Osgood–Schlatter disease

Osgood–Schlatter disease (OSD) is inflammation of

Osgood–Schlatter Disease
the patellar ligament at the tibial tuberosity
(apophysitis).[3] It is characterized by a painful bump Other Apophysitis of the tibial tubercle,
just below the knee that is worse with activity and names Lannelongue's disease,[1]
better with rest.[3] Episodes of pain typically last a few osteochondrosis of the tibial
weeks to months.[4] One or both knees may be affected tubercle[2]
and flares may recur.[3][6]

Risk factors include overuse, especially sports which

involve frequent running or jumping.[3] The underlying
mechanism is repeated tension on the growth plate of
the upper tibia.[3] Diagnosis is typically based on the
symptoms.[3] A plain X-ray may be either normal or
show fragmentation in the attachment area.[3]

Pain typically resolves with time.[3] Applying cold to

the affected area, rest, stretching, and strengthening
exercises may help.[3][4] NSAIDs such as ibuprofen
may be used.[6] Slightly less stressful activities such as
swimming or walking may be recommended.[3]
Casting the leg for a period of time may help.[4] After
growth slows, typically age 16 in boys and 14 in girls,
the pain will no longer occur despite a bump potentially
remaining.[6][7]

About 4% of people are affected at some point in

time.[5] Males between the ages of 10 and 15 are most
often affected.[3] The condition is named after Robert
Bayley Osgood (1873–1956), an American orthopedic
surgeon, and Carl B. Schlatter (1864–1934), a Swiss
surgeon, who described the condition independently in
1903.[1][8]
Lateral view X-ray of the knee demonstrating
fragmentation of the tibial tubercle with
overlying soft tissue swelling.
Specialty Orthopedics
Symptoms Painful bump just below the knee,
worse with activity and better with
rest[3]

Contents Usual Males between the ages of 10

onset and 15[3]
Signs and symptoms
Duration Few weeks to months[4]
Risk factors
Risk Sports that involve running or
Diagnosis factors jumping[3]
Ultrasonography
Diagnostic Based on symptoms[3]
Types
method
Differential diagnosis
Treatment Applying cold, stretching,
Prevention strengthening exercises[3]
Treatment
 Physiotherapy Medication NSAIDs
Surgery Prognosis Good[3]
Rehabilitation Frequency ~4%[5]
Prognosis
Long-term implications
Epidemiology
References
External links

Signs and symptoms

Osgood–Schlatter disease causes pain in the front lower part of the
knee.[9] This is usually at the ligament-bone junction of the patellar
ligament and the tibial tuberosity.[10] The tibial tuberosity is a slight
elevation of bone on the anterior and proximal portion of the tibia.
The patellar tendon attaches the anterior quadriceps muscles to the
tibia via the knee cap.[11]

Intense knee pain is usually the presenting symptom that occurs

during activities such as running, jumping, lifting things, squatting,
and especially ascending or descending stairs and during
kneeling.[12] The pain is worse with acute knee impact. The pain
can be reproduced by extending the knee against resistance,
stressing the quadriceps, or striking the knee. Pain is initially mild
and intermittent. In the acute phase, the pain is severe and
continuous in nature. Impact of the affected area can be very Knee of a male with Osgood–
painful. Bilateral symptoms are observed in 20–30% of people.[13] Schlatter disease

Risk factors
Risk factors include overuse, especially sports which involve running or jumping.[3] The underlying
mechanism is repeated tension on the growth plate of the upper tibia.[3] It also occurs frequently in male
pole vaulters aged 14–22.[14]

Diagnosis
Diagnosis is made based on signs and symptoms.[15]

Ultrasonography

This test can see various warning signs that predict if OSD might occur. Ultrasonography can detect if there
is any tissue swelling and cartilage swelling.[11] Ultrasonography's main goal is to identify OSD in the
early stage rather than later on. It has unique features such as detection of an increase of swelling within the
tibia or the cartilage surrounding the area and can also see if there is any new bone starting to build up
around the tibial tuberosity.
Types

OSD may result in an avulsion fracture, with the tibial tuberosity

separating from the tibia (usually remaining connected to a tendon
or ligament). This injury is uncommon because there are
mechanisms that prevent strong muscles from doing damage. The
fracture on the tibial tuberosity can be a complete or incomplete
break.

