Pediatric Apophysitis Management in the Emergency Department

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Publication Date: February 2025 (Volume 22, Number 2)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-B Credits. CME expires 02/01/2028.

Author

Peer Reviewers

Abstract

Children with sports injuries often present to the emergency department for evaluation and treatment. It can be difficult to differentiate apophyseal injuries from other common pediatric sports medicine injuries, such as fractures, muscular injuries, or ligamentous injuries. However, recognition of apophyseal injuries can help facilitate optimal healing, prevent future injury, and minimize unnecessary testing. This issue aims to help the emergency clinician correctly identify the major anatomic areas of apophysitis in a child, diagnose the condition, and appropriately manage apophyseal injuries in the emergency department. Guidance for activity modification and return precautions are also provided, and indications for when to refer the patient to a specialist are also reviewed.

Case Presentations

A 5-year-old boy with no past medical history presents for heel pain for 1 week...

• The patient has been playing basketball for the past month as part of practices for the upcoming season. To address the pain, the boy’s mother has been giving him ibuprofen “every so often,” but she has not tried other medications or interventions. The patient reports that it hurts particularly in the right heel when he jumps and lands on his feet.
• The boy has had no fevers, rashes, night sweats, or weight loss. The review of systems is negative. On examination, he has an antalgic gait but is able to bear weight. He has full range of motion of the right foot and ankle, and he is neurovascularly intact. He has a positive calcaneal squeeze test. His physical examination is otherwise negative.
• What diagnoses are on your differential?

A 12-year-old girl with no past medical history presents with right knee pain noted primarily after activity...

• The girl is a soccer player and has been participating in a soccer camp this past week. She has been playing for approximately 5 hours a day. She has had some vague knee pain, but on the afternoon of presentation, she had worsening discomfort “just below the knee” and noticed a “bump” that she had not noticed before. The girl reports the pain as 7/10, especially when she is trying to squat or kneel. She is able to bear weight but with some difficulty.
• The girl has not had any fevers, rashes, night sweats, weight gain, or weight loss. She has not yet started her menstrual cycle. To try to relieve the pain, she tried acetaminophen, without much relief, but icing the knee seemed to help. Her physical examination is notable for point tenderness to the right tibial tuberosity, with mild surrounding edema without overlying erythema or calor.
• What management recommendations do you have for this patient?

A 10-year-old boy with ADHD and asthma presents with concerns for left elbow pain...

• The boy is a high-level pitcher on his Little League team. The boy tells you his team hopes to make the Little League World Series this year, and he is the best pitcher on the team. He reports that he has been pitching multiple innings “almost every game.” He recently had a growth spurt but has otherwise been in his normal state of health.
• On examination, he has point tenderness to the medial epicondyle and winces in pain. He is neurovascularly intact otherwise, with good perfusion and full muscle strength.
• Do this patient’s symptoms warrant emergent orthopedic evaluation or outpatient orthopedic follow-up?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.