#86: Overuse Injuries – The Leg Bone’s Connected to the Foot Bone!

June 7, 2023 | By Sam Masur

Audio

Summary:

Osgood Schlatter disease and Sever’s disease sounds scary, but they should not scare you or your patients. Tune into this episode as Dr. Conde walks us through her approach to the knee and ankle musculoskeletal exams then discusses common overuse injuries that can be treated in the primary care clinic!

Overuse Injury Pearls

1. For pediatrics, you should also examine the hips when there are knee complaints; many pathologies (think SCFE) can masquerade as knee pain in history!
2. Ask your patients about their experience at physical therapist offices in your area to develop your own “favorite” referral list and develop relationships with local practices.
3. Pops, snaps, and cracks are not an issue if they’re not painful.
4. Alongside NSAIDs and ice, topical non-steroidals like topical diclofenac, lidocaine patches or cream can help symptom management and are often overlooked.

Overuse Injuries Notes

Sports HPI

• Key history components include location of pain and chronicity. Pain that has been going on for months should make you think of a completely separate differential then pain that started acutely after an injury. 
• Providers should determine if the patient is using any durable medical equipment and what, if any, medications they have tried. 
• Everyone has a different pain tolerance, and as such it is often difficult to interpret pain scores using the numerical pain scoring system. It is much more valuable to determine how their pain affects them functionally. Does the pain cause them to alter their gait? Have they missed practice or has the pain altered their performance in some way? 
• Expert Opinion: Kids will often have a difficult time localizing their pain when asked “where is your pain”. Dr. Conde recommends asking “With your finger tip, show me where you hurt the most?”
• RED FLAG symptoms that should always prompt you to think about labs or imaging include limping, fever, weight loss, pain awakening the patient from sleep, bruising and swelling. 
• Finally, get to know your patient. Find out what sports and teams they play for. Find out how often they practice and when their next game is. Not only does this help you build a mental picture of how often and what level an athlete you are treating, but also builds trust and helps you cater your treatment plan to their individual level.  

How to Master the MSK Exam

General Advice

• The only way to develop a good musculoskeletal exam is to build a system and examine a lot of patients.
• Always review the anatomy. There is no shame in taking out Netter’s or doing a quick internet search once you find out where the patient hurts. We do this all the time in the clinic and we see only Sports Medicine patients!
• Make a template in your note as a cheat sheet (depending on your EMR). This way you can remember some of those pesky special tests. Eventually you won’t even need it!
• Don’t rush to specific exam maneuvers to confirm your diagnosis– always do a complete exam. 
• Dr. Conde recommends the following standardized approach for every exam:
  • Inspection
  • Palpation
  • Range of Motion
  • Strength
  • Special Tests 
• We have included some broad highlights of the exam below, but it is by no means an exhaustive list of special tests and exam maneuvers. 

