Apophysitis and Osteochondrosis: Common Causes of Pain in Growing Bones

 

Am Fam Physician. 2019 May 15;99(10):610-618.

Author disclosure: No relevant financial affiliations.

Apophysitis and osteochondrosis are common causes of pain in growing bones but have differing etiologies and required management. Apophysitis results from a traction injury to the cartilage and bony attachment of tendons in children and adolescents. Most often it is an overuse injury in children who are growing and have tight or inflexible muscle tendon units. Although apophysitis occurs in upper and lower extremities, it occurs more often in the lower extremities, with common locations including the patellar tendon attachment at the patella or tibia (i.e., Larsen-Johansson and Osgood-Schlatter diseases), the calcaneus (i.e., Sever disease), and multiple locations around the hip, including the anterior inferior iliac spine. Other locations include the medial epicondyle, which is common in patients who throw or participate in racket sports, and more rarely at the base of the fifth metatarsal (i.e., Iselin disease). Radiography can be helpful in evaluating for other pathologies but is usually not necessary. Treatment includes stretching the affected muscle groups, relative rest, offloading the affected tendon, icing after activity, and limited use of nonsteroidal anti-inflammatory drugs. Osteochondrosis presents less commonly and refers to degenerative changes in the epiphyseal ossification centers of growing bones. Unlike apophysitis, the etiology of osteochondrosis is unknown. Multiple possible etiologies have been explored, including genetic causes, hormonal imbalances, mechanical factors, repetitive trauma, and vascular abnormalities. Other locations of osteochondrosis include the second metatarsal head (i.e., Freiberg disease), the navicular bone (i.e., Köhler bone disease), the femoral head (i.e., Legg-Calvé-Perthes disease), and the capitellum (i.e., Panner disease). Radiography results may be normal initially; magnetic resonance imaging is more sensitive to early changes. Osteochondrosis generally resolves with relative rest, but close monitoring is needed to ensure resolution. Surgery is rarely needed for either apophysitis or osteochondrosis.

Apophysitis results from a traction injury to the cartilage and bony attachment of tendons in children. Most often it is an overuse injury in growing children, especially those with tight or inflexible muscle tendon units. Osteochondrosis presents less commonly and refers to degenerative changes in the epiphyseal ossification centers of growing bones. Unlike apophysitis, the etiology of osteochondrosis is unknown. The most well-known form of osteochondrosis is Legg-Calvé-Perthes disease. The term osteochondrosis is often confused with the term apophysitis; however, these two conditions should be considered separately because they have different etiologies and management. Table 1 provides a summary of apophysitis and osteochondrosis disorders.1

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Preventive measures for medial epicondyle apophysitis should include taking at least four months off from competitive pitching per year, avoiding use of radar guns, and avoiding the combination of pitching and catching.18,19

C

Major League Baseball position statement for adolescent baseball pitchers

Treatment of Osgood-Schlatter disease should include relative rest and quadriceps and hamstring stretching and strengthening.4,9,16

C

Based on expert opinion and consensus guidelines in the absence of clinical trials

Sever disease treatment should include relative rest, heel cups initially, and heel cord stretches to prevent recurrence.2325

B

Based on a small randomized controlled trial

Osteochondrosis disorders are rare and many are self-limiting. However, physicians should have a low threshold to refer to a pediatric orthopedist, especially if the condition persists longer than four to six months.27,30,31

C

Based on expert opinion and consensus guidelines in the absence of clinical trials


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Preventive measures for medial epicondyle apophysitis should include taking at least four months off from competitive pitching per year, avoiding use of radar guns, and avoiding the combination of pitching and catching.18,19

C

Major League Baseball position statement for adolescent baseball pitchers

Treatment of Osgood-Schlatter disease should include relative rest and quadriceps and hamstring stretching and strengthening.4,9,16

C

Based on expert opinion and consensus guidelines in the absence of clinical trials

Sever disease treatment should include relative rest, heel cups initially, and heel

The Authors

show all author info

SURAJ ACHAR, MD, FAAFP, is a faculty physician at Rady Children's 360 Sports Medicine Program and the associate program director of the University of California San Diego Sports Medicine Fellowship Program. He also serves as a health sciences clinical professor in the Department of Family Medicine and Public Health at the University of California San Diego School of Medicine....

JARROD YAMANAKA, MD, CAQSM, is a sports medicine physician at Fairview Sports and Orthopedic Care, Blaine, Minn.

Address correspondence to Suraj Achar, MD, 9500 Gilman Dr., La Jolla, CA 92023 (e-mail: sachar@ucsd.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Atanda A Jr, Shah SA, O'Brien K. Osteochondrosis: common causes of pain in growing bones. Am Fam Physician. 2011;83(3):285–291....

2. Adirim TA, Cheng TL. Overview of injuries in the young athlete. Sports Med. 2003;33(1):75–81.

3. De Inocencio J. Epidemiology of musculoskeletal pain in primary care. Arch Dis Child. 2004;89(5):431–434.

4. Yanagisawa S, Osawa T, Saito K, et al. Assessment of Osgood-Schlatter disease and the skeletal maturation of the distal attachment of the patellar tendon in preadolescent males. Orthop J Sports Med. 2014;2(7):2325967114542084.

5. Kose O. Do we really need radiographic assessment for the diagnosis of non-specific heel pain (calcaneal apophysitis) in children? Skeletal Radiol. 2010;39(4):359–361.

6. Vaishya R, Azizi AT, Agarwal AK, Vijay V. Apophysitis of the tibial tuberosity (Osgood-Schlatter disease): a review. Cureus. 2016;8(9):e780.

