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Osgood Schlatter’s Disease

What it is

Osgood Schlatter’s Disease, or “tibial tuberosity apophysitis”, is a common condition affecting children and teenagers where the bone at the site of the tibial tuberosity growth plate is inflamed. It is characterised by a gradual, non-traumatic onset of knee pain that worsens rapidly. It most commonly affects physically active children, particularly boys, but any child can develop the condition.

It is a fairly common condition, with estimates that 15-20% of athletic children will experience it at some point, and up to 5% of non-athletic children. Despite this, many parents are unaware of the signs and symptoms, the management on the condition and the long term prognosis for their child. This blog will help explain the nature of the condition and management strategies used by physiotherapists.

 

What causes it

Osgood Schlatter’s Disease is an inflammation and subsequent pain in the growth plate or “epiphyseal plate” in the tibial tuberosity, which is a bony prominence at the front of the shinbone. Growth plates are found at the ends of developing bones and contain cartilage cells that form into adult bone. This process occurs during a growth spurt in children and is how their bones grow and usually occurs in “spurts” over a two-year period.

When this process is occurring the growth plates are weaker as they have not fully formed into adult bones. In this period of rapid growth, a child’s bones grow faster than their muscles causing them to be become tight. In the instance of Osgood Schlatter’s disease the quadriceps muscles and patellar tendon are pulled tight, resulting in pain and inflammation where it attaches to the weakened tibial tuberosity.

Signs and Symptoms:

The most common symptom is intense pain just below the front part of the knee, which presents on activities such as jumping, squatting, running, kicking, climbing stairs and kneeling. The pain tends to start off relatively mild and then increase in intensity until the patient is unable to effectively complete the task due to pain. In addition to pain on activity, the tibial tuberosity may be swollen and tender, even at rest.

In 20-30% of cases, children will experience these symptoms in both knees. In later stages, the growth plate itself may enlarge which tends to look like a bump on the tibial tuberosity. This will often stay even after the condition resolves.

Risk factors

The largest risk factor for developing a patella tendinopathy includes acute changes in load for jumping based tasks. Often such load changes include competing in a tournament, increased playing/training frequency, alterations in shoe-wear or alternations in playing surfaces. Weight gain can also be a contributing factor as this places extra load onto the joints. Patella tendinopathy is a highly prevalent condition in younger, jumping athletes, less than 30 years old.

Factors that can contribute to it

  • Active boys from 11-15 years old are the most likely to experience Osgood Schlatter’s Disease, but girls aged 8-13 years can also be affected. If a child plays multiple sports, they are more likely to experience OSD.
  • Having chronically tight thigh muscles can also make you more likely to experience Osgood-Schlatter’s Disease.
  • Activities involving repetitive, strong quadriceps contractions produce the highest risk. Children who participate in jumping, running, and kicking sports such as football, netball, basketball, soccer etc. are most at risk.

Diagnosis

An accurate diagnosis can usually be made based on the symptoms by a physiotherapist, imaging often won’t be required. An X-ray may or may not show bony fragments at the site of attachment from the patellar tendon to the tibial tuberosity. It is important to see a qualified practitioner for diagnosis, however, as there are several alternative diagnoses that you may be experiencing, including:

  • Sinding-Larson-Johansson syndrome (a similar condition affecting the bottom of the kneecap as opposed to the tibial tuberosity)
  • Patellar tendinopathy
  • Patellofemoral pain
  • Infrapatellar bursitis
  • Fat pad injury
  • Fracture of tibial tuberosity
  • Slipped capital femoral epiphysis

Treatment

The treatment will depend on the findings of the physical assessment, but will likely include pain relief, activity modification, supervised exercise and stretching.

Perhaps the most important treatment we can provide is activity modification. Osgood Schlatter’s is a self-limiting condition, which usually means that the pain experienced during activity is directly related to the amount of inflammation at the tibial tuberosity, rather than a sign of ongoing damage being caused. Activity modification involves modifying the duration, intensity, frequency or type of activity the patient undergoes in order to “manage” symptoms. If the pain is quite severe then rest from strenuous activity may be recommended for a short period of time.

Other treatments may involve strengthening of the muscles surrounding the knee, icing, low intensity activity such as walking and swimming. Stretching, massaging and foam rollers may be used to help to lengthen the tight quadriceps muscles.

Prognosis

As previously mentioned, Osgood Schlatter’s, while painful, is a mostly self-limiting condition. The typical lifespan of the condition lasts for a few weeks to a few months, however in some scenarios people experience symptoms for up to two years.

