Osgood-Schlatter Disease

Osgood-Schlatter disease is an overuse injury, medically known as a traction apophysitis.

It is a disease seen commonly in adolescent boys and is more common in athletes as compared to non-athletes.

The increased activity combined with rapid growth during the adolescent period predisposes athletes to develop this condition.  High intensity sport activity causes repetitive tensile stress over the tendon-tibial tuberosity and results in minor avulsions with an underlying inflammatory reaction.

Clinical presentation

Most commonly seen between 11-year and 13-year-old girls and between 12-year to 15-year old boys.

They generally present with pain over the tibial tubercle just below the knee. The pain is bilateral in only 20%-30% of patients. The pain is usually aggravated by sports involving jumping, squatting, kneeling and is relieved by a period of rest.


Treatment is conservative.

  • Activity modification
  • Rest, Ice
  • Short course of NSAIDs are usually used to reduce pain and inflammation
  • Massage
  • Stretching

Self limiting and will resolve when full skeletal maturity has been achieved.

Overuse injuries of the knee in young athletes

Knee pain is a common concern for which young athletes present to general practitioners, sports physicians and orthopedic surgeons.

Acute macro trauma to the knee, especially in contact or collision occurs less frequently and management is often in consultation with an orthopedic surgeon.

Overuse injuries affecting the knee account for the vast majority of adolescent related knee pain.

Causes of overuse injuries in the young athlete

The underlying pathophysiology of these injuries are related to repetitive and excessive strain on the musculoskeletal structures. This is often associated with a sudden increase in the intensity, duration and volume of physical activity, poor sport specific conditioning, insufficient sport-specific training, poor training techniques and inappropriate equipment for the sport.

Knee pain can either originate intrinsically from within the knee (see below) or referred from hip conditions and spine conditions.

Common causes of knee pain

  • Idiopathic anterior knee pain
  • Osgood Schlatter’s disease
  • Sinding-Larsen Johansson syndrome
  • Bipartite or multi-partite patella
  • Plica Syndrome
  • Iliotibial band (ITB) friction syndrome
  • Quadricep tendonitis
  • Popliteus tendonitis

Diet and the e-sport Athlete

(Written in collaboration with Goliath Gaming)

All athletes require monitoring of their diets to ensure optimal performance in their field of play. E-Sport Athletes are no different. E-sports might not be as physically demanding as more traditional sports, but can be mentally tiring.

Proper nutrition has been shown to increase physical and mental performance, both of which are key factors in e-Sports. There are a number of key factors involved in the success of e-Sports, including cognition, intact reflexes and focus. These factors can be influenced by the fatigue experienced by the player and the foods that he/she eats. Unfortunately, in a sport which involves a decreased caloric need, fast foods and energy drinks are more convenient. The added sugar in these foods lead to a spike and dip of glucose in the system. This results in the player being tired, both physically and mentally. This can result in poor performance immediately, but also puts players at risk of diabetes and obesity in later years.

The basic tenements of good e-Sports nutrition:

  1. Convenience is key due to time constraints
  2. All important micro and macro nutrients need to be included
  3. Vitamin D needs to be supplemented if most time is spent indoors
  4. Avoid sugary and high fat foods

What should a pro-gamers diet look like on game day?

The nutrition building up to a competition is an important facet in the performance of the team. Typically, one needs to eat a larger meal 2-4 hours prior to the competition. This allows for adequate energy stores to be built up prior to the competition and also enables the digestive system to process the nutrients.

A well-balanced meal needs to be eaten, including an easy to digest protein such as fish or meat (chicken/beef) and a well-tolerated side dish (low GI – sweet potatoes, brown rice). This aids in maintaining the glucose levels and prevents a spike and dip. Eating a well-balanced meal prior to the competition also ensures that players with digestive sensitivity minimize pre-competition digestive problems (nausea, vomiting, diarrhea, indigestion – particularly prior to competition).

Fast foods, unhealthy fats, energy drinks and hard-to digest foods need to be avoided prior to competition. Increased blood flow is directed to the stomach to digest these difficult to digest foods, resulting in a decreased mental performance. 

Just before a competition starts, players should be having foods which releases energy quickly, however, still maintains the glycemic level of the body.

 Examples of such foods are:

  • Muesli bars/date bars
  • Nuts
  • Fresh fruit and vegetables
  • Protein shakes or meal repl

Following a competition, due to the decreased caloric needs in e-Sports, it is more important to maintain a healthy diet with good portions of carbohydrates, proteins and fats. This ensures that players get a good night’s sleep following a competition and players maintain optimal mental function.


