I had Osgood Schlatter's Disease myself in both knees as a kid. Mum entered some fun-runs in the 80's and we used to go running together. I was training more than I should have for cross-country in years 5, 6, and 7, and suffered terribly. Terrible night pain. I used to cry. Mum took me to a GP who confirmed the diagnosis with an x-ray and told me to stop running. Crazy sounding diagnosis.

I ran less, and it eventually stopped hurting. I've still got decent bumps on my tibial tubercles to show for it.

Osgood-Schlatter's is an overuse injury of the spot where the quadriceps muscle attaches on the front of the knee (tibial tubercle). It’s the tendon where the quad anchors onto the tibia. It gets sore with too much running, jumping, and kicking. Usually 9-12 year olds. Quite often if they’re having a bit of a growth spurt while they’re doing a lot of training. The body is busy spending resources on the growing, and so the recovery between training sessions doesn’t keep up.

It’s usually sore after training when you cool down. It can ache in bed at night.

We say that it is self-limiting, which means it eventually gets better when you stop growing, but who wants to wait that long?

There’s no long-term problems from it. Once it stops hurting it’s all OK.

It doesn’t need an x-ray or a scan, or any injections or surgery. It's an easy clinical diagnosis and simple conservative management.

DO:

• Try and get to bed earlier. The knee hurts more if you've stayed up a bit later this week.
• Recover after training with good nutrition.
• Ice pack 10mins, 3/day, particularly when it's sore after training.
• Isometric strengthening exercise.

DON’T:

• When it’s sore you’ve got to cut back on running / hopping / jumping / kicking. So that might mean drop 30mins from a training session. Or do a session or two less this week. Or avoid the sprint work and long kicks in a session.

It’s really a matter of adjusting the running load day-to-day depending on how sore it is. If it’s sore - do less.

It's an injury that needs managing through the season. I try and get kids to do a bit less running at training and save it for game day. If it's sore on game day and you need to keep playing, it's safe, in that, it's not going to snap or pop. But it will hurt more for longer if you push through, which is what just has to be done some times.

​Funny sounding name. Not funny at all when it's sore.

Managing training load is crucial in injury prevention and treatment. A graphic in Tom Goon’s blog visualises how training load outweighs all other factors.

Historically we have advised that training loads shouldn’t increase by more than 10% a week. I’m not sure where this number comes from; I’ve got no problem with it; it seems reasonable, and I’ve quoted it hundreds of times.

There’s a 2015 BJSM podcast interview with Tim Gabbett on load management for injury prevention. Specifically Tim talks about this paper:

Spikes in acute workload are associated with increased injury risk in elite cricket fast bowlers 
- Billy T Hulin, Tim J Gabbett, Peter Blanch, Paul Chapman, David Bailey, John W Orchard, 2013.

It is research into fast bowlers, but the principles apply just as well to any athlete.  

The authors measured the acute workload of the last 7 days (and call it “fatigue”) and compare that to the chronic workload of the previous 4 weeks (which they call “fitness”).

For runners, if the training is reasonably homogenous, we could most simply measure the workload as the total kms/week.  

Or we could be more accurate and account for a mixed training program that may include a variety of hills / sprints / cross training etc, by giving each session a rate of perceived exertion (RPE) out of 10, and multiply that score by the number of training minutes:

Training load = session RPE x duration (minutes)

This is called a Foster’s Score, and provides a simple method for quantifying training loads from a variety of different training modalities.

The research subtracted the current one-week average from the previous 4-week average and called this number the “training-stress balance”.

A negative training-stress balance increases the risk of injury by 4 times.

So:

[Last 7 days’ session RPE x duration (minutes)] - ([Last 4 weeks’ session RPE x duration (minutes)] / 4) = TRAINING-STRESS BALANCE

Negative balance = 4 times risk of injury

Essentially this formula means you shouldn’t increase your training load by more than 25% a week.

For people that may be more vulnerable to injury I would change the 4-week average to a 6-week average, therefore, bringing the increase in load each week down from 25% to 16%.  

This more cautious group could include: 

• Pre-season training
• Kids going through growth spurts
• Athletes returning from injury
• Known history of over training injuries
• People without any training history
• Novel exercise modality

A recently published article by Haroy et al, in the British Journal of Sports Medicine, described a simple exercise routine that decreased the number of groin injuries in male footballers by 41%.
​
Groin injuries are very common in football. Research shows that weaker groin muscles are associated with an increased risk of groin muscle injury. So strengthening groin muscles can potentially prevent injury.

The paper studied the Copenhagen Adduction exercise, which has previously been shown to strongly recruit adductor longus.

