Dr. Jeffrey Tucker
11600 Wilshire Blvd. 3412
Los Angeles, CA 90025
Julie is in her junior-year in high school and is a club team soccer player. She came to see me on a Monday afternoon complaining of left-sided frequent mild to moderate patellofemoral pain as well as some distal IT band pain and tightness. Her last match was on Saturday. She fell on the outside of her left knee, when she collided with another player. Her evaluation did not show any ligament laxity in her main knee ligaments (MCL, LCL, ACL, and PCL), nor did she exhibit signs of meniscus involvement. Past history included experiencing Osgood Schlatter’s condition in her left knee early in her freshman year of high school while playing soccer. She had a physical therapist provide treatment for the Osgood Schlatter during and after her freshmen soccer season.
The patient complained of plus 2-3 tenderness and soreness upon palpation of her infra-patellar tendon, and along the bony deposit (bump) on her tibial tuberosity (this was more uncomfortable to palpation than the infrapatellar tendon). She felt tenderness with palpation around the medial aspect of her patellofemoral joint.
After performing knee range of motion and standard orthopedic tests, I performed functional movement tests. Julie was unable to perform a one-legged bridge using her gluteus maximus, without overactivity of her hamstrings and loss of pelvis position.
Next, I asked Julie to perform the Thomas Test. The psoas was tight and this will inhibit the gluteus maximus. To test the strength of the psoas muscle, I had Julie sit at the edge of the examining table with both feet lightly touching the floor and control the natural lumbar arch (neutral posture) as she lifted and held her bent leg in flexion past 90 degrees (I said “just lift your knee up past 90 degrees”). She was unable to hold the leg even slightly off the floor without slumping in her low back. This indicates weakness of the psoas. One way to strengthen a weak psoas is by bringing your knee above 90 degrees. Sit with your knees bent on a low box or bench (6 to 10 inches high). Maintaining good posture and keeping your abs tight, use your hips to raise one bent knee slightly higher than your hips. If you lean forward or backward, you’re not performing the exercise correctly. I had Julie hold it for10 seconds, and return to the starting position. She was instructed to complete 3 sets of 5 repetitions per leg.
Next I watched Julie perform the hands held Overhead Squat movement assessment. Her overhead squat assessment displayed excessive torso forward lean, toes rotating outward, and slight knee valgus. Her single leg squat assessment showed knee valgus and foot flattening. During her passive ROM assessment there was significant lack of dorsiflexion in both ankles. She exhibited tibial internal rotation during passive dorsiflexion.
I suggest that as practitioners we always assess tibial alignment in three positions: 1) weight bearing static posture, noting rotation; 2) non-weight bearing passive tibial rotation when the ankle is dorsiflexed; and 3) weight bearing tibial rotation during active motion during the squat. During the overhead squat motion analysis and passive analysis, I look at the tibia and measure by the direction in which the tibial tuberosity faces relative to the patella and relative to the second toe with the foot in neutral alignment. This patient’s tibia rotated medially on passive motion. I manually tested the muscle strength of the medial versus lateral hamstrings. The semitendinosus and semimembranosus tested tight but weak. This suggests performing manual stretching and fascial release work to the semitendinosus and semimembranosus. I found the best results when I worked the tissue toward the knee. The short head of the biceps femoris was also tight and needed to be worked away from the knee. I think it is important to consider the direction of movement that you do when performing fascial therapy.
Running, cutting, and jumping were all activities that increased Julie’s knee symptoms. When I analysed Julie’s running posture on a follow-up visit she was very flexed at the hip, almost leaning over at about a 20-25 degree angle. This correlates with the weak glut max and tight/weak psoas.
Sarcevic (2008) did a study in regards to the relationship between limitations in ankle dorsiflexion and the occurence of Morbus Osgood Schlatter in children that were participating in athletic activities. He studied 45 children, all of whom were clinically diagnosed with Morbus Osgood Schlatter (MOS). Forty subjects were boys coming ages ranging from 11-14 years of age, and 5 subjects were girls, ages ranging from 10-12 years of age.
Sarcevic defines MOS as a “traction apophysitis of the tibial tubercle caused by repetitive strain, as well as a chronic avulsion of the secondary ossification center.” Many practitioners attribute the main cause of MOS to a strong, chronic pull of the quadriceps during athletic activities. The presence of inflexbility of the hamstrings and quadriceps is a common finding. Strategies for corrective exercise intervention included focusing on the thigh musculature (quads and hamstrings) and improving ankle dorsiflexion.
The results of the Sarcevic study showed that 37 of the 40 boys studied exhibited a dorsiflexion angle (DFA) of 10 ° or less, and 3 had a DFA of 10° or more. All of the 5 girls that participated in the study exhibited a DFA of 10° or less (Sarcevic, 2008). The quadriceps muscle group eccentrically decelerates the lower leg during the stance/ support phase of the running gait. Limitations in ankle dorsiflexion have been associated with pronation of the foot, internal rotation of the tibia, as well as an increase in knee flexion (Sarcevic, 2008). The lack of dorsiflexion in Julie’s ankle probably contributed to the torso lean during the overhead squat and her running gait. The combination of these motion disturbances and the presence of limitations in ankle dorsiflexion may create an increase in shear stress on the quadriceps tendon/ patellar tendon during the act of running. Limitations in dorsiflexion can be attributed to overactivity in the gastroc /soleus complex, and movement compensations are observed during the overhead squat as well as the single leg squat assessments. The correlation that Sarcevic is making between limited dorsiflexion and the presence of MOS can lead the practitioner to identify and address overactivity in the gastroc/soleus complex (inhibit and lengthen) as a possible way to proceed in designing a corrective exercise strategy. Self Myofascial Release (foam rolling) and lengthening techniques of static stretching and PNF can be useful tools in this situation (Clark and Lucett, 2011). This reinforces the concept that conditions such as Morbus Osgood Schlatter should not only focus on a localized area , but address dysfunction affecting the entire kinetic chain.
Initial treatment focused on relieving the pain around the patella, using warm laser. I did soft tissue/fascial therapy to the quads, hamstrings, gastrocsoleus, and psoas. I performed mobilization to the ankle joint to increase dorsiflexion. I had Julie perform foam rolling to the overactive calfs, and stretch the quads and hamstrings. I got her to perform one-legged bridges to increase glute max strength. I felt that she was overusing her quads as a consequence of poor hip flexion. Julie’s symptoms eased up quickly once we restored ankle dorsiflexion and she could recruit her stabilizing muscles. I encouraged her to continue her exercises for eight weeks so she could fully incorporate the muscular recruitment patterns into her soccer play.
Clark, M., and Lucett, S. NASM Essentials of Corrective Exercise. (2011) Lippincott Wiliiams and Wilkins. Baltimore, MD.
Sarcevic, Z. Limited Ankle Dorsiflexion: a predisposing factor to Morbus Osgood Schlatter? (2008) Knee Surgery, Sports Traumatology, Arthroscopy. 6: 726-728