Gym Coach, Vol.

2 (2008) 39-45 Commentary Article

A look at the pathophysiology and rehabilitation of

Osgood-Schlatter Syndrome
Valentin Uzunov
Hataitai Gymnastics, Wellington, New Zealand

ABSTRACT
Osgood-Schlatter Syndrome is childhood prone condition known as an Osteochondrosis. This condition tends effect young
athletes participating in sports that involve a lot of running and jumping, such as dance and gymnastics. It tends to
manifests itself in boys between 10-15yrs and 8-13yr girls, usually a time of peak height velocity. The common signs and
symptoms are local pain, swelling and tenderness over the tibial tuberosity on the dominant leg, which makes
participation in sport painful. The condition is self-limiting without complication if sporting activity is stopped and
conservative treatment sought. However this presents serious limitations for serious athletes who must continue to
training. This article aims to educate coaches on the aetiology, diagnosis, and treatment options of the condition, as well as
well discuss the injury prevention and rehabilitation recommendations. It is believed that an appropriate understanding of
this condition by coaches is important in order to be able to effectively implement preventative measures in their training
programs, make appropriate recommendations to athletes, and work closely with health allies (like physiotherapists, GP,
pediatricians) to be able to reduce losses in training time due to OSS.

Key Words: Osgood-Schlatter Disease, injury prevention, overuse injury, knee injury

INTRODUCTION
In 1903, Robert Osgood, a US orthopaedic surgeon, and
Carl Schlatter a Swiss surgeon, concurrently described the
possible pathophysiology of the disease that now bears
their names, Osgood-Schlatter Disease (1). They described
it as an avulsion of a small portion of the tibial tuberosity
caused by a violent contraction of the quadriceps extensor
mechanism (2) Since then its has been more accurately
labelled as a syndrome rather then a disease with many
proposed theories to further explain its aetiology (OSD aka
OSS), such as, degeneration of the patellar tendon, aseptic
necrosis, infection, (2), trauma, local alternations of the
chondral tissue, overpull by the extensor muscles of the
knee, which can result in patella alta, and traction
apophysitis, eccentric muscle pull and muscle tightness,
and reduced width of the patella angle (3). It is now
generally accepted that OSS is an avulsion fracture of the
growing tibial tubercle (4), characterized by pain at the
tibial tubercle resulting from repeated stress at the
insertion of the patellar tendon due to extensor
mechanism abnormalities (12).
OSS is part of a group of conditions called
osteochondrosis. These are a family of orthopaedic disease
that occur in children, and involve areas of significant
tensile or compressing stress (5) effecting the growing
epiphysis (growth plate) (13). These conditions often arise
©2008 The Gym Press. All rights reserved
in the knee/s, ankle/s, and elbow/s joints. OSS is
categorized as a chronic overuse injury (7), which is most
often diagnosed in young athletes (but not entirely
exclusive), involved in sports that involve a lot of running
and jumping, such as soccer, dance, gymnastics (10). It
usually manifest itself in boys around 10-15yrs of age, and
in girls around 8-13yrs of age, often coinciding with growth
spurts and peak height velocity (1) The condition is usually
unilateral (9), with 25% to 50% of patients developing a
bilateral condition (11). There is a close relationship
between the leg preferentially involved in jumping, and
sprinting and it developing OSS (3). Traditional literature
suggest that boys are more prevalent to OSS than girls, but
more recent evidence indicates that with more and more
girls being involved in sport, there is no longer any
significant difference (14).
The aim of this article is to examine the available literature
and the current body of knowledge of the pathophysiology
of OSS, in order to give coaches a better understanding and
prevention methods. By educating coaches to recognise the
possible signs and symptoms of this condition, coaches
may be able to identify athletes at high/er risk of
developing the condition, and thus be able to plan
preventative measures ahead of time. It will also allow for
coaches to take appropriate treatment steps when
symptoms arise during training as well as being able to
Gym Coach Vol.2, August, 2008 - 39-
V. Uzunov, Gym Coach, Vol.2 (2008) 39-45
Article
effectively work with medical allies like physiotherapists in
implementing a rehabilitation program for gymnasts who
suffer from this condition.
