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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)

What is a tendon and Tendinopathy?

What is a Tendon and Tendinopathy?

A tendon is a strong band of fibrous tissue that connects a muscle to the bone. The role of a tendon is to transmit force between the muscle and bone and act a shock absorber especially in the lower limb.

Pathology or injury to a tendon is referred to as a tendinopathy. Colloquially, a tendinopathy can be described as an overuse injury to a tendon. Especially in the athletic population, tendinopathies can be extremely debilitating chronic injuries which adversely affect an athletes performance. Historically these conditions are poorly managed without physiotherapy guidance.

tendon
Anatomy of a Tendon

Note: previously the above pathology was referred to as ‘tendinitis’, however histopathological studies have indicated a lack of inflammatory cells in patients with tendon pain. The term tendinosis can also be utilised to describe overuse pathology of a tendon.

Common Sites of Tendinopathy:

Common sites for tendon pain include:

  • Achilles (heel) tendinopathy
  • Patella (knee) tendinopathy
  • Adductor (groin) tendinopathy
  • Rotator cuff (shoulder) tendinopathy
  • Elbow (Tennis elbow or golfer’s elbow)
  • Wrist/Thumb (De Quervein’s)

knee tendon shoulder tendon

Symptoms:

The clinical symptoms of clients with overuse tendon pain include:

  • Pain free at rest and initially becomes more painful with use
  • Pain following exercise or activity
  • Pain the morning following exercise/activity, especially upon rising.
  • Athletes report an ability to “run through” the pain or the pain disappears once they “warm-up”. Despite this the pain returns (often worse) once they cool down
  • The athlete/client is able to continue to train/function fully in the early stages of the condition, which likely interferes with the healing process
  • Examination highlights local tenderness
  • Reduced muscular strength or function is apparent secondary to pain

Stages of Tendon Pain:

As proposed by tendon experts Jill Cook and Craig Purdam, tendon pathology should be considered as a continuum. In this light the early intervention can ‘reverse’ the symptoms and pathology of an inappropriately loaded tendon.

Stage 1:          Reactive Tendinopathy           An acutely overloaded tendon

Stage 2:          Tendon Dysrepair                   A worsening of tendon pathology with breakdown of                                                                the matrix of the tendon

Stage 3:          Degenerative Tendinopathy   Chronic tendon pain with areas of cell death and                                                                               collagen and matrix breakdown within the tendon.

tendon pathway

Risk Factors:

Risk factors for tendinopathy include:

  • Increased or excessive load on a tendon
  • Muscular weakness
  • Poor biomechanics or load strategies
  • Inappropriate extrinsic factors (ie shoe wear, ground surfaces, etc)

Physiotherapy and management:

Physiotherapy management of tendon pain is dependant on the location and role of that tendon (ie the management of tendinopathy’s in the upper limb differs from that in the lower limb). Several strategies will be employed by your treating physiotherapist to aid in the tendon recovery as highlighted in the continuum above. These include:

– Load management

– Static strengthening

– Progressive strengthening

– Biomechanical corrections

  • Equipment prescription (ie appropriate runners)
  • Taping or bracing as required

It is worth noting the below strategies have been shown to be detrimental in the recovery process of  tendinopathies:

  • Complete rest
  • Ignoring the pain
  • “Stretching” of the tendon

– “Compression” of the tendon

  • Massage of the tendon (note massage of the attached muscle may be beneficial)
  • Passive approaches (ie injections – especially without the addition of appropriate exercise program)
  • Not adhering to exercise and load advice as guided by your therapist

Evidence supports the fact that exercise based rehabilitation is the best treatment for tendon pain. At Total Physiocare we specialise in the accurate diagnosis, management and return to activity or sport for clients presenting with tendinopathy. Call us now to make an appointment.

jumpingcatching theraband

Blog by Christian Bonello (Physiotherapist)

Anterior Cruciate Ligament (ACL)

 

ACL

What is an ACL?

The Anterior Cruciate Ligament, commonly known as the ACL, is an important ligament of the knee. Along with the posterior cruciate ligament (PCL) the ACL forms a cross (cruciate) between the shin bone (tibia) and to the thigh bone (femur). Together these ligaments provide stability of the knee joint, with the majority of ligamentous support of the knee coming from the ACL.

