You are in: eMedicine Specialties > Orthopedic Surgery > KNEE Osgood-Schlatter DiseaseArticle Last Updated: Jan 5, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 12
  Author: J Andy Sullivan, MD, Clinical Professor of Pediatric Orthopedics, University of Oklahoma School of Medicine J Andy Sullivan is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Association, Oklahoma State Medical Association, and Pediatric Orthopaedic Society of North America Editors: Albert W Pearsall IV, MD, Associate Professor, Department of Orthopedic Surgery, University of South Alabama; Director, Section of Sports Medicine and Shoulder Service, Department of Orthopedic Surgery, University of South Alabama Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Thomas M DeBerardino, MD, Director, John A Feagin, Jr Sports Medicine Fellowship at West Point, Clinical Instructor in Surgery, Orthopedic Surgery Service, Keller Army Community Hospital at West Point; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Carlos J Lavernia, MD, FAAOS, Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital Author and Editor Disclosure Synonyms and related keywords: Osgood-Schlatter condition, tibial tubercle apophyseal traction injury, OSD, OS condition INTRODUCTIONSection 2 of 12
  Osgood-Schlatter (OS) disease is more appropriately described as a disorder or a condition. Osgood, in the English literature, and Schlatter, in the German literature, independently described this condition in 1903. The etiology and treatment of OS condition have been disputed since its original description. OS condition is a traction phenomenon resulting from repetitive quadriceps contraction through the patellar tendon at its insertion upon the skeletally immature tibial tubercle. This occurs in preadolescence during a time when the tibial tubercle is susceptible to strain. OS condition should be distinguished from overuse of the patella-patellar tendon junction, which is referred to as Sinding-Larsen-Johansson syndrome (the adolescent equivalent of jumper's knee). History of the ProcedureThe onset of OS condition is usually gradual, with patients commonly complaining of pain in the tibial tubercle and/or patellar tendon region after repetitive activities. Typically, running or jumping activities that significantly stress the patellar tendon insertion upon the tibial tubercle aggravate the patient's symptoms. A sudden onset of pain with no antecedent symptoms in the region of the tibial tubercle should alert the clinician to assess for a possible tibial tubercle avulsion rather than OS condition. ProblemOS condition is the most frequent cause of knee pain in children aged 10-15 years. This condition can cause loss of time from athletics; however, it is rarely a cause of permanent impairment or disability. The natural history of this condition is self-limiting. In the Krause study (1990), 90% of patients were relieved of all of their symptoms approximately 1 year after onset of symptoms with conservative care. After skeletal maturity, patients may continue to have problems kneeling or may have tenderness over an unfused tibial tubercle ossicle or a bursa that may require resection. Minimal association seems to exist between residual anterior knee pain after OS condition and patellar stability, as was noted in the Krause study. The authors also noted no cases of recurvatum from premature closure of the proximal tibial physis. FrequencyThe true incidence of OS disorder is unknown. Kujala reviewed 412 athletes who presented to a sports clinic with 586 complaints. Sixty-eight patients, with an average age of 13.1 years, were diagnosed with OS condition. These patients did not participate in their sports activities for approximately 3 months because of the condition. Most individuals resumed full activity by 7 months. Kujala (1985) also questioned 389 students and found that 12.9% claimed to have had OS condition. In this group, patients who had not participated in sports had a lower incidence of the condition (4.9%) than those who had played sports. EtiologyThe etiology of OS condition is controversial. Several causes have been hypothesized. The most likely cause is that the apophysis is subject to traction during the adolescent years, which can result in microfractures. The tibial tubercle apophysis appears in children aged 7-9 years. Usually, an apophysis develops proximally toward the epiphysis as the epiphysis grows distally toward the apophysis. Repeated traction from the patellar tendon can cause microfractures in the apophysis, as demonstrated by Lazerte (2000) when he examined resected operative specimens from patients with OS condition. These specimens showed avulsion fractures of portions of the distal tibial tubercle. Ehrenborg (1962) and others histologically examined bone excised from the tibial tubercle and found that viable cancellous bone exists without evidence of necrosis or inflammation. Woolfrey (1960) believed this was due to changes in the lower end of the patellar tendon and secondary new bone formation. Ogden (1976) showed that the tibial apophysis changes from fibrocartilage to hyaline cartilage, making it susceptible to injury. Rosenberg (1992) reviewed 16 nuclear scans, 34 CT scans, and 27 MRIs in patients with this diagnosis. He found that 100% percent of these patients had a normal tendon size, decreased attenuation, and an increased signal. Thirty-two percent of the patients had an ossicle. Rosenberg believed the findings were most consistent with patellar tendinitis. ClinicalObtaining the individual's history and performing a physical examination are usually sufficient for the physician to make