Osgood Schlatters Disease

[sven_inc]

Hey all, if you've been around the traps you may have bumped into me and my ramblings on all things injuries.

As a quick intro I'm a Physio whose really passionate about solving issues and uncovering why things happen. I have a practice dedicated to working things out and solving tricky patient problems which affords me the luxury of testing theories in realtime to find answers.

Anyway,

I've put together a post on Osgood Schlatters Disease that explains why I think my industry has missed the point with it.

If interested please have a read and pass it along to anyone you think it might assist.

It can be a bugger of a thing for young athletes to put up and hopefully it will help or at least point people in a better direction.

I'm an open book and a massive nerd so feel free to let me know your thoughts.

Cheers

http://yourwellnessnerd.com/osgood-schlatter-disease/

 

[Gralin]

No idea mate, I had something like this when playing basketball around 18-20
I got given the quad imbalance line, how my knee cap tracked.

That said I started doing Kung Fu and found the problem went away.

I thought it was stengthing my quads with stances but maybe it was freeing up and strengthening my lower back.

Then again I have some issues now which look to be related to over pronation so who knows

 

[The_Eagles]

I got diagnosed with this at 13/14. I was the best player in the team at 12...ruined my career lol. Man did that area hurt if I touched or pressed it after training and getting bumped in matches. But I got out of PE at school for a year and just chilled on the sidelines

 

[blueboy25]

Thanks for that and it was a interesting read.

As someone who suffered quite badly from OSD from ages 13-16 which kept me up at nights in a lot of pain especially if I had played sport on a hard surface such as basketball.

It was never suggested by my doctor once diagnosed that I should see a physio, it was more here is your diagnosis and we suggest you don't play any sports on hard courts and that was it.

I still have the lumps especially on my left knee/shin.

 

[keyboard_warrior]

Thats an interesting take on things. I would have thought targeting slightly lower than the thoraco-lumbar junction for that neural response you described, given that the innervation for anything knee related is L3-4.

Will try the theory out with my next patient and see if the results are similar

 

[sven_inc]

Thats an interesting take on things. I would have thought targeting slightly lower than the thoraco-lumbar junction for that neural response you described, given that the innervation for anything knee related is L3-4.

Will try the theory out with my next patient and see if the results are similar

Let me know what you find. I can't explain it perfectly yet, but I can almost guarantee that low thoracic/upper lumber spine will be stiff somewhere. It may not work out as perfectly as that L2-4 Femoral Nerve, or the Dermatome/Myotome distribution - it may even have something to do with the Sympathic Nervous system as it exits in the area, but it just seems to be there. Maybe its the start of some broader mechanical chain reaction that a developing Tibial Tuberosity can't tolerate.

What I can see though is by mobilising that area I can get a reproducable change in mobility, function and pain almost across the board. It seems that clinically as those areas free up and the spinal loading of the patient improves things tidy up at the knee. Really seems to be getting to the heart of a whole host of young athletes issues.

 

[Biggie]

My 13 daughter had her athletics season derailed this year due to this.

She’s had some pain in both knees but it got too much this year straight after Xmas. Running a 400 she just started limping. Bloody heartbreaking that was to watch

We’ve taped her knees and she resumed competing a fortnight later ...but never quite got to the level she can get to (missed states)

All scans showed everything intact

Should I check with her regarding her lower back then?

 

[sven_inc]

My 13 daughter had her athletics season derailed this year due to this.

She’s had some pain in both knees but it got too much this year straight after Xmas. Running a 400 she just started limping. Bloody heartbreaking that was to watch

We’ve taped her knees and she resumed competing a fortnight later ...but never quite got to the level she can get to (missed states)

All scans showed everything intact

Should I check with her regarding her lower back then?

Hey mate!

Absolutely, obviously go see someone about it. I cant give specific advice over the net but generically, using a ball or a roller you should be able to find some important spots. Let me know how you go mate!

 

[Cats fan 16]

Hey all, if you've been around the traps you may have bumped into me and my ramblings on all things injuries.

