Apophysitis

The apophysitis is a wide and heterogeneous family of clinical conditions characterized by an often chronic and overuse mechanical stress to any apophysis of a generally immature skeletal system. These conditions, typical of a growing skeletal system, lead to a decrease of function of the affected body part due to the mechanical disruption of the over-mentioned structures. In football players the most frequent conditions of this family are those related to the lower limb. The Osgood-Schlatter (osteochondrosis of the anterior tibial tubercle (ATT)) disease is one of the most frequent apophysitis affecting the young football player. Additionally, the pubic apophysitis due to repeated stress on the proximal adductor insertion is often forgotten and can be the underlying reason (in some cases) for the chronic symptomatology of the young football player with groin pain [1].

This chapter aims to present an overview of the problem of apophysitis in football, an often overlooked problem by the scientific community.

42.2 The Aetiology of Lower Limb Apophysitis

Overuse injuries can affect multiple parts of a young athlete’s body including the physis and the tendons. The bone is growing through the growth plate that makes them susceptible to repetitive microinjuries in the high phases of growth but also at the extremity of the bones where the powerful muscle tendon units are attached. In the growing child/adolescent, this particular area becomes very prone to inflammation as a result of repetitive avulsion micro-traumas leading to an inflammatory stage at the tendon insertion/growth plate [2].

The musculotendinous units and their insertions into the bones are the most important factor in the development of pain in the young athlete and depend on intrinsic and extrinsic factors. Intrinsic factors include bone growth, growth of musculotendinous units, decreased bone density, skeletal maturity, muscle bulk, decreased flexibility and strength, extremity malalignment and psychological factors like high-risk behaviours. Extrinsic factors are a consequence of inappropriate changes in training, improper training surfaces, improper equipment, parental pressure, coaching pressure and peer pressure [3].

They can affect multiple parts of the body and have different clinical manifestations, and for this reason, there are multiple ways to treat and prevent the injuries in the growing child and the young adult, according to the type of presentation and the clinical manifestations.

42.3 Classification of Apophysitis

In the literature there is not a single classification for the “apophysitis” since most of the classifications are related to a specific entity/local as, for example, the Osgood-Schlatter syndrome, which is related to the tibial tuberosity. It will be helpful in terms of distinguishing the different entities to have a classification that would help directing the treatment.

42.3.1 Classification According to Type of Injury

In order to understand the different types of injuries, it is important to understand the mechanism of injury. The extremity of the bones, either at the end covered by cartilage (epiphysis) or where the tendons/muscles are attached (apophysis), can be subject to different types of trauma: avulsion lesions secondary to repetitive tractions over the site, compression lesions or shear lesions [4, 5]. The apophysitis is mostly related to an avulsion-type lesion.

42.3.2 Classification According to the Ability to Play Sports

Time can also be important to define a possible treatment approach but most important is, like the Loder’s [6] classification for slipped capital femoral epiphysis, to define the ability to carry a sports activity or not. This will differentiate the acute unstable lesions from the chronic stage (stable).

For the acute lesions, we suggest to follow a modified Martin and Pipkin [7] classification applied to the treatment of avulsion of the ischial tuberosity. This basic approach updated by McKinney et al. [8] differentiated the fractures according to the degree of displacement of the fragments (Table 42.1).

Table 42.1

Classification of apophyseal avulsion fractures according to McKinney classification

Classification of apophyseal avulsion fractures
Type 1 nondisplaced fractures
Type 2 displacement up to 2 cm
Type 3 displacement > 2 cm
Type 4 symptomatic non-unions or painful exostosis

In Fig. 42.1, we report a case of a 13-year-old football player that was complaining of pain over the ATT. The football player, after a kick, suddenly felt an acute local pain and the inability to bear weight. The X-ray revealed a high-riding patella with an avulsion of the ATT.

Fig. 42.1

X-ray of a 13-year-old footballer that reveals an ATT avulsion

In case of a chronic lesion (type 4 of the McKinney classification), the literature is omissive, and there is a lack of consensus. Probably on this particular case, it will be crucial to combine the clinical evaluation in terms of pain with the results of imaging. This was pointed out by Kose [9] that found out that the radiologic identification of calcaneal apophysitis (Sever’s disease) without the absence of clinical information was not reliable. Radiologic findings that were attributed to Sever’s disease showed a wide variation between independent observers and between separate readings by the same observer. The authors suggested that the diagnosis of calcaneal apophysitis was a clinical decision, and radiographic assessment seemed to be unnecessary. There is no specific classification regarding imaging, and several imaging tools are available for this diagnosis. For this reason it is difficult to interpret the findings.

Nakase et al. [10] in their study aimed to correlate the different findings with the degree of maturity of the bone. Tibial tuberosity development on ultrasonography was divided into three stages: sonolucent stage (stage S), individual stage (stage I) and connective stage (stage C). Age, height, quadriceps and hamstring muscle tightness and muscle strength in knee extension and flexion were determined. These findings were compared with the respective stages of development. They were able to show that thigh muscle tightness and thigh muscle performance change with the skeletal maturation of the distal attachment of the patellar tendon.

According to Arnaiz et al. [11], the MRI can be helpful in terms of differentiating the underlying pathology regarding apophysitis. They advocate that accurate identification of key MRI features of this entity may prevent misdiagnosis and inappropriate management of apophysitis.

In the early 1990s, Kujala and Orava [12] described a classification that tried to put together the clinical aspects with the observation on the different imaging modalities and relate them to the age. Although it is related to the ischial apophysitis injuries in athletes, it may be adjusted to other sites and help the clinician in terms of defining the appropriate therapy (Table 42.2).

Table 42.2

Classification of apophysitis and recommended imaging investigations adjusted for age according to Kujala and Orava [12]

Type of lesion

Patient’s age (yrs)

Recommended imaging investigations

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