Osgood-Schlatter disease


Osgood–Schlatter disease

Refers to inflammation of the patellar ligament at the tibial tuberosity.

Characterized by a painful bump just below the knee.

Caused by stress on the patellar tendon that attaches the quadriceps muscle at the front of the thigh to the tibial tuberosity.

After the adolescent growth spurt, repeated stress from contraction of the quadriceps is transmitted through the patellar tendon to the immature tibial tuberosity.

The stress can cause multiple subacute avulsion fractures along with inflammation of the tendon, leading to excess bone growth in the tuberosity and producing a visible lump which can be very painful.

It is a traction apophysitis of the proximal tibial tubercle at the insertion of the patellar tendon caused by repetitive micro-trauma.

It is an overuse injury related to the physical activity.

Children who actively participate in sports are affected more frequently as compared with non-participants.

Frequency about 4%.

Males between the ages of 10 and 15 are most often affected, coinciding with periods of growth spurts.

It occurs more frequently in boys than in girls, with reports of a male-to-female ratio ranging from 3:1 to as high as 7:1.

The gender difference is related to a greater participation by boys in sports and risk activities than by girls.

The pain is worse with activity and better with rest.

The presenting symptom of knee pain occurs during activities such as running, jumping, squatting, and especially ascending or descending stairs and during kneeling.

The pain is worsened by acute knee impact.

The pain is able to be reproduced by extending the knee against resistance, stressing the quadriceps, or striking the knee.

Episodic pain typically last a few weeks to months.

One or both knees may be affected.

Bilateral symptoms are present observed in 20–30% of patients.

Flares may recur.

Usual onset is in males between the ages of 10 and 15

Duration of pain a few weeks to months.

Pain is initially mild and intermittent.

In the acute phase, the pain is severe and continuous.

Risk factors involve running or jumping, and overuse.

Treatment measures include:applying cold, stretching, strengthening exercises, and NSAIDs.

Casting the lower extremity may help.

Repeated tension on the growth plate of the upper tibia is the underlying mechanism.

It occurs from the combined effects of tibial tuberosity immaturity and quadriceps tightness.

Diagnosis is typically based on the symptoms.

Activities such as kneeling may also irritate the tendon.

The syndrome may develop without trauma or other apparent cause.

However, up to 50% of patients relate a history of precipitating trauma.

Plain X-rays may be normal or show fragmentation in the attachment area.

When growth slows, typically age 16 in boys and 14 in girls, the pain will no longer occur despite a bump that may potentially remain.

Symptoms generally resolve as the growth plate closes.

Diagnosis is made based on signs and symptoms.

Ultrasound can detect if there is any tissue swelling and cartilage swelling, and can identify new bone build up around the tibial tuberosity.

It may result in an avulsion fractures, with the tibial tuberosity separating from the tibia.

The tibial tuberosity may remain connected to a tendon or ligament.

Fracture on the tibial tuberosity can be a complete or incomplete.

Tibial tuberosity fracture classification:

Type I: A small fragment is displaced proximally and does not require surgery.

Type II: The articular surface of the tibia remains intact and the fracture occurs at the junction where the secondary center of ossification and the proximal tibial epiphysis come together

Type III: Complete fracture, that is through the articular surface, including high chance of meniscal damage. This type of fracture usually requires surgery.

Lack of flexibility in quadriceps and hamstrings muscles can be a direct risk indicator for OSD.

Stretching of these muscle groups can help reduce shortening of the muscles and help prevent OSD.

Conservative management with rest, ice, and stretching exercises are recommended.

Mild analgesics such as NSAIDs are suggested.

To prevent recurrence after acute symptoms have improved physiotherapy is recommended, including exercises to improve the strength of the quadriceps, hamstring and gastrocnemius muscles.

Symptoms usually resolve with treatment but may recur for 12–24 months before complete resolution at skeletal maturity, when the tibial epiphysis fuses.

While bracing or casting may provide comfort and help reduce pain as it reduces strain on the tibial tubercle, they rarely required and do not necessarily promote a quicker resolution.

Surgery may be required in persistently symptomatic patients who have stopped growing.

Surgical excision for patients with bony or cartilaginous ossicles, can resolve symptoms and allow activity in several weeks.

It is usually a self-limiting process.

In approximately 10% of patients the symptoms continue into adulthood, despite management.

The ossification of the tubercle can lead to functional limitations and pain for patients into adulthood.

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