As a quick intro I'm a Physio whose really passionate about solving issues and uncovering why things happen. I have a practice dedicated to working things out and solving tricky patient problems which affords me the luxury of testing theories in realtime to find answers.

Anyway,

I've put together a post on Osgood Schlatters Disease that explains why I think my industry has missed the point with it.

If interested please have a read and pass it along to anyone you think it might assist.

It can be a bugger of a thing for young athletes to put up and hopefully it will help or at least point people in a better direction.

I'm an open book and a massive nerd so feel free to let me know your thoughts.

Cheers

http://www.peninsulaphysio.com.au/blog/osgood-schlatters-disease-weve-missed-the-point-entirely/

Interesting take on a tricky injury.

My main concern with palpation findings is that we actually have no idea what a hypomobile joint feels like. Research consistently backs up our inability to 'feel' areas of dysfunction.

Would love to know your thoughts on the mechanism - eg. decreased L3/4 nerve root supply to quad causing weakness. The other thought would be the prevalence and consistent correlation between OSD and loading/activity of the quads, does this still fit with the thoracolumbar theory?

Cheers for the blog link though, love your thoughts on strength work over ergonomics with neck pain, strength is king.

 

[Always Ballin]

Good post sven_inc

I suffered from this from around 14-17. This coupled with an earlier avulsion fracture to my left hip + overuse of the right hip derailed my own athletic career. I was neck and neck best player on our team with a guy who ended up getting drafted (AFL) and I also excelled in athletics.

By the time I was healthy again I was so far behind the mark and lost much of the drive. That's life. Oh well.

The timeline of my injuries and physical dysfunction went like this;

Left hip flexor avulsion fracture > right hip overuse/compensation tendinitis > Osgood Schlatters

I do believe the timeline from hip to knee was highly correlated. Knowing what I do now about strength and conditioning, bio mechanics, and my own injury maintenance/protocols, the picture is quite clear.

If anyone who reads this has a son or daughter experiencing Osgood Schlatter's, I think this post I am writing will be of great value.



Conventional belief about OS is that the bone grows faster than the subsequent muscle, tendons and ligaments AKA connective tissues. Hence, the patellar tendon produces a mechanical stress on the tibial tuberosity (knee bump site of pain) wherein bone growth is occurring (growth plate). Bone grows by first producing softer cartilage that eventually ossifies into bone.

Tightness of the muscles, tendons and ligaments + the soft new progressing bone growth = OS inflammation at tibial tuberosity

That's my basic understanding of it anyways

The treatment protocols for OS in your standard physio are ineffective and a waste of time (and money). Trust me, I went through the whole ordeal. Physio might use an ultrasound treatment, tell me to use a heat pack, stretch your quad and do some knee bends AKA partial knee flexion squats. I think I was also told to do it on a 45 degree wooden board.

None of that really helped.

What did help was when I was referred to a physio that had a much greater understanding of biomechanics and it's relation to joint mobility. He got me looking at the whole body.

Why do some kids get OS and others who grow just as much don't?

FACT: OS is largely associated with movement dysfunction.

Plainly put, knee dominant kids tend to get OS. They overload their anterior chain, particularly the knees. Very common in basketballers and other jumping sports. They lack strength in the posterior chain, in the hips.

As soon as I started to strengthen my posterior chain, and clean up my joint by joint mobility (more on that in a second), my knees got better. I became much more hip dominant.

I read Kelly Starrett's Supple Leopard book about mobility. I started doing "mobility" work which before learning this stuff was a foreign concept to me. Australia is very much behind the rest of the world in this stuff. I mean, using resistance bands to stretch my hips was revolutionary.

Opening up my hips and ankles using bands and foam rolling with a tennis ball all over had a huge impact. Expanding on that you clean up the spine (lumbar/thorracic/cervical), shoulders and even the knees (tibial rotation).

