eMedicine Specialties > Sports Medicine > Lower Limb

Osgood-Schlatter Disease

Munisha Mehra Bhatia, MD, General Academic Pediatrics, Faculty Development Fellow, Children's Memorial Hospital of Northwestern University
Janos P Ertl, MD, Clinical Assistant Professor, Department of Orthopedic Surgery, Chief of Orthopedic Trauma, University of California at Davis; Director of Amputee Clinic, Kaiser Hospital; Gyorgy Kovacs, MD, Department of Orthopedic Surgery, Consulting Surgeon, GOC Clinic

Updated: Apr 28, 2006

Introduction

Background

In 1903, Robert Osgood (1873-1956), a US orthopedic surgeon, and Carl Schlatter (1864-1934), a Swiss surgeon, concurrently described the disease that now bears their names. Osgood-Schlatter disease (OSD) is one of the most common causes of knee pain in active adolescents.

Frequency

United States

OSD affects 20% of athletic adolescents, as compared with the frequency of 4.5% of age-matched nonathletic controls. The disease is bilateral in 20-50% of patients. Boys are affected more commonly than girls, with a male-to-female ratio of 3:1. Boys aged 10-15 years and girls aged 8-13 years typically are affected, coinciding with growth spurts.

Functional Anatomy

In girls younger than 11 years and in boys younger than 13 years, the tibial tubercle consists of cartilaginous tissue. The secondary ossification center or apophysis of the tibial tubercle develops when girls are aged 8-12 years and when boys are aged 9-13 years. During this stage of skeletal development, the Osgood-Schlatter lesion may occur. The most commonly accepted theory is that repeated traction (traction apophysitis) on the anterior portion of this developing ossification center leads to multiple subacute fractures or tendinous inflammation, resulting in a benign self-limited disturbance manifested as pain, swelling, and tenderness.

By the end of the ensuing 2 stages of bony development (eg, epiphyseal and bony stages), the growth plates of the proximal tibia fuse in both males and females (usually when aged 14-18 y) and the OSD usually subsides.

Sport Specific Biomechanics

During running, gymnastics, and other sports requiring repeated contractions of the quadriceps, an extra-articular osteochondral stress fracture or microavulsion occurs. The proximal area of the patellar tendon insertion separates, resulting in elevation of the tibial tubercle. During the reparative phase of this stress fracture, new bone is laid down in the avulsion space, which may result in a deviated and prominent tibial tubercle. When an individual with an injured tibial tubercle continues to participate in sports, more and more microavulsions develop, and the reparative process may result in a markedly pronounced prominence of the tubercle with longer-term cosmetic and functional implications. A separated fragment may develop at the patellar tendon insertion and may lead to chronic nonunion-type pain.

Clinical

History

Knee pain usually is the presenting symptom. Patients usually report that the knee pain occurs during activities such as running, jumping, squatting, and ascending or descending stairs. Pain often subsides with rest and activity modification.
Athletes involved in football, soccer, basketball, gymnastics, and ballet are most commonly affected.
Symptoms often are vague and intermittent in onset.
Symptoms may develop without trauma or other apparent cause.
The patients who present with OSD are male and female adolescents, usually aged 12-15 years.

Physical

The physical examination is very specific with point tenderness over the tibial tubercle. Other physical examination findings may include the following:

Proximal tibial swelling and tenderness
Enlargement or prominence of the tibial tubercle
Reproducible and aggravated pain by direct pressure and jumping (quadriceps contraction)
Pain with resisted knee extension (quadriceps contraction)
Full range of motion of the knee
Hamstring tightness
No effusion or meniscal signs
Negative drawer test (no knee instability)
Normal neurovascular examination
No abnormal findings in the hip and ankle joints

Causes

The cause of OSD is unknown; however, theories suggest that this condition is a result of repeated knee extensor mechanism contraction that causes partial avulsions or microavulsions of the chondrofibroosseous tibial tubercle. OSD usually occurs in those involved in sports that require running and jumping.

Differential Diagnoses

Femur Injuries and Fractures
Knee Osteochondritis Dissecans
Patellofemoral Joint Syndromes
Pes Anserine Bursitis

Workup

Laboratory Studies

Laboratory studies are not required to make the diagnosis of OSD.

