This year the World Congress of Sports Physical Therapists was held in Nyborg in Denmark. This blog covers the diagnosis, prognosis, and management of Osgood Schlatter’s disease,
Overuse Injuries in adolescents – CHARLOTTE ANKER-PETERSEN and KASPER KROMMES
This workshop discussed the recent research around PFP and OSD in relation to rehabilitation.
They addressed the following points:
Not all swelling around the anterior tibial tubercle is Osgood Schlatter’s Disease
Agaronnik, N.D., Landrum, M., Wait, T. and Hogue, G.D., 2022. Osteochondroma of the Tibial Tubercle Masquerading as Osgood-Shlatter Disease: A Case Report. Clinical Medicine Insights: Case Reports, 15, p.11795476221111771.
Osteochondromas are usually benign tumours most seen in the metaphyseal areas of long bones, such as the femur and proximal tibia. They may be mistaken for Osgood Schlatter’s disease (OSD). The paper reports a case study of an 11-year-old boy who developed a “large anterior bony prominence just distal to the tibial tubercle”.
On examination, the bony mass was not tender, and he had FROM in the knee and hip. Unlike other cases reported in the literature this child did have pain on activity potentially due to infiltration into the patella tendon. The mass was getting larger so was excised and the dimensions were measured at 5cm x 4cm x 2cm. Histologically the findings were different to those expected in OSD. He made a full return to sporting activity.
The paper highlights the need to investigate bony lumps when the features for Osgood Schlatter’s are not present such as lack of pain, growth of the mass > 5cm2, pain independent of activity especially in children who are younger than 10. Cases of OSD are rare in the children younger than 10.
Although rare, osteochondromas can become malignant and may cause neurovascular impingement or pathological fracture.
Do you tell your patients with Osgood Schlatter’s Disease they will grow out of it?
Holden, S., Olesen, J.L., Winiarski, L.M., Krommes, K., Thorborg, K., Hölmich, P. and Rathleff, M.S., 2021. Is the Prognosis of Osgood-Schlatter Poorer Than Anticipated? A Prospective Cohort Study With 24-Month Follow-up. Orthopaedic Journal of Sports Medicine, 9(8), p.23259671211022239.
51 adolescents (aged 10-14 years) diagnosed with OSD were given baseline US scans and classified according to OSD type (De Flaviis classification) and maturation of the tibial tuberosity. Secondary outcome measures were recorded and re-evaluated at 24 months. 37% still reported knee pain due to OSD, with a median duration since symptom onset of 42 months. Those patients who had symptoms of longer duration had lower outcomes scores and higher De Flaviis classification at baseline. 32% of those who had a follow up ultrasound at 2 years had evidence of thickening of the patella tendon and increased Doppler activity, ununited ossicles and or bursal involvement.
How can we identify which patients with Osgood Schlatter’s have the potential for longer lasting symptoms?
Sailly, M., Whiteley, R. and Johnson, A., 2013. Doppler ultrasound and tibial tuberosity maturation status predicts pain in adolescent male athletes with Osgood-Schlatter’s disease: a case series with comparison group and clinical interpretation. British journal of sports medicine, 47(2), pp.93-97.
20 symptomatic adolescent male athletes with a mean age of 13.8 years and unilateral or bilateral symptoms of OSD that limited their ability to continue physical activity due to anterior knee pain, were assessed and the results compared to a group of similar age asymptomatic athletes. VAS scores were obtained during palpation of the tibial tuberosity, resisted contraction of the extensor mechanism in 90’ knee flexion prone, and a single leg squat. Ultrasound examination was performed to establish the maturation stage of the anterior tibial tuberosity (ATT) and Doppler examination to assess local bursa and tendon involvement.
Doppler activity may identify the propagation of neo-vessels. These have been associated with the proliferation of nerve fibres and could be a possible explanation for the presence pain in those athletes in whom neovascularisation was observed. This was most evident in Stage 2 of the maturation of the ATT.
Neo-vessel infiltration has been observed on ultrasound during stages 2 and 3 of the ossification phase of the hyaline apophyseal cartilage regulated by vascular endothelial growth factor (VEGF). In this study, inflammation in the bursa was observed in all symptomatic Stage 2 subjects, with the authors suggesting the potential for overproduction of VEGF due to compressive forces. This raises the potential question as to whether the onset of OSD is associated with greater traction or compressive forces at the site of insertion of the patella tendon to the ATT.
A higher percentage of athletes who had higher VAS scores on both palpation and resisted knee extension were found in maturation Stage 2 and were associated with positive findings on Doppler examination, but these findings were not observed in the single leg squat test.
How can we support patients with Osgood Schlatter’s to optimise their recovery?
Rathleff, M.S., Winiarski, L., Krommes, K., Graven-Nielsen, T., Hölmich, P., Olesen, J.L., Holden, S. and Thorborg, K., 2020. Activity modification and knee strengthening for osgood-schlatter disease: a prospective cohort study. Orthopaedic journal of sports medicine, 8(4), p.2325967120911106.
- Relative rest: In patients identified with OSD during Stage 2 of the maturation of the ATT and the presence of neovascularisation of the prepatellar bursa on ultrasound (associated with higher pain scores on resisted quads contraction and palpation) a period of rest (up to 4-5 weeks) is advocated to allow a reduction in compressive forces
- Activity modification with acceptable level of pain no > than 2/10
- Education – address beliefs, give the pain a name, credible explanations, factors that contribute to OSD and risk factors, benefits of treatment plan and RTS plan
- Education – load variables – use of activity ladder to include advise on frequency, duration, intensity, activity type, cumulative weekly load, plan based on pain response
- Support adolescent in self-management and decision making
- Exercises – early stages isometric quads and bridges progressing to squat and lunge as pain subsides
I have written a guide to Osgood Schlatter’s disease that can be used by patients that suspect they may suffer from it and clinicians looking for more information. You can download it for free by following the following link Osgood Schlatter’s Disease patient booklet.
Find Out More
Patient exercise and educational leaflets to download
Exercise and education manual link – OSD
https://journals.sagepub.com/doi/full/10.1177/2325967120911106
Exercise and education manual link – PFP
Email info@angelajacksonphysio.com
If you would like to learn about how to implement return to sport protocols and develop confidence in knowing when an athlete is ready to return to sport, then email me for more details on my practical day course From Assessment to Return to Play in the Junior Athlete or learn online with Active Kids Are Not Mini Adults.
You can also read part 1 of my lessons learned from the World Congress of Sports Physical Therapists HERE.
