0196-6011/85/0701-0005$02.

00/0
THEJOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY
Copyright 0 1985 by The Orthopaedic and Sports Physical Therapy Sections of the
American Physical Therapy Association

Osgood-Schlatter Disease: Review of

Literature and Physical Therapy
Management
T. J. ANTICH, MS, PT,* CLlVE E. BREWSTER, MS, PT

Osgood-Schlatter disease is a traction apophysitis of the tibial tubercle, the weakest

link of the extensor mechanism of the adolescent. Conventional medical treatment
includes plaster casting, injections of various anti-inflammatories, and surgical
removal of painful ossicles in resistant cases. While not a very common condition,
Osgood-Schlatter disease is being seen with increasing frequency in teenage
athletes, especially basketball players (Antich, Lombardo, J Orthop Sports Phys Ther
Downloaded from www.jospt.org at on December 12, 2023. For personal use only. No other uses without permission.

7: 1-4, 1985.) With a focus on muscular tightness as a possible causative factor,

physical therapy evaluation is outlined, followed by techniques for pain control and
stretching exercises for the quadriceps and hamstrings. Ice massage is advocated
as a way for the athlete to treat postexertional discomfort in the area of the tubercle.
The patient and his or her parents must be assured that while residual deformity may
remain, disappearance of symptoms coinciding with closure of the apophyseal plate
is often the end result.
Copyright © 1985 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Osgood-Schlhtter disease is defined as a sep- by continuing minor t r a ~ m a t a ~or' . heterotopic

aration of the tibial tubercle apophysis from the
proximal end of the tibia. This lesion may have a
history of trauma, or may present without a sig-
nificant recognizable injury. KatzI4 classifies this
Journal of Orthopaedic & Sports Physical Therapy®
~~
calcification and ossification in the patellar liga-
ment can occur secondary to o ~ e r u s e . " In- ~~~
stances of tibial tubercle fracture have been re-
ported subsequent to violent quadriceps contrac-

entity as a nonarticular osteochondrosis involving t i o n . ' ~The

the quadriceps muscle/tendon insertion second-
ary to excessive muscle pull. Citing the same
mechanism of increased quadriceps pull on the
adolescent tubercle, Smillie28describes Osgood-
Schlatter disease as a traction epiphysitis. Dor-
land's Medical Dictionary gives as a synonym
"apophysitis tibialis adolescentium," while
Christie4 states that the radiographically evident
bone changes make it a disease entity. He adds
that poor epiphyseal nourishment during a time of
rapid growth can lead to the onset. However,
LaZerte and Rapp'sI7 histological studies of nine
specimens indicate no evidence of primary aseptic
necrosis in any of the tubercles examined.
Increased stress on the weak link of the ado-
lescent knee extensor mechanism accounts for
the symptoms experienced by those patients with
this ~ e s i o n . ' ~An
. ' ~initial
~ ~ ~injury can be furthered
Department of Physical Therapy, Southwestern Orthopaedic Medical
Group, Inc., 501 E. Hardy Street, Suite 200, Inglewood, CA 90301.
~ ~ imbalance in the cross-sectional area
of the quadriceps muscle bulk to the area of
insertion7 also creates a great concentration of
force on. a small area.
HISTOLOGY
Microscopic examination of bony ossicles re-
moved at surgery indicates that the separation is
due to increased tension over a small area of
tendon insertion. All nine cases studied by La-
Zerte and RappI7 demonstrated an anterior cor-
tical bone defect of the tubercle, in addition to
increased vascularization of the infrapatellar ten-
don surrounding the ossicles.
DIAGNOSIS
Osgood-Schlatter disease is easily recognized
in the adolescent with complaints of pain which is
localized to the area of the tibial tubercle. Discom-
fort is usually generated with running,21 kneel-
ing,2321ascending or descending stair^,'^^^' and is
 6 ANTICH AND BREWSTER JOSPT Vol. 7, No. 1
Downloaded from www.jospt.org at on December 12, 2023. For personal use only. No other uses without permission.
Copyright © 1985 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Fig. 1 . A, Lateral view in a 12-year-old male exhibiting separation of the tubercle; 13,ossicle embedded within the infrapatellar
tendon at its insertion in a 13-year-old male.
I

relieved with rest.l4 Weakness of the quadriceps2' patella alta in their series of 185 knees utilizing
and pain on resisted knee e ~ t e n s i o n ~are ~ ~ ~ the
~ ~ Blackburne
' and Peel method of measuring
common signs, as is an enlarged t ~ b e r c l e . ~ . ~ 'patellar position. The mean index of knees with
Journal of Orthopaedic & Sports Physical Therapy®

