Apophyseal Injury

Aka: Apophyseal Injury, Apophysitis, Apophyseal Fracture, Traction Apophysitis

1. See Also
   1. Epiphyseal Fracture
   2. Osteochondrosis
   3. Epiphyseal Plate
   4. Femur Epiphyseal Plates
   5. Fibula Epiphyseal Plate
   6. Foot Epiphyseal Plates
   7. Humerus Epiphyseal Plates
   8. Sternum Epiphyseal Plate
   9. Tibia Epiphyseal Plate
2. Definitions
   1. Apophysis
      1. Secondary ossification sites for tendon insertions
   2. Apophysitis
      1. Apophyseal inflammation prior to Growth Plate closure
3. Epidemiology
   1. Apophysitis is seen most commonly in young athletes
   2. Pelvis is the most common site of Apophyseal Fracture
4. Pathophysiology
   1. Bone grows faster than muscle and tendon during growth spurt in adolescents
   2. Apophysis is 2-5 times weaker than surrounding structures
   3. Results in a physiologic inflexibility at the apophyses
      1. Predisposes to overuse injury especially if tight or inflexible muscles and tendons
5. Images
   1. Apophysitis Sites
      1. 
6. Causes: Extremities
   1. Elbow
      1. Medial Epicondyle Apophysitis (Little Leaguer's Elbow, Thrower's Elbow)
   2. Knee
      1. Inferior Pole of Patella (Larsen-Johansson Disease)
      2. Tibial Tubercle Apophysitis (Osgood-Schlatter Disease)
   3. Foot
      1. Calcaneal Aphophysitis (Sever's Disease)
      2. Fifth Metatarsal aphophysitis (Iselin's Disease)
7. Causes: Pelvis
   1. Anterior Superior Iliac Spine
      1. See Anterior Superior Iliac Spine Avulsion Fracture
      2. Sartorius tendon insertion
   2. Anterior Inferior Iliac Spine
      1. See Anterior Inferior Iliac Spine Avulsion Fracture
      2. Rectus Femoris tendon insertion
   3. Ischial tuberosity
      1. Hamstring tendon insertion
   4. Iliac Crest
      1. Transverse abdominis insertion
      2. External oblique insertion
      3. Internal oblique tendon insertion
   5. Pubic Apophysitis
      1. Pubic Symphysis
      2. Gracilis tendon insertion
      3. Hip adductors insertion
8. Signs
   1. Localized swelling and pain at given apophysis
      1. Provoked by contraction against resistance of the involved tendon insertion
9. Imaging
   1. XRay
      1. Differentiates Apophysitis from avulsion Fracture, Stress Fracture, Bone Tumor, Osteochondrosis
   2. Ulrasound
      1. Widened and fragmented apophysis
10. Differential Diagnosis
    1. Traumatic Injury
    2. Stress Fracture
    3. Avulsion Fracture
    4. Bony Lesions (e.g. Cancer)
    5. Osteomyelitis
    6. Inflammatory Arthropathy (multiple joints involved)
11. Management
    1. See specific Apophysitis causes
    2. Conservative therapy is effective in most cases
       1. Self-limited, resolving as flexibility improves and Growth Plates close
       2. Stretching
       3. Relative rest with cross-training to other activities
       4. Ice Therapy
       5. NSAIDs (judicious use)
    3. Orthopedic or sports medicine Consultation indications
       1. Pain persists after apophysis fusion
       2. Symptoms refractory to conservative management
       3. Red Flags (severe pain, Trauma, inability to bear weight, night pain, systemic symptoms, cancer history)
12. Prevention
    1. Avoid over-training and overuse
    2. Keep pre-high school sports involvement broad without specialization
    3. Encourage cross training
13. References
    1. Achar (2019) Am Fam Physician 99(10): 610-8 [PubMed]