Stress-Related Injuries Involving the Physis of Young Athletes: An Update ~ Dennis Caine, PhD & Nicola Maffulli, MD, PhD, FRCP, FRCS(Orth)

Participation in children’s and youth sports is widespread in Western culture. Trends include increased numbers of participants, greater duration and intensity of training, and earlier specialization and year-round training. Increased involvement and repetition of skills practiced at an early age and continued through the years of growth raises concern about risk of injury.

In particular, there is concern that the tolerance limits of the physis may be exceeded by the repetitive physical loading required in many sports, particularly during the adolescent growth spurt.3 Physeal growth disturbance as a result of injury can result in length discrepancy, angular deformity, or altered joint mechanics, and may cause significant long term disability.

Although typical childhood overuse injuries such as the common apophyseal injuries and patellofemoral pain are readily recognized and treated with little long-term sequalae, the physis is a site of overuse injury that can be easily overlooked.7

Physeal stress injuries are thought to develop when repetitive loading of the extremity disrupts metaphyseal perfusion which may inhibit ossification of the chondrocytes in the zone of provisional calcification.6 The hypertrophic zone continues to widen as the chondrocytes transition from the germinal layer to the proliferative zone.15 Widening of the physis may be seen radiographically, whereas physeal cartilage extension into the metaphysis has been shown with magnetic resonance imaging.9,15

Photo by bp6316. Used with permission. All rights reserved. Source: flickr

Photo by bp6316. Used with permission. All rights reserved. Source: flickr

Baseball pitchers were the first young athletes recognized with physeal stress injury.8 Since then, multiple case reports have documented this injury in baseball pitchers.18

Often associated with persistent pain in the throwing arm, stress changes of the proximal humeral growth plate, represent the effects of repetitive traction and rotational forces across the epiphysis and growth plate.11

Similar cases have been reported in other young athletes involved in overhead sports, including cricket, gymnastics, badminton, swimming, and volleyball.3

There are also reports of physeal stress lesions of the clavicle in a male gymnast4 and stress related physeal fractures of the middle phalanx of the finger in young sport climbers.12 Commonly reported upper extremity physeal stress injuries involve the distal radial physes of gymnasts. 3

Most reports describe distal radius stress reaction with a radiographically widened and irregular physis, especially on the metaphyseal side. However, one study using MRI documented physeal cartilage extension into the metaphysis.9

Cases of stress-related lower extremity physeal injuries involving the proximal tibia, distal femur, distal tibia and fibula, and first metatarsus have been reported in young athletes in a variety of sports.3,13

In summary, although epidemiological data are lacking, it is evident that stress-related physeal injuries occur in young athletes. Most injuries resolved without growth complication during short-term follow-up. However, there are also reports of partial or complete epiphyseal closure in athletes representing basketball, baseball, dance, gymnastics, and football.1,2,10,14,19-21

There are also two reports of varus changes subsequent to sports related stress injury to the distal femoral and/or proximal tibial physes in rugby and tennis players.16,17

Treatment for physeal stress injury is straightforward: rest from loading of the extremity.3,6,7 However, in cases involving growth disturbance, corrective surgery may be required.14,16,17 Clinicians need to educate parents and coaches as to the existence of overuse physeal injury and the need for rest to ensure proper recovery and return to sport participation.

Dennis Caine, PhD, College of Education and Human Development, University of North Dakota, USA.

Nicola Maffulli, MD, Ph.D., FRCP, FRCS(Orth). Department of Musculoskeletal Medicine and Surgery, Faculty of Medicine, University of Salerno, Italy, and  Centre for Sports and Exercise Medicine, Barts and The London School of Medicine and Dentistry, Mile End Hospital, London, UK.


  1. Albanese SA, Palmer AK, Kerr DR, et al.  Wrist pain and distal growth plate closure of the radius in gymnasts. J Ped Orthop 1989; 9: 23-28.
  2. Bak K, Boeckstyns M. Epiphysiodesis for bilateral irregular closure of the distal radial physis in a gymnast. Scand J Med Sci Sports 1997;7:363-366.
  3. Caine D, DiFiori J, Maffulli N. Physeal injuries in children’s and youth sports: Reasons for concern? Brit J Sports Med, 2006, 40:749-760.
  4. Carson JT, McCambridge TM, Carrino JA, et al. Case report: bilateral epiphyseal clavicular stress-related lesions in a male gymnast. Clin Orthop Relat Res 2012;470:307-311.
  5. Carson WG Jr, Gasser SI. Little Leaguer’s shoulder. A report of 23 cases. Am J Sports Med 1998; 26 : 575 – 80 .
  6. DiFiori J, Caine D, Malina R. Wrist pain, distal radial growth plate injury, and ulnar variance in the young gymnast, Am J Sports Med 2006;34:840-849.
  7. DiFiori J. Overuse injury of the Physis: A growing problem. Clin J Sport Med 2010; 336-337.
  8. Dotter WE. Little leaguer’s shoulder. Guthrie Clin Bull 1953;23:68.
  9. Dwek JR, Cardoso F, Chung CR. 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;39:1310-1316.
  10. Ejnisman B, Andreoli CV, Pochini ADC, et al. Proximal humeral epiphysiolysis in a gymnast. Acta Ortop Bras  2007; 15: 290-291.
  11. Hansen NB. Epiphyseal changes in the proximal humerus of an adolescent baseball pitcher. Am J Sports Med 1982;10: 380-384.
  12. Hochholzer T, Schoffl VR. Epiphyseal fractures of the finger middle joints in young climbers. Wilderness Environ Med 2005;16:139–42.
  13. Blatnik TR, Briskin S. Bilateral knee pain in a high-level gymnasts. Clin J Sport Med 2013;23:77-79.
  14. Howe WB, Caine D, Bergman GD, e t al. Wrist pain-gymnastics. Med Sc Sports Exerc 1997 ; 29 : S151 .
  15. Jaramillo D, Laor T and Zaleske DJ.  Indirect trauma to the growth plate: results of MR imaging after episphyseal and metaphyseal injury in rabbits. Radiology  1993; 187:171-178.
  16. Laor T, Wall EJ, Vu LP. Physeal widening in the knee due to stress injury in child athletes. Am J Roentgenol 2006 ; 186 : 1260 – 4 .
  17. Nanni M, Butt S, Mansour R, e t al. Stress-induced Salter–Harris I growth plate injury of the proximal tibia: first report. Skeletal Radiol 2005 ; 34 : 405 – 10.
  18. Ricci AR, Mason DE. Little league shoulder : case report and literature review. Del Med J 2004;76:11-24.
  19. Sato T, Shinozaki T, Fukudo T, e t al. A typical growth plate closure: a possible chronic Salter and Harris Type V injury. J Pediatr Orthop 2002 ; 11 : 155 – 8 .
  20. Shih C, Chang CY, Penn IW.  Chronically stressed wrists in adolescent gymnasts: MR imaging appearance. Radiol 1995; 195:855-859.
  21. Shybut TB, Rose DJ, Strongwater AM. Second metatarsal physeal arrest in an adolescent flamenco dancer: a case report. Foot Ankle Int 2008 ; 29 : 859 – 62 .

Comments are closed.