Osgood-Schlatter's Disease

Definition/Description

Osgood-Schlatters.PNG
Osgood-Schlatter disease is a traction apophysitis at the level of the tibial tubercle due to repetitive strain on the secondary ossification center of the tibial tuberosity. The repetitive strain is from the strong pull of the quadriceps muscle produced during sporting activities. The tibial tuberosity avulsion may occur in the preossification phase or the ossified phase of the secondary ossification center. Once the bone or cartilage is pulled away it continues to grow, ossify and enlarge. The intervening area may become fibrous, creating a separate persistent ossicle or may show complete bony union with some enlargement of the tibial tuberosity. It occurs more often in boys. These traction apophysitises are probably one of the most encountered overuse injuries in children and adolescents [1][2].

Relevant Anatomy

The tibia tubercle (the tuberosity of the tibia) is a large oblong elevation on the proximal anterior aspect of the tibia, just distal to the anterior surfaces of the medial and lateral tibial condyles. 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 musculo-tendonous junction can cause pain and swelling. [3] The pain felt by the patient is mostly unilateral, but often times, could be of bilateral affectation.
 The Osgood-Schlatter disease is localized at the tibial tubercle, distal and anterior to the knee,

Epidemiology /Etiology

Children and adolescents have growth zones in both the femur and the tibia and an apophysis (cartilage bone/cartilaginous material) at the tibial tuberosity. This cartilage (flexible connective tissue that often can be found between two bones), like bones, muscles and tendons, also has a grow capacity. But during the adolescent growth spurt, bones and cartilage grow much faster than muscles and tendons. The slower elongation of the musculotendinous extensor apparatus of the knee (m.quadriceps) inflicts very strong forces on the small site of the insertion of the patellar tendon to the tibial tuberosity. These forces can cause microavulsions of the tibial tuberosity. The cartilage of the tibial tuberosity (the anterior portion of the developing ossification center of the tibial tuberosity) can resist forces but not as bone and when the child or the adolescent does some physical activities the forces at the the patellar tendon and tibial tuberosity increases, which causes pain, irritation and in some cases microavulsions or avulsions fractures of the tibial tuberosity[4].

Increased stress of the musculotendenous junction of the patellar tendon and tibial tuberosity can cause the tendon to pull away from the bone a little bit.  This small amount of tearing leads to increased pain and swelling below the knee cap.  The condition is worsened with activities that subject the patellar tendon to high loads such as squatting, or jumping. In some cases ossification will occur at the area of trauma leading to a bony protuberance at the tibial tuberosity.

Characteristics/Clinical Presentation

Male with Osgood-Schlatter disease

Pain is the leading symptom in this disease and it appears and aggravates during physical activities such as running, jumping, cycling, kneeling, walking up and down the stairs and kicking a ball (knee extension). In sports like basketball, volleyball, soccer, tennis, … the pain increases. The clinical picture consists of pain localized to the area of the tibial tubercle. In some cases the tubercle may be swollen and hypertrophied and there is also tightness of the m. quadriceps. Characteristics such as temperature or intra-articular swelling is not relevant (rarely the tuberosity can feel warm), but swelling, tenderness and pain of the tibial tuberosity often appears.


  • 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 squating, stairs or jumping.
  • In some cases increased bony protuberance at the tibial tuberosity.


Some extra information and excursions available in this video


Differential Diagnosis

Some differential diagnosis can be:

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

Diagnostic Procedures

X-Rays may be utilized to better visualize the musculotendenous junction in severe cases or if avulsion is suspected.

  • The diagnosis is based on typical clinical findings (see clinical presentation). [4]
  • 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. The lateral radiograph generally shows the characteristic picture of prominent tibial tubercle with irregularly ossific nucleus, or free bony fragment proximal to the tubercle. Imaging is also useful to exclude tuberosity epiphysiolysis or tumors. [5]
  • Sonographic examination can also be used. The ultrasound can be directed to demonstrate the appearance of the cartilage and bony surface, the patellar tendon, soft-tissue swelling anterior to the tibial tuberosity, and fragmentation of the tibial tuberosity.

Examination

A diagnosis can be made through a thorough history and examination. Tenderness to palpation over the tibial tuberosity that worsens with weight bearing squat or jumping is fairly indicitive ot this disease.

  • Physical examination reveals pain during palpation of the tibial tubercle.
  • Resisted extension of the knee from 90° flexed position will usually reproduce pain, but resisted straight leg raised test is usually painless.
  • Ely's test, which proves excessive tightness of the quadriceps femoris muscle, is positive in all cases.

Medical Management

Treatment should begin with rest, icing (RICE), activity modification and sometimes nonsteroidal anti-inflammatory drugs.

