy the problem, or at least significantly decrease symptoms, enabling them to continue to train through what may be a critical developmental period for their future sporting career.

Osgood-Schlatter’s and Sever’s are both ‘apophysitis’ conditions, classic phenomena of adolescent growth, in which an area of active bone growth beneath a tendinous attachment (apophysis) becomes inflamed.

Osgood Schlatter’s(11-15 years old) is inflammation of the apophysis that sits beneath the tibial tuberosity at the base of the front of the kneecap. The tibial tuberosity serves as the attachment site for the patellar tendon, through which the quadriceps mechanism operates.

Sever’s disease (9-14 years old) is inflammation of the apophysis that sits beneath the calcaneal (heel) attachment of the Achilles tendon, through which the calf and soleus muscles act to forcefully push off through the ball of the foot during locomotion.

In both conditions the apophysis represents the weakest link in the chain: in the case of Osgood-Schlatter’s it is the knee extension chain; in Sever’s the ankle plantar flexion chain. And in both cases, if there are local dysfunctions in muscle stability, flexibility or biomechanics, or incorrect training loads, the weakest link will undergo repeated microtrauma, leading to inflammation.

In older athletes the comparable weakest link may be the patellar tendon or patellofemoral joint; or the Achilles tendon or Achilles musculotendinous junction. I believe the key is to approach apophysitis problems in the same way as overuse injuries in adults, namely: assess the components of the dysfunctional kinetic chain relating to the injury and remedy any flexibility, stability, muscle strength or biomechanical issues under appropriately modified training loads.

Case study 1: Justin’s limp

Little 10-year-old Justin was a budding young point guard on the basketball court. For the past year he had been limping around for 24 hours after each game or training session because of bilateral heel pain. The week before I saw him, the condition had progressed so that he was now also getting pain during the game.

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For an Achilles problem in an adult I would assess walking and running biomechanics, lower limb alignment, calf and soleus muscle length, proximal stability and footwear. So that’s what I did with Justin.

From assessment two points needed to be addressed:

i. flexibility: calf and soleus length were both inadequate

ii. biomechanics: malalignments at the tibia and forefoot were leading to late pronation and the heel was drifting medially as it lifted off. Justin was also very calf-dominant in his gait, which produced an early heel lift.

I set Justin a regime of daily soft tissue massage, done either by his parents or on a foam roller, and soleus and calf muscle stretches to address his flexibility imbalances. I always take accurate measurements of muscle length at initial assessment so I can track changes – see Table 1 below for how I do this. I find it very helpful to have a target measurement as a goal. The table also shows Justin’s initial measurements and his measurements after one month.

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It is no coincidence that Justin’s symptoms were worse on the left, the side of greatest muscle tightness. During the month, Justin’s range slowly improved and so did his symptoms. In my experience, athletes with Justin’s calf-dominant gait mechanics will always struggle to reach the target values in the table, purely because the soleus and calves do so much work on a daily basis. After a month Justin had reached flexibility values that I was quite happy with.

However, some symptoms still persisted, so I needed to look again at the biomechanics issues. Orthotics provided sufficient support to offload the calcaneal apophysis successfully. The little point guard was able to return to his dribbling, passing and firing-in three pointers without having to hobble around the breakfast table the next morning.

Case study 2: Mitch’s sore knee

Mitch, an avid 15-year-old tennis player, presented with a very sore left knee and a visible and tender lump over his tibial tuberosity. He had struggled for a number of years with the problem, but he and his parents had always understood that relative rest was the only treatment option until the growth plate had fused.

On assessment it was revealed that Mitch overpronated during gait and demonstrated a left trunk shift during left stance phase. Flexibility testing showed a significant loss in tensor fascia lata (TFL) and iliotibial band (ITB) range of movement. The deviations from an ideal gait pattern led to gluteus medius testing, which, as predicted, revealed a very weak glut med and poor left single-leg squat.

On the single-leg squat Mitch could only hold the knee in line if he shifted his trunk to the left; if the trunk was kept straight his knee deviated medially during the squat. Left VMO (vastus medialis) bulk was markedly decreased compared to right and demonstrated poor static activation. Mitch already had orthotics, but they were years old so he’d grown out of them and they were no longer supporting his lower limb appropriately.

From the assessment there were three points that needed to be addressed to enable Mitch to play tennis with his left lower limb in correct alignment and with sufficient flexibility to avoid causing abnormal tensile load on the apophysis:

i. improve gluteus medius and VMO strength and subsequent control during single-leg activities

ii. increase flexibility of tensor fascia latae, vastus lateralis and iliotibial band

iii. reassess and refit orthotics.

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It is a key principle of sports injury management that we should always take one step at a time when problem-solving, so that we know what each specific treatment technique achieves. In keeping with this, I decided to tackle steps i and ii – it’s not as contradictory as it sounds! These two steps are part of the same problem. Because glut med and VMO are weak, TFL and vastus lateralis are being forced to overwork, causing muscle tight- ness. So you need to improve the function and strength of glut med and VMO, in order to achieve a long-term change in flexibility of TFL and vastus lateralis.

If, on the other hand, I went ahead and fitted new orthotics at the same time, I wouldn’t know where the improvement had come from, or, if the pain increased, I wouldn’t know whether it was because Mitch was doing his exercises incorrectly at home or whether the orthotics were contributing. Besides, my gut feeling was that by improving muscle strength and control and increasing flexibility, we would probably remedy the problem so that orthotics would not be needed at all.

My gut feeling was right. Mitch had been suffering with knee pain that had really limited his training and competition loads, when all he needed was a bit of simple assess- ment and problem-solving. The muscle reeducation and strengthening, combined with trigger pointing, massage and stretching, was sufficient to offload the apophysis and subse-quently allow Mitch to play his beloved tennis free from knee pain.

A final caution…

For athletes with apophysitis, it is also very important to set up the training programme correctly, factoring in adequate recovery time and paying particular attention to monitoring ground contacts in any plyometric type activities.

Apophysitis