Osgood-Schlatter Disease Treatment & Management

While there are no definitive prospective studies evaluating the treatment of OSD, including the recommended conservative treatments, The American Academy of Orthopaedic Surgeons and the American Academy of Family Practice recommend the following for the management of Osgood-Schlatter disease (OSD).

• Activity limitation
• Ice
• Anti-inflammatories
• Protective padding
• Quadriceps/hamstring strengthening
• Time

See the following Web sites for additional details

• American Association of Orthopaedic Surgeons in the article on Overuse Syndromes in Children, Osgood-Schlatter Disease [Knee Pain]
• familydoctor.org, Osgood-Schlatter Disease: A Cause of Knee Pain in Children.)

Standard first-line treatment for Osgood-Schlatter disease (OSD) is conservative and non-surgical. Initial treatment includes the application of ice for 20 minutes every 2-4 hours.

Analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs) may be given for pain relief and reduction of local inflammation. However, NSAIDs have not been shown to shorten the course of OSD.

Patellar tendon insertion injections have historically not been recommended. This is due in large part to the possibility of subcutaneous tissue atrophy after corticosteroid injections. A recent study out of Japan looked at lidocaine/dextrose injection vs. just lidocaine. No difference was seen between the two injection groups however both groups reported symptom relief with no adverse outcomes. ^[15]

Long-term immobilization is typically contraindicated, because it may result in increased knee stiffness in mild cases, thus predisposing the athlete to additional sports-related injuries. However, 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, but only for stretching and strengthening exercises.

Inform the patient to avoid pain-producing activities (eg, sports that involve excess amounts of jumping).

Infrapatellar strap, pads, or braces may also be used for support, but none have any proven efficacy.

Once the acute symptoms have abated, quadriceps-stretching exercises, including hip extension for a complete stretch of the extensor mechanism, may be performed to reduce tension on the tibial tubercle. Stretching exercises for the hamstrings, which are commonly tight, may also be performed.

Other than the presence of an ossicle that causes pain with kneeling, there are no long-term disabilities or problems associated with this condition.

The goal of rehabilitation is for the athlete to be able to return to his or her sport as quickly and safely as possible. Since the main treatment is rest, ice, and NSAIDs, the role of physical therapy is limited, if used at all. 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.

Acute phase

Several techniques may be recommended by the physical therapist to alleviate discomfort and avert recurrence of the disease. Treatment recommendations are dependent upon the severity of the condition.

An infrapatellar strap may be recommended during sports activity but has no proven efficacy.

Resting is recommended when pain arises.

Ice should be applied to the area for 20 minutes following activity.

Short-term rest and knee immobilization may be required.

On rare occasions, this author has casted a patient who has severe pain and is noncompliant with conservative care. This is usually with a parent who is intent on relieving the pain. While a brace can be recommended, it is doubtful that it will be used in a noncompliant patient.

Recovery phase

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

Straight leg raises can be performed as follows:

• 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 can be performed as follows:

• 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 can be performed as follows:

• 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°.

Surgery to treat Osgood-Schlatter disease (OSD) is rarely indicated.

Surgery in a skeletally immature patient is almost never indicated. Removal of ossicle fragmentation in immature patients with an unfused apophysis can lead to premature fusion of the tibial tubercle. ^[4]

In a study of the surgical treatment of unresolved Osgood-Schlatter disease (OSD), Pihlajamäki et al concluded that in most young adults, good to excellent functional outcomes can be achieved with surgical treatment of unresolved OSD. ^[16] The investigators examined postsurgical clinical courses, radiographic characteristics, and long-term outcomes of 107 military recruits (117 knees) who were operated on for the condition. Functional outcome data were gathered from medical records, interviews, questionnaires, and physical and radiographic examinations. By the end of a (median) 10-year follow-up period, 93 patients (87%) reported that they could participate without restriction in daily and work activities, and 80 patients (75%) had regained their preoperative sports activity level. In addition, 41 patients (38%) reported the ability to kneel without pain. Minor postoperative complications occurred in 6 patients, and 2 patients required reoperation for OSD.

In a review of a series of patients who were treated operatively, Binazzi et al found that the most widely used procedure was excision of all intratendinous ossicles, with or without removal of a portion of the prominent tibial tubercle. ^[17] A comparison of 2 groups of individuals, 1 with 15 individuals treated with excision of ossicles and 1 with 11 individuals treated with various methods before 1975, clearly showed that results of simple excision of the ossicles were better.

A study looked to determine the outcomes of bursoscopic ossicle excision in young, skeletally-mature, active patients with unresolved symptoms from an ossicle related to prior Osgood-Schlatter disease. The study concluded that bursoscopic ossicle excision showed satisfactory outcomes in selective young, skeletally-mature, and active patients with persistent symptoms and the presence of an ossicle. However, the authors added that bursoscopic surgery showed limitation in reducing the prominence of the tibial tuberosity. ^[18]

In another study, patients treated operatively were found to be no more likely than conservatively treated patients to be relieved of pain or to have improvement of cosmetic appearance.

If a true tibial tubercle avulsion occurs 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.

Indications for surgery

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. ^[19]

Contraindications for surgery

The real question is whether or not surgery is ever indicated in the growing child, as OSD is self-limiting. Trail reviewed 2 groups of symptomatic patients with this condition with 4-5 years of follow-up. ^[20] 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.

While the typical conservative management will relieve the pain associated once skeletal maturity is reached, continued tibial tubercle prominence and pain upon kneeling can be a problem into adulthood.

Complications following resection of an ossicle can include:

• surgical wound infection/dehiscence
• poor cosmesis
• unsightly scar
• peri-incisional numbness
• growth disturbance (skeletally immature)

Trail et al showed 55% of patients had an obvious bony prominence postoperatively. One third of these were quite apparent and troublesome and 3 required repeat procedures to deal with associated discomfort. ^[20]