Is Skeletal Maturity Associated With Anatomical Distribution of Sports-Related Lower Extremity Overuse Pain in Young Athletes?

OBJECTIVE: To evaluate the association between skeletal maturity and the anatomical distribution of sports-related lower extremity overuse pain in young athletes. DESIGN: Retrospective observational cohort study. SETTING: Single-center sports medicine clinic. PATIENTS/PARTICIPANTS: A total of 2565 clinical episodes of sports-related lower extremity overuse pain in athletes aged ≤22 years presenting between January 2017 and November 2025. INDEPENDENT VARIABLES: Skeletal maturity classified according to physeal status (open vs closed). MAIN OUTCOME MEASURES: Anatomical region of overuse pain at presentation. Anatomical distributions were compared between physeal groups, and multinomial logistic regression adjusted for sex and sport type evaluated associations between physeal status and anatomical presentation. RESULTS: Overall anatomical distribution differed significantly according to skeletal maturity (P < 0.001). Although the knee was the most common anatomical region in both groups, athletes with open physes demonstrated relatively greater knee, pelvic girdle, and foot involvement, whereas athletes with closed physes demonstrated relatively greater ankle and lower-leg involvement. In adjusted multinomial logistic regression analyses, open physeal status was independently associated with a greater relative likelihood of foot (relative risk ratio [RRR], 2.65; 95% confidence interval [CI], 1.95-3.61), knee (RRR, 2.45; 95% CI, 1.84-3.27), and pelvic girdle (RRR, 2.25; 95% CI, 1.59-3.20) presentations compared with ankle presentations. These associations remained consistent after additional adjustment for chronological age. CONCLUSIONS: Skeletal maturity was associated with differences in anatomical distribution of sports-related lower extremity overuse pain. These findings suggest that skeletal maturity may influence where repetitive sport-related loading becomes clinically expressed and may improve the clinical interpretation of regional overuse pain in young athletes. CLINICAL RELEVANCE: Considering skeletal maturity when evaluating regional overuse pain may improve the clinical interpretation of sports-related lower extremity pain in young athletes.