7/29/2019 sbdfjk

1/6

0196-601 1/85/0701 0005$02.00/0THE OURNALF ORTHOPAEDICND SPORTSHYSICALHERAPYCopyright0 1985 by The Orthopaedic and Sports Physical Therapy Sections of theAmerican Physical Therapy AssociationOsgood-Schlatter Disease: Review ofLiterature and Physical TherapyManagementT. J. ANTICH, MS, PT,* CLlVE E. BREWSTER, MS, PT

Osgood-Schlatter disease is a traction apophysitis of the tibial tubercle, the weakestlink of the extensor mechanism of the adolescent. Conventional medical treatmentincludes plaster casting, injections of various anti-inflammatories, and surgicalremoval of painful ossicles in resistant cases. While not a very common condition,Osgood-Schlatter disease is being seen with increasing frequency in teenageathletes, especially basketball players (Antich, Lombardo, J Orthop Sports Phys Ther7: 1-4, 1985.) With a focus on muscular tightness as a possible causative factor,physical therapy evaluation is outlined, followed by techniques for pain control andstretching exercises for the quadriceps and hamstrings. Ice massage is advocatedas a way for the athlete to treat postexertional discomfort in the area of the tubercle.The patient and his or her parents must be assured that while residual deformity mayremain, disappearance of symptoms coinciding with closure of the apophyseal plateis often the end result.

Osgood-Schlhtter disease is defined as a sep-aration of the tibial tubercle apophysis from theproximal end of the tibia. This lesion may have ahistory of trauma, or may present without a sig-nificant recognizable injury. KatzI4 classifies thisentity as a nonarticular osteochondrosis involvingthe quadriceps muscle/tendon insertion second-ary to excessive muscle pull. Citing the samemechanism of increased quadriceps pull on theadolescent tubercle, Smillie28describes Osgood-Schlatter disease as a traction epiphysitis. Dor-land's Medical Dictionary gives as a synonym"apophysitis tibialis adolescentium," whileChristie4 states that the radiographically evidentbone changes make it a disease entity. He addsthat poor epiphyseal nourishment during a time ofrapid growth can lead to the onset. However,LaZerte and Rapp'sI7 histological studies of ninespecimens indicate no evidence of primary asepticnecrosis in any of the tubercles examined.

Increased stress on the weak link of the ado-lescent knee extensor mechanism accounts forthe symptoms experienced by those patients withthis ~ e s i o n . ' ~ . ' ~ ~ ~ ~n initial injury can be furthered

Department of Physical Therapy, Southwestern Orthopaedic MedicalGroup, Inc., 501 E. Hardy Street, Suite 200, Inglewood, CA 90301.

by continuing minor t r a ~ m a t a ~ ' . ~ ~r heterotopiccalcification and ossification in the patellar liga-ment can occur secondary to o~ e r u s e . " ~ ~ ~n-stances of tibial tubercle fracture have been re-ported subsequent to violent quadriceps contrac-t i o n . ' ~ ~ ~he imbalance in the cross-sectional areaof the quadriceps muscle bulk to the area ofinsertion7 also creates a great concentration offorce on. a small area.HISTOLOGY

Microscopic examination of bony ossicles re-moved at surgery indicates that the separation isdue to increased tension over a small area oftendon insertion. All nine cases studied by La-Zerte and RappI7 demonstrated an anterior cor-tical bone defect of the tubercle, in addition toincreased vascularization of the infrapatellar ten-don surrounding the ossicles.DIAGNOSIS

Osgood-Schlatter disease is easily recognizedin the adolescent with complaints of pain which islocalized to the area of the tibial tubercle. Discom-fort is usually generated with running,21 kneel-ing,2321scending or descending stair^,'^^^' and is

7/29/2019 sbdfjk

2/6

6 ANTICH AND BREWSTER JOSPT Vol. 7, No . 1

Fig. 1 . A , Lateral view in a 12-year-old male exhibiting separtendon at its insertion in a 13-year-old male.relieved with rest.l4 Weakness of the quadriceps2'and pain on resisted knee e ~ t e n s i o n ~ ~ ~ ~ ~ ~ 'recommon signs, as is an enlarged t~bercle.~.~'D'Ambrosia and MacDonald6 eport reproductionof pain with passive knee flexion, which Jakob eta1.12 attribute to a hypertrophied quadriceps groupexhibiting decreased flexibility.

