Welcome to the 15th edition of the Learn.Physio Research Review!
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Welcome back for another round of Mick’s Research Reviews!
In this issue we’re going to highlight 2 recent papers that focus on 2 knee injuries that affect quality of life in our adolescent and paediatric athletes – ACL injuries and Osgood Schlatters Disease (OSD).
The first paper highlights how an active approach in managing OSD yielded favourable outcomes over a 3 month period and was a breath of fresh air to read compared to the historical approach of rest and “wait-and-see” with OSD patients.
The second paper I summarise is the 2018 consensus paper on prevention, diagnosis and management of ACL injury in paediatrics. It’s a huge paper, in more ways that one, and I have summarised the key points of the 6 key questions it aims to answer.
I have also provided the links to the 2 full text papers so that you can dive into them both a little bit deeper if you wish.
In other news, this will be the last of the Learn.Physio Research Reviews that comes to your email in written form. We are still going to bring to you recent research summaries in the future, but it will be in a more interactive and exciting format.
These changes will take place from mid-late July, so watch this space.
Thanks once again for taking an interest in staying up to date with my fortnightly reviews! I sincerely hope that you have been able to learn something new each Issue, and I cannot wait to bring to you the new format later this year.
Until next time, stay safe and healthy!
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Introduction
Osgood Schlatters Disease (OSD) is a growth-related apophysitis of the knee that affects 1 in 10 adolescents. It is characterised by localised pain to the tibial tuberosity that is aggravated by activities such as running, jumping and landing. Clinically, pain and swelling are localised to the tibial tuberosity, and pain reproduced on palpation of the tibial tuberosity.
OSD can impact the adolescent athlete for longer than the usual “12-18 month” recovery often stated; with one recent paper reporting impaired function at a median 4 years follow-up (Guldhammer et al 2019).
With a gap in the literature in regards to effective management strategies, the aim of this study was to investigate the effects of an intervention consisting of education on activity modification and knee strengthening exercises for adolescents with OSD.
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Methods
Adolescents with knee pain were recruited for this prospective study. They then had a clinical examination performed by 2 experienced physiotherapists. The diagnosis was made clinically, with no radiographs, with the following criteria used to diagnose OSD:
Inclusion criteria:
- Pain localised at the tibial tuberosity that increased with palpation
- Pain on resisted isometric knee extension
Exclusion criteria:
- Knee effusion
- Patellar instability
- Sinding-Larsen Johannson syndrome
- Concomitant injury or pain in the hip/lumbar spine or other structures of the knee (tendinopathy, previous knee surgery or patellofemoral pain)
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Intervention
The intervention included 4 visits with a physiotherapist over a 12-week period, with parents required to take part in all 4 visits. The intervention was divided into 2 blocks (see table below);
- Week 0-4 – load management
- advised to refrain from pain-aggravating activities and sports
- advised to perform basic leg strengthening exercises to preserve muscle strength
- Week 5-12 – progressive home-based knee strengthening and progressive return to activity and sport
- advised to start performing progressive home strength program and follow activity ladder for return to sport
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See link here for an excellent and detailed resource that was published for the patients and parents from this study.
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Outcomes
Self-reported questionnaire was completed at baseline and after 4, 8, 12, 26 and 52 weeks; with the 12-week follow-up being the primary end-point.
The primary outcome measure was self-reported improvement on a 7-point Likert scale ranging from “much improved” to “much worse” with the midpoint being “no change”. Participants were deemed to have had a successful outcome if they reported “improved” or “much improved”.
In addition to this primary outcome measure, the participants also conducted self-reported questionnaires (KOOS and pain NRS), they also had their physical activity measured (ActiGraph GT3X+) and had their lower limb strength measured (isometric knee extension and hip abduction) and lower limb jumping performance measured (single leg vertical and horizontal jumps on their most painful knee).
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Results
51 adolescents (average age 12.7 years, 51% females) were enrolled in this study, who had a mean pain duration of 21 months.
At the primary end-point (12 weeks) 80% of adolescents reported a successful outcome (“improved” or “much improved”) which increased to 90% at 12 months.
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Highest degree of pain during the last week also reduced significantly from a median score of 7/10 at baseline to 2/10 at 12 weeks. Importantly, 27 considered themselves to be pain free from knee pain at 12 weeks, which was very similar at 52 weeks (24 participants).
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In regard to return to sport, 16% returned to sport at 12 weeks which increased to 67% at 6 months and 69% by 12 months.
At 12 weeks follow-up, there were significant improvements in knee extension strength (32%) and hip abduction strength (24%), with similar improvements in single leg vertical jump (19%) and single leg horizontal jump (14%) when compared to baseline.