DISCUSSION and REVIEW
Aetiology
The exact cause and
aetiology of OSS is still
debated (2), but there is
general consensus in
literature that it is
probably caused by one
or more biological,
biomechanical, and
physiological factors.
These are considered to
be: Overpull of the
extensor mechanism in
the knee, linked with
abnormalities in patella
position (figure 1) (20),
and the extensor machenism made up
of the quadriceps muscle group,
increase external tibial
quadriceps tendon, patella, patellar, torsion (3), and possibly
retinaculum, patellar ligament and an an increased Q-angle,
assortment of other soft tissues in that observed especially in
area. The tibial tuberosity is the
associated site of injury in athletes with
flat footed and knock-
OSS. Image source: John Hoppkins kneed children (46).
Sport Medicine Traction-induced,
microtrauma to the
apophysis, due to
chronic overuse (12,16), skeletal immaturity, quadriceps
muscletendon imbalance, hamstring, and calf flexibility
restriction (14, 7) All these factors are reported in literature
to either cause or predispose growing children to OSS. In a
longitudinal study by Atsushi Hirano et al (2002), MRI
was used to track and clarify the nature and course of OSS
in 285 boys from high level junior soccer teams. They
identified and described 5 stages of the condition, each
©2008 The Gym Press. All rights reserved
Commentary
with its distinct characteristics and pathological alterations
(figure 2).
Normal Stage – MRI is normal but symptoms are present.
Early Stage – MRI show no avulsion at the secondary
ossification centre of the tibial tuberosity, but
inflammation around the secondary ossification centre is
present. Symptoms are initially not severe, but progresses
quickly if no treatment is undertaken
Progressive Stage – Presence of partial cartilaginous
avulsion from the secondary ossification centre. Patients
complain of pain, with obvious swelling of patellar tendon
at insertion. Possible thickening of patellar tendon
Terminal Stage – Existence of separated ossicles.
Symptoms present for period of time (around several
months), tenderness, swelling and pain at tibial tuberosity,
with possible thickening of patellar tendon at insertion
site. Pain triggered at stopping and turning motion.
Patellar tendonitis is a possible secondary pathologic
complication due to partial tear of the secondary
ossification centre.
Healing Stage – Osseous healing of the tibial tubercle
without separated ossicles. Visible prominence of tibial
tuberosity, the patellar tendon could still be thickened at
insertion, but not always.
Chronic overuse injuries (especially in young athletes)
make up 30-50% of all paediatric sport injuries in children
(16) Overuse injuries occur when tissue is repeatedly
Figure 2 (below) - A typical case study of OSS progression Figure 2 -
A typical case study of OSS progression in a active child over a 2.3 years
period.(A) At 10.1 years old, development of the tibial tuberosity was in
the cartilaginous stage and normal. (B) At 11.3 years old, this image
showed that a tear had appeared in the secondary ossification center
(arrow) and development of the tibial tuberosity was in the apophyseal
stage.(C) After 1 month, the MR image showed an opened shell like
separation (arrow) and the disease had advanced to the progressive
stage. The growth of the tibial tuberosity had entered the epiphyseal
stage. High signal intensity appeared within the patellar tendon. (D)
After 2 months the MR image showed that an anterior avulsed portion
had been separated (arrow). (E) At 12.4 years old, the ossicle had
moved further superiorly (arrow).
stressed by repeated submaximal (16) and maximal
eccentric loading (6). The process starts when repetitive
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V. Uzunov, Gym Coach, Vol.2 (2008) 39-45
Article
activity fatigues a specific structure such as tendon or
bone. With sufficient recovery the tissue adapts to the
demands and is able to undergo further loading without
injury. Without adequate recovery, microtrauma develops
and stimulates the body’s inflammatory response, causing
therelease of vasoactive substances (histamines,
leukotaxin, necrosin), inflammatory cells (macrophages,
lymphocytes, and plasma cells), and enzymes that damage
local tissue. In chronic or recurrent cases, continued
loading produces degenerative changes leading to
weakness, loss of flexibility, and chronic pain, all of which
as associated with OSS (16, 12).
Contributing factors to overused injuries with special
consideration to OSS can be classified as intrinsic and
extrinsic. With children special consideration needs to be
given to the immature musculoskeletal systems (16).
