Long-term functional and sonographic outcomes in Osgood-Schlatter disease

A comprehensive MRI investigation to identify potential biomarkers of Osgood Schlatter disease in adolescents: A cross sectional study comparing Osgood Schlatter disease with controls

BACKGROUND

Osgood-Schlatter disease (OSD) is the most common knee pain complaint among adolescents playing sports. Despite this, there remains controversy over the pathophysiology and whether specific anatomical characteristics are associated with OSD.

PURPOSE

This study aimed to systematically and comprehensively characterize adolescents with OSD using magnetic resonance imaging (MRI) compared to pain-free controls, including both tissue abnormalities that may be associated with OSD, as well as anatomical characteristics. A secondary objective was to identify potential imaging biomarkers associated with pain.

STUDY DESIGN

Cross-sectional study.

METHODS

Adolescents with OSD and controls were recruited from 2020 to 2022. Following a clinical exam, demographics, pain, sports participation, and Tanner stage were collected. Knee MRI was conducted on the participants' most symptomatic knee (OSD) or the dominant leg (controls).

RESULTS

Sixty-seven adolescents (46 with OSD and 30 controls) were included. 80% of participants with OSD had at least one tissue alteration compared to 54% of controls. Compared to controls, OSD had 36.3 (95%CI 4.5 to 289.7) higher odds of bony oedema at the tibial tuberosity, and 32.7 (95%CI 4.1 to 260.6) and 5.3 (95%CI 0.6 to 46.2) higher odds of bony oedema at the  tibial epiphysis and metaphysis respectively. Participants with OSD also had higher odds of fluid/oedema at the patellar tendon (12.3 95%CI 3.3 to 46.6), and superficial infrapatellar bursitis (7.2).  Participants with OSD had a more proximal tendon attachment (mean tibial attachment portion difference, -0.05, 95% CI: -0.1 to 0.0, p = 0.02), tendon thickness (proximal mean difference, -0.09, 95% CI: -0.4 to 0.2, p = 0.04; distal mean difference, -0.6, 95% CI: -0.9 to -0.2, p = 0.01). Those with bony/tendon oedema had 1.8 points (95% CI: 0.3 to 3.2) higher pain on palpation than those without (t = -2.5, df = 26.6, p = 0.019), but there was no difference between these groups in a functional single leg pain provocation.

CONCLUSION

Adolescents with OSD present with tissue and structural abnormalities on MRI that differed from age-matched controls. The majority had findings in the patellar tendon and bone, which often co-occurred. However, a small proportion of OSD also presents without alterations. It appears these findings may be associated with clinical OSD-related pain on palpation of the tibial tuberosity.

CLINICAL RELEVANCE

Our highlight the pathophysiology on imaging, which has implications for understanding the mechanism and treatment of OSD.

Self-management including exercise, education and activity modification compared to usual care for adolescents with Osgood-Schlatter (the SOGOOD trial): protocol of a randomized controlled superiority trial

BACKGROUND

Osgood-Schlatter is the most frequent growth-related injury affecting about 10% of physically active adolescents. It can cause long-term pain and limitations in sports and physical activity, with potential sequela well into adulthood. The management of Osgood-Schlatter is very heterogeneous. Recent systematic reviews have found low level evidence for surgical intervention and injection therapies, and an absence of studies on conservative management. Recently, a novel self-management approach with exercise, education, and activity modification, demonstrated favorable outcomes for adolescents with patellofemoral pain and Osgood-Schlatter in prospective cohort studies.

AIM

The aim of this trial is to assess the effectiveness of the novel self-management approach compared to usual care in improving self-reported knee-related function in sport (measured using the KOOS-child 'Sport/play' subscale) after a 5-month period.

METHODS

This trial is a pragmatic, assessor-blinded, randomized controlled trial with a two-group parallel arm design, including participants aged 10-16 years diagnosed with Osgood-Schlatter. Participants will receive 3 months of treatment, consisting of either usual care or the self-management approach including exercise, education, and activity modification, followed by 2 months of self-management. Primary endpoint is the KOOS-child 'Sport/play' score at 5 months. This protocol details the planned methods and procedures.

DISCUSSION

The novel approach has already shown promise in previous cohort studies. This trial will potentially provide much-needed level 1 evidence for the effectiveness of the self-management approach, representing a crucial step towards addressing the long-term pain and limitations associated with Osgood-Schlatter.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT05174182. Prospectively registered December 30th 2021. Date of first recruitment: January 3rd 2022. Target sample size: 130 participants.

The mid-term effect of Osgood-Schlatter disease on knee function in young players from elite soccer academies

BACKGROUND

The aim of the study was to evaluate the effect of Osgood-Schlatter disease (OSD) on knee joint function in elite young soccer players. Our hypothesis was that knee joint function in elite young soccer players was impaired following OSD compared with soccer players with no history of OSD.

METHOD

In young male soccer players (n = 36) from elite academies (mean ±SD, age: age: 15,3 ± 1,7 years; height: 1,7 ± 0,06 m; weight: 63,5 ± 8 kg; BMI: 20,7 ± 2). The duration between the completion of treatment or the last complaint to the study commencement was 31 ± 19 months.

RESULTS

The average treatment duration of OSD among study participants was 18,5 ± 12 days (95%, 14-23), and the disease most often manifested in winter and spring, 33% and 31% of cases, respectively. Soccer players with a history of OSD were statistically different in IKDC and KOOS scores when compared with soccer players with no previously reported OSD (Mann-Whitney, p < 0,0001). The soccer players with a history of OSD also use NSAIDs more frequently compared with soccer players with no history of OSD (36% vs 3% respectively).

