Osgood–Schlatter disease (OSD) is

inflammation Inflammation (from la, wikt:en:inflammatio#Latin, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or Irritation, irritants, and is a protective response involving im ...

of the

patellar ligament The patellar tendon is the distal portion of the common tendon of the quadriceps femoris, which is continued from the patella to the tibial tuberosity. It is also sometimes called the patellar ligament as it forms a bone to bone connection when t ...

at the

tibial tuberosity The tuberosity of the tibia or tibial tuberosity or tibial tubercle is an elevation on the proximal, anterior aspect of the tibia, just below where the anterior surfaces of the lateral and medial tibial condyles end. Structure The tuberosity o ...

(

apophysitis In the skeleton of humans and other animals, a tubercle, tuberosity or apophysis is a Tubercle, protrusion or eminence that serves as an attachment for skeletal muscles. The muscles attach by tendons, where the enthesis is the connective tissue bet ...

). It is characterized by a painful bump just below the

knee In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia (tibiofemoral joint), and one between the femur and patella (patellofemoral joint). It is the largest joint in the hu ...

that is worse with activity and better with rest. Episodes of pain typically last a few weeks to months. One or both knees may be affected and flares may recur. Risk factors include overuse, especially sports which involve frequent running or jumping. The underlying mechanism is repeated tension on the

growth plate The epiphyseal plate (or epiphysial plate, physis, or growth plate) is a hyaline cartilage plate in the metaphysis at each end of a long bone. It is the part of a long bone where new bone growth takes place; that is, the whole bone is alive, wi ...

of the upper

tibia The tibia (; ), also known as the shinbone or shankbone, is the larger, stronger, and anterior (frontal) of the two bones in the leg below the knee in vertebrates (the other being the fibula, behind and to the outside of the tibia); it connects ...

. Diagnosis is typically based on the symptoms. A

plain X-ray Projectional radiography, also known as conventional radiography, is a form of radiography and medical imaging that produces two-dimensional images by X-ray, x-ray radiation. The image acquisition is generally performed by radiographers, and the i ...

may be either normal or show fragmentation in the attachment area. Pain typically resolves with time. Applying cold to the affected area, rest,

stretching Stretching is a form of physical exercise in which a specific muscle or tendon (or muscle group) is deliberately flexed or stretched in order to improve the muscle's felt elasticity and achieve comfortable muscle tone. The result is a feeling ...

, and strengthening exercises may help. NSAIDs such as

ibuprofen Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that is used for treating pain, fever, and inflammation. This includes painful menstrual periods, migraines, and rheumatoid arthritis. It may also be used to close a patent ductus arte ...

may be used. Slightly less stressful activities such as swimming or walking may be recommended. Casting the leg for a period of time may help. After growth slows, typically age 16 in boys and 14 in girls, the pain will no longer occur despite a bump potentially remaining. About 4% of people are affected at some point in time. Males between the ages of 10 and 15 are most often affected. The condition is named after

Robert Bayley Osgood The name Robert is an ancient Germanic given name, from Proto-Germanic "fame" and "bright" (''Hrōþiberhtaz''). Compare Old Dutch ''Robrecht'' and Old High German ''Hrodebert'' (a compound of ''Hrōþ, Hruod'' ( non, Hróðr) "fame, glory ...

(18731956), an American orthopedic surgeon, and Carl B. Schlatter (18641934), a Swiss surgeon, who described the condition independently in 1903.

