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Tibial Tuberosity Apophysitis
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Contents
Other Names
- Osgood-Schlatter's Disease
- Osgood Schlatter's Disease
- Osteochondrosis
- Traction apophysitis of the tibial tubercle
- Lannelongue’s disease
- Osteochondrosis of the tibial tubercle
- Traction apophysitis of the tibial tuberosity
- Osteochondritis of the tibial tubercle
Background
- This page refers to Tibial Tuberosity apophysitis (TTA), an overuse injury seen in skeletally immature athletes
- More commonly referred to by its eponym: Osgood Schlatters Disease (OSD)
History
- First documented in the early 1900s separately by both Osgood and Schlatter[1]
Epidemiology
- Affects boys age 10-15, girls age 8-12[2]
- Prevalence of Osgood Schlatter disease is 9.8% in adolescents ages 12 to 15 (need citation)
- Bilateral symptoms in 20% to 30% of patientss[3]
- Initially thought to be more common in males than females
- Now being seen at similar rates in females due increase in female athletes[3]
- OSD affects 21% of athletic adolescents, while it is seen in 4.5% of age matched nonathletic controls[4]

Illustration of Osgood Schlatter's Disease[5]
Pathophysiology
- General
- Characterized by knee pain over the tibial tuberosity with a bony prominence
- Atraumatic, insidious onset of anterior knee pain, at the tibial tuberosity physis where Patellar Tendon inserts
- Generally considered a self-limited condition
- Due to repetitive microtrauma, strain from knee extension onto the tibial tubercle apophysis
- Stages
- Early: Pain on the tibial tuberosity after physical activities
- Late: Pain at rest or during activity
- Mechanism of Injury
- Most often associated with a repetitive running, jumping sport
- Less commonly, can occur with one sudden traumatic event (sprint, landing, leap)
Etiology
- Caused by repetitive strain and microtrauma from extensor forces applied by the patellar tendon onto the apophysis of the tibial tubercle[6]
- Leads to partial loss of continuity at the patellar tendon-cartilage-bone junction
- An inflammatory process begins resulting in patellar tendinitis, which inevitably progresses
- As the disease process continues, the patient develops subacute fractures, irregular ossification
- Bone growth exceeds the ability of the muscle-tendon unit to stretch sufficiently to maintain previous flexibility
- Rapid growth in the leg at the distal femur, proximal tibia (patient is getting taller)
- Leads to increased tension across the apophysis
- Physis is the weakest point in the muscle-tendon-bone-attachment and is at risk of injury from repetitive stress
- Osteochondrosis develops due to softening and partial avulsion of the apophyseal ossification cente
- Other cited contributing causes
- Shortening of the Rectus Femoris
Associated Conditions
Pathoanatomy
- Extensor Mechanism
- Quadriceps tendon inserts into Patella, Patella Tendon in turn attaches to Tibial Tubercle
- Tibial Tubercle
- Develops as a secondary ossification center that provides attachment for the patellar tendon[7]
- Under age 10: Cartilaginous
- Age 11-14: Apophysis
- Age 14-18: Complete bone fusion
- In adolescents, considered the weakest part of the extensor chain until bone fusion occurs
Risk Factors
- Biomechanical
- Poor flexibility of quadriceps and hamstrings
- Extensor mechanism misalignment
- Sports
- Basketball
- Volleyball
- Gymnastics
- Soccer
- Lacrosse
- Figure skating
Differential Diagnosis
- Fractures
- Dislocations & Subluxations
- Patellar Dislocation (and subluxation)
- Knee Dislocation
- Proximal Tibiofibular Joint Dislocation
- Muscle and Tendon Injuries
- Ligament Pathology
- Arthropathies
- Bursopathies
- Patellofemoral Pain Syndrome (PFPS)/ Anterior Knee Pain)
- Neuropathies
- Other
- Bakers Cyst (Popliteal Cyst)
- Patellar Contusion
- Pediatric Considerations