Supplements are used to optimize the diets of athletes. Suplememts are used to support immune function, decrease stress and anxiety and maximize micro-nutrients. 

Supplements that are important in supporting immune function:

  • Multivitamins
  • Vitamin C
  • Probiotics

Supplements used to reduce stress and anxiety

  • Sparse evidence for the use of CBD oil

Micronutrient supplementation important for e-Sport athletes

  • Vitamin D
    • E-sport athletes spend long hours indoors training so often require additional vitamin D
  • Magnesium
    • Supports the immune system and supports deep sleep
  • Omega 3+6

Example of a game day nutrition plan

Game Day Nutrition Plan  
Pre competition (2-4 hours)Larger meal with a good balance of carbohydrates, proteins and fats.Chicken, Fish, beef, brown rice, pasta, oatmeal, eggs.
Immediate pre competition (<30minute)Smaller snack to maintain energy and glucose levels to optimize mental and physical performanceNuts, fruits, snack bars, date bars
During competitionAdequate hydrationWater. Avoid sugary drinks and energy drinks
Post-competitionWell balanced meal as aboveAs above

Conclusion, as adapted by the British E-Sports Association

  • Eat five portions of fruit and vegetables day
  • Cut down on salt and sugary energy drinks
  • Choose wholegrain foods where possible
  • Good sources of proteins should be eaten – fish, beans, eggs, meats. Fish such as salmon or mackerel should be eaten twice per week to optimize healthy fats
  • Don’t skip breakfast
  • Keep hydrated – 6-8 glasses per day is the recommendation

Physio and Medicine Podcast with Cameron Coomer

A podcast chatting all things physiotherapy and medicine related. Giving you insight as a clinician, patient, or someone interested in the medical field! Cameron chats to sports physician Dr. Janesh Ganda about his experience of being involved in professional sports teams and the management of the player’s injuries as well as the impact COVID-19 has had on professional sport.

“Runner’s Knee”

Patello-femoral pain syndrome (PFPS) is the broad term used to describe pain at the front of the knee and around the patella, or kneecap. It is typically called Runners knee or Jumpers knee, as it commonly occurs in athletic individuals who participate in sports. This condition, can, however, affect non-athletes as well. The pain and stiffness that it causes can make daily activities, such as climbing stairs, kneeling, and performing other everyday activities.

A number of things can contribute to the development of PFPS, however, the most common things would be abnormal biomechanical loading, mal-alignment of the kneecap or patella, abnormal patella tracking and training loads which are often increased too quickly.

The knee joint is made up of the lower end of the femur, the tibia and patella. Ligaments and tendons connect the femur to the rest of the knee joint. The four major ligaments in the knee joint are the Medial Collateral Ligament (MCL, Lateral Collateral Ligament (LCL), Anterior Cruciate Ligament (ACL) and Posterior Cruciate Ligament (PCL). These ligaments help to hold the knee together.

The patella rests in the groove of the femur, called the trochlea groove. Movement of the patella assists in making the movement of the knee joint easier. When you bend or straighten the knee, the patella moves back and forth inside the groove. Articular cartilage is found on the underside of the patella, around the femur and the tibia. This allows for gliding of the bones over each other as you move your leg.

Synovium is also found, which is a thin lining of tissue covering the surface of the joint. This assists in lubrication of the cartilage.

What Is Patello-femoral pain syndrome?

Patellofemoral pain occurs when there is an inflammatory process around the structures of the knee, including the tendons, fat pad and synovial tissue.

In some cases, the articular cartilage behind the kneecap can be softened and eventually lead to breakdown. This is called chondromalaciae patella. The pain from this condition is often due to the inflammatory process surrounding the knee due to the cartilage damage. Cartilage has no nerve supply, so does not directly cause pain.


