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Osgood-Schlatter Disease
Osgood-Schlatter disease is an inflammatory injury of the growth plate on the tibia (shin
bone) just below the level of the knee at the tibial tubercle.
This disease may also be referred to as osteochondrosis or apophysitis of the tibial tubercle.
The tibial tubercle is the bony attachment for the quadriceps (front thigh muscle).
Contraction of the quadriceps results primarily in straightening of the leg at the level of the
knee.
A growth plate is an area of developing tissue near the ends of long bones or areas of muscle
attachment. The growth plates in children allow the bones to expand in length thus allowing
a child to reach his or her full height by the age of 16 to 19.
Compared to the surrounding bone and muscles, the growth plate serves as a weak point.
Thus repetitive pulling on a growth plate, especially from a large powerful muscle like the
quadriceps, can result in injury to the growth plate and subsequent pain.
Osgood-Schlatter Disease is usually a self-limited disease –upon reaching skeletal maturity,
the growth plate seals and thus can no longer cause pain.
This condition is very similar in presentation and treatment to Sinding-Larsen-Johansson
Syndrome, which is a traction apophysitis of the inferior pole of the patella.
Cause
Repetitive stress or injury to the growth plate of the tibial tubercle results in
inflammation and subsequent pain.
The injury has a waxing-and-waning course. Even after pain has subsided for
some time, repetitive stress can cause a flare-up.
Risk factors
 Activities that involve jumping and/or jogging
 Boys, especially those between the age of 11 and 18
 Rapid skeletal growth
 Poor physical conditioning

Symptoms

 Swelling, warmth, and/or tenderness below the knee

 A firm bump under the knee that is exquisitely tender to touch
 Pain with activity, especially with knee straightening or vigorous activity
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Diagnosis
 Diagnosis of Osgood-Schlatter disease is made primarily by physical exam
 Difficulty may be present with a straight leg raise, especially against resistance
 The area of skin overlying the tibial tubercle may be enlarged and firm. This
area is also exquisitely tender to touch
 Radiographs may be used to rule out underlying fractures or other bony injuries
in the area
Prevention
 Weight loss to acquire a proper body mass index for age and height
 Warm up and stretching before partaking in physical activity.
 Warming the area with a hot compress or shower may improve stretching
 Maintaining appropriate flexibility, endurance, and muscle strength
 Avoidance of open kinetic leg extensions (such as extending the knee in the sitting
position against resistance)

Treatment
 Initial treatment of this injury consists of modification of activities, ice, stretching,
strengthening exercises, and pain medications
 Activities such as kneeling, jumping, squatting, stair climbing, and running should be
avoided initially
 A patellar band, which is a brace situated between the tibial tubercle and the kneecap,
may help relieve symptoms
 In rare instances, surgery is necessary if conservative treatment has failed. A trial of
immobilization with an elastic knee support, cast, or splint may be tried for 6 to 8
weeks before considering surgery
 Complications of this condition include a persistence of a bump overlying the tibial
tubercle, reoccurrence in adulthood, tearing away (avulsion) of the growth plate from
the tibia.
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ADDUCTOR TENDINOPATHY
Adductor tendinopathy is a condition characterized by tissue damage and inflammation to
the adductor tendon where it attaches into the pelvis, resulting in groin pain. During
contraction of the groin muscles, tension is placed through the adductor tendon at its
attachment to the pelvis. When this tension is excessive due to too much repetition or high
force, damage to the adductor tendon may occur.
Signs and Symptoms
 Dull ache that lasts for long periods
 Tightness, tenderness and/or muscle spasms when you try to flex, extend or rotate the
hip or leg inward
 Point tenderness in the adductor muscle may be present
 Decreased range of motion (ROM) in the hip joint
 May feel tightness in the lower abdominal, spine and hip region.
 Weakness of the adductor muscles can also be experienced as a result of adductor
tendinopathy. This along with the other symptoms may make it difficult to walk or
run and can result in walking with a limp.
 Occasionally, bruising (broken blood vessels) in the groin area or over the adductor
muscles may appear a few days after the injury. This may be in one spot or may span
from the groin to the knees.
 Warmth, redness and/or a tender lump may accompany adductor tendinitis and in
severe cases swelling may occur.