- Patellar Apophysitis (Sinding-Larsen-Johnansson Disease)
- Patellar Pole Avulsion Fracture
- Tibial Tubercle Avulsion Fracture
- Tibial Tuberosity Apophysitis (Osgood Schalatters Disease)
- Proximal Tibial Metaphyseal Fracture
- Proximal Tibial Physeal Injury
Clinical Features
- History
- History of a sport involving running, jumping
- Pain and swelling on tibial tubercle
- Symptoms are exacerbated by kneeling, jumping, running, climbing stairs
- Enlarged tibial tubercle
- Less than 25% of patients complain of pain over the tibial tuberosity (need citation)
- Initially occurs only with activity and subsides at rest, although pain at rest is a finding in later stages
- Physical Exam: Physical Exam Knee
- Tenderness over tibial tubercle, which may feel firm or irregular
- Swelling, thickening may also be observed
- Pain on resisted knee extension
- Antalgic gait, extensor lag may be present
- Notably absent are a joint effusion, restriction in range of motion
- Hamstrings, quadriceps are tight
- Special Tests
Evaluation
Fragmentation, soft tissue swelling over the tibial tuberosity[8]
More subtle fragmentation and soft tissue swelling seen over the tibial tuberosity[9]
Radiographs
- Standard Radiographs Knee
- Helpful to exclude other causes
- Findings
- Acute phase may demonstrate soft tissue swelling
- Irregularity and fragmentation of the tibial tubercle (best seen on lateral view)
- Thickening of the Patellar Tendon

Knee US demonstrating severe irregularity of the tibial tuberosity[10]
Ultrasound
- Findings

Prominent anterior tibial tubercle, associated bone marrow edema, edema of hoffa's fat pad[13]
MRI
- Not required for diagnosis
- Potential findings
- Soft tissue swelling
- Thickening and edema of inferior patellar tendon
- Fragmentation and irregularity of ossification center
Classification
- Not applicable
Management
Nonoperative
- Indications
- Virtually all cases as this is a self limited condition
- Goal is to reduce pain and swelling
- Activity Modification/ Relative Rest
- Prevent continuous contraction of extensor mechanism as guided by level of pain
- No evidence that rest speeds up recovery though activity restriction reduces pain
- May continue with sports as long as pain resolves with rest and does not limit activity
- Can implement alternative activities such as swimming, cycling
- Ice Therapy
- NSAIDS
- Protection
- Knee Pad to pad the tibial tubercle
- Patellar Strap Brace
- Physical Therapy
- Stretching of hamstrings and posterior chain as well as quadriceps
- Formal physical therapy if conservative measures are not effective
- Dextrose Prolotherapy
- Topol et al found it superior to usual care resulting in more rapid, frequent return to pain free athletic activities[14]
- Not recommended
- Corticosteroid Injection can cause subcutaneus atrophy, rupture of the patellar tendon[15]
Operative
- Indications
- Failure of conservative therapy with persistent symptoms
- After physeal fusion has completed
- Technique
- Ossicle excision may be performed in skeletally mature patients with persistent symptoms
Rehab and Return to Play
Rehabilitation
- Postoperative[16]
- Hinged knee brace locked in extension, full weight bearing for 3-4 weeks
- Early passive ROM
- Straight leg raises
- At 4-6 weeks, begin active range of motion, strengthening
Return to Play
- May continue with sports as long as pain resolves with rest and does not limit activity
Complications and Prognosis
Prognosis
- Self limited condition which resolves at the end stages of skeletal growth
- Symptoms may persist for years until the physis fuses
- Cases lasting 12-24 months have been reported[17]
- Surgical
- Pihlajamaki et al performed surgery on 178 refractory in military recruits.
- They found 87% reported no restrictions, 75% hard return to pre-operative level of activity, 38% had no pain when kneeling
- Pihlajamaki et al performed surgery on 178 refractory in military recruits.
