Introduction
Background
Osgood-Schlatter (OS) disease is more appropriately described as a disorder or a condition. Osgood, in the English literature, and Schlatter, in the German literature, independently described this condition in 1903. The etiology and treatment of OS condition have been disputed since its original description.
Radiograph of a patient who is skeletally mature. Note that the tibial tubercle is enlarged and there is an ossicle. A bursa was overlying this.
Radiograph of a patient who is skeletally immature. The tubercle is elongated and fragmented.
OS condition is a traction phenomenon resulting from repetitive quadriceps contraction through the patellar tendon at its insertion upon the skeletally immature tibial tubercle. This occurs in preadolescence during a time when the tibial tubercle is susceptible to strain. OS condition should be distinguished from overuse of the patella-patellar tendon junction, which is referred to as Sinding-Larsen-Johansson syndrome (the adolescent equivalent of jumper's knee).1,2
History of the Procedure
The onset of Osgood-Schlatter disease is usually gradual, with patients commonly complaining of pain in the tibial tubercle and/or patellar tendon region after repetitive activities. Typically, running or jumping activities that significantly stress the patellar tendon insertion upon the tibial tubercle aggravate the patient's symptoms. A sudden onset of pain with no antecedent symptoms in the region of the tibial tubercle should alert the clinician to assess for a possible tibial tubercle avulsion rather than OS condition.
Problem
Osgood-Schlatter disease is the most frequent cause of knee pain in children aged 10-15 years. This condition can cause loss of time from athletics; however, it is rarely a cause of permanent impairment or disability.
The natural history of this condition is self-limiting. In the Krause study, 90% of patients treated with conservative care were relieved of all of their symptoms approximately 1 year after onset of symptoms.3 After skeletal maturity, patients may continue to have problems kneeling or may have tenderness over an unfused tibial tubercle ossicle or a bursa that may require resection. Minimal association seems to exist between residual anterior knee pain after OS condition and patellar stability, as was noted in the Krause study. The authors also noted no cases of recurvatum from premature closure of the proximal tibial physis.
Frequency
The true incidence of Osgood-Schlatter disease is unknown. Kujala reviewed 412 athletes who presented to a sports clinic with 586 complaints.4 Sixty-eight patients, with an average age of 13.1 years, were diagnosed with OS condition. These patients did not participate in their sports activities for approximately 3 months because of the condition. Most individuals resumed full activity by 7 months.
Kujala also questioned 389 students and found that 12.9% claimed to have had OS condition. In this group, patients who had not participated in sports had a lower incidence of the condition (4.9%) than those who had played sports.
Etiology
The etiology of Osgood-Schlatter disease is controversial. Several causes have been hypothesized. The most likely cause is that the apophysis is subject to traction during the adolescent years, which can result in microfractures. The tibial tubercle apophysis appears in children aged 7-9 years. Usually, an apophysis develops proximally toward the epiphysis as the epiphysis grows distally toward the apophysis. Repeated traction from the patellar tendon can cause microfractures in the apophysis, as demonstrated by Lazerte and Rapp when they examined resected operative specimens from patients with OS condition.5 These specimens showed avulsion fractures of portions of the distal tibial tubercle.
Ehrenborg histologically examined bone excised from the tibial tubercle and found that viable cancellous bone exists without evidence of necrosis or inflammation.6,7 Woolfrey believed this was due to changes in the lower end of the patellar tendon and secondary new bone formation.8 Ogden showed that the tibial apophysis changes from fibrocartilage to hyaline cartilage, making it susceptible to injury.9 Rosenberg et al reviewed 16 nuclear scans, 34 CT scans, and 27 MRIs in patients with this diagnosis.10 They found that 100% percent of these patients had a normal tendon size, decreased attenuation, and an increased signal. Thirty-two percent of the patients had an ossicle. Rosenberg believed the findings were most consistent with patellar tendinitis.
Presentation
The individual's history and physical examination are usually sufficient to make a diagnosis of Osgood-Schlatter disease.
OS condition is the most frequent cause of knee pain in children aged 10-15 years. Patients present with a history of pain inferior to the patella at the insertion of the patellar tendon. Typically, individuals report a sport or other activity that aggravates the pain, which generally is improved with rest and worsened with activity. While any activity may be involved, sports involving jumping or running are a common cause.
Physical findings are limited to the area of the tibial tubercle and patellar tendon. Generally, there is a prominence and soft-tissue swelling over the tibial tubercle. Tenderness of the patellar tendon may be present. The remainder of the knee examination usually is normal. Attempted flexion against resistance may produce pain. Patients may resist knee flexion because of inflammation and pain from pull on the patellar tendon. Tight hamstrings and/or quadriceps may also be noted when compared with the uninvolved side.
