CLINICAL Osgood-Schlatter Syndrome

REVIEW
Indexing Metadata/Description
› Title/condition: Osgood-Schlatter Syndrome
› Synonyms: Schlatter-Osgood syndrome; Osgood-Schlatter disease; Osgood-Schlatter
traction apophysitis; apophysitis, Osgood-Schlatter traction; tibial tubercle apophysitis;
apophysitis, tibial tubercle; juvenile soccer knee; knee, juvenile soccer
› Anatomical location/body part affected: Tibial tuberosity (also known as tibial tubercle)
and patellar tendon
› Description: A tibial tubercle apophysitis resulting from repetitive strain on the patellar
tendon insertion.(23) Osgood-Schlatter syndrome (OSS) is the most common cause of
knee pain in adolescents, especially those who participate in sports.(1) The incidence has
been reported as 21% among adolescent athletes compared to 4.5% among adolescent
nonathletes. Among the general adolescent population, the incidence rate has been
reported as 9.8%(23)
› Area(s) of specialty: Orthopedic Rehabilitation, Pediatric Rehabilitation, Sports
Rehabilitation
› ICD-10 codes
• M92.4 juvenile osteochondrosis of patella
(ICD codes are provided for the reader’s reference, not for billing purposes)
› G-codes
• Mobility G-code set
–G8978, Mobility: walking & moving around functional limitation, current status, at
therapy episode outset and at reporting intervals
–G8979, Mobility: walking & moving around functional limitation; projected goal
status, at therapy episode outset, at reporting intervals, and at discharge or to end
reporting
–G8980, Mobility: walking & moving around functional limitation, discharge status, at
Authors
Michael Granado, PT, MPT, ATC, CSCS discharge from therapy or to end reporting
Cinahl Information Systems, Glendale, CA • Changing & Maintaining Body Position G-code set
Andrea Callanen, MPT –G8981, Changing & maintaining body position functional limitation, current status, at
Cinahl Information Systems, Glendale, CA
therapy episode outset and at reporting intervals
–G8982, Changing & maintaining body position functional limitation, projected goal
Reviewers
Amy Lombara, PT, DPT
status, at therapy episode outset , at reporting intervals, and at discharge or to end
Cinahl Information Systems, Glendale, CA reporting
Megan Rabin, MEd –G8983, Changing & maintaining body position functional limitation, discharge status,
Cinahl Information Systems, Glendale, CA
at discharge from therapy or to end reporting
Rehabilitation Operations Council
Glendale Adventist Medical Center,
• Other PT/OT Primary G-code set
Glendale, CA –G8990, Other physical or occupational therapy primary functional limitation, current
status, at therapy episode outset and at reporting intervals
Editor –G8991, Other physical or occupational therapy primary functional limitation, projected
Sharon Richman, MSPT goal status, at therapy episode outset, at reporting intervals, and at discharge or to end
reporting
Cinahl Information Systems, Glendale, CA

–G8992, Other physical or occupational therapy primary functional limitation, discharge

status, at discharge from therapy or to end reporting
January 4, 2019

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2019, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
 • Other PT/OT Subsequent G-code set
–G8993, Other physical or occupational therapy subsequent functional limitation, current status, at therapy episode outset
and at reporting intervals
–G8994, Other physical or occupational therapy subsequent functional limitation, projected goal status, at therapy episode
outset, at reporting intervals, and at discharge or to end reporting
–G8995, Other physical or occupational therapy subsequent functional limitation, discharge status, at discharge from
therapy or to end reporting

.
G-code Modifier Impairment Limitation Restriction
CH 0 percent impaired, limited or restricted
CI At least 1 percent but less than 20 percent
impaired, limited or restricted
CJ At least 20 percent but less than 40 percent
impaired, limited or restricted
CK At least 40 percent but less than 60 percent
impaired, limited or restricted
CL At least 60 percent but less than 80 percent
impaired, limited or restricted
CM At least 80 percent but less than 100 percent
impaired, limited or restricted
CN 100 percent impaired, limited or restricted
Source: https://www.cms.gov/