Type I: A small fragment is displaced proximally and does not Three types of avulsion fractures.
require surgery.

Type II: The articular surface of the tibia remains intact and the fracture occurs at the junction where the
secondary center of ossification and the proximal tibial epiphysis come together (may or may not require
surgery).

Type III: Complete fracture (through articular surface) including high chance of meniscal damage. This
type of fracture usually requires surgery.

Differential diagnosis

Sinding-Larsen and Johansson syndrome,[16] is an analogous condition involving the patellar tendon and
the lower margin of the patella bone, instead of the upper margin of the tibia. Sever's disease is an
analogous condition affecting the Achilles tendon attachment to the heel.

Prevention
One of the main ways to prevent OSD is to check the participant's flexibility in
their quadriceps and hamstrings. Lack of flexibility in these muscles can be direct
risk indicator for OSD. Muscles can shorten, which can cause pain but this is not
permanent.[17] Stretches can help reduce shortening of the muscles. The main
stretches for prevention of OSD focus on the hamstrings and quadriceps.[18]

Direct stretching of the quadriceps can be painful so the use of foam rolling for
self myofascial release can help gently restore flexibility and range of
movement[19][20]

Treatment Example of how to

stretch the quadriceps
Treatment is generally conservative with rest, ice, and specific exercises being muscle.[6]
recommended.[24] Simple pain medication may be used such as acetaminophen
(paracetamol), or NSAIDs such as ibuprofen.[25] Typically symptoms resolve as
the growth plate closes.[24] Physiotherapy is generally recommended once the initial symptoms have
improved to prevent recurrence.[24] Surgery may rarely be used in those who have stopped growing yet
still have symptoms.[24]

Physiotherapy
Recommended efforts include exercises to improve the strength of
the gluteals, quadriceps, hamstring and gastrocnemius
muscles.[24][26]

Bracing or use of an orthopedic cast to enforce joint immobilization

is rarely required and does not necessarily encourage a quicker
resolution. However, bracing may give comfort and help reduce
pain as it reduces strain on the tibial tubercle.[27]
The use of foam rolling for self
myofascial release can help gently
Surgery
restore flexibility and range of
movement[19][20]
Surgical excision may rarely be required in people who have
stopped growing.[28] Surgical removal of the ossicles generally
results in good outcomes, with symptoms improvement after
several weeks.[29]

Rehabilitation

Rehabilitation focuses on muscle strengthening, gait training, and

pain control to restore knee function.[30] Nonsurgical treatments for
less severe symptoms include: exercises for strength, stretches to
increase range of motion, ice packs, knee tape, knee braces, anti- Straight leg raises help strengthen
inflammatory agents, and electrical stimulation to control the quadriceps without the need to
inflammation and pain. Quadriceps and hamstring exercises are bend the knee. The knee should be
commonly prescribed by rehabilitation experts restore flexibility kept straight, legs should be lifted
and muscle strength.[31] and lowered slowly, and reps should
be held for three to five seconds.
Isometric exercises, such as isometric leg extensions, have been
shown to strengthen the knee,[21] reduce pain and inhibition,[22]
and help the tissue repair through Mechanotransduction.[23]

Other exercises can include leg raises, squats, and wall stretches to
increase quadriceps and hamstring strength. This helps to avoid
pain, stress, and tight muscles that lead to further injury that oppose
healing.

Education and knowledge on stretches and exercises are important.

Exercises should lack pain and increase gradually with intensity.
The patient is given strict guidelines on how to perform exercises at Isometric exercises such as the
home to avoid more injury.[30] Exercises can include leg raises, isometric leg extension have been
squats and wall stretches to increase quadriceps and hamstring shown to strengthen the knee,[21]
strength. This helps to avoid pain, stress, and tight muscles that lead reduce pain and inhibition,[22] and
to further injury that oppose healing. Knee orthotics such as patella help the tissue repair through
straps and knee sleeves help decrease force traction and prevent Mechanotransduction.[23]
painful tibia contact by restricting unnecessary movement,
providing support, and also adding compression to the area of pain.

