15 year old athelete

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gerry -> 15 year old athelete (June 10, 2005 3:43:00 AM)
My oldest son participates in basketball at school, and lifts weights. He has also run track (longer distances). He complains of knee pain occaisionally, but consistently over the past couple of years. Worse after activity. He has a thin body build, but is fairly muscular. He has grown significantly in height the past couple of years. Pain is general in nature, no point tenderness. The pain does not limit his participation, but he feels it decreases his effectiveness at times. What thoughts do y'all have? Anything particular to look for? What things would you suggest trying? What other info can I give that would be helpful? Thanks!

JLS_PT_OCS -> Re: 15 year old athelete (June 10, 2005 9:13:00 AM)
Well, localizing the pain would be a good start, if you can. Sometimes it's hard with the general aching that many have. If it is anterior, then you should try to distinguish between Patellar area symptoms and any point tenderness at the patellar tendon, esp at inferior pole, which might indicate patellar tendonopathy or maybe SLJ in such a young man. Any effusions? Catching/locking? Tenderness or prominence of the tibial tuberosity? History of injury? Any hip or thigh pain? J

Synergy -> Re: 15 year old athelete (June 10, 2005 9:20:00 AM)
I agree with Jason in trying to localize his symptoms. Also, if he's ever had any fall or other trauma to his knee, he may have an osteochondroma (would need verification via x-rays). These can create mechanical irritation and cause a great deal of pain at times. Just another thought. :)

gerry -> Re: 15 year old athelete (June 10, 2005 10:47:00 AM)
Thanks Jason and Chris. I'll attempt to localize again this weekend. In the past, occaisionally there will be tenderness over the patella tendon insertion area, but more typically he will just say it hurts "inside" his knee. Rest, ice and an anti-inflamatory usually help, but sometimes it will carry-over several days. My wife was a successful cross-country runner in high school and college, and her big thing is to make sure he has good shoes. As fast as he is growing, we will look at those this week-end also. To answer Jason's questions, no effusion, no catching/locking, no hip or thigh pain. He has taken some decent bumps to his knees, but they do not seem to relate to the running history of pain.

Randy Dixon -> Re: 15 year old athelete (June 10, 2005 12:20:00 PM)
Since we just talked about what do you guys think about Osgood Schlatter's? About shoes, I highly recommend the Nike Free 5.0 or other minimalist shoe, along with some barefoot running on safe surfaces occasionally. This not only strengthens intrinsic muscles but teaches an injury preventing stride which is important for young runners who usually overstride.

Sebastian Asselbergs -> Re: 15 year old athelete (June 13, 2005 2:19:00 AM)
gerry, since the pain is generally "inside" the knee, it may point at patellofemoral dysfunction. This can originate in the lumbo-pelvic area, knee itself (muscular or congenital), foot mechanics, shoes etc etc. Osgood has significant point tenderness over the insertion of the patellar tendon at the tibial tuberosity and usually hurts when kneeling - a bonescan would confirm/deny this. I can not recommend any shoe - since I have NO idea what his feet look like (A, B, EEE?), what his gait is like, and what his running patterns are like. He may do well with a New Balance shoe if he has a narrow heel and wide forefoot (they come in a great variety of widths). First I would try to pinpoint the problem with an assessment....

JLS_PT_OCS -> Re: 15 year old athelete (June 13, 2005 5:03:00 AM)
A good running shoe assessment is important. If he has tenderness at his patellar tendon, you should try an eccentric strength program. If it's patellar, as in Patellofemoral, then take a look at his hip, look for weakness in his gluteus medius, and.... Oh, hell. Just take him to a good orthopedic or sports PT. The APTA's 'Find a PT' database is pretty good. I'm sure once the therapist found out you're also a PT, they could do much better explaining after an exam/treatment plan. I just can't do it justice over the internet. I think if ortho/sports isn't your practice area, don't be afraid to reach out to a colleague in person ....god knows I've had to do that on lots of things before also. I certainly would be of no use to you in your practice area, Gerry. I would bet you know a lot more about what I do than I know about what you do... :) Keep us posted. J

aquatherapysc -> Re: 15 year old athelete (June 21, 2005 7:21:00 AM)
Gerry, Watch your son closely when he runs, he may be overpronating and placing undue stress on his knees and ankles. Many times running technique can be to blame for ailments of this nature. Also, he should avoid running on paved surfaces to limit the shock his knees are absorbing. This also may be growth attributed. As far as heis technique is concerned is he pushing off with his feet or are the rolling slightly? If his feet have a tendency to roll slightly, this could be an indicator of where the pain originates.

