Growth related injuries and pain are common in children and growing adolescents. These injuries occur at the sites of our growth plates, commonly affecting the sites where the tendons attach at these growth plates to the bone. These sites in the skeletally immature individual are known as an apophysis. The most prevalent growth related injuries we see are present in the young athletic populations. These injuries are typically due to tensile loading at these immature apophysis sites. As the tendon is stretched under repeated high tensile loading at these sites, it leads to what is known as a traction apophysitis injury.

These injuries are self-limiting in nature and need appropriate management to improve pain and functional outcomes. With the self-limiting nature of these injuries they typically resolve in time. Once the growth plate ossifies and closes, the pain of these conditions usually resolves. Although these injuries typically resolve, they can really affect the way your child performs at their desired sport. Pain can have a detrimental effect on their performance, which can decrease their enjoyment and satisfaction with sport and movement. This can lead to time loss from the sport, which can derail their development at a time that is crucial. With an appropriate diagnosis, your osteopath at The Reform Lab Osteopathy will provide education and rehabilitation to improve outcomes until the growth plate closes. With this approach, there is an increased chance your child can continue to perform and play. As the rehabilitation does involve a strength and conditioning component, it can serve as an opportunity to improve physical capabilities which may improve their performance match day and into the future.

If your child has described pain or you may even notice they are moving differently (which looks abnormal), it is recommended you bring them in for an assessment to rule out any red flags. Pain in children, especially the growing child can be due to conditions like cancer in the bones (osteosarcoma) or other conditions like Perthes Disease. A condition like Perthes Disease can lead to destruction of the hip joint due to a loss of blood supply. The bone can become brittle and fragment, before dying (osteonecrosis).

Perthes Disease has no known causes and comes on without a traumatic event. Due to the destruction and eventual flattening of the head of the hip joint, it can lead to a leg length discrepancy. So they need to be picked up early so appropriate management can be provided. If we have suspicion of Perthes Disease, we will refer off to an orthopaedic specialist. It typically occurs between the ages 4-8 and mainly affects boys. The child will often walk with a limp and they may experience referred pain into the thigh and knee. The child typically is unable to internally rotate their hip due to the presence of pain.

Freiberg disease is a painful condition in which the head of primarily the 2nd metatarsal of the foot flattens due to a lack of blood flow. If this is not addressed then like Perthes disease, the bone can die and lead to a deformity. It again is not known to have a primary cause, however is prevalent in ballet dancers. This has lead to the hypothesis that repetitive stress through the metatarsal heads leads to a reduced blood supply. It is normally resolved by activity modification, to reduce the stress placed on the metatarsals. Girls are affected five times as more as boys, with a peak age presentation being from ages 11-17.

A Slipped Upper Femoral Epiphysis (SUFE) is a condition that is actually less common in athletic children. It occurs primarily in children classified as obese, affecting this population >80% of the time. It is the most common hip pathology in pre-adolescents and adolescents. This painful condition has no known cause and typically presents as atraumatic hip pain. The child may experience knee and thigh pain, and will struggle to bear weight in the hip leading to a limp. It is believed this condition occurs when the growth site (physis) on the femur is compromised, via increased axial and mechanical forces. This is why those with obesity are thought to suffer with this condition more. This results in deformities to the anatomy of the hip joint, increasing the risk of osteonecrosis to the femoral head. It is often seen in males aged 12-13 and females 11-12 years old. Identifying this condition is crucial to reduce complications later on in life. If we suspect a SUFE, we will refer on for an orthopaedic opinion.

Common Growth Related Injuries

The following conditions are common complaints that we diagnose and manage in the clinic/rehabilitation gym of The Reform Lab Osteopathy and Project Reform.

Pars defect - Spondylolysis
This is a relatively common lower back stress related injury. It initially may begin with a stress reaction, which then can progress into a stress fracture to an eventual fracture. It can either be unilateral (considered stable) or bilateral (considered potentially unstable and increases the risk for a spondylolisthesis). A spondylolisthesis is when one vertebral body shifts forward or backwards on the adjacent vertebral body. This injury has different gradings based on severity.

The young growing athlete is at an increased risk of this injury. Attention to rapid growth spurts in conjunction with back pain is important to note in formulating a diagnosis. If these athletes are also completing high training loads, with inadequate recovery, their risk increases.

Sports involving rapid extension and rotational movements of the trunk are the most prevalent for this condition. Cricket is a major sport this occurs in, it is often referred to as ‘the fast bowlers injury’. Tennis, volleyball, football and gymnastics are also sports where this injury has an increased prevalence.

Why younger athletes are at an increased risk is due to the lay down of immature bone after high peak loads. With inadequate recovery and repetitive high peak loads, a stress fracture can develop. This injury can often be asymptomatic for some time and may present as gluteal pain as the first symptom.

After a diagnosis, which will be confirmed via imaging, structured exercise rehabilitation should be implemented. At The Reform Lab Osteopathy, we provide evidence based management inside the elite gym Project Reform.

