Growth plate injuries

Ross Hauser, MD

Younger athletes suffer many of the same injuries as their adult counterparts. However, there are also some significant differences in the type of injuries sustained by adolescents because of the differences in the structure of growing bone compared with adult bone. The other significant fact is that bone growth occurs at a different rate than ligament, tendon, and muscle growth; which in a young person, can produce its own set of problems.

As a concerned parent, it has probably already been explained to you that your child’s growth plates are those areas at the ends of the bones that are the last tissue to harden into permanent bone. As such, these “soft” areas are very prone to injury. Simply, a growing bone is much more easily injured because the growth plate itself is not fully developed. It does not have the constitutional strength of the ligament or muscle that attaches to it so fractures are common. Avulsion fractures are very common where the soft tissue will pull a piece of the growing bone off (This is described below). As your athlete ages and the bone matures, it is then more common for him/her to injury a ligament or muscle. Hopefully, they will never suffer from such an injury.

The differences between adult bone and growing bone include the following:

The articular cartilage of growing bone is of greater depth than that of adult bone and is able to undergo remodeling at a faster rate.
The junction between the epiphyseal plate and metaphysis is vulnerable to disruption, especially from shearing forces.
Tendon and ligament attachment sites, the apophyses, are cartilaginous plates that provide a relatively weak cartilaginous attachment, predisposing the young athlete to the development of avulsion injuries.
The metaphysis of long bones in children is more resilient and elastic, withstanding greater deflection without fracture, compared to adults. Thus, children tend to suffer incomplete fractures of the greenstick type, which do not occur in adults.
During rapid growth phases, bone lengthens before muscles, tendons, and ligaments are able to stretch correspondingly and before the musculotendinous complex develops the necessary strength and coordination to control the newly lengthened bone. This may lead to muscle, tendon, and ligament injuries, or to a reduction in coordination.
In adults, the weakest link of the ligament-bone junction is the ligament, whereas, in younger athletes, the ligament attachment to bone is relatively strong compared to the apophysis. Thus, the younger athlete is more likely to injure cartilage and bone or completely avulse an apophysis than to have a significant ligament sprain. (1,2)

Of special note is the area of the young, a growing bone called the epiphysis. Growth areas called epiphyses occur at both ends of long bones in children and adolescents. Bone grows from this area to make the child’s bones longer. This is what allows the child’s arms and legs to grow to the appropriate normal length. These epiphyses areas “close” at an average age of 14.5 years for girls, and 16.5 years for boys. These are the ages when most people just about reach their adult height. An important fact to note is that these areas are the weakest parts of the bone. The ligaments are 300% stronger than the epiphyseal area in a Tanner Stage 3 child (period of maximum growth). It is this weak area that is prone to injury in active children and adolescents. (3)

What are we seeing in the above image?

The caption reads Common sites of musculoskeletal injuries and Adolescent athletes. Many of these injuries occur around growth plates and are called osteochondrosis (an umbrella description for a group of problems that affect the child’s growing skeleton.) These include apophyseal (the joints of the spine) and epiphyseal (the rounded end of a long bone) conditions.

Conditions listed are:

Spondylolisthesis secondary to Pars stress fracture:
- In many children, Spondylolysis and Pars defect, and Stress fracture describe the same problem, and the terms are used interchangeably.
- Spondylolisthesis (the slipping of the vertebrae) can occur because the vertebrae are fractured at the pars interarticularis of the lumbar spine. It is most common in the L4 and L5 – the lowest bones of the lumbar portion of the spine and the area prone to the most stress.

Little League Shoulder

Little League Shoulder is obviously shoulder pain experienced by Little League and Babe Ruth League age players mostly between the ages of 11 – 16 years old. It is an overuse injury that causes the growth plate at the top of the arm bone or humerus to distort. The typical symptoms are swelling in the shoulder and of course pain.

Little League Elbow

Little League Elbow is also a common overuse injury. It affects all players not just pitchers. The right side of the infield players like the third baseman, the shortstop, the outfielders, and the catcher who throw more may be at risk. associated with throwing. In the updated 2021 medical publication Stat Pearls (4), this injury is described further as commonly occurring in early adolescence, between the ages of nine to 14 years of age. It is more common in boys and occurs during athletic activities such as football, baseball, or gymnastics. The common mechanisms of injury are a posterior (behind) elbow dislocation and repeated valgus stress (stress on the ulnar collateral ligament – the “Tommy John Ligament.

Iliac crest avulsion

Iliac crest avulsion is considered a more rare injury although it is not rare if it is your player who has it. In this injury, the muscle pulls of the iliac crest of the pelvis. In this injury, acute pain is felt and there can be an audible popping sound. In one case history presented in the medical literature (5) the injury of a 16-year-old indoor soccer player occurred as a result of a sudden twist of the trunk while kicking. A CT scan confirmed that occult chronic mechanical stress on the iliac apophysis had preceded the acute avulsion and also emphasized the crucial role of the tensor fascia lata in the mechanism of the injury. The patient was successfully treated conservatively. In other words, this acute injury was a result of chronic stress on the growth plate.