Knee Exam

• Pro-tip: In pediatrics, you should also examine the hips when there are knee complaints; many pathologies (think SCFE) can masquerade as knee pain in history!
• For examination purposes it is helpful to divide the knee into 4 areas for purposes of inspection and palpation: anterior, lateral, medial, and posterior. 
• Inspection: Examine alignment and determine if there is any valgus or varus alignment of the knee. For acute evaluations, is everything where it’s supposed to be? Is the patella dislocated laterally? Next you should look for soft tissue swelling and effusion. You can identify an effusion by palpating the suprapatellar pouch above the patellar which will often fill with acute injury. You can also “ballot” the medial and lateral joint lines to see if you can move fluid from side to side. 
• Palpation: here we should push on all the major bony landmarks and tendons. Start in the anterior knee and palpate the quadricep tendon, patella, patellar tendon, tibial tubercle and joint lines. Next palpate the medial and lateral knee align the collateral ligaments. Finally finish off by palpating for a baker’s cyst in the popliteal recess. 
• Range of motion: determine if the extensor mechanism (quadriceps tendon-patella-patellar tendon) is intact by asking the patient to perform a straight leg raise off the table. Next determine how much the knee can flex. Always compare the injured side to the non-injured side. 
• The average range of motion is 0 degrees of extension to 140 degrees of flexion
• Strength: this one is pretty self explanatory. Test the strength in flexion and extension and compare to the other side. Make sure to isolate joints when testing.
• Special tests: there are an infinite number of special maneuvers published for the knee. All of them have varying sensitivity and specificity for certain pathologies. Some can get quite obscure as well.
• Anterior  Drawer test (ACL): patient should be supine with hip flexed to 45 and knee flexed to 90. The examiner should sit on the foot and place hands behind the proximal tibia with thumbs lying on anterior tibial plateau. Apply anterior force to the tibia to displace the tibia. If this displacement is greater compared to the contralateral side consider ACL tear. Sensitivity 22%-44% in awake patient, Specificity >95% (Malanga et al., 2003)
• Lachman Test (ACL/PCL): stabilize the distal femur (with a hand or pillow/foam), grip a portion of the proximal tibia, then translate anteriorly and posteriorly feeling for laxity. Describe the degree of translation and the endpoint (soft or abrupt). Sensitivity 80-95%, Specificity 95% (Malanga et al., 2003)
• McMurray’s Test (Meniscus): hold the leg with one hand while placing the other hand along the joint line of the knee. Fully flex the knee while externally rotating the lower leg (for the lateral meniscus) or internally rotating the lower leg (for the medial meniscus). While maintaining this position, the examiner then slowly extends the knee while applying a valgus (for the lateral meniscus) or varus (for the medial meniscus) stress to the joint. Listen and feel for any clicking, popping, or pain within the knee. Sensitivity 70% with a specificity of 71% (Hegedus et al., 2007). 
• Varus and Valgus Stress Test (MCL/LCL): For the varus stress test the patient should be supine on a table with the knee flexed to ~30 degrees. The examiner should place one hand on the lateral aspect of the knee and use the other to grasp the ankle. An valgus force should be applied to the knee. A positive test demonstrates laxity compared to the contralateral side. The varus test is performed in identical manner with a varus force. Both tests should be repeated in full extension. 
• Finally, don’t forget to access gait and function at the end of your examination. The best gait exam is often done watching them walk in when they are benign roomed. 

A Word on Osgood Schlatter’s “Disease” (OSD) and Sinding-Johansson-Larsen Syndrome (SLJ)

• Osgood-Schlatter disease (OSD), also known as tibial tubercle apophysitis, is inflammation of the tibial tuberosity apophysis.
• This is a traction apophysitis caused by overuse of the extensor mechanism (jumping, running)
• OSD usually occurs in between 8-13 in girls and 12-15 in boys (Circi et al., 2017)
• X-rays are not necessary to diagnose OSD. Tenderness and swelling over the distal patellar tendon and enlargement of the tibial tuberosity are common. 
• A firm mass over the tibial tubercle may develop with chronic cases. This usually remains for life. 
• OSD is usually self-limiting and resolves with time, rest, and conservative treatments like ice, stretching, and activity modification.
• You may try a single or double patellar strap, but evidence is minimal for their use. (Circi et al., 2017) 
• Sinding-Larsen-Johansson syndrome (SLJ): is another osteochondrosis of the knee. In this syndrome the  inflammation occurs at the inferior aspect of the patella. Treatment and prognosis are similar.
• Onset for SLJ (8-13 years old) is a bit younger than OSD (10-15 years old) but with a wide overlap.
• X-rays, again, are not necessary to diagnose this syndrome, but should be considered if the pain started secondary to trauma as patellar sleeve fractures present with pain in the same area. 

Foot and Ankle Exam

• Inspection: Examine the anatomy with your patient bare-foot . You should inspect 
• Palpation: Push on the major bony landmarks and tendons, most of which done by the calcaneal squeeze test: cup the posterior calcaneus and squeeze. 
• Range of motion should be assessed and compared to the contralateral side
• Strength: should be tested for the major movements– dorsiflexion, plantarflexion, eversion, and inversion. You may also access hallucis strength in flexion and extension. plantar and dorsiflexion on the ground. A handy anatomic atlas can be very helpful here!
• Balance can indicate strength of small muscles of the foot and ankle, coordination, or underlying neurologic diagnoses (think Rhomberg)
• Finally, don’t forget to assess gait and function focusing on the ankle and foot as well.  

