Osgood-Schlatter Disease

Osgood-Schlatter disease, or apophysitis of the tibial tubercle, is a common orthopedic condition seen in children between 10 and 15 years of age. The disease is caused by the repetitive application of mechanical forces on the knee, leading to microtrauma on the ossification center at the site of insertion of the distal patellar ligament. Patients present with localized knee pain, tenderness, and swelling at the proximal anterior tibia. Diagnosis is clinical and treatment is focused on symptomatic relief. Osgood-Schlatter disease is a self-limiting condition that resolves with skeletal maturity.

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Overview

Definition

Osgood-Schlatter disease is an apophysitis, a painful traction injury, of the cartilage and bone on the anterior, proximal tibial tubercle, where the distal patella tendon inserts.

Osgood-Schlatter disease: a painful inflammation of the tibial tuberosity caused by repetitive traction by the patellar tendon due to repetitive exertion, such as running or jumping

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Epidemiology

  • Occurs in children 10–14 years of age: 
    • Boys: 12–14 years 
    • Girls: 10–13 years 
  • More common in teens who participate in sports that involve running or jumping (e.g., soccer, football, basketball, volleyball, sprinting, gymnastics, figure skating, and ballet)
  • More common in boys than girls
  • Usually occurs during periods of accelerated relative growth
  • Bilateral in 25%–50% of cases

Pathophysiology

Osgood-Schlatter disease occurs due to overuse injury.

  • Mechanical forces applied to the knee, especially during running and jumping, cause microtrauma to the patellar tendon.
  • Repetitive microtrauma leads to small chronic avulsions of patellar tendon at the point of insertion into the tibial tubercle.
  • Swelling and ossification of the distal patellar tendon at point of insertion into the tibia follow.

Clinical Presentation

Osgood-Schlatter disease typically presents during early adolescence with the chief complaint of knee pain.

  • Knee pain:
    • Usually refers exclusively to tibial tubercle
    • Chronic, lasting weeks or months
    • No history of traumatic event marking beginning of symptoms
    • Aggravated by activity, especially jumping
  • Clinical exam findings:
    • Swelling or increased prominence of tibial tubercle
    • Tenderness to palpation at area of swelling
    • Pain evoked when rising from squat or extending knee against resistance
    • Findings can be unilateral or bilateral

Diagnosis

  • Clinical examination is usually sufficient to diagnose this condition. 
  • X-rays may be taken to rule out other diagnoses:
    • Tumor
    • Acute avulsion
    • Osteomyelitis
    • Other knee pathology
  • X-ray findings may include:
    • Soft tissue swelling anterior to tibial insertion of patella tendon
    • Fragmentation or irregularity to tibial tubercle

Osgood-Schlatter disease: lateral radiograph of the knee demonstrating fragmentation of the tibial tubercle with overlying soft tissue swelling

Image: “Review for the generalist: evaluation of anterior knee pain” by Houghton KM. License: CC BY 2.0

Management

Treatment

Most cases are treated successfully with relative rest and symptom management.

  • Reassurance and education to the teen and parents: 
    • Explain that the condition is self-limited.
    • Discuss management and reasons to return or be reevaluated.
  • Control of pain and swelling:
    • Nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen for limited duration 
    • Application of ice for 15–20 minutes up to 2 times/day
  • Modification of activity:
    • Avoid activity that puts strain on the tibial epiphysis. 
    • Complete rest not recommended
    • Consider knee sleeve or pad.
  • Physical therapy: core, hip, and lower extremity stretching and strengthening exercises
  • Surgery:
    • Rarely performed
    • Excision of ossicle after closure of growth plate if pain persists

Complications

The majority of patients are asymptomatic after cessation of growth. Uncommon sequelae include:

  • Persistence of prominence of tibial tubercle, typically pain-free:
    • Most noticeable cosmetic sequelae
    • Some patients note discomfort with kneeling on prominence.
  • Residual ossicles occur in 10% of patients; rarely cause persistent pain that requires removal.
  • Rare association with genu recurvatum (knee hyperextension)

References

  1. Cassas, K. J., & Cassettari-Wayhs, A. (2006). Childhood and adolescent sports-related overuse injuries. American Family Physician, 73(6), 1014. https://www.ncbi.nlm.nih.gov/pubmed/16570735
  2. Ebraheim, N. A., Thomas, B. J., et al. (2019). Orthopedic surgery. In F. C. Brunicardiet al. (Ed.), Schwartz’s principles of surgery, 11th ed. McGraw-Hill Education.
  3. Lawrence, J. T. (2020). The knee. In R. M. Kliegman, et al. (Ed.), Nelson textbook of pediatrics, pp. 361–3623.e1.

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