gerry -> Re: 15 year old athelete (June 28, 2005 1:01:00 PM)
Thanks for all the ideas and input. I know it's been several weeks, but I'm finally getting back to this... Got some new shoes this past week, so we'll see how that helps. Jason, I will consider a good sports PT consult. Since the pain has not limited his activity, I'm trying to look at it myself, and try things to keep it from getting worse, but I'm certainly not above getting help from those with more experience than me! I wanted to supply more info for you guys, though, to see if anything rings a bell. We were able to narrow down the painful area to aneriorly, just below the patella tendon insertion. It could be the very distal end of the tibial tubercle, but it seems just distal to that. Palpating along the anterior ridge of the tibia along the insertion of the anterior tib is not particularly painful to him, and he says it hurts more medially along the surface of the bone. He is gone for a few days to a B-ball camp, so we'll get a good chance to see if the shoes helped any. My wife watches him run, and has good eyes for that sort of thing. She hasn't noted any particular problems, and I think she would say so if she had... Jason, although the tenderness is not right at the patellar tendon, I was wondering about trying some eccentric strengthening with him to see if it helped. Any particular suggestions? We have access to machines and free weights. Thanks again!

USAPT -> Re: 15 year old athelete (June 29, 2005 3:37:00 AM)
gerry, if he's an athelete right, I would attempt functional eccentrics instead of getting on a machine(i.e, dynamic lunging in sagital, frontal, and diagonal planes. I am a huge fan of the 3-D dumbbell matrix exercises from Gary Gray et al. [URL=http://www.wynnmarketing.com]www.wynnmarketing.com[/URL] http://www.functionaldesign.com I have my 9 yo nephew performing these for balance/proprioceptive training. I also do them, there fun and FUNCTIONAL..machines are not. I agree with the others, check his feet. An excessively pronated rearfoot will cause his tibia to internally rotate(it does normally at heel strike but it may be excessive)..thus creating irritation at PF jt thru kinetic chain reaction. Also, if he always runs with traffic or against, tell him to switch direction upon returning home. The roads slant and can predispose a runner to biomechanical impairments. I hope this helps

JLS_PT_OCS -> Re: 15 year old athelete (June 29, 2005 7:59:00 AM)
Pain at/near tibial tubercle...sounds like O-S syndrome to me. I agree with JKral's suggestion of eccentrics. If your son lacks the coordination to do the matrix, start some slow descent (10 seconds) wallsquats as well. Good luck. J

UTDC -> Re: 15 year old athelete (June 29, 2005 8:47:00 AM)
Hi, I hope you guys don't mind me butting into your conversation. I think some excellent points have been raised. One key issue I did not see it whether the complaint is unilateral or bilateral. If this patient has bony pain over the proximal tibia, distal to the tubercle, stress fracture should be on the list of differentials. If the pain is bilateral, this would be less likely. Tibial stress fractures can be a big deal when they involve the anterior tibial cortex as they are prone to non-union and can lead to long term disability. Plain film xray in combination with MRI or bone scan would be helpful. Personally, I would opt for a MRI for a number of reasons. Thanks, Jeff PS- oh yeah, almost forgot- is the patient's physical exam consistent with OSD?

UTDC -> Re: 15 year old athelete (June 29, 2005 8:51:00 AM)
Jason, Assuming that the athlete did in fact have O-S disease and not tendonopathy, what would be the rationale for eccentric exercises. If the physis was the pain generator, would eccentrics not promote further pain? Thanks, Jeff

JLS_PT_OCS -> Re: 15 year old athelete (June 29, 2005 10:30:00 AM)
Hi Jeff. Good suggestion on stress fracture, I agree. I don't know, about the O-S syndrome. I have seen relative rest work the best. Now how much rest is the salient issue. The interesting thing about eccentric emphasis exercise is that they are harder on the musculotendinous unit supposedly. That means we can get a good neuromuscular work with less weight/load than we could tolerate for a regular concentric-pause-eccentric contraction. I use them (eccentric emphasis strength exercises) for areas that could use the work, but have pain or difficulty with greater loads. Hence they end up working out with lower loads, and therefore less joint pain (but good neuromuscular stimulus). I think if no activity modification was done, and we just started eccentrics, I would agree with your contention that it would promote further pain. Used in the context of relative rest, it can be very helpful in maintaining what strength exists and slowing the deconditioning process. Hope that helps. J

