Osteochondrosis; Causes, Symptoms, Diagnosis, Treatment

Osteochondrosis/Osgood Schlatter disease occurs most often in children who participate in sports that involve running, jumping and swift changes of direction- such as soccer, basketball, figure skating, and ballet. It is an inflammation of the area just below the knee where the tendon from the kneecap (patellar tendon) attaches to the shinbone (tibia). Osgood-Schlatter disease most often occurs during growth spurts, when bones, muscles, tendons, and other structures are changing rapidly.

Osgood–Schlatter disease is an injury in which inflammation occurs in the epiphyseal cartilage of the tibial tubercle by repeated traction [rx–rx]. Young athletes are thought to suffer from injuries such as Osgood–Schlatter disease through overuse of the body when it cannot cope with the stress incurred on the tibial tubercle while it is still mechanically vulnerable [rx, rx].  It occurs secondary to repetitive strain and microtrauma from the force applied by the strong patellar tendon at its insertion into the relatively soft apophysis of the tibial tubercle. It is a painful, growth-related overuse condition of the tibial tuberosity, leading to inflammation of the patellar ligament at the tibial tuberosity. It primarily affects young adolescents, athletic population, and usually, resolves with age or skeletal maturity. Therapy is usually conservative, with surgery indicated in a minority of cases. Predisposing factors include poor flexibility of quadriceps and hamstrings or other evidence of extensor mechanism misalignment.

Another name

Osgood Schlatter’s disease, osteochondrosis or traction apophysitis of the tibial tubercle, apophysitis of the tibial tubercle

History of Osgood Schlatter Disease

It is named after

• Robert B. Osgood: Boston orthopedic surgeon (1873-1956)
• Carl Schlatter: Swiss professor of surgery (1864-1934)

Epidemiology > demographics

• male – female ratio >more common in boys
• age bracket > boys 12-15y , girls 8-12y

Location

• bilateral in 20-30%

Risk factors

• jumpers (basketball, volleyball)  or sprinters
• Basketball
• Volleyball
• Sprinters
• Gymnastics
• Football
• Soccer
• Cross-country track and distance running

Pathophysiology

• Stress from extensor mechanism
• Self-limiting but does not resolve until growth has halted

Anatomy

Tibial tubercle is a secondary ossification center  

• age <11y, tubercle is cartilaginous
• age 11-14y, apophysis forms
• age 14-18y, apophysis fuses with a tibial epiphysis
• age >18y, epiphysis (and apophysis) is fused to rest of tibia

Knee Pathology of Osgood Schlatter Disease

The knee is a complex synovial joint that can be affected by a range of pathologies, bone, and cartilage

The appearance and closure/fusion of the tibial tubercle occurs in the following sequence pattern

• Tibial tubercle is entirely cartilaginous (age < 11 years)
• Apophysis forms (age 11 to 14 years)
• Apophysis fuses with the proximal tibial epiphysis (age 14 to 18 years)
• The proximal tibial epiphysis and tibial tubercle apophysis fuses with the rest of the proximal tibia (age > 18 years)

Knee fractures

OSD may result in an avulsion fracture, with the tibial tuberosity separating from the tibia (usually remaining connected to a tendon or ligament). This injury is uncommon because there are mechanisms that prevent strong muscles from doing damage. The fracture on the tibial tuberosity can be a complete or incomplete break.

• Type I – A small fragment is displaced proximally and does not require surgery.
• Type II – The articular surface of the tibia remains intact and the fracture occurs at the junction where the secondary center of ossification and the proximal tibial epiphysis come together (may or may not require surgery).
• Type III – Complete fracture (through the articular surface) including the high chance of meniscal damage. This type of fracture usually requires surgery.

