Overuse Injury of the Epiphyseal Primary Physis

Abstract

Year-round participation in youth sport that involves high levels of repetitive movement fosters an environment in which overuse injuries are likely to occur. Epiphyseal primary physeal stress injuries (PSIs), unique to skeletally immature athletes, are a particular concern, given their potential for growth disturbance. Initially observed in Little League baseball players, these injuries are now known to affect the long bones around the shoulder, elbow, wrist, hand, knee, ankle, and foot of skeletally immature athletes involved in a variety of sport activities.

This article offers an epidemiological and radiologic perspective on the extent and distribution of epiphyseal PSIs in youth sport. We also review a novel framework for understanding the pathophysiologic mechanisms causing these injuries. This information is essential for the early identification of epiphyseal PSIs and devising preventive measures that can reduce a delayed diagnosis and long-term morbidity. Preventing and reducing injury to the epiphyseal growth plates is essential because impairment and dysfunction can result in lifelong morbidity and a risk of premature osteoarthritis.

Keywords

overuse injury - youth sport - imaging - stress injury - fracture

Publication History

Article published online:
29 July 2024

• References

• 1 Caine DJ, Provance AJ. Pediatric and adolescent injury in adventure and extreme sports. Res Sports Med 2018; 26 (Suppl. 01) 5-19
• 2 Jayanthi NA, Post EG, Laury TC, Fabricant PD. Health consequences of youth sport specialization. J Athl Train 2019; 54 (10) 1040-1049
• 3 Pasulka J, Jayanthi N, McCann A, Dugas LR, LaBella C. Specialization patterns across various youth sports and relationship to injury risk. Phys Sportsmed 2017; 45 (03) 344-352
• 4 U.S. Department of Health and Human Services. 2018 Physical Activity Guidelines Advisory Committee Scientific Report. Available at: https://health.gov/sites/default/files/2019-09/PAG_Advisory_Committee_Report.pdf .Accessed March 5, 2024
• 5 Emery CA. Injury prevention in kids' adventure and extreme sports: future directions. Res Sports Med 2018; 26 (sup1): 199-211
• 6 DiFiori JP, Benjamin HJ, Brenner JS. et al. Overuse injuries and burnout in youth sports: a position statement from the American Medical Society for Sports Medicine. Br J Sports Med 2014; 48 (04) 287-288
• 7 Kliethermes SA, Marshall SW, LaBella CR. et al. Defining a research agenda for youth sport specialisation in the USA: the AMSSM Youth Early Sport Specialization Summit. Br J Sports Med 2021; 55 (03) 135-143
• 8 Jayanthi N, Kleithermes S, Dugas L, Pasulka J, Iqbal S, LaBella C. Risk of injuries associated with sport specialization and intense training patterns in young athletes: a longitudinal clinical case-control study. Orthop J Sports Med 2020; 8 (06) 23 25967120922764
• 9 Difiori JP. Overuse injury of the physis: a “growing” problem. Clin J Sport Med 2010; 20 (05) 336-337
• 10 Caine D, DiFiori J, Maffulli N. Physeal injuries in children's and youth sports: reasons for concern?. Br J Sports Med 2006; 40 (09) 749-760
• 11 Caine D, Meyers R, Nguyen J, Schöffl V, Maffulli N. Primary periphyseal stress injuries in young athletes: a systematic review. Sports Med 2022; 52 (04) 741-772
• 12 Nguyen JC, Markhardt BK, Merrow AC, Dwek JR. Imaging of pediatric growth plate disturbances. Radiographics 2017; 37 (06) 1791-1812
• 13 Longo UG, Ciuffreda M, Locher J, Maffulli N, Denaro V. Apophyseal injuries in children's and youth sports. Br Med Bull 2016; 120 (01) 139-159
• 14 Caine DJ, Golightly YM. Osteoarthritis as an outcome of paediatric sport: an epidemiological perspective. Br J Sports Med 2011; 45 (04) 298-303
• 15 Caine D, Howe W, Ross W, Bergman G. Does repetitive physical loading inhibit radial growth in female gymnasts?. Clin J Sport Med 1997; 7 (04) 302-308
