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Basics ⬇

Author: AyoAdu, MD, CAQSM

Description

  • Traction apophysitis of the tibial tubercle at the insertion of the patellar tendon
  • Overuse injury due to repetitive strain or microtrauma of the secondary ossification center of the tibial tubercle

Epidemiology

  • One of the most common causes of knee pain in active adolescents
  • More prevalent in male gender
  • Age of onset coincides with growth spurts, males age 10 to 15 yr, females age 8 to 13 yr.

Etiology and Pathophysiology

  • Chronic repetitive strain and microtrauma cause chronic avulsion of the secondary ossification center (1).
  • The force is increased after periods of rapid growth.
  • Chronic avulsion may cause separation of the patellar tendon insertion from the tibial tubercle, swelling, and enlargement.

Risk-Factors

  • Adolescents
  • Male gender
  • Sports that involve running and jumping
  • Activities that involve direct contact with the knee (e.g., kneeling)
  • Higher body weight
  • Quadriceps muscle tightness (2)[B]

Diagnosis ⬆ ⬇

History

  • Anterior knee pain and swelling
  • Symptoms are bilateral in 20–30% of patients.
  • Pain begins as a dull ache that gradually increases with continued activity.
  • Pain is worsened by running, jumping, direct trauma, kneeling, and squatting.
  • Pain is improved with rest.

Physical Exam

  • Enlarged prominent tibial tubercle
  • Tenderness of the proximal tibial tubercle at the patellar tendon insertion
  • Poor flexibility of the quadriceps and hamstrings
  • Able to maintain full, symmetric knee extension with active straight-leg raise
  • Inability to maintain symmetric knee extension with straight-leg raise, especially in event of acute onset of pain at tibial tubercle, is highly suggestive for tibial tubercle avulsion fracture.
  • Pain is exacerbated by knee extension against resistance, active or passive knee flexion, or by direct trauma to the tibial tubercle.

Differential Diagnosis

Diagnostic Tests & Interpretation

  • Osgood-Schlatter disease is a clinical diagnosis, and radiographs are not required for diagnosis. However, they may be helpful in ruling out other conditions, such as acute tibial apophyseal fracture, osteomyelitis, and tumors (3)[A].
  • X-ray:
    • Lateral view may show an elevated tibial tubercle with anterior soft tissue swelling, fragmentation of the tibial tubercle, or calcification and ossicle formation in the distal patellar tendon.

Treatment ⬆ ⬇

General Measures

  • Relative rest or activity modification is recommended.
  • Activity as tolerated, including sports, is allowed as long as symptoms are tolerable and resolve within 24 hr.
  • Pain control with nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen
  • Protective pad may be worn over tibial tubercle to prevent direct trauma.
  • Ice application especially after exercise
  • If significant symptoms, consider physical therapy consult.

Additional Therapies

  • Osgood-Schlatter disease is usually a benign and self-limited condition that resolves once growth plate closes.
  • Usual course is 6 to 18 mo.
  • Symptoms may continue into adulthood despite conservative measures in 5–10% of patients.
  • Recommended exercises include stretching of the quadriceps and hamstring and strengthening of the quadriceps.

Surgery/Other Procedures

Surgical excision of the enlarged tibial tubercle and free ossicles may be considered in skeletally mature patients if conservative treatment has failed.

Additional Reading ⬆ ⬇

Bloom OJ, Mackler L, Barbee J. Clinical inquiries. What is the best treatment for Osgood-Schlatter disease?J Fam Pract. 2004;53(2):153–156.

References ⬆ ⬇

  1. Gholve PA, Scher DM, Khakharia S, et al. Osgood Schlatter syndrome. Curr Opin Pediatr. 2007;19(1):44–50.
  2. Nakase J, Goshima K, Numata H, et al. Precise risk factors for Osgood-Schlatter disease. Arch Orthop Trauma Surg. 2015;135(9):1277–1281.
  3. Kabiri L, Tapley H, Tapley S. Evaluation and conservative treatment for Osgood-Schlatter disease: a critical review of the literature. Int J Ther Rehabil. 2014;21:91–96.

Clinical Pearls ⬆

  • Athletes may participate in athletic activity as tolerated. Pain level should generally be tolerable, without a decrease in performance, and resolve within 24 hr of activity. If performance is decreased, the athlete should discontinue activity.
  • Athlete should not “play through the pain.” Instead, pain should be used as a measure of when to stop activity.
  • Pain will resolve when the growth plate closes.
  • Future complications can include persistent enlargement of the tibial tubercle, pain with kneeling, and possibly some limitation of activities.
  • Prognosis is excellent, provided the athlete demonstrates good compliance with the physician’s recommendations.