Osgood-Schlatter Disease

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0196-6011/85/0701 -0005$02.00/0 THE JOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyright 0 1985 by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association Osgood-Schlatter Disease: Review of Literature and Physical Therapy Management T. J. ANTICH, MS, PT,* CLlVE E. BREWSTER, MS, PT Osgood-Schlatter disease is a traction apophysitis of the tibial tubercle, the weakest link of the extensor mechanism of the adolescent. Conventional medical treatment includes plaster casting, injections of various anti-inflammatories, and surgical removal of painful ossicles in resistant cases. While not a very common condition, Osgood-Schlatter disease is being seen with increasing frequency in teenage athletes, especially basketball players (Antich, Lombardo, J Orthop Sports Phys Ther 7: 1-4, 1985.) With a focus on muscular tightness as a possible causative factor, physical therapy evaluation is outlined, followed by techniques for pain control and stretching exercises for the quadriceps and hamstrings. Ice massage is advocated as a way for the athlete to treat postexertional discomfort in the area of the tubercle. The patient and his or her parents must be assured that while residual deformity may remain, disappearance of symptoms coinciding with closure of the apophyseal plate is often the end result. Osgood-Schlhtter disease is defined as a sep- aration of the tibial tubercle apophysis from the proximal end of the tibia. This lesion may have a history of trauma, or may present without a sig- nificant recognizable injury. KatzI4 classifies this entity as a nonarticular osteochondrosis involving the quadriceps muscle/tendon insertion second- ary to excessive muscle pull. Citing the same mechanism of increased quadriceps pull on the adolescent tubercle, Smillie28 describes Osgood- Schlatter disease as a traction epiphysitis. Dor- land's Medical Dictionary gives as a synonym "apophysitis tibialis adolescentium," while Christie4 states that the radiographically evident bone changes make it a disease entity. He adds that poor epiphyseal nourishment during a time of rapid growth can lead to the onset. However, LaZerte and Rapp'sI7 histological studies of nine specimens indicate no evidence of primary aseptic necrosis in any of the tubercles examined. Increased stress on the weak link of the ado- lescent knee extensor mechanism accounts for the symptoms experienced by those patients with this ~ e s i o n . ' ~ . ' ~ ~ ~ ~ An initial injury can be furthered Department of Physical Therapy, Southwestern Orthopaedic Medical Group, Inc., 501 E. Hardy Street, Suite 200, Inglewood, CA 90301. by continuing minor t r a ~ m a t a ~ ' . ~ ~ or heterotopic calcification and ossification in the patellar liga- ment can occur secondary to o ~ e r u s e . " ~ ~ ~ In- stances of tibial tubercle fracture have been re- ported subsequent to violent quadriceps contrac- tion.'~~~ The imbalance in the cross-sectional area of the quadriceps muscle bulk to the area of insertion7 also creates a great concentration of force on. a small area. HISTOLOGY Microscopic examination of bony ossicles re- moved at surgery indicates that the separation is due to increased tension over a small area of tendon insertion. All nine cases studied by La- Zerte and RappI7 demonstrated an anterior cor- tical bone defect of the tubercle, in addition to increased vascularization of the infrapatellar ten- don surrounding the ossicles. DIAGNOSIS Osgood-Schlatter disease is easily recognized in the adolescent with complaints of pain which is localized to the area of the tibial tubercle. Discom- fort is usually generated with running,21 kneel- ing,2321 ascending or descending stair^,'^^^' and is Journal of Orthopaedic & Sports Physical Therapy® Downloaded from www.jospt.org at on August 15, 2015. For personal use only. No other uses without permission. Copyright © 1985 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

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Osgood-Schlatter Disease

Transcript of Osgood-Schlatter Disease

01 96-601 1/85/0701 -0005$02.00/0 THE JOURNAL OF ORTHOPAEDIC AND SPORTS PHYSICAL THERAPY Copyright 0 1985 by The Orthopaedic and Sports Physical Therapy Sections of the American Physical Therapy Association

Osgood-Schlatter Disease: Review of Literature and Physical Therapy Management T. J. ANTICH, MS, PT,* CLlVE E. BREWSTER, MS, PT