Once the condition has resolved, most people will not have any ongoing effects, however a small portion of patients will experience an enlargement of the tibial tuberosity, and some will have ongoing discomfort while kneeling on the affected leg.

 

 

At Total Physiocare Heidelberg, Reservoir, Camberwell and Footscray we treat many knee and overuse sporting injuries.

Book an appointment today for your assessment!

Blog by Nicholas Musso (Physiotherapist)

Patella Tendinopathy – Blog by Christian Bonello

The patella tendon is a continuation of the quadriceps tendon and has a role in connecting the quadriceps femoris (4 quadriceps muscles at the front of the thigh) to the tibial tuberosity of the shin. The patella tendon has a principle role in transmitting force through the lower limb, particularly in powerful jumping movements.

Patella tendinopathy is defined as a pathology or injury of the patella tendon, commonly due to overuse mechanisms. For further information please refer to the “What is a tendon and tendinopathy” blog.

Symptoms:

The main symptoms of a patella tendinopathy is pain and tenderness localised to the inferior pole of the patella (ie bottom of knee cap). Patients often report load-related pain that increases with the demand on the knee extensors. Notably this includes activities that store and release energy in the patellar tendon such as jumping and change of direction activities.

Prevalence:

Patella tendinopathy is highly common in jumping athletes with a 45% prevalence reported in basketball players, 32% reported in volleyball players and is common in AFL ruckman. Conversely patella tendinopathy only has a 2.4% prevalence in “in-season” soccer players due to the altered demands of the sport.

Risk factors:

The largest risk factor for developing a patella tendinopathy includes acute changes in load for jumping based tasks. Often such load changes include competing in a tournament, increased playing/training frequency, alterations in shoe-wear or alternations in playing surfaces. Weight gain can also be a contributing factor as this places extra load onto the joints. Patella tendinopathy is a highly prevalent condition in younger, jumping athletes, less than 30 years old.

Diagnosis:

Patella Tendinopathy is medically diagnosed by a physiotherapist.

A physiotherapist will conduct a strength and lower limb power assessment to highlight any differences between the symptomatic and unaffected side, and as a comparison to dominate limb function. Palpation may reveal localised pain and tenderness over patella tendon.

In rare cases, ultrasound may be utilised in the diagnosis of the condition, however is not often required as there is a poor correlation between imaging findings and patient reported symptoms and level of function.

Treatment:

Multiple interventions can be utilised in the treatment of a patella tendinopathy but should primarily be gym based. As the condition can become chronic and often debilitating, treatment is most successful when commenced early.

Your physiotherapist will guide the appropriate management based on your assessment findings and the severity of symptoms which may include:

– Rest from aggravating exercises

– Graduated strengthening exercises (starting with static contractions and building through range with resistance to power based activities)

– Taping

– Load  management strategies or advice

At Total Physiocare Heidelberg, Reservoir, Camberwell and Footscray we treat many knee and overuse sporting injuries.

Book an appointment today for your assessment!

Blog by Christian Bonello (Physiotherapist)

Posterior Cruciate Ligament (PCL) Injury

What is the Posterior Cruciate Ligament?

The Posterior Cruciate Ligament (PCL) is a ligament inside the knee joint. The PCL attaches to the shin bone (tibia) and to the thigh bone (femur). Along with the anterior cruciate ligament (ACL), these ligaments provide stability to the knee.

The main role of the PCL is to prevent the shin bone from sliding backwards on the thigh bone.

Mechanism of Injury

A direct blow to the upper area of the shin bone is the main cause of a PCL injury. In the general public this is seen during motor vehicle accidents where the top of the shin hits the dashboard. In the sporting population, PCL injuries occur when the athlete falls onto their bent knee causing the shin to hit the ground first. This type of mechanism is common in:

  • Football
  • Soccer
  • Basketball
  • Skiing

Signs and symptoms

  • Pain and/or swelling immediately following the injury
  • Difficulty walking
  • The knee may feel unsteady. It may feel like it is going to give way

Grading of Injury

PCL injuries are often graded I, II, III. Grade I and II are partial tears of the PCL whilst a grade III signifies a complete rupture of the ligament

Grade I – The PCL is overstretched resulting in a small partial tear. The knee remains stable.

Grade II – More of the PCL is torn when compared to a grade I. The ligament is now loose. The knee may start to feel unstable at this grade.

Grade III – This PCL is completely torn. The knee joint is now unstable.

