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Tibial Tuberosity Apophysitis

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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

Associated Conditions

Pathoanatomy

  • Extensor Mechanism
  • 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


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

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
    • New bone or callous formation, fragmentation[11]
    • Soft tissue edema of patellar tendon
    • infrapatellar bursitis[12]
    • Thickening of the patellar tendon
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
  • 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

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

Complications

  • Thickened or prominent tibial tubercle (often asymptomatic)
  • Early Knee Osteoarthritis[18]
  • Postoperatively, quadriceps wasting

See Also


References

  1. Ogden JA, Southwick WO (1976) Osgood–Schlatter’s disease and tibial tuberosity development. Clin Orthop Relat Res 116:180–189
  2. 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. 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
  4. 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
  5. https://radiopaedia.org/cases/8146
  6. Gholve PA, Scher DM, Khakharia S, Widmann RF, Green DW (2007) Osgood Schlatter syndrome. Curr Opin Pediatr 19(1):44–50
  7. 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.
  8. https://radiopaedia.org/cases/7511
  9. https://radiopaedia.org/cases/12158
  10. Blankstein A. Ultrasound in the diagnosis of clinical orthopedics: The orthopedic stethoscope. World J Orthop 2011; 2(2): 13-24
  11. 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
  12. 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
  13. https://radiopaedia.org/cases/14154
  14. 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
  15. Rostron PK, Calver RF (1979) Subcutaneous atrophy following methylprednisolone injection in Osgood–Schlatter epiphysitis. J Bone Joint Surg Am 61(4):627–628
  16. 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
  17. Danneberg, Dirk-Jonas. "Successful Treatment of Osgood–Schlatter Disease with Autologous-Conditioned Plasma in Two Patients." Joints 5.03 (2017): 191-194.
  18. 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
Last edited:
30 July 2021 13:51:32