• 16 Ogden JA. Skeletal Injury in the Child. New York, NY: Springer; 2000
• 17 Laor T, Wall EJ, Vu LP. Physeal widening in the knee due to stress injury in child athletes. AJR Am J Roentgenol 2006; 186 (05) 1260-1264
• 18 Schöeffl IS. Epiphyseal stress fractures in the fingers of adolescents: biomechanics, pathomechanisms, and risk factors. Eur J Sports Med 2015; 3: 27-37
• 19 Kanematsu Y, Matsuura T, Kashiwaguchi S. et al. Epidemiology of shoulder injuries in young baseball players and grading of radiologic findings of Little Leaguer's shoulder. J Med Invest 2015; 62 (3–4): 123-125
• 20 Pennock AT, Dwek J, Levy E. et al. Shoulder MRI abnormalities in asymptomatic Little League baseball players. Orthop J Sports Med 2018; 6 (02) 23 25967118756825
• 21 Torg JS, Pollack H, Sweterlitsch P. The effect of competitive pitching on the shoulders and elbows of preadolescent baseball players. Pediatrics 1972; 49 (02) 267-272
• 22 Zhang C, Shen S, Zhang W. et al. Effect of long-term diving on the morphology and growth of the distal radial epiphyseal plate of young divers: a magnetic resonance imaging study. Clin J Sport Med 2019; 29 (04) 312-317
• 23 Caine D, Roy S, Singer KM, Broekhoff J. Stress changes of the distal radial growth plate. A radiographic survey and review of the literature. Am J Sports Med 1992; 20 (03) 290-298
• 24 Chang CY, Shih C, Penn IW, Tiu CM, Chang T, Wu JJ. Wrist injuries in adolescent gymnasts of a Chinese opera school: radiographic survey. Radiology 1995; 195 (03) 861-864
• 25 De Smet L, Claessens A, Lefevre J, Beunen G. Gymnast wrist: an epidemiologic survey of ulnar variance and stress changes of the radial physis in elite female gymnasts. Am J Sports Med 1994; 22 (06) 846-850
• 26 DiFiori JP, Puffer JC, Aish B, Dorey F. Wrist pain, distal radial physeal injury, and ulnar variance in young gymnasts: does a relationship exist?. Am J Sports Med 2002; 30 (06) 879-885
• 27 Guerra MR, Estelles JR, Abdouni YA, Falcochio DF, Rosa JR, Catani LH. Frequency of wrist growth plate injury in young gymnasts at a training center. Acta Ortop Bras 2016; 24 (04) 204-207
• 28 Roy S, Caine D, Singer KM. Stress changes of the distal radial epiphysis in young gymnasts. A report of twenty-one cases and a review of the literature. Am J Sports Med 1985; 13 (05) 301-308
• 29 Shih C, Chang CY, Penn IW, Tiu CM, Chang T, Wu JJ. Chronically stressed wrists in adolescent gymnasts: MR imaging appearance. Radiology 1995; 195 (03) 855-859
• 30 Bärtschi N, Scheibler A, Schweizer A. Symptomatic epiphyseal sprains and stress fractures of the finger phalanges in adolescent sport climbers. Hand Surg Rehabil 2019; 38 (04) 251-256
• 31 Garcia K, Jaramillo D, Rubesova E. Ultrasound evaluation of stress injuries and physiological adaptations in the fingers of adolescent competitive rock climbers. Pediatr Radiol 2018; 48 (03) 366-373
• 32 Meyers RN, Howell DR, Provance AJ. The association of finger growth plate injury history and speed climbing in youth competition climbers. Wilderness Environ Med 2020; 31 (04) 394-399
• 33 Schlegel C, Büchler U, Kriemler S. Finger injuries of young elite rock climbers. Schweiz Z Sportmed Sportraumatol 2002; 50: 7-10
• 34 Schöffl V, Hochholzer T, Imhoff A. Radiographic changes in the hands and fingers of young, high-level climbers. Am J Sports Med 2004; 32 (07) 1688-1694
• 35 Materne O, Chamari K, Farooq A. et al. Injury incidence and burden in a youth elite football academy: a four-season prospective study of 551 players aged from under 9 to under 19 years. Br J Sports Med 2021; 55 (09) 493-500
• 36 Holt JB, Stearns PH, Bastrom TP, Dennis MM, Dwek JR, Pennock AT. The curse of the all-star team: a single-season prospective shoulder MRI study of Little League baseball players. J Pediatr Orthop 2020; 40 (01) e19-e24