Causes Osgood Schlatters Disease

Osgood-Schlatters may be caused by any condition that puts extra stress on the patellar tendon resulting in small breaks at the attachment site. Some of the common causes:

The Symptoms of Osgood Schlatter Disease

• Local pain, swelling, and tenderness over the tibial tuberosity at the attachment of the patellar tendon.
• Pain is experienced during exercise (e.g., running, jumping) or with direct contacts, such as in kneeling.
• Stairs, squatting and kneeling may be painful.
• Quadriceps weakness can be present is chronic cases.
• Bilateral symptoms occur in 20-30% of cases.
• The apophysis may be enlarged in later stages, which looks like a lump that is tender in its active phase.
• Waxing and waning anterior Knee Pain for months
• Bilateral in up to one third of patients
• Knee Pain aggravated by
  • Running
  • Jumping or hurdling
  • Going up and down stairs
  • Direct pressure wwith kneeling
  • Squatting

With Osgood-Schlatter, you may  also experience

• Gradually worsening pain below your knee, at the top of the shin bone.
• Pain that worsens with exercise.
• Swelling and tenderness at the top of the shin.
• A boney growth at the top of the shin.
• Loss of strength in the quadriceps muscle (connecting the hip to the knee).
• Increased tightness in the quadriceps muscle.
• Loss of knee motion.
• Discomfort with daily activities that use your knee, like kneeling, squatting, or walking up and down stairs.

Diagnosis of Osgood Schlatter Disease

Imaging differential considerations include

• Sinding-Larsen-Johansson syndrome: equivalent condition involving the inferior pole of the patella
• jumper’s knee: involves the patellar tendon rather than the bone, and is essentially tendinopathy with focal tenderness, although it may eventually be associated with bony changes (some authors do not distinguish between SLJ and jumper’s knee)
• infrapatellar bursitis

Plain radiograph

Soft tissue swelling with loss of the sharp margins of the patellar tendon is the earliest signs in the acute phase; thus a compatible history is also essential in making the diagnosis. Bone fragmentation at the tibial tubercle may be evident 3 to 4 weeks after the onset.

It is important not to equate isolated ‘fragmentation’ of the apophysis with OSD, as there may well be secondary centers of ossification.

Ultrasound

Ultrasound examination of the patellar tendon can depict the same anatomic abnormalities as can plain radiographs, CT scans, and magnetic resonance images. The sonographic appearances of Osgood-Schlatter disease include ³:

• swelling of the unossified cartilage and overlying soft tissues
• fragmentation and irregularity of the ossification center with reduced internal echogenicity
• thickening of the distal patellar tendon
• infrapatellar bursitis

MRI

MRI, as expected, is more sensitive and specific, and will demonstrate:

• soft-tissue swelling anterior to the tibial tuberosity
• loss of the sharp inferior angle of the infrapatellar fat pad (Hoffa’s fat pad)
• thickening and edema of the inferior patellar tendon
• infrapatellar bursitis (clergyman’s knee)
• a distended deep infrapatellar bursa can be a frequent finding
• bone marrow edema may be seen at the tibial tubercle

Joint Flexibility Testing

• Several methods for measuring joint flexibility have been previously reported. The Beighton method measures the 5 joints of the finger, elbow joint, knee joint, and trunk.^[rx] Alternatively, general joint laxity tests can be conducted on the 7 main joints in the body (wrist, elbow, shoulder, hip, knee, ankle, and spinal column).^[rx] Both methods are similar and are known to be highly reliable.

Treatment of Osgood Schlatter Disease

General measures

• Most patients respond to conservative treatment consisting of rest from painful activities and application of ice.
• Advice about exercise should be tailored to the level of pain experienced by the patient, ie if they are able to continue with minimal discomfort, advise them to continue and return if they deteriorate. If symptoms are disturbing normal routine, a change may be needed in duration, frequency or intensity of exercise.
• Physiotherapy can be helpful by stretching, strengthening, and reducing muscle imbalance of the quadriceps, hamstrings, calf muscles, and iliotibial band.
• If patients cannot tolerate a modified programme, a period of rest should be advised. Once symptoms have decreased to an acceptable level, advice introducing low-impact quadriceps exercises before gradually increasing the intensity of exercise. If symptoms recur, patients should stop exercises or reduce their intensity. Gradually re-establish exercise or increase exercise intensity on the basis of symptoms.
• Referral to a physiotherapist may be necessary to manage rehabilitation, particularly if recovery is slow.
• If pain persists into adulthood a referral to secondary care for assessment is recommended.

Knee Protection

• Immediate restriction of high impact activities such as jumping and running.
• Use an infrapatellar knee strap to dissipate forces away from the site of Osgood Schlatter’s Disease.
• Kinesiology taping may provide both pain relief and load reduction at the site of pain and injury.
• Only on rare occasions, severe Osgood Schlatter’s disease may require crutches.

