> Table of Contents > Osgood-Schlatter Disease (Tibial Apophysitis)
Osgood-Schlatter Disease (Tibial Apophysitis)
David P. Sealy, MD
Robert J. Tiller, MD, FAAFP
image BASICS
DESCRIPTION
  • Osgood-Schlatter Disease (OSD) is a syndrome associated with traction apophysitis and patellar tendinosis that is most common in adolescent boys and girls.
    • Patients present with pain and swelling of the anterior tibial tubercle
  • System(s) affected: musculoskeletal
  • Synonym: Tibial tubercle apophysitis
EPIDEMIOLOGY
Incidence
Incidence in girls increasing with increased participation in organized youth sports; still more common in boys
Prevalence
  • A common apophysitis in childhood and adolescence affecting athletes (21%) and nonathletes (4.5%) (1)[B]
  • Approximately 10% remain symptomatic as adults (2)[C].
  • 10% of all adolescent knee pain is due to OSD.
ETIOLOGY AND PATHOPHYSIOLOGY
Traction apophysitis of the tibial tubercle due to repetitive strain on the secondary ossification center of the tibial tuberosity, concurrent patellar tendinosis, and disruption of the proximal tibial apophysis
  • Basic etiology unknown, exacerbated by exercise
    • Jumping and pivoting sports place highest strain on the tibial tubercle. Repetitive trauma is the most likely inciting factor.
  • Possible association with tight hip flexors and tight quadriceps; increased quadriceps strength in adolescence relative to hamstring strength
  • Early sports specialization increases the risk for OSD 4-fold (3)[B].
RISK FACTORS
  • Affects children and adolescents most commonly from the ages of 8 to 18 years
    • Girls 8 to 14 years
    • Boys 10 to 18 years
  • OSD is slightly more common in boys.
  • Rapid skeletal growth
  • Participation in repetitive-jumping sports and sports with heavy quadriceps activity (football, volleyball, basketball, hockey, soccer, skating, gymnastics)
  • Ballet (2-fold risk compared with nonathletes)
  • Potential increased risk of OSD in adolescents with ADD/ADHD (4)[C]
GENERAL PREVENTION
  • Avoid sports with heavy quadriceps loading (especially deceleration activities—eccentric loading).
  • Patients may compete if pain is minimal.
  • Increase hamstring and quadriceps flexibility.
COMMONLY ASSOCIATED CONDITIONS
  • Shortened (tight) rectus femoris found in 75% with OSD
  • Possible association with ADD/ADHD; adolescents with ADD/ADHD are at risk for other musculoskeletal injuries.
  • Sinding-Larsen-Johansson apophysitis
image DIAGNOSIS
PHYSICAL EXAM
  • Knee pain with squatting or crouching
  • Absence of effusion or condyle tenderness
  • Tibial tuberosity swelling and tenderness
  • Pain increased with resisted knee extension or kneeling
  • Erythema over tibial tuberosity
  • Functional testing: Single-leg squat (SLS) and standing broad jump reproduce pain (3)[C].
DIFFERENTIAL DIAGNOSIS
  • Stress fracture of the proximal tibia
  • Pes anserinus bursitis
  • Quadriceps tendon avulsion
  • Patellofemoral stress syndrome
  • Chondromalacia patellae (retropatellar pain)
  • Proximal tibial neoplasm
  • Osteomyelitis of the proximal tibia
  • Tibial plateau fracture
  • Sinding-Larsen-Johansson syndrome (patellar apophysitis)—pain over inferior patellar tendon
  • Patellar fracture
  • Infrapatellar bursitis
  • Patellar tendinitis—pain over inferior patellar tendon and inferior pole of patella
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
  • Generally a clinical diagnosis. No tests are indicated unless other diagnoses are under consideration.
  • Radiographic imaging of the proximal tibia and knee may show heterotopic calcification in the patellar tendon:
    • X-rays are rarely diagnostic, but appearance of a separate fragment at the tibial tuberosity identifies candidates for potential surgical intervention.
    • Calcified thickening of the tibial tuberosity with irregular ossification at tendon insertion on the tibial tubercle (5)[B]
Diagnostic Procedures/Other
  • Bone scan may show increased uptake in the area of the tibial tuberosity:
    • Increased uptake in apophysis is normal in children, but with OSD, there may be more uptake on the opposite side.
  • Ultrasound is an excellent alternative, showing thickening of the distal patellar tendon and infrapatellar bursa effusion.
  • MRI shows fragmentation of the tibial tubercle and bone edema.
Test Interpretation
Biopsy is not necessary but would show osteolysis and fragmentation of the tibial tubercle.
image TREATMENT
GENERAL MEASURES
  • Frequent ice applications 2 to 3 times per day for 15 to 20 minutes
  • Rest and activity modification—avoid activities that increase pain and/or swelling.
  • Physical therapy helps with hamstring and quadriceps strengthening and stretching.
  • Open- and closed-chain eccentric quadriceps strengthening
  • Avoid aggressive stretching if pain is significant to avoid risk of tibial tubercle avulsion (1)[B].