Assessment

Isolated PCL injuries are uncommon. It is more likely for additional injuries to occur to other structure of the knee. These include damage to the meniscus and/or medial and lateral collateral ligaments and even the ACL.

A thorough physiotherapy assessment is required to discover the extent of the injury and if any other structures are damaged. After gaining you subjective history, your physiotherapist will put you through a series of special tests to determine the extent of the injury.

After a knee injury, you may be referred for an MRI scan. This is often necessary to confirm a PCL injury and other associated injuries. Your physiotherapist, doctor or surgeon can refer you for this scan. You may require a X-Ray if an avulsion fracture (small component of bone pulled away by the ligament) is suspected.

Treatment

The PCL can be treated either conseratively or surgically. This is dependent on the grading of the PCL injury and and other associated injuries.

In the immediate stages following a knee injury, it is advisable to follow the POLICE principle for the initial 48-72 hours. This involves Protection, Optimal Loading, Ice, Elevation and Referral for medical management. It is also advisable to follow the NO HARM program to reduce further bleeding and swelling into the joint: NO Harm, Alcohol, Running or Massage

Conservative Management – May include other injuries as well

Patient who have grade I or II PCL tears usually receive conservative treatment. This treatment can consist of a period of immobilisation of the knee with bracing. During the initial period of rehabilitation it is important to focus on strengthen both the quadriceps and hamstring muscles and to regain full movement of the knee.

Sport and skill specific training is crucial in the latter stages of rehabilitation in order to provide ongoing stability to the knee and to provide a successful return to sport or activity.

Surgical Management

Injuries which involve other structure of the knee and Grade III PCL injuries are likely to require surgical intervention. If a period of conservative management has failed to provide stability to the knee, surgery may also be required.

Similar to that of the ACL, the PCL can be reconstructed arthroscopically. This involves the use of tissue grafts to rebuild you PCL. The graft can be taken from another part of your body, often the hamstring or quadriceps tendon, or from another human donor (cadaver). It can take several months for the new ligament to fully integrate with the bones of your knee.

Rehabilitation

Regardless of whether you have opted to treat your PCL injury surgically or conservatively, it is important you participate in a rehabilitation program under the guidance of your physiotherapist.

The aims of physiotherapy are to:

  • Restore range of motion of your knee
  • Improve strength of the surrounding muscles
  • Address poor biomechanics
  • Improve jumping and landing strategies
  • Skill Retraining/ Sport specific activities
  • Return to Sport
  • Prevent Re-injury

At Total Physiocare we treat hundreds of knee injuries and work closely with multiple orthopaedic surgeons in order to accurately diagnose, manage and rehabilitate clients following an acute knee injury. 

Book an appointment today for your assessment!

Blog By Ryan Harris (Physiotherapist)

Introducing the GLAD program to Total Physiocare – Blog by Christian Bonello

GLA:D program for hip and knee arthritis – What is it?

The GLA:D® program (Good Life with Arthritis: Denmark) is an education and exercise program developed by researchers in Denmark for people with hip or knee osteoarthritis (OA) symptoms.

OA is the most common lifestyle condition affecting individuals 65 year of age and older, but can also affect those as young as 30.

Current national and international clinical guidelines recommend patient education, exercise and weight loss as first line treatment for osteoarthritis. In Australia however, treatment usually focuses on surgery and the GLA:D Australia program offers a better and safer alternative.

Background of the GLA:D program

Research from the GLA:D® Denmark found that patient reported symptoms reduced by 32% after partaking in the program. Other favourable outcomes included less pain, reduced use of pain killers, and less sick leave or absenteeism. GLA:D® participants also reported high levels of satisfaction with the program and increased their levels of physical activity 12 months after starting the program. Similar results have also occurred via the GLA:D Canada Program.

This program is unique in that the education and exercises provided can be applied to everyday activities. By strengthening and correcting daily movement patterns, participants will train their bodies to move efficiently, prevent symptom progression and reduce their pain.

What does GLA:D involve?

The GLA:D program is an eight week intervention and includes education and exercise, based on the latest evidence in osteoarthritis research. The program is supervised by a certified GLA:D physiotherapist, with the aim to help patients manage their OA symptoms.

GLA:D® Australia training consists of:

  • An initial appointment with a GLA:D certified physiotherapist explaining the program and collecting data on baseline functional ability
  • Two education sessions where you will learn about OA, how the GLA:D intervention improves joint stability and can reduce symptoms, and ongoing management following the program
  • Group neuromuscular training sessions which occur twice a week for six weeks to improve muscle control of the joint.

