Osgood–Schlatter disease

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Osgood-Schlatter disease
Classification and external resources
Radiograph of human knee with Osgood–Schlatter disease.png
Lateral radiograph of the knee demonstrating fragmentation of the tibial tubercle with overlying soft tissue swelling.
ICD-10 M92.5
ICD-9 732.4
DiseasesDB 9299
MedlinePlus 001258
eMedicine emerg/347 orthoped/426 radio/491 sports/89

Osgood–Schlatter disease or syndrome (also known as Apophysitis of the tibial tubercle, or knobby knees) is an irritation of the patellar ligament at the tibial tuberosity.[1] It is characterized by painful lumps just below the knee and is most often seen in young adolescents. Risk factors may include overzealous conditioning (running and jumping), but adolescent bone growth is at the root of it.

Location[edit]

Osgood–Schlatter disease occurs at the tendon-bone junction of the patellar tendon and the tibial tuberosity.[2] The tibial tuberosity is a slight elevation of bone on the anterior, proximal portion of the tibia. The patellar tendon attaches the anterior quadriceps muscles to the tibia.[3] OSD takes place just below the kneecap.

Boney Prominence on a 24-year-old male with Osgood-Schlatter disease.

Cause[edit]

Osgood–Schlatter disease generally occurs in boys and girls aged 9–16[4] 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.[5]

Differential diagnosis[edit]

Sinding-Larsen and Johansson syndrome,[6] is an analogous condition involving the patellar tendon and the lower margin of the patella bone, instead of the upper margin of the tibia. Sever's disease is a similar condition affecting the heel.

Avulsion Fractures[edit]

If Osgood Schlatter's goes untreated, an avulsion fracture can occur. This is when the tibial tuberosity breaks apart from the tibia (usually remaining connected to a tendon or ligament). This injury is uncommon because our brains set limitations preventing our strong muscles from doing any damage to our bodies. Mechanisms of fracture are due to a violent eccentric contraction of the quadriceps muscles (ie push-off or landing while jumping).[7] The fracture on the tibial tuberosity can be a complete or incomplete break away (complete usually requires surgery while incomplete can be treated with rehab or RICE).

Three types of avulsion fractures.

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

Type II: The articular surface remains together and the fracture occurs at the junction where the secondary center of ossification and the proximal tibial epiphysis come together (may or may not require surgery)

Type III: Total break (through articular surface) including high change of meniscal damage that usually requires surgery

Prognosis[edit]

The condition is usually self-limiting and is caused by stress on the patellar tendon that attaches the quadriceps muscle at the front of the thigh to the tibial tuberosity. Following an adolescent growth spurt, repeated stress from contraction of the quadriceps is transmitted through the patellar tendon to the immature tibial tuberosity. This 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, 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.[8] In another study, Attention deficit hyperactivity disorder was reported as a risk factor for Osgood–Schlatter disease. The authors claimed that 75% of patients with Osgood–Schlatter disease had also Attention deficit hyperactivity disorder.http://link.springer.com/article/10.1007%2Fs00402-013-1789-3 Intense knee pain is usually the presenting symptom that occurs during activities such as running, jumping, 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 mild and intermittent initially. 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 patients

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.[9]

Prevalence[edit]

In the year 2011, the Nationwide Inpatient Sample from HCUP (Healthcare Cost and Utilization Project) noted that 100% of patients admitted with OSD were discharged from the hospital. Out of the 100%, about half were children who were between ages of 1-17. In 2010, the Nationwide Inpatient Sample recorded that about 53% of all patients admitted and discharged in the hospital with OSD were also between ages of 1-17. In addition, in 2014, a case study of 261 patients was observed over 12 to 24 months. 237 of these patients responded well to sport restriction and nonsteroid anti-inflammatory agents, which resulted in recovery to normal athletic activity.[10]

This graph represents the total amount of subjects that were discharged from the hospital with OSD within the years of 2008 and 2011. 100% of patients admitted were discharged, and each year showed that males obtained the disease more frequently than females. any description

The condition is named after Robert Bayley Osgood (1873-1956), an American Orthopedic surgeon and Carl B. Schlatter, (1864-1934), a Swiss surgeon who described the condition independently in 1903.[11]

Long-term implications[edit]

OSD occurs from the combined affects of tibial tuberosity immaturity and quadriceps tightness.[3] There is a possibility of migration of the ossicle or fragmentation in Osgood-Schlatter patients.[2] The implications of OSD and the ossification of the tubercle can lead to functional limitations and pain for patients into adulthood.[12]

Prevention[edit]

Stretches[edit]

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.[13] Stretches can help reduce shortening of the muscles. The main stretches for prevention of OSD focus on the hamstrings and quadriceps.[14]

Ultrasonography[edit]

This test can see various warning signs that predict if OSD might occur. Some of the things that ultrasonography can detect if there is any swelling that has occurred within the tissue as well as cartilage swelling.[15] 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 tibial tuberosity.

