Overview
Definition:
Osgood-Schlatter disease is a common cause of anterior knee pain in adolescents, characterized by inflammation and pain at the tibial tuberosity, the site where the patellar tendon inserts
It is an apophysitis, a traction apophysitis, resulting from repetitive stress from quadriceps contraction, particularly during activities involving running, jumping, and kneeling.
Epidemiology:
Primarily affects active children and adolescents aged 9-16 years, with a higher incidence in males
It is seen more frequently in sports requiring significant jumping and running, such as basketball, soccer, gymnastics, and track and field
Prevalence rates vary, but it is a leading cause of knee pain in this age group.
Clinical Significance:
While generally a self-limiting condition, Osgood-Schlatter disease can cause significant pain and functional limitation, impacting participation in sports and daily activities
Understanding its management, particularly activity modification and rehabilitation, is crucial for pediatricians and orthopedic specialists to guide young athletes and prevent long-term sequelae.
Clinical Presentation
Symptoms:
Pain localized to the tibial tuberosity, often worse with activity
Swelling and tenderness over the tibial tuberosity
Pain that may improve with rest and worsen with prolonged standing or activity
A visible bony prominence or lump at the tibial tuberosity
Intermittent or chronic pain that can persist for months or even years until skeletal maturity.
Signs:
Palpable tenderness and often a distinct bony prominence or exostosis at the tibial tuberosity
Swelling localized to the area
Pain reproduced with resisted extension of the knee
Pain may be elicited with direct palpation of the tibial tuberosity
Limited range of motion of the knee due to pain, especially in flexion.
Diagnostic Criteria:
Diagnosis is primarily clinical, based on characteristic symptoms and physical examination findings in an adolescent athlete
Radiographic confirmation is not always necessary but can show widening of the apophysis, fragmentation of the tibial tuberosity, or elevation of the tibial tuberosity fragment
Specific diagnostic criteria are not strictly defined but rely on the classic presentation.
Diagnostic Approach
History Taking:
Detailed history of onset and duration of pain
Identification of aggravating activities (running, jumping, squatting)
History of recent growth spurts
Type and intensity of sports participation
Previous knee injuries
Red flags: fever, night pain, systemic symptoms suggesting infection or malignancy.
Physical Examination:
Inspection for swelling and deformity over the tibial tuberosity
Palpation for tenderness and assessment of the size of any bony prominence
Assessment of range of motion of the knee, noting pain with flexion
Resisted knee extension to assess for pain provocation
Examination of the contralateral knee and assessment of gait and posture.
Investigations:
Radiographs (AP and lateral views of the knee) are typically used to confirm the diagnosis and rule out other causes of knee pain
Findings may include a widened or fragmented tibial tuberosity apophysis, avulsion fractures, or irregularity of the physis
Ultrasound can be used to assess soft tissue inflammation
MRI is rarely indicated but may be used to rule out other pathologies.
Differential Diagnosis:
Other common causes of anterior knee pain in adolescents include patellofemoral pain syndrome, Osgood-Schlatter disease variants (e.g., Sinding-Larsen-Johansson syndrome affecting the inferior pole of the patella), infrapatellar bursitis, osteochondritis dissecans, stress fractures, tendinitis, and, rarely, osteomyelitis or tumors.
Management
Initial Management:
Activity modification is the cornerstone of management
This involves reducing participation in activities that exacerbate pain, such as jumping, running, and kneeling
Complete cessation of sport is usually not required unless pain is severe
Rest, ice application for 15-20 minutes several times a day, and NSAIDs (e.g., ibuprofen, naproxen) for pain and inflammation management.
Activity Modification:
Gradual return to activity as pain subsides
Modification of training regimens to include less impact activities
Cross-training with activities like swimming or cycling can help maintain fitness
Education of the patient and parents about the condition and the importance of adhering to activity restrictions.
Rehabilitation:
Once acute pain subsides, a progressive rehabilitation program is initiated
This includes stretching exercises for the quadriceps and hamstring muscles
Strengthening exercises for the quadriceps, hamstrings, and gluteal muscles, focusing on eccentric strengthening
Proprioception and balance exercises
Gradual return to sport-specific activities under supervision.
Supportive Care:
Pain management with oral analgesics as needed
Use of knee pads or patellar tendon straps may provide symptomatic relief during activity
Patient and parent education on the chronic nature of the condition and reassurance that it typically resolves with skeletal maturity
Physiotherapy referral is often beneficial for structured rehabilitation.
Complications
Early Complications:
Persistent pain that limits daily activities
Worsening inflammation of the tibial tuberosity
In rare cases, avulsion fracture of the tibial tuberosity with significant displacement.
Late Complications:
Development of a prominent, bony exostosis at the tibial tuberosity, which can be a cosmetic concern or may become symptomatic with direct pressure (e.g., from kneeling)
Persistent pain into adulthood, though rare
Discomfort with certain activities requiring kneeling.
Prevention Strategies:
Proper warm-up and cool-down routines before and after exercise
Gradual increase in training intensity and duration
Adequate rest periods between training sessions and competitions
Use of appropriate footwear
Avoiding overuse
Strengthening of the quadriceps and hamstring muscles to improve biomechanics.
Prognosis
Factors Affecting Prognosis:
Adherence to activity modification and rehabilitation
Severity of symptoms at presentation
Age of the individual at onset
Continued participation in high-impact sports without adequate rest.
Outcomes:
Most cases of Osgood-Schlatter disease resolve spontaneously with skeletal maturity, typically within 1-2 years
Pain and swelling usually subside, and functional capacity is restored
Persistent bony prominence is common but usually asymptomatic
Surgery is rarely needed and reserved for recalcitrant cases with large, symptomatic exostosis.
Follow Up:
Regular follow-up may be necessary to monitor symptom progression and adherence to treatment recommendations
Once skeletal maturity is reached and symptoms have resolved, long-term follow-up is usually not required unless new or persistent pain develops
Education on managing the residual bony prominence is important.
Key Points
Exam Focus:
Osgood-Schlatter disease is a traction apophysitis at the tibial tuberosity in adolescents
Management is primarily conservative with rest, ice, NSAIDs, and crucial activity modification followed by progressive rehabilitation
Palpable tenderness and swelling over the tibial tuberosity are key signs.
Clinical Pearls:
Emphasize that Osgood-Schlatter disease is a diagnosis of exclusion after ruling out more serious causes of knee pain
The focus is on symptom management and gradual return to play, not on complete cessation of all activities
Education and patient buy-in are vital for successful outcomes
Look for bilateral involvement, which is common.
Common Mistakes:
Overly aggressive treatment with prolonged immobilization or complete cessation of all sports, which can lead to deconditioning
Inadequate rehabilitation, leading to premature return to play and recurrence of symptoms
Failure to consider differential diagnoses, especially in atypical presentations or if red flags are present.