Overall, the 12-week program revealed 71% were “very satisfied” with the results of treatment, with none being “very unsatisfied”. Furthermore, 96% responded that they would recommend the intervention program to a friend with the same type of knee pain.
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Discussion
This is the first study that has specifically looked at an active management strategy to managing OSD, rather than a “wait and see” approach or injections/surgical management; and the results are very promising. With 80% of participants reporting a successful outcome at the end of the 12 weeks intervention, and knee extension strength returning to values similar to that of uninjured adolescents at 12 weeks, this study gives us clinicians the confidence to take a more active approach in managing adolescent athletes with OSD.
Despite these positive results, there were some findings that indicate that OSD can have lingering effects on sports participation and the symptoms can persist well beyond 12 weeks of intervention; with only 16% returning back to sport at 12 weeks post intervention (but increased to 67% by 6 months).
Having a look at the programming in the workbook, and in my humble opinion, the exercises potentially could have progressed even further with the addition of weights, the addition of other exercises such as single leg hip thrusters/arabesque/calf raises to address the kinetic chain, and also the addition of plyometric activities such as skipping and jumping – maybe these additions could have resulted in higher numbers of sports participation at 12 weeks, 6 months and 12 months?
As exciting as these results are, the big thing to be conscious of with this study is that it is a cohort study only and doesn’t compare this particular intervention to another intervention (injections/analgesics), nor have a control group; so, we don’t know if this approach is truly superior to other approaches in the management of OSD.
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Conclusion
In young adolescent athletes with OSD, an active treatment approach combining a short period of activity modification + exercise (4 weeks) followed by 8 weeks of progressive home strengthen and graduated return to activity and sport is a sensible option to employ; and on paper seems like a better way to manage young athletes rather than implementing rest or “waiting and seeing”.
Unfortunately, only 1 in 6 adolescent athletes will return to sport after this 3-month intervention, but 2/3 of them will return to sport by 6 months. This indicates that OSD can have a long-lasting effect on active adolescents that we need to be aware of to manage expectations for athlete, parents and coaches. More work looking at progressive strengthening plans, including plyometrics and graduated returns to sport in this population is needed in the future.
If you’re interested in learning more about adolescent knee injuries, we’ll be releasing a 3hr adolescent knee masterclass with adolescent and paediatric experts Dr Loretta O’Sullivan-Pippia and Dr Ivan Astori very soon – so stay tuned!
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Stay tuned, one of our most detailed and in-depth masterclasses covering all you need to know about the adolescent knee, from diagnosis, rehabilitation, red flags, assessment and much more
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In 2017 the International Olympic Committee (IOC) hosted an international expert meeting for physiotherapists and orthopaedic surgeons who specialise in treating and managing paediatric ACL injuries. This consensus statement addressed 6 fundamental clinical questions regarding the prevention, diagnosis and management of paediatric ACL injuries and provides a comprehensive evidence-based summary to support the clinicians, and parents/guardians of children with ACL injury to make the best possible decisions.
The following is a brief summary of the 6 clinical questions and recommendations; and if you would like to read this entire consensus statement in more detail, you can do so here
Question 1: How can the clinician prevent ACL injuries in children?
- Compelling evidence that ACL injury prevention program work in skeletally mature patients in reducing the risk of a primary injury and 2nd ACL injuries.
- Programs like the 11+ kids have been specifically designed for young soccer players (both male and female) and should be performed as part of regular team training 2-3x per week.
Question 2: How does the clinician diagnose ACL injuries in children?
- If injury prevention programs fail, timely and accurate diagnosis is important for effective management planning and shared decision-making.
- Clinical pearl 1: hemarthrosis is an important clue suggestive of structural knee injury.
- Clinical pearl 2: due to skeletal immaturity, children may sustain different types of knee injuries than adults eg. Sleeve fracture of patella.
- Consider a plain knee radiograph first in paediatric patients to rule out paediatric fractures of the knee.
- MRI to confirm the diagnosis of ACL injury, meniscus tears, osteochondral injury, and other soft tissue structures.
- In children with a locked knee, an acute MRI is warranted to assess presence of bucket-handle meniscal tear or osteochondral injury that may need prompt surgical treatment.
Question 3: What are the treatment options for the child with an ACL injury?
- Once diagnosis is made, the clinician needs to know the available treatment options and discuss these with the child and the parents/guardians.
- Goals of treatment for the child with ACL injury are:
- Restore stable, well-functioning knee that enables healthy active lifestyle across the lifespan.
- Reduce the impact of existing, or the risk of further meniscal or chondral pathology, degenerative changes and need for future surgical intervention.
- Minimise the risk of growth arrest and femur/tibia deformity.
- 2 treatment choices can help the child with ACL injury achieve these goals – high quality rehab alone (non-surgical treatment) and ACL reconstruction plus high quality rehab.
