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Physio Matters

Osgood-Schlatter disease of the knee

Osgood-Schlatter disease is an irritation of the patellar tendon that inserts onto the tibial tuberosity (boney protrusion on the front of the lower leg just below the knee cap). The condition is due to stress on the patellar tendon, which attaches to the quadriceps muscle at the front of the thigh to the tibial tuberosity. Repeated stress from contraction of the quadriceps muscle transmitted through the patellar tendon to the tibial tuberosity can cause small avulsion fractures of the tuberosity along with inflammation of the tendon. This results in excessive bone growth of the tuberosity that produces a visible "bump" on the tuberosity causing pain. Robert Bayley Osgood, an American orthopedic surgeon, and Carl B. Schlatter, a Swiss surgeon, described the condition independently in 1903.

Incidence has been reported as high as 21% among teenage athletes compared to 4.5% of non-athletes. Osgood-Schlatter disease is also common among specific sports such as soccer (30%), football (17%) and male figure skating (14.2%). Children and adolescents specializing in a specific sport, pressure to perform, and decreased time between seasons of a sport can contribute to this overuse injury. Overall boys are more affected by this disease than girls, affecting boys aged 12-15 and girls 8-12 years of age. In 20-30% of cases both knees are affected.

The diagnosis of this condition requires a history and examination of the affected knee. Often, the following findings are evident in the diagnosis of Osgood-Schlatter disease:

  1. Enlarged and/or swollen tibial tuberosity
  2. Pain localized to the tibial tuberosity when palpated
  3. Pain to the tibial tuberosity when running, kneeling, or stair climbing
  4. Poor quadriceps flexibility
  5. Pain to the tibial tuberosity with resisted knee extension (testing the strength of the quadriceps muscle)

Interventions for this condition include the RICE principle: Rest, Ice, Compression, and Elevation. Research also indicates that hamstring and quadriceps stretching be performed to improve flexibility. In addition, current research (2014) indicates that a strengthening program that consists of 3 specific quadriceps exercises may also be implemented. These exercises include: 1. Isometric quadriceps sets (lie on your back, keeping your knee straight, push the back of your knee into the bed, contracting your thigh muscle), 2. Straight leg raises (with a straight leg, lift your leg 5-10 inches off of the bed), 3. Quads over Roll exercises (place a rolled up towel behind your knee and lift the lower leg to straighten the knee, ensuring that the back of the knee stays on the roll). All of these exercises should be performed free of pain. Finally, because Osgood-Schlatter disease is an overuse or repetitive strain injury, decreasing the frequency and intensity of the activities that aggravate the pain will help to improve the condition.

Please consult with your health care provider to establish a diagnosis for your knee pain and determine an appropriate treatment plan.





Warm-up exercises for golfers

Golf season is upon us. The courses in the Okanagan are opening their doors and avid golfers are getting the first rounds of the season under their belts. Unless you’re a snow bird and golfed down south over the winter, you probably haven’t golfed for a few months. As a result, the muscles you relied on heavily last year to swing a club may be a little rusty. Golfers are more prone to injuries during the beginning of the season that any other time of year. A good warm-up and stretching program are beneficial to prevent injury this season. The following are a few tips to remember prior to hitting the links:

 

Aerobic Activity

A low-intensity activity that uses large muscle groups should be performed prior to stretching. This gets your heart rate up, increasing blood flow to muscles. Walking for approximately 10 to 15 minutes, or climbing stairs are examples of this.

 

Stretching

Hold each of the following stretches for 20-30 seconds (do not stretch to the point of pain):

Forearm Stretches – With palm up and elbow straight, extend wrist and fingers back with opposite hand. Then with palm down and elbow straight, flex wrist and fingers down with opposite hand. Perform both stretches with opposite arm.

Neck Stretch – Place your hands behind your back and slowly side flex your neck so that your left ear moves towards your left shoulder. Stretch should be felt on the right side of the neck to the shoulder. Repeat stretch to the right to feel a stretch on the left side of the neck.

Shoulder Stretch – Hold the shaft of the club vertically behind your back. Pull the club upwards with the top hand until you feel a stretch in the shoulder of the bottom hand. Then pull the club downwards with the bottom hand until you feel a stretch in the shoulder of the top hand.

Quadriceps Stretch – Standing on one leg, pull your opposite foot towards your buttock with your hand. Keep both of your thighs together so that your knee is pointing towards the ground. Stretch should be felt on the front of the thigh. Repeat with the opposite leg.