​Haroy et al, offered the Copenhagen at three levels of resistance, based on the players’ pain. Players started with Level 3. If the exercise gave them more than 3/10 pain, they were instructed to do the exercise level below instead: 3 > 2 > 1.

​The training protocol is shown in the following table:

Being only one, quick exercise, compliance was high. They found performing the Copenhagens decreased the risk of groin injury by 41%.

The full article is HERE.

Copenhagens are definitely worth adding to your training. The concept is similar to strengthening hamstrings with the Nordic Hamstring Curl which has been shown to prevent 70%-85% of hamstring strain injuries.

Summary of: 
FOOTBALL RECOVERY STRATEGIES 
(Grégory Dupont, Mathieu Nédélec, Alan McCall, Serge Berthoin and Nicola A. Maffiuletti, 2015)

• High intensity exercise leads to fatigue.  
  
• Fatigue causes a decline in performance.  
  
• A high percentage of injuries occur late in each half of a game, suggesting that fatigue is a risk factor for injury.

• Combination of central and peripheral factors.
  
• Central fatigue = decreased maximal voluntary muscle contraction and sprinting ability.
  
• Peripheral fatigue = muscle soreness, damage, and inflammation.
  
• Depletion of glycogen stores.
  
• Dehydration.
  
• Muscle damage / stiffness / swelling.
  
• Mental fatigue / motivation.
  
• Jet lag / disrupted body clock / stress / poor sleep.

• Immediately after a match, 20M sprint time, quadriceps strength, and vertical jump height are decreased by about 10%.  
  
• Full recovery can take between two and four days.  
  
• Injury rates are increased when there are less than 6 days between matches.

"When playing two matches per week, the 3-day recovery time between two successive matches may consequently be insufficient to fully recover."

Immediately after a match, players should drink a large volume of fluid (about 150% of the sweat loss) with a high concentration of sodium (about 500 to 700 mg/L of water), flavoured milk, and tart cherry or berry juice. Then, they should eat a meal containing high-glycaemic index carbohydrate and protein within the hour following play.

Rehydration and consumption of carbohydrates and protein are effective techniques for optimising repair of muscle damage.  The addition of sodium at 500-700mg/L promotes fluid retention, stimulates thirst, delays urine production, and increases glucose absorption.  It is recommended to drink a large volume of fluid after the match instead of small quantities gradually.

It is recommended to take 1.2g of carbohydrate per kilogram of bodyweight per hour for up to 5 hours after a match to enable maximum re-synthesis of muscle glycogen stores.

20g of milk protein during the first 2 hours of post-exercise recovery stimulates muscle protein synthesis.  Flavoured milk is an effective beverage for post-exercise recovery. It contains carbohydrate and proteins in similar amounts to those used in studies demonstrating improved post-exercise recovery.

Juices such as tart cherry juice, tomato juice, or berry juice are also recommended to enhancing the recovery process. These juices are loaded with a high antioxidant capacity, which reduce oxidative stress and inflammation.

Alcohol delays recovery as it is a diuretic, increases urine output, impairs sleep, delays the muscular recovery process, and decreases maximal strength.

• Sleep is an essential part of recovery management.
  
• Lost sleep reduces endurance performance, maximal strength, cognitive performance, and the immune system.  
  
• Less than 7 hours sleep per night triples the risk of infections and double the risk of musculoskeletal injuries.
  

• Several meta-analyses confirm the benefits of cold-water immersion for recovery.
  
• The recommended regime of cold-water immersion is: whole-body immersion lasting 10 to 20 minutes at a temperature of 12 to 15°C immediately after the match.
  

• Active recovery performed after a match does not present any benefit for physical performance.
  

• Most studies fail to find a significant beneficial effect of massage for recovery.
  
• Psychological benefits: decreased subjective symptoms of soreness / improved perceptions of recovery.
  

• There is no substantial scientific evidence to support the use of stretching to enhance post-exercise recovery.
  
• Stretching is not clinically worthwhile in reducing muscle soreness in the days following exercise. 
  
• Recovery of physical performance is not improved after stretching.
  

• Meta-analysis on the effects of compression garments on recovery following damaging exercise indicated that the use of compression garments had a moderate effect on recovery of muscle strength, muscle power, creatine kinase and in reducing the severity of delayed onset muscle soreness.  
  
• A placebo effect due to wearing the garments could not be excluded.
  

1. The first step is hydration; the mass of the players should be measured and compared to the pre-match body mass in order to propose the appropriate quantity of fluid to drink (150% of body mass lost). The fluid should contain a combination of water and a large amount of sodium (500 to 700 mg/L of water).
   
2. The second step consists in drinking a tart cherry juice and chocolate milk in order to restore glycogen, to reduce oxidative stress and inflammation, to stimulate muscle repair and to promote quality and quantity of sleep.
   