Intrinsic factors that need to considered are: Growth-
related factors. Cartilaginous tissue in children is more
susceptible to repetitive stress, especially in the knees,
elbows, and ankles (16). The development of the tibial
apophysis begins as a cartilaginous outgrowth. During this
stage the tuberosity tissue has a decreased resistance to
mechanical stress (16). Secondary ossification centres
appear with a subsequent progression to an epiphyseal
phase when the proximal tibial apophysis closes and the
tibial apophysis fuses to the tibia (22). Calcification of the
apophysis begins distally at 9yr of age for girls, and 11yrs
for males. Fusion of the apophysis to the tibia can take
place via several ossification centres, and occurs on
average at 12yr of age for girls and 13yrs of age for boys
(also coinciding with the age of OSS development), (23).
Prior and during these developmental ages of the tibial
apophysis, it is more vulnerable to injury, until the
apophysis and epiphyseal are calcified and fused. This is a
critical time for all gymnasts who train long hours at young
ages. Tumbling and vaulting during this period of time
should be carefully monitored and not overdone, especially
for gymnasts who are have predispositions. Full floor
tumbling should be restricted to once a week, and
more time should be spent on predominantly on softer non
impacting surfaces, such as rod-floors, tumble tracks, air
tracks etc, Vaults should be landed on soft surfaces such a
into a pit, soft crash mats. The gymnasts should be
restricted to a dozen full vaults a week spread over a week.
A second growth that needs consideration is the imbalance
between growth and development of long bones, and the
adjacent muscle-tendon attachments (16). This imbalance
can occur rapidly during a growth spurt (peak height
velocity), were bone length can develop faster than muscle-
tendon unit (12) Joint tightness, reduced flexibility (of
special relevance are the quadriceps, and hamstring
muscle groups which are associated with OSS), muscle
imbalance, and knee extensor mechanism dysfunction can
develop as a result of the imbalanced between growth and
development of the bone and muscletendon unit (16).This
can lead to increased traction on the apophysis and stress
at the joint surface of the knee, which is a well established
cause for OSS development (16). Knee extensor
©2008 The Gym Press. All rights reserved
Commentary
mechanism dysfunction is veryoften cited in literature as a
main contributing cause for OSS (9, 20). The extensor
mechanism in the knee consists of the quadriceps muscle
(rectus femoris), patella, patellar tendon, patella
retinacula, and the tibial tuberosity (figure 1)(21). The
patellar is subjected to great forces from its attachment to
the quadriceps rectus femoris muscle (proximally) and the
patellar tendon (distally). The hamstrings are also
undergoing the same stresses as the quadriceps, because of
the difference between the growth rate of the femur, and
the hamstring muscle groups. Increased hamstring
tightness causes increased patellarfemoral joint reaction
forces because of an increased knee flexion moment, which
means the quadriceps has to pull harder during athletic
activities, consequently placing more traction force on the
tibial tubercle (49), Thus it is critical to restore balance
between the quadriceps and hamstring strength, and
flexibility ratios.
There is debate regarding the correct strength H/Q
(hamstring/quadriceps) ratio with regard to injury
prevention, but a ratio 0.6 at an angular velocity of 1.05
rad.s-1 is frequently quoted as the standard for injury
prevention and rehabilitation (50). To a coach this means
nothing, as he/she cannot test it. However regularly testing
and monitoring the gymnast hamstring and quadriceps
ROM and performing 1 hamstring strengthening exercise
for every 3 quadriceps dominant exercises will generally
help maintain this ratio balanced. In a study by Hiroshi
Ikeda et al (1999) published in the journal of orthopedic
surgery, they looked at quadriceps strength, between
athletic and non-athletic boys, with and without OSS. They
determined that repeated traction of the quadriceps
muscle on the tibial tuberosity due to abnormal quadriceps
tightness, and increased eccentric quadriceps strength,
contributed to the development of OSS. Tight quadriceps
muscles are not resilient enough to absorb ground reaction
forces on impact; as a consequence forces act directly on
the bone-tendon junction of the tibial tuberosity (24).
In most cases OSS is treated with conservative therapy, as
it is normally a self-limiting condition. Once the apophysis
and epiphysis close, the symptoms of the condition usually
end. This happens at around 18yrs of age for boys and
girls, with an excellent prognosis for full recovery (1).