This picture is an example of how to stretch the quadriceps muscle.

Treatment[edit]

25 year old male with Osgood-Schlatter disease.
Male with Osgood-Schlatter disease

Diagnosis is made clinically,[16] and treatment is conservative with RICE (Rest, Ice, Compression, and Elevation), and if required acetaminophen (paracetamol), ibuprofen and/or Co-Codamol or stronger if in 'acute phase' & (the pain is severe and continuous in nature). The condition usually resolves in 2–3 years on average.[16]

Bracing or use of an orthopedic cast to enforce joint immobilization is rarely required and does not necessarily give quicker resolution. Sometimes, however, bracing may give comfort and help reduce pain as it reduces strain on the tibial tubercle.[17] Surgical excision may rarely be required in skeletally mature patients.[9] In chronic cases that are refractory to conservative treatment, surgical intervention yields good results, particularly for patients with bony or cartilaginous ossicles. Surgery is usually a good idea for patients that will no longer grow but the knee is still affected by Osgood-Schlatters disease. Excision of these ossicles produces resolution of symptoms and return to activity in several weeks. After surgery, it is common for lack of blood flow to below the knees and to the feet. This may cause the loss of circulation to the area, but will be back to normal again shortly. A high pain may come and go every once in a while, due to the lack of blood flow. If this happens, sitting down will help the pain decrease. Removal of all loose intratendinous ossicles associated with prominent tibial tubercles is the procedure of choice, both from the functional and the cosmetic point of view.[18] According to one study, in the great majority of young adults, the functional outcome of surgical treatment of unresolved Osgood–Schlatter disease is excellent or good, the residual pain intensity is low, and postoperative complications or subsequent reoperations are rare.[19]

Steven Gerrard, Rafael Nadal, Paul Scholes, Danny Welbeck, Stephen Ireland, Jeff Hendrick, and Stu Hayes are sportsmen who have recovered from this condition.[20] The French tennis player, Gaël Monfils wears patella bands in an attempt to combat the condition.[21]

The disease gives pain so it will be difficult to exercise during the start of the symptoms, so physiopherapy after the worst of the swelling is recommended.

Icing the knee can also help prevent swelling, reduce pain and reduce irritation.

Rehabilitation[edit]

Rehabilitation focuses on muscle strengthening, gait training, and pain control to restore knee function.[22] 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 and hamstring exercises prescribed by rehabilitation experts restore flexibility and muscle strength.

Straight leg raises help strengthen the quadriceps without the need to bend the knee. The knee should be kept straight, legs should be lifted and lowered slowly, and reps should be held for three to five seconds.

Client education and knowledge on stretches and exercises is 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.[23] 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 such as patella straps and knee sleeves help decrease force traction and prevent painful tibia contact by restricting unnecessary movement, providing support, and also adding compression to the area of pain. Medical injections to the patellar area such as Hyperosmolar Dextrose injections are effective and safe for treating tendon and cartilage degeneration.[24]

References[edit]

