Basics
Description
- Most frequent cause of knee pain in children aged 10 " �15 yr
- Pain and edema of the tibial tuberosity:
- Tenderness at insertion site for patellar tendon just below the knee joint
- Extra-articular disease:
- Pain is worse with activity and improves with rest
- Caused by repetitive stress and is common in children participating in sports
- Benign, self-limited knee condition
Etiology
- Etiology is controversial
- Leading theory: Microfractures caused by traction on the apophysis
- Pain occurs during activities that stress the patellar tendon insertion onto tibial tubercle.
Diagnosis
Signs and Symptoms
- Pain and swelling over tibial tuberosity
- Pain exacerbated by running, jumping
- Pain relieved by rest
History
- Risk factors:
- Age: 10 " �15 yr of age, associated with growth spurt in puberty
- More common in boys
- Sports: Activities with running, jumping, swift changes in direction (i.e., soccer, basketball, figure skating)
- Knee pain is worse with activity and improves with rest.
- Usually unilateral, with 20% occurring bilateral
Physical Exam
- Prominence and soft tissue swelling over the tibial tuberosity
- Pain reproduced by extending the knee against resistance
- Tenderness over tibial tuberosity at patellar tendon insertion site
- Tight quadriceps and hamstrings compared to unaffected side
- Erythema of tibial tuberosity may be present.
- Knee joint exam is normal.
Essential Workup
Diagnosis is clinical: � �
- Pain, swelling, and tenderness localized to the tibial tubercle
Diagnosis Tests & Interpretation
Imaging
Knee x-ray: � �
- Irregular ossification and fragmentation at the tibial tuberosity may be seen.
- Ultrasound has the advantage of imaging surrounding soft tissues
Differential Diagnosis
- Patellar stress fracture
- Patellar or quadriceps tendonitis
- Prepatellar or infrapatellar bursitis
- Osteochondritis dissecans
- Osteomyelitis
- Patellofemoral pain syndrome
- Septic joint
- Inferior patellar pole traction apophysitis (Sinding-Larsen " �Johansson disease)
- Fat pad impingement (Hoffa disease)
- Referred pain, especially from the hip
Treatment
Initial Stabilization/Therapy
- Stabilize lower extremity in position of comfort.
- Apply ice to affected knee.
Ed Treatment/Procedures
- Rest from painful activities:
- Limited activity for 6 " �8 wk
- Avoid cutting and jumping sports, such as basketball, soccer, volleyball, etc.
- Ice affected area.
- Analgesic medications
- Stretch the quadriceps and hamstrings.
- Apply protective padding to knee during activities.
- Infrapatellar tendon strap may be worn for 6 " �8 wk.
- Avoid corticosteroid injections.
- Reassurance; it is a benign, self-limited condition.
Medication
First Line
Analgesic medications: � �
- Ibuprofen: 10 mg/kg PO q6h
- Acetaminophen: 15 mg/kg PO q4h
Follow-Up
Disposition
Admission Criteria
No admission is necessary. � �
Discharge Criteria
Discharge home. � �
Issues for Referral
If patient fails nonoperative therapy, then refer to pediatric orthopedic surgery: � �
- Rarely, surgical excision is required but is delayed until after skeletal maturity.
Followup Recommendations
Rest from painful activities and follow-up with pediatrician in 2 " �3 wk for repeat exam. � �
Pearls and Pitfalls
- Diagnosis is clinical:
- Pain, swelling, and tenderness at the tibial tuberosity:
- Tenderness and pain worse during and after exercise
- Risk factors:
- 10 " �15 yr of age
- Sports activities with running, jumping
- Treatment is conservative:
- Treat with rest, ice, and NSAIDs
- Avoid sports activities until pain resolves.
Additional Reading
- Bloom � �OJ, Mackler � �L, Barbee � �J. Clinical inquiries. What is the best treatment for Osgood-Schlatter disease? J Fam Pract. 2004;53(2):153 " �156.
- Cassas � �KJ, Cassettari-Wayhs � �A. Childhood and adolescent sports-related overuse injuries. Am Fam Physician. 2006;73(6):1014 " �1022.
- Gholve � �PA, Scher � �DM, Khakharia � �S, et al. Osgood-Schlatter syndrome. Curr Opin Pediatr. 2007;19(1):44 " �50.
- Weiss � �JM, Jordan � �SS, Andersen � �JS, et al. Surgical treatment of unresolved Osgood-Schlatter disease: Ossicle resection with tibial tubercleplasty. J Pediatr Orthop. 2007;27(7):844 " �847.
Codes
ICD9
732.4 Juvenile osteochondrosis of lower extremity, excluding foot � �
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
- M92.5 Juvenile osteochondrosis of tibia and fibula
SNOMED
- 72047008 juvenile osteochondrosis of tibial tubercle (disorder)