Knee Pain- Focus on Osgood Schlatter: Rehabilitation, Prevention, and Biomechanics

Knee Pain- Focus on Osgood Schlatter:
Rehabilitation, Prevention, and Biomechanics
By: Ms. Gina M. Pongetti, MPT, MA, CSCS, ART-Cert, Chicago, IL
Owner and Manager, OccuSport Physical Therapy – Willowbrook and Chicago
Part 7 in Core Health Series
Core Health Series
By Gina M. Pongetti, MPT, MA, CSCS, ART-Cert.
Owner and Manager, OccuSport Physical Therapy – Willowbrook and Chicago
•
The Importance of the Transverse Abdominus
•
The Hinge Theory: Triple Threat of Shoulder, Spine, and Hips for Back Pain
•
Advanced Core Training for Performing Arts
•
Advanced Core Training for Endurance Sports
•
Flexibility for the Endurance Sports Athlete
•
Lower Extremity Health for Irish Dance
•
Knee Pain: Osgood Schlatter Treatment
Credentials
Director, Performing Arts Medicine and Outreach Program, OccuSport Physical Therapy, IL
USA Gymnastics National Health Care Referral Network
Writer for Inside Gymnastics & Inside Cheerleading Magazine, Publisher Chris Korotky
Contributor, Technique Magazine, a publication of USA Gymnastics
Contributor, USECA – US Elite Coaches Association
Featured Speaker, 2000-Present, USA Gymnastics National Coaches Congress
Speaker- Region 5 Gymnastics Congress
Ironman Triathlete, Ironman World Championships, Kona, HI 2006
Active Release Techniques (ART) Provider
Performance Care Staff at National Ironman Events Including World Championships
Biomechanics Instructor
Official Timex Endurance Sports Racing Team Medical Advisory and Sponsor w/ART
- Treatment staff and injury prevention
Director, Endurance Sports Health Program at OccuSport Physical Therapy, IL
Irish Dance and Culture Magazine, Health Care Contributor/Writer
Published: Book, Strength Training for Gymnastics, 2006
Member:
USA Gymnastics
USA Triathlon
Performing Arts Medicine Association
International Dance Medicine Society
American Physical Therapy Association
Sports Section and Performing Arts Special Interest Group
Owner – Adagio Gymnastics Choreography and Dance
All Material © Gina
Pongetti 200
8
Contact Information
Written correspondence regarding thoughts, suggestions, interest in further writings, etc., can be directed to:
OccuSport Physical Therapy
337 W. 75th Street
Willowbrook, IL 60527
630-789-0004
OccuSport Physical Therapy
1131 S. State Street
Chicago, IL 60605
312-588-0508
Email: gpongetti@occusport.com
www.occusport.com
Personal:
Email: adagiogymnastics@hotmail.com
Requests for use of this material or any material in the Core Education Series should be sent in writing to the above
address. Include name, credentials, purpose for use, intended audience, and time of release for information. All
materials are copyright protected including verbal presentation, photocopying, picture reproduction, and inherent
ideas in writings.
Ms. Pongetti is available for speaking engagements as well as article submission and other writing and
presentations. Please contact for availability.
For in-person treatment, please contact the office to schedule an appointment at either location.
All Material © Gina
Pongetti 200
8
Intro
Knees are one of the most treated orthopedic joints in the body.( This means two things: either it is done well, as
a result of all of the information that is present with regards to research, effectiveness, or it is more along the lines
of slipshod treatment because of the mundaneness of the athlete with knee pain.) Unfortunately, I see more of
the latter in the larger corporate environments that churn patients in and out, traditionally choosing the easiest,
least labor-intensive and most unskillful treatment plan. This, to me, is very sad. Even if a therapist has seen 348
knee patients, number 349 is just as important to them as the therapist’s first! On my most recent search for knee
pain in adolescents, I was directed on one search engine to 396 sites, and another to 458. This, to me, is a prime
example of the supply/demand chain: there is obviously a demand for the information if the supply is so everpresent. Unfortunately, this also means that there is a plethora of sub par advice floating around, or “self treat”
as we in the industry refer to it. WebMD was one of the first to exist, providing grand-picture advice, to individual
clients- an oxymoron of sorts; as it, and so many others, has found their way into our version of modern medical
treatment in the US. With the increasing presence of knee pain, and the demand for physical therapy, we have
seen the same trend in the outpatient atmosphere: mass treatment for the individualized problem.
