Does Your Growing Child Have Knee Pain?

Recently, we have seen some young athletes in our clinics, complaining about pain after playing sport. I've written about growing pain in young children/ athletes before. When these children/ athletes are having a growth spurt during adolescence, the long bones grow faster than muscles. The muscles take a while to lengthen so the muscles tend to pull on the attachments on the bone.

This is especially so when a child is active, the muscles will pull on the bony attachments where the muscles attach causing pain (also known as apophysitis).

An area of pain at the knee which is common in children is known as Osgood Schlatters disease (OSD). The pain is located where the patella tendon finishes at the tibia, known as the tibial tuberosity.

Researchers from Denmark studied 51 youth athletes (51 percent female) between the ages to 10 to 14 with OSD. The youths already had pain for an average of 21 months.  Intervention consisted of four visits with a physiotherapist with both child and parent. The first block of treatment focused on decreasing load through decreased activity, education and static hold exercises.

The next block the subjects progressed to exercises which led to a return to their sport. Follow up was done at 4,8,12, 26 and 52 weeks. 

All subjects showed improvement at 12 weeks (study endpoint) with less kids complaining of pain and increased function and quality of life. 31 percent of subjects still suffered from discomfort at 12 weeks, discomfort that they would be not happy to live with, while 80 percent were very satisfied with their treatment results.

Only 16 percent of the subjects managed to return to their sport (RTS) at 12 weeks, compared to 69 percent at 52 weeks follow up. Thigh and hip abduction strength which was the focus of the exercise interventions improved significantly by 12 weeks as did vertical and horizontal single leg jumps.

At one year follow up, only 5 percent of subjects were very unsatisfied with their progress and unable to return to sport.

The study called for significant restrictions (guided by pain/ symptoms response) at the start of sporting activity to decrease load on the tibial tuberosity. Data from the tracking device the subjects wore prior to start of the study to the first block of treatment showed a decrease of 15 minutes per day of moderate to vigorous activity. This may suggest that getting active kids to slow down is difficult. 

Parents may need to explain to the child that activity modification is key to reducing symptoms. Reining in the kids in the short term will help return to sport sooner.

Surprisingly, the tracking devices showed that activity levels decreased by 37 minutes per day by week 12, suggesting that although many reported feeling better and can do more, they were actually less active.

We usually do not encourage stretching the affected muscle as static stretching can place more traction forces on the tendon insertion on the bone. Correct strength training that is pain free often helps to take the load off the tendon attachment. Meaning the weight does not have to be heavy. Elastic bands are very useful too when the young patients cannot handle the weight.

Please come and see us in our clinics if your young and teenage athletes need help.

Reference 

Rathleff MS, Winiarski L, Krommes K et al 92020). Activity Modification And Knee Strengthening For Osgood-Schlatter Disease: A Prospective Cohort Study. Ortho J Sp Med.6(4): 2325967120911106. DOI: 10.1177/2325967120911106

*note that OSD or Osgood Schlatter's disease is not a disease. It is named after Robert Osgood (1873-1956) and Carl Schlatter (1864-1934), an American and Swiss surgeon respectively that described the condition concurrently.

Picture from ESSR

An x-ray of fragmentation of the tibial apophysis n a child with OSD. It is NORMAL in pain free adolescents. 

Help! I Have A Snapping Hip

Yesterday, I saw a 13 year old boy who was brought to our clinic by his parents as he had knee pain as well as a "snapping" hip on the same side. After joining the school's softball team earlier this year, he had trained a fair bit more than in primary school.

He recently developed right knee pain and had a year's history of pain and "snapping" in his right hip. He had previously seen a chiropractor for the last few months. Treatment consisted of  stretching the hip flexors, the Iliotibial band (ITB) and manipulating his hip and spine. He did not get any better after all the treatment with the chiropractor.

I assessed him and confirmed that his knee pain was coming from his tibial tuberosity and indicative of doing too much too soon. That's not too difficult to manage. He definitely had a case of Osgood Schlatter's in his right knee.

There was no pain with clicking in his hip. Nor was locking observed at end of range hip flexion with added internal or external rotation (this rules out hip labral tear). Range of movement in his back, hips, knees and ankles was normal and symmetrical.

There was weakness in his right Gluteus Medius muscle, also his painful knee and snapping hip side, despite that being his dominant side. This greater contralateral pelvic drop was confirmed while watching him run.