Scheuermann’s Disease

This condition most commonly presents in the thoracic spine (middle back). Its cause is unknown, however it is believed genetics are involved. Young athletes that load through flexion and with a family history are at an increased risk. It is characterised by a “hunchback deformity” where the vertebral bodies and spinal discs have anterior wedging of greater than or equal to five degrees in three or more adjacent vertebral bodies. It is most commonly diagnosed in adolescents 12-17 and affects males at a 2:1 ratio. What actually results in the anterior wedging during adolescence is unknown. However, they believe the anterior portion of the vertebral body lacks blood supply during periods of growth which leads to poor mineralisation and deformed ossification. Scheuermann’s disease is characterised on imaging by Schmorls’s nodes, which are intravertebral disc herniations through the vertebral body endplate, into the adjacent vertebral body.

Director and Osteopath Jackson actually has this condition, which was diagnosed once he learnt about it at university. People with Scheuermann’s disease may have an increased risk of hamstring strains and back pain, however there is no solid evidence that confirms this correlation. The condition is managed with exercise rehabilitation to improve strength and function in areas that are potentially affected by this condition. Manual therapy through osteopathy’s thought process to treatment can provide pain relief in the growing child.

Severs Disease

This condition is also known as calcaneal apophysitis, due to its location and pathology. This painful condition affecting the posterior heel where the Achilles tendon inserts, is common in young athletes competing in sports like basketball, football and gymnastics. These sports require forceful loading through the immature growth site. When repetitive jumping for example occurs, the powerful Achilles tendon forcefully pulls on the weak and immature growth plate. It most commonly occurs in children 10-12 and is seen as a precursor to developing Osgood-Schlatter Disease. Research has shown that individuals with Severs Disease are 5 times the risk of developing Osgood-Schlatter Disease compared to children without Severs.

Treatment for this condition should consist of activity modification, and gradual strengthening to the local and surrounding structures. Ensuring that children do not fully stop sport or activity is a priority for us at The Reform Lab Osteopathy. We structure and coach our rehabilitation inside the elite gym Project Reform. Once the growth site matures and ossifies, pain often resolves. This commonly occurs in early teens, however skeletal maturity occurs at different rates for different people.

Osgood-Schlatter Disease & Sinding-Larsen-Johansson Syndrome

These conditions are common reasons for anterior knee pain in the immature growing adolescent. These conditions are more prevalent in the athletic population and are seen more commonly in sports that require jumping, sprinting and change of direction. Osgood-Schlatter Disease occurs at the patellar tendon insertion, the tibial tuberosity of the tibia (shin bone). It is typically caused by repetitive stress from the extensors of the knee, resulting in traction of the tendon away from the immature growth site of the tibial tubercle. The pain will usually come on gradually without the event of trauma. As a result of the forceful traction on the soft immature growth site, a partial avulsion fracture of the tibial tubercle can result in severe prolonged cases. This does not typically cause complications later in life, however a permanent deformity at the front of the knee will occur in the form of a bump. It is more common in boys and typically occurs aged 12-15 in males and 8-12 in girls. It has an increased risk of occurrence during periods of rapid growth (like most growth related injuries). Osgood-Schlatter Disease in 20-30% of cases presents on both sides of the body. Symptoms typically resolve once closure/fusion of the growth site occurs, this normally is between 14-18 years of age.

Sinding-Larsen-Johansson Syndrome (SLJS) is very similar to Osgood-Schlatter Disease, however the pathology occurs at the inferior pole of the patella (kneecap). It presents at a similar time to Osgood-Schlatter Disease and is caused by the same mechanism of repetitive forceful extension. The patella ligament can then traction away from the inferior pole of the kneecap as a result. These conditions often present together, with it also being more prevalent in athletic teenage boys around the age of 12-15.

These two conditions require education and an appropriate structured exercise rehabilitation program. This will help alleviate symptoms, improve strength and functional capabilities. More importantly it will keep these young athletes involved in their sport. Our clinic and rehabilitation facilities are truly unique, as we provide our services in the fully equipped elite gym Project Reform.

Apophysitis of Ischial Tuberosity

The apophyseal site that forms the ischial tuberosity is the most common apophyseal injury to the pelvis. The hamstrings muscle group and its tendon attach to this immature site. This injury largely affects athletes who participate in sports that require high end sprinting, accelerations and decelerations. Sports such as Australian rules football, the rugby codes and soccer are prevalent sports where this injury occurs. This site is one of the final sites to mature and ossify, with it fusing to the rest of the pelvis between the ages of 18-25. So it can occur even as late as early adulthood, whilst the skeleton is still maturing. This injury most commonly occurs in older teens, with it typically occurring later then Osgood-Schlatter Disease and SLJS. This injury in more severe cases, can result in an avulsion fracture of the ischial tuberosity away from the growth site.

This condition needs appropriate management with education and a structured exercise rehabilitation program. Activity modification is recommended, with targeted strengthening to the hamstring muscle complex and surrounding muscles of the lower limb and trunk. At The Reform Lab Osteopathy we provide our rehabilitation in the elite gym Project Reform.