Growth Related Injuries in Athletics

BY BEN HAWKES

This month, I wanted to look into some of the growth related injuries we see in young athletes. Risk factors for these injuries (outside of - you know - growing) include high volumes (and changes in volume) of high intensity running, jumping and change of direction movements, i.e. children and young people who are very physically active during a growth spurt are particularly at risk of injury.  Given we are trying to develop a love of sports and activities in these young people, it would be tragic to inadvertently injure them in the process!

The most common growth-related injuries we see in Athletics are:

• Sever's disease: heel pain caused by inflammation of the growth plate in the calcaneus (heel)
• Osgood-Schlatters disease: pain and swelling below the knee joint

WHAT IS GROWTH RELATED KNEE PAIN IN YOUNG ATHLETES?

Osgood-Schlatters is one of the most common growth related injuries in young athletes.  It is also called Tibial Tuberosity Apophysitis.

• Tibia - Shin bone
• Tuberosity - pointy bit of bone below the knee where the Patellar Tendon connects to the growth plate of the shin bone
• Apophysitis - irritation of the growth point (apophysis) of a bone

Osgood-Schlatters is the irritation of the growth point on the tibia, where the patellar tendon inserts on to it.

HOW CAN GROWTH DEVELOPMENT CAUSE INJURIES IN SPORT?

Osgood-Schlatters was previously thought of as more common in boys, but actually it is around equal between sexes due to improved female participation in sport.  It is common in athletes experiencing rapid growth (>7.2cm / year). This most often occurs at approx. 8-13 years old in girls, 12-15 years old in boys. 

The primary ‘cause’ is repetitive strain of the quadriceps femoris muscle and resultant stress of patellar tendon on tibia, causing traction apophysitis of tibial tuberosity (Curci et al., 2017).  That means running, jumping and change of direction movements are a particular risk.

IDENTIFYING GROWTH SPURT KNEE PAIN

These are some of the key symptoms and identifiers of Osgood-Schlatters in young athletes.

• Tenderness, swelling, thickening of the patellar tendon and enlargement of the tibial tuberosity can often be seen during physical examination.
• It is common to find quad/hamstring 'tightness', and quadriceps weakness on the affected side, and it is useful to ask yourself whether this is a cause or an effect.
• It's common to have pain during activities like running and jumping which load the knee in flexion leading to a strong eccentric quadriceps contraction, and the pain ceases upon rest.

ARE GROWTH PLATE INJURIES SERIOUS?

37% of patients still experience pain 24 months after diagnosis (Holden et al. (2021)). This is a long term condition, and should be treated as such! Though it’s typically thought of as a self-limiting disease simply ending at skeletal maturity (Curci et al., 2017), some patients (reported anywhere from 10% to 40%) report symptoms into adulthood. This is definitely within my definition of serious!

“if not addressed, psychosocial considerations could potentially lead to poorer long-term consequences.” Lyng et al. (2019).

Some of the longer term pain is perhaps due to associated changes (picked up on ultrasound) rather than the condition itself, as outlined by De Flaviis (1989).

• Type 1: Cartilage swelling alone
• Type 2: Cartilage swelling and bony changes (fragmented ossification centre).
• Type 3: Associated tendinopathy, with thickening of distal (lower end) patellar tendon.
• Type 4: Associated infrapatellar bursitis

Clearly, physiotherapists and not coaches should be managing these associated conditions, especially in the case of cartilage, bone and bursa issues. 

Coaches can have a role to play with managing tendon issues in a similar way to a regular patellar tendinopathy: with heavy isometrics and eccentric work.

HOW TO MANAGE GROWTH RELATED INJURIES IN SPORT

If coaches track growth over time (approx. 3-4x per year), we might be able to predict growth spurts and so adapt training to reduce the risk of overuse injuries in young athletes.  

Prevention is obviously ideal, but read on for more information on how to manage young athletes who have already developed symptoms.

1. TRAINING LOAD

The most common management strategy from the qualitative (subjective / non-numerical) research was modification of sports-specific load.

2. PAIN MANAGEMENT

Pain education was discussed as first line of care, and many discussed either mild analgesic or non-steroid anti-inflammatory drugs.

3. STRENGTH TRAINING

Strength training the structure/ muscles around the knee and hip is fundamental to children’s development and reducing the risk of injury. Strength training has been shown to decrease the prevalence of Osgood Schlatters by 67%. 

Rathleff (2020) concluded that 12 weeks of strength training results in 80% of children reducing Osgood Schlatter symptoms and 90% after 12 months of training.

4. ISOMETRICS AND ECCENTRICS

Isometric exercises are tightening (contraction) of specific muscles or groups, without visible moving of the joint, such as planks and glute bridges.  Eccentric exercises are slow lengthening contractions of a particular muscle such as squats.  A combination of these strength training exercises useful for treating tendons injuries.

PRACTICAL COACHING STRATEGIES FOR OVERUSE INJURY MANAGEMENT IN YOUNG ATHLETES

Parents are potentially either a barrier or a facilitator for the rehabilitation of the child's injury. This is absolutely key for coaches to know, as a conversation about or even simply awareness of parent’s attitudes to pain and injury, as well as any attempts at management can play a role in informing your approach to managing the athlete’s condition. Education around management strategies and prognosis going forward to get every stakeholder working together toward the same goal can have a massive impact!

UNDERSTAND CONDITION, LISTEN TO ATHLETE

• What is their sporting and training history, what do they like, not like.
• History of condition – any associated conditions?
• Educate if necessary, reinforcing throughout sessions.
• Inform & educate parents, ‘sell’ the process to them to reinforce message to athlete.

LOAD MANAGEMENT

• Understand the young athlete’s current playing load.
• Remove from sport for the initial period, then introduce activity ladder to Return-To-Play (RTP) with pain monitoring.
• In the meantime, begin a strengthening protocol for lower limbs. 
• Begin with hip / ankle dominant movements (hinges, bridges, yielding isometrics) to avoid irritation of the knee, and gradually increase load tolerance of the knee joint. 
• Continue & progress to trunk, upper body, aerobic and metabolic work more during offloading period. 

GRADED RETURN-TO-PLAY

• In later stages, introduce a graded exposure to eccentric loads, impact forces and higher movement velocity.
• Include co-ordination & movement skills (jump, land, speed, Change-of-Direction, agility) training on top of pure strengthening work. This is key as efficient movement strategies place athletes at a lower likelihood of other injuries which might set back continued loading to manage the knee. This is also just very useful for performance improvement in general!

Hopefully this helps give a little structure to the thought process behind some common growth related injuries - they can definitely seem daunting at times, but can be managed well with a bit of thought and understanding!

ABOUT BEN HAWKES

Ben is a hammer thrower who competes internationally for Great Britain and Northern Ireland and is also a sport massage therapist and strength and conditioning coach.

He has been writing content and producing videos for us for over a year, and his content focuses on hammer throwing tips and strength & conditioning guides for your athletic training!

Instagram: @benhawkes1

Twitter: @ben_hawkes1