Radiographic examination is considered nec-essary in confirming this diagnosis in the adoles-cent with knee pain. In more severe cases, sep-aration and fragmentation of the apophysis maybe seen32as well as irregular ossification of thet~berc le '~.~ 'Fig. 1). In milder cases without radi-ographic bony changes, soft tissue swelling, es-pecially of the infrapatellar fat pads2' may be theonly evidence of this disease. Mital and Matza2'check for a decreased "sharpness" in the angleformed by the tibial apophysis and the infrapatellartendon. Patella infera, as defined by the Insall-Salvati patellar height-to-patellar tendon ratio,was seen in a group of 20 patients with Osgood-Schlatter disease (mean = 1.21 + 0.15).'6 Thisposition was determined to be significantly lower(P < 0.05) than a group of 80 normals (mean =1 OO k 0.1 1 . Conversely, Jakob et a1.12 reported

ation of the tubercle; 13, ssicle embedded within the infrapatellarI

patella alta in their series of 185 knees utilizingthe Blackburne and Peel method of measuringpatellar position. The mean index of knees withOsgood-Schlatterdisease was 0.99, as comparedto 73 normal knees with a mean of 0.84.

Differential diagnosis of this entity includes os-teogenic sarcoma of the proximal tibia2' and os-teomyelitis of the tubercle secondary to contu-~ i o n . ~'Ambrosia and MacDonald6 emphasizethe need to perform a thorough examination onadults with previous histories of Osgood-Schlatterdisease and report arteriovenous fistula as thecause of knee pain in one individual.CONVENTIONAL MEDICAL TREATMENT

A wide range of treatment philosophy exists,with some belief that no treatment is needed otherthan for pain relief.3.'4 mprovement occurs spon-taneously in 1-2 years with or without treatment,the only sequela being residual deformity ofthe tibial t~berc le.~imitation of activity isr e c ~ m m e n d e d ~ ~ ~ ' ~ ~ ~ . ~ ~ , ~ ' . ~ 'ith Willne?' morespecifically restricting running and stairs for 12weeks, and walking barefoot before the age of15. Attributing the problem to lower extremity

7/29/2019 sbdfjk

3/6

JOSPTJulylAug 1985 OSGOOD-SCHLATTER DISEASE 7malalignment involving marked foot pronation andgenu valgum, he advised decreasing the use ofloafers and sneakers, and prescribed "Oxfordshoes with a firm inner shank and 311 6 inch innerheel wedges." Complete relief of symptoms in 65of 78 patients is reported in 6 weeks, with theremainder becoming pain free in 12 weeks.31

Bowers2 recommends use of salicylates andlocal ice application, as needed, to control pain.Conservative treatment to decrease quadricepstension on the t u b e r c ~ e ~ l . ~ ~nd restriction of mo-tion via immobilization from 6 to 8 weeks22 o 3months2' is suggested. ~icheli,~'owever, feelsthat casting is not indicated in the presence of atight, weak quadriceps group.Injection of the tubercle with hydrocortisone15or with lidocaine HCI combined with hydrocor-t i~o ne,~ ' e~amethasone,~~riamcino~one,~ rmethy~prednisolone,~~ay be employed if restric-tion of activities and immobilization are not suc-cessful. Kelly15 utilized up to three hydrocortisoneinjections and reported 52 to 72 patients havingrelief after one injection. Eight and 9 more wereimproved after two and three injections, respec-tively, while 3 of the 72 did not respond to injec-tion.

Levine and ashy yap'^ advocate use of an infra-patellar strap during activities to decrease the pullof the quadriceps against the tibial tubercle andreport improvement in 92% of patients treated(Table 1).

