Critical Thinking

Case football. Osgood Schlatter disease (OSD) also known

Case
Study of Osgood Schlatter Disease

 

The Case study has presented a male, 15-year-old
footballer who has Osgood Schlatter disease. The patient has recently gone
through a growth spurt within the last three months which may indicate the
sudden soreness to the tibial tuberosity. Football is a sport with one of the
highest risk factors for overuse injuries, specifically Osgood Schlatter Disease,
as due to the repetitive actions displayed throughout training sessions and
games it has become apparent that the repetitive trauma has put stress on the ever-maturing
growth plate causing discomfort and pain during and after activity, highlighting
the correlation with Osgood Schlatter disease and football.

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Osgood Schlatter disease (OSD) also known
as an apophysitits, which is portrayed by pain at the site of the patellar
tendon to the tibial tubercle. The name was derived from two physicians named
Dr. Robert Osgood and Dr. Carl Schlatter, who highlighted that the “syndrome”
only occurs up to the age of 18, however beyond this point if treatment has
been pursued, all what will remain is an enlarged tibial tubercle (Rahmatpanah,
2013). OSD occurs during preadolescence, typically between the ages of 8 and 15
years, who are involved in sport. The frequency of overuse injuries is rated at
20% in boys and 13% in girls, the difference in percentage is due to the
predominant sex ratio being 2:1, of boys to girls, although this is beginning
to change due to the growing involvement of girls in sport compared to the
typical “post 16 drop out”. It has been estimated that a total of 21% of
adolescent athletes may develop Osgood Schlatter Disease compared to 4.5% of
non- athletes of the same age who have a smaller chance of developing the
syndrome. (Anderson and Parr, 2011)

 

 Osgood
Schlatter Disease is due to sports such as football, gymnastics, and
basketball, which may put strain upon the skeletally immature tibial tubercle.

The mechanism of this injury is a result of repetitive contraction of the
quadriceps through the patellar tendon insertion of the tibial tuberosity. This
is known to be the leading cause of knee pain within this age bracket, however
should be distinguished between overuse of the patella- patellar tendon
junction which is known to be Sinding-Larsen- Johansson Syndrome (SLJ), jumpers
knee. Pain for SLJ is associated above the tibial tuberosity and located closer
to the patella itself, therefore can be distinguished through palpation
(Strickland, 2011& Georgieva, 2015). This may be identified through the
subjective note taking in addition to palpating the tibial tubercle, as the
patient has indicated that pain is considered significant whilst kneeling or
when placing firm pressure upon the top of the shin bone. Therefore it is clear
that the patient is considered to have OSD rather than SLJ as pain is only
present when palpated through the tibial tubercle.

 

The disease can be characterised by a
swollen lump which is tender at the site of the tibial tubercle, to identify
the stage of the syndrome has been found using ultrasound scanners which not
only analyse the stage of the disease but how much inflammation is within the
tendon. (Strickland, 2011).  

 

Due to the patient showing signs of a
small protrusion around the tibial tuberosity, which is the result of a
fracture to the tibial tubercle, caused by the patellar tendon pulling upon the
tibial tuberosity. Therefore, when the tibial tuberosity fracture heels it
causes the tubercle to become larger (Rahmatpanah, 2013). Upon palpation of the
tibial tuberosity it has been found that the patient has a small protrusion on
the tibial tuberosity, however it should be noted that the lump is benign however,
in some rare cases it is advised that the patient seeks approval as to if the
lump is malignant (Georgieva, 2015).

