Adult Osgood Schlatters?

[KneeKnack]

Hello,

I have gradually developed pain in my left knee over the course of a few years. The pain centres where the patellar tendon attaches to the tibia. There is now a lump there and is tender to touch.

I would usually notice this pain after playing football (soccer), but it has gradually got worse until it hurt during playing and now I can't play any more. I stopped playing for a few months to rest it and do some stretching and strengthening exercises, as recommended by my physio, and I tried to play football again, but the pain has returned with avengance - worse than ever! In fact my knee feels very unstable and I was worried I would cause more damage by trying to run on it as it was starting to give way. That was yesterday - still in a fair amount of pain today, hobbling about. When sitting, I can barely lift my foot off the floor by flexing my knee.

I have to admit I was not exactly dedicated to the regime prescribed to me by the physio due to pressures of time, new parenthood and bone-idleness, so I suspect what has happened is my leg muscles, particularly quads, are weaker than when I was playing and are exacerbating the problem. I am about 5'9'' and around 14 stones (196 punds) so a bit overweight, which I don't imagine helps either, but this knee problem has contributed to my lack of exercise and therefore weight gain...

I'm 36 years old and my physio believes I have an adult version of Osgood Schlatters, or at least something that mimicks it. I didn't have Osgood Schlatters as a teenager and the lump development has only appeared in the last year or two.

I am wondering if the diagnosis is accurate and what are my options.

The physio believes a steroid injection might help rehab, if only to settle the problem down enough to allow exercise to build up the muscles. I'm not sure if this is a good idea long term, although the problem is pretty chronic now and I wonder if it's likely to make it any worse. Is anything possible surgically?

I'm quite frustrated by this injury now and a bit depressed at the prospect of maybe not being able to play football or run again.

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[physiobob]

Try searching the site for "Osgood Schlatters" there is a bunch of posts.

[KneeKnack]

I have searched the site for 'Osgood Schlatters', but most, if not all, posts relate to adolescents or adults who had the condition in adolescence. Because I have only had this problem in my 30s, it cannot be Osgood Schlatters per se, but some sort of 'mock' Osgood Schlatters, if such a thing exists. I also wonder if jumper's knee relates to my symptoms.

[linbin]

hi
i don't agree with the diagnosis of adult Osgood Schatlers.its sounds wierd to me

[KneeKnack]

By definition it is not Osgood Schlatters as I am 36 and I did not have it as an adolescent, and the physio has said as much, but nevertheless the symptoms are very similar.

[msk101]

Hi KneeKnack,

Although Osgood Schaltters relates to adolescents and kids, what your physio is probably referring to is that there is an insertional tendinitis (otherwise called traction apophysitis) at the insertion of your quads tendon onto the tibial tuberosity.

Did your physio prescribe a program of quads stretching (lots of stretches), gentle non-painful strengthening??? i know it can be hectic trying to get these things done so i would suggest trying to incorporate them into your day... do a few stretches every time you go to the loo, everytime you're waiting for the kettle to boil or the toast to pop, every advert during tv programs (if you watch tv that is) etc etc. lots and lots of little bits of exercises generally helps more than trying to squeeze in a huge session.

As far as managing the inflammation (if in fact it is what it sounds like) - can you use a diclofenac sodium (eg. voltaren) gel cream? this can be quite effective especially if combined with some gentle warmth eg. hot water bottle for a couple of minutes first.

So basically, the solution if you do have traction apophysitis, is stretch and strengthen the quads, and your VMO muscle (important part of the quads, which helps kneecap alignment) - see your physio (or another one) and get stuck into the exercises... they're not fun but work.

Cheers
msk101

[KneeKnack]

Hi,

That's exactly what my physio prescribed. Thanks for the advice - I think it is something I certanly need to be doing several times a day, and doing it when watching TV etc is a good idea. Motivation is a bit of an issue for me as I think 'why bother?' if I can't play my sport, but if I were able to see some improvement then that would help.

Thanks also for the advice for the cream - I think I would need something to help.

At the moment I am hobbling a bit so I'll wait a few days before resuming the exercises. I have to keep my leg straight when walking, otherwise it is liable to give way. (the right way, fortunately!)

Traction apophysitis - at least I have a name for it now!

Thanks,

KneeKnack

[emad]

Yes , it is the right accurate diagnosis , just stop all what are you doing ? You need rest at the moment ..Do not even touch it . You can search for some somatic treatment .

cheers
Emad

[alophysio]

Hi,

If it is truly traction apophysitis, then i would also look at unloading the tendon in some way - but not too much because tension is required to maintain tendon strength.

