Adolescent Physiotherapy

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 do 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 of these presentations occur as the growth plate at the heel (Severs disease) or at the tibia (Osgood-Schlatter disease) begins to close. We’ll dive into both of these 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 the 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 necessarily mean we take everything away, but reducing their load by 15-25% can make a huge difference.

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 basically the ideal sport to develop it. While it isn’t just these sports, the development of Osgood-Schlatter disease does require an increased level of activity to develop symptoms, it would be a bit unusual to see a client who partakes in no sport develop Osgood-Schlatter disease.

In clients with Osgood-Schlatter disease, pain is often located quite 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.

Severs 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 impacts 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 participating 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. Some symptoms extending up the Achilles tendon can be seen as a secondary adaptation but are more often reported as a tightness or stiffness sensation rather than pain.

What we will discuss

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.

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 really 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 6 months ago you decided to take up indoor soccer in addition to outdoor soccer. While it is the same sport, the levels of load due to the small-sided short-paced nature of indoor soccer are much higher.

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 quite quickly.

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.

What we will assess

Assessing functional capacity is goal number one of an objective assessment in these cases. We should largely be able to come to a diagnosis during our subjective assessment once we factor in pain location, growth, and activity levels. Now we simply have to be able to determine what is a suitable amount of load and sport that the athlete is able to partake in safely. In most cases there is no question of further damage or injury, that’s really only a question in very very specific cases.

A functional assessment for Osgood-Schlatters will often include:

Squat
Single leg squat
Single-leg calf raise
Squat jump
Hop
Forwards hopping
Running
Sprinting
Change of direction
Deceleration
Deceleration into maximal height jump

A functional assessment of severs disease would often include:

Single-leg calf raise
Jump on spot
Run on spot
Hop on spot
Hopping forwards
Multi-directional hopping
Forwards and backwards hopping
Side-to-side hopping
Running
Sprinting
Change of direction

These aren’t designed as exhaustive lists and often we won’t get through everything on an initial assessment due to pain and irritability of symptoms. It is designed as an activity spectrum so that I am best able to determine where you are comfortable being in levels of activity and sport.

A lot of these movements will be both an assessment for pain production but also an assessment of your movement quality. It’s quite common at this age group for a few movement changes to pop up that could potentially increase your risk profile for sustaining either an acute injury such as an ACL rupture or a gradual onset injury such as patellofemoral pain. Often the changes for the lower limb are most noticeable at the hip, knee, and foot where there can be adaptations and cheats made to make up for a lack of strength, power, or control.

How we treat it

The first step in managing either Osgood-Schlatters disease or Severs disease is to manage your load. This is why 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 lowest priorities to determine what may need to be cut out or lessened. The functional assessment also feeds into this, if you are wanting to compete in sport three times a week along with training and you don’t have the strength and power base to be able to sustain that along with a strengthening program, we may need to cut away some sport with a longer-term goal in mind.

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 be able to address any potential weaknesses or to improve your specific motor pattern deficits.

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. Just as long as we don’t get caught up in hands-on treatment fixing the issue at hand.

Managing continuing to play sport

It is a common misconception that because you have Osgood-Schlatter disease, or because you have Severs disease you have to 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 bit 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 are able to 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 they can often be substituted at any point during the game. Understanding the game, and how we are able to 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 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 wrap for a fair few years but the tide has started to turn on it. It is a movement that has to 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 in essence a passive support system designed to correct foot position, with improving control of pronation one of the most common reasons they are utilised. This can allow stress to be reduced from the heel and the knee as the foot is able to 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 I find that 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 tapings, and 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 be able 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 simply get through day-to-day life without long-term strategies in place.

Treatment Options

Severs disease and Osgood-Schlatter disease are a little different to most other presentations such as low back pain, muscle strain or something along those lines. It takes a more concerted longer-term approach rather than a short treatment style block. If you were to opt for a treatment block I would probably be opting for either of the 6 or 12-week block dependent upon how long symptoms have been present with longer-term symptoms more recommended for the 12-week block option.

For most cases, though I would simply recommend an individualised treatment plan that we will discuss and plan based on your goals and aims for rehabilitation, particularly if you have a certain date or event you are aiming for.