3. The third step is the cold bath. The players should immerse themselves up to the neck at a temperature between 12 and 15°C for 10 to 20 minutes to accelerate the recovery process.
   
4. The fourth step is to wear a compression garment until bedtime.
   
5. The fifth step is to eat a meal high in carbohydrate with a high-glycaemic index and protein within 1 hour after the match (for example soup, well-cooked white pasta or mashed potatoes, chicken or fish, yogurts or cake).
   
6. The final step is to have a good night’s sleep.
   

WATCH DR DUPONT'S PRESENTATION AT ASPETAR'S POST-EXERCISE RECOVERY CONFERENCE:

​I’d guess that most people feel guilty about not stretching enough.

Interestingly, health professionals have changed our tune about the importance of stretching. Research over the last 15 years has suggested static stretching is not as beneficial as was once thought. I’ve been having conversations about the reasons to stretch (or not) for at least the last 15 years, but the current science on stretching just isn’t catching on with the general public.  

So, what do we know?…
​

No.  

​There is a lot of evidence that stretching does not reduce the risk of injury. This systematic review and meta-analysis of randomised controlled trials found stretching does not prevent injuries, whether done before or after training. This randomised controlled trial, and this systematic review concluded stretching before exercising only reduces the risk of injury by less than 1%.  

​Therefore, in practical terms the average athlete would need to continuously stretch for 23 years to prevent one injury. Definitely not worth it.
​

No.  

A systematic review concluded that stretching before or after exercising does not confer protection from muscle soreness (ref). Stretching was found to reduce muscle soreness by a trivially small amount - less than 2%.

​No. Stretching for the amount of time that most people hold their stretches, does not make any actual difference to flexibility. The mechanisms of stretching have been extensively studied. There is moderate evidence from a systematic review that stretching can increase flexibility (ref). However, to achieve an actual improvement in muscle compliance we know the total duration of stretching needs to be at least five minutes per muscle group (ref). Therefore to stretch hamstrings, quads, and calves, both left and right, as part of a warm up before sport, it should take at least 30 minutes - which is practically impossible as part of a warm up. We know the one or two, thirty second stretches the majority of athletes would perform during their warm up are just not enough to actually improve flexibility (ref).
​

What people find most surprising about static stretching is it impairs subsequent performance (ref).

A substantial body of research has shown that sustained static stretching acutely decreases muscle strength and power (ref). Stretching before an endurance event lowers endurance performance and increases the energy cost of running (ref). Cycling efficiency and time to exhaustion are reduced after static stretching (ref).

Pretty much any measure of performance is made worse by stretching.  Static stretching impairs: 

• strength
• maximal  voluntary contraction
• isometric force
• isokinetic torque
• one repetition maximum lifts
• power
• vertical jump
• sprint times
• running economy
• agility
• balance

A comprehensive review (ref) from 2011 concludes:

​Obviously, I’ve been talking about sustained, static stretching. It has been shown that there is no stretch-induced strength loss with dynamic stretching (ref). However, the efficacy of dynamic stretching for increasing flexibility is yet to be determined (ref).
​

I do get people to stretch if there’s a specific pathology that needs treating. And you do need to stretch if you need flexibility to achieve certain positions in your sporting performance (hurdlers / gymnasts / divers, etc).
​

If you’re happy with your stretching routine, keep doing it. If you think it feels good to stretch after exercise then there’s no harm. But I definitely wouldn’t recommend stretching at the expense of other techniques that are proven to aid recovery.

​Osteoarthritis (OA) is a leading and increasing cause of disability and has a significant impact on health-related quality of life. OA places considerable burden on the Australian  healthcare system, affecting 2.1 million Australians (ABS 2022) and costing $4.3 billion annually. 

Osteoarthritis is a structural change to the cartilage and boney surfaces in a synovial joint. Most of the joints in our skeletal system are synovial joints, which is where two opposing bones articulate in a joint capsule filled with synovial fluid. The synovial fluid is a lubricant to help the joint move, as well as a source of nutrition for the cartilage that lines the joint surfaces. The articulating surfaces in synovial joints are lined with articular cartilage, which is a smooth, glossy surface to decrease the friction in the joint (as opposed to fibrous cartilage, which is the rubbery type cartilage that plays a more structural role, found in the meniscus in knees and the rubbery part of your ribs, nose, and ears).

The fleshy parts of muscles and organs is pink because it is full of blood, which brings oxygen and nutrition, and is important for healing damage. Cartilage looks white because it doesn’t have a blood supply, so articular cartilage relies of the synovial fluid for its nutrition. This isn’t as effective as having a blood supply, so when cartilage is damaged it doesn’t heal well. Nanna damages the cartilage in her knees and it never really repairs.

