Football practice among youngsters and teenagers is related to many health benefits. However, not all aspects of this sport are positive, and, sometimes, while practising it, players suffer musculoskeletal injuries due to direct contacts or overstrain.

Besides, it is also common for younger people to suffer injuries caused by an overuse of a growth-related muscle or joint.  The medical term for this bone pain is apophysitis, a condition known as “growth disease”. As expected, apophysitis is an inflammation on the apophysis, a bony protrusion that forms an important insertion point for a tendon. They are secondary growth centres used as tendons joint points (read references 1,2 below).

Apophysitis is a common disease in children and adolescents between 9 and 18 years old, and it is very frequent in young and adolescent athletes. It is a really focused and painful inflammation that occurs around the bone growth area resulting from repetitive stress to soft tissues over the bone insertion. Muscles are forced to be developed faster than the bone structure in itself and this leads to irritation.

As expected, apophysitis can hinder a person from performing any physical activity, and this is a serious affection for elite athletes. Indeed, this happens in sports such as football, in which both the muscle and bone structures are under too much pressure, mainly due to direct contact (read reference 3 below). Young players are more likely to suffer injuries affecting the apophysis because of their skeletal immaturity.

Fortunately, this is a benign disease that is not usually serious and which disappears alone once the growth process has been completed. In any case, the treatment forces the person to modify their sport activity, perform stretching or apply cold, among other actions. 

However, up to date, there have been a few articles describing apophysitis’ incidence, diagnosis, and treatments among adolescent athletes, especially elite football players. This might be due to the fact that the apophyseal injury is normally misdiagnosed ( (read reference 4) and treated as a distention (read reference 5 below). 

Apophysitis among elite football players

FC Barcelona carried out a study called Apophysitis Among Male Youth Soccer Players at an Elite Soccer Academy Over 7 Seasons (Mindaugas Gudelis et al, 2022) aiming to improve the knowledge and treatment of apophysitis, especially among adolescent football players.

During 7 seasons (from July 2008 to June 2015), all the apophyseal injuries in male football players under 19 years old (U-19) of FC Barcelona (FCB) were evaluated.

In this sense, a previous study by Le Gall et al ( (read reference 6 below) has found 33 apophyseal disorders during a 10-season period while in the current study 210 apophyseal injuries were recorded, including 172 simple apophyseal injuries and 38 apophyseal avulsion fractures. This reveals that, on many occasions, it is possible that the apophyseal injuries are diagnosed as other types of injuries.

Simple apophysitis and apophyseal avulsion fracture 

Adolescent athletes who had a major pain in a tendon insertion and who could not fully participate in training sessions or subsequent matches were mainly treated as cases of apophyseal injuries. The medical staff suspected the case of apophyseal injury whenever there was an acute pain during the sport activity after using fingertip pressure onto the affected area.

Once the apophyseal injury was confirmed, they were categorised into two groups: simple apophysitis and apophyseal avulsion fracture. Simple apophysitis is the inflammation of the growth plate’s cartilage in the apophysis caused by overuse. On the other hand, apophyseal avulsion fracture is defined as a displacement of the apophysis caused by a sudden major traction during the sport activity. 

The following are some interesting results of the study:

• Even though football is an asymmetrical movement sport, with the exception of the goalkeeper, apophyseal injuries were observed almost equally in right and left limbs (48.1% and 46.6% respectively). The remaining 5.3% were bilateral cases in the same body locations.
• A total of 196 cases (93.3%) were first injuries and the rest (6.7%) were recurrences. Any of these cases required surgical/operative treatment. 
• One of the main findings of the study was the body location of the apophyseal injury. In their previous study, Peck ( (read reference 7) and Le Gall et al (read reference 6 below) had reported that the most common location for apophyseal injury was the tibial tuberosity. However, in this study, the most frequent body location reported was the anterior inferior iliac spine AIIS and the lesser trochanter was considered to be the least common one.

The most frequent body location for apophysitis was AIIS (43.3%).

•  The return to play in football, both to training sessions and competitions, was faster for athletes with simple apophyseal injuries than for those suffering from apophyseal avulsion fractures.
• The analysis of all the apophyseal injuries demonstrated that younger athletes (7-10 years old) recover faster than older athletes (11-17 years old).

Considerations and recommendations about apophysitis

Apart from the study results, the analysis presents very important keys to the diagnosis and treatment of apophysitis in the future:

Ultrasound examination as an effective method for apophysitis detection

In many cases, the apophysis might not ossify until the very end of the growth process. Thus, it is not observable in simple x-rays  (read reference 8). That is why the ultrasound examination is a useful option to identify it. Besides, ultrasound application reduces radiographic exposure in relation to X-rays. 

A key Foundation for future studies

Despite the results, there are various limitations in this study. One of the main constraints is that the current data were collected from just one football club. For future research, carrying out studies in many clubs would help broaden current findings. Besides, these results might not be applicable in general to all young football players since data were collected from an elite football academy. Finally, the current data are about male football players. Future studies should include a female sample and analyse other sports as well. 

The person over the player

Data confirmed that athletes with apophyseal avulsion injuries take longer to return to training sessions and competitions.

This evidence is key for adolescent players since the elite football academy ecosystem normally puts pressure on players to return to the sport activity as soon as possible. The findings emphasise the importance of giving proper rest to adolescent players. Regular follow-up assessments with a close communication among players, coaches, medical staff, physical therapists, etc. would make the return-to-play safe, reduce the probability of missing training sessions, and avoid injury relapses.

References:

1. Davis KW. Imaging pediatric sports injuries: lower extremity. Radiol Clin North Am. 2010; 48(6):1213- 1235. 
2. Ryu RK, Fan RS. Adolescent and pediatric sports injuries. Pediatr Clin North Am. 1998;45(6):1601- 1635, x.
3. JungeA,Ro ̈schD,PetersonL,Graf-BaumannT,DvorakJ.Prevention of soccer injuries: a prospective intervention study in youth amateur players. Am J Sports Med. 2002; 30(5):652- 659. 
4. 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. 
5. Moeller JL. Pelvic and hip apophyseal avulsion injuries in young ath- letes. Curr Sports Med Rep. 2003; 2(2):110- 115. 
6. Le Gall F, Carling C, Reilly T, Vandewalle H, Church J, Rochcongar P. Incidence of injuries in elite French youth soccer players: a 10-season study. Am J Sports Med. 2006; 34(6):928- 938. 
7. Peck DM. Apophyseal injuries in the young athlete. Am Fam Physi- cian. 1995;51(8):1891- 1895, 1897- 1898. 
8. Frush TJ, Lindenfeld TN. Peri-epiphyseal and overuse injuries in ado- lescent athletes. Sports Health. 2009; 1(3):201- 211.