If you want to overcome OS you need 2 things (in my opinion)

1. Mobility (shoulder-spine-hip-knee-ankle)
2. Balanced strength (hip-knee)

Strength through length is what I always say. You do the mobility to open up and gain the range of motion, then utilize strength movements to reinforce.

Breaking down this into actual specifics is quite simple in my mind;

Always foam roll, massage ball area before using band stretches

MOBILITY (Using bands, tennis ball, foam roller)

Shoulder
- Foam roll/tennis ball the whole shoulder, upper back, neck, traps, pecs, serratus anterior, arm pit, tricep, bicep
- Shoulder extension + Internal/External Rotation (Resistance band stretches)
- Shoulder flexion + Internal/External Rotation (Resistance band stretches)

Spine
- Foam roller on back
- Thoracic extension
- Thoracic rotation

Hip
- tennis ball into the glutes, hips, psoas, upper thigh, upper hamstring, IT band
- Hip extension + Internal/External Rotation (Resistance band stretches)
- Hip flexion + Internal/External Rotation (Resistance band stretches)
- Hip Abduction/Adduction (not as important as above)

Knee
- Clean up Tibial external rotation by using a band distraction mobilization exercise
- roll a tennis ball around the lower hamstring/back of the knee, upper calf/shin
- Go one step further and incorporate a voodoo band flossing of the knee which is essentially just wrapping the knee tightly with a voodoo floss band (i just used an old bike inner tube) creating compression and do some bodyweight squats on the knee, bounce around in deep knee flexion

Ankle
- Foam roll/tennis ball the whole calf, shin, side and top of foot, and especially the bottom of the foot
- Plantarflexion
- Dorsiflexion
-mainly dorsiflexion is what most people lack (being able to get the knee forward) at the ankle joint
- Use a resistance band stretch to open up the ankle, gain ROM in plantarflexion

Why is using resistance bands so much better for stretching?

Well they produce a level of stretch much superior, and they seem to be able to stretch the actual joint capsule. Using a band to stretch my hip extension open was a gamechanger for me (someone who had hip problems)

That seems overly complicated but If I would simplify it to 3 main mobilizations to do for OS it would be;

1. Hip
2. Ankle
3. Spine

Just do some foam rolling/tennis ball, use a band to open up those areas

2. Balanced strength

For OS we want to shift from knee dominance, to hip. We want to develop the posterior chain. But we must first have the mobility. Mobility 1st, strength second.

The number one exercise I'd do for someone with OS?

Back extensions. I'd make them do it all day long. All different kinds of variations. Ones that target the hamstrings more, others that hit the spinal erectors.

The reason why I'd initially use back extensions is because they are not weight bearing. To someone with OS even weight bearing hip extension exercises like a sumo deadlift or a RDL can cause irritation. By using a back extension first, we can build up the posterior chain without any weight bearing. Eventually we want to get to where we can start deadlifting.

What we want to do is get wicked strong in the posterior chain by progressing with back extensions. The stronger someone with OS gets in the posterior chain, the less knee dominant he/she becomes. This is huge for ANY knee issue.

The back extension progression is just holding weights but eventually you'll want to utilize this;



If you don't have access to a back extension platform you can just get someone to sit on your legs/hold them down while you hang off the side of a bed. Can easily put a backpack with weight on to load it. Like this but facing down;

I wouldn't have someone with OS deadlift until they can lift 100kgs on this exercise. I personally have done it up to 150kgs. It's one of the safest deadlift variations out there because of it's orientation. The pad locks your hips in place, so your pelvis doesn't rotate, you can't hyperextend or flex the spine and you can't cheat the weight up. Very effective and safe exercise.

At that point I'd start incorporating some straightbar deadlifts, maybe even eventually progress to some low bar squats, and ideally someday when all knee pain has gone, quad dominant exercises like front squats.

Even if it doesn't get rid of all the OS pain, it should alleviate a lot of it, and make it much easier to play sports.

