Osgood-Schlatter

Key Points:

  • Traction apophysitis of the tibial tubercle is common in adolescents
  • Patella alta is commonly associated with Osgood-Schlatter
  • Non-operative management is the mainstay of treatment and includes activity modification, anti-inflammatories, physical therapy, bracing, and/or injections.
  • Operative interventions include open or arthroscopic ossicle and tubercle excisions.

Description:

Osgood-Schlatter is named for the two doctors who published articles on the condition in 1903. A disease of pre-adolescent to adolescent children, usually ages 11-15 years, where traction of the patella tendon on the tibial tuberosity apophysis causes inflammation and possibly avulsion of the proximal tibial tuberosity. It is a disorder of enchondral ossification. Rather than a tear or degradation within the tendon, the area of mechanical weakness is at the insertion on the cartilage layer separating the tendon from the osseous tuberosity. The ossification anterior to the tuberosity represents the healing process of the traction forces. Histopathology shows increased pathological fibrocartilage anterior to the ossification center.

There is a four-fold increased risk in patients with single sport specialization and is more common in patients with patella alta.

Epidemiology:

Clinical Findings:

Pain, swelling, and enlargement of the proximal tibia at the site of the patella tendon insertion is noted.  A child or adolescent with Osgood-Schlatter symptoms needs a hip exam to screen for conditions involving the hip such as Perthes or slipped capital femoral epiphyses, both of which cause referred pain to the anterior knee.  Point tenderness at the tibial tubercle is the most consistent finding on physical exam.

Imaging Studies:

Lateral radiographs of the knee may be helpful to confirm diagnosis, but this condition is often a clinical diagnosis. Radiographs may show a round, regular ossicle over the tubercle or an increase in size of the tibial tubercle.  There is an association between radiographic patella alta and Osgood-Schlatter disease.  Advanced imaging is rarely needed, but MRI or ultrasound (US) can be used to further investigate.  Patients that have Osgood-Schlatter symptoms can have enough repetitive running and jumping to be at higher risk for other overuse conditions such as osteochondritis dissecans of the femur.  The presence of mechanical symptoms such as catching or popping can indicate an intraarticular source of pain in addition to the Osgood-Schlatter symptoms.

Etiology:

Treatment:

Non-operative management is the mainstay of treatment. Options include rest, activity modification, oral anti-inflammatories or pain medication, physical therapy (PT), immobilization with bracing or casting, and/or injection. Injections of lidocaine, steroid, and dextrose have been reported.   Ice packs after sports or conditioning and use of neoprene sleeves or patellar tendon straps can provide relief of symptoms in some patients.
Patient and parent education is often as important as orthopedic intervention.  This is an overuse condition and the family must find ways to decrease those activities which cause ‘overuse.’  Participation in sports is not always the cause of problems.  The extra conditioning, private practices, private training, and excessive competition contributes to the traction apophysitis.  Discussing this directly with the family involves them in the process of decreasing the ‘overuse’ causing the symptoms. 

When the symptoms threaten a patient’s ability to participate, parents can help decide whether to withhold from sports.  An inability to perform a single leg hop indicates the child or adolescent should refrain from participation.

Operative intervention is rare, and is only indicated for refractory cases. Options include open or arthroscopic excision of ossicle and/or tibial tubercle excision. Indications for ossicle resection include evidence on radiographs, tenderness of ossicle, and a clinically mobile ossicle.

Complications:

Within 1-2 years, nearly half of all patients are completely recovered. There is continued decrease in strength and endurance function of the leg in comparison to control groups at 2 years. The prominent “bump” is common and can be tender to palpation or cause difficulty with kneeling. Genu recurvatum has also been reported after Osgood-Schlatter disease.   Proximal tibial apophyseal fractures can occur and with marked displacement may be associated with compartment syndrome.

References:

  1. Falciglia F, Giordano M, Aulisa AG, Poggiaroni A, Guzzanti V. Osgood-Schlatter lesion: histologic features of slipped anterior tibial tubercle. Int J Immunopathol Pharmacol. 2011 Jan-Mar24(1 Suppl 2):25-9
  2. Hall R, Barber Foss K, Hewett TE, Myer GT. Sports specialization is associated with an increased risk of developing anterior knee pain in adolescent female athletes. J Sport Rehabil. 2015 Feb;24(1):31-5. PMID: 24622506
  3. Kaya DO, Toprak U, Baltaci G, Yosmaoglu B, Ozer H. Long-term functional and sonographic outcomes in Osgood-Schlatter disease. Knee Surg Sports Trauamtol Arthrosc. 2013. 21: 1131-1139
  4. Krause BL, Williams JP, Catterall A. Natural history of Osgood-Schlatter Disease. J Ped Orthop. 1990.10:65-68
  5. Osgood RB. Lesions of the tibial tubercle occurring during adolescence. Boston Med Surg J. 1903.148:114-120
  6. Pihlajamaki HK, Matilla VM, Parviainen M, Kiuru MJ, Visuri TI. Long-term outcome after surgical treatment of unresolved Osgood-Schlatter disease in young men. J Bone Joint Surg Am. 2009 Oct;91(10):2350-8
  7. Pihlajamaki HK, Visuri TI. Long-term outcome after surgical treatment of unresolved Osgood-Schlatter disease in young men: surgical technique. J Bone Joint Surg Am. 2010 Sept92(Suppl 1, Pt 2):258-64
  8. Schlatter C. Verletzungen des schnabelformigen Fortsatzes der obneren Tibiaepiphyse. Bruns Beitr Klein Chir.
  9. Topol GA, Podesta LA, Reeves KD, Raya MF, Fullerton BD, Yeh HW. Hyperosmolar dextrose injection for recalcitrant Osgood-Schlatter disease. Pediatrics. 2011 Nov;128(5):e1121-1128

Top Contributors:

Jennifer Beck, MD