D'Ambrosia and MacDonald6report reproduction Osgood-Schlatterdisease was 0.99, as compared

of pain with passive knee flexion, which Jakob et to 73 normal knees with a mean of 0.84.
a1.12attribute to a hypertrophiedquadriceps group Differential diagnosis of this entity includes os-
exhibiting decreased flexibility. teogenic sarcoma of the proximal tibia2' and os-
Radiographic examination is considered nec- teomyelitis of the tubercle secondary to contu-
essary in confirming this diagnosis in the adoles- ~ i o n D'Ambrosia
. ~ and MacDonald6 emphasize
cent with knee pain. In more severe cases, sep- the need to perform a thorough examination on
aration and fragmentation of the apophysis may adults with previous histories of Osgood-Schlatter
be seen32as well as irregular ossification of the disease and report arteriovenous fistula as the
t ~ b e r c l e ' ~(Fig.
. ~ ' 1). In milder cases without radi- cause of knee pain in one individual.
ographic bony changes, soft tissue swelling, es-
pecially of the infrapatellar fat pads2' may be the CONVENTIONAL MEDICAL TREATMENT
only evidence of this disease. Mital and Matza2' A wide range of treatment philosophy exists,
check for a decreased "sharpness" in the angle with some belief that no treatment is needed other
formed by the tibial apophysis and the infrapatellar than for pain relief.3.'4Improvement occurs spon-
tendon. Patella infera, as defined by the Insall- taneously in 1-2 years with or without treatment,
Salvati patellar height-to-patellar tendon ratio, the only sequela being residual deformity of
was seen in a group of 20 patients with Osgood- the tibial t ~ b e r c l e . ~Limitation of activity is
Schlatter disease (mean = 1.21 + 0.15).'6 This r e c ~ m m e n d e d ~ ~ ~ ' with ~ ~ ~ Willne?'
. ~ ~ , ~ ' . more
~'
position was determined to be significantly lower specifically restricting running and stairs for 12
(P < 0.05) than a group of 80 normals (mean = weeks, and walking barefoot before the age of
1.OO k 0.11). Conversely, Jakob et a1.12 reported 15. Attributing the problem to lower extremity
 JOSPT JulylAug 1985 OSGOOD-SCHLATTER DISEASE 7
malalignment involving marked foot pronation and is not known. Subcutaneous atrophy in 8 of 70
genu valgum, he advised decreasing the use of knees injected with methylprednisolone was seen
loafers and sneakers, and prescribed "Oxford in addition to striae formation in the skin overlying
shoes with a firm inner shank and 3116 inch inner the tubercle.26Patellar tendon avulsions are pos-
heel wedges." Complete relief of symptoms in 65 sible sequellae to Osgood-Schlatter disease and
of 78 patients is reported in 6 weeks, with the from 14'' to 26%" of those seen with this fracture
remainder becoming pain free in 12 weeks.31 reported previous histories of Osgood-Schlatter
Bowers2 recommends use of salicylates and disease.
local ice application, as needed, to control pain.
Conservative treatment to decrease quadriceps PHYSICAL THERAPY EVALUATION
tension on the t u b e r c ~ e ~and
l . ~restriction
~ of mo-
In assessing the patient's knee pain, location
tion via immobilization from 6 to 8 weeks22to 3
(unilateral or bilateral) of pain and its duration is
months2' is suggested. ~ i c h e l i , ~however,
' feels
documented. Whether it is painful during brief
that casting is not indicated in the presence of a
physical activity, or following prolonged activity,
tight, weak quadriceps group.
indicates severity. Answers to questions regard-
Injection of the tubercle with hydrocortisone15
ing presence or absence of pain while walking,
Downloaded from www.jospt.org at on December 12, 2023. For personal use only. No other uses without permission.

or with lidocaine HCI combined with hydrocor-

running, ascending and descending stairs, and
t i ~ o n e , ~de~amethasone,~~
' triamcino~one,~or
kneeling should be documented for later compar-
methy~prednisolone,~~ may be employed if restric-
ison.
tion of activities and immobilization are not suc-
Examining the patient's gait pattern while walk-
cessful. Kelly15utilized up to three hydrocortisone
ing, the therapist looks for an antalgic limp or
injections and reported 52 to 72 patients having
other compensatory mechanism to protect the
Copyright © 1985 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

relief after one injection. Eight and 9 more were

knee from pain. Special attention should be fo-
improved after two and three injections, respec-
cused on whether or not the individual flexes the
tively, while 3 of the 72 did not respond to injec-
involved knee during loading response or at-
tion.
tempts to maintain full extension, thereby reduc-
Levine and ashy yap'^ advocate use of an infra-
ing the need for quadriceps activity.
patellar strap during activities to decrease the pull
Confirmation of the diagnosis is the first task of
of the quadriceps against the tibial tubercle and
the attending therapist. With the patient supine
report improvement in 92% of patients treated
with both knees flexed to 90°, inspection of the
(Table 1).
tubercles is performed. By looking from the side,
Journal of Orthopaedic & Sports Physical Therapy®

