Osgood-Schlatter Disease

Original Editor - Casey Kirkes, Geoffrey De Vos as part of the Vrije Universiteit Brussel Evidence-based Practice Project

Top Contributors - Geoffrey De Vos, Admin, Keta Parikh, Sam Verhelpen, Nicolas D'Hondt, Kim Jackson, Scott Buxton, Michelle Lee, Laurens Dereymaeker, Jetse De Proft, Rachael Lowe, Wanda van Niekerk, Nicolas Everaerts, Casey Kirkes, Nikhil Benhur Abburi, Rucha Gadgil, Lucinda hampton, Jess Bell, Andeela Hafeez, Hanne Velghe, Uchechukwu Chukwuemeka, Vidya Acharya, 127.0.0.1, Tony Lowe, Claire Knott, Naomi O'Reilly, Rishika Babburu and Adam Vallely Farrell  
One Page Owner Keta Parikh as part of the One Page Project

Introduction

Osgood Schlatter disease, also known as osteochondrosis, tibial tubercle apophysitis, or traction apophysitis of the tibial tubercle, is a common cause of anterior knee pain in the skeletally immature athletic population. Clinical presentation classically associates atraumatic, insidious onset of anterior knee pain, with tenderness at the patellar tendon insertion site at the tibial tuberosity. The condition is self-limited and occurs secondary to repetitive extensor mechanism stress activities such as jumping and sprinting. Pain level dictates overall treatment, and management includes symptomatic treatment with ice and NSAIDs, as well as activity modification and relative rest from inciting activities in association with lower extremities stretching regimen to correct underlying predisposing biomechanical factors.

Image 1: Male with Osgood-Schlatter disease

The repetitive strain is from the strong pull of the quadriceps muscle (extensor mechanism) produced during sporting activities. eg Basketball, Volleyball, Sprinters, Gymnastic, Football.

Etiology

The patellar tendon inserts at the tibial tubercle and consists of cartilaginous tissue. This is followed by ossification of the tibial tubercle at ages 10-12 in girls and at ages 12-14 in boys. It is during this stage of bone maturation when Osgood Schlatter disease develops. The prevailing theory is that there is repeated traction over the tubercle leading to microvascular tears, fractures, and inflammation; which then presents as swelling, pain, and tenderness.

Image 2: Jumping female

Osgood Schlatter disease is an overuse injury that occurs in active adolescent patients. It occurs secondary to repetitive strain and microtrauma from the force applied by the strong patellar tendon at its insertion into the relatively soft apophysis of the tibial tubercle. This force results in irritation and severe cases partial avulsion of the tibial tubercle apophysis. Force is increased with higher levels of activity and especially after periods of rapid growth. Rarely trauma may lead to a full avulsion fracture. Predisposing factors include poor flexibility of quadriceps and hamstrings or other evidence of extensor mechanism misalignment.

Risk factors for the disorder include:

• Male gender
• Ages: male 12-15, girls 8-12
• Sudden skeletal growth
• Repetitive activities like jumping and sprinting

Epidemiology

Osgood Schlatter disease is one of the most common causes of knee pain in the skeletally immature, adolescent athlete.

• Onset coincides with adolescent growth spurts between ages 10 to 15 years for males and 8 to 13 years for females.
• The condition is more common in males and occurs more frequently in athletes that participate in sports that involve running and jumping.
• In adolescents, age 12 to 15, the prevalence of Osgood Schlatter disease is 9.8% (11.4% in males, 8.3% in females).
• Symptoms present bilaterally in 20% to 30% of patients.

Relevant Anatomy

The tibial tubercle (the tuberosity of the tibia) is the protuberance along the anterior aspect of the tibia, just distal to the anterior surfaces of the medial and lateral tibial condyles. The tibial tubercle is entirely cartilaginous. It gives attachment to the patellar ligament or patellar tendon. The patellar tendon attaches to the tibial tuberosity inferior to the patella. Stress at this musculotendinous junction can cause pain and swelling. The pain felt by the patient is mostly unilateral, but often it is bilateral.

Image 3: The insertion of patellar tendon at tibial tubercle

The Osgood-Schlatter disease is localized at the tibial tubercle, distal and anterior to the knee.

