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knee-x-ray

What Is Osgood-Schlatters Disease?

Osgood-Schlatter’s disease (OSD) is a few things (on top of being a bit of a mouthful); it’s a growth plate injury in children, notoriously difficult to diagnose and commonly mismanaged. Osgood-Schlatter’s is characterised by swelling and irritation of the growth plate at the top of the shinbone. The growth plate is a layer of cartilage located toward the end of a bone where the bone’s growth occurs. This is why adults cannot suffer this “disease”.

When it comes to kids, two things are pretty much certainties; they’re going to grow and at some point they’re going to hurt themselves. When these two certainties occur simultaneously, children can end up with painful growth-plate injuries that can be difficult to treat and manage effectively. Growth plate injuries are quite a common cause of pain in children and adolescents and Osgood-Schlatter’s causes pain in the front of the knee. Boys are more likely to suffer the condition than girls, and playing in sports that involve lots of running, jumping and kicking increases the chances of it popping up too. Musculoskeletal physiotherapists classify Osgood-Schlatter’s disease as an overuse injury, not a disease!

HOW IS OSGOOD-SCHLATTER’S DIAGNOSED?

Because children’s bodies are physiologically different than adults, it is not uncommon for the Emergency Department or a GP to misdiagnose a child’s pain as another injury. Your child’s physiotherapist will conduct a thorough assessment which will include checking movement patterns of the hip, knee, ankle and foot, assessing muscle strength and muscle length in order to pinpoint the cause of pain. X-rays and other medical imaging are usually not required.

If your child has Osgood-Schlatter’s, they will normally have pain close to where the patellar tendon connects to the shin bone slightly below the knee cap. It can also cause a painful lump to form in that area. For your child, their pain will probably be heightened during physical activity and the pain commonly gets worse with running, jumping and walking up hills. The pain and swelling tends to improve relatively quickly (in the short term) with a bit of rest.

WHAT CAUSES OSGOOD-SCHLATTER’S?

Osgood-Schlatter’s is an overuse injury, which is exactly like it sounds. During a child’s growth spurt, the bones, muscles, and tendons all grow at different rates. In OSD, the tendon connecting the shinbone to the kneecap pulls on the growth plate at the top of the shinbone. Activities and sports such as AFL, soccer and athletics can cause this movement to happen over and over, causing injury to the growth plate. When undergoing physical activity with strong, repetitive muscle contractions in the thigh, micro-fractures can occur due to the immature nature of the joint and bones. Another possible cause of Osgood Schlatter’s in adolescents is the lack of growth of the quadriceps in comparison to the femur bone. During a child’s growth spurt, the slow lengthening of the muscle is unable to keep up with the rapidly lengthening femur, which causes increased tensile force on the tibial tuberosity and more pain.

HOW IS OSGOOD-SCHLATTER’S TREATED?

I’ve seen mild cases of Osgood Schlatter’s Disease resolve themselves within a few weeks, but severe cases must be professionally managed to avoid permanent growth plate damage. Fortunately for the unfortunate child, Osgood Schlatter’s disease is very successfully managed via physiotherapy. Osgood Schlatter’s disease is a self-limiting syndrome which means that with time, complete recovery can be expected with the closure of the tibial growth plate. If OSD hasn’t been treated effectively during childhood, it is not uncommon for there to be recurring discomfort in the knee while kneeling due to enlarged lumps as a result of the distorted growth plate. Although symptoms of Osgood Schlatter’s disease can hang around for months at a time, surgical intervention is hardly necessary.

The goal of the treatment is to control your child’s knee pain and prevent the condition from worsening. Treatment usually includes:

  • The tried and true RICE method (rest, ice, compression, and elevation)
  • Medications such as anti-inflammatories for discomfort and swelling
  • Wrapping or compression of the knee
  • Limit on activity
  • Physiotherapy to help lengthen and strengthen the thigh and leg muscles

What not to do:

  • Stretching! Multiple sources online speak about stretching out the quadriceps, to help lengthen the muscle and alleviate tension on the growth plate. With additional tensile force pulling on a growth plate that is constantly being pulled, no child will thank you for stretching out their quadriceps!

Your child’s physio will also prescribe specific exercises for your child to complete depending on their assessment findings. One of the common reasons adolescents develop Osgood Schlatter’s syndrome is tight quads, hamstrings and calf muscles.  In that case, manual therapy and soft tissue release will assist pain and quicker recovery.

