AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

In 1903, Robert Osgood (1873-1956), a US orthopedic surgeon, and Carl Schlatter (1864-1934), a Swiss surgeon, concurrently described the disease that now bears their names. Osgood-Schlatter disease (OSD) is one of the most common causes of knee pain in active adolescents.

Frequency

United States

OSD affects 20% of athletic adolescents, as compared with the frequency of 4.5% of age-matched nonathletic controls. The disease is bilateral in 20-50% of patients. Boys are affected more commonly than girls, with a male-to-female ratio of 3:1. Boys aged 10-15 years and girls aged 8-13 years typically are affected, coinciding with growth spurts.

Functional Anatomy

In girls younger than 11 years and in boys younger than 13 years, the tibial tubercle consists of cartilaginous tissue. The secondary ossification center or apophysis of the tibial tubercle develops when girls are aged 8-12 years and when boys are aged 9-13 years. During this stage of skeletal development, the Osgood-Schlatter lesion may occur. The most commonly accepted theory is that repeated traction (traction apophysitis) on the anterior portion of this developing ossification center leads to multiple subacute fractures or tendinous inflammation, resulting in a benign self-limited disturbance manifested as pain, swelling, and tenderness.

By the end of the ensuing 2 stages of bony development (eg, epiphyseal and bony stages), the growth plates of the proximal tibia fuse in both males and females (usually when aged 14-18 y) and the OSD usually subsides.

Sport Specific Biomechanics

During running, gymnastics, and other sports requiring repeated contractions of the quadriceps, an extra-articular osteochondral stress fracture or microavulsion occurs. The proximal area of the patellar tendon insertion separates, resulting in elevation of the tibial tubercle. During the reparative phase of this stress fracture, new bone is laid down in the avulsion space, which may result in a deviated and prominent tibial tubercle. When an individual with an injured tibial tubercle continues to participate in sports, more and more microavulsions develop, and the reparative process may result in a markedly pronounced prominence of the tubercle with longer-term cosmetic and functional implications. A separated fragment may develop at the patellar tendon insertion and may lead to chronic nonunion-type pain.

CLINICAL

Section 3 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

History

• Knee pain usually is the presenting symptom. Patients usually report that the knee pain occurs during activities such as running, jumping, squatting, and ascending or descending stairs. Pain often subsides with rest and activity modification.
• Athletes involved in football, soccer, basketball, gymnastics, and ballet are most commonly affected.
• Symptoms often are vague and intermittent in onset.
• Symptoms may develop without trauma or other apparent cause.
• The patients who present with OSD are male and female adolescents, usually aged 12-15 years.

Physical

The physical examination is very specific with point tenderness over the tibial tubercle. Other physical examination findings may include the following:

• Proximal tibial swelling and tenderness



• Enlargement or prominence of the tibial tubercle



• Reproducible and aggravated pain by direct pressure and jumping (quadriceps contraction)



• Pain with resisted knee extension (quadriceps contraction)



• Full range of motion of the knee



• Hamstring tightness



• No effusion or meniscal signs



• Negative drawer test (no knee instability)



• Normal neurovascular examination



• No abnormal findings in the hip and ankle joints

Causes

The cause of OSD is unknown; however, theories suggest that this condition is a result of repeated knee extensor mechanism contraction that causes partial avulsions or microavulsions of the chondrofibroosseous tibial tubercle. OSD usually occurs in those involved in sports that require running and jumping.

DIFFERENTIALS

Section 4 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Other Problems to be Considered

Sinding-Larson-Johansson syndrome
Osteomyelitis
Tibia, fibula, or femur fracture
Tumor
Perthes disease
Quadriceps tendon avulsion
Patellofemoral stress syndrome
Chondromalacia patellae
Patellar tendonitis
Infectious apophysitis
Soft tissue malignancy
Accessory ossification centers

WORKUP

Section 5 of 11  

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• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Lab Studies

• Laboratory studies are not required to make the diagnosis of OSD.

Imaging Studies

• Imaging studies are not required to make the diagnosis of OSD; however, they often are used to rule out osteomyelitis, tumors, and other pathology.
• Radiographs
• • A lateral projection with the knee in slight medial rotation is the preferred view. This view shows the greatest detail of the tibial tubercle.

  • When radiographs are obtained, the most common finding is that the knee films are normal, especially if the child is in the preossification phase.

  • The acute phase of OSD may reveal a prominent and elevated tibial tubercle with anterior soft tissue swelling.

  • In severe cases, radiographs may reveal radiodense fragments or ossicles separated from the tibial tuberosity.