(It really does not take a rocket scientist to figure out that the increase in diagnosis numbers of a problem that has
existed as a result of increase in activity, sport peer pressure demands, college scholarship competitiveness, and
the newly present elite sports training facilities for children to squeeze the past good strength ability out of these
athletes.) Rest, however, is not an equally increasing factor, so the result is overuse and growth related injuries
(bony or muscular).
Osgood Schlatter is a medical diagnosis for a condition of inflammation and irritation of the attachment of the
quadriceps/patellar tendon at the tibial tuberosity: in other words, the bone below the knee cap hurts! Because
this is caused by overuse, tightness, and tissue irritation, the treatment should be simple- do the opposite of all
of these! 1) rest, 2) increase pliability/flexibility, and 3) decrease tissue irritation/scar tissue. Sadly, the third is
most often left out, because it takes knowledge of anatomy above and beyond normal, and an attention to manual
therapy detail that is fleeting.
Hopefully, after reading this educational writing, you will be able to possess knowledge of the condition itself, as
well as a new quality standard for treatment that works.
Here’s to the jumpers and runners in our lives, may they be healthy enough to fly high and travel fast….
Sincerely,
Gina
All Material © Gina
Pongetti 200
8
Osgood Schlatter Disease Description:
Originally described in 1891 by Paget, it is also known as tibial tuberosity apophysitis. As a child grows, growth
plates are active. This is essentially a cartilage-covered growth plate, or an epiphysis, from which the bone grows.
In order for muscles to function in the body, they have to attach in two places in the body to form the fulcrum, as
well as direct which bones move in relation to others. The quadriceps attach into the bone below the knee cap, or
the tibial tubercle (TT). As a person grows, the muscle tension at the attachment increases, which places undo
stress on the growth plates. Some main details:
•
Activity related pain
•
Sports that involve squatting, jumping, stooping, or running
•
Childhood ages of 10-15 (general research consensus of girls 10-12, boys 13-15) but can be outside of
this range
•
Characteristic pain is below the knee cap, 1-3” or directly over the “bump” below the knee, which is the
tibial tuberosity
•
May have swelling, but not always
•
Often characterized by a large “bump” below the knee cap, which is the TT
•
May complain of tenderness with activity and to the touch, usually always present is soreness on and
around the tibial tuberosity and the patellar tendon
•
May have correlation with a growth spurt, or a rapid increase in activity
•
Look back 2-3 months to a rapid increase in activity, as the problem may sit latent, or begin as simply
patellar tendonitis
Conventional Treatment:
Traditional treatment has included RICE, or rest, ice, compression, and elevation. Some MD’s simply recommend
rest, or relieving of the activity that seems to bother or exacerbate the problem. Others will send to physical
therapy. Most outpatient orthopedic therapists will use the following treatments and why we use them sparingly, or
not at all.
•
Electric stimulation, or IFC, for reduction of local tenderness
◊ This seems to offer mixed relief, depends on the patient
•
Ultrasound modality
◊ This is not used because of the growth plates that are present, and the usual occurrence of this with
adolescents steers us away from this
•
Quadriceps strengthening
◊ This is done, however, not with repeated knee extension, which probably caused the problem in the
first place
All Material © Gina
Pongetti 200
8
•
Soft tissue massage to the patellar tendon
◊ This proves successful, to increase blood flow, but usual methods of cross friction massage only
address the local tissues, and not the rest of the tendon
•
Icing
◊ This has mixed results. As icing offers anti-inflammatory responses, some patients respond negatively
to ice or not at all. With all of the modalities and soft tissue mobilization that is done, the goal is to
create heat, localized stretching, and tissue relaxation – which we do using heat.