CONCLUSIONS

OSD among young soccer players, when symptoms resolve, continue about one month and they can return to regular training and participation in games. Wherein, the negative effects in knee joint function were significantly more likely in soccer players with previous OSD history when compared with their peers with no history of OSD. While oral non-steroidal anti-inflammatory drugs was also more widely employed in soccer players with previous OSD history. Potentially this may lead to performance deficits and disadvantages for their future careers and coaches and physicians should be informed.

The development of an informative leaflet for children and adolescents suffering from Osgood-Schlatter disease

The mainstay in the treatment of Osgood-Schlatter Disease (OSD) is guidance on activity modification alongside exercises. The purpose of this study was to create an informative leaflet for patients with OSD, based on evidence and stakeholders perspectives. A synthesis of the literature, including national reference work, clinical research, and systematic reviews informed the initial leaflet. Twelve children with OSD and four clinical experts provided feedback through semi-structured interviews. After incorporating stakeholder input, the leaflet 'Osgood-Schlatter-Information and guidance' was developed. This provides a resource to assist the provision of information and translation of the current evidence.

Eccentric contractions during downhill running induce Osgood‒Schlatter disease in the tibial tuberosity in rats: a focus on histological structures

Osgood-Schlatter disease (OSD), a condition that affects adolescents, causes inflammation, pain, and prominence at the tibial tuberosity. The causes of OSD are not well understood, but eccentric contractions in the quadriceps have been suggested as a possible factor. To investigate this, a study was conducted in which 24 rats were divided into two groups: the downhill treadmill running (DR) group and the control (CO) group. The DR group underwent a preliminary running program for 1 week, followed by a main running program for 3 weeks. The results showed that the deep region of the tibial tuberosity in the DR group was larger than that in the CO group, and inflammatory cytokines involved in gene expression were upregulated in the DR group. The anterior articular cartilage and deep region in the DR group were also immunoreactive to substance P. Additionally, high-activity chondrocytes of small size were observed in the non-calcified matrix. Thus, the DR group exhibited symptoms similar to OSD, including inflammation, pain, and prominence. These findings suggest that eccentric contractions in the quadriceps may play a role in the development of OSD. Further research is needed to better understand the pathophysiology of this condition and develop effective treatment options.

Can we reduce injury risk during the adolescent growth spurt? An iterative sequence of prevention in male academy footballers

Background: The adolescent growth spurt is associated with an increased risk of injury in young athletes.Aim: This study aimed to use an interdisciplinary collaboration between technical coaches, sports scientists, and medical staff to mitigate this risk.Subjects and methods: 77 male academy footballers were followed across two seasons. At-risk players were identified using somatic maturity status and growth rate in stature and the lower limbs, using thresholds of 88% to 92.8% of predicted adult stature, ≥7.2 cm/year, and ≥3.6 cm/year, respectively. During the 2019-20 season, players with symptoms of a growth-related injury or two of three risk factors were included in an intervention strategy that included modified training load, football-specific skills, balance, coordination and landing drills, and an individualised strength program.Results: For players with the three risk factors, there was a significant reduction in the incidence (rate ratio [RR] = 0.14 (5.2 per 1000h → 0.8 per 1000h, p = 0.05) and burden (RR = 0.08 (216 per 1000h → 17 per 1000h, p = 0.02) between the seasons. For players with ≤2 risk factors, there were no significant differences in injury risk between the baseline and intervention seasons.Conclusion: Overall, it may be possible to mitigate injury incidence and burden during the adolescent growth spurt in high-risk athletes.

Osgood-Schlatter Disease: Appearance, Diagnosis and Treatment: A Narrative Review

Osgood-Schlatter disease is the most common osteochondritis of the lower limb in sport-practicing children and adolescents. Its manifestation usually coincides with the appearance of the secondary ossification center of the tibia and is linked to the practice of sports with an explosive component. In the present study, a review of the factors related to its appearance, diagnosis and treatment was carried out. Its appearance seems to be multifactorial and related to multiple morphological, functional, mechanical and environmental factors. Given all the above, risk factor reduction and prevention seem the most logical strategies to effectively prevent the appearance of the condition. In addition, it is essential to create prevention programs that can be objectively assessed and would allow to stop the progress of the pathology, particularly in those sports where high forces are generated on the insertion zone of the patellar tendon at sensitive ages. More studies are needed to clarify which type of treatment is the most appropriate—specific exercises or the usual care treatment.

The Incidence and Management of Osgood-Schlatter Disease in General Practice

Background

Osgood–Schlatter disease (OSD) is a non-traumatic knee problem that is primarily observed in sports-active children and adolescents aged 8–15 years.

Aim

To determine the incidence of OSD and to gain an insight into the management of children and adolescents with OSD in general practice.

Design and setting

A retrospective cohort study was conducted using a healthcare database containing full electronic health records of over 200 000 patients in general practice in and around the Dutch city of Rotterdam.

Method

Patients with a new diagnosis of OSD from 1 January 2012 to 31 December 2017 were extracted using a search algorithm based on International Classification of Primary Health Care coding and search terms in free text. Data on the management of OSD were manually interpreted.

