Sports injury research naturally focuses on adult athletes.  But what about all those school aged players that are the potential stars of tomorrow? This is an often overlooked group of the sporting population but one with a specific set of injuries and factors to consider during their rehabilitation.

Maturation

Before we start looking at the different types of injuries you may encounter working with an adolescent population, it is important that we appreciate the physiology of maturation and what that means for the athlete in front of you.

At the heart of this is the need to consider biological age vs chronological age. If you are working with a particular age group – the U15s for example – you may have players in your squad that are years apart in terms of their maturation. Whilst there is nothing you can do about that, it may inform your clinical reasoning when assessing injuries and planning their rehab program.

As I will present later, some presentations are more prevalent at different stages of maturation and development so knowing your athlete’s maturation status can help aid your diagnosis if they become injured and may also mean you can be proactive with injury prevention depending on the type of environment that you are working.

Peak height velocity (PHV) is a term that is commonly mentioned in the scientific literature surrounding maturation and adolescence. It is the time when young people grow fastest during their adolescent growth spurt and occurs approximately age 11 in girls and 13 in boys but can vary by 2 years or more (Lloyd & Oliver 2012).

During this time we can see huge changes in height with normal male averages 10.3cm/year (but can range between 5.8-13.1cm/year) and females having averages 9cm/year (reported range 5.4-11.2cm/year). There are different reference values depending where you look in the literature however. As well as changes in height, there are large increases in body mass during this period and both of these factors have been shown to increase injury risk. One study (Kemper et al 2015) found that larger changes in body weight were more of a risk factor than height changes for MSK injuries in elite football whereas Wik et al (2020) found that growth rates were related to bone and growth plate injuries in athletics. A more recent paper from Wik and colleagues (2023) also identified a link between higher body mass changes and sudden onset injuries.

 Although teenagers’ bodies are going through considerable change, it very much is still a work in process as they progress towards adulthood. There remain anatomical differences until their early to mid 20s and as such present with a whole range of diagnoses that are not seen in adults. Below is a summary of the the common injury types during this period of anthropometric change and their equivalent adult diagnosis.

Its beyond the scope of this blog to go in to detail regarding all of these so it will focus on the most common and that is apophyseal injuries.

Apophyseal Injuries

This group of injuries is what you will encounter most if you are working with adolescent athletes whether that be in a sporting environment or in a clinic setting.

The apophyses run perpendicular to the physes at the end of the long bones. This orientation, and the fact that they are attachment points for muscles, means that they are susceptible to traction forces (Caine et al 2006).

During growth spurs it is thought that there is a temporary increase in muscle-tendon tightness about the joints and a corresponding loss of flexibility. This is somewhat controversial though.

Another reason that these sites are prone to injury is that the apophyses provide a relatively weak cartilaginous attachment. This, in addition to the factors mentioned previously, can predispose young athletes to the development of micro and/or macro avulsion injuries.

Below is a summary of the most prevelant sites of pain in the lower limb. Working in football these are the most common ones that we see but you can have similar presentations in the upper limb if you work in tennis or throwing sports.

This table above (figure 4) is also also organised in age order. Our bodies’ growth follows a pattern of distal to proximal and this gives rise to the changing patterns of apophyseal injuries. Sever’s tends to present earliest and the pelvic sites later in adolescence due to the differing ages that the growth plates complete their fusion.

Assessing an adolescent

Although the differences between adults and adololecents have been discussed, an accurate history is vital irrespective of the age of the patient. Its important to consider that this may be the first time the young person has been injured and been assessed by a physiotherapist so be sympathetic to that and create a comforting environment. Details surrounding the onset of pain are essential to aid differentiating between a grumbling apophysitis and more traumatic apophyseal avulsion.

As part of the history taking, establishing the athlete’s age is a basic requirement but delving further into recent growth spurts, height relative to their peers, and their recent training history can give you valuable insight into potential contributors to their injury and what factors might be able to be addressed to manage their symptoms.

Localised tenderness at the apophysis will be present and whilst Sever’s or Osgood-Schlatter (OGS) related pain will be fairly obvious, around the pelvis the exact site of tenderness on palpation will aid your diagnosis.

You would naturally proceed to fully assess the affected joint or painful area but in this clinical presentation you will likely find pain on stretching the muscle group that inserts into the affected area e.g. quadriceps for OGS. As well this there will be pain on loading this same muscle whether that be in an isolated fashion or during a functional task.

As ever, always ensure that sinister pathology is excluded to the best of your ability through checking your red flags as unfortunately this can be a time that bone cysts or tumours can develop and masquerade as a MSK diagnosis.

Rehabilitation

For the grumblling apophysitis presenations it is often more appropriate to modify the young person’s training load rather than ruling them out of training. Psychologically this has great benefit and allows them to continue to be involved in the sports they love and socialise with friends and peers. And physically it minimises any deconditioning that might be occur prolonging their return to sports once symptoms have  reduced. This requires close communication with all involved parties and this can be difficult if not working at their club or school. However, being clear with the patient’s parents, involving them and the patient with the decision making, and speaking to the relvant club or school staff can ensure that the proposed load management plan is implemented. They can then use the extra free time they have to work on whatever deficits you have found on asssessment. Commonly this is flexibility and motor control.

If the injury requires time away from the player’s chosen sport, there may be other activities that they can continue with that don’t aggravate their symptoms but still help their physical and mental wellbeing e.g. swimming

Whilst you will be led by your specific assessment findings, try and address these with sport specific drills as early as possible. Get creative to see how you can get the adaptations you require whilst making it as applicable as possible to the sports your patient plays. For example, any proprioceptive or motor control work can involve a ball or some target practice.

And last but not least, try and make rehab FUN!!

Lloyd, R.S., and Oliver, J.L. (2012). The Youth Physical Development Model: A New Approach to Long-Term Athletic Development. Strength and Conditioning Journal, 34(3), pp.61-72.

Wik, E. H., Martínez‐Silván, D., Farooq, A., Cardinale, M., Johnson, A., & Bahr, R. (2020). Skeletal maturation and growth rates are related to bone and growth plate injuries in adolescent athletics. Scandinavian journal of medicine & science in sports, 30(5), 894-903.

Kemper, G. L. J., Van Der Sluis, A., Brink, M. S., Visscher, C., Frencken, W. G. P., & Elferink-Gemser, M. T. (2015). Anthropometric injury risk factors in elite-standard youth soccer. International journal of sports medicine, 1112-1117.

Wik, E. H., Chamari, K., Tabben, M., Di Salvo, V., Gregson, W., & Bahr, R. (2023). Exploring growth, maturity and age as injury risk factors in high-level youth football. Sports Medicine International Open.

Caine, D., DiFiori, J., & Maffulli, N. (2006). Physeal injuries in children’s and youth sports: reasons for concern?. British journal of sports medicine, 40(9), 749-760.