Innovative Treatment: There are 5 main components to our treatment:
1. Heat!!!
Healing can only happen with proper blood flow and oxygen, so we use heat! This is done in 3 ways:
• Moist heat is applied to the tissues of the quadriceps, all the way to the distal insertion, in order to allow the
hands of the therapist to be more effective. This also creates local blood flow, helping to drain the scar tissue
that is relieved from the area with later techniques.
• Graston Technique (GT). This is a technique used on many body parts and orthopedic diagnosis, from
the understanding that surface scar tissue lays down haphazardly, more in the direction of perpendicular vs.
parallel. This decreases function, efficiency, flexibility, and mobility of the muscle, tendon, musculo-tendinous
junction, and the tendinous attachment to the bone.
• Active Release Techniques (ART) – this advanced manual therapy technique addresses the inter- and intramuscular scar tissue and adhesions that form because of repetitive stress and/or compensation patterns. It
also addresses fascial adhesions preventing normal myofascial range of motion. As well, ligaments, tendons,
capsule and borders are addressed. The technique involves 1:1, hands on treatment, in focal areas of the
entire length of a muscle, in order to have the end goal be restoring normal biomechanical function and
allowable motion. Related muscles that are treated include: pes anserine group, articularis genu, vastus
lateralis, vastus medialis oblique, rectus femoris, iliacus, psoas, pectineus, adductor, adductor hiatus, common
peroneal nerve, hamstrings, gastroc, soleus, and lateral capsule.
2. Mobility
Mobility of the patella, the lateral capsule, and all of the musculature that helps to stabilize the knee joint is
important.
•
Patellar mobilization
•
Lateral Capsule soft tissue work
•
Proximal fibular head mobility
All Material © Gina
Pongetti 200
8
3. Flexibility
When treating a condition such as OS, one has to understand the anatomy of the whole lower limb, including the
foot and the hip. If there is simply a local focus on treatment, there is no global thought on the whole extremity.
This is surprising because of the fact that one of the muscles involved in the quad/thigh complex – the rectus
femoris crosses both the hip and knee. The problem of OS is partially one of tension. This undue stress is placed
on the distal attachment of the muscular complex.
However, muscle has two ends and a middle, and flexibility can, and has to, come from all aspects of the muscle.
The theory here, on which we place the basis of our treatment, is by maintaining as much flexibility through the
majority of the muscle, the ends, or attachments, have less tension.
This is also based on the theory of the Total
Available Range Ratio (TARR). This is simply the
premise that the more total range of motion that
the muscle can allow, the less of a percentage
the activity that you do takes up of the total. For
example, if you have a total hamstring flexibility
range of 100 degrees, before compensation, a
soccer kick that allows the leg to get to 75 degrees
relative motion would be at 75% TARR. However,
if the available range went up to 125, then the
percentage of performance use would drop to 50%,
creating less tension, less musculo-tendinous stress,
and therefore, less irritation at the attachments.
The proximal, or top, end of the muscle is above the hip joint,
therefore making both quadriceps flexibility at the thigh and hip
flexor very important. The more that both joints can contribute to the
flexibility, the better!
4. Strengthening
All Material © Gina
Pongetti 200
8
5. Biomechanics
There is a reason that orthopedic problems develop in the body, when they are categorically overuse or activityinduced injuries. Without actually assessing the biomechanics and patterns that the invidual performs on a regular
basis, the problem may occur again, and you are not truly treating the problem – just the symptoms! Here are the
6 main focal points to our advanced treatment:
A. How does the athlete run or jump? Do they truly use the correct musculature
B. Imbalance – left to right. . Is there a Left to Right imbalance in musculature? The ways to test include
strength (such as leg press), plyometric ability (such as jump height variance one leg to other and unilateral as
in comparison to bilateral)
C. Imbalance – anterior/posterior. Is there an imbalance from front to back? Research states strongly that
hamstring strength and a good quadriceps to hamstring ratio is important in decreasing symptoms of most
anterior knee pain. This also includes gluteal strength as well as hip and core stability.
D. Patellar Tracking. The patella sits within the patellar tendon, or the distal quadriceps tendon. Therefore, if
there is soft tissue that is attached to anything associated with the patellar tendon, tracking could be altered.
