Is there a link between posterior tibial slope, maturation and OS?
The posterior tibial slope (PTS) is a radiographic measure of proximal tibial angulation observed on a lateral radiograph and appears to be a contributor towards knee joint stability. A greater PTS may create greater anterior tibial translation and increase shear forces of the femur on the tibia and the ACL as it attempts to resist this forward translation. An increase in PTS has been linked to increase rates of ACL injury, ACL re-rupture and Osgood Schlatter’s in young athletes.
Correlation of Tibial Tubercle Overgrowth with Increased Posterior Tibial Slope
In a recent study, (Rosenthal et al. 2024) the authors investigated whether there is an association between objective measures of anterior tibial tubercle growth and PTS in a group of patients (mean age was 33.1 +/- 14.1 years) who had all had a lateral radiograph and whose proximal tibial physis were closed. They used a novel series of measurements to assess tibial tubercle height (TTH) and anterior tibial tubercle angle (TTA) and assessed the relationship with the degree of PTS.
The results showed an increase in both TTA and TTH correlated with a difference in PTS.
They suggest that there is a link between the development of the tibial tubercle and PTS but not which caused which to emerge. Further research is required to explore whether that finding is relevant in patients with a diagnosis of Osgood’s.
Risk factors for OSD
In a study (Schultz et al. 2022), a cohort of 127 players from the U13 to U16 teams of an elite soccer academy, 17% of the players had a point prevalence of OSD with a peak of the prevalence at 15 years of age (29%), but no time loss from play in 80% of these cases. 30 players (15 symptomatic OSD versus 15 controls) were examined for clinical and ultrasonographic factors according to Ehrenborg matched on calendar-age. A previous history of heel pain was the only reported risk factor for OSD.
Previous authors have reported that growth velocity, clinical and ultrasonographic measures and strength and flexibility deficits were associated with OSD, but this was not supported in this cohort. The age of this cohort may have missed some younger children with OSD and the elite sports setting may have meant that strength and flexibility deficits may have been addressed within their training environment. In addition, ethnicity varies across soccer academy settings and the results may be specific to this cohort. In addition, deficits in flexibility and strength would have been identified and address in this elite setting so may have been less of a factor than in other settings. A further factor not identified was that children of the same age are not at the same stage of maturation, and banding children by age may have obscured whether these children were all earlier to mature than average.
In a different study within an elite soccer setting (Monasterio et al. 2024), collected injury and stature data over 20 consecutive seasons looking retrospectively at the interaction between growth rate on specific injury incidence and burden. Injury incidence for Osgood-Schlatter’s was greater in players who were pre-PHV with quicker growth rates compared to players growing moderately and slowly. So, in contrast with the results from Shultz et al. (2022), more rapid growth-rates were at higher risk for growth-related injuries.
Maturation of the tibial apophysis
A four-stage classification system (Ehrenborg, 1961) is commonly used to assess the developmental features of the tibial apophysis:
- Cartilaginous – characterised by the presence of apophyseal cartilage without a secondary ossification centre.
- Apophyseal – apophysis develops a secondary ossification centre and the patellar tendon attaches to apophyseal cartilage.
- Epiphyseal – patellar tendon attaches to the bone surface with a thin insertional cartilage still present.
- Bony stage – apophyseal cartilage layer is absent and patella tendon attaches to the tubercle. This marks the complete maturity of the tubercle.
In a study (Dinescu et al. 2023), involving 116 children from a sports academy aged between 7 and 18 years (54% male) with no history of MSK disease or trauma, an ultrasound examination of the patella tendon attachment to the proximal tibial apophysis was performed. The results highlighted that the proportion of subjects with grade 4 maturation was 79% in females versus only 11% in males, however the girls in the study were older and participated in different sports which may have affected the outcomes. Maturation of the tibial tuberosity has been shown to be approximately 1-2 years earlier in females. Only 3 subjects had symptomatic OSD findings were in maturation stage 3.
In an older study (Kaneuchi et al. 2018) involving 731 Japanese basketball players aged 6 to 14 years (350 males and 381 females) an ultrasound examination of the patella tendon insertion into the tibial apophysis was performed during a preseason assessment process and classified according to Ehrenborg, (1961). In this cohort, the risk of OSD was higher in stages 2 and 3 of maturation.
References
Rosenthal, R.M., Hunter, C.D., Froerer, D.L., Featherall, J., Metz, A.K., Ernat, J.J., Maak, T.G. and Aoki, S.K., 2024. Correlation of Tibial Tubercle Overgrowth With Increased Posterior Tibial Slope: A Novel Radiographic Assessment. Orthopaedic Journal of Sports Medicine, 12(2), p.23259671231225660.
Dinescu, S., Stoica, D., Bita, C.E., Morosanu, A., Andreea-Iulia, N., Mihaela, C., Alexandru, C.M. and Vreju, F., 2023. Tibial tuberosity maturation assessment by ultrasonography and screening for Osgood-Schlatter Disease in children and adolescent athletes: a cross sectional study.
Kaneuchi, Y., Otoshi, K., Hakozaki, M., Sekiguchi, M., Watanabe, K., Igari, T. and Konno, S., 2018. Bony maturity of the tibial tuberosity with regard to age and sex and its relationship to pathogenesis of Osgood-Schlatter disease: an ultrasonographic study. Orthopaedic journal of sports medicine, 6(1), p.2325967117749184.
Schultz, M., Tol, J.L., Veltman, L. and Reurink, G., 2022. Osgood-Schlatter Disease in youth elite football: Minimal time-loss and no association with clinical and ultrasonographic factors. Physical Therapy in Sport, 55, pp.98-105.
Monasterio, X., Cumming, S., Larruskain, J., Johnson, D.M., Gil, S.M., Bidaurrazaga-Letona, I., Lekue, J.A., Diaz-Beitia, G., Santisteban, J.M. and Williams, S., 2024. The combined effects of growth and maturity status on injury risk in an elite football academy. Biology of sport, 41(1), pp.235-244.