Results

The mean incidence over the study period was 3.8 (95% confidence interval [CI] = 3.5 to 4.2) per 1000 person–years in those aged 8–18 years. Boys had a higher incidence rate of 4.9 (95% CI = 4.3 to 5.5) compared with girls (2.7, 95% CI = 2.3 to 3.2). Peak incidence was at 12 years of age for boys and 11 years for girls. Advice was the most commonly applied strategy (55.1%), followed by rest (21.0%), referral for imaging (19.5%), and physiotherapy (13.4%).

Conclusion

To the authors’ knowledge, for the first time the incidence of OSD has been calculated using GP electronic medical files. There is a discrepancy, especially for imaging and referral to a medical specialist, between the current Dutch general practice guidelines and how GPs actually manage the condition in clinical practice.

The Osgood-Schlatter disease: a large clinical series with evaluation of risk factors, natural course, and outcomes

PURPOSE

The aims of this prospective study were to define sport specific incidence rates in a large Osgood-Schlatter-disease group, to follow the natural course, and to determine late effects, i.e., changes in sport activities and resting pain.

METHODS

A total of 126 consecutive patients with functional pain in and after physical activity and local TT swelling were included in a longitudinal study. Physical examination, ultrasound, and a lateral X-ray were performed in a standardized clinically common manner. Sport participation, growth rate, BMI, and muscle status were recorded and assigned statistically. Follow-up took place after subsidence of functional pain.

RESULTS

Exactly 101 boys and 25 girls showed a mean age at diagnosis of 12.8 years (boys 13.2, girls 11.4 years) complaining an average period of pain of 6.7 months before diagnosis. A sport distribution displayed 64 football (soccer) players, 18 basketball players, seven athletes in track and field, six martial arts sportsmen, and five handball players, all participating in organized sport clubs, 16 patients in other and ten patients in no sports. The standing leg was affected in 69.6% of all football players, whereas the other disciplines did not show any significance. A total of 105 patients could be followed up after a median of 3.6 years; six of them were still symptomatic. Final outcome could be recorded for 99 patients (79 boys, 20 girls). Osgood-Schlatter disease (OSD) symptoms in or after sport activity were reported to last an average of 19.1 months (3-48 months) without differences according to sex nor sport. Exactly 50% of the patients may expect to be free of functional symptoms after the 16th month, 75% after the 25th month. A total of 78.8% of the patients still complained of persistent but not impairing pain in kneeling or on direct TT contact. Exactly 28.3% of all patients responded having switched their sport activity to other disciplines due to OSD.

CONCLUSION

OSD affects mainly adolescent boys active in football and basketball and represents a structural answer to repeated biomechanical stress. Only in football, the statically dominant side is more prone to develop OSD. Age at onset, growth rate, BMI, and muscle imbalance are not significantly predisposing. OSD runs a self-limiting course without specific treatment.

Is the Prognosis of Osgood-Schlatter Poorer Than Anticipated? A Prospective Cohort Study With 24-Month Follow-up

BACKGROUND

Osgood-Schlatter disease (OSD), an apophyseal injury of the tibial tuberosity, affects up to 1 in 10 adolescents. This condition has previously been assumed to be innocuous and to self-resolve with limited intervention.

PURPOSE

To investigate the 24-month prognosis of OSD and examine if ultrasound (US) classification is associated with outcomes.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

This study included a preregistered prospective cohort of 51 adolescents (aged 10-14 years) diagnosed with OSD who were evaluated for 24 months. The primary outcome at 24-month follow-up was whether participants continued to experience OSD-related knee pain. Baseline US scans were collected and characterized by OSD type (De Flaviis classification) as well as maturation of the tibial tuberosity. Secondary outcomes included sports participation, Knee injury and Osteoarthritis Outcome Score (KOOS) Sport/Recreation subscale, and health-related quality of life (European Quality of Life-5 Dimensions-Youth [EQ-5D-Y]). All participants were invited for re-examination by US at follow-up.

RESULTS

A total of 51 patients preregistered for the study, with 90% (n = 46) available at follow-up. Of these 46 participants, 37% (n = 17) still reported knee pain due to OSD. In this subgroup, the median duration since symptom onset was 42 months (interquartile range, 38-51 months). More than 1 in 5 participants reported stopping sport due to knee pain, and those who continued to experience knee pain reported significantly worse KOOS Sport/Recreation scores at follow-up compared with patients with no knee pain (mean 74 [95% CI, 63-84] vs 91 [95% CI, 85-97]). Participants with continued OSD-related pain also had lower health-related quality of life (mean difference in EQ-5D-Y, 0.11 [95% CI, 0.06-0.13]). Higher De Flaviis classification at baseline was significantly associated with an increased risk of knee pain at 2 years. Diagnostic US at follow-up demonstrated primarily tendon changes (thickening, positive Doppler signal), as well as an ununited ossicle in 32% of participants who underwent US scanning at follow-up.

CONCLUSION

Over one-third of the study participants had knee pain at 2-year follow-up, which was associated with lower sports related function and health related quality of life. This questions the assumption that all patients with OSD experience quick recovery. Participants without any changes on imaging at baseline were less likely to report pain at follow-up.