The patella sits within the knee joint like a train on tracks. The most common problem that is found is lateral
capsular tightness along with other coexisting orthopedic problems such as ITB syndrome, irritated vastus
lateralis, or capsule restrictions. Most of the time, these can be reduced using ART and rest.
E. The ankle. There is a significant amount of contribution from the art of the squatting mechanism – including
glut strength, the role of how the hamstring and the quads work together, and what the ankle allows the tibia
and fibula (lower leg bones) to do. The more restricted the ankle, the more motion that comes from the knee
joint, or more stress placed on the knee. Therefore, the available range of motion present in the ankle is
important. This is created or allowed by 4 main things:
•
Subtalar joint mobility
•
Plantar flexor musculature flexibility (including gastroc, soleus, all of the small muscles that track behind
the malleoli, and essentially the achilles tendon)
•
Malleolar mobility (distal ends of the tibia and fibula, lower leg bones)
•
Retinaculum and ligamentous motion
F. Addressing compensations
•
Unfortunately, the body is fairly function-focused, which means that muscles can help other muscles
in need, and the body will adapt so that the functions that are demanded can be performed. This
created compensation pattern sometimes results in scar tissue, or inter-fascial adhesions (can also be
intermuscular or intra-muscular). Without addressing the compensations that have resulted, or the
secondary muscle issues, the original issue will never be completely resolved. The main focus on this
evaluation is:
•
Psoas/Iliacus hip and hip flexor compensation
•
Adductor border to the quadriceps
•
ITB and TFL and their alteration of focus, as well as adhesions
•
Gluteal and hamstring overuse secondary to the need to take focus off of the quad complex with activities
All Material © Gina
Pongetti 200
8
Bracing
There are many braces that are created to do the following: 1) decrease pain, 2) disperse the tension between
the patella and the tibial attachment, and 3) with doing the first two, allow the motion, sport, or lifestyle that the
athlete wants to perform even though the problem is still present. Although I do believe that the bracing does what
it is intended to do, the bracing does not change tissue, alter flexibility, treat the biomechanics difficulties that the
client is having, or allow rest for healing. Although we do use these in certain cases, it is on a patient by patient
basis and must be combined with proper treatment and patient cooperation.
Complications
In certain cases, the risk of small chips of bone pulling off of the tibial tubercle (avulsion fracture) is present, as
well as tearing of the patellar tendon itself. These cases are often present when the athlete and family have dealt
with the signs and symptoms, pushed through, masked with pain medication, and continued through activity. As
well, the tendon is already compromised, and therefore much less able to offer the support that it is intended
too. Sometimes, however, these conditions occur without notice. Please consult your physician for diagnosis and
recommendations.
The Future
1.
The bump.
That characteristic OS “bump” may remain for months or years. Some adults who were affected by OS as a child
still have a visible bony bump. This, however, does not mean that the child is limited or will function differently. OS
is often treated very symptomatically, and therefore, looks can be deceiving!
2.
Return to activity
As long as the pain has subsided, return to activity is allowed. The pain with activity is your guide, as well as
tenderness to touch. If these symptoms are still present, the rest period and treatment protocol may not have
been intense enough. If the athlete returns too quickly, the time taken for treatment and rest may be null and
void. Patience is the key in this situation. Gradual return to activity is necessary. The MD may clear the athlete,
due to reduced tenderness or films that appear more normal. However, common sense prevails that percentages of
increase are what is necessary- including the factors of time spend in activity, intensity of activity, and numbers of
repetitions.
Home Exercise Program: Stretching
Home Exercise Program: Strengthening
•
Hamstring – Standing
•
Quads – straight leg raises
•
Hamstring – doorway
•
Advanced: SLR with Band resistance
•
Quadriceps – standing with neutral hips
•
Swiss ball hamstring and gluteal exercises
•
quads/hip flexors hip roll
•
Performing Arts specific – splits with hip and knee
components
•
calf muscle
◊ Supine hip lifts
◊ Supine leg curls
•
Standing dead lifts
◊ gastroc
◊ Double leg
◊ soleus
◊ Single leg
All Material © Gina
Pongetti 200
8