Adolescent Sports Injury Physio | Osgood-Schlatter & Sever's

Rehabilitation of Adolescent Injuries

Teenagers can be hard work, or at least that’s what a lot of parents tell me. I don’t have kids yet, so I wouldn’t be too sure. But I treat a lot of teenagers and growing kids, and they seem to get a fair few knocks and niggles. Not unknown to teenagers is two very common presentations in the 10-15-year-old age group, both Severs disease and Osgood-Schlatter disease. These both occur in boys and girls around this age group, with girls often getting these presentations first as their bodies and growth plates mature and close slightly earlier than boys. Both presentations occur as the growth plate at the heel (Severs disease) or at the tibia (Osgood-Schlatter disease) closes. We’ll dive into both in a little more depth below. But just remember that the process itself is somewhat self-limiting. As a physiotherapist, I can’t speed up the closure of the growth plate, but that doesn’t mean that we can’t treat and improve function and quality of life. There are multiple avenues to consider before we just throw our arms up and just say “it is what it is”.

Teenagers often love their sport, and with that often comes multiple different sports, school sports and community sports, and weekends travelling all over town for different sporting events. It’s awesome, I love teenagers being active and getting out there and being active. But sometimes it can be a little too much. On occasions we have to sit back and think “what can we take out for a few weeks” just to simply allow the body to settle and recover for a bit. This doesn’t mean we take everything away, but reducing their load by 15-25% can make a significant difference.

Junior footballers competing for the ball

Common Adolescent Injuries

Osgood-Schlatter Disease

Osgood-Schlatter disease is an irritation of the growth plate at the top of the tibia and often occurs between 10-13 years old in girls and 12-14 years old in boys. The way I often think about it is that the growth plate is closing and, by effect, their bones are growing faster than the muscles and tendons can keep up, so it creates a pulling effect on the growth plate. Some clients who suffer from Osgood-Schlatter disease may notice a visible bump turning up where they have their pain. Keep in mind that this bump isn’t anything sinister or bad. It is simply a consequence of the condition and it won’t go away with time.

Osgood Schlatter disease is common in athletes taking part in sports that require high amounts of running and jumping. Basketball is essentially the ideal sport to develop it. While it isn’t just these sports, the development of Osgood-Schlatter disease requires an increased level of activity to develop symptoms, it would be unusual to see a client who partakes in no sport develop Osgood-Schlatter disease.

In clients with Osgood-Schlatter disease, pain is often located distinctly to the top of the shin directly below the kneecap and is often sore to touch. Isolated cases of Osgood-Schlatter disease won’t present with pain in any other location around the knee such as pain around or behind the kneecap, but in longer-term cases that may be possible to see as a secondary site of pain.

Sever's Disease

Severs disease is exactly the same process where there is a growth plate closure, except this time it is occurring at the heel where the Achilles tendon inserts. Severs disease often affects teenagers a little later than Osgood-Schlatter disease does, with it often occurring at around 13 years old for girls and at 14 years old for boys. The process that occurs is that as the growth plate in the heel is closing and the bones are growing at a certain rate, the muscles and tendons struggle to keep up which creates a pulling force upon the growth plate and irritates the area.

As with Osgood-Schlatter disease, the process of the growth plate closure itself is self-limiting. No medical professional can speed up the closure of the growth plate. But that doesn’t mean that we can’t treat the pain and improve both function and quality of life to maintain activity levels. Similarly to Osgood-Schlatter disease, Severs disease often affects children taking part in sports with high levels of running and jumping. Basketball is another prime example. In fact, I suffered from Severs disease from basketball when I was younger. Soccer and athletics are two other prime examples of sports that are commonly associated with Severs disease.

Clients who have Severs disease often report quite isolated symptoms around the back or base of the heel close to the site of the growth plate. I can see some symptoms extending up the Achilles tendon as a secondary adaptation, but are more often reported as a tightness or stiffness sensation rather than pain.

Adolescent Injuries Subjective Assessment

Subjective assessments are integral to developing an appropriate treatment plan, at least when you aren’t getting grunts, groans, or one-word answers from teenagers! Determining the lead up to symptom onset and the level of activity that is going to be the right amount to stay active is key. Understanding training schedules and the irritability of symptoms allows me to develop a pathway forward for them to continue to be active, whilst at the same time minimising symptoms and promoting recovery and rehabilitation.

What Happened?

As with just about every other presentation to a physiotherapist, the first thing I will want to understand is how the pain started and how it has developed since. Some clients may report that a direct knock to the knee may have irritated something that was sitting in the background, whereas others may report simply the slow gradual onset of pain at the knee or at the heel. The location of the pain is the other important factor, ideally to diagnose either Osgood Schlatter disease or Severs disease, the pain should be relatively isolated to the area of the growth plate.

Sports and Activities

The next discussion point for me revolves around sports and general activity. Painting a picture of both your previous and current sporting activities gives a well-rounded picture of who you are as a person and the loads placed upon the specific tissues. I like to get a good understanding of the sports you have played, how long you played them, at what level did you compete, roughly how many hours per week and approximately how many weeks out of the year. We are also looking for something that may have recently changed in the last few months. For example, you may have been playing soccer for the last 5 years, but then, six months ago, you took up indoor soccer in addition to outdoor soccer. While it is the same sport, the levels of load because of the small-sided, short-paced nature of indoor soccer are much higher.