.
› Reimbursement:Reimbursement for therapy will depend on insurance contract coverage. No specific issues or information
regarding reimbursement has been identified
› Presentation/signs and symptoms
• Osgood-Schlatter syndrome (OSS) presents in growing boys and girls as local pain, swelling, and tenderness over the tibial
tuberosity at the attachment of the patellar tendon. The apophysis may be enlarged in later stages(1)
• Pain will be elicited during exercise (e.g., running, jumping) or with direct contact, such as in kneeling(1)
• Pain is associated with resisted knee extension(16)
• Patient may report bilateral symptoms, which are present in 20–30% of cases(1)
• Onset of symptoms is gradual(16)

Causes, Pathogenesis, & Risk Factors

› Causes
• Strong repetitive contractions of the quadriceps are thought to cause a traction force on the tibial tuberosity whereby the
immature secondary ossification center is disrupted. Consequently, OSS is associated with sports participation during the
adolescent growth spurt(1)
• Another reported cause for OSS has been the lack of growth of the quadriceps in comparison to the femur. During a
growth spurt in a child, the lengthening of the muscle is unable to keep up with the rapidly lengthening femur, resulting in
increased tensile force on the tibial tuberosity(3)
› Pathogenesis
• Children and adolescents are most susceptible to OSS due to anatomical and physiological characteristics of their age
–As a child grows, bones go through different stages of development. The tibial tuberosity is initially cartilaginous
(cartilaginous stage). It then enters the apophyseal stage, when the secondary ossification center (apophysis) appears. The
unity of the proximal tibial epiphysis with the tibialapophysis marks the epiphyseal stage. Lastly, when the growth plates
fuse, the bony stage has been reached(1,4)
 –When children’s bones are in the apophyseal stage, the apophysis is unable to withstand tensile forces. When presented
with strong, repetitive muscle contractions, microavulsion occurs at the immature area. The separation results in
symptoms typical of OSS as well as irregular bone growth that explains an enlarged tibial tuberosity afterwards(1,4)
–During growth spurts, there is an imbalance in growth rate between bone and muscle; the musculotendinous structures
are not able to keep up at the same rate as bone growth velocity. This imbalance causes increased tensile forces in the
tendinous insertion, resulting in traction apophysitis at the anterior tibial tuberosity(22)
› Risk factors
• Preadolescent and adolescent children, usually at the beginning of a growth spurt(5)
–Boys: ages 11–15 years
–Girls: ages 8–13 years
• Decreased flexibility of the quadriceps muscle group and hamstring muscle group(26)
• More common in boys(5,6)
• Activities involving repetitive, forced knee extension (quadriceps contractions), such as in jumping or kicking. Those who
participate in sports such as American football, volleyball, basketball, soccer, gymnastics, and figure skating are most
susceptible to increased loading of the patellar tendon and are at higher risk for developing OSS(2,22)
–Regular practice of sports during puberty and reduced length of the rectus femoris muscle were both significantly
associated with OSS in a cross-sectionalstudy of 956 adolescent students(8)
• Increased time participating in sport-specific training during childhood and adolescence increases the risk of developing
OSS and other overuse injuries(22)
• It has been suggested that individuals with Stickler’s syndrome (common autosomal dominant connective tissue disorder)
may be more susceptible to developing OSS. Most individuals with Stickler’s syndrome have no signs or symptoms of
Stickler’s syndrome and thus it is not diagnosed(7)

Overall Contraindications/Precautions
› A rare complication is separation, nonunion, and fragmentation of the tibial tuberosity (ossicles), which may require surgical
resection(2,9,10)
› A possible complication of OSS is the complete avulsion of tibial tuberosity. Frey et al. studied the incidence of tibial
tuberosity fractures in 19 adolescents over a 7-yearspan. In this group, 3 of 19 (15.7%) had preexisting OSS(11)
› Genu recurvatum is a rare complication of OSS that occurs if the anterior portion of the proximal tibial epiphyseal plate
fuses(5)
› Painful kneeling with direct pressure on the anterior knee may still be present years after the bones have fully matured(12)
› See specific Contraindications/precautions to examination and Contraindications/precautions under Assessment/
Plan of Care