Complications
- Thickened or prominent tibial tubercle (often asymptomatic)
- Early Knee Osteoarthritis[18]
- Postoperatively, quadriceps wasting
See Also
- Internal
- External
- Sports Medicine Review Knee Pain: https://www.sportsmedreview.com/by-joint/knee/
References
- ↑ Ogden JA, Southwick WO (1976) Osgood–Schlatter’s disease and tibial tuberosity development. Clin Orthop Relat Res 116:180–189
- ↑ Osgood Schlatter syndrome. Gholve PA, Scher DM, Khakharia S, et al. http://journals.lww.com/co-pediatrics/Abstract/2007/02000/Osgood_Schlatter_syndrome.8.aspx. Curr Opin Pediatr. 2007;19(1):44–50
- ↑ 3.0 3.1 de Lucena GL, dos Santos Gomes C, Guerra RO (2011) Prevalence and associated factors of Osgood–Schlatter syndrome in a population-based sample of Brazilian adolescents. Am J Sports Med 39(2):415–420
- ↑ Kujala UM, Kvist M, Heinonen O (1985) Osgood–Schlatter’s disease in adolescent athletes. Retrospective study of incidence and duration. Am J Sports Med 13(4):236–241
- ↑ https://radiopaedia.org/cases/8146
- ↑ Gholve PA, Scher DM, Khakharia S, Widmann RF, Green DW (2007) Osgood Schlatter syndrome. Curr Opin Pediatr 19(1):44–50
- ↑ Michaleff, Zoe A., et al. "Consultation patterns of children and adolescents with knee pain in UK general practice: analysis of medical records." BMC musculoskeletal disorders 18.1 (2017): 1-12.
- ↑ https://radiopaedia.org/cases/7511
- ↑ https://radiopaedia.org/cases/12158
- ↑ Blankstein A. Ultrasound in the diagnosis of clinical orthopedics: The orthopedic stethoscope. World J Orthop 2011; 2(2): 13-24
- ↑ Blankstein A, Cohen I, Heim M, Diamant L, Salai M, Chechick A, Ganel A (2001) Ultrasonography as a diagnostic modality in Osgood–Schlatter disease. A clinical study and review of the literature. Arch Orthop Trauma Surg 121(9):536–539
- ↑ Osgood-Schlatter lesion: fracture or tendinitis? Scintigraphic, CT, and MR imaging features. Rosenberg ZS, Kawelblum M, Cheung YY, et al. Radiology. 1992;185(3):853–858
- ↑ https://radiopaedia.org/cases/14154
- ↑ Topol GA, Podesta LA, Reeves KD, Raya MF, Fullerton BD, Yeh HW (2011) Hyperosmolar dextrose injection for recalcitrant Osgood–Schlatter disease. Pediatrics 128(5):e1121–e1128
- ↑ Rostron PK, Calver RF (1979) Subcutaneous atrophy following methylprednisolone injection in Osgood–Schlatter epiphysitis. J Bone Joint Surg Am 61(4):627–628
- ↑ Baltaci G, Ozer H, Tunay VB (2004) Rehabilitation of avulsion fracture of the tibial tuberosity following Osgood–Schlatter disease. Knee Surg Sports Traumatol Arthrosc 12(2):115–118
- ↑ Danneberg, Dirk-Jonas. "Successful Treatment of Osgood–Schlatter Disease with Autologous-Conditioned Plasma in Two Patients." Joints 5.03 (2017): 191-194.
- ↑ Robertsen K, Kristensen O, Sommer J (1996) Pseudoarthrosis between a patellar tendon ossicle and the tibial tuberosity in Osgood–Schlatter’s disease. Scand J Med Sci Sports 6(1):57–59
Created by:
John Kiel on 30 June 2019 20:35:01
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Last edited:
4 October 2022 15:57:43
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