Any Injury Prevention Programs

Understanding any injury prevention programs you undertake is also valuable information. I know some sporting programs that are run out of school are providing well-rounded injury prevention and strengthening programs for young athletes. This provides a baseline level of strength that is really important through these developing years when their bodies grow quickly.

Any Growth Lately?

Last but not least is the biggest question, and that is growth. These presentations almost always pop up just after a growth spurt or in the middle of one. Having a child go through a significant period of growth around the specific ages that these two presentations pop up is a good indicator that something may happen soon.

Adolescent Injuries Objective Assessment

An objective assessment for both Osgood-Schlatter Disease and Severs Disease requires specific diagnostic criteria to be met to determine a diagnosis. Extra to this, a functional assessment must assess how the client can move and tolerate loading in distinct movements and body positions. Often I will routinely assess single leg squats, jumping and hopping technique, as well as running technique to assess for changes to biomechanics that can be improved to ensure the athlete returns as a more robust athlete than they were prior.

Isometric Muscle Tests

Often, the first point of call is to perform isometric muscle assessments of the affected area. For Osgood-Schlatter disease this would be an isometric quadriceps contraction, and for Severs Disease it would be a calf raise. Distinct pain at the point of tendon insertion is what we are looking for to help make a diagnosis. Importantly, we can’t just take this as gospel, particularly for Severs Disease as Achilles tendon concerns could also be an insertional Achilles tendinopathy, so we need to continue to assess tendon function through other avenues to ensure we aren’t misdiagnosing. With Osgood-Schlatter Disease, it is ruling out other potential causes, most often this would be patellofemoral pain in this age group.

Muscle Length Tests

Second, these clients often don’t like stretch applied to the region. Muscle length tests can be a high-quality secondary test to help make a diagnosis in these cases presentations. For Osgood-Schlatter Disease, I would routinely perform a Modified Thomas Test. This position allows me to assess the muscle length of the quadriceps, hip flexors, adductors, gluteals, and tensor fascia latae. For Severs Disease, I would choose a knee to wall stretch and a straight knee ankle dorsiflexion test to assess for calf flexibility and ankle mobility along with assessing for symptom reproduction.

Palpation

Palpation and a hands-on assessment of the tendon insertion point and growth plate area are often my third diagnostic criteria. Direct tenderness to the tibial tuberosity with the potential of an increased size of the tibial tuberosity is often the most common finding in Osgood-Schlatter Disease. For Severs Disease direct tenderness to the Achilles tendon insertional area, when coupled with other clinical findings, raises my suspicion of a diagnosis of Severs Disease, as most cases of Achilles tendinopathy don’t present with direct localised tenderness to the same region.

Functional Assessment

The functional assessment of teenagers won’t often affect my diagnosis, but it will form the core part of the rehabilitation plan to maximise function and reduce symptoms in the long term. This assessment needs to determine how does the athlete’s body function under load. I will assess a range of functional activities ranging from stairs, squats, single leg squats, jumping, hopping, and change of direction drills. I will highly individualise it to each client as often sporting goals change and movement patterns are different both between individuals and between different sports. Once we have determined a functional baseline, along with spotting any potential areas of weakness, altered motor control or poor balance or proprioception, we can develop a plan to develop a more robust athlete moving forwards.

Steps to Success for Rehabbing an Adolescent

Training Load Management

The first step in managing either Osgood-Schlatter Disease or Severs Disease is to manage your load. Therefore, it is imperative we have fully fleshed out what your current load and sporting activity look like on a week-to-week basis so that we can determine our highest to the lowest priorities to determine what may need to be cut out or lessened. The functional assessment also feeds into this, if you want to compete in sport three times a week along with training and you don’t have the strength and power base to sustain that along with a strengthening program, we may need to cut away some sport with a longer-term goal in mind.

Exercise Programs

An exercise program is the second most important factor, without that in place we can’t develop the strength, power, and control to reduce the irritation on the growth plate and symptoms will either continue to persist, get worse or just become recurrent if you rest and then come back. An exercise program needs to be individualised to you to address any potential weaknesses or to improve your specific motor pattern deficits.

Hands on Treatment

Hands-on treatment comes in as the third most important. It most definitely still has its place in managing these symptoms, but falls behind load management and exercise. Managing tissue tone through hands-on techniques and improving joint mobility with the use of joint mobilisations should still form a portion of the allocated treatment time. As long as we don’t get caught up in hands-on treatment fixing the issue at hand.

Your Questions About Adolescent Injuries

Are growing pains real?

Yes. Growing pains are common in children, usually between about 3 and 12 years of age. They typically cause an aching pain in both legs, often the thighs, calves or behind the knees, in the evening or at night, and the child is fine the next morning. They do not cause a limp or swelling. Despite the name, they are not directly caused by growth. See your GP if pain is only in one leg, causes a limp, comes with swelling, redness or fever, or is present in the morning, as these are not typical growing pains.