  • Overuse
    • Increase in loading exercises involving the knee
      • Jogging
      • Squatting
      • Climbing stairs
    • Use of improper footwear
    • Changes in playing surface
      • In a Cape Town setting, the camber of the roads can often lead to overuse type injuries
  • Patella Maltracking
    • Increased pressure around the knee region due to abnormal tracking which leads to inflammation around the knee region
    • Risk Factors
      • Muscular Imbalances
      • Improper form


  • Pain on activities that requires repeated bending of the knee
  • Pain sitting for long periods of time with the knee bent
  • Popping or crackling in the knee when climbing stairs or after sitting for a long period of time


Conservative Management

  • RICE for acute pain relief
  • Physical therapy
    • Often indicated to improve stability in the knee and strength around the knee joint
  • Orthotics
    • Indicated if the cause of the knee pain is due to abnormal foot shape

Surgical Management

  • Rarely done
  • Non-responsive cases of PFPS
  • Allows for removal of damaged cartilage or release of the tendon to correct cases of patella maltracking

The Importance of Sleep for e-Sport Athletes

(As published in The Citizen newspaper, in collaboration with Goliath Gaming)

Hundreds of millions of players are engaged daily in virtual and competitive electronic gaming – eSport(1). Player earnings from sponsorships are on the rise and the attention that eSports has received in recent months has increased. With the current COVID-19 pandemic, mainstream sports have decreased. This has seen an increase in the engagement of eSports that allows for socialization and social distancing. It is reported that eSports athletes may dedicate as much as 14 hours per day to practices and matches. This has led to integration of wellness programmes to prolong player performance and career longevity (2).

eSports requires players to have their eyes fixed on a computer screen with excessive exposure to light-emitting diodes (LEDs). LEDs are used to provide illumination for computers, smartphones, tablets and televisions. Recent research has demonstrated that excessive exposure to the blue-light spectrum from LEDs can create retinal and photoreceptor damage. Excessive exposure can also impact the natural circadian rhythm. Melatonin is a hormone synthesized in our bodies, and its role is in the regulation of the natural circadian clock. It is lowest during the awake hours during the day and typically rises at night before sleep (1). Excessive exposure to LED lights, as see in computer screens, can affect melatonin levels.

Sleep is an essential bodily function that frequently does not get sufficient attention. Some authors consider the three pillars of health to be: diet, exercise/ training and sleep. Olympic athletes typically get less than the traditional 8-hour recommendation of sleep per night, and are reported to sleep between 6.5 – 6.8hours per night. (3)

Traditional sports typically involve combination of physical and cognitive abilities. eSports, however, are more reliant on cognitive abilities.

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Negative impact of Sleep Restriction

Players are required to have intact visuo-motor and information processing speeds. Players are required to make quick motor movements in response to rapidly changing information from multiple human players and the environment. They are required to process visual information and respond with fine motor movements of their on screen avatar, which then requires precise movement of the small muscles of their hands.

Sleep restriction has been well documented to decrease reaction times, processing speeds and slower processing of visual information. This leads to impaired visuo-motor performance and effectively “slows down” the eSport athlete, putting them at a competitive disadvantage (4)

Two additional key cognitive processes are attention and working memory.  Attention is required for sustained periods, as eSport matches go for upwards of 40minutes. Selective attention is required to remain focused on the in-game elements and to reduce the impact of out-of game distractions (spectator noise in an arena). Working memory is then required to manage goals both in the short-term and the long-term (e.g. sticking to a predefined battle plan) (4). Sleep restriction has been shown to reduce performance decrements in selective and sustained information, as well as working memory.

The resultant errors due to sleep restriction on reduced reaction times and decreased processing speeds; brief attentional lapses and impaired tactical awareness can be the difference between success and failure in eSports, particularly at the professional gaming level.

Positive effects of sleep extension

Sleep extension refers to increasing sleep duration, thus can either be by supplementing a night of sleep with a nap, or prolonging the night’s sleep. In studies done on traditional athletes, it was noted that sleep extension improves sprint times, tennis serve accuracy, swim sprint and basketball shooting accuracy.

Cognitive performance also improved, ranging from reaction times, psychomotor vigilance tasks, alertness, vigor and mood (3). This all likely translates to better performance in the game due to the reduction of errors resulting from a lapse of attention and reduced processing times.

Healthy sleep hygiene refers to healthy sleep practices that can be trained to improve sleep. This includes utilizing regular routines (e.g. Regular bedtime routine to help you relax and prepare your body for bed) and optimal environments for sleep (Make sure the bedroom is quiet, as dark as possible, and a little on the cooler side, rather than warm). Athletes may not be able to adopt all types of sleep hygiene recommendations but should try to integrate as many as possible to maximize this bodily function. (3)

It is well established that sleep restriction impairs cognitive functioning, which may be detrimental to eSport athlete performance. It is for this reason that athletes should prioritize sleep and adopt better sleep hygiene practices to assist them to perform at their peak.

