Apophysitis – Adolescent ankle, knee and hip pains explained

One of the most common categories of pain in sporty or active children is what is collectively known as apophysitis. Not a very catchy word, but you may know these better by their regional names: Sever’s Disease at the rear of the heel or ankle, Osgood-Schlatter Disease below the knee, Sinding-Larsen-Johansson Syndrome (SLJ) at the base of the kneecap and the one they forgot to name – Ilium Apophysitis –  at the front of the hip. Add to this Osteitis Pubis in the groin for a slightly older, but still youthful, population.

What is Apophysitis

Apophysitis refers to inflammation – itis – of the apophysis – the junction of the growth plate to the musculo-tendinous unit in growing skeletons. It is caused by repetitive stress on the apophysis from the musculo-tendinous unit, and therefore is more likely to affect very active children. I often like to explain to my patients that where kids will get apophysitis, adults will get tendinitis or tendon injury. This is because the growth plate hasn’t fused in children and the apophysis becomes the weak point for any stress or overload. Once it is fused, the attachment on the bone itself (think plantar fasciitis) or the tendon (think rotator cuff, Achilles or patella tendinopathy) becomes the weak point.

Apophysitis presents at first as a dull pain on or after activity at or around the bony site, with the absence of any obvious one-off cause or injury event. Sever’s will feel like ankle pain to most kids. As the severity progresses, pain will be more severe, the onset of pain will be quicker during activity, and the pain will last for longer after activity & often worse after rest (e.g. the next morning). 

There will be precipitating extrinsic factors – change of training surfaces, conditions or type; change of footwear, especially to lower heeled shoes like thongs or football/soccer boots – and intrinsic factors – growth spurts, tight calves or quadriceps, pronating feet, poor running biomechanics and poor core or other muscle strength.

The reported ages of occurrence for all apophysitis conditions vary slightly, but correspond to the ‘growing skeleton’ definition:

  • Sever’s: 8-14 years old
  • OSD & SLJ: 8-15 years old (females 8-13, males 12-15)
  • Ilium: 11-15 years old
  • Osteitis Pubis: 15-25 years old

What is the Treatment

All of these apophysitis conditions are relatively straightforward for a physiotherapist to diagnose and treat without imaging being required. A thorough history and physical examination will point to causative factors that should be addressed prior to or whilst returning to activity in order to reduce the high risk of recurrence.

The factor of repetitive stress cannot be understated. In the past, rest and occasional ice was the only treatment. The pain will often settle with 2-4 weeks rest and icing, however without addressing the underlying factors the pain will return until the growth plates fuse, often once training is ramped up again and coincides with the next growth spurt. And problems will persist for the patient in the musculo-tendinous or bony region as an adult once the growth plate is fused.

More recent knowledge has physios tackling the contributing factors, which is particularly helpful during the initial rest period, or the early stages if the condition has not progressed to the severity to require rest:

    • Foot posture – excessive rolling in or out during gait, rotated heel or forefoot in standing; treated with footwear advice, taping and orthotics
    • Reduced joint range of movement – particularly ankles, hips and lower back; treated with hands on treatment and home exercises
    • Increased muscle tension – calves for Sever’s, quadriceps, adductors, hamstrings, glutes; treated with massage and stretching, dry needling an option > 14 years old depending on the child
    • Muscle weakness – particularly core and hips for OSD, SLJ and Osteitis Pubis; treated with tailored core, pelvis and lower limb strengthening program, Pilates for the serious adolescent athlete >12 years
    • Education  – perhaps the most important, so that children and parents know the signs and how to manage the condition in the future before it gets bad enough to warrant resting from sport
    • Running Biomechanics – evaluating what is happening with each joint and major muscle groups during gait and running, and tailoring stretching, strengthening and running exercises to the individual

 

Each of our physiotherapists at Dandenong Ranges Physio are to assist with assessment, treatment and advice for Sever’s Disease, Osgood-Schlatter’s, SLJ, Ilium Apophysitis or Osteitis Pubis. To make an appointment please call us on 9751 0400.

Choose physio for shoulder injuries before even considering surgery

Evidence supports at least 3 months of physio for shoulder injuries before considering surgery

Shoulder problems account for a large proportion of our caseload, second only to back pain. And of those, the two big ones we see are rotator cuff problems & shoulder impingement syndrome (SIS), and often both.

Surgical procedures have very limited windows of favourable outcomes compared with conservative management for these two problems, and other medical intervention such as cortisone injections even more limited.

Recent evidence shows that conservative management, or physiotherapy and exercises, should always be considered first for any rotator cuff  injury or SIS for a period of at least 3 months. .

These issues generally respond effectively to physiotherapy, with earlier intervention always bringing a more responsive treatment effect, sometimes even when there appears to be significant damage on ultrasound or MRI.

At the end of this article is a basic anatomy lesson, so please refer to that if you get lost in the text below!

How are these diagnosed?

Specific tests by an experienced physiotherapist or sports medicine practitioner in conjunction with radiology will yield a more accurate diagnosis than radiology alone. Often there is no need for radiology whatsoever.

For radiology, ultrasound can be effective in diagnosing very large rotator cuff tears only. MRI, whilst much more accurate, should be read with caution. One 1995 study (Sher et al) showed that in an asymptomatic, painless group of 97 patients across all age groups, 34% had rotator cuff tears, and 15% were full-thickness. Yet they had no symptoms!

Similar studies show bursitis (inflamed bursae) in up to 60% of men and 80% of women regardless of symptoms. We constantly have patients referred for bursitis when the problem is really SIS. 

Some basic anatomy!

The rotator cuff muscles sit around the scapula (shoulder blade) and send their attachments to the front, side and back of the top of the humerus (your upper arm bone). Injuries occur in the tendon or the musculo-tendinous junction near where they insert into the humerus. Around 90% of injuries are degenerative in nature, and as such, are often part of the normal wear and tear in our bodies. The job of the rotator cuff is to control the head of the humerus when we lift our arm, largely so that it doesn’t jam up into the bone above it.

Shoulder Impingement Syndrome (SIS) occurs when the supraspinatus tendon and overlying bursa (which acts as a cushion and to reduce friction on the tendon) get pinched in the sub-acromial space where they sit between the acromion (pointy edge of your shoulder) and the top of the humerus. When there is an injury to the rotator cuff, or if they aren’t working together well, then the humeral head moves upward into the subacromial space on lifting of the arm causing impingement of the supraspinatus tendon and bursa. Hence why we often get rotator cuff injury and SIS occurring together.

Other factors that influence the onset of both of these problems are:

  • Slouched posture, causing the scapula to sit forward or tilt down, reducing the sub-acromial space
  • Weak or poorly functioning scapula muscles and postural muscles of the back
  • History of occupational or sports using the arm above the head repetitively, or with heavy lifting
  • History of cortisone into the subacromial region increases risk of degenerative rotator cuff tendons
  • Presence of autoimmune disease (Ankylosing spondylitis, Rheumatoid Arthritis) or Diabetes

What is the treatment?

Physiotherapy involves addressing postural and biomechanical causative factors as well as providing symptomatic relief in the early stages with hands-on treatment (massage, dry needling, spinal mobilisation if required). The most important thing is to address the function of the scapula (shoulder blade) muscles and to correct the position of the scapula itself with postural exercises. Strengthening for the upper limb is progressed as pain reduces and graded toward returning to full activity over time.

The patient should also rest from aggravating activities in the early stages of rehabilitation, such as repetitive overhead movements, holding dead weights by the side (eg shopping bags) and slouching whilst working, relaxing or driving. Symptoms should start to improve within two weeks for most people. Full recovery can take between 6 – 26 weeks, and for rotator cuff tears there is often some ongoing rehab required.

Evidence suggests that surgery for SIS, where the pressure is relieved in the sub-acromial space by removing part of the acromion bone or the bursa itself, is no more effective than conservative treatment (Setola et al, 2015, & Saltychev et al, 2013). And cortisone injections are only effective for short term pain relief, and much more effective when combined with conservative physiotherapy management.

Surgical opinion for rotator cuff tears should only be considered for a healthy population under 50 years old that require high level use of the upper body for work or recreation, and only for tears greater than 3cm in length, and always after attempting at least 3 months of conservative management first.  