Quadriceps stretching into knee flexion with hipextension s used to stretch the muscle group anddecrease tension on the apophysis. While Katz14states that "rarely is the pain severe enough torequire plaster-cast immobilization," 12~of Mitaland Matza's groupz2underwent surgical removalof painful ossicles with instantaneous relief ofsymptoms.COMPLICATIONS

Premature closure of the anterior tibial epiphy-sis resulting in genu recurvatum has been re-p ~ r t e d . ' ~ , ~ ~ , ~ 'onflicting reports of patellaalta'2~2',30 nd patella infera16 exist, while thecausal or effectual relationship with this disease

TABLE 1Improvement with infrapatellar stap*Definite improvement 79.1%Some improvement 12.5%No improvement 8.3%

From Levine and Kashyap.lg

is not known. Subcutaneous atrophy in 8 of 70knees injected with methylprednisolone was seenin addition to striae formation in the skin overlyingthe tubercle.26Patellar tendon avulsions are pos-sible sequellae to Osgood-Schlatter disease andfrom 14'' to 26%" of those seen with this fracturereported previous histories of Osgood-Schlatterdisease.PHYSICAL THERAPY EVALUATION

In assessing the patient's knee pain, location(unilateral or bilateral) of pain and its duration isdocumented. Whether it is painful during briefphysical activity, or following prolonged activity,indicates severity. Answers to questions regard-ing presence or absence of pain while walking,running, ascending and descending stairs, andkneeling should be documented for later compar-ison.

Examining the patient's gait pattern while walk-ing, the therapist looks for an antalgic limp orother compensatory mechanism to protect theknee from pain. Special attention should be fo-cused on whether or not the individual flexes theinvolved knee during loading response or at-tempts to maintain full extension, thereby reduc-ing the need for quadriceps activity.

Confirmation of the diagnosis is the first task ofthe attending therapist. With the patient supinewith both knees flexed to 90 inspection of thetubercles is performed. By looking from the side,a silhouette image of one knee against the otherreveals enlargement of the apophysis, if present(Fig. 2). Palpation of the tubercle is then performedand tenderness is assessed as none, slight, mild,moderate, or marked (Table 2).

Due to the prevalence of Osgood-Schlatter dis-ease during the early adolescent years, at a timewhen musculoskeletal pain may be secondary tothe inability of muscles to elongate at the samerate as bony growth, tightness of knee muscula-ture must be checked. With the patient still supine,hamstring length is assessed by the examiner'sflexing the hip while maintaining the knee in fullextension. Comparison between involved and un-involved limbs in unilateral problems, or compari-son to normal values in the cases of bilateralinvolvement, aids the therapist in decidingwhether or not muscular tightness plays a role inthe conditon.

Knee flexion range of motion, taking into ac-count rectus femoris tightness, is performed withthe patient prone (Fig. 3). The knee is passively

7/29/2019 sbdfjk

4/6

BREWSTER JOSPT Vol. 7, o. 1

Fig. 4. Hamstring stretching is performed w ith a 10-sec staticstretch. Note limited flexibility in this patient with posteriorpelvic rotation (tight lumbodorsal fascia), inability to keep kneestraight (tight hamstrings), and outward rotation of foot (tighthip external rotators).

Fig. 2. Silhouette appearance of knees flexed to 90 revealsmild e nlarge men t of left tibia1 tubercle .TABLE 2

Assessment of tend erness on palpationSlight Only complains of pain after questioningMild Voluntarily reports pain on palpationModerate Withdraws knee from exam iner's hand;may indicate pain verballyMarked Withdraws knee and attempts to grabexaminer's hand

Fig. 3. Assessment of passive knee flexion range of motionincluding evaluation of rectus femoris tightness.

flexed by the examiner until either the end of rangeor pain is encountered. If this stretch begins tohurt, the patient must be questioned as to thelocation of the pain, as this will influence treat-ment. If pain from this prone stretching is felt inthe area of the infrapatellar tendon or tuberclearea, stretching the quadriceps is contraindicated,as the pain is caused by further pulling away ofthe apophysis. If the strain is felt up in the musclebelly or at the proximal attachment of the muscle,quadriceps stretching will be performed as part ofthe treatment. The results of muscle tightnesstests along with the location of pain with stretch-ing are recorded.

Manual muscle testing of the knee extensorsand flexors can be performed with the patientsitting on the end of the plinth with presence orabsence of pain noted. Muscle tone is assessedin the long sitting position as the patient performsa quadriceps set. Quadriceps atrophy should bechecked in the form of girth measurements.PHYSICAL THERAPY TREATMENT

Of primary concern to the therapist treatingOsgood-Schlatter disease is relief of pain in thearea of the tubercle. lontophoresis is the modalityof choice, and a trial period of not more than threetreatments should be undertaken.'. o Use of ananti-inflammatory medication and local anesthetichelps decrease swelling and pain.We feel the benefits of iontophoresis are: 1)Inhibition of pain from the electrical current used;2) method of administering medication withoutinjecting the tendon/muscle junction, thus avoid-ing the possibility of associated tendon damage;

7/29/2019 sbdfjk

5/6

JOSPT JulylAug 1985 OSGOOD-SCHLATTER DISEASE 9

Fig. 5 . A, Quadriceps stretch position for individuals withextreme tightne*; B, advanced quadriceps stretch positionwhich increases rectus femoris stretch across the anterior hip.