  • Occasionally, the radiographs may reveal irregularity, fragmentation, or increased density of the ossification of the tibial tubercle. This pattern may be a normal variant in asymptomatic children.

• Ultrasound may reveal a normal tubercle and signal changes consistent with thickening (more echogenic) in the patellar tendon and hypoechoic area of the adjacent soft tissue.
• CT scan or MRI may reveal changes at the insertion of the patellar tendon.

TREATMENT

Section 6 of 11  

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• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Acute Phase

Rehabilitation Program

Physical Therapy

Several techniques may be recommended by the physical therapist to alleviate discomfort and avert recurrence of the disease. Treatment recommendations are dependent upon the severity of the condition.

• An infrapatellar strap may be recommended during sports activity.



• Resting is recommended when pain arises.



• Ice should be applied to the area for 20 minutes following activity.



• Stretching of the quadriceps and hamstring muscles helps prevent the development of OSD.



• Short-term rest and knee immobilization may be required.



• Knee braces are used for long-term immobilization (6 wk) in severe cases (eg, pain persists longer than 24 h following sports activity and/or limits daily activity) or for noncompliant patients with increasing symptoms.

Medical Issues/Complications

Long-term immobilization is contraindicated because it may result in increased knee stiffness in mild cases, thus predisposing the athlete to additional sports-related injuries.

Surgical Intervention

If conservative treatment has failed, surgical excision of the united painful ossicle is recommended. Removal of ossicle fragmentation in immature patients with an unfused apophysis should be approached with caution, as a resultant recurvatum deformity may occur due to premature fusion of the tibial tubercle.

Tibial tubercle avulsions occasionally can occur due to the contracture of the extensor mechanism. Open reduction and internal fixation (ORIF) usually is recommended, depending on the size and displacement of the fragment as well as the phase of apophyseal closure. (See Osgood-Schlatter Disease in Orthopedic Surgery journal.)

Consultations

An orthopedic consultation is recommended.

Other Treatment

Cortisone injections are not recommended.

Recovery Phase

Rehabilitation Program

Physical Therapy

See Physical Therapy, Acute Phase.

The following regimen recommendations for patients with OSD are taken from Meisterling, Wall, and Meisterling:

• Straight leg raises
  
  
  • Lie on the floor with the back propped up a few inches with the elbows.
  
  
  
  • Bend the unaffected knee to a comfortable position. Using adjustable ankle weights with half-pound increments, determine the weight at which 10 raises can be performed on the affected leg.
  
  
  
  • Tighten the thigh muscles and lift the affected leg 12 inches, keeping the leg straight.
  
  
  
  • Hold for 5 seconds.
  
  
  
  • Slowly lower the leg and relax.
  
  
  
  • Start with 10 repetitions for each leg.
  
  
  
  • When 15 repetitions have been performed comfortably, increase the weight by half a pound and drop back to 10 repetitions.
  
  
  
  • Once 15 repetitions again can be performed comfortably, increase the weight again, to a maximum of 7-12 lb.  
     
• Short-arc quadriceps exercises
  
  
  • Lie back with the unaffected knee bent (same as for straight leg raises).
  
  
  
  • Place a few rolled up towels under the affected knee to raise it 6 inches from the floor.
  
  
  
  • Tighten the thigh muscles and straighten the leg until it is 12 inches from the floor.
  
  
  
  • Hold for 5 seconds.
  
  
  
  • Slowly lower the leg and relax.
  
  
  
  • Start with 10 repetitions for each leg and increase to 15, using the same ankle weight and repetition progression as for straight leg raises.
     
• Wall slides
  
  
  • To do wall slides or quarter seats, stand about 12 inches from a smooth wall and lean back against it with the feet shoulder width apart.
  
  
  
  • Holding a light dumbbell in each hand with the arms straight down, bend the knees and slowly lower the body 4-6 inches.
  
  
  
  • If pain is felt, the body has squatted too far.
  
  
  
  • Hold for 5 seconds and then rise up quickly.
  
  
  
  • Start with 10 repetitions and increase to 15, gradually increasing the dumbbell weight in the same type of progression as for straight leg raises.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The goal of rehabilitation is for the athlete to be able to return to his or her sport as quickly and safely as possible. The physical therapist and the physician determine when the athlete is ready to resume competition, depending on the findings of the clinical examination and functional testing. The pain may take up to 6-24 months to resolve. If an individual returns to activity too soon, he or she may worsen the condition. Athletes need to work on improving the flexibility and strength of the quadriceps and hamstring muscles throughout the course of rehabilitation to ensure that they are ready to return to sports.