 

Clinical Pilates update

Clinical Pilates is a safe, effective form of exercise for any age, fitness level or medical condition. Clinical Pilates utilizes a wide variety of exercises designed to improve core stability, flexibility, endurance and posture.

Liam Gellie has recently completed an updated Clinical Pilates course with an interesting new focus. A main focus of this course was breathing control in relation to performing exercises, a concept that is often missed despite its importance in producing highest quality movements. A key emphasis was also placed on training lumbo-pelvic stability through the course. Lumbo-pelvic stability is the ability to maintain good control in the lumbar spine and pelvis throughout movement. Poor lumbo-pelvic stability is a feature commonly seen in patients with lower limb injuries and low back pain.

Jen Vardy is an experienced physiotherapist with the highest possible training in Clinical Pilates, and post-graduate training in Women’s Health. Jen splits her time between Olinda and another clinic in Croydon, and sees a variety of general sprains/sprains, Women’s Health, sports injuries and Clinical Pilates.

Tim Hardiman also runs Clinical Pilates classes at Dandenong Ranges Physio. Tim comes from a background in sports physiotherapy, injury rehabilitation  and pain management.

Please don’t hesitate to contact us here at Dandenong Ranges Physiotherapy to see how Clinical Pilates will be able to benefit you, no matter what your goal.

We have small classes every day including Saturday mornings and after hours during the week, and experienced physiotherapists to guide you in individually tailored programs.

https://www.drphysio.com.au/services/clinical-pilates/

Sports Injury Season is here in Olinda!

Sporting season has well and truly begun with a variety of sports starting to kick into gear. It is at this time of year that we commonly see a number of overuse injuries (eg. Sever’s disease, Achilles tendinopathy) beginning to appear, usually due to sudden increase in training loads. A variety of acute injuries (eg. ankle sprain, muscle strain) are also seen with increased prevalence in the contact sports such as football, soccer and basketball.

The physiotherapy team here at Dandenong Ranges Physio are well equipped to deal with any sporting injury and will have you back to the field ASAP!. Tim Hardiman has worked extensively with the Northern Territory Football League (NTFL) and Northern Territory U/18 competitions. Jerome Higgins has assisted first with Olinda FC and Monbulk FC during previous seasons gone by. Liam Gellie is the current senior club captain of Upper Ferntree Gully FC as well as previously providing match day assistance to the U/19 team.

https://www.drphysio.com.au/conditions-we-treat/sports-physiotherapy/

Evidence based Health Care begins with Education

 

When your health practitioner tells you that you ‘have a subluxed vertebra’, ‘a disc is out’, or that they are helping to ‘flush toxins’ by massaging, alarm bells should start ringing. The problem is the alternative health practitioner field is so littered with junk terms that it’s hard sometimes to separate the wheat from the chaff. Some practitioners who use these terms or concepts do so with the right intention – they may be trying to simplify their communication or explanation of the problem into a form that they think the patient can understand. Others, in my opinion, likely have no idea that these terms are in fact meaningless or have no basis in fact. In many cases clinicians use these terms to alarm people into thinking they need more therapy than they truly might. In either case, I think it is unhelpful to both the practitioner and the patient when these terms are used, and we should all feel the need to call out bulldust when we see or hear it. But how can the lay person know when they are being deceived by a health practitioner, either knowingly or unknowingly?

Let’s go back a step and allow me to qualify my position on this. I am not trying to demonise specific alternative health disciplines. I firmly believe that a manual or health therapist must have some inherent level of intuition, compassion and ‘feel’ to be a good practitioner. These things can’t necessarily be easily taught or learnt, though they can be refined with education, experience and mentoring. But a great health practitioner has those qualities as well as an education based in fact, knowledge and reason. The science world calls this evidence based practice. This allows a health practitioner to assess and diagnose based on fact and experience, to give treatment based on evidence showing that these treatments work for a particular problem, and to know when to refer on when the problem is outside their scope of practice. Knowing the boundaries or limitations of practice is perhaps the greatest challenge to less educated health practitioners, or those for whom their knowledge is not entirely based on evidence.