- Regardless of rehab-alone, or ACL reconstruction plus rehab, the principles of rehab are the same.
- Rehab consists of 4 distinct phases that have clinical and functional milestones that should be achieved before moving onto the next phase.
- Rehab must be thorough, progressive in nature and focus should be on dynamic, multi-joint neuromuscular control of the athlete during rehab/strengthening exercises.
- The pathway for return to sport for either option is the same with passing a series of strength tests, hop tests and psychological readiness tests before returning to sport.
- Return to sport should be delayed 6 months for rehab-alone.
- Return to sport for ACLR paediatric patients should be delayed at least 12 months.
Key point: Children are not small adults; they cannot be expected to perform unsupervised training independently with perfect technique. Exercises and functional goals must be modified from adults and the rehab conducted in close collaboration with the child’s parents/guardians.
- There are 3 indications for paediatric ACL reconstruction:
- The child has a repairable associated injury (bucket-handle meniscus tear, repairable meniscus lesion or osteochondral defect.
- The child has recurrent, symptomatic knee giving way after high quality rehab.
- The child experiences unacceptable participation restriction.
- There are 3 possible techniques for paediatric reconstruction:
- Trans-physeal ACL reconstruction – similar to the technique the surgeon would use for an adult.
- Physeal-sparing ACL reconstruction – avoids physeal damage in patients with markedly open physes.
- Partial trans-physeal ACL reconstruction – combines a trans-physeal tibial tunnel with a physeal-sparing technique on the femoral side.
- Soft tissue autografts should be used for ACL reconstructions in paediatric patients.
- Allografts are not indicated in paediatric outcomes due to poor clinical outcomes.
Question 4: What are the most important considerations when making treatment choices?
- Assessing patients skeletal age, in addition to chronological age is necessary to individualise treatment – with the main goal of skeletal assessment is to define remaining knee growth and protecting the physis being an important consideration.
- The orthopaedic surgeon should image the knee to determine if the femoral and tibial physes and the tibial tubercle apophysis are open. If the growth areas are closed, then independent of chronological age, the child can be treated as an adult.
- As mentioned above, children who have repairable additional injuries at ACL injury diagnosis should be treated with early ACLR with repair of associated injuries (eg. Meniscus repair).
- When there are no additional injuries warranting repair, there are conflicting views ranging from early ACLR for all children, to high quality rehab to begin with, with the option for delayed ACLR if recurrent instability despite high quality rehab.
- One must be conscious of the fact that a well performed ACLR and preservation of the meniscus can restore knee stability but if the child received inadequate rehab the child can still have many poor outcomes. Similarly, high quality rehab will not salvage a poorly positioned graft or inappropriate graft (allograft).
- If the patient elects to attempt rehab-alone, Clinicians need to be alert to instability episodes and secondary injuries that require prompt assessment and treatment.
- Risks associated with ACLR:
- Growth disturbance is rare (2%), but a serious risk of ACLR.
- 2nd ACL rupture – 25% of patients under 25yrs who return to pivoting sports after ACLR have been shown to sustain a new ACL injury to either side.
- Poor long term knee health – meniscectomy is associated with increased risk of knee osteoarthritis, therefore preserving during surgery meniscus is key.
- Post-operative knee stiffness.
- Infection.
Question 5: How does the clinician measure outcomes that are relevant to the child with an ACL injury?
- Assessing PROMs provides insights into the patients function that can’t be evaluated via clinical tests or imaging and is important when managing ACL injuries in children.
- Measures developed for adults may not be valid for children and adolescents, and paediatrics have different levels of comprehension.
- Outcome measures that have been developed for children are:
- Child health questionnaire, PedsQL, paediatric PROMIS (health-related quality of life).
- Pedi-IKDC and KOOS-child (knee specific).
- Paediatric Functional Activity Brief Scale (activity level assessment).
Question 6: What are the clinician’s roles and responsibilities?
- Treatment decisions that involve children are amongst the most difficult and striking a balance between ethical principles can be challenging especially when there are conflicts in opinion between health professionals.
- One thing is agreed upon, and that is, injury prevention programs are fundamental to the best interests of the child, and clinicians have an obligation to support policies and practices that encourage teams/clubs to prioritise injury prevention.
- In the event of an ACL injury the clinician and or parents/guardians are obliged to serve the best interest of the child and the clinician must talk to the child and adults in comprehensible ways. Importantly, the child must always be involved in these discussion of treatment choices.
- The clinician has an important role in the treatment decision, and the clinician must give a clear idea of the range of interventions that are optimal, acceptable and not desirable; and be able to justify this with references to best quality research and clinical experience.
For a more detailed look at this consensus statement including the phases of rehab and criteria to return to sport, you can read it by clicking here
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