Consult with your physiotherapist for the best advice specific to your knee.

Physiotherapy Management

The goal of physical therapy is to accelerate your recovery and return to pain-free activity. There are many physical therapy treatments that have been shown to be effective in treating OS, and among them are:

• The range of Motion Therapy – Your physical therapist will assess the motion of your knee and its surrounding structures, and design gentle exercises to help you work through any stiffness and swelling to return to a normal range of motion.
• Strength Training – Your physical therapist will teach you exercises to strengthen the muscles around the knee so that each muscle is able to properly perform its job, and stresses are eased so the knee joint is properly protected.
• Knee Stretching Exercises – Osgood Schlatter disease is caused by muscle length not keeping up with bone growth during growth spurts. Stretching the thigh muscles will combat this and reduce the tension on the tibial tuberosity. Click the link to find out the quickest, most effective ways to stretch the knee muscles.
• Strengthening Exercises – ensuring there is no muscle weakness around the knee can help to reduce the chance of developing Osgood Schlatters.
• Manual Therapy – Physical therapists are trained in manual (hands-on) therapy. If needed, your physical therapist will gently move your kneecap or patellar tendon and surrounding muscles as needed to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own.
• Pain Management – Your physical therapist may recommend therapeutic modalities, such as ice and heat, or a brace to aid in pain management.
• Functional Training – Physical therapists are experts at training athletes to function at their best. Your physical therapist will assess your movements and teach you to adjust them to relieve any extra stress on the front of your knee.
• Education – The first step to addressing your knee pain is rest. Your physical therapist will explain why this is important and develop a plan for your complete rehabilitation.
• Ice & TENS Machine – A combination of ice treatment and a home tens machine will reduce pain and improve the healing rate. This usually hastens the recovery rate of sufferers. Ice is useful at home or after exercise.
• Functional Training – Rest is important in the management of Osgood Schlatter disease and relief of pain. Whether or not you should continue playing sport is dependent on symptoms. It is best to discuss your exercise workload with your physiotherapist for advice on how to best manage your return sport while respecting your injury.
• Foam Rollers Exercise – One of the common reasons for developing Osgood Schlatter’s disease is excessively tight quadriceps muscles, ITB, hamstrings, hip flexors, and calf muscles. Your physiotherapist will prescribe specific stretches for you if they assess that you are tight in these muscle groups. Massage and foam rollers are beneficial especially in the early phase when stretches create pain at the Osgood Schlatter’s disease site.
• Strengthening Exercise- Your muscle control around the knee will usually need to be addressed to control or maintain your symptoms during the active phase of Osgood Schlatter’s Disease. Your physiotherapist will commonly prescribe or modify exercises for you.
• Foot Arch Control & Orthotics – Your foot biomechanics or arch control may be inadequate for your intensity of the sport. Your physiotherapist can assist both the assessment and corrective exercises for your dynamic foot control.
• Active Foot Correction Exercises –  can be beneficial as both a preventative and corrective strategy. Occasionally, your foot biomechanics may be predisposing you to torsional stresses that can cause abnormal knee forces, which can cause knee injury. In these instances, foot orthotics may need to be prescribed. There are mixed views on how effective these are since the foot structure is rapidly changing at this age. Ask your physiotherapist or podiatrist for advice.

Pharmacological

• Medication – Common pain remedies such as aspirin, acetaminophen, ibuprofen, and naproxen can offer short-term relief. Other medications, including muscle relaxants and anti-seizure medications, treat aspects of spinal stenoses, such as muscle spasms and damaged nerves.
• Corticosteroid injections – Your doctor will inject a steroid such as prednisone into your back or neck. Steroids make inflammation go down. However, because of side effects, they are used sparingly.
• Anesthetics – Used with precision, an injection of a “nerve block” can stop the pain for a time.
• Muscle Relaxants – These medications provide relief from spinal muscle spasms.
• Neuropathic Agents – Drugs(pregabalin &gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
• Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
• Topical Medications: These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
• Calcium & vitamin D3 – to improve bones health and healing fracture.
• Glucosamine & diacerein – can be used to tightening the loose tension and regenerate cartilage or inhabit the further degeneration of cartilage.
• Corticosteroid– to healing the nerve inflammation and clotted blood in the joints. Lumbar epidural steroid or anesthetic injections have low-quality evidence to support their use
• Diatery suppliment -to remove the general weakness & improved the health.
• Ice
• Knee (tendon) brace
• Sleep Medications
• Anti-inflammatory drugs

Alternatively, you can simply take medical marijuana orally and use a cannabis oil salve, lotion or crème on the affected area.