Examination
› Contraindications/precautions to examination
• A tibial tuberosity fracture may present similarly to OSS, except that extensive knee effusion and the inability to extend the
knee will also be present on physical examination. Radiographs will also identify the avulsed tuberosity(1)
› History
• History of present illness/injury
–Mechanism of injury or etiology of illness: When did the symptoms begin? Does the patient report a specific injury or
trauma? Did the patient hear a “pop,” “crunch,” or tearing sensation at the time of injury? When does the pain occur? Has
the patient recently (past 6 months) gone through a growth spurt? The onset of OSS usually is insidious, as there may be
an inability to identify a traumatic event.(2) Patients will usually describe a gradual onset of intermittent symptoms.(1) Was
the pain concurrent with a growth spurt?
–Course of treatment
- Medical management: Ask about patient’s past and current medical management for knee pain. How has the pain
responded to treatments?
- Corticosteroid injections are not recommended due to case reports of subcutaneous atrophy(2)
 - Injections with lidocaine and the addition of dextrose are associated with improved symptoms and sports participation
compared with lidocaine alone or typical conservative care for child athletes with chronic OSS(25)
- Based on a small U.S. RCT of 54 athletes (65 knees), girls and boys between the ages of 9 and 17 years
- Injections were administered over the apophysis and patellar tendon once a month for 3 months
- Usual care included individual physical therapy (hamstring and quadriceps stretching and exercise)
- After 3 months, 67% of subjects in the combination injection group were asymptomatic, 23% of the lidocaine-only
group were asymptomatic, and 14% of the control group were asymptomatic with sports participation
- After 12 months, 84% of subjects in the combination injection group were asymptomatic, 46% of the lidocaine-only
group were asymptomatic, and 14% of the control group were asymptomatic with sports participation
- Medications for current illness/injury: Determine what medications clinician has prescribed; are they being taken?
Oral analgesics such as NSAIDs for pain commonly are prescribed in the acute phase
- Diagnostic tests completed (1)
- The American College of Radiology expert panel on musculoskeletal imaging conducted a systematic review of
the literature published through 2012. Its recommendations for cases of nontraumatic knee pain in children and
adolescents are the following:(19)
- Radiography is the initial imaging choice
- MRI should be ordered when knee pain is persistent, the initial radiographs are nondiagnostic (normal radiographs or
joint effusion), and knee symptoms indicate an internal derangement
- MRI is not indicated before a physical examination or routine conventional radiographs. MRI is also not indicated
when there is diagnostic evidence of other conditions such as complex regional pain syndrome, inflammatory
arthritis, stress fracture, or osteonecrosis
- Plain radiographs should include at least one frontal view of one or both knees, a lateral view of the affected knee, and
tangential patellar views. Referred pain from the hip must be considered in cases of nontraumatic knee pain, and hip
radiographs should be considered if there is clinical evidence of or concern for hip pathology(19)
- Radiographs commonly are taken to rule out other conditions such as a tibial tuberosity fracture, malignancy, or
infection
- MRIs are able to indicate joint effusion, communicative popliteal cysts, proliferative changes of the synovial
membrane, osteophytes, subchondral cysts, articular cartilage loss, meniscal and/or ligamentous tears and/or
degeneration, bone marrow edema, fractures, and osteonecrosis(19)
- Home remedies/alternative therapies: Document any use of home remedies (e.g., ice or heating pack) or alternative
therapies (e.g., acupuncture) and whether they help
- Previous therapy: Document whether patient has had physical therapy for this or other conditions and what specific
treatments were helpful or not helpful
- Aggravating/easing factors (note length of time each item is performed before the symptoms come on or are eased):
Document if there are any specific activities that exacerbate the symptoms. Pain increases with exercise in those
participating in sports that involve jumping and cutting activities.(2) Even kneeling(12) and stair climbing(13) have been
documented to cause symptoms
–Body chart: Use body chart to document location and nature of symptoms. Pain is localized to the tibial tuberosity as
the source of anterior knee pain and often is bilateral. Referred pain from hip or back is the leading cause of knee pain in
children with serious hip disease(19)
–Nature of symptoms: Document nature of symptoms (e.g., constant vs. intermittent, sharp, dull, aching, burning,
numbness, tingling). Pain usually is intermittent and mild, but potentially constant and severe in the acute case.(1)
Patients may complain of swelling over the tibial tubercle. Does the patient report any complaints of catching, clicking,
or “snapping” pain? These are indicative of a loose body, meniscal tear, and inflamed synovial plica. Any sensation of
“giving way”?
–Rating of symptoms: Use a visual analog scale (VAS) or 0–10 scale to assess symptoms at their best, at their worst,
and at the moment (specifically address if pain is present now and how much). Wall graded the severity of OSS on the
following scale:(2)
- Grade 1: Pain after activity that resolves within 24 hours
- Grade 2: Pain during and after activity that does not limit activity and resolves within 24 hours
- Grade 3: Constant pain that limits sports and daily activity
 –Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (a.m., mid-day, p.m., night);
also document changes in symptoms due to weather or other external variables
–Sleep disturbance: Document number of wakings/night, if any
–Other symptoms: Document other symptoms patient may be experiencing that could be indicative of a need to refer to
physician
–Barriers to learning
- Are there any barriers to learning? Yes__ No__
- If Yes, describe ________________________