Apophysis avulsion of the pelvis

Apophysis avulsion of the pelvis is described in the medical literature (6) as “rare injuries typically affecting young athletes with not yet ossified (not yet bone) cartilaginous growth plates.” The injury occurs with a sudden and forceful contraction or passive lengthening (stretching) of the muscles. Typically part of the pelvic bone is pulled away. This occurs at the rectus femoris (one of the quadriceps) insertion at the anterior inferior iliac spine (on the pelvis), the sartorius (the longest muscle connecting the hip and thigh) insertion at anterior superior iliac spine (on the pelvis), the hamstring insertion at the ischial tuberosity (IT), the tensor fasciae latae (a thigh muscle) on the iliac crest and the rectus abdomens insertion on the superior corner of the pubic symphysis. The injury occurs during acceleration, a jump, or a kick; less frequently they follow a direct trauma or an overuse situation with the onset of a stress fracture following a prolonged apophysitis (inflammation of the growth plate) of the pelvis.

Legg-Calvé-Perthes disease

Legg-Calvé-Perthes disease is typically seen in boys between the ages of 4 and 8 years old. Typical characteristics are noticeable limp, awkward gait, or difficulty in walking or maintaining balance. Usually, the child will complain of subacute hip pain. In this problem, the blood supply to the ball of the hip at the growth plate is cut off. Avascular necrosis can occur and the ball of the hip will flatten out as the bone dies from lack of blood circulation. In many cases, physical therapy can help in some cases surgery may be required.

Osgood-Schlatter disease

Osgood-Schlatter disease: Chronic knee pain may develop in young people, especially teenage athletes, and is often due to Osgood-Schlatter disease, a condition whereby the tibial tubercle becomes painful where the patellar tendon attaches to the tibia. Pain occurs because the tendon attaches to the same area of the tibia that is growing. The pain is exacerbated by physical activity, especially running and jumping, and often limits participation in sports, resulting in the young athlete’s physician recommending cessation of playing sports. Needless to say, this advice is not popular. A better treatment is to strengthen the fibro-osseous junction of the patellar tendon onto the tibial tubercle, eliminating the problem. Please see our companion article: Osgood-Schlatter Disease.

Osteochondritis dissecans

Osteochondritis dissecans is a localized injury or condition affecting an articular surface of a joint, that involves separation of a segment of cartilage and subchondral bone. It is found most commonly in the knee although other joints can be affected, notably the elbow, ankle, and hip. Osteochondritis dissecans affect two distinct populations of patients as differentiated by the status of the physes (growth plates). Children and adolescents between the ages of five and approximately 16 years old, who have open physes, are classified as having the juvenile form of the disease. Older adolescents, who have closed physes, and adults are classified as having the adult form. Repetitive microtrauma is thought to be the primary mechanism responsible for the development of Osteochondritis dissecans, however, other causes including acute trauma, ischemia, ossification abnormalities, and genetic factors have also been proposed. In our companion article Non-surgical treatments for Osteochondritis dissecans, we present our published case reports of osteochondritis dissecans in young baseball players. The first case was a 13-year-old pitcher with osteochondritis dissecans of the knee. He had been following the usual rest and ice recommendations from his other doctor and was unable to return to sports for months. The second case was that of another 13-year-old pitcher. His MRI revealed osteochondritis dissecans of the capitellum (in the elbow). He had not been able to pitch for six months by the time he came to Caring Medical, after having an orthopedist tell him that he will never pitch again.

What are we seeing in this image?

On the left, we see the epiphyseal growth plates of the elbow.

In this image, the message is an injury to the elbow ligaments is a more frequent and commonly overlooked injury in the young athlete. The instability caused by ligament injury may lead to conditions such as osteochondroses and osteochondritis dissecans.

At the capitellum (the is the lateral or outer) part of the humeral condyle (upper arm bone) that articulates with the radial head, compression against the radial head either causes or promotes osteochondritis dissecans.

Classification of growth plate injuries

The Salter and Harris classification of growth plate injuries is commonly used to describe injuries to the growth plate. The Salter 1 injury is a nondisplaced fracture. The x-ray is often normal and according to traditional orthopedic teaching, this can cause the examining practitioner to miss the diagnosis. The diagnosis should be based on clinical findings of point tenderness over the epiphyseal area. (7) Types 1 and 2 have excellent prognoses for prompt healing and no residual problems or growth disturbance. Types 3 and 4 require open reduction and internal fixation (surgery) and have a more guarded prognosis. Lastly, Type 5 can go unrecognized and has the potential to lead to major growth disturbances.

The traditional orthopedic surgeon’s recommendation for a young athlete with a normal x-ray and palpatory tenderness is rest. However, the RICE treatment (Rest, Ice, Compression, Elevation) is detrimental not only to the ligaments and tendons but also to the articular cartilage. Diminished weight-bearing has been shown to lead to degeneration of the articular cartilage. (8) This research citation comes from 1981. Its value in understanding the critical need to have weight loading as part of a healing program was demonstrated by a March 2021 paper in the Journal of Functional Morphology and Kinesiology (9) which cited this research and added: “It is necessary to consider that mechanical loading is important not only during the development of the musculoskeletal system but also after development and is essential for the maintenance of healthy articular cartilage.”

