Osgood-Schlatter Disease (Knee Pain): Physiotherapy Management

Osgood-Schlatter's disease also known as osteochondrosis or traction apophysitis at the level of the tibial tubercle due to repetitive strain on the growth plate of the tibial tuberosity. The repetitive strain is from the strong pull of the quadriceps muscle(extensor mechanism) produced during sporting activities like:

• Basketball
• Volleyball
• Sprinters
• Gymnastic
• Football

ETIOLOGY

The Patellar tendon inserts at tibial tubercle. Repeated traction and microtrauma at the insertion causes microvascular tear, inflammation and fracture. Osgood-Schlatter disease, is an overuse injury characterized by ossification of bone along the growth plate, the tibial tubercle.

Osgood-Schlatter Disease

Due to excessive growth, the ability of the muscle-tendon unit to stretch sufficiently and maintain flexibility is hampered, and there is increased tension across the tibial tubercle apophysis.

In severe cases, repetitive strain may lead to softening and partial avulsion of the tibial tubercle apophysis resulting into osteochondritis.

EPIDEMIOLOGY

High prevalence in immature adolescent
Most common in males, that engage in running, jumping and sprinting activities.
Onset occurs in male at 10-15 years and in female at 8 -14 years.

Relevant Anatomy

The tibial tubercle (the tuberosity of the tibia) is the protuberance along the anterior aspect of the tibia, just distal to the anterior surfaces of the medial and lateral tibial condyles.

Osgood-Schlatter Disease

The tibial tubercle is entirely cartilaginous. It gives attachment to the patellar ligament or patellar tendon. The patellar tendon attaches to the tibial tuberosity inferior to the patella.

Stress at this musculotendinous junction can cause pain and swelling. The pain felt by the patient is mostly unilateral, but often it is bilateral.

The Osgood-Schlatter disease is localized at the tibial tubercle, distal and anterior to the knee.

Clinical Presentation and Examination

Anterior knee pain associated with or without swelling, is the leading symptom in this disease and it aggravates during physical activities such as running, jumping, cycling, kneeling, walking up and down the stairs and kicking a ball(knee extension) . The clinical picture consists of pain localized to the area of the tibial tubercle.

Painful palpation of the tibial tuberosity.

• Pain at the tibial tuberosity that worsens with physical activity or sport.
• Increased pain at the tibial tuberosity with sports activity.
• In some cases increased bony protuberance at the tibial tuberosity.
• Secondary to pain,Ely's test- there is tightness of Quadriceps.
• Resisted isometrics of the Quadricep muscle is painful.

Differential Diagnosis

Conditions that show similar presentation:

• Jumper’s knee (patellar tendinitis) or Sinding- Larsen-Johanssen syndrome
• Synovial plica injury
• Tibial tubercle fracture
• Osteochondroma of the proximal tibia
• Fat Pad Syndrome

The diagnosis is based on typical clinical findings.
Radiographic examinations of both knees should always be performed, in both the anterior-posterior and lateral projections, to rule out the possibility of tumors, fractures, ruptures or infections.

A picture of prominent tibial tubercle with soft tissue swelling, calcification of the patellar tendon, or free bony fragment proximal to the tubercle can be seen.

An utmost care must be taken, for accurate diagnosis, as sometimes the tibial protuberance may not be pathological. Therefore, clinical correlation must be done.

Prognosis

The condition is self-limiting and hence recovers within a month
Sometimes the pain may persist up to 2 years, if unnoticed or left untreated.
Medical Management

Conservative treatment

Treatment should begin with rest, icing (RICE), activity modification and sometimes non-steroidal anti-inflammatory drugs.

Surgical treatment

Osgood-Schlatter Disease

Surgical procedures should be avoided until the child has grown up and the bone growth has been completed to avoid growth-plate arrest and the development of recurvatum and or valgus of the knee.

Surgical treatment, we identified different surgical procedures such as drilling of the tibial tubercle, excision of the tibial tubercle (decreasing the size), longitudinal incision in the patellar tendon, excision of the ununited ossicle and free cartilaginous pieces (tibial sequestrectomy), insertion of bone pegs and/or a combination of any of these procedures.

Osgood-Schlatter Disease

Physical Therapy Management

Pain Relief

• The pain usually subsides with the cessation of growth at the tibial tubercle.
• Ice application after activity reduces the anterior knee pain.
• Limiting the sports activity, for 6-8 weeks is advisable.
• Gentle stretch to Quadricep and Hamstring muscle ,along with strengthening of Vastus Medialis Oblique muscle decreases pain.
• Patellar loading is decreased by patellar tapping/ McConnel tapping, and by the use of brace.

Exercise Therapy

Low-intensity Quadriceps-strengthening exercises, such as isometric multiple- angle quadriceps exercises, are therefore instituted earlier in the conditioning program.

High-intensity Quadriceps exercises and Hamstring stretching are introduced gradually and have been proven effective with high evidence rating. Incorporation of high-intensity Quadricep exercise can intensify pain.

Shockwave

Extracorporeal Shockwave therapy is a treatment which has been discussed in the use of Osgood-Schlatter disease but due to the low value evidence recommendations cannot be made for this treatment.

Activity Limitation

Non-operative treatment of this disease is based on the same principles that apply all overuse injuries.

Today, there is no need for total immobilization, or for totally refraining from athletic activities. Of vital importance is that the physician inform the parents, the coach, and the child athlete of the natural course of this disease.

The child should continue his normal physical activities, to the limit that the pain allows it, so lower intensity of frequency of exercising (activity modification). Also swimming, as a secondary athletic activity, is very good during this disease (no discomfort).

Also knee-braces, tapes, slip-on knee support with an infrapatellar strap or pad are recommended and may help during physical activities and can reduce pain.

Research by Gerulis et al has shown that limitation of physical activity, physical load restriction, and conservative treatment are more effective than physical load restriction and activity limitation alone