• 37 Caine D, Cochrane B, Caine C, Zemper E. An epidemiologic investigation of injuries affecting young competitive female gymnasts. Am J Sports Med 1989; 17 (06) 811-820
• 38 Caine D, Knutzen K, Howe W. et al. A three-year epidemiological study of injuries affecting young female gymnasts. Phys Ther Sport 2003; 4: 10-23
• 39 Dixon M, Fricker P. Injuries to elite gymnasts over 10 yr. Med Sci Sports Exerc 1993; 25 (12) 1322-1329
• 40 Materne O, Chamari K, Farooq A. et al. Shedding light on incidence and burden of physeal injuries in a youth elite football academy: a 4-season prospective study. Scand J Med Sci Sports 2022; 32 (01) 165-176
• 41 Monasterio X, Gil SM, Bidaurrazaga-Letona I. et al. The burden of injuries according to maturity status and timing: a two-decade study with 110 growth curves in an elite football academy. Eur J Sport Sci 2023; 23 (02) 267-277
• 42 Lishen QJO, Jianhua O. Epiphyseal injury in gymnasts. Chin J Sports Med 1983; 2: 7-12
• 43 Knowles SB, Marshall SW, Guskiewicz KM. Issues in estimating risks and rates in sports injury research. J Athl Train 2006; 41 (02) 207-215
• 44 Caine D, Maffulli N, Meyers R, Schöffl V, Nguyen J. Inconsistencies and imprecision in the nomenclature used to describe primary periphyseal stress injuries: towards a better understanding. Sports Med 2022; 52 (04) 685-707
• 45 Jaramillo D, Laor T, Zaleske DJ. Indirect trauma to the growth plate: results of MR imaging after epiphyseal and metaphyseal injury in rabbits. Radiology 1993; 187 (01) 171-178
• 46 Dwek JR. A structural and mechanism-based perspective toward understanding pediatric and adult sports injuries. AJR Am J Roentgenol 2016; 206 (05) 980-986
• 47 DiFiori JP, Mandelbaum BR. Wrist pain in a young gymnast: unusual radiographic findings and MRI evidence of growth plate injury. Med Sci Sports Exerc 1996; 28 (12) 1453-1458
• 48 Hochholzer T, Schöffl VR. Epiphyseal fractures of the finger middle joints in young sport climbers. Wilderness Environ Med 2005; 16 (03) 139-142
• 49 Jawetz ST, Shah PH, Potter HG. Imaging of physeal injury: overuse. Sports Health 2015; 7 (02) 142-153
• 50 Ecklund K, Jaramillo D. Imaging of growth disturbance in children. Radiol Clin North Am 2001; 39 (04) 823-841
• 51 Rogers LF, Poznanski AK. Imaging of epiphyseal injuries. Radiology 1994; 191 (02) 297-308
• 52 Chan D, Aldridge MJ, Maffulli N, Davies AM. Chronic stress injuries of the elbow in young gymnasts. Br J Radiol 1991; 64 (768) 1113-1118
• 53 Santelli J, McCambridge TM, Valasek AE, Standiford K. Proximal radial head fractures in young gymnasts: a case series of newly described overuse injuries. Clin J Sport Med 2019; 29 (01) e1-e3
• 54 Wilson PL, Wyatt CW, Searls WC. et al. Elbow overuse injuries in pediatric female gymnastic athletes: comparative findings and outcomes in radial head stress fractures and capitellar osteochondritis dissecans. J Bone Joint Surg Am 2021; 103 (18) 1675-1684
• 55 Hajdu S, Schwendenwein E, Kaltenecker G. et al. Growth potential of different zones of the growth plate—an experimental study in rabbits. J Orthop Res 2012; 30 (01) 162-168
• 56 Stokes IA, Clark KC, Farnum CE, Aronsson DD. Alterations in the growth plate associated with growth modulation by sustained compression or distraction. Bone 2007; 41 (02) 197-205
• 57 Dwek JR, Cardoso F, Chung CB. MR imaging of overuse injuries in the skeletally immature gymnast: spectrum of soft-tissue and osseous lesions in the hand and wrist. Pediatr Radiol 2009; 39 (12) 1310-1316
• 58 Wik EH, Lolli L, Chamari K. et al. Injury patterns differ with age in male youth football: a four-season prospective study of 1111 time-loss injuries in an elite national academy. Br J Sports Med 2021; 55 (14) 794-800
• 59 Alexander CJ. Effect of growth rate on the strength of the growth plate-shaft junction. Skeletal Radiol 1976; 1: 67-76
