COMMON ADOLESCENT CONDITIONS – PART TWO: KNEE

Part two of load related adolescent conditions focuses on the knee.

Osgood-Schlatters Disease

 What?

An irritation of the insertion of the patella tendon into the tibia. This differs from adult patella tendinopathy due to the immaturity of the adolescent skeleton which means it affects the actively remodelling trabecular metaphyseal bone.

How?

It is usually due to the area’s inability to deal with an increase in activity (particularly activity that uses that area eg running or jumping sports). It can also be related to growth spurts which puts increased tension through the muscles and therefore tendons.

 When?

More common in boys and usually between the ages of 10-15 compared with girls which is usually between the ages of 8-13.

How does it resolve?

Usually self resolves with time (6-24 months) however the reason it’s best to seek treatment/advice is due to the pain that accompanies the condition which can affect sports performance and most importantly day to day activities. 

What is the treatment?

The main focus of treatment is to reduce pain levels. This can be done in a few different ways including:

-       Manual therapy (eg muscle massage)

-       Taping to offload the tendon

-       Exercises to strengthen key areas 

-       Implementation of load management strategies (eg RPE scale)

-       Advice regarding recovery (eg icing)

The main takeaways about the condition are:

-       The adolescent will grow out of it

-       It can still be quite painful so there should be a focus on pain relief

-       Load management with guidance from a physiotherapist can allow the continued participation in sport without compromising day to day function 

If you would like your injury reviewed by one of our physiotherapists, then don’t hesitate to book an appointment. All of our physiotherapists specialise in sport and have had extensive experience with adolescent athletes.

Knee osteoarthritis: is it as debilitating as we think?

Osteoarthritis (OA) is the result of wear and tear of the joint cartilage. It can result in pain and stiffness when loading a joint. But is OA always a sign we need to protect our joints and stop certain activities? The answer may surprise you.

What is OA?

Osteoarthritis is a break-down of the cartilage in our joints. It mostly affects weightbearing joints such as hips and knees and these joints are subject to larger forces. It was previously thought that joints with OA were to be ‘protected’ by limiting how much we bend, move and load them. We now know this is not true – in fact exercise is one of the most effective ways of reducing osteoarthritic pain. 

Knees in particular appear to have many connotations around them and it is widely (but incorrectly) thought that exercise is harmful to our knees. In fact it is quite the opposite – weight bearing exercise helps bone, muscles and other soft tissue adapt to make our knees stronger and more robust. This means an improvement in joint range of motion, muscle length and strength and functional capacity. 

How much value should you place on a scan?

It is also important to know that while a scan may show significant osteoarthritic findings, this certainly does not correlate to pain, function or quality of life! Even with ‘severe’ osteoarthritic findings on a scan, very positive functional outcomes can be seen with the above program.  

What will help?

The latest guidelines around osteoarthritis, show the most effective way to slow the progression of the pathology is to perform regular weight bearing, strength based exercise. There is good evidence to say this can also significantly reduce pain and improve function. Anti-inflammatories may also help pain and swelling, however you should always consult your doctor before using medication.

It is recommended to perform land based strength exercises 2-3x weekly, such as squats, steps up or leg press. The sets, reps and weight will initially be determined by strength, function and pain levels. This is nicely complimented by aerobic exercises such as walking, bike riding or pool based exercise, although aerobic exercise is not shown to have the same benefit as land-based strengthening. 

Our physiotherapists can create a knee strengthening program you can perform at home, all tailored to your individual goals and ability. 

PatelloFemoral Pain Syndrome (PFPS)

What is PFPS?

Patellofemoral pain is the most common cause of pain at the front of the knee.

It occurs with ‘patella mal-tracking’ i.e. when the under surface of the patella (kneecap) slides in the grove of the femur as the knee bends and straightens as the quadriceps contract and relax. 

When the knee is bent, mal tracking often causes the patella to shift laterally, causing pain with squat, moving from sitting to standing and using stairs.                  

How did I get PFPS?

Causes of PFPS can vary, including;

o   Over training i.e. people who over exercise with repetitive type movement i.e. cycling/hopping/jumping and running (especially hills and stairs) with insufficient time for recovery or excessive training loads.

o   Change in training: i.e. changing footwear, running surface or increases in training intensity.

o   Poor motor control at the quadriceps, hip (glutes) and foot/ankle (hyper or hypo-mobility).

o   Abnormal knee/hip size and shape i.e. patella shape, femur shape or whether the patella sits high or low. Variations in an individual’s shape of the femur, tibia and/or hips can affect how the quadriceps muscles pull on the patella.

o   Post-surgery i.e. post ACL surgery or after a lengthy time off

Where does it hurt?

Do you pain at the front of the knee around the kneecap? Is there pain AND clicking/crunching?

Note: A noisy knee without pain isn’t necessarily a bad thing.

Do I need a scan of my knee?

No.

In most cases this should be easily diagnosed by your physiotherapist or sports physician. If you aren’t getting results with your treatment and rehab then you may be referred for a scan.

What should I avoid doing?

-       Complete rest

Repetitive running, cycling or deep squatting is likely contributing to your pain but engaging in physical activity is also helping to keep your muscles strong. Talk to your physio about activity modification.

-       Don’t panic

Your knee will get better with targeted strength, stretching/rolling and other techniques. Note that due to the tissues involved, this can take months rather than weeks, persistence of your home exercise program will be important.

-       Don’t train through high levels of pain, mild pain is usually ok.

Low or mild discomfort can be acceptable during activity, but if you are still sore 24-72 hours later then you may have done too much, too quickly.

-       Exercises such as lunges and deep squats and stairs/hill running may aggravate your knee initially however you these will likely be re-introduced in the later stages of rehab. 

I’ve been having physio and not getting better, what should I do?

Ask yourself;

-       ‘Am I still over doing high impact activities, and/or underdoing strength / control activities?’

-       ‘Am I getting enough recovery between sessions?’

PFPS frequently co-exists with other issues such as patella tendinopathy, fat pad impingement and patella hypermobility. It’s important to distinguish if any of these are involved by asking your physiotherapist.

Other less common diagnosis includes; bursitis, Osgood-Schlatter disease (OSD), Sinding-Larsen-Johansson syndrome and referred pain from the hip.

What’s the best treatment for PFPS?

Best practice for PFPS rehabilitation is a combination of…

-       A short period of rest or de-loading

-       Regular progressive loading

-       Avoid painful knee ranges

-       Taping and braces can help in the short term

-       Your GP or health professional will be able to advise regarding anti-inflammatory use.

 Speak to your physiotherapist who will assess and prescribe the optimum amount and intensity of exercises for you.

Author: Peter Gangemi - Master of Physiotherapy