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Hi there, I was wondering if anyone could give me some advice on a fourteen year old patient I observed during a training clinic recently. He presented with left knee pain in the pataellofemoral area and had a diagnosis of Osgood-schlatter's disease. On observation during examination he had a marked genu valgum of the left leg with an internally rotated tibia and marked forefoot adduction. When he walked the left leg circumducted noticeably and he walked in low gear with both feet. Both his Hallux were markedly abducted from the midline of his feet and the lesser toes leaving a fair space between them and appeared excessively long compared to his other toes although palpation of his mtpjs did not show an abnormal parabola position. He could not evert his left foot during examination although the right was fine. He did not appear to have any leg length discrepancy and he stated that he was not sporty but quite clumsy. His younger brother suffered from dwarfism but there was no other family history of growth or MSK problems. His Hamstrings were extremely tight.
He was referred from Physio and was referred back there for stretching exercises. Can anyone tell me what tests would be expected to be carried out on this patient and what could be done as a short term/long term treatment optio please? What was going on here and could Podiatry offer him a better solution than this? Any thoughts greatly appreciated :)

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Hi Maloures,

There is a possibility of femoral anteversion or tibial torsion here. Alternatively, the position of the acetabulae may be too far forward. These conditions are developmental and are usually bilateral, but they are all causes of intoeing.

The halluces might be at fault - metatarsus primus adductus?

Any of these conditions is unlikely to improve beyond the 15th year and will probably require orthopaedic surgery for correction.

As the mother of a son who had the condition, I would say that the condition is self limiting and needs no intervenion other than the child not exercising to the point of discomfort. My son had a growth spurt, was very tall for his age.and the condition was exacerbated by cross country running.
He wore a simple arch support as he does have flat feet, did less cross country running and grew out out of the condition within a year or so. He now has no problems, does not need to wear an arch support and can partake in sport as he desires.

To talk about surgery at this stage is a little premature.

CM

maloures,

Please can you give more clinical data to help us help you , e.g. Pain increases on activity , hip flexor tightness, glut Med strength , tib post strength, any developmental delay ,barlow manoeuvre, is hamstring tightness biased, image diagnostics ect. Ect. 

Also don’t forget your DDx’s such as Sinding-Larsen Johansson Disease, Referred SCFE ect.

Thank You , Jon

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There is lots to consider.

Yes its self limiting generally.

Surg should be an after thought.

Rest , ice and treatment to reduce the loads on the insertion of the patella tendon are important.

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Crazy Mary

Hi Jon, thanks for the help; basically this young person had been referred to Podiatry by a physio who had diagnosed Osgood-Schlatter as a tentative diagnosis and there were no x-rays etc to accompany the case. There was no pain/swelling etc around the tibial tuberosity; the young man was not particularly sporty but did like to walk and he felt as though his left knee and left ankle were giving way laterally and this made him feel discomfort.
The Podiatrist I was with did a full range of muscle testing etc and his hamstrings were tight; he had difficulty extending his left leg at the knee - no hip or back pain.
His left tibia appeared internally rotated as did the knee when left to swing loose from the end of the couch and on standing you could see that his left tibia did internally rotate and his left knee faced slightly inwards. His feet were also showing forefoot adductus with it seeming particularly marked on the left side with both hallux having a wide space between them and the second toes. (metatarsus adductus?) Both his hallux were also extremely long. He could not evert his left foot at all either non-weightbearing or weightbearing but did not appear to have sensory problems of any kind (Peroneal problems?) and his walk was as described above.
Apologies for the not so scientific description (still getting to grips with a lot of the terminology as a student). I thought this would be an interesting case study but felt that his referral back to a physio could have been unnecessary? What could be done for a person of his age conservatively and is surgery a last resort? Also what would be the overall diagnosis? Is it internal Tibial torsion with related pathologies of the forefoot or peroneal dysfunction or metatarsus adductus etc etc. The decision was made on the basis of until the knee instability was sorted out it was best to ,eave any orthotics etc until later.
I just found it quite an involved set of problems and an interesting introduction to the clinical environment. All your thoughts appreciated
Regards, M

Hi M,

[quote=maloures;186983]still getting to grips with a lot of the terminology as a studentQUOTE]

Did this patient present in a Univeristy Clinic?

Jon

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Hi Maloures,

I'm late to this discussion, but it seems to me that all the talk of bony torsions and surgery may be a bit premature. Might be best to take things back to the beginning, keep things as simple as they can be and try to actually form a diagnosis.

My opinion is that in a non-sporty lad with no pain or swelling in the region of the tibial tuberosity then we are probably not dealing with Osgood-Schlatters. But that's just my gut feeling from my sofa having not seen the patient.

Re-visit what you do and don't know about the patients symptoms and work through it logically.

Ian

Just my two cents but have you considered that the knee pain at the patella femoral on the anteverted side might be due to the disproportionate vector of pull of each of the quadriceps when loaded? Ie: the vastus lateralis wants to pull straight with an internally rotated knee complex and is causing lateral wear on the articular surface of the patella. Also with tight hams there will be an increased transverse rotation if the tighter of the group is semimemb. and semitend. during ambulation. How is the pain when stair climbing?

Just a thought.

[quote=Jon Griffin;186985]Hi M,

Hi Jon, no, most definitely not; I would have had a chance to have asked far more questions if he had :)

Thanks Ian, after reading up on the condition afterwards I agree with this view and have tried to search and read literature that relates to each of the problems that were brought up during the consultation. In trying to write up a case study my aim was to talk about one pathology and discuss the differential diagnosis and why these were dismissed. He had a lot going on though and I wasn't sure which end to start as it were! I will keep plugging away :)

Related threads:
Other threads tagged with Osgood Schlatters
Ankle dorsiflexion and Osgood Schlatters disease
Osgood Schlatters/Sever's Disease
Taping/Bracing Osgood-Schlatter's

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