Once articular cartilage is damaged, the joint tries to reinforce and repair the damaged area by laying down new tissue. It would be great if cartilage repaired itself with new cartilage cells, but the joint wants to make itself even stronger than the obviously insufficient cartilage, so it lays down a stronger building block - bone cells. So when we say that Nanna has “worn away” her knee to the point where it’s “bone on bone”, it’s not just that she’s worn away the cartilage, but actually there’s also a build up of “extra” bone, as the knee tries to make itself stronger than cartilage. Rather than being a nice smooth, glossy surface, the extra bone is now a bit rough, so we might hear and feel some gravely crunching and creaking in an osteoarthritic joint.

Osteoarthritis occurs most frequently in the knees, hips, hands, and spine and is more common the older we get. 59% of people with OA have knee OA. Osteoarthritis is diagnosed with an X-ray that shows the changes to the bony profile in the joint.

When we look at what causes osteoarthritis:

1. The biggest contributor is a previous traumatic injury that has physically damaged the cartilage. This can be a landing/twisting injury or sprain, where the trauma of knocking one bone against the other, takes a “divot” or tear in the cartilage, or bruises the cartilage and underlying bone. 
2. The second biggest cause of osteoarthritis is genetic - the way our joints age, based on our family history. Nanna had a hip replacement and so will I.
3. The third biggest contributor to osteoarthritis is BMI. Every 5 kg of weight gain, confers a 36% increase in the risk of OA. Interestingly, it isn’t the extra pressure through the joints of being heavy that causes a problem - fat people have a higher rate of hand osteoarthritis too (which are non weight-bearing joints). The problem with BMI is the systemic inflammatory effect of cytokines produced by fat tissue. Being fat causes inflammation that irritates joints, so fat people get osteoarthritis (and have heart attacks from the scarring/hardening of coronary arteries, also as a reaction to systemic inflammation caused by adipose tissue).

Osteoarthritis isn't painful most of the time. At a certain age, essentially everyone will have arthritic changes in their joints without knowing about it. When we X-ray the joint, it doesn’t look as good as it used to, but it doesn’t hurt. It’s a bit like my grey hair and wrinkles - they don’t look great anymore, and it's a sign that I’m getting older, but I don’t expect them to be painful.

If an arthritic joint is painful, it tends to go through phases of being sore and not being sore at all. It can be sore for a day, a week, a month, or a year, but then will be fine again. Whether or not it is sore is not determined by the severity of the changes we see on the X-ray. We can see nasty looking joints that have never been sore, and we see very sore joints that look fine on the X-ray. There isn’t much of a correlation. 

What determines whether or not the osteoarthritis hurts is the body’s perception of "vulnerability" in that joint - essentially whether or not it feels strong or weak. Pain is an alarm system “software”, employed to defend against damage to the "hardware”. We can have different levels of sensitivity of how easily the alarm is triggered. Very commonly, an arthritic joint starts to hurt more after a period of rest, as the body looses some fitness, muscles loose some strength, an arthritic joint gets less support from the external scaffolding of the muscles, it feels more vulnerable, and communicates that by being painful, as a way of saying “be careful”.

So that gives us some treatment options for arthritis:

WEIGHT LOSS (Adipose)

• We know that a 5kg reduction in weight over a 10-year period decreased the likelihood of symptomatic knee OA by 50%. 
• Losing 5% of body weight has been shown to provide some pain relief, and 10% provides significant reductions in pain.

EXERCISE

• Stay as active as possible. Rest doesn’t help. Improve muscle mass and strength so the joint is more supported and feels less vulnerable.
• Both aerobic walking and quadriceps' strengthening exercises have been shown to reduce pain and disability in subjects with knee OA.

PAIN RELIEF

• Paracetamol.
• Hot packs.
• Taping.
• Sleeves.

SURGERY

• There’s a lot of research showing that “tidy up” operations, or arthroscopic surgery for osteoarthritis is no better than an exercise program. It’s the exercise you do after the surgery that provides more benefit than the surgery itself. 
• For people that never get on top of their arthritis with weight loss and exercise, the pain can get so severe that they end up needing a total joint replacement, where the bones are replaced with a metal and plastic joint. 

How do you decide when it’s time to have a joint replacement?

I suggest it’s time when you really can’t walk anymore because of the pain, and/or the pain is stopping you sleeping at night. Joint replacements last for about 25 years on average, so don’t rush into doing it too early. The rehab after surgery is 3-12 months before the leg completely feels like it’s yours. The joint replacements are good for relieving pain, but unfortunately we don’t see improvements in patients’ activity levels after surgery. Total hip replacements are easier all around than total knee replacements.