Non-surgical treatment for lower limb apophyseal injuries

Lower limb apophyseal injuries are common in children and adolescents. The most common are traction apophysitis of the tibial tubercle and calcaneal apophysis. Various treatments are used for apophyseal conditions. This review provides information for health professionals and families who are deciding on treatment.

To assess the benefits and harms of non-surgical treatment versus placebo, no treatment, or another treatment on overall pain, physical function, or participation in physical activity in children and adolescents with lower limb apophyseal injuries.

We searched the following databases with no language restrictions up to 4 January 2025: Cochrane Central Register of Controlled Trials (CENTRAL; 2025, Issue 1) via Ovid, MEDLINE Ovid, Embase Ovid, CINAHL Plus, ClinicalTrials.gov (clinicaltrials.gov), and World Health Organization's International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/en/).

We searched for randomised controlled trials (RCTs) reported in full text, abstract form, or as unpublished data.

Our critical outcomes were overall pain, physical function, participation in sport, withdrawals due to adverse events, and serious adverse events. The primary time point was up to three months for overall pain, physical function, and participation in sport (measured in days), and the end of the trial period for adverse event outcomes.

We assessed the risk of bias (RoB) in the findings using the Cochrane tool RoB 2.

We calculated the standardised mean difference (SMD) or mean difference (MD) for continuous outcomes. We used the random-effects model to combine data and quantified heterogeneity using the I² statistic. When we were unable to pool data, we described results narratively. We assessed the certainty of the evidence using GRADE.

We included 10 RCTs, seven on calcaneal apophysitis and three on traction apophysitis of the tibial tubercle. The studies involved 654 children, whose mean age was 10.3 to 13.3 years. Most of the participants were male (73%). Six studies compared intervention versus placebo or no treatment (or both), and five studies compared one intervention versus another. In the studies reporting our critical outcomes, there were five intervention groups: pharmaceutical interventions (e.g. dexamethasone), taping, foot orthoses/heel straps, heel lifts, and heel cushioning. Placebo interventions were lidocaine injections, saline via iontophoresis, or non-stretch tape. 'Usual care' comparators were poorly described but included exercise, stretches, nonsteroidal anti-inflammatories, and massage.

Pharmaceutical intervention versus placebo for children with traction apophysitis of the tibial tubercle Compared to placebo, the evidence is very uncertain about the effects of dexamethasone on overall pain (MD -0.52, 95% CI -1.24 to 0.20; 1 study, 23 participants; very low-certainty evidence), physical function (MD -1.76, 95% CI -16.08 to 12.56; 1 study, 19 participants; very low-certainty evidence), and participation in sport (MD 7.90, 95% CI -0.41 to 16.21; 1 study, 16 participants; very low-certainty evidence) in the short term. The evidence is very uncertain about adverse events in the studies of dexamethasone or dextrose versus placebo (RR 1.31, 95% CI 0.88 to 1.96; 2 studies, 74 participants; very low-certainty evidence). Withdrawals due to adverse events were not measured. Pharmaceutical intervention versus usual care for children with traction apophysitis of the tibial tubercle Compared to usual care, the evidence is very uncertain about the effects of dexamethasone on overall pain (MD -0.80, 95% CI -1.73 to 0.13; 1 study, 21 participants; very low-certainty evidence), physical function (MD 2.68, 95% CI -17.56 to 22.92; 1 study, 16 participants; very low-certainty evidence), and participation in sport (MD 0.85, 95% CI -7.13 to 8.83; 1 study, 11 participants; very low-certainty evidence) in the short term. The evidence is very uncertain about adverse events in the study of dexamethasone versus usual care (RR 1.36, 95% CI 0.88 to 2.10; 1 study, 30 participants; very low-certainty evidence). Withdrawals due to adverse events were not measured. Taping versus placebo for children with calcaneal apophysitis Compared to placebo, the evidence is very uncertain about the effects of Kinesio tape on overall pain (MD 0.10, 95% CI -1.25 to 1.45; 1 study, 22 participants; very low-certainty evidence) and physical function (MD 6.10, 95% CI -0.08 to 12.28; 1 study, 22 participants; very low-certainty evidence) in the short term. Participation in sport, adverse events, and withdrawals due to adverse events were not measured. Foot orthoses versus heel lifts for children with calcaneal apophysitis Compared to heel lifts, foot orthoses likely result in little to no difference in overall pain (MD 0.00, 95% CI -0.44 to 0.44; 1 study, 123 participants; moderate-certainty evidence) or physical function (MD -1.30, 95% CI -7.58 to 4.98; 1 study, 124 participants; moderate-certainty evidence) in the short term. There were no adverse events reported (11 studies, 101 participants; moderate-certainty evidence). Participation in sport and withdrawals due to adverse events were not measured. Heel cushioning versus heel braces for children with calcaneal apophysitis Compared to a heel strap, the evidence is very uncertain about the effect of heel cushioning on physical function in the short term (MD -2.00, 95% CI -12.48 to 8.48; 1 study, 43 participants; very low-certainty evidence) and on adverse events (RR 1.05, 95% CI 0.07 to 15.69; 1 study, 43 participants; very low-certainty evidence). Overall pain, participation in sport, and withdrawals due to adverse events were not measured. Certainty of the evidence We downgraded our certainty level for most of the evidence because of risk of bias, imprecision, and possible publication bias.

Evidence for non-surgical treatment of lower limb apophyseal injuries is limited. We rated it mostly low to very low certainty. The studies included in this review had heterogeneous outcomes, which restricted meaningful synthesis. Outcomes were primarily focused on pain, physical function, or activity participation, and the studies did not specifically target children who had persistent symptoms of apophysitis causing functional limitations. None of the trials measured quality of life, even though cohort studies have previously reported that apophyseal injuries can impact this long-term. Nor did the trials examine economic impacts, despite the costs of non-surgical treatments for apophyseal conditions to families and healthcare systems.

None REGISTRATION: Protocol DOI: https://doi.org/10.1002/14651858.CD015156.