Osgood-Schlatter Disease

Introduction

Osgood-Schlatter Disease (OSD) or osteochondrosis or tibial tubercle apophysitis or traction apophysitis of the tibial tubercle is a common cause of anterior knee pain in skeletally immature athletes. Clinically present as atraumatic insidious anterior knee pain with tenderness the site of insertion of the patellar tendon in the tibial tuberosity.[1] The condition occurs secondary to common extensor mechanism stress activities such as jumping and running and athletic activities such as Basketball Volleyball Sprinters Gymnastic Football.[1]

Overall treatment and management includes symptomatic treatment with ice and nonsteroidal anti-inflammatory drug activity modulation, and relative rest from strenuous activity and lower extremity stretching regimens to modify underlying predisposing biomechanics. [1][2]

Figure 1: Male with Osgood-Schlatter syndrome

Etiology

OSD typically develops during skeletal maturity (10-12 years in girls and 12-14 years in boys) . The cause can be attributed to repetitive traction resulting in microvascular tears fractures and inflammation; which then manifests as painful swelling and blisters.

OSD is an overuse injury that is more likely to occur in active younger patients. Typical pressure and microtrauma cause irritation and in severe cases partial rupture of the tibial tubercle apophysis. Rarely, trauma can result in a complete avulsion break. The side effects include negative Other evidence of misalignment of quadriceps and hamstring mobility or extensor mechanisms [3].

Risk factors for the disorder are[4]:

• Male gender
• Ages: male 12-15, girls 8-12
• Sudden skeletal growth
• repetitive activities, such as jumping and sprinting

Epidemiology

OSD is one of the most common causes of knee pain in adolescent athletes. [1]

• The pubertal growth spurt usually occurs between the ages of 10 and 15 years in males and 8 to 13 years in females (11.4% in males and 8.3% in females) [5].
• It is more common in men and athletes involved in track and field sports.
•  

Relevant Anatomy

Figure 3: Insertion of the patellar tendon at the tibial tuberosity

OSD is located on the tibial tubercle anteriorly and distally to the knee joint.

Clinical Presentation and Examination

Pain in the front of the knee, with or without swelling, is the main symptom of the condition and is worsened with physical activities such as running, jumping, biking, kneeling, going up and down stairs, and kicking a ball (extending the knee). Clinical manifestations include localized pain The area of the tibial tuberosity.

• Pain on palpation of the tibial tubercle.
• Tibial tubercle pain can worsen with physical activity or exercise.
• Physical activity can increase pain in the tibial tubercle.
• In some cases, the bony protrusion at the tibial tuberosity increases.
• Test secondary to painEly – tight quadriceps.
• Resistance isometric contractions of the quadriceps are painful. [8]

[9]

Differential Diagnosis

Conditions that behave similarly:

• Jumper’s knee (patellar tendonitis) or Sinding-Larsen-Johanssen syndrome [8]
• Synovial plica injury[8]
• Tibial tubercle fracture[8]
• Osteochondroma of the proximal tibia.[8]
• Fat Pad Syndrome

These disorders are also located at the patellar tendon and can cause similar knee problems.

Diagnostic Procedures

Radiography is usually not needed and is done in severe cases or when avulsions are suspected.

Figure 4: Lateral radiograph of the knee showing fragmentation of the tibial tubercle with soft tissue swelling.

• Diagnosis is based on typical clinical presentation (see Clinical Presentation). [10]
• X-rays of both knees should always be performed in anteroposterior and lateral projections to rule out the possibility of tumor rupture or infection. A picture of a prominent tibial tubercle with soft tissue swelling and calcification of the patellar tendon or Free bone fragments proximal to the nodules can be seen.
• Great care must be taken to make an accurate diagnosis, as sometimes tibial hump may not be pathological. So clinical relevance has to be done.

Prognosis

• Excellent prognosis.[8]
• This condition is self-limited, so it resolves within a month
• Sometimes the pain can last up to 2 years if left unnoticed or untreated.

Medical Management

1. Conservative management: Treatment should begin with active modulation of resting ice packs (RICE), sometimes with nonsteroidal anti-inflammatory drugs. [8]
2. Surgical treatment: Surgery should be avoided until the child is outgrown and skeletal growth is complete to avoid growth plate arrest and development of knee reflexion and/or valgus. Surgical treatment We identify different surgical procedures such as drilling Tibial tuberectomy (reduction in size) of the tibial tuberosity Longitudinal incision in the patellar tendon Resection of unbonded ossicles and free cartilage mass (tibial sequestrotectomy) Insertion of bone screws and/or any combination of these procedures. [11]

Physical Therapy Management

Pain Relief

• Pain usually subsides as growth of the tibial tubercle stops.
• Applying ice after activity can reduce pain in the front of the knee. [8]
• It is recommended to limit physical activity to 6-8 weeks. [8]
• Gently stretches the quadriceps and hamstrings while strengthening the vastus medialis obliques and reducing pain. [8][11]
• Patellar load reduction with patellar tap/McConnel tap and use of braces. [8]

[12]

Exercise Therapy

Therefore, low-intensity quad strengthening exercises, such as isometric multi-angle quad exercises, are performed early in the training program. Gradually introduce high-intensity quadriceps exercises and hamstring stretches that have been shown to be effective Evidence rating. [11] Incorporating high-intensity quadriceps exercises can exacerbate pain.

[13]

Shockwave

Extracorporeal shock wave therapy is a treatment that has been discussed in the context of OSD, but no recommendation can be made for this treatment due to the low value of the evidence. [14]

Activity Limitation

Nonsurgical treatment of this condition is based on the same principles that apply to all overuse injuries.

• It is not necessary to be completely immobilized or to avoid physical activity altogether today.
• It is critical that physicians inform parents, coaches, and child athletes of the natural history of the disease.

The child should continue his normal physical activity until the pain allows it to reduce the intensity of the frequency of movement (activity adjustment). Swimming is also very good (without discomfort) as a supplementary physical activity during this disease. And knee pads on the knees An infrapatellar strap or pad is recommended for support, which may help with physical activity and reduce pain. [15]

The study by Gerulis et al. [16] showed that physical activity restriction of physical load and conservative treatment are more effective than simple physical load restriction and activity restriction.