Apophysitis of the tibial tubercle is a chronic fatigue injury due to repeated microtrauma at the patellar tendon insertion onto the tibial tuberosity, that causes pain and swelling below the knee joint, where the patellar tendon attaches to the top of the shinbone (tibia), a spot called the tibial tuberosity and usually affecting boys between ages 10-and 15 years. When the quadriceps muscle on the front of the thigh works, it pulls on the patellar tendon. The tendon in turn pulls on the tibial tuberosity. If the tension is too great and occurs too often while the bone is developing, it can pull the growth area of the tibial tuberosity away from the growth area of the shinbone. Treatment includes conservative and surgical options. Conservative treatment includes modifying physical activities, using ice packs, nonsteroidal anti-inflammatory drugs (NSAIDs), braces, and pads.
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)
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
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 the 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)
Causes
- Caused by repetitive strain and microtrauma from extensor forces applied by the patellar tendon onto the apophysis of the tibial tubercle
- 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
- Infrapatellar Bursitis
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]
- Underage 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
- Biomechanical
- Poor flexibility of quadriceps and hamstrings
- Extensor mechanism misalignment
- Sports
- Basketball
- Volleyball
- Gymnastics
- Soccer
- Lacrosse
- Figure skating
Differential Diagnosis
- Fractures
- Distal Femur Fracture
- Patellar Fracture
- Tibial Plateau Fracture
- Dislocations & Subluxations
- Patellar Dislocation (and subluxation)
- Knee Dislocation
- Proximal Tibiofibular Joint Dislocation
- Muscle and Tendon Injuries
- Quadriceps Contusion
- Iliotibial Band Syndrome
- Quadriceps Tendonitis
- Patellar Tendonitis
- Popliteus Tendinopathy
- Extensor Mechanism Injury
- Patellar Tendon Rupture
- Quadriceps Tendon Rupture
- Patellar Fracture
- Ligament Pathology
- ACL Injury
- PCL Injury
- MCL Injury
- LCL Injury
- Meniscal Pathology
- Posterolateral Corner Injury
- Multiligament Injury
- Arthropathies
- Knee Osteoarthritis
- Septic Arthritis
- Gout
- Bursopathies
- Prepatellar Bursitis
- Pes Anserine Bursitis
- MCL Bursitis
- Infrapatellar Bursitis
- Patellofemoral Pain Syndrome (PFPS)/ Anterior Knee Pain)
- Chondromalacia Patellae
- Patellofemoral Osteoarthritis
- Osteochondral Defect Knee
- Plica Syndrome
- Infrapatellar Fat Pad Impingement
- Patellar Instability
- Neuropathies
- Saphenous Nerve Entrapment
- Other
- Bakers 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)
Diagnosis
- 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 the 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
Radiographs
- Standard Radiographs Knee
- Helpful to exclude other causes
- Findings
- The 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 demonstrates 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 the inferior patellar tendon
- Fragmentation and irregularity of ossification center
Treatment
Nonoperative
- Indications
- In virtually all cases as this is a self-limited condition
- The goal is to reduce pain and swelling
- Activity Modification/ Relative Rest
- Prevent continuous contraction of extensor mechanism as guided by the 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 a more rapid, frequent return to pain-free athletic activities[14]
- Not recommended
- Corticosteroid Injection can cause subcutaneous atrophy, rupture of the patellar tendon[15]
Operative
- Indications
- Failure of conservative therapy with persistent symptoms
- After physeal fusion has been completed
- Technique
- Ossicle excision may be performed in skeletally mature patients with persistent symptoms