TLDR EXPLANATION -
Hip, ankle, spine moblity
Strengthen posterior chain significantly to become hip dominant
Movement will change, knee will get better

Eventually want to get to the point where you can do heavy deep barbell squats with perfect form, because weighted, full ROM compounds are the best way to maintain mobility. IE I use heavy dips to maintain shoulder extension mobility. But this is long term down the line stuff.

 

[Always Ballin]

I forgot to mention;

Just prior to the onset of my hip and knee injury cascade, I had been riding a BMX bike heavily, every day to school and back. It was quite a long and intense ride. BMX bikes are short and using it so much clearly overdeveloped my quads and hip flexors. Knee dominance development, weak posterior chain.

 

[sven_inc]

Interesting take on a tricky injury.

My main concern with palpation findings is that we actually have no idea what a hypomobile joint feels like. Research consistently backs up our inability to 'feel' areas of dysfunction.

Would love to know your thoughts on the mechanism - eg. decreased L3/4 nerve root supply to quad causing weakness. The other thought would be the prevalence and consistent correlation between OSD and loading/activity of the quads, does this still fit with the thoracolumbar theory?

Cheers for the blog link though, love your thoughts on strength work over ergonomics with neck pain, strength is king.

Hey mate, thanks for taking an interest.

The mechanism it seems is based more around stiffness and it's ability to force compensation and poor loading.

Mechanically it seems that a stiff back either pulls slack from the Femoral nerve or asks the muscles that associate with those levels to tighten/stiffen as a result. I'm thinking it's a form or support or protection as the nervous system is our most precious commodity and the body will always prioritise central safety over peripheral function.

Like most issues it seems that the Osgood Schlatters is an issue in its own right, but one that in all likelihood can't exist if your spine is functioning normally. The spinal dysfunction is the first step in a chain reaction of events that leads to a knee issue - Growing or not.

That's what I have in my head anyway.

 

[Gene Simmons]

Gee I feel like I've stumbled on an Osgood Schlatters community!

I got diagnosed with OS firstly in my left knee when I was about 11, and around 12 in my right knee.. At the time, I was told by my Doc that it will take care of itself by the time I'm 16... nothing...multiple x-rays...saw specialists..I was advised against any surgeries... now I'm well into my 30's and live with OS in both knees, I try and stay as active as possible but I live with the pain everyday (but I honestly don't think I can remember never having the pain) so I've just learned to live with it.

I struggle with simple things like squatting without grimacing, and temperature changes (like this morning) is a real b%^h!

But both knees do make an interesting conversation 'point' and I sometimes like to freak people out

 

[Always Ballin]

A stiff back can be a myriad of things but pathologically it's associated with the same basic movement/mechanical loading dysfunctions of most young athlete knee injuries.

Overdeveloped quads, hip flexors. Psoas ties in at the lumbar spine and attaches to the femoral head region. Basic rotated pelvic dysfunction (APT/PPT)

Young athletes with developed posterior chains are much less predisposed to OS, or any real knee injury. Strong, balanced posterior chain (spinal erectors/glutes/hamstrings) allows for proper spinal/hip function, which means a proper balance of agonist/antagonist muscle lengths. It's commonly known in knee rehab circles that the hamstring is a big stabilizer of the knee joint.

As far as the connection between L3-L4/Lumbar region of the spine, nerve innervation and OS.. This is obvious. Pelvic tilt dysfunctions indicating muscle strength/length imbalances mean nerve compression/tightness and thus movement/mechanical loading errors.

Nerves return to optimal function when you address muscle length/strength through mobility.

Knee injuries can start from incorrect cervical spine positioning. Spinal > Knee is an obvious connection, but you'd be foolish to leave out the hip.

Fix Spine>Hip>Knee>Ankle through mobility and strengthening and you fix most injuries of an overuse variety. Most if not all injuries in part are due to chronic bad mechanics such as ACL non-contact tears. The NFL screens draftees for flat foot/feet dysfunction as it is a good indicator of potential ACL/MCL/Knee injuries.