  • Consult orthopedic surgery for tibial tuberosity fracture or complete avulsion.
  • Electrical stimulation and iontophoresis may be beneficial (1)[B].
  • Patients with marked pronation may benefit from orthotics.
  • A single study showed benefit from an infrapatellar strap and many experts recommend the use of a knee brace with an H- or U-shaped buttress (1)[C].
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MEDICATION
First Line
  • Any analgesic may be considered.
  • NSAIDs may help control pain.
  • Opioids are not recommended as first line.
Second Line
  • More potent analgesics, such as opioids, may be considered for short-term use in extreme situations.
  • Corticosteroid injections are not recommended.
  • Hypertonic glucose and/or Xylocaine injections have shown recent benefit (6)[C].
ISSUES FOR REFERRAL
When conservative therapy is unsuccessful, consider surgical referral.
SURGERY/OTHER PROCEDURES
  • Débridement of a thickened, cosmetically unsatisfactory tibial tubercle (rare) or removal of mobile heterotopic bone
  • Surgical excision of a painful tibial tubercle is rarely needed (<5%) and may be successfully done with bursoscopy instead of an open procedure (5)[C].
  • Recent report of successful pain elimination in OSD with percutaneous screw fixation of the tibial tuberosity (2)[C]
  • 75% return to normal sport activity and 89% are not restricted from competition due to recurrent pain.
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
  • Athletes may return to play if pain is controlled.
  • Presence of pain does not preclude competition.
Patient Monitoring
With worsening of symptoms only
PATIENT EDUCATION
  • Avoid jumping sports or reduce activities that increase pain and swelling.
  • Assure family that symptoms and findings will diminish with time and rest.
  • Patients can safely play sports with mild pain.
  • Quadriceps stretching and strengthening are important.
PROGNOSIS
  • Except in rare cases, this is a self-limiting illness that resolves within 2 years of full skeletal maturation.
  • 10% of patients with OSD as adolescents will have symptoms in adulthood. Up to 60% of adults with prior OSD report occasional symptoms and pain with kneeling.
  • Most patients with OSD have residual “knots” of tibial tubercles that never completely resolve.
REFERENCES
1. Kabiri L, Tapley H, Tapley S. Evaluation and conservative treatment for Osgood-Schlatter disease: a critical review of the literature. Intl J Ther Rehab. 2014;21(2):91-96.
2. Narayan N, Mitchell PD, Latimer MD. Complete resolution of the symptoms of refractory Osgood-Schlatter disease following percutaneous fixation of the tibial tuberosity [published online ahead of print February 12, 2015]. BMJ Case Rep.
3. Hall R, Barber Foss K, Hewett TE, et al. Sports specialization's association with an increased risk of developing anterior knee pain in adolescent female athletes. J Sport Rehabil. 2015;24(1):31-35.
4. Guler F, Kose O, Koparan C, et al. Is there a relationship between attention deficit/hyperactivity disorder and Osgood-Schlatter disease? Arch Orthop Trauma Surg. 2013;133(9):1303-1307.
5. Eun SS, Lee SA, Kumar R, et al. Direct bursoscopic ossicle resection in young and active patients with unresolved Osgood-Schlatter disease. Arthroscopy. 2015;31(3):416-421.
6. Topol GA, Podesta LA, Reeves KD, et al. Hyperosmolar dextrose injection for recalcitrant Osgood-Schlatter disease. Pediatrics. 2011;128(5):e1121-e1128.
Additional Reading
&NA;
  • Kaya DO, Toprak U, Baltaci G, et al. Long-term functional and sonographic outcomes in Osgood-Schlatter disease. Knee Surg Sports Traumatol Arthrosc. 2013;21(5):1131-1139.
  • Nierenberg G, Falah M, Keren Y, et al. Surgical treatment of residual Osgood-Schlatter disease in young adults: role of the mobile osseous fragment. Orthopedics. 2011;34(3):176.
  • Pihlajamäki 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;92(Suppl 1, Pt 2):258-264.
  • Sailly M, Whiteley R, Johnson A. Doppler ultrasound and tibial tuberosity maturation status predicts pain in adolescent male athletes with Osgood-Schlatter's disease: a case series with comparison group and clinical interpretation. Br J Sports Med. 2013;47(2):93-97.
Codes
&NA;
ICD10
  • M92.50 Juvenile osteochondrosis of tibia and fibula, unsp leg
  • M92.51 Juvenile osteochondrosis of tibia and fibula, right leg
  • M92.52 Juvenile osteochondrosis of tibia and fibula, left leg
Clinical Pearls
&NA;
  • Infrapatellar pain in an adolescent athlete undergoing a rapid growth spurt is OSD, patellar tendinosis, or Sinding-Larsen-Johansson syndrome.
  • Always consider lumbar disc disease, osteogenic sarcoma, or hip pathology in the differential diagnosis of OSD.
  • OSD is generally self-limited. Athletes should modify activity based on pain. Mild pain is not a contraindication to athletic participation.
  • Treatment focuses on strengthening and stretching of the hamstrings and quadriceps.
  • 10% of adolescents with OSD will be symptomatic as adults.