Signs and symptoms

Osgood–Schlatter disease causes pain in the front lower part of the knee. This is usually at the ligament-bone junction of the patellar ligament and the

.Çakmak, S., Tekin, L., & Akarsu, S. (2014). Long-term outcome of Osgood-Schlatter disease: not always favorable. Rheumatology International, 34(1), 135–136. The tibial tuberosity is a slight elevation of bone on the

anterior Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position prov ...

and

proximal Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position pro ...

portion of the

. The

patellar tendon The patellar tendon is the distal portion of the common tendon of the quadriceps femoris, which is continued from the patella to the tibial tuberosity. It is also sometimes called the patellar ligament as it forms a bone to bone connection when t ...

attaches the anterior

quadriceps The quadriceps femoris muscle (, also called the quadriceps extensor, quadriceps or quads) is a large muscle group that includes the four prevailing muscles on the front of the thigh. It is the sole extensor muscle of the knee, forming a large ...

muscles to the tibia via the knee cap. Intense knee pain is usually the presenting symptom that occurs during activities such as running, jumping, lifting things, squatting, and especially ascending or descending stairs and during kneeling. The pain is worse with acute knee impact. The pain can be reproduced by extending the knee against resistance, stressing the quadriceps, or striking the knee. Pain is initially mild and intermittent. In the acute phase, the pain is severe and continuous in nature. Impact of the affected area can be very painful. Bilateral symptoms are observed in 20–30% of people.

Risk factors

Risk factors include overuse, especially sports which involve running or jumping. The underlying mechanism is repeated tension on the

of the upper

. It also occurs frequently in male pole vaulters aged 14–22.

Diagnosis

Diagnosis is made based on signs and symptoms.

Ultrasonography

This test can see various warning signs that predict if OSD might occur.

Ultrasonography Ultrasound is sound waves with frequencies higher than the upper audible limit of human hearing. Ultrasound is not different from "normal" (audible) sound in its physical properties, except that humans cannot hear it. This limit varies fr ...

can detect if there is any tissue swelling and

cartilage Cartilage is a resilient and smooth type of connective tissue. In tetrapods, it covers and protects the ends of long bones at the joints as articular cartilage, and is a structural component of many body parts including the rib cage, the neck an ...

swelling. Ultrasonography's main goal is to identify OSD in the early stage rather than later on. It has unique features such as detection of an increase of swelling within the tibia or the cartilage surrounding the area and can also see if there is any new bone starting to build up around the

Types

$Three types of avulsion fractures$ OSD may result in an

avulsion fracture An avulsion fracture is a bone fracture which occurs when a fragment of bone tears away from the main mass of bone as a result of physical trauma. This can occur at the ligament by the application of forces external to the body (such as a fall ...

, with the

separating from the tibia (usually remaining connected to a

tendon A tendon or sinew is a tough, high-tensile-strength band of dense fibrous connective tissue that connects muscle to bone. It is able to transmit the mechanical forces of muscle contraction to the skeletal system without sacrificing its ability ...

ligament A ligament is the fibrous connective tissue that connects bones to other bones. It is also known as ''articular ligament'', ''articular larua'', ''fibrous ligament'', or ''true ligament''. Other ligaments in the body include the: * Peritoneal li ...

). This injury is uncommon because there are mechanisms that prevent strong muscles from doing damage. The fracture on the tibial tuberosity can be a complete or incomplete break. Type I: A small fragment is displaced

ly and does not require surgery. Type II: The

articular surface A joint or articulation (or articular surface) is the connection made between bones, ossicles, or other hard structures in the body which link an animal's skeletal system into a functional whole.Saladin, Ken. Anatomy & Physiology. 7th ed. McGraw- ...

of the tibia remains intact and the fracture occurs at the junction where the secondary center of

ossification Ossification (also called osteogenesis or bone mineralization) in bone remodeling is the process of laying down new bone material by cells named osteoblasts. It is synonymous with bone tissue formation. There are two processes resulting in t ...

and the proximal tibial

epiphysis The epiphysis () is the rounded end of a long bone, at its joint with adjacent bone(s). Between the epiphysis and diaphysis (the long midsection of the long bone) lies the metaphysis, including the epiphyseal plate (growth plate). At the join ...

come together (may or may not require surgery). Type III: Complete fracture (through articular surface) including high chance of meniscal damage. This type of fracture usually requires surgery.