If your child has been complaining of a sore knee or has been limping or showing signs of discomfort, don’t let the issue linger for too long. Call one of our musculoskeletal physiotherapy experts on (02) 8964 4086 and get a diagnosis and treatment plan before any long term damage occurs.

man-sore-neck

Why putting up with chronic pain causes more problems

I was down at Manly Beach the other day sucking in some big ones having been worked for 90 mins solid by my beach volleyball coach Martine and couldn’t help but overhear a conversation two men were having. As a long practicing physio there are a few buzzwords I can’t help but tune into and when bloke 1 said to bloke 2 “hopefully my back sorts itself out soon, I haven’t had a surf in months” I was instantly hooked. Unfortunately, it’s common for me to see new clients who have been suffering a form of chronic pain or immobility due to a condition or injury for months, even YEARS, but every time I’m still shocked. Look, I know not everybody loves seeing the GP or attending to annoying medical issues when there are other things going on in life, but chronic pain is not something anybody should be living with for any extended period of time. It’s not only uncomfortable at the time, but chronic pain and the underlying causes can eventually cause permanent physical and even neurological damage to parts of the brain if left undiagnosed and untreated.

What is pain?

The simple version of pain as endorsed by The International Association for the Study of Pain is that it is as an unpleasant sensory and emotional experience associated with actual or potential tissue damage. But pain is not simple. Pain is not only a physical sensation, it can be influenced by a number of external factors such as personal attitude, personality, resilience and has the ability to negatively affect emotional and mental wellbeing. For example, take two people suffering the same ACL injury – they are experiencing the same condition, yet their experience of living with the pain will be vastly different and their recoveries will differ based on their physiological make-up along with their psychological attitudes.[1]

There are two main categories of pain that physiotherapists see and treat: acute and chronic.

Acute pain only lasts for a short time but can be incredibly intense. Commonly occurs after surgery or due to physical trauma such as a motor vehicle accident or a sporting injury. Acute pain is the body’s warning alarm telling you to seek help. Although acute pain usually improves as the body heals, sometimes it doesn’t.

Chronic pain is the type of pain that stays with you long after surgery or an immediate injury and is commonly caused by underlying conditions. Conditions like migraines, osteoporosis, arthritis and other musculoskeletal issues are all commonly diagnosed chronic diseases that musculoskeletal physiotherapists see all the time. Just to keep us on our toes, chronic pain can exist without a clear reason or underlying cause. Remember the definition above of pain; actual OR POTENTIAL tissue damage. Yes, you can have pain without any damage! Chronic pain is commonly a symptom of other diseases but can actually be a disease in its own right, caused by changes within the central nervous system.

How does pain work?

Your lower back pain, knee pain, neck pain, ankle pain and every other pain all the way to your little pinky pain comes from the brain itself. Pain is the end result of your brain evaluating information and coming up with a best guess of how to translate that information and to where. Your body contains nerves called nociceptors that detect any dangerous changes in temperature, chemical balance or pressure in your body and send alerts to the brain, but the pain you feel is all in the brain and controlled by the brain. Thanks heaps brain.

Most of the time your brain gets it right, but sometimes it doesn’t. For example, referred pain in your leg is common to experience when it is actually your lower back causing the issue. Another example of the brain’s power is phantom limb pains commonly experienced by amputees in limbs that are no longer there. If that’s not the perfect example of the power of the brain, I don’t know what is. They have pain when the limb doesn’t even exist!!

How can ignoring chronic pain lead to more problems?

I’m sure other physiotherapists on the Northern Beaches are just as sick of hearing ‘no pain, no gain’ applied to every painful scenario as I am. Even during and after short term bouts of experienced pain, your brain increases stress hormones in your body, which can make it harder to think, cause anxiousness, lethargy, fatigue, slower recovery and lead to muscle tightness. Even that “dicky knee when it gets cold”, that “sore back” or “dodgy shoulder” is capable of causing long term physical and psychological effects. Pain affects the proper functioning, strength and efficiency of the human body. This often leads to altered movement patterns, compensatory tightness in other areas of the body, limb weakness and can cause chronic stiffness and exacerbate the pain.

It is imperative to address any pain as soon as you realise that it is not just going to disappear in a couple of days. Your GP will agree with musculoskeletal physiotherapists that the evidence supporting early treatment in almost any acute injury or painful condition is well documented.

Don’t let your pain today progress and evolve into more than something that can be relatively easily fixed with physio intervention. Instead of thinking “no pain, no gain” when you get an injury, focus on allowing yourself to understand that we need to heal, we need to relax and we need to look after ourselves because putting your body and brain through continuous pain is doing much more harm than good.

[1] McArdle S. Psychological rehabilitation from anterior cruciate ligament-medial collateral ligament reconstructive surgery: a case study. Sports Health. 2010;2(1):73–77. doi:10.1177/1941738109357173

soccer-kids-playing

Why do some children get Sever’s Disease and how is it treated?