Nano-Arthroscopic Ultrasound-Guided Excision of Unresolved Osgood-Schlatter Disease

The nano-arthroscopic ultrasound-guided ossicle excision technique is used in the management of an unresolved Osgood-Schlatter disease. The NanoScope is inserted slightly lateral to the proximal patella tendon and moved on between the ossicle and anterior surface of the proximal tibia under ultrasonographic guidance. The 5-mm skin incision is made as a working portal on the medial side of the proximal patella tendon. The proximal border of the ossicle is clearly identified after bursectomy. Then, the ossicles are removed piece by piece using a 2-mm arthroscopic punch. During the resection, the remaining ossicle is continuously confirmed by ultrasound. Finally, the complete excision of the ossicle is shown by the nano-arthroscopic view and ultrasound. The patient is allowed to have a full weight-bearing and an unrestricted range of motion on the day of surgery. Patients are permitted to resume their sports activities without any restriction after 6 weeks. This technique is recommended to athletes who suffer from painful unresolved Osgood-Schlatter disease because of the benefits of it being a minimally invasive surgery with an early postoperative recovery.

Current management strategies in Osgood Schlatter: A cross-sectional mixed-method study

BACKGROUND

Osgood Schlatter disease (OSD) is the most common knee condition in adolescent athletes aged 9-16. Without evidence to guide clinical practice, it is unclear how OSD is managed. The aim of this study was to investigate how international healthcare professionals (general practitioners, physiotherapists, rheumatologists, sports and exercise medicine doctors, and orthopedic surgeons) diagnose and manage OSD.

METHODS

This mixed-method study used a convergent parallel design. A quantitative questionnaire and semi-structured interview covered prognosis, diagnosis, treatment, and return to play of adolescents with OSD. For quantitative data, those who reported likely/very likely considered "for" and unlikely/very unlikely "against" (for specific diagnostic/management strategy). Qualitative data analysis used a phenomenological approach.

RESULTS

Two hundred and fifty-one healthcare professionals completed the questionnaire. The most common diagnostic criterion was pain at the tibial tuberosity (97% for). The most common treatments were patient education (99%) and exercise therapy (92%). Other treatment options were more heterogeneous, for example, pain medication (31% for and 34% against). Managing training load (97%), pain intensity (87%), and psychological factors (86%) were considered the most important factors influencing the return to activities. Several themes emerged from the interviews (on N = 20) including imaging, pain management, family, and psychosocial factors influencing prognosis.

CONCLUSION

Diagnosis criteria of OSD were relatively well agreed upon, whereas the triangulation of qualitative and quantitative data showed heterogeneity of treatments. Psychosocial factors including family were highlighted as critical in the management of OSD.

Activity Modification and Knee Strengthening for Osgood-Schlatter Disease: A Prospective Cohort Study

Background:

Osgood-Schlatter disease (OSD) affects 1 in 10 adolescents. There is a lack of evidence-based interventions, and passive approaches (eg, rest and avoidance of painful activities) are often prescribed.

Purpose:

To investigate an intervention consisting of education on activity modification and knee-strengthening exercises designed for adolescents with OSD.

Study Design:

Case series; Level of evidence, 4.

Methods:

This study included 51 adolescents (51% female; age range, 10-14 years) with OSD. The 12-week intervention consisted of an activity ladder designed to manage patellar tendon loading and pain, knee-strengthening exercises, and a gradual return to sport. The primary outcome was the global reporting of change at 12 weeks, evaluated with a 7-point Likert scale (successful outcome was considered “much improved” or “improved”). Additional endpoints were at 4, 8, 26, and 52 weeks. Secondary outcomes included the Knee injury and Osteoarthritis Outcome Score (KOOS), objective strength, and jump performance.

Results:

Adolescents reported a mean pain duration of 21 months at enrollment. After 12 weeks, 80% reported a successful outcome, which increased to 90% at 12 months. At 12 weeks, 16% returned to playing sport, which increased to 69% at 12 months. The KOOS subscores of Pain, Activities of Daily Living, Sport and Recreation, and Quality of Life improved significantly (7-20 points), and there were improvements in knee extension strength (32%; P < .001), hip abduction strength (24%; P < .001), and jumping for distance (14%; P < .001) and height (19%; P < .001) at 12 weeks.

Conclusion:

An intervention consisting of activity modification, pain monitoring, progressive strengthening, and a return-to-sport paradigm was associated with improved self-reported outcomes, hip and knee muscle strength, and jumping performance. This approach may offer an alternative to passive approaches such as rest or wait-and-see, often prescribed for adolescents with OSD.

Registration:

NCT02799394 (ClinicalTrials.gov identifier)

No superiority of dextrose injections over placebo injections for Osgood-Schlatter disease: a prospective randomized double-blind study

PURPOSE

Osgood-Schlatter disease (OSD) is a traction apophysitis of the tibial tuberosity. Patellar tendinopathy and deep infrapatellar bursitis have recently been shown to contribute to pain in patients with OSD. We compared the effects of dextrose injection and saline injection.

METHODS

We performed a clinical trial from April 2012 to January 2016 and included 49 knees from 37 boys and 1 girl (mean age, 12.3 ± 1.1 years) for whom conventional conservative therapy for > 1 month was ineffective. They were randomly assigned to receive double-blind injections of 1% lidocaine (1 mL) with 20% dextrose (1 mL; dextrose group) or 1% lidocaine (1 mL) with saline (1 mL; saline group). Injections were administered monthly for 3 months by a single investigator. The Victorian Institute of Sport Assessment (VISA) score was used to evaluate anterior knee pain.

RESULTS

Overall, 43 knees were included; 6 knees were lost to follow-up. The mean pre-injection VISA scores in the dextrose and saline groups were 58.7 ± 18.3 and 63.4 ± 16.4, respectively. No significant differences were found between the two groups at any time point. The mean VISA score before injections significantly increased at the 1-month follow-up in both groups (P < .01). The injection had no adverse effects.

