“Apophysitis”: A Common Cause of Knee Pain in Children

by Kenneth Taylor MD

Knee pain is all too familiar to many adults, and is a frequent complaint of active children as well.  Children and adolescents are susceptible to knee pain during periods of rapid growth.  Muscles and tendons that are used and over-used during sports and play tend to contract and tighten while long bones around the knee are lengthening.  This creates a ‘tug-of-war’ phenomenon that leads to stress and eventually inflammation and pain at the growth centers where the muscles and tendons attach to bone.

The medical term for this phenomenon is apophysitis.  The medical world recognized the physicians that first described these apophysitis’ by bestowing naming rights, and therefore many of these disorders sound more like law firms than medical ailments.  Osgood-Schlatter Disease is apophysitis that occurs at the tibial tubercle (just below the kneecap).  Sinding-Larsen-Johansson Disease is apophysitis at the patella (kneecap).

Osgood-Schlatter disease is characterized by inflammation of the growth plate of the leg just below the knee at the tibial tubercle, a prominence just below the kneecap. The tibial tubercle is the bony attachment on the large bone of the lower leg (tibia) of the big, powerful thigh muscle (quadriceps) and patellar tendon. The growth plate is an area of relative weakness, and injury to it occurs due to repeated stress or vigorous exercise. It is a temporary condition of the tibial tubercle that is uncommon after age 16.

Risk Factors

  • Overzealous conditioning routines, such as running, jumping, or jogging
  • Being overweight
  • Boys between 11 and 16
  • Rapid skeletal growth
  • Poor physical conditioning (strength and flexibility)
  • Single sport specialization and year-round schedules

Preventive Measures

  • Lose weight or maintain ideal body weight
  • Appropriately warm up and stretch before practice or competition
  • Maintain appropriate conditioning
    • Muscle strength
    • Flexibility and endurance
    • Cardiovascular fitness
  • Exercise moderately, avoiding extremes
  • Use proper technique

General Treatment Considerations

Initial treatment consists of medications and ice to relieve pain, stretching and strengthening exercises (particularly of the quadriceps and hamstrings), and modification of activities. Specifically, kneeling, jumping, squatting, stair climbing and running on the affected knee should be avoided. The exercises can all be carried out at home for acute cases. Chronic cases often require a referral to a physical therapist or athletic trainer for further evaluation or treatment. Uncommonly, the affected leg may be immobilized for 6 to 8 weeks .  A patellar band (a brace between kneecap and tibial tubercle on top of the patellar tendon) may help relieve symptoms. Surgery is recommended in the growing patient in the rare situation of failed conservative treatment. Surgery is occasionally necessary after skeletal maturity if the ossicle (bony bump) becomes painful.

Medication

  • Anti-inflammatory medications, such as aleve and ibuprofen or other minor pain relievers, such as acetaminophen, are often recommended.  While they can provide relief of acute pain, they should not be taken prior to sporting activities.  The reduction in pain may allow the athlete to overexert and further worsen the condition.
  • Cortisone injections are rarely, if ever, indicated. Cortisone injections may weaken tendons, therefore it is better to give the condition more time to heal with rest.

Heat and Cold

  • Cold is used to relieve pain and reduce inflammation for acute and chronic cases. Cold should be applied for 10 to 15 minutes every 2 to 3 hours for inflammation and pain and immediately after any activity that aggravates symptoms.
  • Heat may be used before performing stretching and strengthening activities prescribed by a physician, physical therapist, or athletic trainer.

Sports and physical activity are essential to our children’s health.  At times, this activity can be a source of pain and injuries.  Apophysitis syndromes such as Osgood-Schlatter and Sinding-Larsen-Johansson are generally self-limited and respond to conservative management such as rest, anti-inflammatory medications and ice.  At times, referral to a physical therapist for strengthening and stretching exercises may be beneficial.  Chronic cases will benefit from consultation with a sports medicine physician with expertise in treating children.

KenDr. Kenneth Taylor is a primary care physician with fellowship training and board certification in Sports Medicine. He is director of the UCSD Primary Care Sports Medicine Fellowship and is involved in clinical research trials related to sports medicine. Dr. Taylor is a team physician for the San Diego professional indoor soccer franchise (Sockers), head team physician for the UC San Diego Intercollegiate and Club Athletics, and medical director for the International Surfing Association.  He sees patients at Rady Children’s Hospital’s 360 Sports Medicine Facility and at UCSD Family & Sports Medicine Clinic in La Jolla.

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