‘Johnny’ is 14, plays soccer, and has a 4 year history of bilateral knee pain with no specific traumatic onset. Over this time he has seen 3 doctors, 2 physical therapists, 2 physical therapy assistants, 1 chiropractor, and 1 personal trainer. He has been X-rayed twice and received an MRI. He got the diagnosis of Osgood Schlatter disease 2 years after the beginning of the problem. Symptoms since have been worsening, and he has been on and off the soccer team over the past year. He can play for 2-3 weeks until the pain gets unbearable and then has to sit out for 2 weeks to allow the pain to calm down. When it gets really bad he goes to physical therapy. Thankfully things start to get better and 6 weeks later he returns to the pitch. Excited to be able to play again he suffers the same problem 1 month later when the team has a tournament and he has to play 3 games in one weekend. Pain is so bad that he has difficulty walking down the stairs in his house. He finally returns to the doctor and is told that he should not play his freshman year of high school soccer and is advised to look for other sports like swimming where he will not hurt his knees. ‘Johnny’ and his parents are devastated.
The above scenario with differing circumstances is something we commonly see at PreventPT. The adolescent athlete is demoralized, frustrated, and depressed. The cause? Inflammatory growth plate syndromes and symptom mismanagement. Read on to learn what these are, how they come about, and what you can do to prevent the above catastrophic events from happening to your child.
What is a growth plate and how does it get injured
As kids grow, bones lengthen through a specific area of the bone called the growth plate. The growth plate is located toward the ends of our long bones. When too much stress is applied to the growth plate, it becomes inflamed, traumatized and painful and in severe cases can fracture.
In adolescents there are 3 common growth plates that can become inflamed and injured. Two are located in the knee and the third is in the heel. Each area has a formal medical name associated with trauma to that area.
- Sinding Larsen Johansson: growth plate in the knee cap
- Osgood Schlatter: the upper leg tibial growth plate
- Sever’s: the growth plate in the heel
What is Osgood Schlatter disease
Osgood-Schlatter syndrome is representative of pain and inflammation in the growth plate (red below) of the tibia where the patellar tendon inserts into the bone and runs up into the quad muscle (pink). It presents itself with pain, swelling, and tenderness to touch just below the knee. In severe cases you may see a bony bump in the area as well.
Jumping, running, squatting, and kneeling are all activities that may be limited due to pain in this area as these movements engage the quad and pull on the growth plate at the insertion of the patellar tendon.
What is sinding-larsen-johansson
Sindling Larsen Johansson is inflammation and pain emanating out from the growth plate in the knee cap. Like Osgood-Schlatter’s, pain typically is aggravated by jumping, running, and squatting. Too much of these activities tend to load the growth plate with excessive stress and inflammation sets in.
Quad engagement (pink) causes compression of the knee cap into the bone below it (red arrow). Excessive load across this area is what irritates the growth plate (green).
What is Severs disease
Sever’s Disease is represented by inflammation and pain at the growth plate of the heel or calcaneous bone (green highlight below). Pain can radiate out in any direction around the heel and tenderness to palpation can be present. Like the other growth plate syndromes impact activities such as running and jumping can aggravate the pain.
The achilles tendon (pink above) inserts adjacent the growth plate. Excessive forces through this area feed the trauma and inflammation in the growth plate.
When does Osgood Schlatter go away
We see the greatest incidence of all 3 syndromes between the ages of 9 and 14 years old when the kids are growing. All of them are directly related to the growth plate and once the child has stopped growing it is no longer a source of pain.
How to treat Osgood Schlatters and the other growth plate injuries
Pain in the growth plates can occur in approximately 20% of adolescent athletes and 5% of non-athletes. These numbers drastically point to the culprit where weight bearing and loaded activities that include running and jumping are the related cause. Medical doctors know this and after ruling out a fracture with X-rays they will commonly recommend taking some time off of sport to allow the injured tissue time to heel. Sometimes they will prescribe medications for pain and inflammation or refer the kids to physical therapy.
Typical physical therapy will recommend ice, teach taping techniques, recommend some stretches, and engage the athlete in some strengthening exercises.
That’s the cookie cutter text book version on how to treat these problems and works for some, but unfortunately can also lead to the devastating scenario above as experienced by ‘Johnny’. Read on to learn how to really treat these syndromes.