  1. ^ Nowinski RJ, Mehlman CT (1998). "Hyphenated history: Osgood-Schlatter disease". Am J. Orthop. 27 (8): 584–5. PMID 9732084. 
  2. ^ a b Çakmak, S., Tekin, L., & Akarsu, S. (2014). Long-term outcome of Osgood-Schlatter disease: not always favorable. Rheumatology International, 34(1), 135-136.
  3. ^ a b Nakase, J., Aiba, T., Goshima, K., Takahashi, R., Toratani, T., Kosaka, M., & ... Tsuchiya, H. (2014). Relationship between the skeletal maturation of the distal attachment of the patellar tendon and physical features in preadolescent male football players. Knee Surgery, Sports Traumatology, Arthroscopy, 22(1), 195-199.
  4. ^ Yashar A, Loder RT, Hensinger RN (1995). "Determination of skeletal age in children with Osgood-Schlatter disease by using radiographs of the knee". J Pediatr Orthop 15 (3): 298–301. doi:10.1097/01241398-199505000-00006. PMID 7790482. 
  5. ^ Vreju F, Ciurea P, Rosu A (December 2010). "Osgood-Schlatter disease--ultrasonographic diagnostic". Med Ultrason 12 (4): 336–9. PMID 21210020. 
  6. ^ Sinding-Larsen and Johansson syndrome at Who Named It?
  7. ^ Ogden, John A; Southwich, Wayne O (May 1976). "Osgood-Schlatter's Disease and Tibial Tuberosity Development". Clinical Orthopaedics & Related Research 116 (116): 180–189. PMID 1277640. 
  8. ^ Kujala UM, Kvist M, Heinonen O (1985). "Osgood-Schlatter's disease in adolescent athletes. Retrospective study of incidence and duration". Am J Sports Med 13 (4): 236–41. doi:10.1177/036354658501300404. PMID 4025675. 
  9. ^ a b Gholve PA, Scher DM, Khakharia S, Widmann RF, Green DW (2007). "Osgood Schlatter syndrome". Curr. Opin. Pediatr. 19 (1): 44–50. doi:10.1097/MOP.0b013e328013dbea. PMID 17224661. 
  10. ^ Bloom, J (2004). What is the best treatment for Osgood-Schlatter disease? Journal of Family Practice, vol 53(2), p153-156.
  11. ^ Osgood-Schlatter disease at Who Named It?
  12. ^ Kabiri, L., Tapley, H., & Tapley, S. (2014). Evaluation and conservative treatment for Osgood-Schlatter disease: A critical review of the literature. International Journal Of Therapy & Rehabilitation, 21(2), 91-96.
  13. ^ Lucena, G. L., Gomes, C. A., & Guerro R. O. (2010). Prevelance and Associated Factors of Osgood-Schlatter Syndrome in a Population-Based Sample of Brazilian Adolescents. The American Journal of Sports Medicine, 39, 415-420. doi:10.1177/0363546510383835
  14. ^ Kabiri, L., Tapley, H., & Taplay, S. (2014). Evaluation and conservative treatment for Osgood-Schlatter disease: A critical review of the literature. International Journal of Therapy and Rehabilitation, 21, 91-96.
  15. ^ Nakase, J., Aiba, T., Goshisma, K., Takahashi, R., Toratani, T., Kosaka, M., Ohashi, Y. & Tsuchiya, H. (2014). Relationship between the skeletal maturation of the distal attachment of the patellar tendon and physical features in preadolescent male football players. Knee Surgery Sports Traumatol Arthrosc, 22, 195-199. doi:10.1007/500167-012-2353-3
  16. ^ a b Cassas KJ, Cassettari-Wayhs A (2006). "Childhood and adolescent sports-related overuse injuries". Am Fam Physician 73 (6): 1014–22. PMID 16570735. 
  17. ^ Engel A, Windhager R (1987). "[Importance of the ossicle and therapy of Osgood-Schlatter disease]". Sportverletz Sportschaden (in German) 1 (2): 100–8. doi:10.1055/s-2007-993701. PMID 3508010. 
  18. ^ O. Josh Bloom and Leslie Mackler (February 2004). "What is the best treatment for Osgood-Schlatter disease?" (pdf). Journal of Family Practice 53 (2). 
  19. ^ Hariri, S.; York, S. C.; O'Connor, M. I.; Parsley, B. S.; McCarthy, J. C. (2011). "Career Plans of Current Orthopaedic Residents with a Focus on Sex-Based and Generational Differences". The Journal of Bone and Joint Surgery 93 (5): e16. doi:10.2106/JBJS.J.00489. PMID 21368070. 
  20. ^ Simply the best. Guardian. 18 May 2008
  21. ^ Gael could miss French Open. Sky Sports. 21 April 2009
  22. ^ Baltaci, H., Ozer, V., and Tunay, B. (2004). Rehabilitation of avulsion fracture of the tibial tuberosity. Knee Surgery, Sports Traumatology, Arthroscopy. 12, 115-118.
  23. ^ Baltaci, H., Ozer, V., and Tunay, B. (2004). Rehabilitation of avulsion fracture of the tibial tuberosity. Knee Surgery, Sports Traumatology, Arthroscopy. 12, 115-118.
  24. ^ Topol, G. A., Podesta, L. A., Reeves, K. D., Raya, M. F., Fullerton, B. D., and Yeh, H. (2011). Hyperosmolar Dextrose Injection for Recalcitrant Osgood-Schlatter Disease. Pediatrics. 128 (5), e1-e8.