Clinical Presentation and Examination

Anterior knee pain associated with or without swelling, is the leading symptom in this disease and it aggravates during physical activities such as running, jumping, cycling, kneeling, walking up and down the stairs and kicking a ball(knee extension) . The clinical picture consists of pain localized to the area of the tibial tubercle.

• Painful palpation of the tibial tuberosity.
• Pain at the tibial tuberosity that worsens with physical activity or sport.
• Increased pain at the tibial tuberosity with sports activity.
• In some cases increased bony protuberance at the tibial tuberosity.
• Secondary to pain,Ely's test- there is tightness of Quadriceps.
• Resisted isometrics of the Quadricep muscle is painful.

Differential Diagnosis

Conditions that show similar presentation:

• Jumper’s knee (patellar tendinitis) or Sinding- Larsen-Johanssen syndrome
• Synovial plica injury
• Tibial tubercle fracture
• Osteochondroma of the proximal tibia.
• Fat Pad Syndrome

These diseases are also localized at the patellar tendon and can cause similar knee problems.

Diagnostic Procedures

Radiological imagining is usually not required, and is done in severe cases or if an avulsion is suspected.

Image 4: Lateral view X-ray of the knee demonstrating fragmentation of the tibial tubercle with overlying soft tissue swelling.

• The diagnosis is based on typical clinical findings (see clinical presentation).
• Radiographic examinations of both knees should always be performed, in both the anterior-posterior and lateral projections, to rule out the possibility of tumors, fractures, ruptures or infections. A picture of prominent tibial tubercle with soft tissue swelling, calcification of the patellar tendon, or free bony fragment proximal to the tubercle can be seen.
• An utmost care must be taken, for accurate diagnosis, as sometimes the tibial protuberance may not be pathological. Therefore, clinical correlation must be done.

Prognosis

• Excellent prognosis.
• The condition is self-limiting and hence recovers within a month
• Sometimes the pain may persist up to 2 years, if unnoticed or left untreated.

Medical Management

1. Conservative treatment: Treatment should begin with rest, icing (RICE), activity modification and sometimes non-steroidal anti-inflammatory drugs.
2. Surgical treatment: Surgical procedures should be avoided until the child has grown up and the bone growth has been completed to avoid growth-plate arrest and the development of recurvatum and or valgus of the knee. Surgical treatment, we identified different surgical procedures such as drilling of the tibial tubercle, excision of the tibial tubercle (decreasing the size), longitudinal incision in the patellar tendon, excision of the ununited ossicle and free cartilaginous pieces (tibial sequestrectomy), insertion of bone pegs and/or a combination of any of these procedures.

Physical Therapy Management

Pain Relief

• The pain usually subsides with the cessation of growth at the tibial tubercle.
• Ice application after activity reduces the anterior knee pain.
• Limiting the sports activity, for 6-8 weeks is advisable.
• Gentle stretch to Quadricep and Hamstring muscle ,along with strengthening of Vastus Medialis Oblique muscle decreases pain.
• Patellar loading is decreased by patellar tapping/ McConnel tapping, and by the use of brace.

Exercise Therapy

Low-intensity Quadriceps-strengthening exercises, such as isometric multiple- angle quadriceps exercises, are therefore instituted earlier in the conditioning program. High-intensity Quadriceps exercises and Hamstring stretching are introduced gradually and have been proven effective with high evidence rating.  Incorporation of high-intensity Quadricep exercise can intensify pain.

Shockwave

Extracorporeal Shockwave therapy is a treatment which has been discussed in the use of Osgood-Schlatter disease but due to the low value evidence recommendations cannot be made for this treatment.  

Activity Limitation

Non-operative treatment of this disease is based on the same principles that apply all overuse injuries.

• Today, there is no need for total immobilization, or for totally refraining from athletic activities.
• Of vital importance is that the physician inform the parents, the coach, and the child athlete of the natural course of this disease.

The child should continue his normal physical activities, to the limit that the pain allows it, so lower intensity of frequency of exercising (activity modification). Also swimming, as a secondary athletic activity, is very good during this disease (no discomfort). Also knee-braces, tapes, slip-on knee support with an infrapatellar strap or pad are recommended and may help during physical activities and can reduce pain.  

Research by Gerulis et al has shown that limitation of physical activity, physical load restriction, and conservative treatment are more effective than physical load restriction and activity limitation alone