Osgood-Schlatter's Disease

Background

Osgood-Schlatter's disease is an overuse injury, whereby repetitive strain resulting from an imbalance between the pull of the quadriceps and the strength of the apophysis at the patellar tendon insertion on the tibial tubercle leads to chronic avulsion or separation of the attachment of the patellar tendon to the tibial tubercle. This in turn promotes fibrous tissue formation to create a tender, bony protrusion at the proximal, anterior surface of the tibia.

Epidemiology

  • Common in young athletes with strong or inflexible quadriceps and relatively weak tibial tubercles who are experiencing pubertal growth spurts
    • Common activities associated with OS include soccer, basketball, ice hockey, and gymnastics
    • Athletes are 4X more likely to experience OS than non-athletes
  • Affects boys 10-15y/o and girls 8-13y/o
    • More likely in males
  • Most common cause of knee pain in children less than 16 years old. 
  • 20-50% of the cases are bilateral

Clinical Presentation

Diagnosis of OS is generally made clinically.

  1. Patient will complain of anterior knee pain that increases gradually over time. Pain starts as an ache and can progress to pain that causes limping or impairs activity.
  2. Pain is usually worsened by direct trauma, kneeling, running, jumping, squatting, climbing stairs, and walking uphill. Pain is relieved by rest.
  3. Physical examination usually demonstrates very tender prominent tibial tuberosity with no limitation of mobility of the knee. Pain may be reproducible if patient extends knee against resistance, or squats with the knee fully flexed.
  4. Increased BMI correlates with increased severity
  5. Patella alta is regularly seen with OS, but the exact relationship between the two is unclear
  6. Duration is typically 6-18 months with symptoms resolving when the growth plate closes
    • 10% will continue to have sensitive bony prominences into adulthood but no chronic knee pain
  7. The diagnosis is clinical and a radiographic examination is not necessary.
  • A/P and lateral knee x-rays are typically no done unless a patient fails conservative therapy or presents with a more acute history

Differential Diagnosis

  • Sinding-Larsen-Johansson (similar process but involves the inferior pole of the patella)
  • Stress fracture of the tibia
  • Avulsion fraction of the tibial tubercle
  • Patellar tendinosis
  • Patellar fracture
  • Quadriceps tendon avulsion
  • Plica syndrome
  • Hoffa disease

Treatment

  • Complete recovery is expected in 90% of patients. Symptoms can wax and wane for up to 24 mo. Pain usually resolves once the tibial growth plate closes.
  • Conservative treatment is recommended
  • Rest.
  • NSAIDS.
  • Icing knee after sporting activities.
  • Protective knee padding.
  • Limiting Activities as necessary. Most athletes can play if the pain is mild, and can be controlled with NSAIDs and ice.
  • Physical Therapy – Improves strength and flexibility of surrounding musculature.
  • Surgical treatment is reserved for patients who have failed conservative treatment. These patients have chronic, unresolved, painful OS. Surgical excision of retained intratendinous ossicles or free cartilaginous tissue may improve symptoms in skeletally mature patients.

Sever's Disease

Sever's disease is an overuse syndrome that involves the apophysis where the Achilles' tendon inserts to the calcaneal bone. Most affected children are between 9-12 years of age. There is often heel pain and tenderness can be elicited if both sides of the insertion area are palpated.

Treatment consists of strengthening of the muscle of the leg by doing dorsi and plantar flexion exercises of the foot. Analgesics and icing may help. The placement of a 1/4" heel pad in all shoes may alleviate the pain.

References

Bloom, OJ and Mackler, L. What is the best treatment for Osgood-Schlatter Disease? J Fam Practice 2004 Feb 53(2):153

Dyment, Paul. Apophyseal Injuries. Pediatric Annals. January 1997.

Gholve PA, Scher DM, Khakharia S, Widman RF, Green DW. Osgood Schlatter syndrome. Curr Opin Pediatr 2007; 19(1): 44-50.

Hanada M1, Koyama H, Takahashi M, Matsuyama Y. Relationship between the clinical findings and radiographic severity in Osgood-Schlatter disease. Open Access J Sports Med. 2012 Mar 9;3:17-20.

Jakob RP, von Gumppenberg S, Engelhardt P. Does Osgood--Schlatter disease influence the position of the patella? J Bone Joint Surg Br. 1981;63B(4):579-82.

Kienstra, A.J., Macias, C.G., Osgood-Schlatter disease (tibial tuberosity avulsion). UpToDate.com, Topic 6289 Version 19.0.

Weiss JM1, Jordan SS, Andersen JS, Lee BM, Kocher M. Surgical treatment of unresolved Osgood-Schlatter disease: ossicle resection with tibial tubercleplasty. J Pediatr Orthop. 2007 Oct-Nov;27(7):844-7.

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