Persistent Osgood Schlatter Disease
Osgood Schlatter, also known as tibia apophysitis, is typically a condition seen in patients aged 9 to 15 years old (1). Pain from Osgood Schlatter disease (OSD) is due to the repetitive traction force across the tibia tubercle apophysis (1). The tibia tubercle is typically found 3cm distal to the tibia articular surface (3). The patella tendon will insert at the tibia tubercle (3). The repetitive stress at the tibia tubercle can lead to a chronic avulsion of the secondary ossification center (1). Over time, this chronic avulsion can lead to a fibrous nonunion that leads to a chronic ossicle remaining in the patella tendon (1).
There are multiple hypotheses as to why some patients experience persistent pain in adulthood. One hypothesis is that the ossicle within the patella can acts as an irritant (6). Alternatively, the enlarged tibia tubercle has also been thought to act as a mechanical irritant on the patella tendon (6).
Research has shown that 60% of patients with adolescent OSD will continue to have pain that continues into adulthood (1). Patients will typically complain of pain with repetitive kneeling, jumping, and running (1). It is less common to experience pain with rest (6). Physical exam may reveal swelling and enlargement of the tibia tubercle (2). The tibia tubercle may also be painful to touch.
Standard lateral radiographs of the knee can show fragmentation at the level of the tibia tubercle (3). The fragmentation can help differentiate from other pathologies at the tibia tubercle, like an osteochondroma of the tibia, which would not be fragmented (3). MRIs can also show edema at the tibia tuberosity and also infrapatellar bursitis (3). Due to the fragments seen within the patella tendon insertion on MRI, the tendon may appear enlarged and edematous (4).
Pain localized over the tibia tubercle from either an enlarged tibia tubercle or ossicle within the patella tendon is first treated conservatively. Activity modifications are necessary and then physical therapy with a focus on quadricep and hamstring strengthening (1). Patients can also try a strap brace or knee compression sleeve (2). Injections of corticosteroids in the area of the tibia tubercle can lead to skin atrophy, skin hypopigmentation, and potentially patella tendon rupture. Studies have also looked at injecting hypertonic dextrose into both the most distal portion of pain over the tibia tubercle and within the painful portion of the patella tendon (5). There is mixed data on the usefulness of the hypertonic dextrose injection for OSD (5).
Some patients will fail conservative treatment and will need to consider surgical options. Surgery can involve debridement of the tendon irritant or drilling at the tibial apophysis to encourage healing (1). Ossicle debridement is typically done arthroscopically (8). If pain persists after ossicle debridement, a reduction osteotomy of the tibia tubercle can be done (6). Ossicle removal and tibia tubercle osteotomy during the same surgery can also be done.
Pain from OSD is typically self limiting in adolescence. However, some patients will have persistent pain with kneeling. Those patients can be treated conservatively with physical therapy and activity modification. If pain remains persistent, a variety of surgical options exist with no clear consensus for treatment.
By Gregory Rubin, DO
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1) Pagenstert, Geert, et al. “Reduction Osteotomy of the Prominent Tibial Tubercle After Osgood-Schlatter Disease.” Arthroscopy: The Journal of Arthroscopic & Related Surgery: Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association, vol. 33, no. 8, Aug. 2017, pp. 1551–57. PubMed, https://doi.org/10.1016/j.arthro.2017.02.012.
2) Neuhaus, Cornelia, et al. “A Systematic Review on Conservative Treatment Options for OSGOOD-Schlatter Disease.” Physical Therapy in Sport: Official Journal of the Association of Chartered Physiotherapists in Sports Medicine, vol. 49, May 2021, pp. 178–87. PubMed, https://doi.org/10.1016/j.ptsp.2021.03.002.
3) Rajakulasingam, R., et al. “Tibial Tuberosity Lesions.” Clinical Radiology, vol. 76, no. 2, Feb. 2021, p. 153.e1-153.e7. PubMed, https://doi.org/10.1016/j.crad.2020.07.027.
4) Gill, Kara G., et al. “Magnetic Resonance Imaging of the Pediatric Knee.” Magnetic Resonance Imaging Clinics of North America, vol. 22, no. 4, Nov. 2014, pp. 743–63. PubMed, https://doi.org/10.1016/j.mric.2014.07.010.
5) Topol, Gastón Andrés, et al. “Hyperosmolar Dextrose Injection for Recalcitrant Osgood-Schlatter Disease.” Pediatrics, vol. 128, no. 5, Nov. 2011, pp. e1121-1128. PubMed, https://doi.org/10.1542/peds.2010-1931.
6) Arendt, Elizabeth A. “Editorial Commentary: Tibial Tubercle Prominence After Osgood-Schlatter Disease: What Causes Pain?” Arthroscopy: The Journal of Arthroscopic & Related Surgery: Official Publication of the Arthroscopy Association of North America and the International Arthroscopy Association, vol. 33, no. 8, Aug. 2017, pp. 1558–59. PubMed, https://doi.org/10.1016/j.arthro.2017.04.001.
7) Gaulrapp, Hartmut, and Christian Nührenbörger. “The Osgood-Schlatter Disease: A Large Clinical Series with Evaluation of Risk Factors, Natural Course, and Outcomes.” International Orthopaedics, vol. 46, no. 2, Feb. 2022, pp. 197–204. PubMed, https://doi.org/10.1007/s00264-021-05178-z.
8) Tsakotos, George, et al. “Osgood-Schlatter Lesion Removed Arthroscopically in an Adult Patient.” Cureus, vol. 12, no. 3, Mar. 2020, p. e7362. PubMed, https://doi.org/10.7759/cureus.7362.
9) El-Husseini, Timour F., and Amr Atef Abdelgawad. “Results of Surgical Treatment of Unresolved Osgood-Schlatter Disease in Adults.” The Journal of Knee Surgery, vol. 23, no. 2, June 2010, pp. 103–07. PubMed, https://doi.org/10.1055/s-0030-1267474.