Imaging Studies

Imaging studies are not required to make the diagnosis of OSD; however, they often are used to rule out osteomyelitis, tumors, and other pathology.
Radiographs
- A lateral projection with the knee in slight medial rotation is the preferred view. This view shows the greatest detail of the tibial tubercle.
- When radiographs are obtained, the most common finding is that the knee films are normal, especially if the child is in the preossification phase.
- The acute phase of OSD may reveal a prominent and elevated tibial tubercle with anterior soft tissue swelling.
- In severe cases, radiographs may reveal radiodense fragments or ossicles separated from the tibial tuberosity.
- Occasionally, the radiographs may reveal irregularity, fragmentation, or increased density of the ossification of the tibial tubercle. This pattern may be a normal variant in asymptomatic children.
Ultrasound may reveal a normal tubercle and signal changes consistent with thickening (more echogenic) in the patellar tendon and hypoechoic area of the adjacent soft tissue.
CT scan or MRI may reveal changes at the insertion of the patellar tendon.

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

Medical Issues/Complications

Long-term immobilization is contraindicated because it may result in increased knee stiffness in mild cases, thus predisposing the athlete to additional sports-related injuries.

Surgical Intervention

If conservative treatment has failed, surgical excision of the united painful ossicle is recommended. Removal of ossicle fragmentation in immature patients with an unfused apophysis should be approached with caution, as a resultant recurvatum deformity may occur due to premature fusion of the tibial tubercle.

Tibial tubercle avulsions occasionally can occur due to the contracture of the extensor mechanism. Open reduction and internal fixation (ORIF) usually is recommended, depending on the size and displacement of the fragment as well as the phase of apophyseal closure. (See Osgood-Schlatter Disease in Orthopedic Surgery journal.)

Consultations

An orthopedic consultation is recommended.

Other Treatment

Cortisone injections are not recommended.

Recovery Phase

Rehabilitation Program

Physical Therapy

See Physical Therapy, Acute Phase.

The following regimen recommendations for patients with OSD are taken from Meisterling, Wall, and Meisterling:

Straight leg raises
- Lie on the floor with the back propped up a few inches with the elbows.
- Bend the unaffected knee to a comfortable position. Using adjustable ankle weights with half-pound increments, determine the weight at which 10 raises can be performed on the affected leg.
- Tighten the thigh muscles and lift the affected leg 12 inches, keeping the leg straight.
- Hold for 5 seconds.
- Slowly lower the leg and relax.
- Start with 10 repetitions for each leg.
- When 15 repetitions have been performed comfortably, increase the weight by half a pound and drop back to 10 repetitions.
- Once 15 repetitions again can be performed comfortably, increase the weight again, to a maximum of 7-12 lb.
Short-arc quadriceps exercises
- Lie back with the unaffected knee bent (same as for straight leg raises).
- Place a few rolled up towels under the affected knee to raise it 6 inches from the floor.
- Tighten the thigh muscles and straighten the leg until it is 12 inches from the floor.
- Hold for 5 seconds.
- Slowly lower the leg and relax.
- Start with 10 repetitions for each leg and increase to 15, using the same ankle weight and repetition progression as for straight leg raises.
Wall slides
- To do wall slides or quarter seats, stand about 12 inches from a smooth wall and lean back against it with the feet shoulder width apart.
- Holding a light dumbbell in each hand with the arms straight down, bend the knees and slowly lower the body 4-6 inches.
- If pain is felt, the body has squatted too far.
- Hold for 5 seconds and then rise up quickly.
- Start with 10 repetitions and increase to 15, gradually increasing the dumbbell weight in the same type of progression as for straight leg raises.

A good rule of thumb with regard to squats and wall slides for patients with patellar pain of any kind is a relative restriction of not flexing the knee beyond 90°.

Maintenance Phase

Rehabilitation Program

Physical Therapy

The goal of rehabilitation is for the athlete to be able to return to his or her sport as quickly and safely as possible. The physical therapist and the physician determine when the athlete is ready to resume competition, depending on the findings of the clinical examination and functional testing. The pain may take up to 6-24 months to resolve. If an individual returns to activity too soon, he or she may worsen the condition. Athletes need to work on improving the flexibility and strength of the quadriceps and hamstring muscles throughout the course of rehabilitation to ensure that they are ready to return to sports.

Medication

The goals of pharmacotherapy are to reduce morbidity and prevent complications.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Short-term NSAIDs may be used for pain relief. Steroids are not recommended for use in this condition. NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. Their mechanism of action is not known, but they may inhibit cyclo-oxygenase activity and prostaglandin synthesis. Other mechanisms may exist as well, such as inhibition of leukotriene synthesis, lysosomal enzyme release, lipoxygenase activity, neutrophil aggregation, and various cell membrane functions.