Complications can arise during and after skeletal maturity,
as a results patients not following physician’s
recommendations, and continue to take full part in sports,
without any activity modification or rest (1). The typical
complications are tibial tuberosity deformity, which is
almost inevitable, nonunion of tendon to tibial tuberosity,
patella alta after skeletal maturity, increasing likelihood
of lateral patellar dislocation, knee degenerative arthritis,
bursal chondromatosis, which has been documented only
once, as a result of untreated OSS. Softening of cartilage,
displaced avulsion fracture of tibial tubercle, usually
occurs in athletes without pre-existing OSS, but the most
common reported complication is ossicle formation.
(9,1,26,4,10). Most of these complications arise due to
extensor mechanism dysfunction, and thus are treated by
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V. Uzunov, Gym Coach, Vol.2 (2008) 39-45
Article
restoring normal extensor mechanism function (39).
Ossicle formation occurs as a result of a partial tear
developing in the secondary ossification centre during the
progressive stage. If the tear extends to the anterior parts
that consist of bone and cartilage, small regions of the
preossification or anterior secondary ossification centers
may be avulsed superiorly forming an open-shell like
separation (Figure 2, C). (2). If the gap formed is small,
fibrocartilage can bridge the gap and ossify, with such a
situation leading to the healing stage of OSS (2, 4). If the
gap is large, fibrocatilage will not be able to bridge the gap
and, the avulsed fragment/s mature to form separate
ossicles/s within the patellar tendon, with such a situation
being characteristic of the terminal stage of OSS (2).
Approximately 10% of ossicles fail to unite with the tibial
tubercle. These patients will continue to experience
anterior knee pain, even after ossification of tibial
tuberosity, and will require surgical excision to alleviate
the pain (4).
Diagnosis
Diagnosis of OSD is not clinically challenging once signs
and symptoms are clearly present, but it is very difficult to
diagnose clinically at its onset (12, 2). In most
circumstances patient who have obvious signs and
symptoms, can be diagnosed by a family physician, with a
physical exam (15). However based on the study by Atsushi
Hirano et al. (2002) it is advised that a specialist, sports
doctor, or physiotherapist, make the diagnosis using a
physical exam and an MRI (ideally) or X-ray as well. This
is particularly applicable if check-up is done at onset of
symptoms. Prior to making a definite diagnosis, doctors
should also rule out other possible anterior knee pain
conditions, such as, Sindling-Larson-Johansson syndrome,
osteomyelities, tibia, fibula, femur or patellar fracture,
tumor, patellar tendonitis (jumpers-knee), slipped capital
femoral epiphysis, Perthes disease, petellofemoral
syndrome, and osteochondrosritis dissecans, some of
which may require a imaging study , and thus further
supporting the need to have and MRI or X-ray done for a
definitive diagnosis (1,17, 10).
The standard clinical diagnostic signs, symptoms, and tests
are:
1. Pain, swelling and aching around tibial tubercle, with the
possibility that the tibial tubercle is reddened, raised or
tender to palpation (12),
2. Visible enlargement or prominence of tibial tubercle (1).
3. Pain generally occurs during activities involving the legs
(especially eccentric contractions of quadriceps) and goes
away with rests (24).
4. There is no history of the knee giving way, locking out,
or catching (10).
5. Pain worsens with activities that require squatting,
walking up and down stairs, and forceful contractions of
the quadriceps muscle. (17).
6. No signs of effusion, minuscule damage, and normal
neurovascular examination (1).
7. No limitations in the hip ROM, and especially no pain
with hip internal rotation (symptoms of slipped capital
©2008 The Gym Press. All rights reserved
Commentary
femoral epiphysis and Perthes disease, which can cause
referred pain to knee) (10)
Commonly used diagnostic tests for OSD are:
1. Pain elicited with extension of the knee at 900 of flexion,
while a resisted straight-leg raise does not. (14)
2. An alternative test is to force the tibia into internal
rotation, while slowly extending the knee from 900 of
flexion; at about 30deg, flexion produces pain that
subsides immediately with external rotation of the tibia.
(40)
3. Pain can also be reproduced with passive hyperflexion of
the knee. (17). 4. A positive Ely test (19)
5. Point tenderness eliciting pain approximately 2inches
under knee cap over tibial tuberosity. (18)
6. Full ROM is available at the knee, but tightness in
hamstring muscle group is noticeable (1).