Quadriceps stretching into knee flexion with hip

a silhouette image of one knee against the other
extension is used to stretch the muscle group and
reveals enlargement of the apophysis, if present
decrease tension on the apophysis. While Katz14
(Fig. 2). Palpation of the tubercle is then performed
states that "rarely is the pain severe enough to
and tenderness is assessed as none, slight, mild,
require plaster-cast immobilization," 12°/~of Mital
moderate, or marked (Table 2).
and Matza's groupz2underwent surgical removal
Due to the prevalence of Osgood-Schlatter dis-
of painful ossicles with instantaneous relief of
ease during the early adolescent years, at a time
symptoms.
when musculoskeletal pain may be secondary to
the inability of muscles to elongate at the same
COMPLICATIONS rate as bony growth, tightness of knee muscula-
ture must be checked. With the patient still supine,
Premature closure of the anterior tibial epiphy-
sis resulting in genu recurvatum has been re- hamstring length is assessed by the examiner's
p ~ r t e d . ' ~ , ~Conflicting
~,~' reports of patella flexing the hip while maintaining the knee in full
alta'2~2',30and patella infera16 exist, while the extension. Comparison between involved and un-
causal or effectual relationship with this disease involved limbs in unilateral problems, or compari-
son to normal values in the cases of bilateral
TABLE 1 involvement, aids the therapist in deciding
Improvement with infrapatellar stap* whether or not muscular tightness plays a role in
Definite improvement 79.1% the conditon.
Some improvement 12.5% Knee flexion range of motion, taking into ac-
No improvement 8.3% count rectus femoris tightness, is performed with
From Levine and Kashyap.lg the patient prone (Fig. 3). The knee is passively