You'd be foolish to think that only a few back stretches/exercises will adequately address an issue like OS. You need to address everything for the best possible result. A forward head posture throws off spinal alignment, something that I see in virtually every teenage boy. Probably playing too many video games and looking down at his phone.

If he can't get his hip flexion deeper than 90 degrees on a Thomas test, without flexing the spine, that's a huge problem for OS.

If he can't get into true hip extension with glutes actually working and not just arching the lumbar spine like a stripper, that's a huge problem for OS.

If he can't get his knee over his toes in a dorsiflexion test of the ankle, that's a problem for OS.

If his thoracic spine is so jacked up he can't even get basic extension and rotation, you sure as hell bet his lumbar is dysfunctional.

 

[Cats fan 16]

A stiff back can be a myriad of things but pathologically it's associated with the same basic movement/mechanical loading dysfunctions of most young athlete knee injuries.

Overdeveloped quads, hip flexors. Psoas ties in at the lumbar spine and attaches to the femoral head region. Basic rotated pelvic dysfunction (APT/PPT)

Young athletes with developed posterior chains are much less predisposed to OS, or any real knee injury. Strong, balanced posterior chain (spinal erectors/glutes/hamstrings) allows for proper spinal/hip function, which means a proper balance of agonist/antagonist muscle lengths. It's commonly known in knee rehab circles that the hamstring is a big stabilizer of the knee joint.

As far as the connection between L3-L4/Lumbar region of the spine, nerve innervation and OS.. This is obvious. Pelvic tilt dysfunctions indicating muscle strength/length imbalances mean nerve compression/tightness and thus movement/mechanical loading errors.

Nerves return to optimal function when you address muscle length/strength through mobility.

Knee injuries can start from incorrect cervical spine positioning. Spinal > Knee is an obvious connection, but you'd be foolish to leave out the hip.

Fix Spine>Hip>Knee>Ankle through mobility and strengthening and you fix most injuries of an overuse variety. Most if not all injuries in part are due to chronic bad mechanics such as ACL non-contact tears. The NFL screens draftees for flat foot/feet dysfunction as it is a good indicator of potential ACL/MCL/Knee injuries.


You'd be foolish to think that only a few back stretches/exercises will adequately address an issue like OS. You need to address everything for the best possible result. A forward head posture throws off spinal alignment, something that I see in virtually every teenage boy. Probably playing too many video games and looking down at his phone.

If he can't get his hip flexion deeper than 90 degrees on a Thomas test, without flexing the spine, that's a huge problem for OS.

If he can't get into true hip extension with glutes actually working and not just arching the lumbar spine like a stripper, that's a huge problem for OS.

If he can't get his knee over his toes in a dorsiflexion test of the ankle, that's a problem for OS.

If his thoracic spine is so jacked up he can't even get basic extension and rotation, you sure as hell bet his lumbar is dysfunctional.

I like your thoughts and I see you strongly subscribe to Boyle's joint by joint approach and regional interdependence. It certainly makes a lot of sense, but in my humble opinion it's not always this simple (or complicated depending how far up the kinetic chain you start treating).

In terms of exercise suggestion, I'd have to go with just two exercises, as it increases the chances that the person will actually do them. I'd suggest a hip hinge with knees blocked to promote hip and not knee dominant pattern. And then probably a rear foot elevated lunge (depending on irritability) to get some length through eccentric work on back leg, and do both sides. 3 x 12.

 

[Always Ballin]

I like your thoughts and I see you strongly subscribe to Boyle's joint by joint approach and regional interdependence. It certainly makes a lot of sense, but in my humble opinion it's not always this simple (or complicated depending how far up the kinetic chain you start treating).

In terms of exercise suggestion, I'd have to go with just two exercises, as it increases the chances that the person will actually do them. I'd suggest a hip hinge with knees blocked to promote hip and not knee dominant pattern. And then probably a rear foot elevated lunge (depending on irritability) to get some length through eccentric work on back leg, and do both sides. 3 x 12.