Treatment
This patient is often difficult to treat because the athlete can for at least a period of time,
continue to participate in sports activity. Conservative methods include relative rest, ice,
massage, therapeutic ultrasound. Oral NSAIDS and/or corticosteroid injections may have a
role. Surgery (adductor tenotomy) is reserved for recalcitrant cases. Surgical success
depends on an accurate diagnosis and optimal rehabilitation (8-10 weeks).
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ANKLE SPRAIN
Ankle sprains are one of the most common injuries sustained during recreational and
competitive sports such as soccer, basketball, football, and running.
Depending on the extent of the injury, inadequate treatment of an ankle sprain may lead to
chronic pain, decreased range of motion, or instability.
Of all types of ankle injuries, 75% to 85% are ankle sprains, with the majority of them
caused by an ankle inversion injury. Approximately 40% of ankle sprains can lead to
chronic injury.
There are a number of contributing factors that may predispose an individual to sustain an
ankle sprain, which can include the following:
 Previous history of ankle sprain/injury
 Older individuals who are sedentary
 Overweight individuals/obesity
 “Weekend warriors,” who do not train/engage in sports actively and consistently
 Type and frequency of sport that involves more stress on the ankle complex

Anatomy
The ankle or talocrural joint, is a junction of tibia, fibula and talus.
The ligament of ankle are:
 Anterior talofibular ligament (ATFL)
 Calcaneofibular ligament (CFL)
 Posterior talofibular ligament (PTFL)
 Deltoid ligament complex (DLC) made up of (the anterior and posterior tibiotalar
ligaments , the tibiocalcaneal ligament and the tibionavicular ligament)
The ATFL is the most commonly injured ligament, followed by the CFL.
The CFL is usually injured in combination with ATFL.
Sprains to both the ATFL and CFL are a result of combined inversion and planter flexion
mechanism.
A less likely mechanism of eversion may cause injury to the DLC.
The most stable position of the ankle is in dorsiflexion.

Classification of Ankle Sprains

Regardless of whether the lateral or medial ligaments are injured, the severity of an ankle
sprain is typically placed into one of 3 grades based on the amount of ligamentous damage:
 Grade I : ankle sprains result in a stretching of the ligamentous fibers and are
considered minor sprain.
 Grade II : ankle sprain result in a partial tearing of the ligamentous fibers and are
considered to be moderate sprains.
 Grade III : ankle sprain result in substantial tearing of the ligamentous fibers and are
considered severe sprains.
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Signs and Symptoms

Grade I:
 Stretching of ligaments usually the ATFL
 Point tenderness
 Limited dysfunction
 No laxity
 Able to bear full weight
 Little to no edema
Grade II:
 Partial tearing of ligaments, usually the ATFL and CFL
 Point and diffuse tenderness
 Moderate dysfunction
 Slight to moderate laxity
 Antalgic gait and pain with full weight bearing, may need supportive to ambulate
 Mild to moderate edema
Grade III:
 Substantial tearing of ligaments, may involve the PTFL in addition to the ATFL and
CFL
 Point and diffuse tenderness
 Moderate to severe dysfunction
 Moderate to severe laxity
 Limited to no ability for full weight bearing without supportive device
 Severe edema

Treatment
The basic tenets of ankle sprain treatment include the PRICE (protection, rest, ice,
compression, and elevation) method:
For Grade I ankle sprains, protection may or may not be needed. Simple RICE therapy
with activity as tolerated is initiated. Initially, range of motion exercises are instituted to
prevent stiffness, and then gradually, strengthening and balance exercises are
recommended.
For Grade II ankle sprains, PRICE treatment is used, and the ankle can be protected
with the use of an air-cast splint. Once the pain and swelling have improved, return to
activity and stretch/ strength therapy are recommended.
For Grade III ankle sprains, the athlete may need to be immobilized in a short leg cast
or cast brace for 2 to 3 weeks. Rarely will an individual require surgery, unless there is
another complicated issue. Afterward, treatment is similar to that for Grade I and II
injuries.
Anti-inflammatories such as ibuprofen can be used, and analgesics such as acetaminophen
may also be helpful for pain control.
Surgical intervention is reserved for those cases where conservative therapy with
immobilization and physical therapy has failed.
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ACHILLES TENDINITIS
Usually resulting from trauma, athletic over activity, or improperly fitting shoes with a
stiff heel counter, Achilles tendinitis can also be caused by inflammatory conditions such
as ankylosing spondylitis, reactive arthritis, gout, RA, and calcium pyrophosphate
dihydrate crystal deposition disease (CPPD). It also has been associated with treatment
with fluoroquinolones. Pain, swelling, and tenderness occur over the Achilles tendon at its
attachment and in the area proximal to the attachment.
Crepitus on motion and pain on dorsiflexion may be present. Ultrasonography aids in the
diagnosis. Management includes NSAIDs, rest, shoe corrections, heel lift, gentle
stretching, and sometimes a splint with slight plantar flexion. Because the Achilles tendon
is vulnerable to rupture when involved with tendinitis, it was felt in the past that treatment
by a corticosteroid injection could worsen this possibility. However, this view is being
challenged and fluoroscopic guided steroid injections have been successfully performed.