A word on Sever’s Disease 

• Also known as calcaneal apophysitis
• An overuse injury that presents with either unilateral or bilateral heel pain from repetitive stress on the calcaneal growth plate. 
• Common during periods of rapid growth due to high cell turnover at the growth plate
• Unfortunately for kids, the apophysis is the weakest point in the muscle-tendon-bone chain.
• Posterior heel pain is the most common musculoskeletal complaint in children between 8 and 15 years. Sever’s is the most common culprit. Plantar fasciitis, while a common adult diagnosis, is extremely rare in children. (Fares et al., 2021)
• This is a clinical diagnosis that commonly presents with unilateral or bilateral posterior heel pain, most often in the setting of increased physical activity. They often will limp or alter their gait due to the pain. 
• Physical exam with show a positive calcaneal squeeze test 
• There is no imaging necessary. X-ray can be obtained if the child has unilateral heel pain that is refractory to conservative treatment. 
• Imaging may be obtained if concerned for osteomyelitis, stress fracture, or bone cyst. These all much less common than Sever’s 
• Symptoms are self-limiting and will resolve with the closure of the apophysis usually between the ages of 12 and 15. 
• Conservative treatments like activity modification, stretches, and ice are helpful
• Orthotics such as heel cups are often recommended. They provide cushion and relaxes the achilles tendon by providing lift. They have been found to reduce pain when compared to other conservative interventions (Fares et al., 2021) 

Finding Moderation in Youth Athletics

• General recommendation is training 1 hour per year of age per week. 
• Watch out for multi-sport athletes and make sure you’re asking about ALL activities and overlapping activities. Ask if they can alternate activities like adding swimming. The more variety in sport builds resilience and decreases the risk of overuse. (Brenner et al., 2016)
• Athletes should take at least one day off per week from sports to allow for mental and physical recovery. (Brenner et al., 2016) 
• Athletes should take a total of 2 to 3 months off every year from a specific sport. This time can be divided throughout the year. (Brenner et al., 2016) 

When to Refer

• Higher level athletes with a specific activity (eg.: gymnastics).
• Help with Return-to-Play
• Specific needs like casting or splints 
• Patients who fail initial therapy 
• Consideration of more advanced imaging such as MRI or bone scan.

Goal

Listeners will explain the basic approach to diagnosis and management of overuse injuries in pediatric patients  to improve the outpatient management of common sports injuries.. 

Learning objectives

After listening to this episode listeners will…  

1. Describe specific historical features of the sports medicine HPI.
2. Be familiar with the diagnostic approach for common knee and ankle sports medicine injuries.
3. Recognize what makes pediatric sports injuries and overuse injuries distinct from adult injuries.
4. Learn the utility of at least two specific exam maneuvers for the lower extremities.

Disclosures

Dr. Conde reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Papakyrikos C, Ward B, Conde A, Masur S, Chiu C, Berk J. “#86: Overuse Injuries – The Leg Bone’s Connected to the Foot Bone!”. The Cribsiders Pediatric Podcast. https://www.thecribsiders.com/ June 7, 2023.

References: 

Brenner JS; COUNCIL ON SPORTS MEDICINE AND FITNESS. Sports Specialization and Intensive Training in Young Athletes. Pediatrics. 2016 Sep;138(3):e20162148. doi: 10.1542/peds.2016-2148. PMID: 27573090.

Circi E, Atalay Y, Beyzadeoglu T. Treatment of Osgood-Schlatter disease: review of the literature. Musculoskelet Surg. 2017 Dec;101(3):195-200. doi: 10.1007/s12306-017-0479-7. Epub 2017 Jun 7. PMID: 28593576.

Fares MY, Salhab HA, Khachfe HH, Fares J, Haidar R, Musharrafieh U. Sever’s Disease of the Pediatric Population: Clinical, Pathologic, and Therapeutic Considerations. Clin Med Res. 2021 Sep;19(3):132-137. doi: 10.3121/cmr.2021.1639. PMID: 34531270; PMCID: PMC8445662.

Hegedus EJ, Cook C, Hasselblad V, Goode A, McCrory DC. Physical examination tests for assessing a torn meniscus in the knee: a systematic review with meta-analysis. J Orthop Sports Phys Ther. 2007 Sep;37(9):541-50. doi: 10.2519/jospt.2007.2560. PMID: 17939613.

Malanga GA, Andrus S, Nadler SF, McLean J. Physical examination of the knee: a review of the original test description and scientific validity of common orthopedic tests. Arch Phys Med Rehabil. 2003 Apr;84(4):592-603. doi: 10.1053/apmr.2003.50026. PMID: 12690600.