Physical Therapy Management

Exercise Therapy

The physiotherapist can focus on excercises to improve the flexibility and stenghten the surrounding musculature. This incudes the quadriceps, hamstring, iliotibial bands and the gastrocnemius muscle. High-intensity quadriceps-strengthening exercises increase stress across the tibial tuberosity and are initially avoided. . stretching should initially be performed statically at a low intensity to prevent pain before progressing to dynamic or PNF stretching. A duration of at least thirty seconds with three repetitions is recommended at least once a day to increase the range of motion. 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. (level of evidence: 1a) [6] 

Shockwave

Extracorporeal Shockwave therapy is a treatment which has been discussed in the use of osgood-schlatters but due to the low value evidence reccomendations cannot be made for this treatment. (level of evidence: 4) [7] 

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. (level of evidence: 5) [8] 

Research by Gerulis et al (level of evidence: 2b) [9] has shown that limitation of physical activity, physical load restriction, and conservative treatment are more effective than physical load restriction and activity limitation alone

Taping

Taping: patellar tendon unloading technique
This technique has not been researched in this patient’s population; however, patients report that it decreases the pain. There are different usable ways to perform this technique.

The effectiveness of McConnell Taping has not been researched for this patient population; however, use of this taping technique alone has been attributed to improved knee flexion range of motion and decreased pain with activity. (level of evidence: 2b)[10] .

Prognosis

The symptoms tend to subside within 2 years, and the prognosis is excellent in the majority of cases. So the symptoms of Osgood-Schlatter will generally decline and disappear in most patients if non operative treatment is carried out long enough, especially after bone growth is terminated. (level of evidence: 3b) [11]Persistent symptoms are followed by development of loose fragments above the tibial tubercle, or within the patellar ligaments. In these cases, the symptoms will disappear only after surgical treatment. (level of evidence: 4)[12]

Education is valueable to assure the patient that his condition is temporary.

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 sequesstrectomy), insertion of bone pegs and/or a combination of any of these procedures.

References

  1. Kaya DO, Toprak U, Baltaci G, Yosmaoglu B, Ozer H. Long-term functional and sonographic outcomes in Osgood-Schlatter disease. Knee Surg Sports Traumatol Arthrosc. 2013 May fckLRlevel of evidence 3B
  2. Blankstein A, Cohen I, Heim M, Diamant L, Salai M, Chechick A, Ganel A. Ultrasonography as a diagnostic modality in Osgood-Schlatter disease. A clinical study and review of the literature. © Springer-Verlag 2001, Arch Orthop Trauma Surg (2001) 121 :536–539 www.springerlink.com/content/efbpdx4ythtqjqyu/fulltext.pdf fckLRlevel of evidence 2B
  3. Baltaci G, Ozer H, Tunay V. B. Rehabilitation of avulsion fracture of the tibial tuberosity following Osgood-Schlatter disease. © Springer-Verlag 2003, Knee Surg Sports Traumatol ArthroscfckLR(2004) 12 : 115–118 www.springerlink.com/content/xnbxdt65aggv30dy/fulltext.pdffckLRLevel of evidence 4
  4. 4.0 4.1 Çakmak S , Tekin L, Akarsu S. Long-term outcome of Osgood-Schlatter disease: not always favorable. Rheumatology International January 2014, Volume 34, Issue 1, pp 135-136
  5. C Reid D. Sports injuries assessment and rehabilitation. Churchill Livingstone USA, 1992, p 406 – 411
  6. Purushottam A. Gholvea, David M. Schera,b, Saurabh Khakhariaa,Roger F. Widmanna,b and Daniel W. Greena,b. Osgood Schlatter syndrome. Curr Opin Pediatr 19:44–50.2007 Lippincott Williams & Wilkins. Level Of Evidence : 1A
  7. Sportverletz Sportschaden. 2012 Dec;26(4):218-22. doi: 10.1055/s-0032-1325478. Epub 2012 Oct 9.[Extracorporeal shock wave therapy for patients suffering from recalcitrant Osgood-Schlatter disease].Lohrer H, Nauck T, Schöll J, Zwerver J, Malliaropoulos N. Level Of Evidence : 4
  8. C Reid D. Sports injuries assessment and rehabilitation. Churchill Livingstone USA, 1992, p 406 – 411 (level of evidence: 5)
  9. Gerulis V, Kalesinskas R, Pranckevicius S, Birgeris P. Importance of conservative treatment and physical load restriction to the course of osgood-schlatter's disease. Clinic of Pedia Surgery. 2003;2(5):57-64. Level Of Evidence : 2B
  10. Mason M, Keays SL, Newcombe PA. The effect of taping, quadriceps strengthening, and stretching prescribed separately or combined on patellofemoral pain. Physiother. 2011;16:109-119. Level Of Evidence : 2B
  11. Ross MD, Villard D. Disability levels of college-aged men with a history of Osgood-Schlatter disease.J Strength Cond Res. 2003 Nov;17(4):659-63. Level Of Evidence : 3B
  12. Nakase J, Aiba T, Goshima K, Takahashi R, Toratani T, Kosaka M, Ohashi Y, Tsuchiya H. Relationship between the skeletal maturation of the distal attachment of the patellar tendon and physical features in preadolescent male football players. Knee Surg Sports Traumatol Arthrosc. 2012 Dec 22 : Level Of Evidence:2C