• Medical history
–Past medical history
- Previous history of same/similar diagnosis: Any previous lower extremity musculoskeletal problems or injuries?
- Comorbid diagnoses: Ask patient/caregiver about other problems, including diabetes, cancer, heart disease, cognitive
disorders, psychiatric disorders, orthopedic disorders, etc.
- The results from a Turkish prospective noncontrolled trial of 74 children in whom OSS was diagnosed indicate a
strong association between OSS and attention-deficit hyperactivity/disorder (ADHD)(20)
- In 56 of 74 children with OSS, ADHD subsequently was diagnosed by a clinical psychologist based on the DSM-5
criteria
- 20/56 children participated in regular sporting activities; ADHD was significantly higher among subjects who did not
participate in any kind of formal sporting activities
- Researchers hypothesized that children with ADHD are prone to overuse injuries related to hyperactivity
- Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken
(including over-the-counterdrugs)
- Other symptoms: Ask patient about other symptoms he/she may be experiencing that may be indicative of a more
serious diagnosis. Symptoms such as weight loss, pallor, fever, and anorexia are systemic symptoms of osteosarcoma(14)
–Social/occupational history
- Patient’s goals: Document what the patient (and parents) hope to accomplish with therapy and in general
- Vocation/avocation and associated repetitive behaviors, if any:Does the patient participate in recreational or
competitive sports?
- Functional limitations/assistance with ADLs/adaptive equipment: Document use of any assistive or adaptive devices
- Living environment: Stairs, number of floors in home, with whom patient lives, caregivers, etc.
› Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be
appropriate to patient medical condition, functional status, and setting)
• Anthropometric characteristics: Document height, weight, and BMI and compared to age- and sex-related normative
data
• Arousal, attention, cognition (including memory, problem solving)
–Assess child’s ability to follow single-step and multistep directions and attend to task; assess for impulsivity(20)
• Assistive and adaptive devices: For patients with severe pain, determine the need for crutches for ambulation
• Balance: Assess static and dynamic standing balance using the balance subscale of the Bruininks-Oseretsky Test of Motor
Proficiency, Second Edition (BOT-2) or isolated tests such as single-limb stance (eyes open/closed) or tandem stance (eyes
open/closed). Compare to age and sex normative data
• Cardiorespiratory function and endurance: Document patient’s ability to ambulate, jog, or run prior to exacerbation of
symptoms. Note time, distance, or both prior to symptom reproduction. Note patient’s rate of perceived exertion using the
Borg Rating of Perceived Exertion (RPE) Scale
• Circulation: Palpate for distal pedal pulses. Should be normal in cases of OSS
• Functional mobility (including transfers, etc.)
–Review sports-related motion related to pain in athletes and ability to use stairs and squat in nonathletes
–Assess for reproduction of pain with kneeling, sit to stand, squatting, and stair negotiation
• Gait/locomotion: Evaluate severe cases for antalgic gait pattern or excessive compensatory mechanisms. Pay close
attention to whether the patient flexes the knee during loading or if the knee is kept in full extension to diminish the
quadriceps activity and reduce the likelihood of pain(13)
–Decreased ankle dorsiflexion can cause compensatory increased knee flexion, tibial inversion, and pronation during
stance phase of gait, placing increased stress on the patellar tendon(21)
 • Joint integrity and mobility: Assess bilateral knee joint mobility, including patellofemoral joint and proximal tibiofibular
joint mobility. Use Paris Stoddard Scale and note any symptom reproduction
• Muscle strength: Assess bilateral lower-extremity strength using manual muscle testing (MMT). Quadriceps weakness
and muscle atrophy may be present in chronic cases. Pain may be produced with resisted knee extension(1,15)
• Observation/inspection/palpation (including skin assessment): Assess for focal tenderness(15) or enlargement of the tibial
tuberosity. Visible and palpable soft-tissue edema is commonly found at the tibial tuberosity. There is often a “lump,” a
painful enlargement of tibial tuberosity at the insertion point of patellar tendon. There should be an absence of knee joint
effusion because OSS is extraarticular.(2) Erythema is not typically present with OSS.(16) Assess patellar location (alta,
baja, medial/lateral tilt) and patellar tracking. Assess quadriceps muscle. Take muscle girth measurements(1)
• Posture: Assess for leg-length discrepancy and sacroiliac dysfunction. Check for genu recurvatum (a possible complication
of OSS) and tibial torsion
• Range of motion: Assess bilateral lower extremities for active and passive ROM. It is important to assess hip ROM in
order to rule out hip pathology as the source of pain and functional limitations. Loss of full active knee extension can be
indicative of a tibial tuberosity avulsion fracture.(1) Assess muscle length of the rectus femoris, hamstrings, gastrocnemius/
soleus, iliotibial band, and other hip flexors/rotators
–Limitations of ankle dorsiflexion ROM (< 10°) were found in 93.3% of subjects with OSS (42/45)(21)
• Self-care/activities of daily living (objective testing): OSS rarely causes disability in self-care activities
• Sensory testing: Dermatome scan should be normal
• Special tests specific to diagnosis
–Percussion: Direct percussion of tibia away from patellar tendon attachment should not produce bone pain (as in stress
fracture)
–Ely’s test: Used to assess for rectus femoris pain and restricted knee flexion ROM in prone. The test is positive if the hip
rises from the table as the knee is flexed. If pain is elicited at the location of the patellar tendon or tibial tuberosity instead
of the typical stretch sensation in the muscle belly, then quadriceps stretching may need to be delayed(13)
–Ober’s test: Used to assess for tightness of iliotibial band and tensor fasciae lata(3)