What is Sever's disease?

Sever's disease is a common cause of heel pain in active children, usually between 8 and 14 years old. It happens when the Achilles tendon pulls on the growth plate at the back of the heel, which becomes irritated, often during growth spurts and with lots of running and jumping. Pain is felt at the back or bottom of the heel and is often worse during and after sport. It settles once the growth plate matures, and in the meantime, managing load, calf strengthening and good footwear help most kids keep playing.

How much sport is too much for my child?

There is no exact number, but a common guide is that young athletes should not do more hours of organised sport per week than their age in years. Other helpful guides include at least one or two rest days each week, a few months of the year away from their main sport, and being careful when training loads increase quickly, such as during representative seasons. Playing multiple sports is generally better than specialising early. Ongoing pain, tiredness or a drop in enjoyment are signs the load may be too high.

Is strength training safe for teenagers?

Yes. Supervised strength training with good technique is safe for children and teenagers and is supported by leading sports medicine organisations. It does not stunt growth. It can improve strength, coordination and performance, and helps reduce the risk of sports injuries. The focus should be on learning good technique with bodyweight exercises first, then gradually adding load. I often include strength work in adolescent rehab programs to help young athletes return to sport more robust.

Managing Continuing to Play Sport

It is a common misconception that because you have Osgood-Schlatter Disease, or because you have Severs Disease, you must stop playing sports and allow it to get better because it is a self-limiting condition. This couldn’t be further from the truth. In fact, I recommend my clients continue to engage in physical activity, whether that be individual activities or in a team sport, just that we may need to back off a bit.

Often what we might need to do is back off from training a little during the week and take away some specific parts of training, such as reducing sprint distances, or taking away some time from gameplay scenarios. What this can allow us to do is manage the symptoms throughout the week to allow the strengthening program to take place, and then we can take on a little more over the weekend but still manage game time.

Managing game time can happen in a couple of different ways and often it comes down to how substitutions can take place in your sport. For example, a netball player often won’t be able to be substituted until the end of a quarter, whereas in soccer, we can often substitute them at any point during the game. Understanding the game, and how we can manipulate the situation to allow you to maintain playing time and avoid losing fitness and strength, is the key to allowing an athlete to continue playing sport.

Adjunct Treatments

These can be a bit of a lifesaver for some clients, and it can really allow them to maintain function and improve their load tolerance. Taping techniques and orthotics are often the best options for adjunct treatments for this subgroup of clients.

Orthotics can work really well for both Osgood-Schlatter Disease and Severs Disease clients as it allows the foot to have a more stable base to load from. Pronation, or the movement of the foot flattening, got a bit of a bad rap for a few years, but the tide has turned on it. It is a movement that must happen as it is a way for the foot to absorb load. However, if it happens too much, too early, or too fast, that’s where it can become problematic. Orthotics are a passive support system designed to correct foot position, with improving control of pronation one of the most common reasons I utilise them. This can allow stress to be reduced from the heel and the knee, as the foot can tolerate greater amounts of load. As a trial, I will often do what is called low dye taping prior to recommending clients opt for orthotics. Low dye taping attempts to mimic the effect of an orthotic. If clients respond well to the taping, I often find they will respond well to an orthotic.

When looking at other taping techniques, these best suit Osgood-Schlatter Disease, other than the low dye taping, there are not too many others I have found overly successful with Severs Disease. With Osgood-Schlatter disease there can be variations such as tibial rotation taping, or taping directly across the tibial tuberosity (the site of the growth plate) being the two I find the most success with.

It’s important to remember with adjunct treatments aren’t long-term treatments. They are designed as a stop-gap to allow you to maximise your function. I would recommend that any client with either of these two presentations utilise these as part of a bigger clinical management plan rather than solely rely on them to get through day-to-day life without long-term strategies in place.

Client balancing on one leg with tape supporting their foot and ankle

Adolescent Injury FAQs

It usually settles once the growth plate at the top of the shin closes, which can take 12 to 24 months from when symptoms start. Flare-ups often come and go with growth spurts and busy sport seasons. With the right load management and exercises, most young athletes keep playing with far fewer symptoms along the way.

Usually not. It is a common misconception that children with Osgood-Schlatter or Sever's disease must stop sport until it settles. We manage their training load, adjust how much they do across the week and build strength, so most can keep playing.

Yes. A parent or guardian needs to be present for clients under 18, particularly for the first appointment. It lets us talk through the diagnosis, the plan and how to manage sport and training together, and you can tell me about recent growth and training directly.

Each consultation is 45 minutes and costs $110, for both your first appointment and follow-ups. Dry needling, taping and exercise bands are included at no extra cost. If you need a longer course of rehab, my 3, 6 and 12 week rehabilitation programs work out cheaper than paying per session.

Yes. You can claim a rebate from your health fund for every session. PRP Physio is not a preferred provider for any fund, so your rebate may be slightly smaller than at a preferred provider. Your fund can confirm the exact amount using item code 500 for your first consultation and 505 for follow-ups.

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Adolescent & Junior Sports Physio