You can think of the bump like what you see with "heel spurs". The tendon pulls away at the bone a bit. THe body (in trying to protect the site of injury) then throws bone at the site which just keeps getting pulled away a bit.

So a combination of rest and gentle exercises and stretches are required. But i would also try to find out why it started there. Has anything changed to increase the load on that knee? Why is it that knee and not the other?? Is there some other dysfunctional joints involved?

Cheers

[KneeKnack]

I have unloaded the tendon by not playing football or running, but still have to walk and negotiate stairs so I can't completely unload it. Crouching I find difficult.

This condition came on gradually over the course of a few years (maybe 4?) but it has only become bad enough this year that I had to completely stop playing sport, although I suppose it stopped me from doing much running previousl to that.

I am right footed so I suspect I get this in my left knee because it has to do all the weight bearing as I stop & push while I kick & control mostly with the right. My muscles are definitely too tight, plus there is a weakening of the muscles on the left leg as well. I think the problem tendon leads to weak muscles and the weak muscles add to the problem tendon!

I also have large calf muscles which I'm told may result in muscle imbalance. I am also an over-supinator (?) when running/walking.

[alophysio]

hi - a traction apophysitis is usually because the bones are too soft relative to the muscles.

Try to find someone who can look at how your body is loading in the tendon.

For chronic tendons, you need to overload the tendon to get it going.

A bit confusing i suppose but if you can find any information on "stress shielding" theory of tendon degeneration, it might help.

Otherwise it is hard to help without seeing you.

Good luck

[KneeKnack]

Thanks for your interesting post.

I had been seeing a physiotherapist but I was discharged before I resumed sport and it was upon resuming sport that it returned in anger! The physio suggested I see an orthapaedic surgeon next.

Whilst doing the physio is probably going to help, there is not much I can do at the moment to strengthen and stretch the surrounding muscles without experiencing some discomfort in the knee, so I wonder if I'm doing more harm than good.

One question I have: how does strengthening the quads reduce pressure on the patellar tendon where it attaches to the tibia? Will there not be as much strain on it as before? I'm thinking a chain is only as strong as its weakest link.

I googled 'stress shielding' - I can't say I fully understand everything due to the medical terminology used, but is the idea that partial (but not complete) unloading of the tendon allows it to recover and accumulate tissue, and then reloading it?

[emad]

Well , The tendinitis or the problem of Osgood which you have can be caused by :
* Fall at the exact insertion
* Overuse ..which means strengthening you are doing may worsen your problem .

You need complete rest , however if there is limping then you tend to use muscles and some muscles are not used which means over long term weakness

cheers
Emad

[KneeKnack]

* Fall at the exact insertion

By this do you mean some sort of impact on the knee that caused the initial problem? I don't recall this happening, and in any case I have had this condition over the course of a few years,so I would expect it to have healed, although at first it was relatively mild - i.e. I would only feel it after exercise (a short while after and continuing for a few days) but now I feel it all the time. It certainly hurts if I bang it or put pressure on it now.

I have tried rest, and while that alleviates symptoms after a few weeks, as soon as I try to run it will return. I am resting it completely just now (apart from walking) and then going to try more intensive stretching and strengthening to see if that helps. I won't be doing anything that causes me discomfort in the area... if that's possible.

[alophysio]

Hi kneeknack,

perhaps what you have is insertional tendinosis of the patella tendon.

Stress shielding theory as i understand in my own simple brain is that a tendon is strong when sujected to normal stresses. the "stress shielding" part occurs when altered biomechanics occur which allows part of the tendon to become unloaded or 'shielded'. This part of the tendon then becomes weaker because it is not under the normal stresses like before and so more susceptible to injury. A chronic tenodinosis develops as the tendon goes down a degenerative spiral.

Your question about quads strengthening is EXCELLENT. I have often wondered the same (when other physios suggest it). Overuse would require a CHANGE in motor pattern and biomechanics.

I would be looking at eccentric loading of the patella tendon as a possible solution to your problem...

Good luck!

[msk101]

Hi again,
As i mentioned before an insertional tendinitis or traction apophysitis fits your description of symptoms, and i agree with Alophysio that eccentric quads strengthening would be a good option. Eccentric loading has been proven to be highly beneficial for achilles tendon strengthening and in chronic tendinopathies is highly functional and encourages tendon remodelling in stronger fibre arrangements.

These exercises are allowed to be a little bit uncomfortable at the time but not outright painful. you shouldn't be sore for more than an hour after - or you did too much.

Doing nothing at all will eventually lead to weakness and then reaggravation of the problem when you start doing things again.

You could also try a patellar tendon strap (available at most bigger pharmacies - simple padded strap which velcro's around the knee, should sit on the patella tendon between the kneecap and the bump on your tibia firmly but not constrictively) which can assist in unloading the tendon to allow some release while the inflammation settles and it will let you do some rehab.