Prognosis
The condition is usually self-limiting and is caused by stress on the patellar tendon that attaches the
quadriceps muscle at the front of the thigh to the tibial tuberosity. Following an adolescent growth spurt,
repeated stress from contraction of the quadriceps is transmitted through the patellar tendon to the immature
tibial tuberosity. This can cause multiple subacute avulsion fractures along with inflammation of the tendon,
leading to excess bone growth in the tuberosity and producing a visible lump which can be very painful,
especially when hit. Activities such as kneeling may also irritate the tendon.[32]

The syndrome may develop without trauma or other apparent cause; however, some studies report up to
50% of patients relate a history of precipitating trauma. Several authors have tried to identify the actual
underlying etiology and risk factors that predispose Osgood–Schlatter disease and postulated various
theories. However, currently, it is widely accepted that Osgood–Schlatter disease is a traction apophysitis of
the proximal tibial tubercle at the insertion of the patellar tendon caused by repetitive micro-trauma. In other
words, Osgood–Schlatter disease is an overuse injury and closely related to the physical activity of the
child. It was shown that children
who actively participate in sports are affected more frequently as
compared with non-participants. In a retrospective study of adolescents, old athletes actively participating in
sports showed a frequency of 21% reporting the syndrome compared with only 4.5% of age-matched
nonathletic controls.[33]

The symptoms usually resolve with treatment but may recur for 12–24 months before complete resolution
at skeletal maturity, when the tibial epiphysis fuses. In some cases the symptoms do not resolve until the
patient is fully grown. In approximately 10% of patients the symptoms continue unabated into adulthood,
despite all conservative measures.[28]

Long-term implications

OSD occurs from the combined effects of tibial tuberosity immaturity and quadriceps tightness.[11] There is
a possibility of migration of the ossicle or fragmentation in Osgood-Schlatter patients.[10] The implications
of OSD and the ossification of the tubercle can lead to functional limitations and pain for patients into
adulthood.[18]

Of people admitted with OSD, about half were children who were between the ages of 1 and 17. In
addition, in 2014, a case study of 261 patients was observed over 12 to 24 months. 237 of these people
responded well to sport restriction and non-steroid anti-inflammatory agents, which resulted in recovery to
normal athletic activity.[34]

Epidemiology
Osgood–Schlatter disease generally occurs in boys and girls aged 9–16[35] coinciding with periods of
growth spurts. It occurs more frequently in boys than in girls, with reports of a male-to-female ratio ranging
from 3:1 to as high as 7:1. It has been suggested that difference is related to a greater participation by boys
in sports and risk activities than by girls.[36]

Osgood Schlatter’s disease resolves or becomes asymptomatic in the majority of cases. One study showed
that 90% of reported patients had symptom resolution in 12–24 months. Because of this short symptomatic
period with most patients, the number of people who become diagnosed is a fraction of the true number.[37]

For adolescents between the ages of 12-15, there is a disease prevalence of 9.8% with a greater 11.4% in
males and 8.3% in females.[38][39][40] Osgood-Schlatter’s disease presents bilaterally in a range of about
20%-30% of patients.[38][39]
It was found that the leading cause for the incidence of the disease was regular sport practicing and
shortening of the rectus femoris muscle in adolescents that were in the pubertal phase.[41] For there is a
76% prevalence of patients with a shortened rectus femoris in those who suffer from the Osgood-Schlatter’s
disease.[41] This risk ratio shows the anatomical relationship between the tibial tuberosity and the
quadriceps muscle group, which connect through the patella and its ligamentous structures.

In a survey of patients with the diagnosis, 97% reported to have pain during palpation over the tibial
tuberosity.[42] The high risk ratio with people with the disease and palpatory pain is likely the reason that
the number one diagnosis method is with physical examination, rather than imaging as most bone
pathologies are diagnosed.

Research suggests that Osgood-Schlatter’s disease also increases the risk of tibial fractures.[43] It’s possible
that the rapid tuberosity bone development and other changes to the proximal aspect of the knee with those
who suffer from the disease is the culprit to the increased risk.

Because increased activity is a risk factor for developing Osgood-Schlatter’s, there is also research that may
suggest children and adolescents with ADHD are at higher risk.[44] Increased activity and stress on the
tibial tuberosity would be greater in a more active population in the 9-16 age bracket, but this study was still
not conclusive as to which aspect of ADHD was the cause of the higher incidence.  

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