This year I noted more treatments of adolescents with pain at the front of the knee and I had many more discussions with parents about this too. I am at the stage of having teenage children myself so I am in this “circle” and it was also late winter/early spring so the later part of the season for popular sports such as football and netball.
The knee is a complex joint, allowing bending while supporting heavy loads and changing directions.
It is sensitive to small problems in alignment, activity, training and overuse and any sport which involves a lot of running, jumping, change of direction or direct knee trauma is “hard” on the knees.
So, I want to explain why adolescents are susceptible to knee pain and what we can be done to prevent the knee pain next season and treatment options.
The knee pain I am talking about here is not from a specific injury but gets better with rest and is worse with/after activity and generally I find it is accompanied by excessive quadricep tension.
Why adolescents are prone to anterior knee pain?
Adolescents grow fast, often going through growth spurts, and their bones grow quicker than the muscles, tendons and fascia (our soft tissues). For the knee this means the femur (thigh bone), tibia and fibular (lower leg bones) and the patella (knee cap) are growing and also changing shape.
Recent research on teenage knee pain is pointing towards an association between the teenage knee pain and alterations in the knee cap shape and also the dislocation of the knee cap.
2 - on the boney protrusion (tibial tuberosity) a little more underneath the knee cap - this is called Osgood Schlatter Disease.
The causes of the two are similar, they are both caused by the excess pulling of the patella tendon. The patella tendon is the tendon of the quadriceps muscles of the thigh, they merge into one tendon just above the knee and it continues down across and around the knee cap and inserts on the tibial tuberosity (a boney protrusion). Tendons attach muscles to bone.
In the case of Osgood Schlatters there is too much pulling on the insertion point of the tendon, the tibial tuberosity, which is cartilage and thought to be weak before maturity and this causes the tenderness, inflammation and sometimes a more pronounced “bump” on the tibial tuberosity plus sometimes thickening of the patella tendon. This normally occurs in girls age 8 -12 and boys 12 - 15 years.
For Sinding Larsen Johansson syndrome this is inflammation of the patellar ligament and so pain is immediately beneath the knee cap, again caused by too much pulling. Interestingly, this occurs mostly in younger boys and aged 10-13 years.
Both Osgood Schlatters and Sinding Larsen Johansson are not permanent diseases and they tend to ease with age when growth is less rapid. However it is worth noting that there is evidence suggesting some adolsecent knee pain correlates with knee pain into early adulthood .
Knee pain can exist without there being the obvious pain from either of the two above diagnoses. The predisposing factor associated with anterior knee pain is “tight” quadriceps and hamstrings.
Adolescents who enjoy sport are naturally physically active and generally continue with their sport despite pain. It is hard to stem their activities, as many are part of teams, any time out can be a LONG time for an adolescent and sport provides a great physical and mental outlet.
The two most common and identifiable causes of knee pain in adolescents are both underneath the knee cap.
They are in slightly different sites at the front of the knee:
1- immediately underneath the knee cap - this is called Sinding Larsen Johansson Syndrome2 - on the boney protrusion (tibial tuberosity) a little more underneath the knee cap - this is called Osgood Schlatter Disease.
The causes of the two are similar, they are both caused by the excess pulling of the patella tendon. The patella tendon is the tendon of the quadriceps muscles of the thigh, they merge into one tendon just above the knee and it continues down across and around the knee cap and inserts on the tibial tuberosity (a boney protrusion). Tendons attach muscles to bone.
In the case of Osgood Schlatters there is too much pulling on the insertion point of the tendon, the tibial tuberosity, which is cartilage and thought to be weak before maturity and this causes the tenderness, inflammation and sometimes a more pronounced “bump” on the tibial tuberosity plus sometimes thickening of the patella tendon. This normally occurs in girls age 8 -12 and boys 12 - 15 years.
For Sinding Larsen Johansson syndrome this is inflammation of the patellar ligament and so pain is immediately beneath the knee cap, again caused by too much pulling. Interestingly, this occurs mostly in younger boys and aged 10-13 years.
Both Osgood Schlatters and Sinding Larsen Johansson are not permanent diseases and they tend to ease with age when growth is less rapid. However it is worth noting that there is evidence suggesting some adolsecent knee pain correlates with knee pain into early adulthood .
What can be done to prevent this type of knee pain?
Adolescents who enjoy sport are naturally physically active and generally continue with their sport despite pain. It is hard to stem their activities, as many are part of teams, any time out can be a LONG time for an adolescent and sport provides a great physical and mental outlet.
However for symptom relief a combination of training load reduction or rest and the limitation of the movement/sport that generates pain needs to be considered for improvement. This should also be combined with progressive muscle strengthening and a progressive return to activity. The muscle strengthening aims to address muscle imbalances (muscle “tightness”, strength and weakness).
A recent study (2) over a 12 week period demonstrated high rates of success with knee pain improvement following a plan with included activity modification and load management in the first 4 weeks, then doing progressive home-based exercises and progressing to a gradual return to play over a 12 week period. Throughout the study pain levels were monitored and activity and exercises adjusted accordingly.
This result is encouraging and this approach appears a good first strategy.
A recent study (2) over a 12 week period demonstrated high rates of success with knee pain improvement following a plan with included activity modification and load management in the first 4 weeks, then doing progressive home-based exercises and progressing to a gradual return to play over a 12 week period. Throughout the study pain levels were monitored and activity and exercises adjusted accordingly.
This result is encouraging and this approach appears a good first strategy.
Sports Massage and Remedial Therapy role is:
to help reduce knee pain by treating the “tight” leg muscles (the quadriceps, hamstrings and calf muscles which all directly influence the knee) and to provide guidance to both the adolescent and parent on monitoring pain levels, modifying activities, home strengthening exercises and to advise on return to sport.
It is worth noting that there are other factors that may contribute to adolescent anterior knee pain:
Other things to consider:
- Imbalance of thigh muscles (quadriceps and hamstrings particularly) that support the knee joint, one is tighter or stronger than the other.
- Problems with alignment of the legs between the hips and the ankles
- Using improper sports training techniques or equipment
- Footwear suitability and changes in playing surface.
As always any questions on any of the above please get in touch.
Nicky Holbrook
June 2023