OSS Prevention and Rehabilitation
As the late Dutch humanist and theologian Desiderius
Erasmus Roterodamus said “prevention is better then
cure”. This is always the case, and it’s important that
coaches understand and implement preventative measure
to identify young gymnasts who are prone or at greater risk
of developing this condition. From the discussion of the
pathophysiology of the condition, there are several
preventative strategies useful to coaches.
1-Regular physical testing of the quadriceps and
hamstrings to determine the risk of imbalance in strength
and flexibility.
2- Coach awareness. Coaches need to know the signs and
symptoms of kids at risk, or who are showing potential
onset symptoms.
3- Adding regular quadriceps stretches into every
flexibility program, from day 1 of sport involvement, to
balance out all the hamstring flexibility done in gymnastics
4- Inclusion of 1 hamstring exercise for every 3 quadriceps
exercises, matched in intensity.
5- Regular height measurements of gymnasts in order to
be able to track height velocity. Its important to be aware
of when the gymnasts is having/starting a growth spurt as
gymnasts are most at risk during this developmental stage.
Gymnasts undergoing a growth spurt should have their
training revised to reduce the volume and frequency of
high intensity, high impact, lower body activity, which
involves strong eccentric quadriceps contractions such as
tumbling on the floor, vaulting, and repetitive high
landings. Gymnasts can continue to work their skills, but
at a modified and reduced rate while undergoing the
growth spurt.
It is important to be vigilant for gymnasts, who show signs
and symptoms, and to monitor their training programs
effectively, to prevent gymnasts from doing too much to
soon. This condition is easily preventable with smart
training and program design.
For gymnasts who have developed this condition treatment
without complications can be divided into three phases:
acute, recovery, maintenance. Treatment management is
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V. Uzunov, Gym Coach, Vol.2 (2008) 39-45
Article
usually conservative, for 6months to a 1 year (12). During
the acute phase treatment management should
concentrate on reducing the signs and symptoms of
inflammation, and pain (12). The best treatment
management depends on the severity of the symptoms,
and the initial management of the first signs leading to the
initial diagnosis of OSS. This has a significant impact on
the course of the rehabilitative process during the recovery
phase (12, 10). Recommended options to manage the
condition are: RICE (rest, ice, compression, elevate),
warming up properly before activity, icing for 20min after
activity, short term rest or immobilization (2-3wks),
activity modification like running slower, avoiding deep
knee bending footwear, and
use of a infrapetellar strap
(figure 3) during activity
(12,18, 1,14 31,9,28,64).
Unfortunately these
remedies have shown little
evidence of improving
outcome, but have been
shown to be effective means
of pain management (35).
For acute flare-ups, and
relief of inflammation, the
Figure 3 – A standard
infrapetella strap, has been shown
use of anti-inflammatory
to decrease pain in 19 of 24 (79%) medication, an algesics, and
knees after 6 to 8 weeks of use in cryotherapy is
one study (64). recommended. If pain is
mild, and there is no inflammation, using a heating pad or
warm, moist compresses for 15min be fore activity can help
reduce symptoms and pain, as well as 15-20min of icing
after activity (6,32). During the acute phase it is very
important that symptoms of inflammation are first
controlled. Physical therapy is not commenced
immediately as it can exacerbate acute symptoms. For the
ambitious athlete suspending physical activity altogether is
not an option, so coaches must effectively modify their
training program till pain is relieved. The only form of
physical therapy allowed is hamstring, calf, and hip
stretching which can begin immediately as recommended
by a qualified physiotherapist not a GP (6, 14). Long term
immobilization (6wks+) is only recommended for
extremely severe cases, (especially in children) (12),
usually enforced by using a cast where compliance to
conservative treatment is not adhered too (27,10).
The recovery phase can start once pain is controlled and
the inflammation disappears. The main focus of the
rehabilitation program is to return the patient to his or her
sport or activity as safely as possible (7). Hamstring and
quadriceps stretching and hamstring strength are the main
objectives. (12) Quadriceps strength in usually not a
problem in young athletes, but it can become a problem in
chronic cases, resulting in muscle atrophy, requiring
strengthening exercises as well (12). Initially in the
strengthen program for chronic cases with muscle atrophy,
exercises should be done with minimal knee flexion in
order to reduce the load on the tibial tubercle (19).
