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Osgood-Schlatter Disease: Practical Treatment for a Self-Limiting Condition

Eric J. Wall, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 26 - NO. 3 - MARCH 2021


In Brief: Osgood-Schlatter disease is one of the most common causes of knee pain in active adolescents. It is a generally benign disturbance at the junction of the patellar tendon and the tibial tubercle apophysis, and treatment during its 12- to 24-month course should be matched to severity. Mild symptoms require only patient education and moderation of activity, but severe symptoms call for a period of rest (or, rarely, immobilization) followed by aggressive quadriceps strengthening. Other conditions such as Sinding-Larsen-Johansson disease may occur simultaneously, and long-term effects can include a prominence on the anterior knee or painful kneeling.

Osgood-Schlatter disease (OSD), a very common cause of knee pain in adolescents, is a disturbance of the patellar tendon attachment to the tibial tubercle apophysis. Ultrasound and magnetic resonance imaging (MRI) scans in OSD patients frequently reveal signal changes in the patellar tendon and soft tissue adjacent to the tubercle and less frequent changes in the tubercle itself (1,2).

The condition most commonly affects young people who participate in jumping and cutting sports, such as basketball, volleyball, figure skating, gymnastics, and soccer, and is bilateral in about 20% of cases. The exact cause is unknown, but it probably involves repetitive microavulsion (overuse) of the chondrofibroosseous tibial tubercle.

OSD typically develops in girls between the ages of 8 and 13 and in boys between 10 and 15—at the beginning of their growth spurt (3). One report (4) put the prevalence of the condition in athletic adolescents at 21%, as compared with 4.5% in age-matched nonathletes.The condition has been more frequent in boys, although the ratio may be equalizing with girls' increased participation in sports (5).

Typically, OSD is self-limiting, but it can take 12 to 24 months to run its course. Pain usually remits on skeletal maturity, but a small percentage of patients develop a painful ossicle, which can necessitate surgical excision (6). On long-term follow-up, 24% of patients have some limitation of activities, and 60% have discomfort with kneeling (3).

Diagnosis

History and physical exam. Diagnosis of OSD is usually straightforward. Patients often point to the tibial tubercle as the source of their anterior knee pain, and many also complain of swelling and prominence over the tubercle. The pain generally occurs during activity and remits with rest. Its onset is insidious, and the patient typically cannot identify an acute traumatic cause. Severity can be roughly described in terms of three grades, depending on the duration of pain (table 1). These are similar to the jumper's knee classification of Blazina et al (7). There should not be a history of the knees giving way, locking, or catching.


Table 1. Grades of Osgood-Schlatter Disease Severity

Grade Characteristics

1 Pain after activity that resolves within 24 hours
2 Pain during and after activity that does not limit activity and resolves within 24 hours
3 Constant pain that limits sports and daily activity

On examination, knee tenderness is very well localized over the tibial tubercle. The patient usually has full knee range of motion with no effusion or instability and no meniscal signs. To exclude other conditions, the physical exam should also include an assessment of range of motion at the hip and palpation of the inferior patellar pole (discussed in "Differential Diagnosis," below).

Imaging studies. If the history and physical exam indicate OSD at an adolescent's initial visit to a primary care physician, radiographs are not required. Radiographs can be normal, or they can show irregular ossification of the tibial tubercle (figure 1), but this can be a normal variant in asymptomatic adolescents. Another possible finding is an ossicle on the distal patellar tendon (figure 2).

[FIGURE 1]

OSD patients whose radiographs show fragmentation of the apophysis are more likely to have chronic symptoms than patients whose radiographs are normal (3).

[FIGURE 2]

For patients who have had an acute onset of pain, radiographs should be obtained to rule out an avulsion fracture of the tibial tubercle. For patients with night pain, other non-activity-related pain, or tenderness that is not directly localized to the tibial tubercle, radiographs should also be obtained to rule out a tumor, infection, or osteochondritis dissecans.

Ultrasound and MRI scans can confirm the diagnosis of OSD, but are generally unnecessary.

Differential Diagnosis

Other causes of chronic anterior knee pain besides OSD include Sinding-Larsen-Johansson (SLJ) disease, patellofemoral syndrome, and osteochondritis dissecans (figure 3). SLJ disease and patellofemoral syndrome occasionally coexist with OSD in adolescents.

[FIGURE 3]

SLJ disease involves pain, swelling, and tenderness of the inferior patellar pole at the origin of the patellar tendon. Unlike the more obvious OSD, this diagnosis will be missed unless the examiner palpates the inferior patellar pole with the patient's knee extended and the patellar tendon relaxed. Repeating the exam with the knee flexed 90° should reveal diminished tenderness as the patellar tendon becomes taut. Radiographs are usually normal but can show calcification or an elongated inferior patellar pole.

Patellofemoral syndrome probably arises from repetitive stress of the patella on the femur, but the exact etiology is unknown. Patients present with a history of chronic activity-related anterior knee pain that vaguely localizes to the peripatellar area. The exam for patellofemoral syndrome is best done with the patient's knee flexed 20° to 30°. With the knee in this position the patella begins to contact the trochlear groove of the femur. Pain is elicited with light manual pressure by rubbing on the patella with a side-to-side motion.

Osteochondritis dissecans is a rare but serious cause of adolescent knee pain involving an abnormality of the articular cartilage and the underlying bone. Patients present with diffuse knee pain, and can have loss of motion and a knee effusion. The diagnosis of osteochondritis dissecans is usually made with radiographs because there is no reliable clinical test. The condition can lead to permanent knee damage and requires orthopedic referral.

Hip range of motion should be assessed in any adolescent with knee pain; limitation of, or pain with, internal rotation should prompt radiographic studies to rule out a slipped capital femoral epiphysis and Perthes' disease.