CONCLUSIONS

We were not able to show the efficacy of dextrose injections compared to that of saline.

LEVEL OF EVIDENCE

Randomized controlled trial. Level I.

Long-term Prognosis and Impact of Osgood-Schlatter Disease 4 Years After Diagnosis: A Retrospective Study

Background:

Knee pain is common during adolescence, with Osgood-Schlatter disease (OSD) being the most frequent condition. Despite this, research regarding the long-term prognosis of OSD is limited.

Purpose:

To evaluate the prognosis 2 to 6 years after the diagnosis of OSD.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

This retrospective cohort study included patients diagnosed with OSD at a single orthopaedic department between 2010 and 2016. Patients were contacted in 2018 and asked to complete a self-reported questionnaire regarding knee pain, knee function (Knee injury and Osteoarthritis Outcome Score [KOOS] Sports/Recreation subscale), Health-related quality of life (HRQoL) (youth version of EuroQol 5 dimensions 3 levels [EQ-5D-3L-Y]), and physical activity.

Results:

Out of 84 patients, 43 responded. Of these, 60.5% (n = 26) reported OSD-related knee pain at follow-up (median follow-up, 3.75 years). The median symptom duration was 90 months (interquartile range, 24-150 months) for those still experiencing knee pain, and 42.9% of these reported daily knee pain. Fifty-four percent with knee pain had reduced their sports participation compared with 35.3% of those without knee pain. KOOS Sports/Recreation subscale scores were significantly lower in those with knee pain compared with those without knee pain (53 [95% CI, 42-63] vs 85 [95% CI, 76-94], respectively). Participants with knee pain reported lower HRQoL (0.71 [95% CI, 0.57-0.84]) compared with those without knee pain (0.99 [95% CI, 0.97-1.00]).

Conclusion:

This study indicates that OSD may not always be self-limiting. The lower self-reported function and HRQoL in those with continued pain may be a consequence of impaired physical activity due to knee pain.

Screening of the Maturity Status of the Tibial Tuberosity by Ultrasonography in Higher Elementary School Grade Schoolchildren

This study aimed to obtain screening data on the maturity status of the tibial tuberosity in schoolchildren of higher elementary school grades for risk management of Osgood-Schlatter disease (OSD). The maturity stages and cartilage thicknesses at the tibial tuberosity were determined by ultrasonography on the occasion of a school-based musculoskeletal examination for 124 grade 5-6 elementary schoolchildren, and their associations with the students' demographic characteristics and OSD were examined. The time-dependent changes of the maturity status of the tibial tuberosity were also examined in grade 5 students (n = 26) by a longitudinal survey. The cross-sectional survey showed that the epiphyseal stage was reached in 89% of girls and 35% of boys. The girls who had experienced menarche (n = 28) were all in the epiphyseal stage and had a decreased cartilage thickness (p = 0.004, after adjusting maturity stages). Students with OSD (n = 5) were all girls in the epiphyseal stage, and only two of them had an increased cartilage thickness. During the longitudinal survey, a marked increase in cartilage thickness from the previous measurement was observed in three boys (without clinical symptoms) and a girl who newly developed OSD. Two students with OSD without chronic pain had thin cartilage. In conclusion, for schoolchildren of higher elementary school grades, the risk of OSD is higher among girls with the epiphyseal stage. Cartilage thickness may not contribute to the diagnosis of OSD, since thick cartilage is not very common in OSD. However, cartilage thickness may reflect the status of OSD.

Relationship Between Lower Limb Tightness and Practice Time Among Adolescent Baseball Players With Symptomatic Osgood-Schlatter Disease

Background:

Osgood-Schlatter disease (OSD) is characterized by traction apophysitis of the tibial tuberosity. Few studies on symptomatic and asymptomatic OSD have correlated findings with clinical examination.

Purpose:

To investigate the relationship between lower limb tightness and practice time among adolescent baseball players with symptomatic OSD.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

The study participants were 402 male baseball players (N = 804 knees) with a mean ± SD age of 10.9 ± 1.5 years (range, 7-14 years). Participant age, height, body weight, body mass index, practice time per week, range of motion of the hip and ankle joints, heel-buttock distance (HBD), and straight-legged raise angle were evaluated. Tibial tuberosity development, as assessed with ultrasonography, was classified into 4 stages: cartilaginous, apophyseal, epiphyseal, and bony. Knees that were classified as apophyseal or epiphyseal were investigated. Participants were divided into 3 groups: non-OSD, asymptomatic OSD, and symptomatic OSD.

Results:

Of 400 knees in the apophyseal and epiphyseal stages, 23 knees had asymptomatic OSD, and 11 had symptomatic OSD. Players with symptomatic OSD practiced for significantly longer than the non-OSD group (P = .001) and asymptomatic OSD group (P = .001). Players with symptomatic OSD also had a larger HBD (P = .006) and smaller range of motion regarding internal rotation of hip (P = .023) and dorsiflexion of the ankle (P = .013) than the non-OSD group.

Conclusion:

Players with symptomatic OSD had longer practice times than the non-OSD and asymptomatic OSD players. Symptomatic OSD was also associated with tightness of the lower limbs as assessed by the HBD and range of motion in the hip and ankle joints.

Repair of Patellar Tendon Avulsion from the Tibial Tubercle: Case Report

Introduction:

Pre-existing conditions and surgical interventions, such as those associated with Osgood-Schlatter disease, can lead to atypical patellar tendon ruptures. These cases can present irregularly and be challenging to diagnose. Patellar tendon rupture from the tibial tubercle insertion region is a rare, and currently undocumented condition, requiring surgical intervention to restore knee joint functionality for daily activities. This presentation requires a unique treatment approach, as standard reconstruction techniques do not apply.