Downloaded from www.jospt.org at on December 12, 2023. For personal use only. No other uses without permission.
Copyright © 1985 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Fig. 2. Silhouette appearance of knees flexed to 90° reveals
mild enlargement of left tibia1 tubercle.
TABLE 2
Journal of Orthopaedic & Sports Physical Therapy®
Assessment of tenderness on palpation
Slight Only complains of pain after questioning
Mild Voluntarily reports pain on palpation
Moderate Withdraws knee from examiner's hand;
may indicate pain verbally
Marked Withdraws knee and attempts to grab
examiner's hand
Fig. 3. Assessment of passive knee flexion range of motion
including evaluation of rectus femoris tightness.
BREWSTER JOSPT Vol. 7,No. 1
Fig. 4. Hamstring stretching is performed with a 10-sec static
stretch. Note limited flexibility in this patient with posterior
pelvic rotation (tight lumbodorsal fascia), inability to keep knee
straight (tight hamstrings), and outward rotation of foot (tight
hip external rotators).
flexed by the examiner until either the end of range
or pain is encountered. If this stretch begins to
hurt, the patient must be questioned as to the
location of the pain, as this will influence treat-
ment. If pain from this prone stretching is felt in
the area of the infrapatellar tendon or tubercle
area, stretching the quadriceps is contraindicated,
as the pain is caused by further pulling away of
the apophysis. If the strain is felt up in the muscle
belly or at the proximal attachment of the muscle,
quadriceps stretching will be performed as part of
the treatment. The results of muscle tightness
tests along with the location of pain with stretch-
ing are recorded.
Manual muscle testing of the knee extensors
and flexors can be performed with the patient
sitting on the end of the plinth with presence or
absence of pain noted. Muscle tone is assessed
in the long sitting position as the patient performs
a quadriceps set. Quadriceps atrophy should be
checked in the form of girth measurements.
PHYSICAL THERAPY TREATMENT
Of primary concern to the therapist treating
Osgood-Schlatter disease is relief of pain in the
area of the tubercle. lontophoresis is the modality
of choice, and a trial period of not more than three
treatments should be undertaken.'. l o Use of an
anti-inflammatory medication and local anesthetic
helps decrease swelling and pain.
We feel the benefits of iontophoresis are: 1)
Inhibition of pain from the electrical current used;
2) method of administering medication without
injecting the tendon/muscle junction, thus avoid-
ing the possibility of associated tendon damage;
 JOSPT JulylAug 1985 OSGOOD-SCHLATTER DISEASE
Downloaded from www.jospt.org at on December 12, 2023. For personal use only. No other uses without permission.
Copyright © 1985 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
Fig. 5. A, Quadriceps stretch position for individuals with
extreme tightne*; B, advanced quadriceps stretch position
which increases rectus femoris stretch across the anterior hip.
Journal of Orthopaedic & Sports Physical Therapy®
Fig. 6. Residual deformity in a 28-year-old male with neither
pain nor functional limitations of the left knee.
3) localization of treatment required for the size
of this particular lesion.
The active pad of the PhoresoP (Motion Con-
trol, Salt Lake City, UT) unit is positioned over the
tubercle of the knee which is supported in about
30' of flexion. The sides of the adhesive pad are
then taped down to the skin for better contact
and to prevent leakage. One cc of dexametha-
sone-sodium-phosphate and 1 cc of lidocaine HCI
9
are injected into the positive electrode. Treatment
time is for 20 minutes at up to 5.0 ma. Proper
post-treatment application of lotion to both elec-
trode sites minimizes the hazard of skin irritation.
Following three treatments with iontophoresis
performed every other day, tenderness to palpa-
tion is reassessed, and the patient's subjective
change in conditions is recorded.
The next phase of treatment addresses tight
musculature if found on initial e v a l ~ a t i o n Heat-
.~~
ing with hot packs to the anterior and posterior
thigh is followed by quadriceps and/or hamstring
stretching. Hamstrings are stretched over the side
of a plinth (Fig. 4) with the involved knee in full
extension and the foot pointing upward (neutral
hip rotation). A static stretch of 10 sec is used
with the patient instructed to slide his hands down
his anterior leg until he feels a stretch either in the
posterior thigh or at the hamstrings insertion.
Quadriceps stretching is performed with the
patient lying prone, pulling his foot up toward his
buttocks. Strain should be felt in the muscle belly,
and not at the tenoperiosteal junction. For cases
of extreme tightness, a belt may be needed
around the dorsal foot (Fig. 5A), whereas patients
with less quadricep tightness can be sidelying with
the involved leg up, allowing for a greater rectus
femoris stretch with passive hip extension (Fig.
56).
Strengthening of the involved limb quadriceps
is performed in cases of atrophy secondary to
disuse. Isometric quadricep sets, straight leg
raises, and short arc quadricep exercises are
standard, and are performed only if they are pain
free. Exercise concludes with a 5-minute ice mas-
sage to the area of the tubercle.
SUMMARY
The symptoms, diagnosis, and conventional
