1.5 Coxa vara and coxa valga

In adults the normal angle of inclination of the fem­oral head, or neck of the femur, is about 128 degrees. An abnormal increase in this angle is called coxa valga and a decrease is called coxa vara.

The acquired type of coxa vara is, by far, the most prevalent and occurs most often in adolescent boys between 10 and 16 years of age. It is commonly termed adolescent coxa vara.

The pathological mechanics of coxa vara and coxa valga result from the combined stresses of an abnor­mal increase or decrease in weight bearing. A varia­tion of more than 10 to 15 degrees can produce sig­nificant shortening or lengthening of an extremity.

Coxa valga and coxa vara can be caused by many etiological factors – for example, hip injury, paralysis, non-weight bearing, or congenital malformation. Coxa vara and coxa valga are described according to where the structural changes have occurred in the femur – that is, neck (cervical), head (epiphyseal), or combined head and neck (cervicoepiphyseal).

Adolescent coxa vara is found in boys who have displacement of the upper femoral epiphysis. Boys who are most prone to adolescent coxa vara have been found to be obese and sexually immature or tall and lanky, having experienced a rapid growing phase. Trauma such as hip fracture or dislocation may result in acute coxa vara. More often, through con­stant stress, a gradual displacement may take place.

Medical Treatment. Management in the early stages of coxa vara involves use of crutches and the prevention of weight bearing to allow revascularisation of the epiphyseal plate. Where deformity, displacement, and limb shortening are apparent, corrective surgery may be elected by the physician.

1.6 Osgood-schlatter condition

Many terms have been applied to the Osgood-Schlaiter condition; the most prevalent are apophysitis, osteochondritis, and epiphysitis of the tibial tubercle. It is not considered a disease entity, but rather the re­sult of a separation of the tibial tubercle at the epiphyseal junction.

The cause of this condition is unknown, but direct injury and long-term irritation are thought to be the main inciting factors. Direct trauma (as in a blow), osteochondritis, or an excessive strain of the patellar tendon as it attaches to the tibial tubercle may result in evulsion at the epiphyseal cartilage junction.

Disruption of the blood supply to the epiphysis re­sults in enlargement of the tibial tubercle, joint ten­derness, and pain upon contraction of the quadriceps muscle. The physical educator may be the one to de­tect this condition from the complaints of the stu­dent, who should be immediately referred to a phy­sician.

Local inflammation is accentuated by leg activity and ameliorated by rest. The individual may be unable to kneel or engage in flexion and extension movements without pain. The knee joint must be kept completely immobilized when the inflammatory state persists. Forced inactivity, provided by a plaster cast, may be the only answer to keeping the overactive adolescent from using the affected leg.

Therapeutic Treatment. Early detection may reveal a slight condition in which the individual can continue a normal activity routine, excluding overexposure to strenuous running, jump­ing, and falling on the affected leg. All physical edu­cation activities must be modified to avoid quadri­ceps muscle strain while preparing for general physical fitness.

While the limb is immobilized in a cast, the indi­vidual is greatly restricted; weight bearing may be held to a minimum, with signs of pain at the affected part closely watched by the physician. Although Osgood-Schlatter condition is self-limiting and tempo­rary, exercise is an important factor in full recovery. Physical education activities should emphasize the ca­pabilities of the upper body and nonaffected leg to prevent their deconditioning.

After arrest of the condition and removal of the cast (or relief from immobilization), the patient is given a graduated reconditioning program. The ma­jor objectives at this time are reeducation in proper walking patterns and restoration of normal strength and flexibility of the knee joint. Strenuous knee movement is avoided for at least 5 weeks, and the demanding requirements of regular physical educa­tion classes may be postponed for extended periods depending on the physician's recommendations. Al­though during the period of rehabilitation emphasis is placed on the affected leg, a program must also be provided for the entire body.

The criteria for the individual to return to a regu­lar physical education program would be as follows:

1. Normal range of movement of the knee

2. Quadriceps muscle strength equal to that of the unaffected leg

3. Evidence that the Osgood-Schlatter condition has become asymptomatic

4. Ability to move freely without favoring the af­fected part

Following recovery, the student should avoid all activities that would tend to contuse, or in any way irritate again, the tibial ruberosity.