Osgood Schlatter’s
Where is it painful for a client with Osgood Schlatter's?
Classical patient features for Osgood Schlatter's
Age: Only seen in childhood/adolescence 10-15
Gender: Most common in boys (12-15) compared to females (10-12)
Sport: increased prevalence in sports with high tendon load (plyometric) including basketball(30-35%), volleyball (40%), netball, highjump, long jump, triple jump, soccer(10-15%), football
Area of symptoms for Osgood Schlatter's
– More commonly ipsilateral but can be bilateral
– Localised to the tibial tuberosity, may have some symptoms at the insertion of the patella tendon however will not report any close to the inferior pole of the patella
Characteristics of symptoms for a client with Osgood Schlatter's
– Very localised
– “pulling type pain”
– Very sharp with activity
Typical activity capability/restriction for Osgood Schlatter's
– Progressive with restriction with activities that require high spring loads of the lower limb
– Limitations in running, jumping, hopping, change of direction and acceleration
– Inhibit or reduced performance in sport
Behaviour of symptoms for Osgood Schlatter's
Agg: jumping, change of direction, decelerating, decline (stairs/walking) running, sitting with knees bent, crossing legs kneeling
Ease: sit with legs out straight or laying down, rest, NSAIDs
24 hour OS: progressive worsening with activity, progressive resolution with rest
Typical history of a client with Osgood Schlatter's
– Occurs with adolescents going through a growth spurt
– Can be insidious or occur after trauma (commonly an activity with high spring load ie high jump)
– Will progressively worsen with activity and performance will deteriorate
– Onset with energy-storing loads
– Check for other apophysis injuries
Pathobiological mechanisms underlying Osgood Schlatter's
– Nociceptive with all presentations
– Unlikely to have much nociplastic pain as prognosis ~ 6 weeks in majority of cases and normally quick resolution of symptoms
– If avulsion and more strict immobilisation are required start to consider nociplastic influences
Proposed pathology for Osgood Schlatter's
– Excessive traction being placed on the apophysis of the tibial tuberosity vis the patella tendon
– Can lead to osteochondritis lesion on the tibial tuberosity
– Note poor evidence into the exact etiology
– With acute trauma and as the growth plate weak region is susceptible to boney injury
Physical impairments & associated structure/tissue sources (ie P/E findings)
Local:
– Tenderness on palpation at the superior aspect of the tibial tuberosity
– knee extension // pain on contraction and or reduced strength
– quads sensitivity and/or wastage
– Increased prominence of the tibial tuberosity // if progressed symptomatology
– may have some local swelling, no joint swelling
Typical contributing factors to patella tendinopathy
Local:
– Tenderness on palpation at the superior aspect of the tibial tuberosity
– knee extension // pain on contraction and or reduced strength
– quads sensitivity and/or wastage
– Increased prominence of the tibial tuberosity // if progressed symptomatology
– may have some local swelling, no joint swelling
Remote:
– glutes sensitivity to palpation
– femoral nerve sensitivity
– Increased prevalence of reduced strength in other LL muscles (calves, quads, glutes)
– tightness in anterior and lateral hip compartments
Functional:
– Tip: therapist should sequentially increase tendon load with functional activities (ie DL squat, SL squat, jumping, hopping, plyos)
– Will get worse with progressive loading // no warm-up effect
Typical contributing factors for Osgood Schlatter's
– Reduced length of rectus femoris
– Reduced length of the iliopsoas
– Reduced length of hamstrings
– High body weight
– Knee extensor strength
Relevant precautions/ contraindications to P/E and treatment
– Severity and irritability
– Consider avulsion fracture if highly irritable and acute onset of symptoms
Relevant diagnostic imaging for Osgood Schlatter's
– X-ray may be directed to rule out an apophyseal fracture
– Ultrasound has some benefit on pathology changes however not much value
– MRI gold standard
Typical prognosis for Osgood Schlatter's
– the majority of adolescents get full symptom resolution within 6 weeks
– in more extreme cases the patient may need activity modification for up to 6 months
– Rare: some cases reported fragmentation at the tibial tuberosity when not managed appropriately // will need more extreme management and return to play between 12 to 18 months
Differential diagnosis for patella tendinopathy
– Infrapatellar bursitis // compression and inflammatory signs
– PFPS // PFJ assessment, compression with wind up
– Fat Pad // palpation and Hoffa’s test
– Referred from hip // clear hip tests
– Referral from Lx // neurological and lumbar spine assessment
Imaging
– avulsion of the patella tendon
– Tib plateau fracture
– Stress fracture of the patella
– Osteochondritis Desiccans
Subjective exam special questions
– Cancer
– patella instability (dislocations)
Management/treatment selection of Osgood Schlatter's
High-level evidence:
Relative load reduction:
– specific to the adolescents agg activities
– progressive increase in load with the return to activities
– full return to sport within 6 weeks for the majority of patients
Low level of evidence for rehabilitation // secondary to success with just relative rest
Exercise
– Strengthening exercises (quads)
– progressive increase in loading throughout rehab protocol and incorporate with a return to sport
Note: reduction in physical activity levels does not seem to be associated with pain resolution
No evidence (but makes sense)
– for mobility programming including hamstring, quads, hip flexors as they are all risk factors
Differential diagnosis for Osgood Schlatter's
– Infrapatellar bursitis // compression and inflammatory signs
– PFPS // PFJ assessment, compression with wind up
– Fat Pad // palpation and Hoffa’s test
– Referred from hip // clear hip tests
– Referral from Lx // neurological and lumbar spine assessment
Imaging
– avulsion of the patella tendon
– Tib plateau fracture
– Stress fracture of the patella
– Osteochondritis Desiccans
Subjective exam special questions
– Cancer
– patella instability (dislocations)
References
Antich, T.J. and Brewster, C.E., 1985. Osgood-schlatter disease: review of literature and physical therapy management. Journal of Orthopaedic & Sports Physical Therapy, 7(1), pp.5-10.
Bahr R. The IOC manual of sports injuries. 1st ed. Sweden: International Olympic Commitee; 2012.
Brukner P, Khan K. Clinical sports medicine (volume 1 injuries). 5th ed. Australia: McGraw-Hill Education; 2017.
Neuhaus, C., Appenzeller-Herzog, C. and Faude, O., 2021. A systematic review on conservative treatment options for OSGOOD-Schlatter disease. Physical Therapy in Sport.
Gholve, P.A., Scher, D.M., Khakharia, S., Widmann, R.F. and Green, D.W., 2007. Osgood schlatter syndrome. Current opinion in pediatrics, 19(1), pp.44-50.
Nakase, J., Goshima, K., Numata, H., Oshima, T., Takata, Y. and Tsuchiya, H., 2015. Precise risk factors for Osgood–Schlatter disease. Archives of orthopaedic and trauma surgery, 135(9), pp.1277-1281.
Uzunov, V., 2008. A look at the pathophysiology and rehabilitation of Osgood-Schlatter Syndrome. Gym Coach, 2, pp.39-45.