Ibuprofen (Motrin, Ibuprin)

DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.

Dosing

Adult

200-400 mg PO with food q4-6h while symptoms persist; not to exceed 3.2 g/d

Pediatric

5-10 mg/kg/dose PO q6-8h; not to exceed 40 mg/kg/24h

Interactions

Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently; may increase serum levels of digoxin

Contraindications

Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal or hepatic insufficiency, or high risk of bleeding; ocular problems, granulocytopenia, and anemia may occur

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy

Ketoprofen (Orudis, Oruvail, Actron)

For relief of mild to moderate pain and inflammation. Small dosages initially are indicated in small and elderly patients and in those with renal or liver disease.
Doses over 75 mg do not increase therapeutic effects. Administer high doses with caution, and closely observe patient for response.

Dosing

Adult

25-50 mg PO q6-8h prn; not to exceed 300 mg/d

Pediatric

<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults

Interactions

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy

Naproxen (Naprelan, Anaprox, Aleve, Naprosyn)

For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclo-oxygenase, which results in a decrease of prostaglandin synthesis.

Dosing

Adult

500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d

Pediatric

<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d

Interactions

Contraindications

Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency

Precautions

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug

Flurbiprofen (Ansaid)

May inhibit cyclo-oxygenase enzyme, which in turn inhibits prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.

Dosing

Adult

200-300 mg/d PO divided bid/qid

Pediatric

Not established

Interactions

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Follow-up

Return to Play

After the pain has resolved (which may take 6-24 mo), the patient may return to play as tolerated. The patient may need to participate less frequently, run at a slower speed, or decrease jumping activities. Premedicating or relying on NSAIDs regularly before or after competition is not advised. An intensive rehabilitation program of stretching exercises helps to decrease the likelihood of developing pain with vigorous sports activity. OSD usually resolves by the time the adolescent is aged 18 years.

Complications

The most common long-term complications are pain on kneeling as an adult and the cosmesis of a bony prominence on the anterior knee. Less common complications are the persistence of a painful ossicle requiring surgical excision and a displaced avulsion of a tibial tubercle.

Prevention

Activity modification and regular stretching and strengthening exercises provide the best prevention.

Prognosis

The prognosis is excellent. OSD usually resolves by the time the patient is aged 18 years, when the tibial tubercle apophysis ossifies. The likelihood for long-term sequelae increases in severe cases, in cases in which treatment is not sought, or in cases in which the patient demonstrates poor compliance with the physician's recommendations.

Education

OSD is a self-limited illness that resolves as the patient approaches adulthood. For acute flare-ups, anti-inflammatory medications, ice, elevation, and rest are recommended. For prevention, the patient should engage in activity and sports as tolerated without development of knee pain. Regular daily stretching and strengthening exercises should be performed to help prevent OSD. Inform patients regarding the activities that aggravate the condition and regarding the self-limiting nature of the disease.

For excellent patient education resources, visit eMedicine's Foot, Ankle, Knee, and Hip Center, Arthritis Center, and Bone Health Center. Also, see eMedicine's patient education article Knee Pain.

Miscellaneous

Medicolegal Pitfalls

The most significant medicolegal pitfall is failing to diagnose another condition that could result in long-term permanent damage (eg, tumor, osteochondritis dissecans). Most other conditions have a more concerning clinical examination or history. Therefore, always obtain radiographs and consider the possibility of a referred pain syndrome from the hip.

Special Concerns

If a patient is noncompliant, the clinician may recommend immobilization in a knee brace for a minimum of 6 weeks. The brace should be removed daily, only for stretching and strengthening exercises.

