"The Strickland Protocol"

A Cure for Osgood-Schlatter's Disease

Chapters:

1. Who is Jenny Strickland? – Biography p3 2. What is Osgood-Schlatter’s Disease? p4 3. Who is affected? p4 4. What are the signs and symptoms? p4 5. Other causes of childhood knee pain? p6 6. What causes Osgood-Schlatter’s Disease? p6 7. Is Osgood-Schlatter’s Disease damaging and how long does it last? p8 8. Can it be treated? p9 9. What happens if it’s not treated? P10

10. How successful is the Strickland Approach? p11 11. The Strickland Approach p13 12. The Strickland Protocol p14 13. Prevention p26 14. Summary flowchart p27 15. Appendices – I. Pilot Study Abstract p28

II. Return to Sport Protocol p29 III. Quotes from other published authors p31 IV. Quotes from patients and parents p32 V. Risks and Responsibilities p33

16. BONUS CHAPTER: Stretching for kids p34

Who is Jenny Strickland? I was hand-reared in New Zealand and was mad about sport as a youngster. I didn’t suffer from Osgood-Schlatter’s Disease myself but can imagine how I would have reacted to being told by a medical practitioner to “give up sport until I grew out of the condition”! I played hockey and cricket as my main sports and was fortunate enough to represent my province (county) in both sports at the elite level, and was Captain of the Auckland cricket team for a number of years. I qualified as a (Chartered) Physiotherapist in 1984 and have spent my professional career specialising in sports injuries ever since. I was the team physiotherapist at International Level for many sports including New Zealand Women’s hockey, basketball, Cook Islands netball, England cricket and Lacrosse, and the 1990 Commonwealth Games to name a few. Most recently I was selected the Lead Physio at the 2012 Olympic and Paralympic Games Equestrian Venue. The pinnacle of my career to date. So I have been lucky to have been involved at the highest level in a number of sports which gives me an informed and experienced knowledge of how sporting injuries happen and what physical stresses occur in the different sports. I came over to England in 1992 to set up my own specialist sports injury clinic in Dartford, Kent where I still see patients. I also worked in the National Health Service (NHS) for a few years until I took up a Senior Lecturer’s position in Sports Science at Greenwich University in 1997, where I still am. This allows me, in my opinion, to have the best of both worlds – my patients and students pose me questions and my research tries to answer them. It is a never –ending learning curve that is exciting and very fulfilling. I am about to embark on the next stage of my formal learning and study for a PhD. I have published a number of academic papers about sporting injuries and have presented at International conferences and seminars. I have also run a number of courses for Physiotherapists on gait analysis (running) and shoulder rehabilitation. My discovery of this Osgood-Schlatter’s Disease treatment approach has been but one area that I like to think has made a difference to athletes’ lives. I will continue to try to answer the next questions I face.

What is Osgood-Schlatter’s Disease? Osgood-Schlatter's disease (not really a disease but more a syndrome) is the most common cause of knee pain in growing children. It affects between 10 – 30% of active children between the ages of 9 – 16, and can be extremely painful and debilitating. It appears as a painful and swollen lump at the top of the shin bone (tibia), below the tendon from the kneecap (patella), and can severely restrict the activity of youngsters especially in sports involving jumping, kicking and sprinting. Who is affected? Children who are going through their secondary growth spurts, between the ages of 9 to 16, but it depends on the child. Osgood-Schlatter’s Disease is ALWAYS associated with growth spurts. Additionally the kids are usually mad keen on their sports or involved competitively, so that they often spend more than 12 hours a week playing or training. Sports that involve lots of kicking, sprinting or jumping are most commonly involved (e.g. football/ soccer, gymnastics, basketball, netball, athletics), and of course there is a bias towards different sports in different countries so numbers are different in each country. But it is a world-wide problem that needs a solution. What are the signs and symptoms of Osgood-Schlatter’s Disease? It's usually pretty easy to see if your child has Osgood-Schlatter’s Disease. There is usually a swollen area or painful lump at the top of their shinbone (tibia), where the patella tendon from the front of the knee attaches.

Pain is the main symptom and is often worse after activity. The child will complain of pain and point to the front of their knee – exactly to the site of the lump. They will also often find that they can't run as fast or have pain when kicking or jumping. As the

condition worsens they may even find it difficult to go up and down stairs, squat or kneel. They may find that even walking after exercise becomes painful and you will notice them limping. Sometimes the condition appears gradually over a period of weeks or months, sometimes it seems to be set off by a knock or fall onto the knee. It can occur to either knee or sometimes both at the same time! It doesn’t appear to always be the dominant knee only. Tightness in their knee muscles is also a common feature, especially their quadriceps (muscle at the front of the thigh). Statistics show that boys tend to affected more than girls, but this may be due to sports participation levels as countries that have more equal involvement find the incidences more even. In my experience I have found about a 2:1 ratio of Boys: Girls in the United Kingdom. So if your child has...

1. A painful lump at the front of their knee 2. Is going through a growth spurt 3. Plays lots of sport 4. Is between 9 and 16 years old

...it is highly likely they will have Osgood-Schlatter’s Disease.

Visible lump of Osgood-Schlatter’s disease

Other causes of knee pain in kids? There are a number of rarer causes which you should be aware of if your child doesn't fit all of the above features. These include infections, malignancy (cancer), cysts, fractures and juvenile arthritis. If in any doubt you MUST consult with your Health Professional (Doctor, Physiotherapist etc), as these conditions will need swift and appropriate medical treatment.

What causes Osgood-Schlatter’s Disease ? There is no definitive answer to this yet. I am currently researching this topic so hope in time to be able to fill in some gaps to our knowledge about this disabling condition. However at present the consensus seems to be that there may be a muscle imbalance which puts more pressure on the soft growing centre of the bone (the epiphysis) which unfortunately is where the tendon is directly attached to. Think of a rope attached to cement that hasn't quite yet hardened – if you pull on the rope you will pull away some of the cement too. Hence causing pain, inflammation and ongoing repair. This is what we see with Osgood-Schlatter’s Disease with the soft bone being pulled away by a very strong muscle-tendon. The bone is not strong enough to take the load. However there is a growing awareness of the influence that tight muscles may play. In this situation there would be a constant background pulling on the tendon attachment site, which would be exaggerated with a forceful contraction such as seen with a kicking or jumping motion. And this base level of tightness would be greater in stronger athletes – like the ones that are vulnerable to Osgood-Schlatter’s Disease. My research suggests that the imbalance that occurs is a GROWTH imbalance between the rate of growth of the bone, and that of the muscle's ability to keep up with it! Anyone who has seen the sometimes phenomenal growth of these youngsters would testify to the fact that these children appear to add inches overnight! And 66% of their growth occurs in the knee region, so if a child grows 3 cm, 2 of those were either side of the knee (one above and one below). So both of these sites would be involved in Osgood-Schlatter’s Disease, and those 2 cm would have a direct effect on the attachment site.

I just think that the muscle can't keep up with this incredible growth spurt, and so pulls away from the bone. Osgood-Schlatter’s Disease is formally categorised as a 'traction apophysitis' condition which means a 'pulling away from the soft bone'. In fact it may not be the muscle itself but the fascia that wraps around it that is the culprit, but more on that as we go on. So if the muscle is tight, why can't we just stretch it? And here is the dilemma. If you perform a standard stretch to the quadriceps muscle, it will pull on the tendon attachment – making the condition worse, not better.

My approach takes this fundamental problem and we have proved that we can get around it.

To buy the Strickland Protocol treatment manual go to;http://www.osgood-schlatter-disease.com/buy-osgood-schlatter-manual.html