Assessment/Plan of Care
› Contraindications/precautions
• Only those contraindications/precautions applicable to this diagnosis are mentioned below, including with regard
to modalities. Rehabilitation professionals should always use their professional judgment in their assessment and
treatment decisions
–Clinicians should follow the guidelines of their clinic/hospital and what is ordered by the patient’s physician. The
summary presented below is meant to serve as a guide and does not replace orders from a physician or the specific
protocols of the treatment clinic
• If a tibial tuberosity fracture is suspected, treatment should cease as surgery will most likely be required(2)
• Any suspicion of malignancy should also involve discontinuing physical therapy and referring the patient back to the
physician
› Contraindications/precautions to use of modalities
• Cryotherapy contraindications(15)
–Cold intolerance
–Raynaud’s syndrome
–Medical instability
–Cryoglobulinemia
–Cold urticaria
–Over a regenerating peripheral nerve
–Over a circulatory compromise
–Over an area of peripheral vascular disease
–Paroxysmal cold hemoglobinuria
• Cryotherapy precautions(15)
–Hypertension
–Thermoregulatory disorders
 –Over a superficial peripheral nerve
–Over an open wound
–Over an area of poor sensation
–Individuals with poor cognition
–In the very young or very old
–Persons with aversion to cold
• Electrotherapy contraindications (in some cases, when approved by the treating physician, electrotherapy may be used
under some of the circumstances listed below when benefits outweigh the perceived risk)(15)
–Over the trunk or heart region in patients with demand-type pacemakers and implantable cardioverter defibrillators
(ICDs)
–Over the pelvic, abdominal, lumbar, or hip region of a pregnant woman
–Over the carotid bodies
–Over the phrenic nerve, eyes, or gonads
–Over areas of known peripheral vascular disease
–Over areas of active osteomyelitis
–Over areas of hemorrhage
• Electrotherapy precautions(15)
–With patients without intact sensation
–With patients who cannot communicate
–With patients with compromised mental ability
–With cardiac dysfunction (uncontrolled hypertension or hypotension, irregular heartbeat)
–Over active or previous neoplasms
–With electrodes
- Over compromised skin, unless treating wound specifically
- Over tissues that are vulnerable to hemorrhage
- Cervical region in patients with history of stroke or seizures
–Do not use within 5 yards of diathermy units or other source of electromagnetic radiation
› Diagnosis/need for treatment: Conservative management, including rest/activity restriction, ice, NSAIDs, knee brace,
and physical therapy, is typically recommended.(24) Physical therapy is necessary to address extrinsic and intrinsic factors
associated with patient’s risk. A conservative therapeutic regimen is indicated to reduce pain and restore function
› Rule out
• Patellofemoral pain syndrome
• Patella fracture or subluxation
• Sinding-Larsen-Johansson syndrome (separation of patella tendon at proximal attachment)
• Patellar tendonitis
• Infrapatellar bursitis
• Tibial plateau or tibial tuberosity fracture
• Stress fracture of the proximal tibia
• Slipped capital femoral epiphysis
• Legg-Calve-Perthes disease
• Osteochondritis dissecans
• Meniscal injury
• Osteomyelitis of the proximal tibia
• Neoplasm of the proximal tibia
› Prognosis
• OSS has a self-limiting course: complete recovery can be expected with closure of the tibial growth plate (1–2 years).(16)
About 90% of patients respond well to nonoperative treatment, but symptoms may wax and wane for 12–24 months before
complete resolution.(1) Discomfort in kneeling(12) and diminished functional abilities(3) may continue even longer in some
cases
 • There are very few long-term complications; however, in rare cases individuals may develop osteoarthritis of the knee,
asymptomatic residual large tibial tuberosities, displaced avulsion fracture of the tibial tuberosity, or painful ossicle within
the distal patellar tendon(1)
› Referral to other disciplines
• Although symptoms of OSS may linger for months, few patients have poor outcomes with conservative treatment; surgical
intervention is seldom necessary. Patients who are unresponsive to a period of conservative care may need to be referred
for an orthopedic consultation for further evaluation(9)
• Surgical excision of bony or cartilaginous ossicles and tubercleplasty may be necessary when the condition becomes
chronic and unresponsive to conservative treatment(17)
› Treatment summary
• According to current opinion, about 90% of patients respond well to a variety of conservative treatment plans that include
relative rest with activity modification, cryotherapy for pain management, therapeutic exercises, and patient education as
the primary components(1)
• Prospective randomized controlled intervention trials are lacking. Existing evidence pertaining to treatment interventions
is limited and most of the published literature consists of case studies.(24) U.S. researchers conducted a 2014 systematic
review of the literature and concluded that there is strong evidence supporting clinical diagnosis of OSS but there is a lack
of strong research to guide clinicians in the treatment of OSS(23)
–Further research is required to establish definitive functional outcome measures and effective treatment interventions
–Strong evidence based on systematic reviews supports the use of stretching tight musculature within pain-free range to
avoid the risk of causing a tibial tubercle avulsion fracture
–Strong evidence based on a systematic review and expert consensus supports appropriate strengthening, primarily
quadriceps. Exercises should be performed only if they are pain free to decrease the risk of tibial tubercle avulsion
fracture. May need to begin with isometric quadriceps exercises if patient presents with atrophy and significant pain
–Scarce evidence is available from RCTs and systematic reviews to support physical therapy interventions; lesser quality
studies and expert opinions are more prevalent
–There is only one case series in the literature regarding knee orthotics to manage OSS, but many experts agree that the use
of knee orthotics can be beneficial in symptom management. The most common orthoses designed for patients with OSS
are the infrapatellar half-moon buttress and patellofemoral knee orthoses with H buttress
–Strong evidence supports iontophoresis for pain relief; however, the research is dated (1985 systematic review).
Treatment recommendations are a maximum trial period of 3 treatments with a 20-minute duration up to 5.0 milliamps
every other day with dexamethasone-sodium phosphate and 1cc of hydrogen chloride
–The results from two systematic reviews emphasized the importance of patient education regarding activity modification
to decrease symptoms, heat modalities for warm-up, and cold modalities after aggravating activities. Avoid activities that
reproduce pain and then gradually increase activity level