GLA:D® Australia is being unveiled in private and public hospitals and physiotherapy clinics.

Can I participate in GLA:D Australia ?

GLA:D® Australia is a program for all individuals who experience any hip and/or knee osteoarthritis symptoms, regardless of severity or x-ray reports. You may participate in the GLA:D® Australia program if you have a hip or knee joint problem that resulted in visiting a health care provider.

You may not be eligible to participate in the GLA:D® Australia program if you have

  • Other sources of knee pain including; tumor, inflammatory joint disease, result of hip fracture, soft tissue or connective tissue problems
  • Inflammatory conditions that are more pronounced than osteoarthritis problems (for example chronic generalized pain or fibromyalgia)
  • are not able to understand english

If you have queries in regards to the eligibility criteria please feel free to contact us.

You do not need a referral from your Doctor to partake in the GLA:D program. However you may be eligible for a rebate from Medicare for some of the cost of the program, if deemed appropriate by your GP.

FIND OUT MORE:

The GLA:D program will commence across Total Physiocare sites in May 2017. Please contact you closest clinic via phone or email for further information or to register your interest.

Why not give it try today and book an appointment today for your assessment! 

Blog by Christian Bonello (Physiotherapist)

Meniscus Tear

What is the Meniscus? – Blog By Ryan Harris

The meniscus is a crescent shaped disc of fibrocartilage that is located in the knee joint. The role of it is to distribute the weight of the body and absorb shock within the knee during movement. Each knee has two meniscus, one laterally and the other medially.

Mechanism of Injury

There are two main reasons for tearing this structure.

Traumatic

A Traumatic meniscus tear is more likely seen in the younger, more active population. It most commonly occurs when the foot is planted on the ground and a twisting force is applied upon the knee. This twisting force is often caused by another person.

Degenerative

In the older adult, a degenerative tear is most likely to occur. This may be due to the natural age related changes of the meniscus or arthritic changes of the femur tearing into the meniscus.

Signs and Symptoms

  • An incident of a painful twist of the knee,
  • Some people may describe a tearing sensation,
  • Clicking, popping, or locking of the knee,
  • Minimal immediate swelling which increases of the next 24hours
  • Tenderness of the knee joint line.

Healing

The location of the meniscus tear will determine its capacity of healing. 

The outer rim of the meniscus has a blood supply from the synovial capsule. This allows it to have a capacity to heal overtime with conservative treatment, depending on the size and type of the tear.

The central part of the meniscus has no blood supply, instead gaining its nutrients from the synovial fluid. Injuries to this area of the meniscus do not usually heal overtime and often require surgery.

Assessment

Your Physiotherapist will perform a comprehensive physical examination and perform special test to diagnose your injury

It is important to undergo a thorough physiotherapy assessment as other knee injuries such as an ACL tear and/or medial and lateral collateral ligament tears may be present.

If a meniscus tear is suspected, your physiotherapist, doctor or surgeon may refer you for a MRI. This will aid in determining the location and type of tear and will help guide the appropriate treatment pathway.

Conservative Rehabilitation

Small tears and tears that occur in the outer ring that have no restriction of movement can be treated conservatively. Conservative treatment consists of:

  • Eliminating swelling
  • Restoring full range of motion
  • Strengthening of the knee and lower limb,
  • Enhancing pelvic stability
  • Improving lower limb proprioception and jumping/landing strategies
  • Sport specific activities, 
  • Gradual return to sport.

Surgical Management

Meniscectomy

Surgical intervention may be required

Following a period of conservative treatment, surgical intervention may be required. This is performed arthroscopically (keyhole). During the surgery, the surgeon will inspect the meniscus and surrounding structures via a small camera. Once the tear is identified, the surgeon will remove the affected tissues and clean up the surrounding area. The aim of surgery is to protect as much of the meniscus as possible, although it may be necessary to have a complete removal of the meniscus. 

Meniscal Repair

The surgeon may decide to repair the tear in younger patients with a recent tear in the outer rim as these tears have a chance to heal over time. Rehabilitation for meniscal repairs are greater as time is needed to get the meniscus a chance to heal.

Rehabilitation

It is important to commence rehabilitation prior to surgery. “Prehabilitation” can increase the recovery speed post operatively and in some cases, the patient can avoid surgery all together.

