Growth-plate injuries

Key points

A 2006 systematic review, a study that searches for all the research on a question, places the growth plate between a bone’s end and its shaft¹.
Studies disagree on how common growth-plate fractures are: 30% of 2,650 children’s long-bone fractures in a 1990 study, 5.7% in a 2016 US trauma database^2,3.
In sport, reviews describe sudden fractures and stress injuries from repeated loading, reported in many repetitive youth sports^1,4.
How often growth was disturbed after a fracture varied by study and site: 4.4% of 157 lower-radius injuries followed for an average of 25.5 years, and 52% of 564 lower-femur fractures pooled from 16 studies^5,6.
A 2013 review found properly supervised weight programmes were not linked to more acute injury in adolescents, but long-term effects on growth plates are unknown⁷.

What it is

Where the growth plate sits

Long bones grow in length at the growth plate, a layer of cartilage that is replaced by bone at about 18 to 21 years⁸. A 2006 systematic review of growth-plate injuries in young athletes calls the plate the physis¹. It places it between the epiphysis (the bone’s end) and the metaphysis (the flared part of the shaft)¹.

Engraving of the upper and lower ends of the tibia and fibula of a young adult, seen from the front, with the middle of both shafts left out. At the knee end, a dark wavy line runs across the top of the tibia, dipping down at the front where the bony bump below the knee sits, and another dark line crosses the top of the fibula beside it. At the ankle end, dark lines cross the lower tibia and the lower fibula just above the joint. These lines mark where each bone's growth plate was. Thin blue lines trace the edges of the joint surfaces. — Where the growth plates of the shin bones were, front viewHenry Vandyke Carter, in Henry Gray, Anatomy of the Human Body (1918), Fig. 261. Public domain, via Wikimedia Commons. (source, Public domain)

A 2016 review explains that Salter and Harris described two kinds of growth plate⁹. Pressure plates sit at the ends of long bones, inside joints, bear weight and give growth in length⁹. Traction plates, or apophyses, sit where muscles attach, outside joints, and give growth in width⁹. Overuse problems of apophyses, such as Osgood-Schlatter disease and Sever’s disease, are common in young athletes and have their own pages¹.

Why the plate is a weak point

The 2006 review notes that growth-plate cartilage resists stress less than adult joint cartilage¹. It also resists shear and tension less than the bone beside it¹. Forces that might tear a ligament in an adult can therefore injure the growth plate instead¹.

The 2016 review explains that Salter and Harris found fractures typically run through one weak layer of the plate⁹. Later tissue studies found that injuries commonly cross several layers, depending on the forces involved⁹. That is why, the review says, type II fractures can stop growth, though in theory they spare the growing cells⁹.

Two ways the plate is hurt in sport

The 2006 review found both sudden (acute) injuries and stress injuries¹. The same review describes the stress injury as seeming to come from repeated loading¹. The loading changes blood flow on the shaft side and gets in the way of cartilage hardening, so the plate widens¹. The widening is usually temporary, but in some cases growth becomes uneven, slows, stops, or the plate closes early¹.

The Salter-Harris types

A 2016 review states that the 1963 Salter-Harris classification of growth-plate fractures remains the most widely used⁹. It sorts fractures into five types⁹:

Type	Path of the break	What reviews note
I	Straight through the growth plate, separating the bone end⁹	A 2024 review describes Little League shoulder as a type I stress fracture¹⁰
II	Along the plate, then out through the shaft side⁹	The most common type, 74% of growth-plate fractures⁹
III	Along the plate, then out through the bone end⁹	Runs into the joint; arthritis after injury is possible besides growth arrest⁹
IV	Across the plate, from shaft side to bone end⁹	A bony bar, a bridge of bone across the plate, can form if it heals out of line, with uneven growth⁹
V	A crush injury of the plate⁹	Rare, and some authors question whether it exists⁹

The same review adds that crush damage can also arise as a stress injury, as in gymnasts who repeatedly load an extended wrist⁹. It notes that the classification describes a generic plate, which limits how well it indicates the outlook for any one fracture⁹. In one population study, 16% of growth-plate fractures did not fit the classification¹¹.