Sever’s disease, aka calcaneal apophysitis to musculoskeletal physiotherapists is the most common cause of heel pain in growing athletes. Sever’s Disease isn’t really a true disease per se and was actually first identified by Patrick Haglund in 1907[1], but it was James Sever’s characterisation of the disease in 1912 that led to it being named after him.[2] Maybe it just had more dramatic ring to it? Sever’s disease is the inflammation of the calcaneal apophysisa, located on the heel close to where it connects into the Achilles tendon. Sever’s Disease most commonly occurs before or during a child’s peak growth spurt and is often seen when they begin a new sport or footy season. It is most common in boys between the ages of 8 and 12 and quite frequently in girls between the ages of 8 and 10 years old who are also active in sports.

How is Sever’s Disease diagnosed?

For your physio to find the cause of your child’s heel pain and rule out more serious conditions, they will ask some thorough questions about their medical history and ask questions about recent activities or injuries. There is rarely the need for any blood tests or x-rays, your physiotherapist will perform what’s called a squeeze test and some other tests to confirm the diagnosis of Sever’s Disease. During the squeeze test (which is exactly what it sounds like) if the child’s medial and lateral sections of the heel are tender and there are no symptoms such as red skin or swelling, almost always indicates a diagnosis of Sever’s disease.

       Symptoms include:

  • Pain in the back or bottom of the heel
  • Limping
  • Walking on toes
  • Difficulty running, jumping or participating in usual activities or sports
  • Pain when the sides of the heel are squeezed
  • Tiredness

What causes Sever’s Disease?

When children (especially boys) are going through a growth spurt, the bones will grow first and the muscles and tendons can take a while to catch up. In Sever’s disease, the area around the heel bone can become quite sore and swollen where the Achilles tendon attaches to it. Children who participate in running and jumping sports such as AFL, soccer, Basketball and athletics are more likely to end up with Sever’s disease. Research has also shown that wearing boots with studs or spikes increases the risk of developing Sever’s disease.[3]

     Factors contributing to Sever’s Disease in children include changes to:

  • Height and weight – high BMI children have higher rates of the disease
  • The frequency of physical activity – AFL carnivals over a few consecutive days
  • The type of physical activity – Changing sports or starting new ones eg. Netball, gymnastics
  • Shoes and equipment – Many football boots have a lower heel that can add pressure to the apophysis by stretching the Achilles tendon slightly. Lots of barefoot running and even walking in thongs on the soft sand at Dee Why can cause the same increased load.

How is Sever’s Disease treated?

As with most soft tissue injuries, in the first stages of recovery your physio will recommend the R.I.C.E method – Rest, Ice, Compression, and Elevation. Unfortunately, no one treatment method has been definitively proven to be better than others in the long-term management of Sever’s disease. During the early phase your child will probably be unable to walk pain-free, so the first aim is to prescribe your child with some active rest activities and keep away from pain-provoking activities for the time being. Your physio will use and teach your child a range of pain relieving techniques including joint mobilisations for stiff ankles and give the area a good massage in order to restore full Range of Motion, reduce pain and regain full foot biomechanics. A good musculoskeletal physiotherapist will also want to see your child’s biomechanics and technique in action and if they have injured themselves playing AFL or another sport, getting your physio to check it out will help reduce flare ups in the future.

How does Sever’s Disease affect my child’s sport?

Sever’s disease is a self-limiting condition and will fully heal with the right treatment. The first important step is to seek treatment when early signs of Sever’s become apparent. Sub-optimally treated Sever’s disease can cause a permanent bone deformity at the rear of the heel bone which can be painful and annoying. For the time being, seeing a physio will be be helpful to learn ways to stretch the Achilles tendon and keep pain under control. Limit your child’s sport load during the initial period and monitor their return to sport closely afterwards.

If your child is between the ages of 8 to 12 and is complaining of heel pain with no exterior causes, you should suspect Sever’s disease until proven otherwise. Sever’s Disease is a common issue seen by your local Dee Why physio due to the high number of active kids on the Northern Beaches (a positive and a negative there) and they are the best people to speak to if your child is complaining of a sore ankle.

