Knee pain/Osgood Schlatter

Last time we reviewed growth plate issues of the heel, so called Sever’s Disease. Please reference back to that article for a review of apophysitis.

Another location for this problem is just below the knee, so called Osgood Schlatter syndrome.  Here, we have the same basic problem: the powerful patella tendon pulls against the tibial (shin bone) growth plate as it undergoes rapid lengthening during puberty;  the tendon moves up the bone as it lengthens, causing inflammation and pain.

The location of the pain is quite specific: the “tibial tubercle”– that bump at the top of your shin just below your kneecap (see heading illustration). The area is typically swollen with at least mild redness and tenderness.  Like Sever’s in the heel, this apophysitis is a problem of early adolescence (10-13 girls, slightly more common in 12-14 boys), and is caused by the repetitive jumping action of some of the same sports– basketball, volleyball, soccer, plus additional ones like skating(figure and speed) as well as dance.

The problem is differentiated from another common knee problem “patellofemoral syndrome” (“chondromalacia”) which is PROBABLY (its controversial) caused by wearing of the lubricating cartilage behind the kneecap (not meniscal cartilage) where the pain is higher up and behind the kneecap, without the bump below the knee and with a somewhat duller pain. Meniscal cartilage tears, ligament and tendon damage almost always follow acute, more severe injury.  Old guys like me can have meniscal injury just from overuse and age; young athletes do not suffer from those problems–only damage from big hits to the joint can injure a kid’s knee.

Usually treatment involves pain management.  Nonsteroidal antiinlammatory drugs (NSAIDs) like ibuprofen and naproxen are the mainstay. A big part of the problem is generated by quadriceps tightness, so stretching and flexibility training is very important. Modify the athlete’s training/practice routine to limit overuse and allow for best competitive performance is key, so a good trainer and understanding/smart coaching is essential. A good knee pad that limits hits to the tender inflamed tibial tubercle provides relief from that problem.

Regarding overtraining, let’s recall as I think its important–max 2 seasons at one sport, a third season of a completely different one, and one season with only not organized general fitness training is my recommendation for limits to training schedule (less is certainly acceptable). Remember, Mom and Dad, we are talking about CHILDREN–they are supposed to have fun and free time.

If your younger teen is troubled by knee pain, give me a call and let’s discuss it.  Thanks for following.

Heel Pain/Sever Disease

Presently children will be starting fall sports training–football for boys, field hockey for girls, soccer and cross country for both.  Foot problems are a common problem for these athletes. About the most frequent foot complaint not caused by trauma that I see is heel pain, and most often the problem is a condition called Sever’s disease (note– I’ve heard the name pronounced to rhyme with “leather” or “weaver,” so take your pick).

The technical term here is “calcaneal (kal-KAY-knee-al) apophysitis (ah-pah-fis-I-tis). The calcaneus is the main bone of the heel; you can feel it at the bottom of the foot.  The apophysis, or growth plate, typically  doesn’t close until 12-14 in girls and 13-15 in boys, so that is the upper range to see this problem with beginning being onset of rapid growth, about 8-9 for girls, 9-11 for boys.

Sever’s disease is caused by the powerful Achilles tendon pulling against the open growth plate of a younger adolescent  when the bone is growing most rapidly. The pain results from the tendon pulling at the growth plate while actually moving along the bone over time as it is growing in order to maintain proper anatomic condition, coupled with the constant pounding at the heel while running.  Pain is sharp and can be elicited by pinching the heel with the fingers at either side.  Bilateral involvement is not uncommon. That is one way to differentiate it from some other problems with similar though subtly different symptoms. Stress fractures are almost always one sided and typically further up the foot.  Plantar fasciitis pain is also further forward at the heel/instep junction and usually gets worse with more running (“second step” pain).  Achilles tendonitis is usually behind the ankle and above the heel and hurts worse with jumping, when the Achilles pulls and the foot flexes down.

Although the discomfort is unsettling,  Sever’s disease is fortunately not serious.  It can certainly disrupt an athlete’s training or performance; however as the child reaches adult stature, the growth plate closes and the disorder will gradually resolve on its own without any longer term disability.  Treatment consists of modified training: less running outside of competition, more non-weight bearing aerobic training like biking, swimming, water running; non-steroidal pain medications like ibuprofen(avoid caffeine with this drug).   Cushioned insoles–either “off the rack” which can be purchased at shoe stores or custom made by your podiatrist (make sure they aren’t TOO thick) can be helpful.  If very disruptive a period of rest from sports and physical therapy will usually work.

Prevention is also key: proper shoes, stretching before playing, conditioning (its more common in overweight athletes).  Too much training is a problem here as well–DON’T OVERDO!!(my advise–max 1 sport for 2 seasons, a different sport for the 3rd and take the 4th season OFF–no formal competitive program).

If your child is experiencing foot pain please give me a call and let’s discuss it.  Send along questions or comments, and thanks for following.

Vaping, and your child

We see and hear more information every day regarding “e-cigarettes” or “electronic nicotine delivery systems”(“ENDS”).  Last year saw the largest one year increase in use among teens.  21% of teens reported using ENDS in the previous 30 days–up from 12% the previous year–representing a total of 1.5 million more teens vaping year over year. This is alarming.

There are many misconceptions and half truths about vaping:

  • Is it safer than cigarettes?  Probably yes, but that is a very low bar.  There is no evidence that, as claimed, it is safer for pregnant women or the developing fetus. In smoking adults ENDS are often used as a steppingstone in the quitting process. However the evidence of benefit so far is inconclusive and the US Preventive Service Task Force for smoking has not endorsed ENDS as a smoking cessation strategy.  In teens the effect is the opposite–kids tend to start out vaping and advance to cigarettes.
  • “Vape juice” is FDA approved.  This is a generally true statement but it is misleading. Many of the ingredients ARE approved–to CONSUME(eat).  The GI tract, of course, is very different from the pulmonary.  So you like orange juice?  In your lungs?
  • There are numerous chemicals contained in vape juice besides flavorings.  Only 13% of youths understood that they were inhaling nicotine. 70% of teens see no harm in its use.  However, besides nicotine, vape juice contains numerous known carcinogens, like diacetyl, formaldehyde, nitrosamines, benzene, as well as nickel, tin, and lead.

And there’s more.  Nicotine is known as a “gateway drug” which potentiates other drugs like cocaine,  and is associated with other illicit drug experimentation–marijuana, opiates, heroine, methamphetamines–as well as risky behaviors like binge drinking and early onset sex/more sexual partners.  Nicotine exposure increases the risk of poor focus and attention, lower impulse control, mood and anxiety disorders.

Vape juice is produced with sweet tasting flavors like mint, pina colada, mango which are specifically designed to appeal to youth.  Many of the strategies  employed by the ENDS industry mimic those of “Big Tobacco” to reach the youth market that were disallowed  by the tobacco liability settlement of 1998.

The current industry leader is JUUL, which has grown to dominate 75% of the market spearheaded by copious social media site advertising.  It comes in an elongated cartridge resembling a flash drive, designed to appeal as “sleek” and “cool” and has the added advantage of being easily concealed from parents view.  One JUUL cartridge contains the equivalent of 200 cigarette puffs of nicotine.

I urge all parents to be aware of the risks of these products to your child and to discuss them with your middle and high school children.  If you yourself are a smoker or a vaper–be aware: YOUR CHILDREN ARE WATCHING!

Here are some helpful websites with the above information:

Click to access AAP-JUUL-Factsheet.pdf

Click to access 5AsENDSfactsheet.pdf

Click to access ENDShandout_Clinicians.pdf


Send along questions and comments, and thanks for following.