Monitoring of the knee is crucial during rehabilitation as the remaining meniscus and underlying articular cartilage need to adapt to the new load that is being placed upon them. Your physiotherapist will continue to reassess your knee after each progression of exercises to ensure your knee is coping with the new stresses. If an increase in pain or swelling is seen, the rehabilitation program will be altered as a result. 

The same rehabilitation principles apply for both, conservation and post surgical care. The principles are outline above. The exception being a meniscal repair which requires an initial period of rest to allow for healing to occur before commencing rehabilitation.

At Total Physiocare Heidelberg, Camberwell, Reservoir & Footscray, we have seen many knee arthroscopy surgeries due to the close hospital affiliations we have.

Book an appointment today for your assessment!

Post by Ryan Harris(Physiotherapist)

Hamstring Strain

What is a hamstring strain? – Blog By Ryan Harris

A hamstring strain is a common lower limb injury. It occurs when there is a tear of one or more of the hamstring muscles. This can range from a mild tear involving only a few muscle fibres to a complete rupture of the muscle.

Anatomy

The hamstring muscles are located in the back of the thigh. There are 3 main muscles in the hamstring. Located medially are the semitendinosus and semimembranosus muscles. Biceps femoris consists of two muscle heads and is located laterally.

Types

There are two types of hamstring strains, identified by the mechanism of the injury. It is important to distinguish the mechanism because it helps to predict the prognosis of the injury.

Type 1 – Sprinting related

Type 1 hamstring strains occur during high speed running. During the stride cycle, the hamstring is working hard to eccentrically slow the swinging tibia and control knee extension in preparation for contact with the ground. Type 1 hamstring strains typically recover quicker than type 2 strains, despite a greater initial decline in function.

Type 2 – Stretch related

Stretch related hamstring strains occur when excessive stretch in place upon the muscle. As a result, this more commonly occurs in sports like gymnastics and ballet. Whilst a type 2 strain does not have as much of an initial limitation in function when compared to type 1, the recovery is often longer.

Diagnosis

A thorough examination from your physiotherapist will be able to diagnose a hamstring strain. Common signs include bruising, pain on hamstring contraction, reduced flexibility and a palpable lump or gap within the muscle.

Ultrasound scans and MRI are often used to help determine the location and severity of a hamstring strain. Depending on severity, hamstring strains can be graded 1, 2 or 3.

Grade 1 Hamstring Strain

With a grade 1 hamstring strain you have overstretched the muscle without tearing the muscle fibres. You can still walk and you may not feel the strain until after the activity.  You will be aware of some hamstring discomfort and unable to run at full speed. There will be mild swelling and spasm. There is usually no strength or flexibility deficits. 

Grade 2 Hamstring Strain

With a grade 2 hamstring strain you may limp when you walk and there are partial tears in the muscle. You will usually feel pain and twinges during activity. You may notice some hamstring muscle swelling and your hamstring will be tender to palpate. There will also be strength and flexibility deficits to the muscle. 

Grade 3 Hamstring Strain

A grade 3 hamstring strain is a severe injury involving a full rupture or severe tear of the muscle. There may be a lump you can feel above where the depression is.  Swelling will be noticeable immediately and bruising will usually appear below the injury site a day later. You may need crutches to walk and will feel severe pain and weakness in the muscle. These strains may require surgical intervention. 

Diagnostic MRI may also be used to specifically identify the grade of hamstring tear and its exact location.

Treatment

Your physiotherapist will conducted a thorough assessment of your hamstring to determine the type of severity on the injury.

Using this information, a structured treatment plan will be development, focusing on:

  • Reducing hamstring pain,Image result for hamstring strain exercises
  • Restoring full range of motion of the muscle,
  • Strengthening the hamstring muscles,
  • Strengthening other contributing lower limb muscles,
  • Enhancing lumbo-pelvic control and stability,
  • Addressing any accompanying neural mobility restriction,
  • Improve function and technique of sport specific activities,
  • Reducing the likelihood of re-injury.

Prevention

Hamstring injuries can be a recurrent problem. To reduce the risk of re-injury, it is imperative you follow the following recommendations. 

  • A proper warm up with sport specific drills is recommended
  • Post cooling down period and stretching after activity
  • Appropriate loading and speed programs
  • Gradually increasing intensity of games prior to returning to sport
  • Ensure appropriate foot biomechanics / gradual progression of playing surface
  • Ensure appropriate strength between the hamstring and the quadriceps.

At Total Physiocare, we have a wealth of experience in sporting injuries and management.

Book an appointment today for your assessment!

Post by Ryan Harris (Physiotherapist)