Fig. 6. Residual deformity in a 28-year-old male with neitherpain nor functional limitations of the left knee.3) localization of treatment required for the sizeof this particular lesion.

The active pad of the PhoresoP (Motion Con-trol, Salt Lake City, UT) unit is positioned over thetubercle of the knee which is supported in about30' of flexion. The sides of the adhesive pad arethen taped down to the skin for better contactand to prevent leakage. One cc of dexametha-sone-sodium-phosphate and 1 cc of lidocaine HCI

are injected into the positive electrode. Treatmenttime is for 20 minutes at up to 5.0 ma. Properpost-treatment application of lotion to both elec-trode sites minimizes the hazard of skin irritation.

Following three treatments with iontophoresisperformed every other day, tenderness to palpa-tion is reassessed, and the patient's subjectivechange in conditions is recorded.

The next phase of treatment addresses tightmusculature if found on initial eval~at ion.~~eat-ing with hot packs to the anterior and posteriorthigh is followed by quadriceps and/or hamstringstretching. Hamstrings are stretched over the sideof a plinth (Fig. 4) with the involved knee in fullextension and the foot pointing upward (neutralhip rotation). A static stretch of 10 sec is usedwith the patient instructed o slide his hands downhis anterior leg until he feels a stretch either in theposterior thigh or at the hamstrings insertion.Quadriceps stretching is performed with thepatient lying prone, pulling his foot up toward hisbuttocks. Strain should be felt in the muscle belly,and not at the tenoperiosteal junction. For casesof extreme tightness, a belt may be neededaround the dorsal foot (Fig.5A), whereas patientswith less quadricep tightness can be sidelying withthe involved leg up, allowing for a greater rectusfemoris stretch with passive hip extension (Fig.56).

Strengthening of the involved limb quadricepsis performed in cases of atrophy secondary todisuse. Isometric quadricep sets, straight legraises, and short arc quadricep exercises arestandard, and are performed only if they are painfree. Exercise concludes with a 5-minute ice mas-sage to the area of the tubercle.SUMMARY

The symptoms, diagnosis, and conventionalforms of treatment for Osgood-Schlatter diseaseare reviewed. Physical therapy evaluation mustconcentrate on assessment of tight musculature(quadriceps, hamstrings, calf) as a possible causeof this entity. Treatment concentrates on: I ) de-creasing the pain, 2) improving flexibility, and 3)return to function.

Perhaps the most important part of rehabilita-tion is education of the adolescent and his par-ents, with a reassurance that his condition istemporary and related to the time in his growthwhen his epiphyseal plates are the weak link ofhis musculoskeletal system. Activities should bepain limited with instruction in continuation of a

7/29/2019 sbdfjk

6/6

10 ANTICH AND BREWSTER JOSPT Vol. 7, No. 1home programwith ice massage following. Expla-nation that a prominent tubercle may be presentindefinitely ( ~ i ~ .), but that pain with activityshould cease following the teenage years, mayprevent later concerns regarding continued pres-ence of an enlarged tubercle.

The authors would like to thank the other members of the PhysicalTherapy Research Committee of the Southwestern Orthopaedic Med-ical Group, Inc. for their suggestions and review of the manuscript inits preparation for publication: Matthew C. Morrissey, MS, PT; CelesteCriswell Randall. MS. PT; and Roxie Westbrwk, PT.

The guidance and assistance of Ms. Elizabeth Stone is gratefullyappreciated.