• 60 Bailey DA, Wedge JH, McCulloch RG, Martin AD, Bernhardson SC. Epidemiology of fractures of the distal end of the radius in children as associated with growth. J Bone Joint Surg Am 1989; 71 (08) 1225-1231
• 61 Wang Q, Wang XF, Iuliano-Burns S, Ghasem-Zadeh A, Zebaze R, Seeman E. Rapid growth produces transient cortical weakness: a risk factor for metaphyseal fractures during puberty. J Bone Miner Res 2010; 25 (07) 1521-1526
• 62 Bright RW, Burstein AH, Elmore SM. Epiphyseal-plate cartilage. A biomechanical and histological analysis of failure modes. J Bone Joint Surg Am 1974; 56 (04) 688-703
• 63 Morscher E. Strength and morphology of growth cartilage under hormonal influence of puberty. Animal experiments and clinical study on the etiology of local growth disorders during puberty. Reconstr Surg Traumatol 1968; 10: 3-104
• 64 Speer DP, Braun JK. The biomechanical basis of growth plate injuries. Phys Sportsmed 1985; 13 (07) 72-78
• 65 Heyworth BE, Kramer DE, Martin DJ, Micheli LJ, Kocher MS, Bae DS. Trends in the presentation, management, and outcomes of Little League shoulder. Am J Sports Med 2016; 44 (06) 1431-1438
• 66 Abbassi V. Growth and normal puberty. Pediatrics 1998; 102 (2 Pt 3): 507-511
• 67 Nguyen JC, Lin B, Potter HG. Maturation-dependent findings in the shoulders of pediatric baseball players on magnetic resonance imaging. Skeletal Radiol 2019; 48 (07) 1087-1094
• 68 Tariq SM, Patel V, Gendler L. et al. Pediatric thrower's elbow: maturation-dependent MRI findings in symptomatic baseball players. Pediatr Radiol 2024; 54 (01) 105-116
• 69 Wik EH. Growth, maturation and injuries in high-level youth football (soccer): a mini review. Front Sports Act Living 2022; 4: 975900
• 70 Post EG, Bell DR, Trigsted SM. et al. Association of competition volume, club sports, and sport specialization with sex and lower extremity injury history in high school athletes. Sports Health 2017; 9 (06) 518-523
• 71 Ritzer EE, Yang J, Kistamgari S, Collins CL, Smith GA. An epidemiologic comparison of acute and overuse injuries in high school sports. Inj Epidemiol 2021; 8 (01) 51
• 72 Roos KG, Marshall SW, Kerr ZY. et al. Epidemiology of overuse injuries in collegiate and high school athletics in the United States. Am J Sports Med 2015; 43 (07) 1790-1797
• 73 Changstrom BG, Brou L, Khodaee M, Braund C, Comstock RD. Epidemiology of stress fracture injuries among US high school athletes, 2005-2006 through 2012-2013. Am J Sports Med 2015; 43 (01) 26-33
• 74 Mann DC, Rajmaira S. Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in children aged 0-16 years. J Pediatr Orthop 1990; 10 (06) 713-716
• 75 Digby KH. The measurement of diaphyseal growth in proximal and distal directions. J Anat Physiol 1916; 50 (Pt 2 ): 187-188
• 76 Bahrs C, Zipplies S, Ochs BG. et al. Proximal humeral fractures in children and adolescents. J Pediatr Orthop 2009; 29 (03) 238-242
• 77 Greig D, Silva M. Management of distal radius fractures in adolescent patients. J Pediatr Orthop 2021; 41 (Suppl. 01) S1-S5
• 78 Domzalski M, Mackenzie W. Growth arrest of the proximal tibial physis with recurvatum and valgus deformity of the knee. Knee 2009; 16 (05) 412-416
• 79 Sato T, Shinozaki T, Fukuda T. et al. Atypical growth plate closure: a possible chronic Salter and Harris type V injury. J Pediatr Orthop B 2002; 11 (02) 155-158
• 80 Nanni M, Butt S, Mansour R, Muthukumar T, Cassar-Pullicino VN, Roberts A. Stress-induced Salter-Harris I growth plate injury of the proximal tibia: first report. Skeletal Radiol 2005; 34 (07) 405-410
• 81 Dempewolf M, Kwan K, Sherman B, Schlechter JA. Youth kicker's knee: lateral distal femoral hemiphyseal arrest secondary to chronic repetitive microtrauma. J Am Acad Orthop Surg Glob Res Rev 2019; 3 (08) e079
• 82 Nguyen JC, Caine D. Youth soccer players: patterns of injury involving the primary growth plates of epiphyses. Skeletal Radiol 2024 ; January 4 (Epub ahead of print)