Case Report:

A 65-year-old Caucasian male, with a remote history of gout and surgical intervention for symptomatic Osgood-Schlatter disease, suffered sudden hyperflexion with eccentric contraction of the right knee while hiking. The patient presented with massive right knee effusion and significant tenderness over the tibial tubercle, with an inability to extend the knee. After radiographs were inconclusive, magnetic resonance imaging was performed showing a tear of the medial aspect of the distal patellar tendon.

Conclusion:

Surgical intervention for Osgood-Schlatter disease can be a potential risk factor for patellar tendon rupture from the tibial tubercle. Since a variety of surgical interventions for symptomatic Osgood-Schlatter disease exist, it is important to consider the long-term effects and counsel patients on the associated risks of the procedures. Initial diagnosis of patellar tendon rupture can be surprisingly challenging when the presentation is atypical. Attention to detail during physical examination and evaluation of imaging is a necessity for early detection and treatment, which can afford excellent functional outcomes

Pathogenic Factors Associated With Osgood-Schlatter Disease in Adolescent Male Soccer Players: A Prospective Cohort Study

Background:

A previous cross-sectional study reported that pathogenic factors associated with Osgood-Schlatter disease (OSD) in adolescent athletes include increased quadriceps muscle tightness, lower leg malalignment, and development of apophysitis in the tibial tuberosity.

Purpose:

To confirm these pathogenic factors associated with OSD in a longitudinal study with regard to physical function and performance.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

In this study, 37 boys (mean age, 10.2 ± 0.4 years) were recruited from 2 soccer teams at an elementary school. This cohort study was conducted over an observation period of 1 year, with measurements recorded at baseline, followed by screening for OSD every 6 months. Variables evaluated at baseline included physical function (morphometry, joint flexibility, and lower extremity alignment), presence of Sever disease, and kicking motion.

Results:

Pathogenic factors associated with OSD in the support leg of adolescent male soccer players included height, weight, body mass index, quadriceps femoris muscle tightness in the kicking and support legs, and gastrocnemius muscle tightness, soleus muscle tightness, and medial longitudinal arch in the support leg. Additional factors included a diagnosis of Sever disease and distance from the lateral malleolus of the support leg’s fibula to the center of gravity during kicking.

Conclusion:

The onset of OSD was found to be affected by many factors, including developmental stage, physical attributes, and pre-existing apophysitis. In particular, a diagnosis of Sever disease and backward shifting of the center of gravity during kicking increased the risk of the subsequent onset of OSD, suggesting that these factors are very important as a possible focus for interventions.

Therapeutic interventions in children and adolescents with patellar tendon related pain: a systematic review

Objective

Evaluate effectiveness and harms of interventions for patellar tendon related pain in children and adolescents.

Design

Systematic review and meta-analysis.

Data sources

Medline via Pubmed, Embase via OVID, CINAHL via Ebsco, SportDiscus up until 24 November 2017 were searched.

Eligibility criteria for selecting studies

Inclusion criteria were (1) controlled or randomised controlled clinical trials (RCTs), (2) participants with diagnosis of patellar tendon related disorder, (3) participants≤18 years of age at enrolment and (4) published in a peer-reviewed English or Scandinavian language journal.

Results

Of 530 studies identified, eight were included after screening, with three included in data synthesis. To be included in data synthesis, we required studies to have included (and have data available for) a minimum of 10 participants under 18 years. All studies were rated as being at high risk of bias. For adolescents with patellar tendinopathy, one RCT compared eccentric exercises to usual care and found no difference between groups. In adolescents with Osgood-Schlatter disease (OSD), injection of local anaesthetic with dextrose proved superior to either usual care or local anaesthetic alone (three armed RCTs). In a retrospective case controlled study in adolescents with OSD, surgery provided no benefit over conservative management in terms of persistent symptoms and had a higher complication rate.

Conclusion

There is weak evidence to support the use of dextrose injection with local anaesthetic and no evidence to support the use of specific types of exercises to treat children/adolescents with OSD/patellar tendinopathy. Until further evidence arises, clinicians should include load modification and advise on a return to sport based on symptoms.

Intra-articular Large Ossicle Associated to Osgood-Schlatter Disease

Osgood–Schlatter disease (OSD) is known as a self-limiting condition but surgical excision of the ossicles may be required in adults resistant to conservative treatments. The ossicle associated to OSD is generally small and located outside the joint near the tibial tubercle; however, large or intra-articular ossicle has been reported rarely. Here, we report an unusual case of OSD with a separated, large-sized ossicle that protruded into the knee joint and treated by arthroscopy-assisted excision of the ossicle.

Bony Maturity of the Tibial Tuberosity With Regard to Age and Sex and Its Relationship to Pathogenesis of Osgood-Schlatter Disease: An Ultrasonographic Study

BACKGROUND

Although tensile force on an immature tibial tuberosity is considered the main cause of Osgood-Schlatter disease (OSD), the relationship between bony maturity and the pathogenesis of OSD remains obscure.

PURPOSE

To survey the bone maturation process of the tibial tuberosity by age and sex and clarify its relationship to OSD.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 731 Japanese basketball players aged 6 to 14 years were enrolled in this study. Ultrasonographic examination was performed in all participants (1462 knees) to evaluate the bony maturity of the tibial tuberosity by use of the Ehrenborg classification. The age- and sex-specific prevalence of each stage was investigated, and the prevalence of symptomatic OSD and its relationship with bony maturity were also assessed.

