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Osgood-Schlatter Disease (Tibial Apophysitis)

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Osgood-Schlatter Disease (Tibial Apophysitis)

BASICS

DESCRIPTION

Incidence in girls increasing with increased participation in organized youth sports; Still more common in boys é á

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 é á

Initial Tests (lab, imaging)

Biopsy is not necessary but would show osteolysis and fragmentation of the tibial tubercle. é á

When conservative therapy is unsuccessful, consider surgical referral. é á

With worsening of symptoms only é á

11 Kabiri é áL, Tapley é áH, Tapley é áS. Evaluation and conservative treatment for Osgood-Schlatter disease: a critical review of the literature. Intl J Ther Rehab. 2014;21(2):91 " ô96.22 Narayan é áN, Mitchell é áPD, Latimer é áMD. Complete resolution of the symptoms of refractory OSD following percutaneous fixation of the tibial tuberosity tuberosity [published online ahead of print February 12, 2015]. BMJ Case Rep.33 Hall é áR, Barber Foss é áK, Hewett é áTE, 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 " ô35.44 Guler é áF, Kose é áO, Koparan é áC, et al. Is there a relationship between attention deficit/hyperactivity disorder and Osgood-Schlatter disease? Arch Orthop Trauma Surg. 2013;133(9):1303 " ô1307.55 Eun é áSS, Lee é áSA, Kumar é áR, et al. Direct bursoscopic ossicle resection in young and active patients with unresolved Osgood-Schlatter disease. Arthroscopy. 2015;31(3):416 " ô421.66 Topol é áGA, Podesta é áLA, Reeves é áKD, et al. Hyperosmolar dextrose injection for recalcitrant Osgood-Schlatter disease. Pediatrics. 2011;128(5):e1121 " ôe1128.

732.4 Juvenile osteochondrosis of lower extremity, excluding foot é á

  • 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
  • Patients present with pain and swelling of the anterior tibial tubercle

EPIDEMIOLOGY

  • 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

  • Basic etiology unknown, exacerbated by exerciseJumping 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].
  • Jumping and pivoting sports place highest strain on the tibial tubercle. Repetitive trauma is the most likely inciting factor.

RISK FACTORS

  • Affects children and adolescents most commonly from the ages of 8 to 18 yearsGirls 8 to 14 yearsBoys 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]
  • Girls 8 to 14 years
  • Boys 10 to 18 years

GENERAL PREVENTION

  • Avoid sports with heavy quadriceps loading (especially deceleration activities " öeccentric 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

DIAGNOSIS

HISTORY

  • Unilateral or bilateral (30%) pain of the tibial tuberosity
  • Pain exacerbated by exercise, especially jumping and landing after jumping
  • Pain upon kneeling on the affected side(s)
  • Antalgic or straight-legged gait

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) " öpain over inferior patellar tendon
  • Patellar fracture
  • Infrapatellar bursitis
  • Patellar tendinitis " öpain over inferior patellar tendon and inferior pole of patella

DIAGNOSTIC TESTS & INTERPRETATION

  • 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]
  • 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]
  • 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.
  • Increased uptake in apophysis is normal in children, but with OSD, there may be more uptake on the opposite side.

TREATMENT

GENERAL MEASURES

  • Frequent ice applications 2 to 3 times per day for 15 to 20 minutes
  • Rest and activity modification " öavoid 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].

MEDICATION

  • Any analgesic may be considered.
  • NSAIDs may help control pain.
  • Opioids are not recommended as first 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

SURGERY/OTHER PROCEDURES

  • Debridement 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.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Athletes may return to play if pain is controlled.
  • Presence of pain does not preclude competition.

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 " Ł of tibial tubercles that never completely resolve.

COMPLICATIONS

  • Rarely, a heavily fragmented and inflamed tibial ossicle will avulse and require surgery.
  • Rare complications in adulthood include pseudoarthrosis of the tibial tubercle, genu recurvatum, patella alta, and ossicle fragmentation possibly leading to osteoarthritis of the knee.

REFERENCES

ADDITIONAL READING

  • Kaya é áDO, Toprak é áU, Baltaci é áG, et al. Long-term functional and sonographic outcomes in Osgood-Schlatter disease. Knee Surg Sports Traumatol Arthrosc. 2013;21(5):1131 " ô1139.
  • Nierenberg é áG, Falah é áM, Keren é áY, et al. Surgical treatment of residual Osgood-Schlatter disease in young adults: role of the mobile osseous fragment. Orthopedics. 2011;34(3):176.
  • Pihlajam â Ąki é áHK, Visuri é áTI. 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 " ô264.
  • Sailly é áM, Whiteley é áR, Johnson é áA. 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 " ô97.

CODES

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

ICD9

SNOMED

CLINICAL PEARLS

  • 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