ACL3ACL2

 

The ACLs two main roles are:

(A) Prevent the forward translation of the tibia on the femur

(B) Assist with rotational stability of the knee

Prevalence:

The rate of ACL injury is highly common in the sporting population. It is often associated with sports that require cutting, pivoting and sudden deceleration such as Australian Rules Football, netball, basketball, soccer, gymnastics, hockey and downward skiing.

ACL4

Risk Factors:

There are multiple risk factors that may influence the incidence of an ACL injury, as listed below:

Non-modifiable risk factors:

  • Genetics: athletes with an ACL tear are twice as likely to have family history of ACL tears
  • Females: There is approximately a x6 times greater incidence of ACL tears in females. This is likely attributed due to anatomical variations, hormonal involvement and neuromuscular deficits.
  • Previous ankle or knee injury with residual joint laxity

Modifiable risk factors:

  • Muscle strength imbalance (low hamstrings to quadriceps strength ratio)
  • Poor neuromuscular control and coordination
  • Bio-mechanical factors such as poor hip and ankle control, reduced core strength, reduced ankle range of motion and a deficit in lower limb strength
  • Reduced sport specific fitness/conditioning
  • In-proper technique and body positioning for sport specific skills
  • Environmental conditions: playing surface and wet weather
  • Inadequate shoe wear
  • Increased Body Max Index (BMI)

Mechanism of injury:

Two thirds of ACLs injuries occur in a non-contact situation, which often involve the athlete landing in knee hyperextension, a side pivoting motion and/or decelerating suddenly. In footage of ACL ruptures, the knee is commonly seen to track inwards compared to the foot (valgus moment) and is accompanied by a knee inwards rotation motion.

During an ACL rupture, an athlete will often describe an audible “pop” or “crack” and a feeling of the knee giving way or instability. The majority of complete ACL tears are often followed by few minutes of severe pain and the sportsperson will be unable to continue their activity. Often the athlete will have a reduced range of knee motion, particularly extension, following the incident.

Judd

Assessment:

The best time to exam an ACL tear is within the first hour following the injury, as following the first 24-72 hours, hemarthrosis (bleeding into the joint space) and swelling occurs and may limit the examination findings.

It is important to present for medical assessment as soon as possible following an injury, even if significant swelling has occurred. Your physiotherapist will perform a comprehensive physical examination and perform special tests to diagnose your injury.
It is important to undergo a thorough physiotherapy assessment as other knee injuries such as damage to the meniscus and/or medial and lateral collateral ligaments of the knee may accompany an ACL tear.Often an investigation or imaging may be required to confirm an ACL tear and conversely rule out other injuries. You may be referred by your physiotherapist, doctor or surgeon for knee MRI scan. Occasionally an X-Ray may also be indicated if an avulsion fracture (small component of bone pulled away by ligament) is suspected during the mechanism of injury.

Management;

In the acute stage following an ACL tear it is advisable to follow the RICER principal for the first 48-72 hours. This involves Rest, Ice, Compression, Elevation, and a Referral for medical management. In addition to this it is advised you follow the No HARM protocol to further limit bleeding and swelling into the joint: No Heat, Alcohol, Running or Massage.

brace

A torn ACL can be managed in several ways including conservatively, with bracing, or via a surgical reconstruction. The benefits and associated risks of all methods can be discussed with your treating physiotherapist or healthcare professional in order to tailor a treatment plan specific to your presentation and future goals. In short; young, active individuals aiming to return to a pivoting sport or activity are often candidates for ACL reconstruction surgery.

During ACL reconstruction surgery, the torn ACL is replaced with a graft that aims to replicate the normal functions of the ligament. Several graft options may be explored in discussion with your surgeon, most commonly including:

(A) Bone-patella-tendon-bone (BPTB): where part of the middle third of the patella tendon (knee tendon) and a piece of the tibial bone (shin bone) are taken to make the graft

(B) Hamstring tendon graft: where the semitendinosis (hamstring) tendon is bundled and looped (+/- gracilis (groin) tendon) to form the graft

(C) Quadriceps tendon graft (less common)

(D) Taking the above tendons from the uninjured leg

(E)  Synthetic grafts such as the LARS ligament graft, however this is rarely utilised in modern practice.