Osgood-Schlatter disease is a traction apophysitis of the tibial tubercle, the weakest link of the extensor mechanism of the adolescent. Conventional medical treatment includes plaster casting, injections of various anti-inflammatories, and surgical removal of painful ossicles in resistant cases. While not a very common condition, Osgood-Schlatter disease is being seen with increasing frequency in teenage athletes, especially basketball players (Antich, Lombardo, J Orthop Sports Phys Ther 7: 1-4, 1985.) With a focus on muscular tightness as a possible causative factor, physical therapy evaluation is outlined, followed by techniques for pain control and stretching exercises for the quadriceps and hamstrings. Ice massage is advocated as a way for the athlete to treat postexertional discomfort in the area of the tubercle. The patient and his or her parents must be assured that while residual deformity may remain, disappearance of symptoms coinciding with closure of the apophyseal plate is often the end result.

Osgood-Schlhtter disease is defined as a sep- aration of the tibial tubercle apophysis from the proximal end of the tibia. This lesion may have a history of trauma, or may present without a sig- nificant recognizable injury. KatzI4 classifies this entity as a nonarticular osteochondrosis involving the quadriceps muscle/tendon insertion second- ary to excessive muscle pull. Citing the same mechanism of increased quadriceps pull on the adolescent tubercle, Smillie28 describes Osgood- Schlatter disease as a traction epiphysitis. Dor- land's Medical Dictionary gives as a synonym "apophysitis tibialis adolescentium," while Christie4 states that the radiographically evident bone changes make it a disease entity. He adds that poor epiphyseal nourishment during a time of rapid growth can lead to the onset. However, LaZerte and Rapp'sI7 histological studies of nine specimens indicate no evidence of primary aseptic necrosis in any of the tubercles examined.

Increased stress on the weak link of the ado- lescent knee extensor mechanism accounts for the symptoms experienced by those patients with this ~ e s i o n . ' ~ . ' ~ ~ ~ ~ An initial injury can be furthered

Department of Physical Therapy, Southwestern Orthopaedic Medical Group, Inc., 501 E. Hardy Street, Suite 200, Inglewood, CA 90301.

by continuing minor t r a ~ m a t a ~ ' . ~ ~ or heterotopic calcification and ossification in the patellar liga- ment can occur secondary to o ~ e r u s e . " ~ ~ ~ In- stances of tibial tubercle fracture have been re- ported subsequent to violent quadriceps contrac- t i o n . ' ~ ~ ~ The imbalance in the cross-sectional area of the quadriceps muscle bulk to the area of insertion7 also creates a great concentration of force on. a small area.

HISTOLOGY

Microscopic examination of bony ossicles re- moved at surgery indicates that the separation is due to increased tension over a small area of tendon insertion. All nine cases studied by La- Zerte and RappI7 demonstrated an anterior cor- tical bone defect of the tubercle, in addition to increased vascularization of the infrapatellar ten- don surrounding the ossicles.

DIAGNOSIS

Osgood-Schlatter disease is easily recognized in the adolescent with complaints of pain which is localized to the area of the tibial tubercle. Discom- fort is usually generated with running,21 kneel- ing,2321 ascending or descending stair^,'^^^' and is

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6 ANTICH AND BREWSTER JOSPT Vol. 7, No. 1

Fig. 1 . A, Lateral view in a 12-year-old male exhibiting separ tendon at its insertion in a 13-year-old male.

relieved with rest.l4 Weakness of the quadriceps2' and pain on resisted knee e ~ t e n s i o n ~ ~ ~ ~ ~ ~ ' are common signs, as is an enlarged t~berc le.~.~ ' D'Ambrosia and MacDonald6 report reproduction of pain with passive knee flexion, which Jakob et a1.12 attribute to a hypertrophied quadriceps group exhibiting decreased flexibility.