Differential diagnosis

Sinding-Larsen and Johansson syndrome Sinding-Larsen and Johansson syndrome, named after Swedish surgeon Sven Christian Johansson (1880-1959), and Christian Magnus Falsen Sinding-Larsen (1866-1930), a Norwegian physician, is apophysitis of the inferior pole of the patella. It is analog ...

, is an analogous condition involving the

and the lower margin of the

patella The patella, also known as the kneecap, is a flat, rounded triangular bone which articulates with the femur (thigh bone) and covers and protects the anterior articular surface of the knee joint. The patella is found in many tetrapods, such as m ...

bone, instead of the upper margin of the tibia.

Sever's disease Sever's disease, also known as calcaneus apophysitis, is an inflammation at the back of the heel (or calcaneus) growth plate in growing children. The condition is thought to be caused by repetitive stress at the heel. This condition is benign and ...

is an analogous condition affecting the Achilles tendon attachment to the

heel The heel is the prominence at the posterior end of the foot. It is based on the projection of one bone, the calcaneus or heel bone, behind the articulation of the bones of the lower Human leg, leg. Structure To distribute the compressive for ...

Prevention

One of the main ways to prevent OSD is to check the participant's flexibility in their quadriceps and hamstrings. Lack of flexibility in these muscles can be direct risk indicator for OSD. Muscles can shorten, which can cause pain but this is not permanent. Stretches can help reduce shortening of the muscles. The main stretches for prevention of OSD focus on the

hamstrings In human anatomy, a hamstring () is any one of the three posterior thigh muscles in between the hip and the knee (from medial to lateral: semimembranosus, semitendinosus and biceps femoris). The hamstrings are susceptible to injury. In quadrupe ...

and

. Direct stretching of the quadriceps can be painful so the use of

foam rolling A foam roller is a lightweight, cylindrical tube of compressed foam. It may be used for many reasons, including increasing flexibility, reducing soreness, and eliminating muscle knot, muscle knots. Foam rolling is a method of self-myofascial rele ...

for self myofascial release can help gently restore flexibility and range of movement Myofascial release with a foam roller

Osgood Schlatters Exercise Isometric Leg Extensions

Treatment

Treatment is generally conservative with rest, ice, and specific exercises being recommended. Simple pain medication may be used such as

acetaminophen Paracetamol, also known as acetaminophen, is a medication used to treat fever and mild to moderate pain. Common brand names include Tylenol and Panadol. At a standard dose, paracetamol only slightly decreases body temperature; it is inferior ...

(paracetamol), or NSAIDs such as

. Typically symptoms resolve as the growth plate closes. Physiotherapy is generally recommended once the initial symptoms have improved to prevent recurrence. Surgery may rarely be used in those who have stopped growing yet still have symptoms.

Physiotherapy

Recommended efforts include exercises to improve the strength of the gluteals,

hamstring In human anatomy, a hamstring () is any one of the three posterior thigh muscles in between the hip and the knee (from medial to lateral: semimembranosus, semitendinosus and biceps femoris). The hamstrings are susceptible to injury. In quadrupeds, ...

and

gastrocnemius The gastrocnemius muscle (plural ''gastrocnemii'') is a superficial two-headed muscle that is in the back part of the lower leg of humans. It runs from its two heads just above the knee to the heel, a three joint muscle (knee, ankle and subtalar ...

muscles. Bracing or use of an

orthopedic cast An orthopedic cast, or simply cast, is a shell, frequently made from plaster or fiberglass, that encases a limb (or, in some cases, large portions of the body) to stabilize and hold anatomical structures—most often a broken bone (or bones), in ...

to enforce joint immobilization is rarely required and does not necessarily encourage a quicker resolution. However, bracing may give comfort and help reduce pain as it reduces strain on the tibial tubercle.