.
Problem Goal Intervention Expected Progression Home Program
Tibial pain on Decrease pain intensity Knee protection Progress as indicated Recommend home
quadriceps exertion _ _ and appropriate for program for pain
_ _ Restrict high-impact each unique patient management as
_ Return to sport/regular activities such as _ indicated for each
Knee pain that restricts daily activities running and jumping. _ patient
sports participation _ Promote low-impact _
_ _ cross-training _
_ Normalize weight (bicycling, elliptical
Antalgic gait/disturbed bearing and gait trainer, water running,
weight-bearing status patterns or swimming). Correct
training errors such as
jumping technique that
increase risk
_
_
Prescription/
application of devices
and equipment
_
Infrapatellar strap(18)
or knee padding to
minimize risk of blunt
trauma.(1,2) Knee
immobilizer for 3–
6 weeks in severe
cases(1,2,5)
_
_
Physical agents and
mechanical modalities
_
Iontophoresis, ice
packs, and/or ice
massage for pain(13)
_
_
Functional training
_
Graduated program
for return to running.
An aggressive sports-
specific reconditioning
program may be needed
for athletes after a
prolonged period of
activity modification(2)
Pain-restricted Increase/maintain Therapeutic exercises Progress as indicated Home exercise
quadriceps strength quadriceps strength and _ and appropriate for _
with risk for decreased general lower-extremity Begin with multiangle each unique patient Isometric quadriceps
general lower-extremity strength isometric quadriceps sets, straight leg
strength exercises and other raises, and short arc
low-resistance knee- quadriceps exercises if
extension exercises to pain free(13)
reduce traction on tibial
tuberosity(3)
Quadriceps and Increase/maintain Therapeutic exercises Progress as indicated Recommend home
hamstrings muscle general lower extremity _ and appropriate for program for flexibility
tightness flexibility Quadriceps stretching each patient management as
if pain free at the indicated for each
tibial tuberosity.(13) patient
Stretching of the
hamstrings, iliotibial
band, gastrocnemius,
and hip flexor/rotator
muscles should also be
performed(3)
_
_
Manual therapy
_
Assisted quadriceps and
hamstrings stretching