Hamstring Stretch – Place one foot 2 feet in front of the other. Bend at the hips and lean forward towards the leg that is outstretched, pulling your toes up towards you. Stretch should be felt on the back of the upper leg. Repeat with the opposite leg.

Groin Stretch – With feet 2 to 3 feet apart and toes pointing straight ahead, bend one knee and keep the other knee straight. Shift your hips towards your bent knee, feeling a stretch in the groin of the straight leg. Repeat to the opposite side.

Trunk Rotation Stretch – With a club held horizontally in the small of your back, turn your trunk to one side without twisting your hips. Repeat to the opposite side.

Trunk Extension Stretch – With a club held horizontally in the small of your back, arch your back backwards, keeping your knees straight. Hold this stretch for only a few seconds.

Trunk Side Flexion Stretch – Side bend your trunk to one side by sliding one hand down the side of your thigh. Repeat to the opposite side.

 

Golf Drills

After you stretch, start by gently swinging an iron. Ensure that you start with half swings, gradually increasing your back swing. This drill should be performed both right and left handed. If there is a driving range available, practice your swing mechanics before your tee time. This will help to further warm-up your muscles for your round of golf.



Returning to sport after a concussion

In my last column I discussed the assessment of concussions using both the SCAT3 and the new technology of the X2 patches. Today, I will discuss the steps players or athletes should follow after a concussion when returning to play. Returning to normal activities, which include sport participation, is a step-by-step process, which is as follows:

 

1.  Rest Only (no activity)

Tasks that require concentration such as school or work should be limited. Do not participate in any physical activity until you can perform tasks requiring concentration without any symptoms. Proceed to Step 2 only when there are no concussion symptoms present at rest.

 

2.  Light Aerobic Activity

Start with light exercise such as walking or cycling on a stationary bike. Refrain from performing any resistance training (lifting weights). Your symptoms should be monitored while performing the exercise. If symptoms occur, stop exercising immediately and return to rest (Step 1). If there are no concussion symptoms you may proceed to step 3 the following day.

 

3.  Sport Specific Activity (low impact)

Perform activities that pertain to your sport. For example, if you play hockey try some light skating. If you play baseball then try throwing a ball. Refrain from any body contact or high impact motions. This would include any checks to the boards in a hockey practice or hitting a ball with a bat in baseball practice. If symptoms are present then return to rest (Step 1) until they have resolved. If there are no symptoms proceed to step 4.

 

4.  Practice - Drills without Body Contact

Participate in practices with your team. Ensure that you do not participate in any drills that require body contact. If symptoms occur then return to rest in Step 1. Progressing to step 5 will vary with the severity of the concussion of each athlete. If there are no symptoms present then proceed to step 5 only after you have received medical clearance.

 

5.  Practice - Drills with Body contact

Slowly incorporate drills that require body contact. If you have symptoms return to step 1. If there are no symptoms you can proceed to step 6.

 

6.  Game Play

Hooray! You’re back in the game! Be safe and have fun.

 

Remember that if you have concussion like symptoms in any of the above steps, please return to step 1 (Rest). Once symptoms have resolved you may start the step wise process again. If symptoms persist please consult with your physician. These return to play guidelines were established by the Consensus Statement on Concussion in Sport.



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Assessment of concussions

In my last column I discussed the basics of concussions, including symptoms that may accompany a hit to the head. Today, I will touch on how medical personnel may assess concussions and also discuss new research that that is taking place right here in our community.

As I touched on in my last column, concussions can present with many different symptoms. To ensure concussions are managed properly, it is helpful to have an “action plan” at the venue where the sporting event takes place. Coaches, trainers, players, and parents should be made aware of a plan that will help to assist players after a hit to the head. A “safety person” or trainer on the team should be available to assist in managing injuries and particularly concussion related incidents. That person should be familiar with the action plan and understand what to do if a concussion is suspected. The first step the safety person should do is remove the player or athlete from the play. The player should not be left alone and signs and symptoms of a concussion should be monitored. It is important to note that medications should not be administered at this time. The athlete should then be evaluated by a medical professional as soon as possible and the parents or guardians should be informed that there may be a suspected concussion. The most important thing to take away from the action plan is that if a concussion is suspected it is very important that the player must not return to play in the game or activity that day. He or she should be evaluated medically prior to returning to the sport (which will be discussed in my next column). If the player is unconscious phone 911 immediately. Assume that there is a possible neck injury and continue to monitor the airway, breathing, and circulation of the unconscious player.

Many contact sports teams are now adopting a method of determining pre-season or baseline scores on specific concussion tests. These tests evaluate many factors such as memory, concentration, balance, coordination, orientation of time, and neck and concussion type symptoms. If a player were to sustain a concussion in the season, baseline scores can be compared with post-concussion scores to determine the presence and severity of a concussion. An assessment tool known as the SCAT3 (Sports Concussion Assessment Tool – 3rd Edition) is a standardized evaluation and can be used for those athletes 13 years of age and older. There is a Child SCAT3 version for those under 13 years. The SCAT 3 is designed to be administered by medical professionals and should not be used solely to diagnose a concussion without a professional medical opinion. An athlete may score “normally” on the SCAT 3 even when a concussion is present.

Components of the SCAT 3 include the following:

  1. Symptom Evaluation – athletes rate a list of symptoms from 0 (symptoms not present) to 5 (severe symptoms).
  2. Orientation Assessment – athletes are asked a series of questions such as the date, time, and year.
  3. Memory – a list of words are read aloud to the athlete. The athlete then repeats the list of words back to the evaluator.
  4. Concentration – a list of digits are read aloud to the athlete. The athlete then repeats the list in reverse order back to the evaluator.
  5. Neck Examination – range of motion, tenderness, sensation, and strength are assessed by the evaluator.
  6. Balance testing – various stances are evaluated for 20 seconds each. A tandem gait (walking along a line with one foot in front of the other) is performed.
  7. Upper limb coordination – athlete must touch their nose with their index finger and then return to the starting position (an outstretched arm) 5 consecutive times.
  8. Memory Recall – athletes are asked to repeat the words given to them in step 3.

 

In addition to the SCAT 3, there are new concussion assessment products being researched in our own backyard. As a physiotherapist with the Kelowna Chiefs Junior Hockey Club, we have partnered up with the Integrative Sports Concussion Research Group (ISCRG) at the University of British Columbia – Okanagan (UBCO). Researchers are investigating cerebrovascular, neurocognitive, and sensorimotor effects concussions have on young athletes in order to better understand how the brain responds to a concussion. One component of their research is having athletes wear an electronic patch (Xpatch) or electrode behind their ear when participating in sport. These patches are made by a company called X2 Biosystems and have the ability to monitor and record force and impact. For example, if an athlete sustains a hit to the head or upper body, the X2 patches will record the impact as a linear or rotational force, and can also determine the extent and direction of the impact. This information is uploaded by the researchers who then monitor the forces. If an athlete sustains a concussion he or she will undergo extensive concussion testing, comparing results to baseline scores, and with the help of the Xpatches researchers can determine the amount of force or impact the athlete sustained that may have contributed to the concussion.

All of this technology and information has proved to be invaluable to the Kelowna Chiefs Junior Hockey Club in helping us to make more informed decisions based the assessment, monitoring, and return to play of concussed players. As a team we are honored to be a part of such progressive research in hopes that the information gathered from the study may have the potential to better understand how concussions impact athletes. Two of the UBCO researchers that work closely with the Kelowna Chiefs are Colin Wallace and Sandy Wright. More information can be found on the ISCRG website at www.iscrg.ca.



Read more Physio Matters articles

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About the Author

Kristi Scott, B.Sc., M.Sc.P.T., CAFCI

Kristi is a registered physiotherapist. She joined her mother, Shirley Andrusiak, at Guisachan Physiotherapy after graduating from the Masters of Science in Physical Therapy Program at the University of Alberta in 2010. She also holds an Undergraduate Bachelor of Science Degree from the University of Victoria. Since graduating Kristi has completed numerous continuing education courses including manual therapy, vertigo, and golf related rehabilitation.  She has also completed her training with the Acupuncture Foundation of Canada Institute, and is certified to perform acupuncture techniques, holding a designation of CAFCI.

Kristi brings an energetic, exercise based approach to her practice. She focuses on client centered care, education, exercise prescription, and manual therapy techniques.  She has a special interest in hockey related injuries and volunteers for the Kelowna Chiefs Junior Hockey Club.

You can contact Kristi by email at [email protected]

 




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The views expressed are strictly those of the author and not necessarily those of Castanet. Castanet presents its columns "as is" and does not warrant the contents.


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