Osgood-Schlatter disease: what is it, symptoms, treatment, prognosis

What is Osgood-Schlatter disease?

Osgood-Schlatter diseaseAlso known as osteochondrosis or traction apophysitis of the tibial tuberosity, it is a common cause of pain in the front of the knee in people with an immature skeleton. Common sports associated with this condition include:

• Basketball;
• Volleyball;
• Run;
• Gymnastics;
• Football.

The clinical picture classically links the atraumatic, insidious onset of pain in the front of the knee with soreness at the insertion of the patellar tendon at the tibial tuberosity. The state is self-limited and occurs secondary to repetitive stress on the extensor mechanisms, such as jumping and running. The pain level determines the overall treatment, and therapy includes symptomatic ice and NSAID treatment, as well as changes in activity and relative rest from stimulating actions in combination with the stretching mode of the lower limbs to correct the main predisposing biomechanical factors.

Despite the fact that the disease is benign, recovery can be prolonged and cause a lack of sports. The disease develops gradually and is usually associated with repetitive knee movements. Soreness usually occurs over the tibial tubercle.

Causes and risk factors

The patellar tendon attaches to the tibial tuberosity and is made up of cartilage. This is followed by ossification of the tibial tuberosity at the age of 10-12 years in girls and at the age of 12-14 years in boys. Osgood-Schlatter disease develops during this stage of bone maturation. The prevailing theory is that re-tensioning of the tubercle results in microvascular rupture, fracture, and inflammation; which then appears as edema and soreness.

Osgood-Schlatter disease is an overuse injury that occurs in active adolescents. It occurs secondarily in relation to repetitive deformations and microtraumas due to force, applied by a strong patellar tendon when inserted into a relatively soft apophysis tibial tubercle. This force leads to irritation and partial detachment of the apophysis of the tibial tubercle. Strength increases with increasing activity levels and especially after periods of rapid growth. In rare cases, trauma can lead to a complete avulsion fracture. Predisposing factors include poor quadriceps and hamstring flexibility, or other signs of a displaced extensor mechanism.

Risk factors for the disease include:

• Male;
• Age: men 12-15 years old, girls 8-12 years old;
• Sudden skeletal growth;
• Repetitive activities such as jumping and running.

Epidemiology

Osgood-Schlatter disease is one of the most common causes of knee pain in young athletes with an immature skeleton. The onset coincides with spikes in growth in adolescents aged 10 to 15 for men and 8 to 13 for women. The disease is more common in men and more common in athletes who engage in sports that include running and jumping. Among adolescents aged 12 to 15 years, the prevalence of Osgood-Schlatter disease is 9.8% (11.4% in men, 8.3% in women). Symptoms appear on both sides in 20-30% of patients.

Pathophysiology

The tibial tuberosity develops as a secondary center of ossification, providing attachment of the patellar tendon. The growth of the bones exceeds the ability of the muscle-tendon block to stretch sufficiently to maintain the same flexibility, which leads to an increase in tension across the apophysis. Fusis is the weakest point in the muscle-tendon-bone junction (as opposed to a tendon in an adult) and is therefore at risk of repetitive stress injury. With repeated contraction of the muscle mass of the quadriceps muscle, especially with repeated forced extension of the knee, as is observed in sports, requiring running and jumping (basketball, football, gymnastics), softening and partial separation of the apophyseal center of ossification may occur, followed by osteochondritis.

The appearance and closure / fusion of the tibial tuberosity occurs in the following sequence:

• The tibial tuberosity is completely cartilaginous (age <11 years).
• Apophysis forms (age from 11 to 14 years).
• The apophysis fuses with the proximal epiphysis of the tibia (ages 14 to 18).
• The proximal tibial epiphysis and the apophysis of the tibial tubercle fuse with the rest of the proximal tibia (age> 18 years).

Signs and symptoms

A child between 8 and 15 years old usually has pain in the front of the knee with or without edema, which can be unilateral or bilateral. Soreness begins with a dull pain localized over the tuberosity of the tibia, gradually increasing with increasing activity. The presentation is typical of an insidious beginning with no prior trauma. The pain usually diminishes at rest and goes away within minutes or hours after the cessation of stimuli or sports. The pain is especially worse when running, jumping, straight knee injury, kneeling and squatting. The increased protrusion of the tibial tuberosity is accompanied by soreness over the junction of the patellar tendon. Poor quadriceps and hamstring flexibility may be a predisposing factor. Pain can be reproduced with resistance knee extension and active or passive knee flexion.

Diagnostics

Osgood-Schlatter disease is a clinical diagnosis and radiographic evaluation is usually not required. Plain X-rays may be used to rule out additional diagnoses such as fracture, infection, or bone swelling if the manifestation is severe or atypical. Radiographic evaluation may also be indicated to evaluate avulsion of the apophysis or other injuries following a traumatic event. Classic radiographic findings in Osgood-Schlatter disease include a raised tibial tubercle bones with soft tissue swelling, fragmentation of the apophysis, or calcification of the distal tendon patella. It is worth noting that these signs can also be considered normal variants and do not always reflect pathology, so clinical correlation is of paramount importance.

Treatment

Ultimately, the state is self-limiting, but it can persist for up to 2 years, until the apophysis heals. Treatment includes relative rest and varying physical activity based on the level of pain. There is no evidence that rest accelerates recovery, but limiting activity is effective in reducing pain. Patients can play sports as pain dissipates with rest and does not restrict sports-related activities.

Topical application of ice and ice can be used to relieve pain. non-steroidal anti-inflammatory drugs (NSAIDs). A knee protector can be worn over the tibial tuberosity to protect against direct injury. Exercises to stretch the hamstrings and to stretch and strengthen the quadriceps can be a helpful addition. If pain does not respond to conservative measures, formal physical therapy may be required.

In severe, prolonged cases, a short period of knee immobilization may be considered. There is no evidence to recommend injection therapy or surgery for Osgood-Schlatter disease. Symptoms usually go away on their own with the disappearance of pain after closing the apophysis. Long-term consequences may include a thickening or protruding tubercle of the tibia, but in the vast majority of cases, it is asymptomatic.

- Surgical intervention.

In about 10% of cases, symptoms may persist> 1–2 years after skeletal formation. In patients with mature skeletons and persistent symptoms, bone removal may be performed.

Surgery is rarely indicated for disease, but may be attempted to excise the bursa overlying. In general, surgery is not more beneficial than treatment and is more likely to cause complications.

Forecast

The prognosis of Osgood-Schlatter disease is excellent. The disorder is self-limiting, but it can take months to resolve. In about 10% of patients, symptoms may persist into adulthood. These long-term consequences occur when a person does not seek treatment or does not adhere well to recommended treatment. Cases have been reported where pain can last for several years.