Surgery

Surgical excision may rarely be required in people who have stopped growing. Surgical removal of the ossicles generally results in good outcomes, with symptoms improvement after several weeks.

Rehabilitation

Rehabilitation focuses on muscle strengthening, gait training, and pain control to restore knee function. Nonsurgical treatments for less severe symptoms include: exercises for strength, stretches to increase range of motion, ice packs, knee tape, knee braces, anti-inflammatory agents, and electrical stimulation to control inflammation and pain.

Quadriceps The quadriceps femoris muscle (, also called the quadriceps extensor, quadriceps or quads) is a large muscle group that includes the four prevailing muscles on the front of the thigh. It is the sole extensor muscle of the knee, forming a large ...

and

exercises are commonly prescribed by rehabilitation experts restore flexibility and muscle strength.

Isometric exercise An isometric exercise is a form of exercise involving the static contraction of a muscle without any visible movement in the angle of the joint. The term "isometric" combines the Greek words ''isos'' (equal) and ''-metria'' (measuring), meaning ...

s, such as isometric

leg extension The leg extension is a resistance weight training exercise that targets the quadriceps muscle (m. quadriceps femoris) in the legs. The exercise is done using a machine called the Leg Extension Machine. There are various manufacturers of these mach ...

s, have been shown to strengthen the knee, reduce pain and inhibition, and help the tissue repair through

Mechanotransduction In cellular biology, mechanotransduction ('' mechano'' + '' transduction'') is any of various mechanisms by which cells convert mechanical stimulus into electrochemical activity. This form of sensory transduction is responsible for a number of ...

. Other exercises can include leg raises, squats, and wall stretches to increase quadriceps and hamstring strength. This helps to avoid pain, stress, and tight muscles that lead to further injury that oppose healing. Education and knowledge on stretches and exercises are important. Exercises should lack pain and increase gradually with intensity. The patient is given strict guidelines on how to perform exercises at home to avoid more injury. Exercises can include leg raises, squats and wall stretches to increase quadriceps and hamstring strength. This helps to avoid pain, stress, and tight muscles that lead to further injury that oppose healing. Knee

orthotics Orthotics ( el, Ορθός, translit=ortho, lit=to straighten, to align) is a medical specialty that focuses on the design and application of orthoses, or braces. An is "an externally applied device used to influence the structural and functio ...

such as patella straps and knee sleeves help decrease force traction and prevent painful

contact by restricting unnecessary movement, providing support, and also adding compression to the area of pain.

Prognosis

The condition is usually self-limiting and is caused by stress on the

that attaches the

quadriceps muscle The quadriceps femoris muscle (, also called the quadriceps extensor, quadriceps or quads) is a large muscle group that includes the four prevailing muscles on the front of the thigh. It is the sole extensor muscle of the knee, forming a large ...

at the front of the

thigh In human anatomy, the thigh is the area between the hip (pelvis) and the knee. Anatomically, it is part of the lower limb. The single bone in the thigh is called the femur. This bone is very thick and strong (due to the high proportion of bone ...

to the

. Following an adolescent growth spurt, repeated stress from contraction of the

is transmitted through the patellar tendon to the immature tibial tuberosity. This can cause multiple subacute

s along with inflammation of the tendon, leading to excess bone growth in the tuberosity and producing a visible lump which can be very painful, especially when hit. Activities such as kneeling may also irritate the tendon. The syndrome may develop without trauma or other apparent cause; however, some studies report up to 50% of patients relate a history of precipitating trauma. Several authors have tried to identify the actual underlying etiology and risk factors that predispose Osgood–Schlatter disease and postulated various theories. However, currently, it is widely accepted that Osgood–Schlatter disease is a traction apophysitis of the proximal tibial tubercle at the insertion of the patellar tendon caused by repetitive micro-trauma. In other words, Osgood–Schlatter disease is an overuse injury and closely related to the physical activity of the child. It was shown that children who actively participate in sports are affected more frequently as compared with non-participants. In a retrospective study of adolescents, old athletes actively participating in sports showed a frequency of 21% reporting the syndrome compared with only 4.5% of age-matched nonathletic controls. The symptoms usually resolve with treatment but may recur for 12–24 months before complete resolution at skeletal maturity, when the tibial epiphysis fuses. In some cases the symptoms do not resolve until the patient is fully grown. In approximately 10% of patients the symptoms continue unabated into adulthood, despite all conservative measures.