RESULTS

The process of bone maturation occurred 1 to 2 years earlier in female participants compared with male participants. Among female participants, 59.2% were already at the epiphyseal stage (stage E) by 10 years of age, and 47.4% were skeletally mature by 14 years. Among male participants, conversely, only 8.0% were at stage E by 10 years of age, and only 13.8% were skeletally mature by 14 years. The overall prevalence of symptomatic OSD was 6.8% (males, 6.4%; females, 7.2%), and the onset was 1 year earlier in the female participants. The prevalence of symptomatic OSD tended to increase with age and bony maturity, significantly increasing from the cartilaginous stage (stage C) to the apophyseal stage (stage A) (odds ratio, 9.48) and from stage A to stage E (odds ratio, 2.22).

CONCLUSION

The tibial tuberosity matures earlier in female participants. The risk of OSD is greater in stage A than stage C and in stage E than stage A. The risk of OSD increases with age in males but not in females.

Reduction Osteotomy of the Prominent Tibial Tubercle After Osgood-Schlatter Disease

PURPOSE

To evaluate the functional and clinical outcome of a new closing-wedge osteotomy for the prominent tibial tubercle after Osgood-Schlatter disease.

METHODS

Between 2010 and 2014, 7 consecutive adults (mean age, 28.6 years; range, 26-35 years) were treated by closing-wedge reduction osteotomy of a painful tibial tubercle. All patients had prior nonsurgical and surgical treatment. Preoperative and postoperative tubercular prominence, Caton-Deschamps index for patellar height, the Kujala Anterior Knee Pain Scale, Lysholm Knee Score as well as visual analog scale score and Tegner activity scores were recorded.

RESULTS

Mean follow-up after reduction osteotomy was 31.3 months (27-41 months). The bony prominence of the tibial tubercle was significantly reduced (mean 8 mm, P < .001) and the Caton-Deschamps index was lowered from 1.29 to 1.09 (P < .001). From preoperative to last follow-up, the Kujala Anterior Knee Pain Scale increased from 54.71 preoperative to 84.71 (P < .001); the Lysholm Knee Score improved from 72.42 to 94.14 (P < .001); the Tegner activity score increased from 3.1 to 5.7 (P < .001), whereas the visual analog scale significantly decreased from 5.8 to 1.2 (P < .001). No complications were recorded, and all patients were satisfied with clinical outcome.

CONCLUSIONS

Closing-wedge osteotomy of the tibial tubercle effectively reduced the bony prominence after Osgood-Schlatter disease and consecutively improved the outcome in terms of knee pain and function. Thus, we can recommend this procedure in selected patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Correlation between Magnetic Resonance Imaging Characteristics of the Patellar Tendon and Clinical Scores in Osgood-Schlatter Disease

Purpose

This study aims to evaluate magnetic resonance imaging (MRI) findings in young adults with symptomatic Osgood-Schlatter disease (OSD) and compare those in young adults without OSD.

Materials and Methods

We compared MRI findings between young adults with OSD (OS group, n=30) and the equivalent number of young adults without OSD (control group). Visual analog scale scores and Kujala scores were evaluated and correlation analysis was performed in the OS group.

Results

In the OS group, MRI revealed that the patellar tendon was attached to the tibia more widely, resulting in a reduced free tendon portion, and more proximally to the articular surface (p<0.001). The correlation analysis between MRI findings and clinical scores showed statistically significant correlations (p<0.01). In the OS group, 43% presented with patellar tendinopathy or bone marrow edema at the distal attachments.

Conclusions

Compared to the control group, the relatively small free portion and relatively proximal attachment of the patellar tendon were observed with MRI in the OS group. The free portion of the patellar tendon was positively correlated with the clinical scores. Patellar tendinopathy was also frequently encountered in the OS group.

Endoscopic Management of Osgood-Schlatter Disease

Osgood-Schlatter disease is a common cause of anterior knee pain in sports-practicing adolescents. The long-term outcomes have not always been favorable, and some adolescents have persisting knee pain into adulthood. Excision of the ossicle together with debridement of the tibial tuberosity is indicated if the pain is not relieved with conservative measures. An endoscopic technique for excision of the ossicle associated with Osgood-Schlatter disease is reported. It has the advantages of avoidance of painful surgical scars and preservation of the integrity of the patellar tendon, with the potential for improved cosmetic and functional results.

Direct bursoscopic ossicle resection in young and active patients with unresolved Osgood-Schlatter disease

PURPOSE

The aim of this study was to determine the outcomes of bursoscopic ossicle excision in young and active patients with unresolved Osgood-Schlatter disease.

METHODS

This retrospective study included 18 male military recruits. A direct bursoscopic ossicle excision was performed using low anterolateral and low anteromedial portals. Outcomes were evaluated using the Lysholm knee score, pain score on a visual analog scale (VAS) (from 0 to 10), and Tegner activity scale score. In addition, patients were asked whether they could kneel or squat and whether they were able to return to their duty after surgery. Patient satisfaction was evaluated using the VAS and by asking whether patients thought that the prominence of the tibial tuberosity was reduced and whether they would recommend the same surgical treatment to others. Complications after surgery were also evaluated.