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1.         Difrancisco-Donoghue J, Balentine J, Schmidt G, Zwibel H. Managing the health of the eSport athlete: An integrated health management model. BMJ Open Sport Exerc Med. 2019;5(1).

2.         Kemp C, Pienaar P, Rae D. Brace yourselves: esports is coming. South African J Sport Med. 2020;32(1):1–2.

3.         Vitale KC, Owens R, Hopkins SR, Malhotra A. Sleep Hygiene for Optimizing Recovery in Athletes: Review and Recommendations. Int J Sports Med. 2019;40(8):535–43.

4.         Bonnar D. Sleep and performance in Eathletes: For the win! 2019;61(03):368.

Infections in athletes

Dr Janesh P Ganda

Infection in athletes


Endurance training can predispose an athlete to several infections because of numerous factors:

  • Increased training loads
  • Stress – physical & mental
  • Travel
  • Dry air in the plane
  • Other passengers
  • Poor sleep
  • Increased contact with sick individuals
  • Work environment
  • Race expo
  • Training partners

The immune system is essentially comprised of 2 inter-dependant systems

1. the non-specific Innate immune system,
2. the more specific Acquired immune system.

  1. Innate “Non-specific” immune system
  • Essentially the body’s first line of defense which includes the skin and mucus membranes
  • Exercise affects this system and can lead to higher risk of infection: such dysfunction occurs at a structural level, as well as at a cellular level. Acute bouts of exercise have been shown to lead to increased immune-cellular modulators. However, chronic intense training leads to a decrease = higher risk of infection
  • The effects of this include the increased risk of various infections because of possible immune-suppression

2. Acquired “Specific” immune system

  • The body’s Acquired immune system forms a memory and attacks infectious agents which were previously recognized by the body’s immune system
  • Cellular component and antibody component – antibodies recognize antigens which then kickstarts the inflammatory process to attack the offending agent
  • Changes in the antibody status and the cellular component of this system also result in a diminished immune system

Does exercise always result in an increased risk of infection?

The simple answer is NO, in fact it has been shown that regular, moderate exercise actually decreases the risk of infection. However, the risk of infection has been shown to increase in athletes who engage in regular bouts of high intensity exercise, or in athletes who undergo high training loads. This is demonstrated by the J-curve below.

TIPS to reduce the risk of infections, focusing on Upper Respiratory Tract Infections (URTI’s)

  • Space high intensity sessions and race events far enough apart to allow for adequate recovery
  • Ensure adequate quality sleep
  • Maintain a well-balanced diet
  • Vitamin C (500mg/day) during periods of heavy training
  • Avoid over training and chronic fatigue
  • Thorough hand washing
  • Remain well-hydrated

To exercise or not to exercise, that’s the question

It’s very common for athletes to visit a Sports Medicine Practice before major events and during single/multi-stage endurance events (OMTOM, Comrades Marathon, Ironman, Cape Epic, Wines2Whales etc.) or in a team (rugby, soccer, hockey etc.) to ask for advice on whether an illness should stop them from training. Training with an illness can have severe side effects – the development of a condition called a viral myocarditis can occur. This condition could lead to severe cardiac damage, and even death.

WHEN NOT TO EXERCISE – if you have any of the following symptoms:

  • Fever
  • Muscle Pains
  • Chest pains
  • Tachycardia (elevated resting heart rate)
  • Excessive fatigue
  • Excessive shortness of breath
  • Swollen painful lymph nodes.

Disclaimer – Information supplied in articles is generalised and does not constitute individualised medical advice. Patients are always advised to seek proper medical advice from a qualified medical professional.

Concussion in the paediatric population

What is a concussion?

Concussion is defined as a “complex pathophysiological process affecting the brain, induced by traumatic biomechanics features :

  1. Caused by either a direct blow to the head, face, neck or elsewhere in the body with an “impulsive force transmitted to the head.”
  2. Results in a rapid onset of short lived impairment in neurological function that resolves spontaneously.
  3. Functional disturbance, rather than a structural injury
  4. Results in a graded set of clinical symptoms that may, or may not, involve loss of consciousness.
  5. No abnormality on standard neuroimaging is seen in a concussion (1)

Concussion Rates in school sports

It was recently estimated that 3.8 million recreation and sport related concussions occur annually in the United States (2).