PreventPT
How our medical system is failing our kids and what led to ‘Johnny’s’ disastrous situation above
It is all too frequent that the medical community mismanages these growth plate injuries. Adolescence is a critical time in our development. Kids love to play and sport is a natural expression of this. When they are in pain, it is difficult to stop doing the thing they love. Unfortunately the medical community commonly underestimates the severity of these problems and tells the parent that it is ‘growing pains’ and the child will grow out of it. Problem is, sometimes that can take years and this puts the adolescent athlete in a difficult position. Either give up playing and get out of pain, or endure the pain and continue the sport they love. In the end they often combine the two and will take small breaks to alleviate the severe acute complaint and then return shortly thereafter.
The kids that love the game too much and cannot stand sitting out will push the medical doctors for other solutions and often the result is a referral to physical therapy. This can be a great solution, but at times can still not be the answer to properly manage the problem.
The cause of this is related to our insurance based medical model which forces our physical therapists to see 10-20 patients per day detracting from the quality of care they can provide. They are forced to triage care and put out the biggest fire that is in front of them at the time. And in the case of the growth plate injuries that means dealing with the pain. They will offer modalities, massage, ice, and stretching; all of which are appropriate for dealing with the acute complaint of pain. After 2-4 weeks the kid feels better and returns to sport to only have the same problem resurface.
How to really heal Osgood-Schlatters and other inflammatory growth plate injuries
The key is understanding that the load to the growth plate is the problem. In all the above scenarios load is too simply understood to be playing sport, running, or jumping. In actuality, load across the growth plate is more complex than that and there needs to be a more comprehensive understanding of what it is and how you quantify it.
Load or stress and strain across the bone and growth plate is dependent on multiple factors:
- Compressive force into the bone x the # repetitions. Jumping 5 times is not the same load as jumping 20x.
- Load can be influenced by muscle flexibility. As a muscle is stretched to it’s endpoint it will compress the joints and increase the load. Restoring flexibility if limited can thus help decrease the cumulative load across the bone.
- Load can be influenced by muscle flexibility. As a muscle is stretched to it’s endpoint it will compress the joints and increase the load. Restoring flexibility if limited can thus help decrease the cumulative load across the bone.
- Postural integrity has an impact on load. If the core is unstable then the legs need to work harder to compensate for that inefficiency.
- Postural alignment plays a part. If an individual cannot control for proper alignment in the legs when jumping and running, then rotary stress is increased and negatively influences the load across the bones.
- Improper foot and arch mechanics can increase the loads. The arch of the foot is a spring absorption mechanism and if dysfunctional can lead to increased loads across the bones
- Disuse atrophy and strength deficits can influence the load. Chronic knee pain feeds avoidance of activities which in turn leads to weakness. If the muscles are weak then they cannot accept the load and increased stress enters into the growth plates. Strength training takes 6+ weeks to start to show true musculo-tendoneous change.
- All the above can interact to alter motor control. Our body subconsciously alters the way it moves to compensate for all the fundamental movement problems as noted above. This results in poor functional movements, ie the way you squat, lunge, balance, stabilize. Without good functional movements our performance suffers.
As you can see, it is complicated and assessing load to treat these problems is a complex task. Using a systematic process that comprehensively evaluates all the potential components is essential in getting to the root of the cause. This takes time and unfortunately our insurance based medical model does not afford the clinician the luxury to perform the musculoskeletal biomechanical analysis needed to tease out all the components that need to be addressed.
PreventPT’s Systematic Approach
Here at Prevent Physical Therapy, INC we afford you that time and use a comprehensive system to target prioritized findings to keep you on your path to reach your goals. We take our clients through fundamental movement testing with the Selective Functional Movement Assessment (SFMA) and then clean up your functional movement using the Functional Movement Screen (FMS). We then build your strength foundation to prepare you for explosive activities using the Fundamental Capacity Screen (FCS) to objectify your body’s needs to safely return you to sport. Prior to returning to sport we use the Move2Perform analysis tool to quantify your injury risk to know you are ready. If risk is too high we reassess and return to the prioritized items that need to be addressed. Time is never rushed or sacrificed due to insurance limitations or other outside influence and one on one care with a doctor of physical therapy is all you will ever get.
If you want to learn more, discuss your presentation, or find out how PreventPT can help you or your child