Now let’s put a few common terms out there and attempt to decipher them:

–       ‘Your hips are out’ – if your hip was really out of its socket somehow, then you would know about it. Start with 10/10 groin pain, nausea and shooting pain down the inside or front of your thigh. This term could mean that a person may have muscle imbalance around the pelvis or lower back, a lumbar spine stiffness issue, a structural scoliosis, or more likely a ‘I have no idea what the cause of your non-specific lower back pain is’.

–       ‘A rib/disc is out/subluxed – see above for symptoms, with pain around the associated spinal level. In Australia, around 1% of lower back pain are diagnosed to a specific cause. Many are likely due to a number of factors or ‘non-specific’ issues. When disc injuries occur, they are often slow burning. Less than 1% occur suddenly and when they do the disc doesn’t pop out, it ruptures. Rib joint injuries can occur suddenly and are painful, but again they don’t pop out of place.

–       ‘Flush toxins’ – do I really need to go into this one? I think you get the point!

So remember when you see you health practitioner – ask questions, seek to understand your problem from a scientific or anatomical point of view and don’t be sold by junk terms.

 

Congratulations and Goodbye to Felix Kang

This week marks Felix Kang’s last with us. He is set for a very exciting opportunity, moving to Beijing in early May to take up a position as a physiotherapist with Team China. Felix’s role will be to help prepare athletes and other sports medicine colleagues for the upcoming Tokyo Olympics in 2020.

Congratulations and well wishes to Felix from all of us at Dandenong Ranges Physio!

Run For The Kids, Team James – a fundraiser for the Royal Children’s Hospital

Last year we were a proud t-shirt sponsor for Team James in the Run For The Kids fun-run. A group of local parents began jogging, some for the first time and many for the first time in years, for the sole purpose of raising money for the Royal Children’s Hospital. This year, Jerome has joined the team, & Team James is doing it again – but they don’t need many new t-shirts! So we thought a better way to sponsor them would be to ask our patients to dig in and help out for this great cause – and we’ll match it dollar for dollar! All proceeds go to the Royal Children’s Hospital.
You can donate directly below, and let us know via email or phone. Or you can give our reception a call and pledge a donation directly to us, and we will call you after the race to honour that pledge.

James’s story, written by his mum, Nikki from Kalorama:

Our son, James was born with a congenital heart defect called Hypo-plastic left heart syndrome. This basically means the left side of his heart wasn’t formed properly in utero and wouldn’t be able to support his circulation once he was born.

In order to survive, James needed several, incredibly risky, open heart surgeries that could only be performed at the Royal Children’s Hospital. If it wasn’t for the hospital and the amazing people who work there, James wouldn’t be here today.

Last year I took up running in order to participate in the Run for the Kids and support this worthwhile cause. It wasn’t easy! But I was soon joined by an amazing group of men and women who also wanted to be part of our journey as well as give back to the hospital that gives us all so much. The Jogging for James Team was born! ????

I think every parent, regardless of need, is reassured knowing we have such a world class facility on our doorstep.

This is our opportunity to keep it there. Let’s support this wonderful hospital – please donate today. ????

Thank you SO much for your help. We truly appreciate it. Xx

Conservative vs Surgical Management of Knees

Stop! Please don’t bother seeing that knee surgeon until you’ve really attempted and followed through with a decent physio rehab first. The research I am going to present to you may be alarming, so have a seat. But for physiotherapists and GP’s it really proves what we have witnessed for years – the huge number of unnecessary orthopaedic procedures that are performed each year in Australia, and how long it takes orthopaedic surgeons to change their practices to align with modern evidence.

As a young graduate in the late 1990’s, we were drilled that knee arthroscopy ‘clean outs’ were a given for meniscal (cartilage) tears & degenerative or wear and tear, and that ligament reconstructive surgery was needed for cruciate ligament injury (ACL & PCL).  

OK let’s look at the hard evidence evidence shall we.

Acute Meniscal or Cartilage tears, less than six months old: Three studies recently (Van de Graaf et al., 2016, Swart et al., 2016, & Petersen et al., 2015) found small results in favour of partial meniscal surgery compared with physiotherapy and exercise for up to six months for physical function and pain. No differences found at 12, 24 & longer term month follow-ups for pain and function (both short and long term). The disclaimer, and really the only reason to have surgery for a torn meniscus, is the presence of a mechanical lock or block in movement that wasn’t there prior to the injury. These locks or blocks are a result of the acute tear and often come and go, or can be manipulated out of place as they are likely floating bits of cartilage or bone.

