Clinical Musings (Adolescents) II

We will continue with our discussion of adolescent conditions and injuries that we often see in the clinic.

A year ago a young boy and his father came to the clinic. The boy was 11 years old and was a basketball player. He stated that he plays basketball everyday before and after school. He stated that he was starting to feeling pain in his knees. He stated that this pain is worsening and that running and jumping are extremely painful. His father stated that he holding his son from basketball at this time.

Upon inspection it was seen that the child's knee was indeed swollen at the tibial tuberosity, which can be seen below. This is the structure that anchors your knee cap and the entire quadriceps muscles to the rest lower leg. There is a growth plate at this point and is commonly irritated in growing children. It was also seen that the boy's tibial tuberosity was extremely tender to the touch. He also presented with significant tightening of the quadriceps muscles with testing. What this child was experiencing was Osgood-Schlatter's disease (OS).

http://en.wikipedia.org/wiki/File:Gray345.png

Much like Sever's Disease (Discussed last week), Osgood-Schlatter's disease is a terrible name for a somewhat common condition. Much like Sever's Disease, OS is not a disease at all,  but an apophysitis (please see my last post for more information about apophysitis). Instead of a apophysitis of the heel, OS is an apophysitis of the patella tendon. This condition is also caused by rapid bone growth that muscles and tendons cannot keep up with leading to pulling on the growth plate of the tibial tuberosity. 

If left untreated this condition can lead to progressive bone growth at the tibial tuberosity and eventual deformation of the structure. As seen below, the bone growth will become permanent and could cause life long irritation. 

http://en.wikipedia.org/wiki/File:MaleWithOsgoodSchlatter.jpg

The treatment for this condition holding the patient from all jumping and running activities. In the beginning ice is very important to decrease inflammation because NSAIDS (Advil other OTC anti-inflammatories) are not always safe for adolescents. Progressive stretching of the quadriceps and manual mobilizations should also be done by a therapist. 

This patient was non-compliant with treatment and continued with basketball. He is now 15 and has a permanent deformation at the tibial tuberosity that is painful with most active movements. 

Clinical Musing (Adolescents)

Adolescent kids are sometimes the hardest people to treat. They are usually pretty nervous about being treated and they are terrible symptom reporters. Although it is difficult, they are usually the most fun to interact with once they get comfortable with you.

The next few post I am going to outline some common adolescent conditions that we see in the clinic. 

Sever's Disease

A young girl came into the clinic, with her mother, complaining of heel and ankle pain. She is a soccer player and is very active. She stated that she has felt progressive increase in pain with running walking. She stated that at this point she is unable to run and that she is unable to walk without limping. She said the whole ankle and heel is painful. What this patient was experiencing was Sever's Disease.

Sever's Disease (also Sever's Apophysitis/Calcaneal Apophysitis) is actually a terrible name for a somewhat common dysfunction. From here on out I will refer to it as Sever's Apophysitis (SA) because it is actually a more accurate description of the condition. SA is not a disease but is rather repetitive structural damage at the growth plate of the heel from the Achilles tendon. This usually happens in growing children that participate in sports. Apophysitis is technical description of a tendon pulling on a bone to the point that the bone starts to pull away from the rest of the bone. As you can imagine this can be a severely (pun totally intended) painful condition. 

http://en.wikipedia.org/wiki/File:Gray1241.png

As seen above the Achilles tendon attaches to the heel bone at the posterior foot. In pubescent children, bones tend to grow faster than muscles and this causes increased tension along tendons such as the Achilles  There is a growth plate in the heel bone which can become irritated with this increased tension from the Achilles. This increasing irritation is referred to as Sever's Apophysitis. 

Treatment for this condition is usually manual massage of the calf, gentle and progressive stretching and strengthening activities, possibly bracing and taping techniques. Acutely ice and heat are also helpful. It is also important to hold kids from sports activities in the short run to avoid further injury.

This patient is doing much better and has been able to return to practice recently on a limited program. 

Clinical Musings II

A few weeks ago a patient came into the office complaining of shoulder pain with most shoulder movements that woke her up in the night. When asked where the pain was located she stated that the pain was in the lateral shoulder. She then started to rub the outside of her arm. When asked if she feels pain when she rubs her arm in the area that usually hurts with shoulder movement, she stated the she does not.  This is an extremely common presentation for shoulder pain.

What this patient was experiencing was referral pain from the rotator cuff. Lateral shoulder pain that occurs with movement but does not hurt with palpation is usually referral pain from the infraspinatus tendon of the rotator cuff.

The rotator cuff (RTC) is a term that is thrown out there a lot and is usually referred to without much knowledge of what it actually is. The RTC is actually a group of 4 muscles: The infraspinatus, subscapularis, supraspinatus and the teres minor. 

http://www.creativerehab.net/

These four muscles are the primary movers and stabilizers of the shoulder. People think that you only injure your RTC by playing sports, but most often times we can injure these structures by poor posture and repetitive habits. 

The patient I was seeing was an avid exerciser that just finished knee surgery. During that time she was exercising her upper body exclusively and thus caused irritation to her RTC. This is what was causing her pain. More specifically, she was presenting with infraspinatus tendinitis (inflammation of the tendon). 

Treatment for this condition is usually trigger point release techniques (either dry needling or deep massage), Ultrasound, RTC strengthening, and shoulder mobilizations. This patient has been seen for 3 weeks and is showing vast improvements. Unfortunately, physical therapy is not always helpful and more aggressive treatment maybe necessary.