Exercises should be pain-free, involving isometrics or low
©2008 The Gym Press. All rights reserved
Commentary
load high repetition knee extension exercises (12).
Stretches must target the quadriceps muscle belly with
minimal stress to the tibial tubercle, two joint stretching
exercises should be incorporated only when adequate
flexibility is achieved. (12) Overzealous stretching can lead
to complication rather than benefits and should be
discouraged. (12). Studies show that physical load
restriction during the acute and recovery phases has great
benefits in prevention of complications, and during the
course of OSD. (33).
Conservative therapy is initiated during the normal, early
and progressive stages of the course of OSS, there is a 90%
chance of an early recovery and progression to the
maintenance stage and eventually the healing stage if
treatment begins with the first signs of OSS. (2). From the
study by Atsushi Hirano et al (2002), it takes on average
3.8weeks to return to modified training if treatment starts
from the normal or early stage, 6.3 weeks from progressive
stage, and 13.2 weeks from the terminal stage, but usually
not symptom free. In the terminal stage, symptoms
alleviation is a result of reduced patellar tendonitis which
is a secondary complication. (2). In other literature the
most often reported prognosis is 6-24months till return to
sport (1). However it must be remembered that “everyone
recovers from injury at a different rate” (7), and these
recovery times are averages, and should only be used a
guidelines. Gymnasts can also continue working on
elements that do not aggravate their condition.
The progression to the maintenance phase is usually
through the recommendation by a general physician or
physiotherapist after an examination, showing clear signs
of recovery. Care must be taken to ensure that the athlete
is not returning to sport too soon, as complication can
arise. (1). A number of functional tests can be performed to
test the patient’s ability to safely return to sport.
Functional progressions that can be used to determine if
patient is ready to return to sport are (7):
1. The patient tibial tuberosity is no longer tender to touch.
2. The injured knee can be fully straightened and bent
without pain.
3. The knee and leg have regained normal strength
compared to the uninjured knee and leg.
4. Individual is able to jog straight ahead without limping.
5. Individual is able to sprint straight ahead without
limping.
6. Individual is able to do 45-degree cuts.
7. Individual is able to do 90-degree cuts.
8. Individual is able to do 20-yard figure-of-eight runs.
9. Individual is able to do 10-yard figure-of-eight runs.
10. Individual is able to jump on both legs without pain
and jump on the injured leg without pain If pain returns it
is recommended that patient take a further 6months,
continuing conservative therapy, and rehabilitation
program (26).
CONCLUSIONS
OSS is a common overuse injury that occurs equally in
active boys and girl who participate in sports involving
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V. Uzunov, Gym Coach, Vol.2 (2008) 39-45
Article
regular running and jumping, particularly if done on hard
surfaces. There are 5 stages to the condition, with
symptoms presenting themselves in the Early stage. The
condition is self-limiting, and can be treated effective if
diagnosed in the early stage with conservative treatment,
and rehabilitative exercises, with minimal restrictions. If
the condition is untreated and it progresses to the terminal
stage, the condition can greatly restrict sport participation,
and may eventually lead to the need for surgery if ossicles
calcify.
Commentary
Coaches should understand the aetiology of this condition
in order to indentify athletes at risk and implement the
necessary injury preventative measures. Rehabilitation is
effective only when the acute symptoms are under control
Every care is taken to assure the accuracy of the information published
within this article. The views and opinions expressed within this article,
are those of the author/s, and no responsibility can be accepted by The
Gym Press, Gym Coach or the author for the consequences of actions
based on the advice

ACKNOWLEDGEMENTS
This article is an abbreviated version of original manuscript by Valentin Uzunov (2007). An in-depth look at the pathophysiology and
treatment of Osgood-Schlatter Disease. Research project submission for Massey University. If you would like a copy of the full
unmodified version, contact Valentin Uzunov a
valentin.uzunov@gmail.com

Address for correspondence: Valentin Uzunov, Hataitai Gymnastics, Wellington, New Zealand.
valentin.uzunov@gmail.com

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3. Antonio Gigante, Claudia Bevilacqua, Massimo G Bonetti & Francesco Greco (2003) ‘Increased external tibial torsion in
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