Because you've had this problem in one form or another for so long, it's not going to be a quick fix. Often in achilles cases it can take 6-9 months of consistent training (eccentric first, then concentric and always with stretching) to heal a chronic inflammation of the tendon. Don't expect instant results but do persevere.

msk101

[alophysio]

hi msk101 - thanks for the above. I just wanted to raise a technical point.

chronic tendon injuries do not have any inflammatory markers (?Histamine) but rather neural sensitising markers (?Prostaglandin E2). I believe it has been shown in Achilles tendon midsubstance problems as well as ECRB lateral epicondylalgia.

So "tendinitis" is actually thought to be tendinosis and the reason why there is pain is thought to be because there is increased vascular ingrowth into the injured tendon and thus associated small nerve fibres - which is thought to contribute to the pain.

The eccentric loading is thought to be LOTS of heavy loaded stretching which might break the vessels and nerves in the injured tendon and return it to its normal collagen mess with less vascularity.

Alfredson's work as well as ?Kahn and other researchers support this theory.

Sorry to get heavy...i hope i made sense...

[KneeKnack]

Thanks for your interesting posts.

Not being a medical person, I had to look up 'eccentric' exercises, and as I suspected it does not mean I should embellish my exercises with extravagant flourishes and wear an outrageous outfit...

It means strengthening exercises that involve extending the muscle e.g. by lowering a heavy weight - am I right?

And you say that these exercises will rerrange the fibres in the tendon to make it stronger etc - is that about right in layman's terms? I take it that whilst my tendon is sore, it doesn't necessarily mean it is thinner and more prone to snap? Obviously, that wouldn't be good.

I have bought a patellar tendon strap and will use it. I used it last time although I had to go off the field with my bad knee, but I suspect that was because I was doing intense exercise after months of not very much.

It makes sense to me that I should gradually build up intensity and hopefully that will mean my tendon will recover.

Interesting theory about the extra vascular presence in tendinosis, and how the eccentric loading can reduce the vascularity.

[alophysio]

thanks kneeknack - Please please please see someone about how to do the exercises before you do them on your own...ideally you need the diagnosis confirmed!! Get an U/S of the area to see if it really is a tendinosis or not. Some U/S operators (sonographers) can use certain settings to see the bloodlfow in tendons etc...very cool!

Cheers

[KneeKnack]

OK, will do!

Although I have a list of exercises my physio gave me to do so I will do them when it is less sore - I presume the physio knew what he was doing when he prescribed those...

[emad]

Hallo All :

The thread went very fast until I come back to check it .
I am still at the point of heavey programs of strengthening will worse your case , however complete rest is not appropraite too . Just ordinary life of walking and active simple exercises .

There is a point not discussed or included , we neglected the Brain role ( Nervous System ) in controlling the patient´s pain however there is strong current evidence that pain copme from the Brain .

There are special somatic techiques and meditations are used to control pain ,some physiotherapists are practising it , it is really of value I am using it with my patients .

Wishing you the best
Emad

[KneeKnack]

I'm not planning to do any heavy exercises - just gradually build things up. If I'm getting a bad reaction to it then I'll stop.

The pain is not of the excrutiating variety, so I'm not sure if trying to reduce pain alone is going to be of use to me. I assume I am getting pain because there is something amiss there, so I would rather address the cause of the pain rather than try to suppress it.

[emad]

Yes , that is correct gradual input to the nervous system is the appropriate approach , then gradual increase .

I remember I have seen one patient with typical signs and symptoms of Osgood Sc. as described in orthopedic books .

cheers
Emad

[alophysio]

Hi,

In a true tendinosis, the pain is not a symptom of injury but rather a by product of having increased blodd vessels and nerves in the tendon - therefore when you stretch the tendon, it is not under stress to the point of injury but the vessels might be being stretched - but they don't belong there anyway.

Hope it helps

[jacinta]

hi kneeknack,

a friend of mine, 24y.o./male
had similar symptom like yours.
thr was h/o fall, knock onto a stone right on the tibial tuberosity about 11/12 ago.
he c/o pain and discomfort develop insidiously.
hiking was stopped for some time, he continued to swim and slow jog.
strecthes were done to maximum.
pain now resolved, muscle powers are good, and no muscle tightness.
but a rigid lump of a peanut size is pretty noticeable in his left tibial tubersity.

u can try to keep up with more strectching,
e.g: sit on your left heel (right under your gluts) with right leg extended.
as your tolerance increase, change to lying down from above position.
you'll experience a nice strecth along your quads to knee.

all the best trying.

regards,
jacinta