RESULTS

The mean Lysholm knee score was 71 preoperatively and improved to 99 after surgery. The mean VAS pain score was 6.5 in the preoperative period and decreased to 0.9 after surgery. In addition, the mean Tegner activity scale score improved from 2.7 preoperatively to 6.2 at final follow-up. However, 4 patients were not able to return to their duty, and 4 patients still had difficulties with kneeling after surgery. A superficial infection occurred in 1 patient, and a recurrent ossicle formation was found in 1 patient. Of 18 patients, 17 were satisfied with their surgical outcomes, and the mean VAS score for patient satisfaction was 8.8. Furthermore, all but 1 patient would recommend the same surgical treatment to others. However, 6 patients did not believe that the prominence of the tibial tuberosity was reduced.

CONCLUSIONS

Bursoscopic ossicle excision showed satisfactory outcomes in selective young and active patients with persistent symptoms. However, bursoscopic surgery showed limitation in reducing the prominence of the tibial tuberosity.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Complete resolution of the symptoms of refractory Osgood-Schlatter disease following percutaneous fixation of the tibial tuberosity

Osgood-Schlatter disease is a common cause of anterior knee pain in adolescents. In a good proportion of cases the pain is relieved through stopping sport alone, or by doing so in conjunction with undertaking physiotherapy. However, resolution of symptoms may take several years. A proportion of teenagers are prevented from participating in sport for a prolonged period as a result of the condition, and some have persisting knee pain into adulthood. We report the use of a new surgical treatment for this disease. We describe the case of a 12-year-old boy who was unable to play rugby for a year due to this pain. Following percutaneous fixation of the tibial tuberosity his symptoms entirely resolved and he returned to competitive sport 6 weeks after surgery. A year later the screw was removed. As soon as he resumed sport his symptoms immediately returned and he requested that the screw be replaced. Following replacement his symptoms once more resolved.

Assessment of Osgood-Schlatter Disease and the Skeletal Maturation of the Distal Attachment of the Patellar Tendon in Preadolescent Males

BACKGROUND

Osgood-Schlatter disease (OSD) is a traction apophysitis of the tibial tuberosity. Ultrasonography (US) is able to detect pathologic changes, such as cartilage swelling and fragmentation of the tibial tubercle ossification center.

PURPOSE

To compare the US stages of tibial tuberosity development and the physical features and prevalence of OSD in this patient cohort.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Subjects included 238 males (n = 476 joints) with a mean age of 11.4 ± 1.6 years (range, 7-14 years). The tibial tuberosity development on US was divided into 3 stages: the cartilaginous stage (stage C), apophyseal stage (stage A), and epiphyseal stage (stage E). It was then investigated whether the subjects had pain in the tibial tuberosity on application of pressure. Age, height, body weight, body mass index (BMI), heel-buttock distance (HBD, cm), and straight-leg raise angle (SLRA) were evaluated. To confirm the diagnosis of OSD, the participant had to fulfill the following clinical criteria: pain with direct pressure on the tibial apophysis, fragmentation of the bone, and irregularity of the ossification center detected by US.

RESULTS

The tibial tuberosity was stage C in 195 knees, stage A in 105 knees, and stage E in 176 knees. The subjects' heights, weights, and BMIs significantly increased with advancing development of the tibial tuberosity. The HBD increased in stage E (P < .01). The SLRA was not significantly different among groups. There was fragmentation of the bone and irregularity of the ossification center in 32 knees (6.8%): 0 in stage C, 21 (4.3%) in stage A, and 11 (2.3%) in stage E. Fragmentation of the bone and irregularity were observed significantly more often in stage A (P < .01). On the other hand, there were 10 joints with OSD (2.1%): 0 in stage C, 3 (0.6%) in stage A, and 7 (1.5%) in stage E. OSD was observed significantly more often in stage E than in the other stages (P < .05).

CONCLUSION

The present study showed that the HBD increased from stage A to stage E. The prevalence of OSD was highest in stage E.

Relationship between the skeletal maturation of the distal attachment of the patellar tendon and physical features in preadolescent male football players

PURPOSE

The aim of this study was to compare ultrasonography stages of the tibial tuberosity development and physical features.

METHODS

This study examined 200 knees in 100 male football players aged 10-15 years. Tibial tuberosity development on ultrasonography was divided into 3 stages: Sonolucent stage (stage S), Individual stage (stage I), and Connective stage (stage C). Age, height, quadriceps and hamstring muscle tightness, and muscle strength in knee extension and flexion were determined. These findings were compared with the respective stages of development.

RESULTS

The tibial tuberosity was stage S in 27 knees, stage I in 69 knees, and stage C in 104 knees, with right and left sides at the same stage in 95 %. Average age and height significantly increased with advancing tibial tuberosity development. Quadriceps tightness increased with tibial tuberosity development. Hamstring tightness decreased with development. The strength of both knee extension and flexion increased with advancing development, with a greater change seen in knee extension, hamstring/quadriceps ratio: stage C, 0.74; stage A, 0.64; stage E, 0.53.

CONCLUSIONS

Osgood-Schlatter pathogenesis reportedly involves increased quadriceps tightness with rapidly increasing femoral length during tibial tuberosity development. In this study, it was confirmed that quadriceps tightness increased, yet hamstring tightness decreased, suggesting that quadriceps tightness is not due to femoral length alone. Other factors, including muscle strength, may be involved. The study shows that thigh muscle tightness and thigh muscle performance change with the skeletal maturation of the distal attachment of the patellar tendon. These results add new information to the pathogenesis of Osgood-Schlatter disease.