As noted above, the history may suggest a need for radiography to rule out an avulsion fracture of the tibial tubercle, a tumor, an infection, or osteochondritis dissecans.

Treatment

Treatment for OSD depends on the severity of the condition.

Grades 1 and 2. Many adolescent patients with grade 1 or grade 2 symptoms (pain that lasts no more than 24 hours after activity) and their parents may only need reassurance that the condition is usually self-limiting and that the enlarged tubercle is not a tumor.

Patients can play sports as long as pain is tolerated and resolves within 24 hours. When symptoms flare up, short-term rest from the offending activity typically eliminates pain. Total rest is not recommended as it can lead to deconditioning and increase the chance of recurrence with return to sports.

Shock-absorbent insoles in sports shoes may decrease peak stress on the tendon and tuberosity. Icing the knee for 20 minutes after activity may also be beneficial. Hamstring and quadriceps stretching is recommended by most authors.

The standard neoprene knee sleeve is generally not beneficial, but other types of knee sleeves that pad the tibial tubercle can help, especially for preventing repeated contusions to the tender tubercle. Wrestling gel pads and basketball knee pads are inexpensive and are sold at sporting goods stores.

Anti-inflammatory medications may be administered as needed after sports activity, but I recommend against routine usage and routine pretreatment. Cortisone injection is not recommended.

Grade 3. A few adolescent athletes have grade 3 OSD (constant pain that limits daily activity and sports performance). They generally do not want to wait out the 12 to 24 months it may take for their condition to spontaneously resolve, so after periods of rest they can have recurrent symptoms.

OSD at this grade warrants more intense treatment than grade 1 or 2. Rarely, a 3- to 4-week course of immobilization with a cast or brace is indicated for severe recurrent disease that has resisted the first-line treatment. In the adolescent population, immobilization is often required to enforce the physician's recommendation of rest. The routine use of casting for OSD does not seem to alter the natural history (3).

After rest or immobilization, patients can start a rehabilitation program of progressive quadriceps exercises (see "Coping With Osgood-Schlatter Disease"). Bone, cartilage, and tendons have been shown to hypertrophy and strengthen with gradually increasing stress.

In a recent study (8) of athletes with resistant grade 3 OSD, a dual hinged knee brace that limited motion to between 0° and 40° allowed the athletes to return to sports with immediate cessation of pain. These findings should be considered preliminary, however, since the study involved only six OSD patients and had no control group.

Complications and Sequelae

Painful ossicle. Patients who have OSD may develop a painful ossicle in the distal patellar tendon. Ossicle excision can be curative and is a fairly minor procedure to consider for OSD that has resisted aggressive nonsurgical treatment (6). Some authors recommend tubercle excision or reduction in additon to ossicle excision (9).

Painful kneeling. Sixty percent of patients with OSD may have painful kneeling as adults (3).

Displaced avulsion fracture of the tibial tubercle. OSD is occasionally associated with a displaced tibial tubercle avulsion fracture, which typically requires operative repair. This injury, however, usually occurs in athletes without preexisting OSD, and therefore the risk of this rare complication does not warrant cessation of sports in patients who have OSD (10).

Permanent bump. OSD can leave a large bump on the anterior knee. Patients, especially girls, should be warned of this cosmetic sequela.

Educate and Moderate

OSD, one of the most common causes of adolescent knee pain, is generally benign. Mild symptoms require only patient education and activity moderation. Athletes who have severe symptoms may benefit from rest or, possibly, short-term immobilization, followed by an aggressive rehabilitation program.

References

  1. DeFlaviis L, Nessi R, Scaglione P, et al: Ultrasonic diagnosis of Osgood-Schlatter and Sinding-Larsen-Johansson diseases of the knee. Skeletal Radiol 120219;18(3):193-197
  2. Rosenberg ZS, Kawelblum M, Cheung YY, et al: Osgood-Schlatter lesion: fracture or tendinitis? Scintigraphic, CT, and MR imaging features. Radiology 1992;185(3):853-858
  3. Krause BL, Williams JP, Catterall A: Natural history of Osgood-Schlatter disease. J Pediatr Orthop 1990;10(1):65-68
  4. Kujala UM, Kvist M, Heinonen O: Osgood-Schlatter's disease in adolescent athletes: retrospective study of incidence and duration. Am J Sports Med 120215;13(4):236-241
  5. Micheli L: Pediatric and Adolescent Sports Medicine, in Griffin LY (ed): Orthopaedic Knowledge Update: Sports Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 349-360
  6. Mital MA, Matza RA, Cohen J: The so-called unresolved Osgood-Schlatter lesion: a concept based on fifteen surgically treated lesions. J Bone Joint Surg (Am) 120210;62(5):732-739
  7. Blazina ME, Kerlan RK, Jobe FW, et al: Jumper's knee. Orthop Clin North Am 1973;4(3):665-678
  8. Badelon O: Knee-brace with limited range of motion for severe chronic articular cartilage and Osgood-Schlatter diseases, abstracted. Pediatric Orthopaedic Society of North America, annual meeting program 1996, p 117
  9. Flowers MJ, Bhadeshwar DR: Tibial tuberosity excision for symptomatic Osgood-Schlatter disease. J Pediatr Orthop 1995;15(3):292-297
  10. Levi JH, Coleman CR: Fracture of the tibial tubercle. Am J Sports Med 1976;4(6):254-263

Dr Wall is director of sports medicine in the department of pediatric orthopedic surgery at the Cincinnati Children's Hospital Medical Center. Address correspondence to Eric J. Wall, MD, Children's Hospital Medical Center, Dept of Pediatric Orthopedic Surgery, 3333 Burnet Ave, Cincinnati, OH 45229-3039.


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