A 17-year-old female player presented with a 12-month history of localised left hip pain. This has become much worse over the three months leading up to her visit. This appeared to have coincided with a period where she was training more regularly. The pain was predictably made worse by running, and other physical activity, and improved by rest. The pain was very well localised to the anterior superior iliac spine (ASIS) region and anterior aspect of the iliac crest and was associated with localised tenderness in this region. There was modest discomfort with resisted hip flexion but an otherwise normal examination.
There appears to be subtle widening of the apophysis of the left iliac crest on an AP x-ray of the pelvis. The x-ray series is otherwise normal. There is bone oedema within the anterior superior aspect of the left iliac bone over a length of approximately 40 mm AP. This involves the width of the iliac blade at the crest. The growth plate appears wide with T2 increased signal consistent with an apophyseal avulsion injury. No other significant bone abnormality identified.
There are seven apophyses located about the hip and pelvis. All of these have been reported as sites of both acute traumatic avulsion and apophysitis. Injuries to the iliac crest apophysis are relatively uncommon. These injuries are generally due to overuse, rather than caused by an acute trauma. The iliac apophysis develops anteriorly and then ossifies from anterior to posterior as a patient progresses towards skeletal maturity. This apophysis is one of the last to close in the body, with the average chronologic age of completion being 16 years in boys and 14 years in girls. As this case illustrates, ossification can be more delayed, occurring as late as 20 years in boys and 18 years in girls.
As with ‘apophysitis’ at other sites this generally resolves spontaneously. Treatments that have been reported in the literature include physical therapy, activity modification, anti -inflammatory medication and the use of compressive garments. The use of bone stimulators and pulsed ultrasound have also been described. The critical treatment however is patient education and controlled loading. It is essential the player, their parents and coaches understand that there is a clear relationship to training volume and that there is a need to make sure that this is managed appropriately. The player should also be reassured that this is generally a self-limiting problem that will resolve at skeletal maturity.
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