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: [email protected] www.occusport.com Personal: Email: [email protected] 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