MEDICATION

Section 7 of 11  

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The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Drug Category: Nonsteroidal anti-inflammatory drugs (NSAIDs)

Short-term NSAIDs may be used for pain relief. Steroids are not recommended for use in this condition. NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

FOLLOW-UP

Section 8 of 11  

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Return to Play

After the pain has resolved (which may take 6-24 mo), the patient may return to play as tolerated. The patient may need to participate less frequently, run at a slower speed, or decrease jumping activities. Premedicating or relying on NSAIDs regularly before or after competition is not advised. An intensive rehabilitation program of stretching exercises helps to decrease the likelihood of developing pain with vigorous sports activity. OSD usually resolves by the time the adolescent is aged 18 years.

Complications

The most common long-term complications are pain on kneeling as an adult and the cosmesis of a bony prominence on the anterior knee. Less common complications are the persistence of a painful ossicle requiring surgical excision and a displaced avulsion of a tibial tubercle.

Prevention

Activity modification and regular stretching and strengthening exercises provide the best prevention.

Prognosis

The prognosis is excellent. OSD usually resolves by the time the patient is aged 18 years, when the tibial tubercle apophysis ossifies. The likelihood for long-term sequelae increases in severe cases, in cases in which treatment is not sought, or in cases in which the patient demonstrates poor compliance with the physician's recommendations.

Education

OSD is a self-limited illness that resolves as the patient approaches adulthood. For acute flare-ups, anti-inflammatory medications, ice, elevation, and rest are recommended. For prevention, the patient should engage in activity and sports as tolerated without development of knee pain. Regular daily stretching and strengthening exercises should be performed to help prevent OSD. Inform patients regarding the activities that aggravate the condition and regarding the self-limiting nature of the disease.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center, Arthritis Center, and Bone Health Center. Also, see eMedicine's patient education article Knee Pain.

MISCELLANEOUS

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• Follow-up
• Miscellaneous
• Multimedia
• References

Medical/Legal Pitfalls

• The most significant medicolegal pitfall is failing to diagnose another condition that could result in long-term permanent damage (eg, tumor, osteochondritis dissecans). Most other conditions have a more concerning clinical examination or history. Therefore, always obtain radiographs and consider the possibility of a referred pain syndrome from the hip.

Special Concerns

• If a patient is noncompliant, the clinician may recommend immobilization in a knee brace for a minimum of 6 weeks. The brace should be removed daily, only for stretching and strengthening exercises.

MULTIMEDIA

Section 10 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Media file 1:  Image courtesy of John T. Killion, MD; OSA Pediatric Orthopeaedics
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Media file 2:  Image courtesy of John T. Killion, MD; OSA Pediatric Orthopeaedics
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REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

• Behrman R, Kliegman R, Nelson WE. Osgood-Schlatter disease. In: Nelson Textbook of Pediatrics. Vol 14. Philadelphia, Pa: WB Saunders; 1992:1705.
• Bloom OJ, Mackler L, Barbee J. Clinical inquiries. What is the best treatment for Osgood-Schlatter disease?. J Fam Pract. Feb 2004;53(2):153-6. [Medline].
• Demirag B, Ozturk C, Yazici Z, Sarisozen B. The pathophysiology of Osgood-Schlatter disease: a magnetic resonance investigation. J Pediatr Orthop B. Nov 2004;13(6):379-82. [Medline].
• Epstein B. Common problems affecting adolescents - Osgood Schlatter disease: A common cause of knee pain. In: Iowa Health Book: Family Practice. Iowa City, Iowa: The University of Iowa; 1995.
• Flowers MJ, Bhadreshwar DR. Tibial tuberosity excision for symptomatic Osgood-Schlatter disease. J Pediatr Orthop. May-Jun 1995;15(3):292-7. [Medline].
• Meisterling R, Wall E, Meisterling M. Coping with Osgood-Schlatter disease. In: The Physician and Sports Medicine. Vol 26. New York, NY: McGraw-Hill; 1998.
• Ross MD, Villard D. Disability levels of college-aged men with a history of Osgood-Schlatter disease. J Strength Cond Res. Nov 2003;17(4):659-63. [Medline].
• Staheli L. 2nd ed. Fundamentals of Pediatric Orthopedics. Philadelphia, Pa: Lippincott-Raven; 1998:56, 123.
• Tachdjian MO. Clinical Pediatric Orthopedics: The Art of Diagnosis and Principles of Management. Vol 1. Stamford, Conn: Appleton & Lange; 1997:107-108.
• Wall E. Osgood-Schlatter disease: Practical treatment for a self-limiting condition. In: The Physician and Sports Medicine. Vol 26. New York, NY: McGraw-Hill; 1998.

Article Last Updated: Apr 28, 2006