Multimedia

Media file 1: Image courtesy of John T. Killion, MD; OSA Pediatric Orthopeaedics

Media file 2: Image courtesy of John T. Killion, MD; OSA Pediatric Orthopeaedics

References

Behrman R, Kliegman R, Nelson WE. Osgood-Schlatter disease. In: Nelson Textbook of Pediatrics. Vol 14. Philadelphia, Pa: WB Saunders; 1992:1705.
Bloom OJ, Mackler L, Barbee J. Clinical inquiries. What is the best treatment for Osgood-Schlatter disease?. J Fam Pract. Feb 2004;53(2):153-6. [Medline].
Demirag B, Ozturk C, Yazici Z, Sarisozen B. The pathophysiology of Osgood-Schlatter disease: a magnetic resonance investigation. J Pediatr Orthop B. Nov 2004;13(6):379-82. [Medline].
Epstein B. Common problems affecting adolescents - Osgood Schlatter disease: A common cause of knee pain. In: Iowa Health Book: Family Practice. Iowa City, Iowa: The University of Iowa; 1995.
Flowers MJ, Bhadreshwar DR. Tibial tuberosity excision for symptomatic Osgood-Schlatter disease. J Pediatr Orthop. May-Jun 1995;15(3):292-7. [Medline].
Meisterling R, Wall E, Meisterling M. Coping with Osgood-Schlatter disease. In: The Physician and Sports Medicine. Vol 26. New York, NY: McGraw-Hill; 1998.
Ross MD, Villard D. Disability levels of college-aged men with a history of Osgood-Schlatter disease. J Strength Cond Res. Nov 2003;17(4):659-63. [Medline].
Staheli L. 2nd ed. Fundamentals of Pediatric Orthopedics. Philadelphia, Pa: Lippincott-Raven; 1998:56, 123.
Tachdjian MO. Clinical Pediatric Orthopedics: The Art of Diagnosis and Principles of Management. Vol 1. Stamford, Conn: Appleton & Lange; 1997:107-108.
Wall E. Osgood-Schlatter disease: Practical treatment for a self-limiting condition. In: The Physician and Sports Medicine. Vol 26. New York, NY: McGraw-Hill; 1998.

Keywords

OSD, tibial tubercle osteochondrosis, traction apophysitis, knee pain

Contributor Information and Disclosures

Author

Munisha Mehra Bhatia, MD, General Academic Pediatrics, Faculty Development Fellow, Children's Memorial Hospital of Northwestern University
Munisha Mehra Bhatia, MD is a member of the following medical societies: Ambulatory Pediatric Association and American Academy of Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

Janos P Ertl, MD, Clinical Assistant Professor, Department of Orthopedic Surgery, Chief of Orthopedic Trauma, University of California at Davis; Director of Amputee Clinic, Kaiser Hospital
Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Hungarian Medical Association of America, Orthopaedic Trauma Association, and Sierra Sacramento Valley Medical Society
Disclosure: Nothing to disclose.

Gyorgy Kovacs, MD, Department of Orthopedic Surgery, Consulting Surgeon, GOC Clinic
Disclosure: Nothing to disclose.

Medical Editor

Andrew L Sherman, MD, Associate Professor, Departments of Neurological Surgery, Orthopedics, and Rehabilitation, University of Miami Miller School of Medicine
Andrew L Sherman, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American College of Sports Medicine, and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Marlene DeMaio, MD, Consulting Staff, Department of Orthopedic Surgery, Assistant Professor, Bone & Joint/Sports Medicine Institute, Naval Medical Center
Marlene DeMaio, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American College of Sports Medicine, American Orthopaedic Foot and Ankle Society, and American Orthopaedic Society for Sports Medicine
Disclosure: Nothing to disclose.

CME Editor

Jon Whitehurst, MD, Consulting Staff, Rockford Orthopedic Associates
Disclosure: Nothing to disclose.

Chief Editor

William Jay Bryan, MD, Clinical Professor, Department of Orthopedic Surgery, Baylor University College of Medicine
William Jay Bryan, MD is a member of the following medical societies: Texas Orthopaedic Association
Disclosure: Nothing to disclose.

Further Reading

eMedicine Specialties > Sports Medicine > Lower Limb

Osgood-Schlatter Disease

Introduction

Background

Frequency

United States

Functional Anatomy

Sport Specific Biomechanics

Clinical

History

Physical

Causes

Differential Diagnoses

Other Problems to Be Considered

Workup

Laboratory Studies

Imaging Studies

Treatment

Acute Phase

Rehabilitation Program

Physical Therapy

Medical Issues/Complications

Surgical Intervention

Consultations

Other Treatment

Recovery Phase

Rehabilitation Program

Physical Therapy

Maintenance Phase

Rehabilitation Program

Physical Therapy

Medication

Nonsteroidal anti-inflammatory drugs (NSAIDs)

Ibuprofen (Motrin, Ibuprin)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Ketoprofen (Orudis, Oruvail, Actron)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Naproxen (Naprelan, Anaprox, Aleve, Naprosyn)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Flurbiprofen (Ansaid)

Dosing

Adult

Pediatric

Interactions

Contraindications

Precautions

Pregnancy

Precautions

Follow-up

Return to Play

Complications

Prevention

Prognosis

Education

Miscellaneous

Medicolegal Pitfalls

Special Concerns

Multimedia

Media file 1: Image courtesy of John T. Killion, MD; OSA Pediatric Orthopeaedics