Desired Outcomes/Outcome Measures

› Desired outcomes/Outcome measures
• Decrease pain intensity
–VAS
• Return to sport/regular daily activities
–BOT-2, Sport-specific activities (e.g., jumping, cutting, running)
–Patient satisfactory survey
• Normalized weight-bearing and gait patterns
–Gait assessment
• Increase/maintain quadriceps strength and general lower-extremity strength
–MMT
• Increase/maintain general lower extremity flexibility
–Goniometry
–Flexibility reassessment

Maintenance or Prevention
› Maintain appropriate flexibility and strength of surrounding knee musculature
› Educate in a proper warm-up, cool-down, stretching protocol
› Use ice following activity and follow the recommendations regarding the use of prescribed NSAIDs

Patient Education
› See “Osgood-Schlatter disease” from the Mayo Clinic at
https://www.mayoclinic.org/diseases-conditions/osgood-schlatter-disease/symptoms-causes/syc-20354864
Note
› Recent review of the literature has found no updated research evidence on this topic since previous publication on January 5,
2018

Coding Matrix
References are rated using the following codes, listed in order of strength:

M Published meta-analysis RV Published review of the literature PP Policies, procedures, protocols

SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
C Case histories, case studies
G Published guidelines
RU Published research utilization report
QI Published quality improvement report
L Legislation
PGR Published government report
PFR Published funded report
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation

References
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