Long-term implications

OSD occurs from the combined effects of tibial tuberosity immaturity and quadriceps tightness. There is a possibility of migration of the

ossicle The ossicles (also called auditory ossicles) are three bones in either middle ear that are among the smallest bones in the human body. They serve to transmit sounds from the air to the fluid-filled labyrinth (cochlea). The absence of the auditory ...

or fragmentation in Osgood-Schlatter patients. The implications of OSD and the

of the

tubercle In anatomy, a tubercle (literally 'small tuber', Latin for 'lump') is any round nodule, small eminence, or warty outgrowth found on external or internal organs of a plant or an animal. In plants A tubercle is generally a wart-like projection ...

can lead to functional limitations and pain for patients into adulthood. Of people admitted with OSD, about half were children who were between the ages of 1 and 17. In addition, in 2014, a case study of 261 patients was observed over 12 to 24 months. 237 of these people responded well to sport restriction and non-steroid

anti-inflammatory agents Anti-inflammatory is the property of a substance or treatment that reduces inflammation or swelling. Anti-inflammatory drugs, also called anti-inflammatories, make up about half of analgesics. These drugs remedy pain by reducing inflammation as op ...

, which resulted in recovery to normal athletic activity.

Epidemiology

Osgood–Schlatter disease generally occurs in boys and girls aged 9–16 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. It has been suggested that difference is related to a greater participation by boys in sports and risk activities than by girls. Osgood Schlatter's disease resolves or becomes asymptomatic in the majority of cases. One study showed that 90% of reported patients had symptom resolution in 12–24 months. Because of this short symptomatic period with most patients, the number of people who become diagnosed is a fraction of the true number. For adolescents between the ages of 12–15, there is a disease prevalence of 9.8% with a greater 11.4% in males and 8.3% in females. Osgood-Schlatter's disease presents bilaterally in a range of about 20%-30% of patients. It was found that the leading cause for the incidence of the disease was regular sport practicing and shortening of the rectus femoris muscle in adolescents that were in the pubertal phase. For there is a 76% prevalence of patients with a shortened rectus femoris in those who have the Osgood-Schlatter's disease. This risk ratio shows the anatomical relationship between the tibial tuberosity and the quadriceps muscle group, which connect through the patella and its ligamentous structures. In a survey of patients with the diagnosis, 97% reported to have pain during palpation over the tibial tuberosity. The high risk ratio with people with the disease and palpatory pain is likely the reason that the number one diagnosis method is with physical examination, rather than imaging as most bone pathologies are diagnosed. Research suggests that Osgood-Schlatter's disease also increases the risk of tibial fractures. It's possible that the rapid tuberosity bone development and other changes to the proximal aspect of the knee with those who have the disease is the culprit to the increased risk. Because increased activity is a risk factor for developing Osgood-Schlatter's, there is also research that may suggest children and adolescents with

ADHD Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by excessive amounts of inattention, hyperactivity, and impulsivity that are pervasive, impairing in multiple contexts, and otherwise age-inapp ...

are at higher risk. Increased activity and stress on the tibial tuberosity would be greater in a more active population in the 9-16 age bracket, but this study was still not conclusive as to which aspect of ADHD was the cause of the higher incidence.

References

External links

{{DEFAULTSORT:Osgood-Schlatter Disease Chondropathies Inflammations Knee injuries and disorders Wikipedia medicine articles ready to translate Wikipedia emergency medicine articles ready to translate