Radiographic examination is considered nec- essary in confirming this diagnosis in the adoles- cent with knee pain. In more severe cases, sep- aration and fragmentation of the apophysis may be seen32 as well as irregular ossification of the t~berc le '~.~ ' (Fig. 1). In milder cases without radi- ographic bony changes, soft tissue swelling, es- pecially of the infrapatellar fat pads2' may be the only evidence of this disease. Mital and Matza2' check for a decreased "sharpness" in the angle formed by the tibial apophysis and the infrapatellar tendon. Patella infera, as defined by the Insall- Salvati patellar height-to-patellar tendon ratio, was seen in a group of 20 patients with Osgood- Schlatter disease (mean = 1.21 + 0.15).'6 This position was determined to be significantly lower (P < 0.05) than a group of 80 normals (mean =

1 .OO k 0.1 1 ). Conversely, Jakob et a1.12 reported

ation of the tubercle; 13, ossicle embedded within the infrapatellar

I

patella alta in their series of 185 knees utilizing the Blackburne and Peel method of measuring patellar position. The mean index of knees with Osgood-Schlatter disease was 0.99, as compared to 73 normal knees with a mean of 0.84.

Differential diagnosis of this entity includes os- teogenic sarcoma of the proximal tibia2' and os- teomyelitis of the tubercle secondary to contu- ~ i o n . ~ D'Ambrosia and MacDonald6 emphasize the need to perform a thorough examination on adults with previous histories of Osgood-Schlatter disease and report arteriovenous fistula as the cause of knee pain in one individual.

CONVENTIONAL MEDICAL TREATMENT

A wide range of treatment philosophy exists, with some belief that no treatment is needed other than for pain relief.3.'4 Improvement occurs spon- taneously in 1-2 years with or without treatment, the only sequela being residual deformity of the tibial t~berc le.~ Limitation of activity is r e c ~ m m e n d e d ~ ~ ~ ' ~ ~ ~ . ~ ~ , ~ ' . ~ ' with Willne?' more specifically restricting running and stairs for 12 weeks, and walking barefoot before the age of 15. Attributing the problem to lower extremity

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malalignment involving marked foot pronation and genu valgum, he advised decreasing the use of loafers and sneakers, and prescribed "Oxford shoes with a firm inner shank and 311 6 inch inner heel wedges." Complete relief of symptoms in 65 of 78 patients is reported in 6 weeks, with the remainder becoming pain free in 12 weeks.31

Bowers2 recommends use of salicylates and local ice application, as needed, to control pain. Conservative treatment to decrease quadriceps tension on the t u b e r c ~ e ~ l . ~ ~ and restriction of mo- tion via immobilization from 6 to 8 weeks22 to 3 months2' is suggested. ~ ichel i ,~ ' however, feels that casting is not indicated in the presence of a tight, weak quadriceps group.

Injection of the tubercle with hydrocortisone15 or with lidocaine HCI combined with hydrocor- t i~one,~ ' de~amethasone,~~ triamcino~one,~ or methy~prednisolone,~~ may be employed if restric- tion of activities and immobilization are not suc- cessful. Kelly15 utilized up to three hydrocortisone injections and reported 52 to 72 patients having relief after one injection. Eight and 9 more were improved after two and three injections, respec- tively, while 3 of the 72 did not respond to injec- tion.

Levine and ashy yap'^ advocate use of an infra- patellar strap during activities to decrease the pull of the quadriceps against the tibial tubercle and report improvement in 92% of patients treated (Table 1).

Quadriceps stretching into knee flexion with hip extension is used to stretch the muscle group and decrease tension on the apophysis. While Katz14 states that "rarely is the pain severe enough to require plaster-cast immobilization," 12°/~ of Mital and Matza's groupz2 underwent surgical removal of painful ossicles with instantaneous relief of symptoms.

COMPLICATIONS

Premature closure of the anterior tibial epiphy- sis resulting in genu recurvatum has been re- p ~ r t e d . ' ~ , ~ ~ , ~ ' Conflicting reports of patella alta'2~2',30 and patella infera16 exist, while the causal or effectual relationship with this disease

TABLE 1 Improvement with infrapatellar stap*

Definite improvement 79.1% Some improvement 12.5% No improvement 8.3%

From Levine and Kashyap.lg

is not known. Subcutaneous atrophy in 8 of 70 knees injected with methylprednisolone was seen in addition to striae formation in the skin overlying the tubercle.26 Patellar tendon avulsions are pos- sible sequellae to Osgood-Schlatter disease and from 14'' to 26%" of those seen with this fracture reported previous histories of Osgood-Schlatter disease.

