Pelvic apophyseal injuries in young athletes

Injuries at the pelvic area in young athletes due to training can be Apophyseal or Apophysitis. Apophyseal injuries occur in skeletally immature athletes, as an acute injury, primarily between the ages of 13 and 25. Apophysitis is a chronic injury due to traction at the tendon insertion area. As a result we have a gradual onset of pain with no clear history of injury. Examination reveals tenderness to palpation at the musculotendinous insertion into the bone.

Apophyseal avulsion fractures are usually acute, and the displaced fragment may be bony or cartilaginous. The mechanism of injury is from a violent muscle contraction that occurs across an open apophysis. Sudden onset of pain, swelling, and weakness are usual the symptoms of an apophyseal avulsion fracture. Generally, there is no history of direct trauma. Radiographs is always necessary to confirm the diagnosis. Treatment of all of the apophyseal is usually non operative.

Ice should be used at the beginning and rest. Then stretching, strengthening, and proprioception. Most of these injuries are managed conservatively, and indications for surgical fixation are exceedingly rare only in significant displaced avulsions. Premature return to sport may result in re-injury.

Anterior superior iliac spine avulsion (ASIS) occurs during sudden contraction of the sartorius when the hip is extended with the knee flexed. On clinical examination, localized tenderness and/or swelling is present and flexion and abduction of the thigh provokes the symptoms. On x-rays displacement of the ASIS is noted. Marked displacement is rare.

Anterior inferior iliac spine avulsion (AIIS) can result after contraction of the rectus femoris with kicking. Examination reveals local tenderness and swelling in the region of the AIIS and exacerbation with active flexion. On x-rays demonstrate displacement of the AIIS.

Ischial tuberosity apophyseal injuries. The ischial apophysis is the site of the hamstring and adductor magnus origin, and it is the last apophysis to unite (at approximately age 25). The mechanism of injury is a vigorous hamstring contraction with the hip flexed and the knee extended. In runners, this injury occurs most often in hurdlers. The athlete complains of pain at the ischial tuberosity and difficulty sitting. Gait may be antalgic. On examination, hip flexion with the knee extended will cause symptoms; thus, the presentation and examination are similar to a hamstring injury in an adult.

Radiographs may demonstrate a displaced fragment of the ischial tuberosity. When the displasement of the avulsed fragment is greater than 2cm may require surgical fixation. Complications are more frequent than other apophyseal injuries (ASIS and AIIS). In addition, time to full rehabilitation is often longer than that of other apophyseal avulsion injuries.

Iliac crest apophysis avulsion occurs with the sudden contraction of the abdominal muscles that is opposed by simultaneous contraction of the gluteus medius and tensor fascia latae. This may result from excessive arm swing and trunk rotation while running and may occur also with a sudden change in direction. On examination, resisted abduction produces pain of the ipsilateral side and palpation of the iliac crest is painfull. Oblique x-rays will reveal an avulsion of the iliac crest.

Lesser trochanter apophysis avulsion occurs with a sudden contraction of the iliopsoas muscle. The athlete experiences a sudden pain of anteromedial hip while running. On examination, passive internal and external rotation and active hip flexion reproduces the symptoms. Gait is antalgic. Radiographs demonstrate an avulsion of the lesser trochanter.

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