Indications
Surgery to treat Osgood-Schlatter disease is rarely indicated. Occasionally, adults have a large ossicle and an overlying bursa, which may cause pain with kneeling. If so, treatment consists of excision of the bursa, ossicle, and any prominence.11 Surgical treatment is rarely, if ever, indicated in children. See Treatment.
Relevant Anatomy
Ossification of the tibial tubercle normally begins in children aged 7-9 years. Ossification of the tubercle begins distally and advances toward the extension of the physis that is ossifying distally. The patellar tendon attaches into the unossified distal portion. Strong forces exerted on the patellar tendon during the adolescent years can produce microfracture of the tibial tubercle at its insertion into the tibial diaphysis.
Contraindications
The real question is whether or not surgery is ever indicated in the growing child, as Osgood-Schlatter disease is self-limiting. Trail reviewed 2 groups of symptomatic patients with this condition with 4-5 years of follow-up.12 One group was treated surgically with tibial sequestrectomy, and the other was managed conservatively. Surgery was found to offer no significant benefit over conservative care. In addition, a significant complication rate was identified with tibial sequestrectomy.
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| Workup: Osgood-Schlatter Disease |
| Treatment: Osgood-Schlatter Disease |
| Follow-up: Osgood-Schlatter Disease |
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| References |
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References
Gholve PA, Scher DM, Khakharia S, Widmann RF, Green DW. Osgood Schlatter syndrome. Curr Opin Pediatr. Feb 2007;19(1):44-50. [Medline].
Pommering TL, Kluchurosky L. Overuse injuries in adolescents. Adolesc Med State Art Rev. May 2007;18(1):95-120, ix. [Medline].
Krause BL, Williams JP, Catterall A. Natural history of Osgood-Schlatter disease. J Pediatr Orthop. Jan-Feb 1990;10(1):65-8. [Medline].
Kujala UM, Kvist M, Heinonen O. Osgood-Schlatter''s disease in adolescent athletes. Retrospective study of incidence and duration. Am J Sports Med. Jul-Aug 1985;13(4):236-41. [Medline].
Lazerte GD, Rapp HH. Pathogenesis of Osgood-Schlatter's disease. Am J Pathol. Jul-Aug 1958;34(4):803-15. [Medline].
Ehrenborg G. The Osgood-Schlatter lesion. A clinical study of 170 cases. Acta Chir Scand. Aug 1962;124:89-105. [Medline].
Ehrenborg G. The Osgood-Schlatter lesion. A clinical and experimental study. Acta Chir Scand Suppl. 1962;Suppl 288:1-36. [Medline].
Woolfrey BF, Chandler EF. Manifestations of Osgood-Schlatter's disease in late teen age and early adulthood. J Bone Joint Surg Am. Mar 1960;42-A:327-32. [Medline].
Ogden JA, Southwick WO. Osgood-Schlatter''s disease and tibial tuberosity development. Clin Orthop. May 1976;(116):180-9. [Medline].
Rosenberg ZS, Kawelblum M, Cheung YY. Osgood-Schlatter lesion: fracture or tendinitis? Scintigraphic, CT, and MR imaging features. Radiology. Dec 1992;185(3):853-8. [Medline].
Orava S, Malinen L, Karpakka J, et al. Results of surgical treatment of unresolved Osgood-Schlatter lesion. Ann Chir Gynaecol. 2000;89(4):298-302. [Medline].
Trail IA. Tibial sequestrectomy in the management of Osgood-Schlatter disease. J Pediatr Orthop. Sep-Oct 1988;8(5):554-7. [Medline].
Visuri T, Pihlajamäki HK, Mattila VM, Kiuru M. Elongated patellae at the final stage of Osgood-Schlatter disease: a radiographic study. Knee. Jun 2007;14(3):198-203. [Medline].
Binazzi R, Felli L, Vaccari V. Surgical treatment of unresolved Osgood-Schlatter lesion. Clin Orthop. Apr 1993;(289):202-4. [Medline].
DeBerardino TM, Branstetter JG, Owens BD. Arthroscopic treatment of unresolved Osgood-Schlatter lesions. Arthroscopy. Oct 2007;23(10):1127.e1-3. [Medline].
Weiss JM, Jordan SS, Andersen JS, Lee BM, Kocher M. Surgical treatment of unresolved Osgood-Schlatter disease: ossicle resection with tibial tubercleplasty. J Pediatr Orthop. Oct-Nov 2007;27(7):844-7. [Medline].
Further Reading
Related eMedicine topics
Osgood-Schlatter Disease (Emergency Medicine)
Osgood-Schlatter Disease (Radiology)
Osgood-Schlatter Disease (Sports Medicine)
Tibial Tubercle Avulsion
Tibial Tubercle Fracture
Keywords
Osgood-Schlatter disease, tibial tubercle apophyseal traction injury, OSD, OS condition, apophysitis tibialis adolescentium, Schlatter disease, Schlatter-Osgood disease, osteochondritis, osteochondrosis