ACHILLES TENDON RUPTURE

Complete rupture tend to occur in middle-aged patients and those without pre-existing
complaints. Partial ruptures occur in well-trained athletes and involve the lateral aspect of
the tendon.
Acute ruptures commonly occur when pushing off with the weight bearing foot while
extending the knee, but they also can be caused by a sudden or violent dorsiflexion of a
plantar flexed foot.
Most Achilles tendon ruptures occur approximately 2 – 6 cm proximal to its insertion to the
calcaneus, in the so-called "watershed" region of reduced vascularity.
Signs and Symptoms
 Sharp pain and a pop heard at the time of complete rupture are commonly reported.
Patients often describe a sensation of being kicked in the Achilles tendon. Most have
an immediate inability to bear weight or return to activity.
 A palpable defect may be present in the tendon initially.
 Partial rupture is associated with an acutely tender, localized swelling that
occasionally involves an area of nodularity.
 The Thompson test is positive with complete Achilles tendon rupture.
 Partial ruptures are also difficult to accurately diagnose, and MRI should be used to
confirm diagnosis.
Treatment
 Non operative treatment: requires immobilization to allow hematoma
consolidation. Putting the foot with 20 degrees or less of planter flexion.
Conservative treatment is best for small partial ruptures.
 Operative treatment: is generally preferred for young, athletic and active person
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Hallux Valgus
In hallux valgus, deviation of the large toe lateral to the midline and deviation of the first
metatarsal medially occurs. A bunion (adventitious bursa) on the head of the first
metatarsophalangeal (MTP) joint may be present, often causing pain, tenderness, and
swelling.
Hallux valgus is more common in women. It may be caused by a genetic tendency or
wearing pointed shoes, or it can be secondary to RA or generalized OA.
Stretching of shoes, use of bunion pads, or surgery may be indicated. Metatarsus primus
varus, a condition in which the first metatarsal is angulated medially, is seen in association
with or secondary to the hallux valgus deformity.

PLANTAR FASCIITIS
Plantar fasciitis, which is seen primarily in persons between 40 and 60 years of age, is
characterized by pain in the plantar area of the heel. The onset may be gradual or may follow
some trauma or overuse from some activity, such as athletics, prolonged walking, using
improper shoes, or striking the heel with some force. Plantar fasciitis may be idiopathic; it
also is likely to be present in younger patients with spondyloarthritis. The pain
characteristically occurs in the morning upon arising and is most severe for the first few
steps. After an initial improvement, the pain may worsen later in the day, especially after
prolonged standing or walking.
The pain is burning, aching, and occasionally lancinating. Palpation typically reveals
tenderness anteromedially on the medial calcaneal tubercle at the origin of the plantar fascia.
The plantar fascia is a dense, fibrous connective tissue structure originate from the medial
tuberosity of the calcaneus.
Of its three portions-medial, lateral and central bands- the largest is the central portion.
The plantar fascia is an important static support for the longitudinal arch of the foot.
Strain on the longitudinal arch exerts its maximal pull on the plantar fascia, especially its
origin on the medial process of the calcaneal tuberosity.
Treatment includes relative rest with a reduction in stressful activities, NSAIDs, use of heel
pad or heel cup orthoses, arch support, and stretching of the heel cord and plantar fascia. A
local corticosteroid injection is often of help.
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 Shoulder Joint:
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 Elbow Joint :
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 Wrist Joint:
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 Hip Joint:
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 Knee Joint:
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 Ankle Joint: