Treatment ideas for today’s pediatric athletes, who reject rest as a therapy option.

The need for specialized medical care in young children participating in sports has greatly expanded over the past decade. This is due to the increased frequency and intensity of youth participation in sports, resulting in a rise in the prevalence of injuries. According to the National SAFE KIDS Campaign, each year an estimated 3.5 million injuries are sustained by children under the age of 15 while playing sports or participating in recreational activities.1 

One of the areas most prone to injury in the pediatric athlete is the knee. While this cohort of skeletally immature athletes suffer from a number of adult-like knee ailments, such as ligament sprains, osteochondral defects, and patellofemoral pain syndrome, they also have conditions that are unique to them. In particular, this group is susceptible to the development of apophysitises at the tibial tubercle and/or distal patellar pole, such as Osgood-Schlatter’s "disease" (OSD) and Sinding-Larsen-Johansson’s "disease" (SLJD).

Historically, these conditions were treated with the recommendation of rest, knowing that the athlete would ultimately experience a decrease in symptoms as they mature skeletally. However, today’s pediatric athletes are unwilling to accept this treatment plan and are searching for interventions that will allow them to keep participating in their sports at a high level. The purpose of this article is to discuss the prevalence of these growth-related knee injuries, as well as to outline possible physical findings, assessment tools, and treatment ideas to address the resulting impairments and functional limitations associated with OSD and SLJD.

Prevalence

OSD and SLJD are the two apophysitises found at the knee in the immature athlete. Both are caused by an excessive traction force created by the quadriceps muscle on the patellar tendon. OSD occurs at the tibial tubercle apophysis, while SLJD occurs at the distal patellar pole. OSD typically develops in girls between the ages of 8 and 13 and in boys between the ages of 10 and 15.2 The condition is typically self-limiting, as the apophysis usually fuses between the ages of 13 and 16. Kujala et al reported that this condition occurs in 21% of pediatric athletes, compared to 4.5% of age-matched nonathletes.3 Often, the surrounding soft tissue (that is, subpatellar bursa) can become irritated, allowing for increased pain and dysfunction. SLJD has a similar presentation, but it tends to develop earlier in childhood and ends between the ages of 12 and 13.

Examination

The examination should include a good history and assessment of the entire lower extremity. The patient typically will complain of increased knee pain during sports participation, particularly when running and jumping, which decreases with rest. Daily activities such as stair climbing and squatting may also be painful. At the knee, palpation is usually the most effective tool in determining whether an apophysitis is present, as point tenderness is a cardinal sign. With OSD, the patient will have palpable tenderness over the tibial tubercle. With SLJD, the distal patellar pole needs to be assessed by gently gliding the patella inferiorly with the knee in full extension and then palpating the area. The patient will also often have pain with resisted knee extension. Radiographs and magnetic resonance imaging can be used to detect changes in the areas as well.

The causes of the injuries are typically multifactorial. Overuse is usually a factor, but biomechanical dysfunction is often to blame in predisposing the athlete to develop these conditions. An effective examination should include an assessment of lower-extremity flexibility and range of motion, with particular focus on quadriceps and hamstring flexibility and hip external and internal range of motion. Manual muscle testing should be completed with concentration on hip and knee strength. The feet need to be assessed for movement patterns that lead to dysfunction at the knee, such as excessive midfoot and hindfoot pronation with concomitant internal tibial rotation. Typical impairment findings include hip external rotation and abduction weakness, and hamstring and quadriceps inflexibility. Biomechanically, patients can perform a number of functional tasks to assess their movement patterns. The patient’s gait, double- and single-leg squatting mechanics, anterior lunging, single-leg balance, stair-step ups and downs, and double- and single-leg jumps are all looked at to determine if appropriate movement strategies that protect the knee are being used.

Treatment

Interventions are aimed at controlling pain, improving strength and flexibility, and improving movement patterns to take stress off of the anterior knee. For pain control, nonsteroidal anti-inflammatory drugs are often used in conjunction with a cryotherapy program. Ice applied for 10–15 minutes, or direct ice massage to the area for 6 minutes after activity, is beneficial. It is applied with the knee in a flexed position to lengthen the involved soft tissue and reach the distal patellar pole more effectively. The use of a brace—specifically, an infrapatellar strap—may be trialed to see if the modification of stress decreases pain. No research on the effectiveness of using these braces to treat these conditions is currently available. However, anecdotally, braces appear to help with some patients. The strap may sometimes increase pain if it is improperly applied too close to the inflamed area. Therefore, appropriate application is necessary to ensure a reduction in symptoms. If the brace happens to increase symptoms due to overstressing regional tissues, or provides no relief, its use should be discontinued.

Therapeutic exercise should consist of lower-extremity stretches and progressive resistive exercises. Frequently, these athletes are undergoing a phase of rapid growth, which is frequently associated with periods of decreased lower-extremity flexibility. Stretching is instituted to improve quadriceps length, with specific focus on the two-joint muscle, the rectus femoris. Passive hamstring stretching is typically instituted prior to active stretching to allow adequate rest to the inflamed extensor tendon insertion. Other areas are addressed as needed.