True, but the way I approach it is, even if it's more than a joint by joint approach, you need to at least tick those boxes and address them. You might not be able to rid 100% of Osgood symptoms, but you can get the kid moving right, ideally like a sprinter with his hip extensors, I feel like that's going to alleviate some if not a good deal of the pain. Much better approach than what conventional physios prescribe for Osgood... Knee bends and vmo patellar tracking.. Really? Lol

Good choices with the exercises. I like back extensions for that reason. Pure hip extension, no knee. Hard for a novice to hurt themselves on a 45 degree back extension platform. Hips locked in place, no axial loading, just pure extensor development. Easy to load with weight too.

Young sporting programs are big on core work, planks and stuff. But you never see them work on the posterior core. Maybe some glute bridges, but not nearly enough to balance out the ab stuff. A simple reverse plank would go a long way to a lot of these programs.

Funny you mention eccentric work, as I've been doing some research into it recently... The literature seems to show that eccentrics build up tendons. My own experience in the gym seems to support this. I'm big on the negative portion, especially at the end range. Pretty much every muscle i've incorporated it with I am now bulletproof there to a degree. I always used to strain my pecs from time to time, then I started doing some end range of motion weighted stretches on the pec fly machine. Eventually building up to the whole stack, just doing negatives. Chest feels like steel now, never tight always loose, pliable.

Same regarding my hamstrings. I think this might be why nordic hamstring curls are so successful as an exercise. Eccentric work is definitely needed in an athlete's program.

 

[Cats fan 16]

True, but the way I approach it is, even if it's more than a joint by joint approach, you need to at least tick those boxes and address them. You might not be able to rid 100% of Osgood symptoms, but you can get the kid moving right, ideally like a sprinter with his hip extensors, I feel like that's going to alleviate some if not a good deal of the pain. Much better approach than what conventional physios prescribe for Osgood... Knee bends and vmo patellar tracking.. Really? Lol

Good choices with the exercises. I like back extensions for that reason. Pure hip extension, no knee. Hard for a novice to hurt themselves on a 45 degree back extension platform. Hips locked in place, no axial loading, just pure extensor development. Easy to load with weight too.

Young sporting programs are big on core work, planks and stuff. But you never see them work on the posterior core. Maybe some glute bridges, but not nearly enough to balance out the ab stuff. A simple reverse plank would go a long way to a lot of these programs.

Funny you mention eccentric work, as I've been doing some research into it recently... The literature seems to show that eccentrics build up tendons. My own experience in the gym seems to support this. I'm big on the negative portion, especially at the end range. Pretty much every muscle i've incorporated it with I am now bulletproof there to a degree. I always used to strain my pecs from time to time, then I started doing some end range of motion weighted stretches on the pec fly machine. Eventually building up to the whole stack, just doing negatives. Chest feels like steel now, never tight always loose, pliable.

Same regarding my hamstrings. I think this might be why nordic hamstring curls are so successful as an exercise. Eccentric work is definitely needed in an athlete's program.

For sure. VMO work and patella tracking work is ridiculous and such a short sighted view, not taking any biomechanics into question. Treating the knee as a knee, and not the knee as part of a complex connected body.

Eccentric work is fantastic as it has been shown to generate as much muscle length as static stretching, whilst having the ability to increase strength. We are actually 1.1 - 1.3 times stronger in the eccentric phase of an exercise, and adding more eccentric work will increase strength and muscle cross sectional area (bigger muscles).
Additionally, it's role in tendon strength work is definitely beneficial. Not so long ago, it was thought that all you needed to fix or strengthen tendons was purely eccentric work, but recent research suggests that the concentric portion is beneficial too and tendons respond well to a program based around;
- hypertrophy to strength to power. In that order (S & C principles really).

I must say I hadn't really considered back extensions for OS, mainly because it can be a difficult one to get a young teenager to do. It could definitely work, providing the kid doesn't jam into too much lumbar hyperextension.

Good thoughts.