Osgood-Schlatter Disease

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

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Male with Osgood-Schlatter disease

Definition/Description

Osgood-Schlatter's disease also known as osteochondrosis or traction apophysitis at the level of the tibial tubercle due to repetitive strain on the growth plate of the tibial tuberosity. The repetitive strain is from the strong pull of the quadriceps muscle(extensor mechanism) produced during sporting activities.

Sports like:

• Basketball
• Volleyball
• Sprinters
• Gymnastic
• Football

ETIOLOGY:

The Patellar tendon inserts at tibial tubercle. Repeated traction and microtrauma at the insertion causes microvascular tear, inflammation and fracture. Osgood-Schlatter disease, is an overuse injury characterized by ossification of bone along the growth plate, the tibial tubercle. Due to excessive growth, the ability of the muscle-tendon unit to stretch sufficiently and maintain flexibility is hampered, and there is increased tension across the tibial tubercle apophysis. In severe cases, repetitive strain may lead to softening and partial avulsion of the tibial tubercle apophysis resulting into osteochondritis.

EPIDEMIOLOGY

• High prevalence in immature adolescent
• Most common in males, that engage in running, jumping and sprinting activities.
• Onset occurs in male at 10-15 years and in female at 8 -14 years.

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.

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.

Some extra information and excursions available in this video

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.

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.

• 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

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

Physical Therapy Management

Exercise Therapy

The physiotherapist can focus on exercises to improve the flexibility and strenghten the surrounding musculature. This includes the quadriceps, hamstring, iliotibial band 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)  

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)  

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)  

Research by Gerulis et al (level of evidence: 2b)  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) .

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.