The Perfect Storm for Athletic Injuries: Youth, Growth and Hormones

By Jennifer Allyn

Jaramillo

Childhood sports have become increasingly intense and competitive, as young athletes dedicate more time and energy to one specific sport and even specialize in specific functions within that sport.  It goes to reason then that the type of injuries, particularly repetitive injuries, are becoming more intense as well. 

“Couple intense pressure to excel at one specific sport, along with the typical things that happen in young people’s bodies, particularly, puberty and growth spurts, and you have a period of intense stress on the skeleton that can lead to injuries,” said Diego Jaramillo, MD, MPH, from Miami Children’s Hospital in Miami.

MRI (coronal 3D gradient echo image) Shows residual widening of the growth plate with a tongue of cartilage (arrow) Extending into the metaphysis

During growth spurts, the physis at the ends of the long bones and at the apophysis where tendons insert, are weak. Injuries to the physis result in growth arrest, while injuries to the apophysis can lead to avulsion. In addition, the increased bone porosity of a young skeleton coupled with the increase in muscle strength, can stress a skeleton and predispose it to damage. Repetitive injury to the physeal cartilage can disrupt endochrondral ossification and result in a wide, irregular physis with extensions of cartilage into the metaphysis.

Puberty, including the hormonal influences on the growth plate, also increases the vulnerability of the skeleton to injury.

“At the time of fastest growth, the growth plate is more likely to get separated from the bone, both in the long bones and at the muscle insertions in the apophysis,” said Dr. Jaramillo. “For both boys and girls, there is also an estrogen-mediated increase in bone porosity, which particularly affects the distal radius.” This is why, according to Dr. Jaramillo, distal radial fractures peak for girls at age 11 versus age 13 in boys. 

Following x-rays, most young athletes are diagnosed using CT, especially for injuries that involve the head or that are primarily osseous such as the triplane fracture. MRI is reserved for injuries involving cartilage or ligaments, while ultrasound is gaining use for diagnosing ligamentous injuries and occult fractures.

LEFT: 12 year old gymnast girl with pain Radiograph at presentation. Arrow points to wide irregular growth plate. RIGHT: 12 year old gymnast girl with pain Radiograph after two months of rest.

“CT is the main technique used for evaluating acute head injuries and complex fractures, while MRI is used most often for severe head injuries to visualize the brain and for the evaluation of internal derangement of the joints and cartilage,” Dr. Jaramillo said. “Ultrasound is beginning to play an increasingly important role in the evaluation of injuries that require dynamic imaging, including tendinous and ligamentous abnormalities and muscle hernias.”

It is not just common youth sports, like soccer, tennis, gymnastics and baseball, where young athletes are getting injured. There is also concern for hockey players, rock climbers and competitive cyclists. Rest is recommended for all injuries, particularly to avoid the premature closure of the growth plate.

“It is fundamental for young athletes to rest appropriately when sports injuries are detected,” Dr. Jaramillo said. “Stress injuries to the growth cartilage are reversible, but if the offending activity continues, there can be growth plate concerns like shortening and deformity. There is even the risk of permanent damage to the joint, particularly in osteochondritis dissecans. Overall, any physeal widening is an indication to rest.”