The "snapping hip" sound was reproduced over his right greater trochanter when he was in left side lying when I straightened and bent his right hip. It was a fairly loud "clicking" and/or "snapping" sound each time I bent and straightened his hip. There was some local tenderness over his Gluteus Medius, Gluteus Maximus and Tensor Fascia Lata muscles and over the greater trochanter itself.

Snapping hip on outside part of R hip

This explained his "snapping hip" on the outer part of his hip. While my young patient did have pain over his outer hip, I've treated other cases where patients did not complain of pain there with the exact same condition.

Following treatment, my patient was pain free and I taught him and his parents what to do to maintain that.

This "snapping hip"condition is also known as Coxa Saltans, can also happen in adults. My young patient described above has a extra articular or outside the hip joint condition.  It can also be intra articular or inside the hip joint.

It's Psoas Major/ Iliacus if inner part of R hip

If the condition occurs on the inner part of the hip, extra articularly, it is usually due to the Psoas Major or Iliacus muscle. A snapping hip inside the hip is usually confirmed by an MRI. Those who have intra articular hip snapping will usually complain of hip catching, painful clicking or locking. And that will probably have to be another post.


Reference

Winston P, Awan R et al (2007). Clinical Examination And Ultrasound Of Self-Reported Snapping Hip Syndrome In Elite Ballet Dancers. AJSM. 35(1): 118-126. DOI: 10.1177/0363546506293703.

Playing More Sports Beneficial For Young Children - Straits Times Forum Page

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I have written previously that you should not push young athletes to specialize in a single sport too early. It was a very popular article on our blog with many readers asking to share it.

In the article in the forum page today of the Straits Times, scientific studies suggest that children who play multiple sports between six and twelve are much better off. They develop stronger motor control skills, aerobic fitness and confidence.

Children who specialize in a single sport before twelve are more prone to overuse injuries and burnout.

I see many cases like this when the child is trying to get to a school of their choice via the Direct School Admission scheme which allows students to gain direct entry to a secondary school or junior college based on their sporting talents. Children in the Singapore Sports School are particularly prone.

Late specialisation sports includes track and field, badminton, football and basketball. So those of you who have children in these sports please remember not to push them. You can definitely support wholeheartedly them if they are interested.

You read it here first. Have a look the at Straits Time article if you're keen in the Forum section on page B8.

Young Athletes Are Not Small Adults

I've had a few worried parents message or call me on the past two weekends saying that their child has had sharp pain suddenly without any falls or accident. A common area of complaint is in the knee or heel.

After a few short questions and answers I am usually able to reassure the parent that their child is fine and nothing is really serious about the painful episode.

Often these young children/ athletes have growing pain. The long bones grow quite quickly (especially if they are having a growth spurt) and the muscles don't lengthen quite as quickly. When the child is active, this shorter muscle(s) often pull on the bony attachments and cause pain.

Their muscles usually will not have developed enough strength to compensate for the sudden increase in lever lengths.

My older boy who is eight plays football once a week. Other days he's at the playground running, jumping and climbing etc. He's growing taller and  his muscles are not always strong enough to generate the forces required to move his longer and now heavier legs. As a result, he often has this "growing pain" in the night especially after he'e been particularly active.

I just taped my older boy's leg last night

From treating all the young and teenage athletes in our clinics, we observe that it may take up to about nine months for the muscles to develop length and strength after a growth spurt in their bones.
This form the basis of injuries that these young athletes get. If the bones grow longer and the muscles don't quite catch up in length, the muscle will be relatively shorter and hence tighter.

The area most prone to overload is where the muscle attaches via the tendons to the bones. Hence these pain and injuries we see are growth related.  Common areas are where the Achilles tendon inserts in the heel bone (usually known as Severs disease, although it is definitely not a disease), and the patella tendon on the shin bone (Osgood Schlatters disease).

Other areas include the quadriceps tendon into the knee cap (Sindling Larsen disease) and the attachment of the hip flexors onto the pelvis.

It is usually due to overload of the tendon attachment to the bone from doing too much too soon (without rest) that causes these pain or injuries.

Majority of the time, most of these cases get better when the muscles "catch up" with the bone growth by lengthening and getting stronger.

Stretching the muscle may be worse sometimes as static stretching can place more traction forces on the tendon insertion on the bone. We tend to teach our young patients and their parents to use the trigger ball instead.

Correct strength training that is pain free often helps the muscle take load off the tendon attachment. Don't use a load that is too heavy.

Come see us in our clinics if your young or teenage child athlete needs help.