• Cannabis oil  (orally)
• Cannabis salve, lotion or crèm
• vitamin
• selenium
• zinc, manganese, and vitamin B6
• ice affected area
• rest from the activity
• anti-inflammatory drugs
• Simple analgesia such as paracetamol or ibuprofen, as needed, for pain.
• Corticosteroid injection is not recommended.
• One study has shown that injection of the patellar tendon enthesis/tibial apophysis with 12.5% dextrose was safe and well tolerated in adolescents with recalcitrant Osgood-Schlatter disease. This treatment resulted in more rapid and frequent achievement of unaltered sport and asymptomatic sport.

Surgical for Osgood Schlatter Disease

• Surgery is rarely required.
• Some patients who have recurrent symptoms into adulthood may require surgical treatment.
• There may be an ossicle under the distal patellar tendon as a consequence of the disease.
• Subperiosteal dissection of the osseous fragment is usually undertaken.
• Surgical treatment usually gives excellent results in these unresolved cas

Brace Use

• The Bort Osgood Schlatters Brace – Knee Support for Osgood Schlatter is one of BraceAbility’s higher quality braces for Osgood Schlatters disease. It features anatomically contoured knit, a splint on either side of the knee for lateral support and a silicone pad insert for Osgood Schlatters disease treatment.

Low-profile Osgood Schlatter Band

• Looking for a less restrictive way of treating Osgood Schlatters? The DeRoyal Osgood Schlatters Band – Osgood Schlatter Strap has a very low-profile design that makes it ideal for use with activity. It provides tension control over the patella tendon, making it an effective treatment for Osgood Schlatters disease.

It is also suitable for treating:

• Jumper’s knee/patella tendonitis
• Runner’s knee

The Exercise of Osgood Schlatter Disease

Quadriceps Stretching

Research indicates that a loss of knee flexion range of motion—likely due to tight quadriceps— may be one cause of Osgood-Schlatter disease. Stretching the quads can help take pressure off the patellar tendon and tibial tubercle where Osgood-Schlater knee pain is felt.

An easy exercise for children to do is the towel quad stretch. To perform the stretch, lie on your stomach, and bend your knee up as far as possible. Loop a towel around your ankle, and grasp the towel to gently pull your knee up further. You should feel a stretch in the front of your thigh. Hold the stretch for 15 seconds, and then release slowly. Repeat 3 times.

The hamstring muscles course along the back of your thighs from your hip to just behind your knees. Tightness here may create excessive tension in the knee when your child is straightening their knees out.

Stretching your hamstrings can be an important component of your Osgood-Schlatter exercise plan. Performing the towel hamstring stretch or a standing hamstring stretch are simple ways to improve the flexibility of the hammys. Hold each stretch for 15 seconds and perform 3 times for each stretch.

Tightness in your calf muscles may change the way your knee moves when walking and running, and this may place increased stress through your patella tendon, leading to Osgood-Schlatter disease.

Working on calf stretches can help improve the flexibility of your lower extremity, leading to a decrease in knee pain while running.

Be sure to hold your stretches for about 15 seconds and repeat each one 3 times. Stretches should be done slowly and gently and should be stopped if the pain is felt.

Osgood-Schlatter disease is mainly thought to be a problem that comes with rapid growth in a child, and therefore a lack of muscle flexibility is considered the main cause of the knee pain that comes with the diagnosis. Does that mean that strengthening should be ignored? Not at all.

Keeping your lower extremity muscles strong can help keep stress and strain to a minimum at the painful areas in the front of your knees. Exercise should include:

• Knee exercises
• Hip strengthening
• Ankle strengthening

Most people benefit from performing 10 to 15 repetitions of each exercise a few times a week to maintain good muscle strength in the lower extremities.