Who it affects

How common growth-plate fractures are

Studies of children’s fractures gave quite different figures for how common growth-plate fractures are^3,11. Some gave incidence, how many new cases appear in a group over a set time. Person-years are a count of people multiplied by the years each was followed.

Study	What it found
All children in Olmsted County, Minnesota, 1979 to 1988	951 fractures in 850 children, 279.2 per 100,000 person-years; boys outnumbered girls two to one¹¹
1990 study, 2,650 long-bone fractures in children aged 0 to 16	30% involved the growth plate²
2016 US National Trauma Data Bank, ages 18 or under	5.7% of long-bone fractures; 71% in males; the tibia was the most common site³
Danish children with tibia, lower femur or lower fibula fractures	35 per 100,000 person-years, highest for the lower tibia and lower fibula¹²

The trauma database authors note their share is lower than earlier studies, which reported 18% to 30%³. The 2006 review gives about 15% of all children’s fractures¹.

In Olmsted County, the finger bones were the most common site (37%), and type II the most common type (54%)¹¹.

Sudden injuries in sport

The 2006 review found acute growth-plate injuries made up as much as 30% of sports injuries in one study¹. It concluded the share is probably much lower, 1% to 12% depending on the sport¹. In one large population study it reviewed, falls were the largest single cause¹. Competitive sports accounted for 33.5% and recreation such as biking and skiing for 21.7%¹.

Stress injuries from repeated loading

A 2022 review covered 128 articles on growth-plate stress injuries, 101 of them case reports or series⁴. It reports that youth in many high-impact, repetitive sports may have these injuries⁴. The sports included baseball, climbing, dance, gymnastics, swimming and tennis, at the shoulder, elbow, wrist, hand, knee, ankle and foot⁴. Cross-sectional studies, which look at a group once, gave these rates⁴:

At the shoulder in 0% to 36.6% of baseball players⁴.
At the wrist in 10% to 83% of gymnasts⁴ and 52.6% of platform divers⁴.
In the fingers of 5% to 58% of rock climbers⁴.

The review notes that some imaging changes caused no symptoms⁴. It adds that no prospective cohort studies had yet given incidence figures⁴.

Growth spurts and training load

The 2006 review states the plate appears especially open to injury during rapid growth, when it becomes thicker and more fragile¹. A 2024 scoping review of 30 studies of elite youth athletes found that injuries linked to growth were most common in the teenage growth spurt¹³. It reports that faster height gains went with more bone and growth-plate injuries in male track and field athletes¹³. The 2006 review calls the idea that growth spurts tighten muscles and tendons controversial¹.

A 2017 systematic review of 24 studies looked at overuse growth-plate injuries in youth athletes¹⁴. It found five risk factors: periods of fast growth, age, size, how much athletes trained, and past injury¹⁴. A 2024 American Academy of Pediatrics clinical report states that overuse injuries can come from repeated stress without enough recovery¹⁵.

What studies found

How often growth was disturbed after a fracture

Studies of growth-plate fractures in children counted growth disturbance, growth arrest (growth stopping) or early closure of the plate^6,12,16. Their rates differed widely:

Study	Growth found disturbed
16 pooled studies, 564 lower-femur fractures	52%, from 36% of type I to 64% of type IV⁶
Prospective cohort, 332 children, arm and leg long bones	30.1% growth arrest, highest after lower-femur fractures (86%)¹⁶
124 children with lower-tibia fractures, mean 57 weeks	12.1% early closure, with no case after type I¹⁷
236 Danish children, tibia, lower femur or lower fibula	9.7% early closure with a leg length difference or deformity¹²
157 lower-radius injuries in 157 patients, mean 25.5 years	4.4% of radial injuries shortened by 1 cm or more⁵
Case series gathered in the 2006 review	0% to 75%; the authors judged a poor outlook probably 0% to 37%¹

The authors of the 332-child cohort note their rate is higher than earlier reports of up to 5.5%¹⁶. They add that definitions of arrest vary and the true rate may be lower¹⁶. A number of children were near the end of growth, where arrest likely matters less¹⁶. In the lower-radius study, only 2 patients had severe problems with function⁵.