ACL Reco

Rehabilitation:

Rehabilitation for a reconstructed or conservatively managed ACL tear should be under the direct supervision of a physiotherapist. This is integral as there is a 6-30% recurrence rate of ACL injury in the years following an ACL tear, and this risk can also affect the opposite knee.

The aims of physiotherapy are to:

(A) Restore knee joint range of motion

(B) Improve knee and lower limb strength

(C) Address poor biomechanics and improved jumping/landing strategies

(D) Skill retraining

(E) Facilitate return to sport or activity

(F) Prevent re-injury rate

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 or ACL injury. Call us now to make an appointment!

treatment treatment4 treatment3 treatment2

Patellofemoral Pain Syndrome

Patellofemoral pain syndrome (PFPS) is a common condition which frequently affects adolescents and young adults. It is characterised by a gradual onset of vague pain at the front the knee (anterior knee pain), routinely under or around the knee cap. Pain is usually aggravated by activities such as climbing stairs, squatting, running, cycling or sitting for l

ong periods. Despite being a very common presentation, many people are unaware of the symptoms and management of this condition. This blog will help explain the condition and pathways of management used by physiotherapists.

 

knee1

What is PFPS?

The knee is one of the largest joints in the body and one of the most complex.  It is made up of the femur (thigh bone), the tibia (shin bone) and the patella (knee cap). Certain structures in the knee joint allow for smoother movement. The knee cap rests in a groove on the top of the thigh bone known as the trochlear. When you bend your knee, the knee cap slides back and forth within this groove. Cartlidge on the surface of all of these bones allow the bones to glide freely against each other with movement.

PFPS occurs when the nerves sense pain in the soft tissues or bones involved in the knee joint.

In some cases PFPS can lead to chondromalacia patella, which refers to the degeneration of the cartlidge on the underside of the knee cap. This cartlidge break down leads to inflammation and therefore pain.

knee2

CAUSE:

This condition can be caused by a variety of different factors. A sudden increase in load on the knee such as an increase in the frequency, duration or intensity of running. Incorrect training or changes in footwear or playing surface can also be contributing factors in the development of pain.

Poor tracking of the knee cap in the trochlear groove can also lead to patellofemoral pain syndrome. The knee cap is pushed to the side of the groove when the knee is bent and this can be caused by a range of factors.

Issues with lower limb alignment from the hips extending down to the ankles and also problems with muscular imbalance and weakness.

KNOWN CONTRIBUTING FACTORS:

  • Hip internal rotation (hip rolling inwards)
  • Valgus knees (knock knees)
  • Foot posture
  • Muscle tightness
  • Knee cap position
  • Quadriceps muscle control

SYMPTOMS:

PFPS is characterised by a gradual onset of dull aching pain in the front of the knee. This pain can be present in one or both knees. Pain is usually aggravated by activities that repeatedly bend the knee, sitting for long periods of time with the knee bent and popping or grinding sounds or sensations when climbing stairs or standing up after long periods of sitting.

INVESTIGATIONS:

X-rays and other scans are not required in the diagnosis of this condition.

MANAGEMENT:

Treatment of this condition aims to reduce pain and address relevant contributing factors.

Exercise is currently the best form of treatment for PFPS. These exercises are aimed at improving knee stiffness, strength, endurance and control. A large focus is placed on exercises to strengthen the quadriceps muscle as it is the main stabiliser of the knee cap.

Other management strategies include taping, orthotics, bracing and soft tissue massage.

Surgical intervention is very rarely required/ advised, and is only implemented when conservative management fails.

PROGNOSIS:

With specific exercises and addressing contributing factors, people are able to make a full recovery from this condition and return to playing sports and running.

Do you or your child have Patellofemoral pain syndrome? Book in for an initial assessment with our team at Total Physiocare now.

Blog written by Alice Smith