A lack of a proper Injury tracker in youth sports (2), makes this number in accurate for concussions in the paediatrics population, however, highlights the need for school injury surveillance to be able to quantify concussions in this population group. 

Represents approximately 8.9% of all high school injuries in the USA. (3) 

The 6 R’s of concussion (4)


  1. The suspected diagnosis of a concussion can include one or more of the following domains
    1. Symptoms – Somatic(headache), cognitive (feeling in a fog) and/or emotional symptoms (labile mood)
    2. Physical signs (loss of consciousness, amnesia)
    3. Behavioral changes (Irritability)
    4. Cognitive impairment (slowed reaction times)
    5. Sleep disturbance (Insomnia)
  1. On field care
    1. Clear indicators of a concussion – immediate removal from field of play (What you see) (4)
      1. Seizure (fits)
      2. Loss of consciousness – confirmed or suspected
      3. Unsteady on feet or balance problems or falling over or poor coordination
      4. Confused
      5. Disorientated – not aware of where they are or who they are or the time of day : Dazed, blank or vacant look
      6. Behavioural changes e.g. more emotional or more irritable
    2. Suggestive of a concussion (What you see) (4)
      1. Lying motionless on ground
      2. Slow to get up off the ground
      3. Grabbing or clutching of head
      4. Injury event that could possibly cause concussion
    3. Symptoms of a concussion (What you are told) (4)
      Mental clouding, confusion, or feeling slowed down
      Visual problems
      Nausea or vomiting
      Drowsiness / Feeling like “in a fog“ / difficulty concentrating : “Pressure in head”
      Sensitivity to light or noise
      Difficulty concentrating

Remove from field of play immediately if concussion is confirmed of suspected


  1. Patients who have had a concussion or suspected concussion should not be placed back on the field until being evaluated by a trained health care practitioner.
    1. Clinical evaluation should be done including the latest SCAT 5
    2. Determination of the clinical status of the patient – has the patient improved or worsened
    3. Determine the need for further concussion investigations
      1. Neuropsychiatric testing – done to evaluate the patients cognitive recovery. According tho the Berlin consensus, it forms a “cornerstone” of concussion management, however, it should never be used as the sole diagnostic marker for a concussion. 
      2. In cases of a structural brain injury being suspected, CT scans are the most predictive in assessing fractures and intra-cerebral bleeds. Generally patients with underlying structural damage deteriorate over the course of the injury. (2) 


  1. Cognitive rest
    1. Due to the functional nature of the brain injury, athletes often have trouble with focusing at school, taking tests and trying to keep up with assignments.
      1. Rest may include temporary leave from school, shortening of the athletes school day ,reduction in work loads.
      2. Taking standardized tests while recovering should be discouraged because lower than expected scores can occur.
      3. Other activities which can exacerbate symptoms such as video games, playing on a laptop etc should be avoided to ensure symptoms do not worsen. (2)

Return to school strategy (5)

  1. Physical Rest
    1. Physical rest is required to restore the energy imbalance following the concussion. 
    2. The exact amount of rest still needs to be adequately defined (5), however, a good guideline is 14 days for athletes under the age of 18. Following this minimum “stand down period” (3), athletes can enter their graded return to play.
    3. It can take some athletes under 18 almost 4 weeks to recover from a  concussion. Age appropriate symptom scores should be used (Child SCAT 5)
    4. Patients should have total rest for 24-48 hours after which they can gradually increase activity as long as it does not exacerbate symptoms.

Return to Play/Rehabilitation

  1. “When in doubt, sit them out”
  2. Although a vast majority of patients with a concussion will become asymptomatic within a week of their concussion numerous studies demonstrate a longer recovery of full cognitive function is required as compared to adults – 7-10days longer. (5)
  3. Graded Return to play protocol should be employed once the patient is symptom free. It will take an athlete a minimum of 5 days to progress through the protocol to resume full game participation, provided symptoms don’t return. If symptoms re-occur, the patient is required to go back to a previous stage before progressing.


  1. McCrory et al. Br J Sports Med. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Berlin, October 2016
  2. Halstead et al. Sport related concussion in children and adolescents. American Academy of Paediatrics, Volume 126, (3) September 2010
  3. Gessel et al. Concussion among United States collegiate athletes. J Athl Train.2007:42 (4):495-503 
  4. World Rugby Concussion guidance, implemented 01 August 2015
  5. McRoy et al. Br J Sports Med. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016.