forms of treatment for Osgood-Schlatter disease
are reviewed. Physical therapy evaluation must
concentrate on assessment of tight musculature
(quadriceps, hamstrings, calf) as a possible cause
of this entity. Treatment concentrates on: I ) de-
creasing the pain, 2) improving flexibility, and 3)
return to function.
Perhaps the most important part of rehabilita-
tion is education of the adolescent and his par-
ents, with a reassurance that his condition is
temporary and related to the time in his growth
when his epiphyseal plates are the weak link of
his musculoskeletal system. Activities should be
pain limited with instruction in continuation of a
 10 ANTICH AND BREWSTER
home program with ice massage following. Expla-
nation that a prominent tubercle may be present
indefinitely ( ~ i 6),
~ .but that pain with activity
should cease following the teenage years, may
prevent later concerns regarding continued pres-
ence of an enlarged tubercle.
Downloaded from www.jospt.org at on December 12, 2023. For personal use only. No other uses without permission.
The authors would like to thank the other members of the Physical
Therapy Research Committee of the Southwestern Orthopaedic Med-
ical Group, Inc. for their suggestions and review of the manuscript in
its preparation for publication: Matthew C. Morrissey, MS, PT; Celeste
Criswell Randall. MS. PT; and Roxie Westbrwk, PT.
The guidance and assistance of Ms. Elizabeth Stone is gratefully
appreciated.
Copyright © 1985 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
REFERENCES
1. Bertolucci LE: Introduction of antiinflammatory drugs by iontopho-
resi: Double blind study. J Orthop Sports Phys Ther 4:103-108,
1982
2. Bowers KD: Patellar tendon avulsion as a complicationof Osgwd-
Schlatter's disease. Am J Sports Med 9:356-359, 1981
3. Bunch WH: Decision analysis of treatment choices in the osteo-
chondroses. Clin Orthop 158:91-98.1981
4. Christie AC: Osteochondritis or epiphysitis. JAMA 87:291-295.
1926
Journal of Orthopaedic & Sports Physical Therapy®
5. Cole JP: A study of Osgood-Schlatter disease. Surg Gynecol
Obstet 65:55-57, 1937
6. D'Ambrosia RD, MacDonald GL: Pitfalls in the diagnosis of Os-
good-Schlatterdisease. Clin Orthop 110:206-209, 1975
7. Ehrenborg G, Engfeldt B. Olsson SE: On the aetiology of the
Osgood-Schlatter lesion: An experimentalstudy in dogs. Acta Chir
Scand 122:445-457,1961
8. Grass AL: Treatment of Osgood-Schlatter injury. JAMA 240:212-
213. 1978
9. Hand WL, Hand CR, Dunn AQ: Avulsion fractures of the tibial
tubercle. J Bone Joint Surg (Am) 53:1579-1583,1971
10. Harris PR: lontophoresis: Clinical research in musculoskeletal in-
flammatory conditions. J Orthop Sports Phys Ther 4:109-112,
1982
11. Holstein ER, Lewis GB, Schulze ER: Heterotopic ossification of
patellar tendon. J Bone Joint Surg (Am) 45656, 1963
12. Jakob RP. VonGumppenberg S. Engelhardt P: Does Osgood-
Schlatter disease influence the position of the patella? J Bone Joint
Surg (Br) 63579-582, 1981
JOSPT Vol. 7, No. 1
13. Jeffreys TE: Genu recurvatum after Osgood-Schlatter's disease:
Report of a case. J Bone Joint Surg (Br) 47:298-299,1965
14. Katz JF: Nonarticular osteochondroses. Clin Orthop 158:70-76.
1981
15. Kelly JM: Osgood-Schlatter's disease: A review of 108 cases. J
Irish Med Assoc 64:630-635,1971
16. Lancourt JE. Christini JA: Patella alta and patella infera: Their
etiological role in patellar dislocation, chondromalacia, and apo-
physitis of the tibial tubercle. J Bone Joint Surg (Am) 57:1112-
1115,1975
17. La Zerte GD, Rapp IH: Pathogenesis of Osgwd-Schlatter's dis-
ease. Am J Pathol34:803-811,1958
18. Levi JH, Coleman CR: Fractures of the tibial tubercle. Am J Sports
Med 4:253-263,1976
19. Levine J, Kashyap S: A new conservative treatment of Osgood-
Schlatter's disease. Clin Orthop 158:126-128, 1981
20. Micheli LJ: Overuse injuries in children's sports: The growth factor.
Orthp Clin North Am 14:337-360,1983
21. Mital MA, Matza RA: Osgood-Schlatterdisease: The painful puz-
zler. Phys Sportsmed 560-73, 1977
22. Mital MA, Matza RA, Cohen J: The so-called unresolved Osgood-
Schlatter lesion. J Bone Joint Surg (Am) 62:732-739, 1980
23. Ogden JA, Southwick WO: Osgood-Schlatter's disease and tibial
tubercle development. Clin Orthop 116:180-189,1976
24. Osgood RB: Lesions of the tibial tubercle occurring during adoles-
cence. Boston Med Surg J 148:114-116,1903
25. Reichmaster J: Injectionof the deep infrapatellar bursa for Osgood-
Schlatter's disease. Clin Proc Child Hosp DC 3521-24, 1961
26. Rostron PKM, Calver RF: Subcutaneous atrophy following meth-
ylprednisolone injection in Osgood-Schlatter epiphysitis. J Bone
Joint Surg (Am) 61:627-628, 1979
27. Scotti DM, Sadhu VK, Heimberg F, O'Hara AE: Osgood-Schlatter's
disease, an emphasis on soft tissue changes in roentgendiagnosis.
Skeletal Radiol 4:21-25, 1979
28. Smillie IS: Injuries to the Knee Joint, Ed. 5. Edinburgh: Churchill
Livingstone. 1978
29. Smillie IS: Diseases of the Knee Joint, Ed. 2. Edinburgh: Churchill
Livingstone, 1980 F
30. Stirling RI: Implications of Osgood-Schlatter'sdisease (abstract). J
Bone Joint Surg (Br) 34:149-150, 1952
31. Willner P: Osgood-Schlatter'sdisease: Etiologyand treatment. Clin
Orthop 62:178,1969
32. Woolfrey BF, Chandler EF: Manifestations of Osgood-Schlatter's
disease in late teen age and early adulthood. J Bone Joint Surg
(Am) 42:327-332.1960