a diagnosis of OS condition. OS condition is the most frequent cause of knee pain in children aged 10-15 years. Patients present with a history of pain inferior to the patella at the insertion of the patellar tendon. Typically, individuals report a sport or other activity that aggravates the pain, which generally is improved with rest and worsened with activity. While any activity may be involved, sports involving jumping or running are a common cause. Physical findings are limited to the area of the tibial tubercle and patellar tendon. Generally, there is a prominence and soft tissue swelling over the tibial tubercle. Tenderness of the patellar tendon may be present. The remainder of the knee examination usually is normal. Attempted flexion against resistance may produce pain. Patients may resist knee flexion because of inflammation and pain from pull on the patellar tendon. Tight hamstrings and/or quadriceps may also be noted when compared to the uninvolved side. INDICATIONSSection 3 of 12
Surgery to treat OS condition is rarely indicated. Occasionally, adults have a large ossicle and an overlying bursa, which may cause pain with kneeling. If so, treatment consists of excision of the bursa, ossicle, and any prominence. Surgical treatment is rarely, if ever, indicated in children. See Treatment. RELEVANT ANATOMYSection 4 of 12
Ossification of the tibial tubercle normally begins in children aged 7-9 years. Ossification of the tubercle begins distally and advances toward the extension of the physis that is ossifying distally. The patellar tendon attaches into the unossified distal portion. Strong forces exerted on the patellar tendon during the adolescent years can produce microfracture of the tibial tubercle at its insertion into the tibial diaphysis. CONTRAINDICATIONSSection 5 of 12
The real question is whether or not surgery is ever indicated in the growing child, as OS condition is self-limiting. Trail (1988) reviewed 2 groups of symptomatic patients with this condition with 4-5 years of follow-up. One group was treated surgically with tibial sequestrectomy, and the other was managed conservatively. Surgery was found to offer no significant benefit over conservative care. In addition, a significant complication rate was identified with tibial sequestrectomy. WORKUPSection 6 of 12
Imaging Studies
Histologic FindingsLazerte examined resected operative specimens in patients with OS condition. He demonstrated avulsion fractures in the distal portion of the tibial tubercle. Ehrenborg and others examined histologic specimens of bone excised from portions of tibial tubercles and found viable cancellous bone without evidence of inflammation or avascular necrosis. TREATMENTSection 7 of 12
Medical therapyMost patients respond to conservative care that consists of rest and avoidance of the offending activity. Stretching of the quadriceps and hamstrings before engaging in athletics may be helpful. Applying ice after physical activity may decrease swelling and pain. Immobilization by casting or bracing usually is unnecessary except in severe cases. Nonsteroidal anti-inflammatory drugs may be used but have not been shown to decrease the course of the disease. Steroidal injections should not be used. Other than the presence of an ossicle that causes pain with kneeling, there are no long-term disabilities or problems associated with this condition. Surgical therapyBinazzi (1993) reviewed a series of patients who had been treated operatively. He stated that treatment generally is conservative and only rarely does surgical treatment become necessary. His indications for surgery were persistence of pain and swelling. The most widely used procedure was excision of all intratendinous ossicles, with or without removal of a portion of the prominent tibial tubercle. A comparison of 2 groups of individuals, one with 15 individuals treated with excision of ossicles and one with 11 individuals treated with various methods before 1975, clearly revealed that results of simple excision of the ossicles were better. In another study, patients treated operatively were no more likely than conservatively treated patients to be relieved of pain or have improvement of cosmetic appearance. The authors' preferred method of management of this condition is as follows:
COMPLICATIONSSection 8 of 12
Surgery is rarely indicated. Following resection of an ossicle, complications include continued pain and displeasure with the cosmetic appearance. In a study by Trail (1988), 55% of patients had an obvious bony prominence postoperatively. One third of these prominences were quite marked and troublesome, and 3 required a subsequent shaving. One patient lost 10° of flexion, and another patient had 10° of recurvatum. Other complications that may occur include dehiscence, unsightly scar, anesthesia lateral to the scar, and continued presence of sequestra. OUTCOME AND PROGNOSISSection 9 of 12
OS condition has a natural history that is self-limiting. In the Krause study (1990), 90% of patients were relieved of all their symptoms approximately 1 year following onset of symptoms with conservative care. Occasionally, patients may have continued problems kneeling into adulthood or have a tender ossicle and/or bursa that may require resection. FUTURE AND CONTROVERSIESSection 10 of 12
The only controversy is whether or not surgery plays a role in the patient's treatment prior to skeletal maturity. Given the risks and benefits, evidence suggests that surgery is rarely, if ever, indicated. MULTIMEDIASection 11 of 12
REFERENCESSection 12 of 12
Osgood-Schlatter Disease excerpt Article Last Updated: Jan 5, 2007 | |||||||||||||||||||