Balance and Coordination

Some people with Osgood-Schlatter disease may exhibit impaired balance or proprioception, and this may place excessive strain on the knees, especially during high-level sports and activities. Keeping balance in tip-top shape may help lessen the pain that your child feels in his or her knees.

Balance exercises may include:

• The single leg stance
• The T-stance
• The BAPS board

Working on proprioception exercises requires that you create situations where your balance may be compromised, so safety is a must at all times. Check in with your PT to find the best way to accomplish this task.

• Rectus femoris stretch – Kneel on your injured knee on a padded surface. Place your other leg in front of you with your foot flat on the floor. Keep your head and chest facing forward and upright and grab the ankle behind you. Gently bring your ankle back toward your buttocks until you feel a stretch in the front of your thigh. Hold 15 to 30 seconds. Repeat 2 to 3 times.
• Straight leg raising – Lie on your back with your legs straight out in front of you. Bend the knee on your uninjured side and place the foot flat on the floor. Tighten the thigh muscle on your injured side and lift your leg about 8 inches off the floor. Keep your leg straight and your thigh muscle tight. Slowly lower your leg back down to the floor. Do 2 sets of 15.
• Prone hip extension – Lie on your stomach with your legs straight out behind you. Fold your arms under your head and rest your head on your arms. Draw your belly button in towards your spine and tighten your abdominal muscles. Tighten the buttocks and thigh muscles of the leg on your injured side and lift the leg off the floor about 8 inches. Keep your leg straight. Hold for 5 seconds. Then lower your leg and relax. Do 2 sets of 15.
• Knee stabilization – Wrap a piece of elastic tubing around the ankle of your uninjured leg. Tie a knot in the other end of the tubing and close it in a door at about ankle height. Stand to face the door on the leg without tubing (your injured leg) and bend your knee slightly, keeping your thigh muscles tight. Stay in this position while you move the leg with the tubing (the uninjured leg) straight back behind you. Do 2 sets of 15. Turn 90 degrees so the leg without tubing is closest to the door. Move the leg with tubing away from your body. Do 2 sets of 15. Turn 90 degrees again so your back is to the door. Move the leg with tubing straight out in front of you. Do 2 sets of 15. Turn your body 90 degrees again so the leg with tubing is closest to the door. Move the leg with tubing across your body. Do 2 sets of 15. Hold onto a chair if you need help balancing. This exercise can be made more challenging by standing on a firm pillow or foam mat while you move the leg with tubing.
• Side-lying leg lift – Lie on your uninjured side. Tighten the front thigh muscles on your injured leg and lift that leg 8 to 10 inches (20 to 25 centimeters) away from the other leg. Keep the leg straight and lower it slowly. Do 2 sets of 15.
• Clam exercise – Lie on your uninjured side with your hips and knees bent and feet together. Slowly raise your top leg toward the ceiling while keeping your heels touching each other. Hold for 2 seconds and lower slowly. Do 2 sets of 15 repetitions.

Other Osgood Schlatters Treatment Components

• But of course, how to treat Osgood Schlatters is not with orthotics alone. In fact, simply wearing a band or brace for the condition may not bring relief.
• Perhaps the best treatment for Osgood Schlatter disease is taking a rest from or limiting one’s time doing activities that irritate the knee. A brace can help ease irritation from the limited activity.
• Over-the-counter anti-inflammatory pain medications can relieve pain and bring down any swelling, which can help with treatment for Osgood Schlatters. The same can be said for ice and heat therapy
• Stretching these muscles before and after participation in sports or other physically exerting activities is another important element of Osgood Schlatter’s treatment for a child.

Prevention

Fortunately, there is much that can be done to prevent the cascade of events that lead to OS. Physical therapists focus on:

• Educating coaches, parents, and athletes on guidelines for sports participation, explaining common causes of overuse injuries, and providing strategies for prevention.
• Educating athletes on the risks of playing through pain.
• Scheduling adequate rest time to recover between athletic events.
• Tracking a young athlete’s growth curves (height, weight, BMI) to identify periods of increased injury risk.
• Developing an athlete-specific flexibility and strengthening routine to be followed throughout the athletic season.
• Encouraging consultation with a physical therapist whenever symptoms appear.

References