Osgood Schlatter Syndrome

Osgood Schlatter is a condition that causes knee pain in adolescents.  There is traction of the patellar tendon on the anterior tip of the tibia, at the bottom of the knee.   It is noticeable in children between the ages of 9-14, and it is especially noticeable in children who enjoy sports.  Sports with running or jumping tend to be associated with this condition.    The pain of this condition may be worse with kneeling, running, jumping, squatting, climbing stairs.  It may occur on one side or both sides.  It tends to be noticed after a growth spurt.

Normally the diagnosis can be made without an xray.   The range of motion of the affected knee is not affected.  Tenderness to touching the anterior tibia may be present.  Extending the knee against resistance may be painful, or there may be pain when squatting with the knee flexed.    A similar condition, jumper’s knee, will cause pain in the patellar tendon rather than on the tibia.

Most cases of Osgood Schlatter will resolve with icing and rest over several months.  Avoidance of sports is not necessary, although aggravating activities may be avoided.   Playing with mild pain is normally ok.   Occasional exacerbations may be noticed from time to time.  These should resolve quickly.  Stretching of the quad and hamstrings muscles prevents flare ups of this condition.

Surgery for Osgood Schlatter is not normally needed.  In some cases surgery is performed after growth ceases, since residual bone formation may interfere with knee mechanics.

Sometimes prominence of the anterior tibia is noticed after this condition.  Some people with this condition have a history of knee swelling or pain associated with activity.

Posterior Cruciate Ligament Injury

The posterior cruciate ligament (PCL) prevents the tibia (shin bone) from moving backwards relative to the femur (thigh bone).  Injuries to this ligament tend to occur when the knee is bent and the upper leg moves forwards relative to the lower leg, such as when it collides with a car dashboard or a person.

Injury to this structure may not cause many symptoms.  There may be pain in the back of the knee with squatting or kneeling, a slight limp, or loss of the full range of knee flexion.  With chronic injury to the PCL, there may be problems using stairs or ramps.

The principles of therapy are rest, ice, compression, elevation, medications and protection.  Often crutches are recommended if weight bearing causes pain, but otherwise crutches are not necessary.  Return to light duty activity is ok soon after an injury.

Most PCL injuries do not occur by themselves.  They are often associated with meniscus injuries or other trauma to the knee.  They are also difficult to distinguish from other ligament injuries to the knee.  When the PCL is injured, there is often no pop sensation, just a vague feeling of discomfort.

Meniscus injury

The meniscus is a piece of cartilage in the knee.  It looks like a contact lens holder, a pair of cups facing up at the top of the lower leg, where the bony prominences  of the upper leg bone (femur) slide back and forth.  The meniscus can be injured when the knee is twisted or bent, in particular when the knee is flexed.  Injuries to the meniscus are common in people who play sports such as soccer, basketball and football, but they can occur in anyone who twists their knee.

When the meniscus is injured, there is often swelling, pain, and decreased range of motion.

Treatment of the injured meniscus is best with the following:

Avoid positions and activities that irritate the knee, such as kneeling, squatting, twisting, or taking steps.

Elevation of the leg

Ice packs to the knee to reduce swelling and soreness

Using crutches if the pain is severe

Using a brace if the knee is unstable

As the pain improves, straight leg raising without resistance is recommended, as well as working with a physical therapist.

MRI studies and possibly a referral to orthopedic surgery are recommended when the above treatments are not helpful, or when the range of motion of the knee does not recover.

Sometimes a meniscus injury occurs with minimal trauma.  This tends to happen in people who are older.  Normally physical therapy is sufficient for improving this condition, and surgery is not needed.

Thoracic Outlet Syndrome

The thoracic outlet is a part of the body between the neck and the arm.  Three major structures pass through this – the nerves of the arm (the brachial plexus), the subclavian vein, and the subclavian artery.  Compression of the thoracic outlet structures often occurs by a muscle, muscular band or a cervical rib.  When any of these structures is compressed or squeezed, a person may develop symptoms of pain, color change, or numbness.  Sometimes these symptoms occur with specific arm positions.  This condition is known as thoracic outlet syndrome (or TOS).

Vascular thoracic outlet syndrome is a rare condition caused by compression of the subclavian artery or subclavian vein.  Sometimes these are referred to as arterial or venous TOS.  They may cause symptoms of swelling or bluish color change, pain in the fingers, coldness or pale coloration in the fingers, or poor oxygen supply to the fingers.  When compression of the vein or artery is confirmed, vascular surgery treatment is recommended.

Neurogenic thoracic outlet syndrome is a more common condition.  It may be related to a history of trauma or repetitive movement.  Symptoms of neurogenic TOS may include pain and weakness in the hand, pain in the neck or the back of the head, and tingling.  Coldness and color change may also occur, but this can be caused by nerve irritation rather than vascular changes.  No arm swelling or pulse changes are present with neurogenic TOS.

The symptoms of neurogenic thoracic outlet syndrome can sometimes be triggered by movement of the head or arms.  Rotating and tilting the head is one way to trigger the symptoms.  Another way is to raise the arms to the level of the shoulders , extend the wrists and tilt the head towards one side.  Sometimes this is a useful test during an office evaluation.  Congestion of veins on the chest or absence of a radial artery pulse with positioning of the arm is a helpful clue for vascular TOS.

Because TOS is affected by positioning of the arm, diagnostic testing for this can be misleading.  A chest xray will evaluate for the presence of an extra rib at the bottom of the neck.  The cervical rib is sometimes present at birth and it may influence symptoms of TOS.  In many patients, EMG or nerve conduction tests are normal.  The EMG is most helpful because it can assess for other conditions that mimic TOS.  MRI or MRA testing results can be variable, and often they are not helpful.

Treatment of TOS may benefit from physical therapy, medications, injection of anesthetic into a muscle that causes TOS, or sometimes surgery.  Surgery is rarely necessary for neurogenic TOS.

The following is a link to a thorough discussion of TOS, its diagnosis, and treatment at a TOS treatment center.


Broken bone repair


More than 600000 surgeries are done every year to repair bones.  Screws, plates or rods are used to fix the position of the bones so that they can heal.  The cost for this surgery varies from about $5000-30000, depending on the bone and the nature of the injury.

The goal of surgery is to move the broken bone to the right position and then maintain that position to facilitate healing.

Different tools and techniques are used to repair broken bones.  These include:

External fixation- a technique when screws or nails poke through the skin.  It is useful when there is injury to the soft tissues, when the skin and muscles are also unstable.

Rods or nails- for long, straight bones, a rod can be placed in the center of the bone to hold the ends together, or fixed to a splint to hold different positions along a line.

Screws- short or long screws can attach medium and larger bone fragments to each other, sometimes without any splinting

Titanium plate- a plate is used like an internal splint, to hold screws that would otherwise be unstable.   It is normally left inside although at times it can be removed.

Wires- are used for small bones that cannot be held by screws