Overview
Definition:
Osgood-Schlatter disease (OSD) is a common cause of anterior knee pain in skeletally immature individuals, characterized by inflammation and pain at the tibial tubercle, where the patellar tendon inserts
Sinding-Larsen-Johansson disease (SLJ) is a similar condition affecting the inferior pole of the patella, where the patellar tendon originates.
Epidemiology:
OSD typically affects active adolescents aged 10-15 years, with a higher incidence in males, especially those involved in sports requiring repetitive knee extension and jumping
SLJ is more common in slightly younger adolescents, typically 8-13 years old, and also more prevalent in sports participants.
Clinical Significance:
Both OSD and SLJ are benign, self-limiting conditions that are important for medical professionals to recognize and manage appropriately to prevent chronic pain and functional limitations
Differentiating between them and understanding their management is crucial for pediatricians, sports medicine physicians, and orthopedic surgeons preparing for DNB and NEET SS examinations.
Clinical Presentation
Symptoms:
Pain localized to the tibial tubercle (OSD) or inferior pole of the patella (SLJ)
Pain is exacerbated by activity, especially running, jumping, kneeling, and squatting
Tenderness to palpation over the affected area
Swelling and warmth may be present over the tibial tubercle or patellar pole
A visible bony prominence may develop at the tibial tubercle in OSD.
Signs:
Point tenderness directly over the tibial tubercle (OSD) or inferior patellar pole (SLJ)
Pain elicited with resisted knee extension
Pain with quadriceps contraction
Swelling and possibly erythema over the affected area
Full range of motion is usually preserved, but may be painful.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on history and physical examination findings
Radiographic evidence is usually not required for diagnosis but can support it and rule out other conditions
Key findings include localized pain and tenderness at the characteristic anatomical location in an active adolescent.
Diagnostic Approach
History Taking:
Detailed history of onset and duration of pain
Activities that aggravate or alleviate pain
History of recent growth spurt
Involvement in sports or activities with repetitive jumping or running
Any history of direct trauma to the knee
Red flags: severe pain limiting ambulation, fever, redness, or swelling suggestive of infection or inflammatory arthropathy.
Physical Examination:
Palpate the tibial tubercle for tenderness and swelling (OSD) and the inferior pole of the patella for tenderness and swelling (SLJ)
Assess range of motion of the knee
Evaluate for pain with resisted knee extension and quadriceps contraction
Examine the entire lower extremity for alignment issues or other sources of pain.
Investigations:
Plain radiographs (lateral view of the knee) are often sufficient to confirm the diagnosis and rule out other causes of knee pain
Findings in OSD may include widening of the infrapatellar fat pad, fragmentation or irregularity of the tibial tubercle apophysis, and soft tissue swelling
Findings in SLJ may include fragmentation or irregularity of the inferior patellar pole
MRI or CT scans are rarely necessary but can be useful for complex cases or to exclude other pathologies.
Differential Diagnosis:
Other causes of anterior knee pain in adolescents include patellar tendinitis, patellofemoral pain syndrome, tibial stress fractures, osteochondritis dissecans of the patella, juvenile idiopathic arthritis, and infections like osteomyelitis
These can be differentiated by location of pain, associated symptoms, and radiographic findings.
Management
Initial Management:
Activity modification is the cornerstone of treatment
This involves reducing or temporarily ceasing activities that cause pain, such as running, jumping, and sports
Complete rest is usually not necessary
Ice application to the affected area for 15-20 minutes several times a day can help reduce pain and inflammation.
Medical Management:
Analgesics, such as acetaminophen or non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen, can be used to manage pain and inflammation
Doses should be appropriate for the adolescent's age and weight
For ibuprofen, a common starting dose is 400-800 mg thrice daily
For naproxen, 250-500 mg twice daily
These are typically used for short durations as needed for pain control.
Surgical Management:
Surgical intervention is rarely required for Osgood-Schlatter disease or Sinding-Larsen-Johansson disease
It is typically reserved for cases with persistent, disabling pain that has not responded to conservative management for at least 6-12 months, or for specific complications like a symptomatic, non-united ossicle causing chronic impingement
Procedures may include excision of the ossicle or release of the patellar tendon.
Supportive Care:
Education of the patient and parents about the benign nature and expected course of the condition is crucial
Physiotherapy may be beneficial for quadriceps and hamstring stretching and strengthening exercises once pain subsides
Gradual return to activity should be guided by symptom resolution.
Complications
Early Complications:
Persistent pain and inflammation
Limitation of participation in sports and daily activities
Development of a prominent, sometimes painful, bony lump at the tibial tubercle (OSD).
Late Complications:
In rare cases, persistent pain can continue into adulthood
The bony prominence at the tibial tubercle may remain and can occasionally be a source of irritation with direct trauma or prolonged kneeling
Non-union of the apophysis can lead to chronic pain.
Prevention Strategies:
Proper warm-up and cool-down routines before and after physical activity
Gradual increase in training intensity and duration to avoid overuse
Maintaining flexibility and strength in the quadriceps and hamstring muscles
Proper footwear can also help
Addressing biomechanical issues if present.
Prognosis
Factors Affecting Prognosis:
Adherence to activity modification and conservative management
Skeletal maturity at the time of presentation
Severity of symptoms and duration
Promptness of diagnosis and intervention.
Outcomes:
The prognosis for both Osgood-Schlatter disease and Sinding-Larsen-Johansson disease is generally excellent, with most cases resolving completely with skeletal maturity
Pain typically subsides within 1-2 years of onset
The bony prominence from OSD usually remains but is often asymptomatic.
Follow Up:
Follow-up is usually guided by symptoms
Periodic check-ups may be necessary for adolescents with persistent pain or functional limitations
Education on gradual return to sports and long-term management strategies is important
Most patients do not require formal long-term follow-up once pain resolves and skeletal maturity is reached.
Key Points
Exam Focus:
OSD is pain at the tibial tubercle apophysis
SLJ is pain at the inferior patellar pole
Both are traction apophysitis due to repetitive forces from the quadriceps mechanism
Diagnosis is primarily clinical
Management is conservative: rest, ice, NSAIDs, and activity modification
Surgical intervention is rare.
Clinical Pearls:
Always palpate the tibial tubercle and inferior patellar pole specifically
Differentiate from patellar tendinitis (tenderness more distal in the tendon)
Emphasize to young athletes and parents that these are temporary conditions that resolve with growth
Gradual return to sport is key to preventing recurrence.
Common Mistakes:
Over-treating with aggressive physiotherapy or premature return to sport, leading to exacerbation of pain
Misdiagnosing as a more serious condition like a fracture or infection due to lack of specific examination
Neglecting to counsel patients and parents on the expected benign course and self-limiting nature of these conditions.