REFERENCES1. Bertolucci LE: Introduction of antiinflammatory drugs by iontopho-

resi: Double blind study. J Orthop Sports Phys Ther 4:103-108,1982

2. Bowers KD: Patellar tendon avulsion as a complication of Osgwd-Schlatter's disease. Am J Sports Med 9:356-359, 1981

3. Bunch WH: Decision analysis of treatment choices in the osteo-chondroses. Clin Orthop 158:91-98.1981

4. Christie AC: Osteochondritis or epiphysitis. JAMA 87:291-295.1926

5. Cole JP: A study of Osgood-Schlatter disease. Surg GynecolObstet 65:55-57, 19376. D'Ambrosia RD, MacDonald GL: Pitfalls in the diagnosis of Os-

good-Schlatter disease. Clin Orthop 110:206-209, 19757. Ehrenborg G, Engfeldt B. Olsson SE: On the aetiology of the

Osgood-Schlatter lesion: An experimental study in dogs. Acta ChirScand 122:445-457,1961

8. Grass AL: Treatment of Osgood-Schlatter njury. JAMA 240:212-213. 1978

9. Hand WL, Hand CR, Dunn AQ: Avulsion fractures of the tibialtubercle. J Bone Joint Surg (Am) 53:1579-1583,1971

10. Harris PR: lontophoresis: Clinical research in musculoskeletal n-flammatory conditions. J Orthop Sports Phys Ther 4:109-112,1982

11. Holstein ER, Lewis GB, Schulze ER: Heterotopic ossification ofpatellar tendon. J Bone Joint Surg (Am) 45656, 1963

12. Jakob RP. VonGumppenberg S. Engelhardt P: Does Osgood-Schlatter disease influence the position of the patella? J Bone JointSurg (Br) 63579-582, 1981

13. Jeffreys TE: Genu recurvatum after Osgood-Schlatter's disease:Report of a case. J Bone Joint Surg (Br) 47:298-299,1965

14. Katz JF: Nonarticular osteochondroses. Clin Orthop 158:70-76.1981

15. Kelly JM: Osgood-Schlatter's disease: A review of 108 cases. JIrish Med Assoc 64:630-635,1971

16. Lancourt JE. Christini JA: Patella alta and patella infera: Theiretiological role in patellar dislocation, chondromalacia, and apo-physitis of the tibial tubercle. J Bone Joint Surg (Am) 57:1112-1115,1975

17. La Zerte GD, Rapp IH: Pathogenesis of Osgwd-Schlatter's dis-ease. Am J Pathol34:803-811,1958

18. Levi JH, Coleman CR: Fractures of the tibial tubercle. Am J SportsMed 4:253-263,197619. Levine J, Kashyap S: A new conservative treatment of Osgood-Schlatter 's disease. Clin Orthop 158:126-128, 1981

20. Micheli LJ: Overuse injuries n children's sports: The growth factor.Orthp Clin North Am 14:337-360,1983

21. Mital MA, Matza RA: Osgood-Schlatter disease: The painful puz-zler. Phys Sportsmed 560-73, 1977

22. Mital MA, Matza RA, Cohen J: The so-called unresolved Osgood-Schlatter lesion. J Bone Joint Surg (Am) 62:732-739, 1980

23. Ogden JA, Southwick WO: Osgood-Schlatter's disease and tibialtubercle development. Clin Orthop 116:180-189,1976

24. Osgood RB: Lesions of the tibial tubercle occurring during adoles-cence. Boston Med Surg J 148:114-116,1903

25. Reichmaster J: Injection of the deep infrapatellar bursa or Osgood-Schlatter's disease. Clin Proc Child Hosp DC 3521-24, 1961

26. Rostron PKM, Calver RF: Subcutaneous atrophy following meth-ylprednisolone injection in Osgood-Schlatter epiphysitis. J BoneJoint Surg (Am) 61 627-628, 197927. Scotti DM, Sadhu VK, Heimberg F, O'Hara AE: Osgood-Schlatter'sdisease, an emphasis on soft tissue changes n roentgen diagnosis.Skeletal Radiol 4:21-25, 1979

28. Smillie IS: Injuries to the Knee Joint, Ed. 5. Edinburgh: ChurchillLivingstone. 1978

29. Smillie IS: Diseases of the Knee Joint, Ed. 2. Edinburgh: ChurchillLivingstone, 1980 F

30. Stirling RI: Implications of Osgood-Schlatter's disease (abstract). JBone Joint Surg (Br) 34:149-150, 1952

31. Willner P:Osgood-Schlatter'sdisease: Etiology and treatment. ClinOrthop 62:178,1969

32. Woolfrey BF, Chandler EF: Manifestations of Osgood-Schlatter'sdisease in late teen age and early adulthood. J Bone Joint Surg(Am) 42:327-332.1960