 

It should be noted that the patients’
quadriceps tightness should be recorded as Osgood Schlatter may occur due to
increased facilitation of the quadriceps with precipitously increasing femoral
length during the stages of the tibial tuberosity development (Nakase et al,
2014).Treatment  The goals for treatment are to ensure
that the patient has a relief in pain, can demonstrate full joint mobility, and
being able to be involved with previous activities prior to the condition.  For these goals to be achieved the
patient will need to limit physical activity for up to 6-8 weeks with a gradual
return to sport, this will limit the patients pain and allow the injury site to
heal (Gerulis, 2003).  This will help
reduce the physical load but can be aided through taping techniques and braces
to decrease patellar loading, which can be worn during and after activity. The
most effective taping strategy is the McConnell taping as the use of this
taping strategy alone has attributed to improved knee range of motion and
decreased pain during activity, however the effectiveness has not been
researched within the patient population, thus limiting the validity of use
(Mason, 2011). Treatment is predominantly conservative
as it can be treated with the application of POLICE (Protection, Optimal
Loading, Ice Compression and Elevation), physical therapy and medication
(NSAIDS) to relieve pain. However, treatment by a sports therapist can utilise
specific modalities which can improve the efficiency of the healing process
(Nakase et al, 2014). Treatment within the 4- week plan will
begin with cryotherapy and rest. Cryotherapy, the application of cold,
predominantly used to reduce the risk of inflammation during the first two
stages of tissue healing. (Snyder, J. et al, 2011). The cryo- cuff, will be as
cold as 6 degrees to a maximum of 10 degrees which will cause vasoconstriction,
decreasing the amount of histamine in the blood reaching the site of injury to
further decrease inflammation. This in- turn will reduce pain and is advised to
be done at home. After 3 to 5 days’ contrast therapy will be advised to cause a
“muscle pump” moving the inflammation out of the knee, increasing lymphatic
drainage (K?pi?ska, 2013). Although not all inflammation can be
removed through cryotherapy in the early stages of OSD, ultrasound is used.

Specifically, pulsed ultrasound is recommended rather than continuous ultrasound,
at a low intensity of 0.3W/cm2 (1.5Hz frequency and 200?s pulse duration,
to reduce the amount of disturbance to the tissue. Ultrasound uses mechanical
energy, which is like sound waves where vibration occur but at a higher
frequency. Ultrasound uses longitudinal waves consisting of areas of
compression and refraction. The energy passing through the material will cause
oscillation of the particles within the tissue. 
During application to the patient the transducer head should target the
tissue at 90 degrees to minimise energy loss, as 15 degrees has been
highlighted to be a critical angle for loss of energy, thus failing to
penetrate the tissue as required. The best absorption tissues are; tendon,
ligament, fascia and bone.  It is
therefore essential to understand that as protein content increases absorption
rate increases, thus if a fracture has occurred or a protrusion from OSD,
general application of ultrasound would not be appropriate as the vibrations
within the tissue will cause a substantial amount of pain for the patient and
make the fracture worse. LIPUS however, aids the formation of callus at a
cellular level, decreasing the vibrational effects, although should be applied
with caution as there are controversial statements made suggesting the
adolescent patients are unsure if ultrasound has caused pain relief or cryo-
therapeutic modalities. (Watson, 2015). High intensity Laser Therapy (HILT) has
been highlighted to improve chronic pain. The term LASER is an abbreviation for
“Light Amplification by Stimulated Emission of Radiation”.  Laser light behaves the same as light itself,
meaning that it only travels in a straight line at a constant velocity in space
(Alayat et al, 2013). Like ultrasound LASER can be reflected, refracted,
transmitted and absorbed. The purpose of this by increasing electron spin rates
by passing photon energy through a medium to produce a single directional beam
which has a different wavelength than the original light beam. The benefits of
HILT are that it reaches greater depths within a joint compared to low
intensity laser therapy (Suputtitada,
2016). Pulsed high intensity laser therapy works better in more chronic conditions
compared to LILT as this has greater benefit for those of acute injuries
(Baxter, 2008). The dosage for LASER is ambiguous, due to many
journals suggesting energy density to be the most important factor for
suggesting dosage, however others believe power output to be the most
significant factor. However, most authorities suggest that energy density per
treatment session should be within a range of 0.1-12.0j/cm2, although it has
been noted that some treatments can go up to 30J/cm2. Additionally, the maximal
dosage during a single treatment session is 4J/cm2 and should not be exceeded.