Progressive resisted exercise is initiated to improve lower-extremity strength, to help attenuate the forces, and to decrease the stress on the knee. Terminal knee extension is strengthened using straight-leg raises, close-chain knee extensions with resistance bands, and leg presses with an emphasis on controlled full-knee extensions. At the hip, the abductors and external rotators are strengthened. The posterior aspect of the gluteus medius, which is responsible for both of these motions, is targeted. Some exercises that are used include: hip abduction with slight extension and external rotation, band-resisted hip external rotation in sidelying, band-resisted lateral walking, and sidelying plank exercises. Other strengthening exercises are implemented to address other findings from the initial assessment.

The goal of functional training is to relieve stress at the anterior aspect of the knee and to transition the athletes to more safely participate in their sport without pain. This is accomplished by improving dynamic knee control in the transverse and sagittal planes by promoting quadriceps/hamstring cocontraction, as well as an increased use of the posterior hip musculature during activities. The patients begin with wall squats, in which they flex their knees until they are over their toes, and then they flex at their hips, reaching forward. A resistance band can be used around their distal femurs to cue them to keep their knees in an abducted position. The patients are progressed to other activities, including: single-leg squats, anterior lunges, medial/lateral balance-board squats with active hip abduction against a resistance band, and single-leg balances with the knee flexed on and off of a perturbation pad.

After the patient is relatively pain-free, plyometric training is implemented. The focus of our plyometric program is to instruct the patients in proper jumping and landing techniques and improve their strength and power.4,5 The patients are instructed to use proper knee control during takeoffs and landings, and to land with their knees and trunk flexed, with good balance. They are also taught how to avoid leg dominance, or an overuse of one leg,6 to balance the forces between the two legs. Their progression to single-leg jumps occurs as their ability to control femoral adduction and internal rotation improves.

Finally, education is an important factor in the rehabilitation of children with apophysitis. Activity modification is occasionally necessary to decrease pain so that strengthening and other interventions will be effective. This involves educating the patient and family about the reasons behind the decision, instructing them about the course of treatment, and starting them on a home modality and exercise program to decrease the pain. Return to sports needs to be patient specific, and the patient should be educated about his or her self-assessment of pain levels. Understanding this will help the patient make educated decisions regarding appropriate levels of discomfort during sports participation. Immobilization or surgery is rarely required. However, occasionally it is necessary to excise a painful ossicle in the area in question.

Coupled with the dramatic increase in the intensity and frequency of sports participation in skeletally immature children is the increased prevalence of overuse injuries in young athletes, such as OSD and SLJD. Prior management focusing on rest is no longer acceptable for today’s young, motivated athletes. Therefore, managing inflammation early and effectively, as well as addressing any potential strength, flexibility, or biomechanical impairments, is critical for facilitating the safe and rapid progression of the pediatric athlete back to the field and into the game.

Matthew Ritchey, PT, DPT, is a physical therapist at the Sports Medicine Biodynamics Center at Cincinnati Children’s Hospital Medical Center. As a member of the OT/PT department at Cincinnati Children’s Hospital, he has had the opportunity to present nationally on a number of topics concerning the pediatric athlete. He can be reached at matthew.ritchey@cchmc.org.

Mark V. Paterno, PT, MS, MBA, SCS, ATC, is the coordinator of orthopaedic and sports physical therapy at the Sports Medicine Biodynamics Center and Division of Occupational and Physical Therapy at Cincinnati Children’s Hospital Medical Center. Paterno has presented nationally on various topics, including pediatric sports medicine and knee injuries in female athletes. He can be reached at mark.paterno@cchmc.org.

References

1. Safe Kids Worldwide. Sports Injury Fact Sheet. Washington: Safe Kids Worldwide; 2004. Available at: http://www.safekids.org Accessed July 25, 2005.

2. Krause BL, Williams JP, Catterall A. Natural history of Osgood-Schlatter disease. J Pediatr Orthop. 1990;10: 65–68.

3. Kujala UM, Kvist M, Heinonen O. Osgood-Schlatter’s disease in adolescent athletes. Retrospective study of incidence and duration. Am J Sports Med. 1985;13: 236–241.

4. Hewett TE, Lindenfeld TN, Noyes FR, Riccobene JV. The effect of neuromuscular training on the incidence of knee injury in female athletes: a prospective study. Am J Sports Med. 1999;27: 699–706.

5. Ford KR, Hewett TE, Myer GD. Rationale and clinical techniques for anterior cruciate ligament injury prevention among female athletes. J Athl Train. 2004;39:352–364.

6. Hewett TE, Myer GD, Paterno MV. Strategies for enhancing proprioception and neuromuscular control of the knee. Clin Orthop. 2002;402:76–94.