7. Tok F, Demirkaya E, Ozçakar L. Musculoskeletal ultrasound in pediatric rheumatology. Pediatr Rheumatol Online J. 2011;9:25.

8. Frush TJ, Lindenfeld TN. Peri-epiphyseal and overuse injuries in adolescent athletes. Sports Health. 2009;1(3):201–211.

9. Circi E, Atalay Y, Beyzadeoglu T. Treatment of Osgood-Schlatter disease: review of the literature. Musculoskelet Surg. 2017;101(3):195–200.

10. Longo UG, Ciuffreda M, Locher J, Maffulli N, Denaro V. Apophyseal injuries in children's and youth sports. Br Med Bull. 2016;120(1):139–159.

11. Kivel CG, d'Hemecourt CA, Micheli LJ. Treatment of iliac crest apophysitis in the young athlete with bone stimulation: report of 2 cases. Clin J Sport Med. 2011;21(2):144–147.

12. Arnaiz J, Piedra T, de Lucas EM, et al. Imaging findings of lower limb apophysitis. AJR Am J Roentgenol. 2011;196(3):W316–W325.

13. Zucker EJ, Lee EY, Restrepo R, Eisenberg RL. Hip disorders in children. AJR Am J Roentgenol. 2013;201(6):W776–W796.

14. Forrester RA, Eyre-Brook AI, Mannan K. Iselin's disease: a systematic review. J Foot Ankle Surg. 2017;56(5):1065–1069.

15. Yen YM. Assessment and treatment of knee pain in the child and adolescent athlete. Pediatr Clin North Am. 2014;61(6):1155–1173.

16. Valentino M, Quiligotti C, Ruggirello M. Sinding-Larsen-Johansson syndrome: a case report. J Ultrasound. 2012;15(2):127–129.

17. Otoshi K, Kikuchi S, Kato K, et al. Age-specific prevalence and clinical characteristics of humeral medial epicondyle apophysitis and osteochondritis dissecans: ultrasonographic assessment of 4,249 players. Orthop J Sports Med. 2017;5(5):2325967117707703.

18. Norton R, Honstad C, Joshi R, Silvis M, Chinchilli V, Dhawan A. Risk factors for elbow and shoulder injuries in adolescent baseball players: a systematic review [published online ahead of print April 9, 2018]. Am J Sports Med. https://journals.sagepub.com/doi/10.1177/0363546518760573. Accessed February 12, 2019.

19. Major League Baseball. Pitch Smart Guidelines. https://www.mlb.com/pitch-smart/pitching-guidelines. Accessed October 29, 2018.

20. Wilk KE, Yenchak AJ, Arrigo CA, Andrews JR. The Advanced Throwers Ten Exercise Progam: a new exercise series for enhanced dynamic shoulder control in the overhead throwing athlete. Phys Sportsmed. 2011;39(4):90–97.

21. Haws BE, Stone AV, Usoro AO, Marquez-Lara A, Mannava S, Freehill MT. Optimal management of physeal elbow injuries in the skeletally immature athlete remains undefined: a systematic literature review. J ISAKOS: Joint Disord Orthop Sports Med. 2018;3:38–45.

22. de Lucena GL, dos Santos Gomes C, Guerra RO. Prevalence and associated factors of Osgood-Schlatter syndrome in a population-based sample of Brazilian adolescents. Am J Sports Med. 2011;39(2):415–420.

23. Ishikawa SN. Conditions of the calcaneus in skeletally immature patients. Foot Ankle Clin. 2005;10(3):503–513, vi.

24. James AM, Williams CM, Haines TP. Effectiveness of interventions in reducing pain and maintaining physical activity in children and adolescents with calcaneal apophysitis (Sever's disease): a systematic review. J Foot Ankle Res. 2013;6(1):16.

25. Wiegerinck JI, Yntema C, Brouwer HJ, Struijs PA. Incidence of calcaneal apophysitis in the general population. Eur J Pediatr. 2014;173(5):677–679.

26. Elengard T, Karlsson J, Silbernagel KG. Aspects of treatment for posterior heel pain in young athletes. Open Access J Sports Med. 2010;1:223–232.

27. Talusan PG, Diaz-Collado PJ, Reach JS Jr. Freiberg's infraction: diagnosis and treatment. Foot Ankle Spec. 2014;7(1):52–56.

28. Carmont MR, Rees RJ, Blundell CM. Current concepts review: Freiberg's disease. Foot Ankle Int. 2009;30(2):167–176.

29. Shanley J, James DR, Lyttle MD, Andronikou S, Knight DM. Kohler's disease: an unusual cause for a limping child. Arch Dis Child. 2017;102(1):109.

30. Sunilkumar M, Ajith T. Kohlers disease of the tarsal navicular in a 7-years-old child. Ann Paediatr Rheum. 2014;3(3):135–137.

31. Tiwari V, Gamanagatti S, Mittal R, Nag H, Khan SA. Correlation between MRI and hip arthroscopy in children with Legg-Calve-Perthes disease. Musculoskelet Surg. 2018;102(2):153–157.

32. Ibrahim T, Little DG. The pathogenesis and treatment of Legg-Calvé-Perthes disease. JBJS Rev. 2016;4(7):1.

33. Claessen FM, Louwerens JK, Doornberg JN, van Dijk CN, Eygendaal D, van den Bekerom MP. Panner's disease: literature review and treatment recommendations. J Child Orthop. 2015;9(1):9–17.

34. Sakata R, Fujioka H, Tomatsuri M, et al. Treatment and diagnosis of Panner's disease. A report of three cases. Kobe J Med Sci. 2015;61(2):E36–E39.

 

 

Copyright © 2019 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Sep 15, 2019

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article