Adolescent Athletes: Don't Forget the Growth Plates

Jimmy is a 12-year-old baseball pitcher with shoulder pain in his throwing arm. His pain, somewhat diffuse along the lateral edge of the shoulder, came on gradually throughout the season and was worse after throwing. You examine him and he has pain with resisted external rotation, range of motion is limited by pain, and impingement signs are positive.

Does Jimmy have impingement syndrome? Well, since you already saw the title to this article, you hopefully know that the answer is no and is less likely in most adolescents.

While the information about Jimmy is limited, it all suggests he is dealing with Little Leaguer’s Shoulder, or proximal humeral epiphysiolysis (PHE). The point of that very brief case study was to illustrate that, for the most part, children and adolescents deal with a different set of injuries, particularly when they are overuse injuries.

PHE is one of several growth plate/physeal overuse injuries that are common in youth athletes. Other common growth plate injuries include:

  • Osgood-Schlatter Disease (tibial tubercle apophysitis)
  • Sever’s Disease (calcaneal apophysitis)
  • Little League Elbow (medial epicondylar apophysitis)
  • Iliac crest apophysitis
  • Ischial tuberosity apophysitis

If you were reading closely, you may have noticed that everything I listed is an apophyseal injury with the exception of Little League Shoulder, which is an epiphyseal injury. So what is an apophysitis, and what differentiates an epiphyseal injury from an apophyseal injury? An apophysis is a site of attachment of a muscle tendon at the end of a long bone, which plays a role in development of bone shape but not of longitudinal bone growth. An epiphysis is also at the end of long bone but is susceptible to compressive forces instead of traction forces. Epiphyseal injuries can alter growth of the bone. In either case, chronic physeal injuries occur by repetitive traction or rotational forces occurring at the growth plate through repetitive loading of the muscle that attaches to that particular location. These injuries typically occur during times of increased growth of that particular growth center.

One important thing to consider when an athlete presents with what may be one of these injuries is that different growth plates close within different age ranges. Therefore, athletes are potentially more vulnerable to particular growth plate injuries at specific age intervals:

  • Sever’s Disease: 7-10 years
  • Little league elbow: under 10 years
  • Osgood Schlatter Disease: 11-15 years
  • Little League Shoulder: 11-16 years
  • Iliac crest apophysitis: 10-20 years
  • Ischial tuberosity apophysitis: 11-23 years

There are a variety of other possible conditions with which a young athlete could present, so thorough examination is vital. Once the clinician is sure they are dealing with a musculoskeletal issue, other pathology such as sprains, strains, tendinopathies, and stress fractures that do not involve the growth plate should be ruled in or out. The clinician should also keep in mind the possibility of an avulsion fracture occurring at the affected apophysis and refer accordingly if suspected.

So what does physical therapy look like for a young athlete who comes in with one of these overuse injuries? Well, most of the evidence that’s out on any of these injuries suggests rest from the aggravating activity as the primary component of treatment. No brainer, right? Beyond rest, evidence varies as far as what other components of treatment should be included for each type of injury. However, these young athletes have likely been performing the same activity for at least 9 months out of every year. If they play a second sport because someone told them single-sport athletes have a higher risk of injury, they probably play that second sport on top of the first sport instead of giving up any time playing the primary sport.

With that in mind, education is going to be cornerstone of physical therapy treatment for athletes with growth plate injuries. That doesn’t mean the physical therapist should just tell them to stop playing their sport so much and do some other stuff for cross-training. They’ve heard that much already.  Physical therapists have the skill set to equip these athletes with cross-training programs that directly address the impairments that led to the overuse injury and were created as a result of the injury.

Additionally, physical therapy can help to restore (or create) full range of motion, strength, and neuromuscular control necessary for the particular athlete’s sport demands. After a sufficient rest period and the necessary physical therapy, a progressive return to sport program is vital to gradually increase the load back to the athlete’s pre-injury level.

Another extremely important role for physical therapists as it relates to these (and any other) overuse injuries in youth sports is prevention. Physical therapists can coordinate and communicate with local teams, schools, and training centers to disseminate information about injury prevention and create maintenance cross-training plans for prevention of overuse injuries.

If youth athletes are not a physical therapist’s typical patient population, growth plate injuries related to overuse, particularly some of the less common ones, may not be the first thing that comes to their mind. This article did not cover any one injury in great detail, so I encourage you to utilize some of the attached references if you would like to learn more about any of them. Also, while overuse physeal injuries were highlighted in this article, many of the same treatment and education principles apply for any other overuse injury in a young athlete. Feel free to leave a comment or contribute some additional information through Facebook or Twitter.