This is because beyond 2j/cm2 the LASER transmission is utilising thermal
energy and that one must appreciate that delivery and absorption of energy in
the tissue will result in some levels of heat and temperature change. If
applying LILT, photobiactivation occurs meaning the use of light therapy causes
the stimulation of biological events but there are no significant temperature
changes within the tissue. The biological events include; altered cell
proliferation, activation of phagocytes, increased cellular metabolism,
stimulation of macrophages, stimulation of mast cells degranulation, activation
and proliferation of fibroblasts, altered endogenous opioid production, and
many more (Turner, 2004). Moreover, LASER is suitable for Osgood Schlatter
healing production as it does not cause disturbance within the tissue like
ultrasound. Although, has similar characteristics to ultrasound (Thermal and
non- thermal settings) Laser uses light rather than sound waves which stops
vibrations within the tissue therefore being more suitable for protrusions
within OSD, as the bony point will not vibrate, causing pain, allowing the
energy provided to stimulate the efficiency of the healing process (Baxter,
2008). Alternatively, interx- therapy is a non- invasive
interactive neuro-stimulation. This modality is used for treating pain,
injuries and promoting the natural process. The idea behind interx technology
is ‘Tibetan taping’ however using electrical pulses at specific frequencies
rather than taping with fingers.  It has
been found to have great success with a plethora of injuries acute and chronic
such as sprained ankles, rotator cuff injuries, impingement, tennis elbow,
Osgood Schlatter and many more. Treatment typically lasts between 20-30 minutes
however, even 10 minutes of treatment is sufficient to provide pain relief for
acute trauma. A treatment plan for this modality is close together and varying
from one to a maximum of 6 in a short space of time. This can be spread to
twice a week or once a week for 6 weeks. Interx is applied to the skin at the
site of pain and/or inflammation, it may also be applied to the spinal column
to stimulate the nerves, this is more beneficial for more nerve related
injuries, such as fibromyalgia. Therefore, when treating the patient, the
therapist will apply the interx to the tibial tubercle and hold on this spot
for 20 minutes. The patient should feel the sensation of “pins and needles”
within the site of inflammation. This process will lessen pain immediately
after treatment, however there may be some residual pain. Therefore, the true
benefits of treatment can be expected the following day which have been known
to last a maximum of 2 days. As treatment continues with the Interx, the
patient should begin actively moving their knee from flexion to extension,
aiming to straighten their knee fully, whilst the Interx is on the knee. this
procedure provides pain relief to the patient by inhibiting the neural message
from the muscle to the central nervous system, allowing their leg to straighten
without causing the “stretch- reflex” action to occur.   After care advice is vital for this process as it
allows the therapist to understand the treatment process. The patient will be asked
to monitor changes to their body, as due to the neuro- stimulation reaching the
central nervous system, the patient may feel sleepy after treatment, so is
advised to rest as this will aid recovery, although the patient may begin to
ache after the pain has subsided allowing the therapist to treat the new aching
area as the pain has localised. This is a common and good reaction to treatment
and should be reported to the therapist to improve for the next treatment (Frost,
2017). 

In conclusion, Osgood Schlatter Disease
is a debilitating condition for primarily adolescent males however, this gender
gap is narrowing due to more active girls. Although, OSD is known for resolving
itself once the patient’s growth spurt has complete (this may take up to 2-3
years) (Domingues, 2013), many adolescence will complain of knee pain and may
drop out of sport all together. Highlighting, the importance for their
mentality to receive treatment, to aid the pain and allow the patient to
continue with their chosen sport. The patient presented to the therapist would
highly benefit from the modalities researched, enabling them to continue with
football training and increase the range of motion which has been limited. References Anderson, M. K.,
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