gerry -> Re: 15 year old athelete (June 30, 2005 5:53:00 AM)
Thanks again folks! I'm learning a lot from the discussion, and really appreciate the time. He is not tender over the patella tendon insertion, or over the tibia tubercle, really. He describes the pain slightly distal to that. I still think it could be the very distal potion of the tubercle, and may still run in for an X-ray. I'd like to rule out the stress fracture, also. I should know, but right now can't remember if it is bilateral or not. I'll ask him later. He participated in a basketball camp the last few days, and took ibuprofen regularly. He said his legs didn't hurt much, but he didn't get as much playing time as he wanted, either. He also wore his new shoes. Most of his running these days is on the basketball court. I'll try to get him in to the office and watch him run on the treadmill to look at his rearfoot. I also like the idea of those matrix exercises. He has dumbells at home he uses frequently. The course and other info on that website looked interesting. Anyone been to that particular course? Fairly expensive, but I would consider it if highly recommended.

JLS_PT_OCS -> Re: 15 year old athelete (June 30, 2005 6:10:00 AM)
With no pain on the tubercle, and some possible medial tibial plateau area, I am leaning more toward Jeff's line of thinking with stress fracture. Plain films are recommended. J

USAPT -> Re: 15 year old athelete (June 30, 2005 9:17:00 AM)
I agree with Jeff and Jason. Gerry, I have not been to the courses but a guy I used to work with was and that's how I am now onto them. He is a big fan of Gary Gray Good luck

gerry -> Re: 15 year old athelete (July 1, 2005 11:52:00 AM)
Just wanted to let y'all know, he says the pain is bilateral. I know that decreases the chance it's stress fractures, and I'm glad, but will run in for an X-ray. I'll let you know! He's going on a week long hike in the Rockies, so it will be interesting to see how his legs do. It will be a lot of ascending and descending, but maybe not so much jumping as b-ball. I'd still like opinions from anyone else familiar with Gary Gray's stuff...

srcase -> Re: 15 year old athelete (July 1, 2005 2:32:00 PM)
Gerry, I have been to Gary Gray's course and it is definitely unique. I think the videos that come before the course are very worthwhile. The 50-circuit exercise session is fun too. But, it is somewhat difficult to wrap one's mind around the material in the way it is presented during the course, more just a conversation than anything organized/structured. I found it difficult to take notes too. But I still learned a new way of looking at the body. The thing that stands out to me in your son's case, is that according to Gary Gray, knee pain is rarely the knee's fault. The knee is usually the victim of poor mechanics at either the foot or the hip. However, in my experience, when the pain is bilateral and vague in nature, suspicions arise about lumbar involvement. Your son is at that age when he is growing faster than his soft tissues can keep up, and he is definitely at risk for growth plate injuries. At this point, given his activity level, and without any objective testing bseides gait analysis and palpation, it would be impossible to form a theory about what is causing his pain. I highly recommend that you take him to an orthopedic physician and follow-up a PT. Sarah

gerry -> Re: 15 year old athelete (October 25, 2005 10:46:00 AM)
Greetings all, Thought I would update anyone who was interested in this thread. My son's legs calmed down to where we did not see anyone about them over the summer. He turned 16 at the beginning of September. He plays pick-up ball occaisionally, but without much problem. Practice just started last week at school, and he came home saying he was not going to be able to play if his knees kept hurting like they were that day! The tenderness seemed to be in the same place as before, just distal to the tibial tubercle. This morning, I took him to a local orthopedist who has a good reputation for treating high school atheletes. X-rays were done. His growth plates are still open (so he will be taller than me...). On the lateral view, you could really see the "pulling away" of the tibial tubercle. After palpating the area, the orthopod gave him the diagnosis of Osgood Schlatters. Randy was the first to suggest that. The thing that was throwing me off at the beginning was that his complaint was more general. But later, after localizing the discomfort, it seemed more distal that where I thought it would be with OS. The orthopod commented on his dictation that the films were not typical (or something to that effect). I asked him after he finished dictating if the area was not typical for OS, but then he said it was what they would usually see. So maybe I misheard his dictating. It looked a little odd to me. Anyway, the orthopod did not recommend any limitations, or any treatment. He said when the growth plates close, his pain would go away. Anti-inflamatories and ice after playing as needed until then. Anybody want to add anything on what they have found that helps OS symptoms? Looking back, Jason mentioned relative rest (which is what I have always heard recommended), and maybe eccentric work. Thanks!

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