Osgood-Schlatter Disease: Knee Injury and Pediatric Pain Management
This overview is part of a Chronic Overuse Injuries Primer. View the introduction.
History/Pathogenesis
Osgood-Schlatter disease (OSD), which is osteochondrosis/traction apophysitis of the tibial tubercle, is an overuse injury that is familiar among preadolescent athletes. It is frequently responsible for anterior knee pain, typically presenting at the tibial tuberosity insertion site of the patellar tendon. The common occurrence of OSD, specifically in the preadolescent population, is attributed to the rapid bone growth occurring during this stage of life. The growth exceeds the stretch limit of the muscle-tendon attachment required to maintain flexibility prior to growth, increasing tension across the apophysis making the structure particularly vulnerable to stress and injury.
The vulnerability of the patellar tendon in combination with repetitive quadriceps contraction and forced knee extension explains the near 20% occurrence rate of OSD in adolescent athletes. Reported symptoms and pain are often atraumatic, intermittent, and vague. Often, reported pain coincides with athletic activity and seasonal sports. Usually, the condition occurs as a result of repetitive stress to the patellar tendon, meaning that it progresses gradually over time, rather than a single trauma to the knee.1-4
Prevalence/Epidemiology
OSD is one of the most prevalent sources of anterior knee pain in young athletes. The majority of cases are seen during the primary growth periods (males: ages 10-15; females: ages 8-13). The prevalence of OSD from ages 12 to 15 is 11.4% in males and 8.3% in females. OSD occurs especially in 12- to 15- year-old males, with boys having fivefold greater incidence who are active in sports, especially with excessive running/jumping activities.1,4-6
Signs/Symptoms
Activity-related pain and swelling localized to the tibial tuberosity, with the secondary ossification center (apophysis) of the tibial tuberosity developing during preadolescence and early adolescence during rapid maturity growth period. Usually this condition is caused by mechanical stress and excessive tension on growing tibial tuberosity apophysis.
High Risk Activities for OSD
Activities that require running and jumping during adolescence, specifically sports such as track and field, basketball, football, soccer, and gymnastics.
Anatomical Risk Factors
- Extensor mechanism malalignment
- Inadequate flexibility in the quadricep and hamstring groups
- Quadriceps femoris strength during knee extension
- Rapid skeletal growth 1,7-11
Physical Exam
The tibial tubercles may or may not be enlarged and tender but will present with palpable tenderness over the tibial tuberosity. Look for stigmata of extensor mechanism malalignment, especially patella alta. OSC usually presents with tightening of hamstrings and heel cords, and weak quadriceps muscles, especially for the athletic demand needed.
Diagnostic Tests
Enlarged tibial tuberosities, irregularity of tibial tuberosity, with loosening of ossicle separation of tuberosity and patella alta should be evaluated with baseline x-rays, MRI, musculoskeletal diagnostic U/S testing, or bone scan testing.
Differential Diagnosis
Other types of patellar tendonitis; r/o avulsion fracture of the tibial tuberosity (acutely); r/o tumors in the tibial tuberosity.
Prevention
Warming up/dynamically stretching related muscle groups prior to playing sports may help prevent or reduce tendon strain, with an emphasis on the quadricep, hamstring, and calf groups. Training intensity modification as well as varying athletic activities may help reduce the likelihood of developing OSD.3
Acute Treatment
Emphasis on hamstring, heel cord, and quadriceps stretching exercises, as well as vastus medialis oblique (VMO) strengthening exercises; relative rest/exercise/activity modifications according to positive symptoms; simple modalities (ice/TENS/topical refrigerants, etc.); local padding/taping, possible knee immobilizer strategies.
Long-Term Treatment/Rehab
OSD is known as a self-limiting condition that is treated in accordance with pain level. Though time is the only proven solution, conservative treatment is recommended to help reduce pain (progression dependent on pain level). Treatment consists of relative rest and activity modification before moving to stretching/strengthening of the quadricep and hamstring groups upon resolution of acute symptoms. Stretching should aim to reduce tension on the tibial tubercle.
If the condition does not respond to conservative measures, formal physical therapy may be considered. Support aids (infrapatellar straps, braces, and pads) may be used, but effectiveness has not been documented. There is no literature supporting efficacy of surgical intervention or injection therapy for OSD. Symptoms usually resolve upon apophysis fusion (conclusion of growth spurt), meaning that symptoms may be present for multiple years depending on patient age at diagnosis. The only reported long-term or residual effect of OSD is a resultant ossicle that causes knee pain upon kneeling, reportedly present in 60% of adults who were diagnosed with OSD.
Regenerative medicine techniques are now on the forefront of research and for potential treatments for chronic overuse musculoskeletal/sports injuries. These techniques, such as platelet-rich plasma and stem cell injection options, should be considered on a case-by-case setting for OSD.1,3,4,12-16
Practical Takeaways
- Osgood-Schlatter disease (OSD), osteochondrosis/traction apophysitis of the tibial tubercle, is an overuse injury that is familiar among preadolescent athletes. It is frequently responsible for anterior knee pain, typically presenting at the tibial tuberosity insertion site of the patellar tendon.
- OSD is one of the most prevalent sources of anterior knee pain in young athletes. The majority of cases are seen during the primary growth periods (males: ages 10-15; females: ages 8-13).
- For the diagnosis, the tibial tubercles may or may not be enlarged and tender but will present with palpable tenderness over the tibial tuberosity. Look for stigmata of extensor mechanism malalignment, especially patella alta.
- Treatment should emphasize hamstring, heel cord, and quadriceps stretching exercises; vastus medialis oblique (VMO) strengthening exercises; relative rest/exercise/activity modifications according to positive symptoms; and simple modalities (ice/TENS/topical refrigerants, etc.); local padding/taping, possible knee immobilizer strategies.