[1] HAGLUND P: Ueber fractur des epiphysenkerns des calcaneus, nebst allgemeinen bemerkungen ueber einige

aehnliche juvenile knochenkernverletzungen. Archiv fur

klinische Chirurgie 82: 922, 1907

[2] SEVER JW: Apophysitis of the os calcis. N Y Med J 95:1025, 1912

[3] Sever’s Disease: What Does the Literature Really Tell Us? Rolf W. Scharfbillig, PhD* Sara Jones, PhD† Sheila D. Scutter, PhD May/June 2008 • Vol 98 • No 3 • Journal of the American Podiatric Medical Association

man-warming-up-winter

Tips on reducing your chances of an injury as it gets colder

Going for my early bird swim at Dee Why pool this weekend it took a few minutes longer than usual for my muscles and joints to really get going. I couldn’t quite put my finger on it until I got out of the pool and a fresh gust of wind reminded me… Winter Is Coming. Checking the weather and in 2 days the minimum temperature has dropped 7 degrees. Did you know that May, June and July are the busiest months for sport and exercise related injuries in Australia?[1] While you can attribute some of that rise to the winter contact ball sports, a contributor to the rise in muscle and tendon related injuries is the drop in temperature. The muscles and ligaments of the body function and perform better when they are warmer. It’s also easier to get out of bed and actually go on that early morning run too when it’s not 5 degrees. Let’s look at how the cold affects the performance and injury rate of the muscles and tendons and how you can lower your chances of a cold related injury.

Can cold weather make joints and muscles hurt more?

My Dad is one of those people who say that his joints can predict the weather, “a cold front is coming through” he’d say on a 30 degree day and it did seem like he picked it once or twice (little did I know at the time that he constantly consulted the Bureau of Meteorology as much as Gen-Y checks Facebook). But let’s just say science is far less convinced than he and a few other patients of mine who are convinced that their arthritic conditions can predict the weather. Over the years a number of studies have looked at the correlation between temperature, weather and barometric pressure with none being totally conclusive.[2] That being said, some studies have shown a plausible link between barometric pressure and cold weather on some specific arthritic conditions or under less strict conditions.[3] If you believe your joints hurt more in the cold, I’m not going to not believe you.

Increase your warm-up time and quality

This is probably the single most important piece of advice if you are undertaking any physical activity during the winter months.[4] Cold muscles and ligaments mixed with physical activity are going to equal a lot of pain. Cold muscles, tendons and ligaments are more likely to lead to muscle sprains and joint strains due to decreased flexibility and elasticity.[5] If you normally warm up for 5 minutes, extend it to 10 as it gets colder, if you normally don’t warm up, extending that to 10 minutes is fine too.  A good warm-up:

  • Prepares the body and mind for the activity
  • Increases the body’s core temperature
  • Increases the heart rate
  • Increases breathing rate
  • Stimulates flexibility and power

Don’t skimp on the cool-down either!

Many musculoskeletal physiotherapists will agree that failing to cool down adequately is a major contributor to muscular and tendon injuries. I don’t know why but it doesn’t seem like it’s cool to cool down. After physical exercise the body needs time to slow down and recover, so cool down immediately after your activity for at least 5 to10 minutes. Sports and exercise physiotherapists recommend your cool-down can be the same sort of exercise as the warm-up with low intensity body movement such as jogging or walking substituted for running.

Can stretching help to reduce injuries?

Stretching before and after physical activity helps to promote maximum flexibility, relax the muscles, return them to their resting length and promotes recovery by assisting in the body’s natural repair process. When stretching it is important to:

  • Stretch all muscle groups that will be or were involved in the activity
  • Stretch gently and slowly
  • Don’t bounce or try and stretch too quickly
  • Only ever stretch to the point of mild discomfort – PAIN DOES NOT EQUAL GAIN
  • Don’t hold your breath – breathe slow and easy

Don’t forget to stay hydrated

While it may not be scorching hot outside your body is still going to need a healthy dose of water daily. Dehydration is one of the major causes of muscle cramps and the winter months are an easy time to lost sight of drinking a couple of litres of the good stuff every day. Please don’t think a couple of shots of something harder will warm you up either, alcohol will only impair your coordination and your body’s ability to regulate your temperature which could lead to an injury. Caffeine drinks also cause dehydration, so steer clear of excessive coffee and energy drinks too if you can.

[1] https://www.aihw.gov.au/reports/injury/hospital-care-for-australian-sports-injury-2012-13/contents/table-of-contents

[2] The influence of weather on the risk of pain exacerbation in patients with knee osteoarthritis – a case-crossover study. Ferreira, M.L. et al. Osteoarthritis and Cartilage , Volume 24 , Issue 12 , 2042 – 2047

[3] Deall C, Majeed H (2016) Effect of Cold Weather on the Symptoms of Arthritic Disease: A Review of the Literature. J Gen Pract (Los Angel) 4:275. doi: 10.4172/2329-9126.1000275

[4] Woods K, Bishop P, Jones E. Warm-up and stretching in the prevention of muscular injury. Sports Med 2007;37:1089-1099.

[5] Scott, E E F et al. “Increased risk of muscle tears below physiological temperature ranges.” Bone & joint research vol. 5,2 (2016): 61-5. doi:10.1302/2046-3758.52.2000484