Degenerative or Osteoarthritic knees: The evidence has been around since 2002 that surgery, including meniscectomy and arthroplasty (where the cartilage that lines the joint surface is ‘cleaned up’) just simply does not work. Yet it’s been happening all of the that time. Why? Probably because the public is blind to the evidence and hasn’t forced the orthopaedic bodies to make their members accountable.

Siemieniuk et al (2017) makes a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease, based on linked systematic reviews; further research is unlikely to alter this recommendation. They found that, among patients with a degenerative medial meniscus tear, knee arthroscopy was no better than exercise therapy. Knee replacement is the only definitive therapy, but it is reserved for patients with severe disease after non-operative management has been unsuccessful. And the outcomes for surgery are always better combined with a pre-operative period of physiotherapy and exercise, or ‘pre-hab’.

Like total knee replacements, in all cases the outcomes for ACL and PCL after two and five years after injury is better for patients who undergo physiotherapy and exercise and have no surgery, or is delayed after a period of decent ‘pre-hab’ ( Filbay et al, 2017). The most surprising aspect of recent studies is how unnecessary cruciate ligament surgery is for most of the population. The only guidelines for having a knee reconstruction for ACL or PCL tears is if you participate in a high level activity that requires sudden stopping and pivoting (like AFL, netball, basketball, volleyball, gymnastics) or if you are experiencing ongoing subjective instability and pain. And, as is the case for meniscal injury, surgery does not have any effect on the possibility of developing arthritis in the future – the damage is done in the actual injury not in the aftermath, though there is some limited evidence that surgery may actually worsen the likelihood of future arthritis.

I will add by admitting that yes, I have a vested interest in this topic. But it really is in your best interest too. And whose interest is it to perform unnecessary and  surgery? Trawling through the research on knees alone makes me wonder how many unnecessary orthopaedic surgeries there are each year. Remember that the number of orthopaedic surgeries performed each year is directly related to …… the number of orthopaedic surgeons.

Home Care Physiotherapy

Dandenong Ranges Physio now offers extensive Home Care Physiotherapy services across Melbourne’s eastern suburbs and into the Yarra Ranges and Dandenong Ranges. Based in Melbourne’s beautiful Dandenong Ranges, D.R.Physio has been providing a high quality home care services for many years in conjunction with Kate Rae, Occupational Therapist. In late 2017, we expanded your capacity to take on more home care clients, seeing a need in the community to offer real solutions for people at home who are suffering from pain, mobility issues, social and physical isolation and associated co-morbidites. We aim to provide just that – real solutions to individual needs, not just mobility assessments and gait aid provisions (though we do that too!).

From pain relieving and mobility enhancing hands-on treatment that we use in-clinic, or balance and strengthening programs, or gait and mobility aids, we cover all musculoskeletal needs. And working in close co-ordination with Kate Rae, OT, means we have close access to quality allied health provision across all home needs.

Please see our brochure below and call us on 9751 0400 or email info@drphysio.com.au to enquire about our home care rates and services.

DRPhysio Home Care Physiotherapy

 

Shoulder Pain health tips

For anyone about to lurch into some house painting, heavy pruning or even some cleaning around the house, look after your shoulders better by following these handy health tips:

  • When gardening or painting, get yourself as high as possible so you do not reach at or above shoulder height, even for short periods this can be detrimental to shoulder soft tissue like tendons
  • Use painting extension poles whenever painting high parts or ceilings, but keep the pole close to your chest to reduce lever arms
  • Switch arms regularly, don’t wait until they fatigue completely
  • Keep your elbows as close to your body as possible to reduce lever arm
  • Pick up objects or weights (garden pots, kitchen pots/pans, bags) with your thumb pointing forward or out – NEVER with your thumb and wrist turned in toward you
  • When lifting, keep the weight as close to your body as possible
  • When pushing or producing outward/downward force (like grinding your new outdoor concrete bench!) keep your elbows close to your body and use your body weight to provide the force, not your shoulders

If all fails, ignore this and call Dandenong Ranges Physio instead. We’re happy to help!