Apophysitis: Growing pain in young athletes

By: Sydney DeVoss, PT, DPT.

What is it?

Is your young athlete going through a growth spurt and having knee, heel, or hip pain?
Do they get pain and swelling after participating in their sport? He or she might be
suffering from apophysitis, a growth related injury to the apophysis, or secondary growth
plate, in a long bone. The apophysis is where tendons will attach the muscle to the
bone, so when a bone is growing faster than the muscle and tendon that it attaches to,
the tendon is placed under a large tensile load and can tug at the apophysis. This
creates inflammation and pain at the joint, and often tenderness to pressure on the bony
prominence. 1,2

Apophysitis can occur in any long bone of the body, but most commonly occurs in the
calcaneus (Sever’s disease), the tibial tubercle (Osgood Schlatter’s), at the bottom of
the knee cap (Sinding-Larsen Johansson), or at the iliac crest (Iliac apophysitis).
Sever’s presents as pain at the heel at the base of the Achilles tendon, and is typically
seen in girls 7-9 and boys 8-15. 2 Osgood Schlatter’s presents as pain 1.5-2 inches
below the kneecap on the front of the shin and is mostly seen in girls 8-12 and boys 12-

15. 2 Sinding-Larsen Johansson presents as pain on the lowest tip of the kneecap, and is
    mostly observed in children 10-13. 2 Iliac apophysitis presents as pain in the hips and
    lower abdomen, and occurs most commonly in ages 14-18. 1
    Apophyseal injuries are most commonly seen among athletes in high impact sports,
    such as gymnastics, soccer, and basketball, due to the repetitive loading at the joint. 2
    Apophyseal injuries are primarily diagnosed through taking a complete medical history
    and through a full evaluation, but can be confirmed on x-ray. 2 Pain is often worse with
    stretching the joint and with activity, and is improved with rest. 1

How should I treat it?

Pain can occur with increased play or in more extreme cases with simple activities like
walking or squatting. Most of the time, kids can continue to train, but are advised to
decrease their training load or intensity if pain levels increase. A heel cup or tendon
strap may provide some pain relief during activity and help reduce post exercise
swelling. 1,2

Conservative treatment, including physical therapy, is recommended for an apophyseal
injury. Treatment will often include reducing tension in the muscle that attaches at the
injury site, addressing muscle weakness, and correcting body mechanics to reduce
stress placed on the area of pain. Your physical therapist will provide an individualized

exercise program for muscle strengthening and range of motion, based on what was
found during your evaluation.

Untreated apophysitis can lead to the apophysis becoming fractured, and this is called
an avulsion fracture. Surgery is not usually necessary, unless the injury has progressed
to an avulsion fracture that is non-union or non-displaced. 1,2

How can I prevent apophysitis?

Training programs should limit excessive repetitive movements, and incorporate multi-
plane movements. Additionally, teams should incorporate strength training in all muscle
groups, especially the underused muscles for that sport. Range of motion exercises are
also recommended to reduce the stress placed on the apophysis. 1,2

Overtraining and early sport specialization can also increase risk for developing an
apophyseal injury, due to the repetitive movements.

References:

1. Longo UG, Ciuffreda M, Locher J, Maffulli N, Denaro V. Apophyseal injuries in
   children's and youth sports. Br Med Bull. 2016 Dec;120(1):139-159. doi:
   10.1093/bmb/ldw041. Epub 2016 Nov 23. PMID: 27941042.
2. Maruszczak, K., Madej, T., & Gawda, P. (2024). Lower Limb Osteochondrosis
   and Apophysitis in Young Athletes—A Comprehensive Review. Applied
   Sciences, 14(24), 11795. https://doi.org/10.3390/app142411795