What went with growth problems

Displacement, where the broken ends have moved out of line, went with growth problems in four studies^6,12,16,17:

In the pooled lower-femur studies, displaced fractures had four times the odds of growth arrest⁶.
In the lower-tibia study, each millimetre of first displacement raised the relative risk (how many times more likely closure was) by 1.15¹⁷.
In the Danish cohort, fractures displaced by 3 mm or more had a hazard ratio of 12 for early closure¹².
In the 332-child cohort, children with arrest were older on average and more often displaced¹⁶.

The 2006 review concluded that type I and especially type II injuries are not as harmless as first described¹. In published sport cases, mostly in male athletes, it found growth disturbance in 8 of 50¹. Follow-up was short or unreported in some, and most athletes were 13 to 17, with less growth left to disturb¹.

How stress injuries turned out

The 2006 review found most stress injuries resolved without affecting growth over short follow-up¹. Several reports, though, describe early closure of part or all of the plate¹. The 2022 review of 128 articles found most patients, across sites and sports, returned to their sport after a period of rest⁴. In the same review, 57 of 448 reported cases (12.7%) had a growth disturbance⁴. Late presentation and not keeping to rest were common in those cases⁴.

Two reviews of return to sport looked at single sites^18,19:

Climbers’ fingers: in a 2026 scoping review of adolescent sport climbers, 91% returned to climbing, after 2 weeks to 6 months¹⁸.
Upper ulna: a review of 40 studies covered 174 athletes with upper-ulna stress injuries¹⁹. Of these, 74 had growth-plate injuries, aged 11 to 26; the rest had stress fractures¹⁹. Across the whole group, return rates were 67% to 100% with or without surgery¹⁹. Almost half of those who had surgery had first not improved without it¹⁹.

The 2022 review of 128 articles concluded that prospective studies are still needed on incidence and long-term skeletal health⁴.

Weight training before the plates close

A 2013 review noted growth plates are weaker than the bone around them⁷. It said the literature does not definitively answer whether strength training is safe for adolescents⁷. In its authors’ earlier survey of 500 sports medicine experts, respondents judged it very likely false that lifting should wait until the plates close⁷. Reviews from 2006 to 2022 report:

2006: an evidence-based review found that of 22 training studies in pre- and early-pubertal youth, 10 monitored injuries, and 3 injuries were reported²⁰. The programmes did not change growth in height or weight²⁰.
2010: a literature review states that no prospective youth study with professional instruction reported growth-cartilage injury²¹.
2013: the review above found properly supervised programmes were not linked to more acute injury in adolescents, but long-term effects on growth plates are unknown⁷.
2022: a review of weightlifting in children and adolescents reports that injury rates appear relatively low and severe injury is uncommon²².

The 2022 finding is about injury in general, not growth plates²². On injury, it points the same way as the 2006 and 2013 reviews^7,20.

Limits on load in published statements

The 2017 review of 24 studies also found that prevention strategies stressed limits on participation and sport-specific training programmes¹⁴. It also found little consensus on risk factors, prevention and management¹⁴.

A 2024 baseball review reproduces the Pitch Smart pitch-count recommendations of USA Baseball and Major League Baseball¹⁰. The daily maximum runs from 50 pitches at ages 7 to 8 to 105 at 17 to 18, with more rest days after more pitches¹⁰. It notes that young players can get around pitch counts by playing on several teams¹⁰.

Connections

The growth plate is the layer of cartilage where long bones grow in length⁸. In the US trauma database, the tibia (shinbone) was the most common site³. The Danish cohort also counted the lower femur (thigh bone) and lower fibula¹². The humerus (upper arm bone) page covers its upper growth plate and Little League shoulder^23,24. The distal radius and wrist pages cover gymnasts’ wrists^25,26.

Apophyses have their own pages: Osgood-Schlatter disease and Sever’s disease¹. A 2022 review defines bone stress injury in general as overuse of generally normal bone, as the stress fracture page describes²⁷. In 476 pitchers aged 9 to 14, pitch counts went with elbow pain, as the elbow ulnar collateral ligament page describes²⁸.

Youth lifting is covered on the resistance training and free weights and machines pages^21,29. The power clean page covers weightlifting injury in youth²².