Activity and weight-bearing are necessary to maintain the biochemical and structural integrity of ligaments and tendons, as well as cartilage growth.(10,11)

Growth plate or Physeal injuries in the U16 soccer player

A multinational team of doctors published research in the Scandinavian Journal of Medicine and Science in Sports (10) on the incidence, severity, and burden of physical injuries in a youth elite soccer academy. Information like this helps doctors more quickly identify the cause of pain in teenage and adolescent athletes.

551 youth male soccer players from Under-9 to Under-19 were included and observed over four consecutive seasons.
Injuries involving the physis were diagnosed and recorded according to type, location, and diagnosis.
Injury incidence, severity (days lost), and injury burden were calculated per squad per season (25 players/squad).

Results:

There were 307 physical injuries:
- 262 apophyseal (85%) spine-joint,
- 26 physical- (9%),
- 2 epiphyseal (long bones such as the thigh bone) – (1%) and
- 17 other physical injuries (5%)
with 80% causing time loss.

The U-16s had the highest-burden

Apophyseal injuries of the hip-pelvis resulted in the greatest burden
Peak apophyseal injury incidence per body parts occurred in:
- U-11 for foot-ankle
- U-14 for knee
- and in U-17 for hip-pelvis.

Treatment of growth plate injuries

We have seen patients in their 20s who have already been recommended for a joint replacement. The reason for such dramatic recommendations is due to the effect of cortisone injections, RICE, pain prescriptions, and other traditional treatments done at a young age. Research indicates RICE and NSAIDs are detrimental to a child’s long-term musculoskeletal health. If those methods fail and then orthopedic surgery is done with poor results, you cannot undo that surgery. It can begin a string of additional surgeries trying to chase the pain. On the other hand, seeking a practitioner who understands joint laxity and restoration, along with sports mechanics, can take the young athlete down a more curative path.

In the image, we see the epiphyseal growth plates and ligaments that support the shoulder. It should be noted that the ligament support is in a similar location to the growth plate.

Please see my companion article on Osgood-Schlatter Disease.

Joint laxity, or the looseness of a joint, can create a fine balance between an athlete’s ability to excel in sport and the likelihood of injury. A good example of this is gymnastics. The greater the joint laxity in the child, the more likely that child will be able to do all of the required contortion movements in gymnastics. Hypermobile joints are exhibited by being able to do things such as bending the elbow or knee past the point of neutral, doing the splits, touching the floor with the palm while bending forward at the waist, or touching the thumb to the forearm. While these antics are often used for entertainment by flexible children, repetition can lead to sustained laxity and injury down the line. Ligament laxity creates joint instability and overuse injury as those described above. If the joint laxity is not addressed, growth plate problems can occur.

1 Brukner P. Clinical Sports Medicine. New York City, NY: McGraw-Hill Book Company, 1995, pp. 521-540.
2 Landry M. Brukner & Khan’s Clinical Sports Medicine. Physiotherapy Canada. 2014;66(1):109. [Google Scholar]
3 Ehrlich MG, Hulstyn M, d’Amato C. Sports injuries in children and the clumsy child. Pediatric Clinics of North America. 1992 Jun 1;39(3):433-49. [Google Scholar]
4 Saeed W, Waseem M. Elbow Fractures Overview. InStatPearls [Internet] 2020 Aug 10. StatPearls Publishing. [Google Scholar]
5 Coulier B. Acute avulsion of the iliac crest apophysis in an adolescent indoor soccer. Journal of the Belgian Society of Radiology. 2015;99(2):20. [Google Scholar]
6 Filippo C, Alessandro N, Cristina G, Margherita M, Francesco P, Francesco C. Apophyseal avulsion fractures of the pelvis. A review. Acta Bio Medica: Atenei Parmensis. 2018;89(4):470. [Google Scholar]
7 Barkley K. Child and adolescent athletes. In Baker C (ed.) The Hughston Clinic Sports Medicine Book. Baltimore, MD: William and Wilkins; 1995, pp. 87-93.
8 Palmoski M. Running inhibits the reversal of atrophic changes in canine knee cartilage after removal of a long leg case. Arthritis and Rheumatism. 1981;24:1329-1337. [Google Scholar]
9 Monaco G, El Haj AJ, Alini M, Stoddart MJ. Ex vivo systems to study chondrogenic differentiation and cartilage integration. Journal of Functional Morphology and Kinesiology. 2021 Mar;6(1):6. [Google Scholar]
10 Zernicke R. Endurance training. In Sports Medicine: The School-age Athlete. Reider B. (ed.) Philadelphia PA: W.B,. Saunders, 1996, pp. 3-18.
11 Noyes F. Biomechanics of ligament failure. II. An analysis of immobilization, exercise, and reconditioning effects in primates. Journal of Bone and Joint Surgery. 1974;56A:1406-1418.

This article was updated October 7, 2021