PHYSICAL THERAPY EVALUATION

In assessing the patient's knee pain, location (unilateral or bilateral) of pain and its duration is documented. Whether it is painful during brief physical activity, or following prolonged activity, indicates severity. Answers to questions regard- ing presence or absence of pain while walking, running, ascending and descending stairs, and kneeling should be documented for later compar- ison.

Examining the patient's gait pattern while walk- ing, the therapist looks for an antalgic limp or other compensatory mechanism to protect the knee from pain. Special attention should be fo- cused on whether or not the individual flexes the involved knee during loading response or at- tempts to maintain full extension, thereby reduc- ing the need for quadriceps activity.

Confirmation of the diagnosis is the first task of the attending therapist. With the patient supine with both knees flexed to 90°, inspection of the tubercles is performed. By looking from the side, a silhouette image of one knee against the other reveals enlargement of the apophysis, if present (Fig. 2). Palpation of the tubercle is then performed and tenderness is assessed as none, slight, mild, moderate, or marked (Table 2).

Due to the prevalence of Osgood-Schlatter dis- ease during the early adolescent years, at a time when musculoskeletal pain may be secondary to the inability of muscles to elongate at the same rate as bony growth, tightness of knee muscula- ture must be checked. With the patient still supine, hamstring length is assessed by the examiner's flexing the hip while maintaining the knee in full extension. Comparison between involved and un- involved limbs in unilateral problems, or compari- son to normal values in the cases of bilateral involvement, aids the therapist in deciding whether or not muscular tightness plays a role in the conditon.

Knee flexion range of motion, taking into ac- count rectus femoris tightness, is performed with the patient prone (Fig. 3). The knee is passively

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BREWSTER JOSPT Vol. 7, No. 1

Fig. 4. Hamstring stretching is performed with a 10-sec static stretch. Note limited flexibility in this patient with posterior pelvic rotation (tight lumbodorsal fascia), inability to keep knee straight (tight hamstrings), and outward rotation of foot (tight hip external rotators).

Fig. 2. Silhouette appearance of knees flexed to 90° reveals mild enlargement of left tibia1 tubercle.

TABLE 2 Assessment of tenderness on palpation

Slight Only complains of pain after questioning Mild Voluntarily reports pain on palpation Moderate Withdraws knee from examiner's hand;

may indicate pain verbally Marked Withdraws knee and attempts to grab

examiner's hand

Fig. 3. Assessment of passive knee flexion range of motion including evaluation of rectus femoris tightness.

flexed by the examiner until either the end of range or pain is encountered. If this stretch begins to hurt, the patient must be questioned as to the location of the pain, as this will influence treat- ment. If pain from this prone stretching is felt in the area of the infrapatellar tendon or tubercle area, stretching the quadriceps is contraindicated, as the pain is caused by further pulling away of the apophysis. If the strain is felt up in the muscle belly or at the proximal attachment of the muscle, quadriceps stretching will be performed as part of the treatment. The results of muscle tightness tests along with the location of pain with stretch- ing are recorded.

Manual muscle testing of the knee extensors and flexors can be performed with the patient sitting on the end of the plinth with presence or absence of pain noted. Muscle tone is assessed in the long sitting position as the patient performs a quadriceps set. Quadriceps atrophy should be checked in the form of girth measurements.

PHYSICAL THERAPY TREATMENT

Of primary concern to the therapist treating Osgood-Schlatter disease is relief of pain in the area of the tubercle. lontophoresis is the modality of choice, and a trial period of not more than three treatments should be undertaken.'. l o Use of an anti-inflammatory medication and local anesthetic helps decrease swelling and pain.

We feel the benefits of iontophoresis are: 1) Inhibition of pain from the electrical current used; 2) method of administering medication without injecting the tendon/muscle junction, thus avoid- ing the possibility of associated tendon damage;

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JOSPT JulylAug 1985 OSGOOD-SCHLATTER DISEASE 9

Fig. 5. A, Quadriceps stretch position for individuals with extreme tightne*; B, advanced quadriceps stretch position which increases rectus femoris stretch across the anterior hip.

Fig. 6. Residual deformity in a 28-year-old male with neither pain nor functional limitations of the left knee.

3) localization of treatment required for the size of this particular lesion.

The active pad of the PhoresoP (Motion Con- trol, Salt Lake City, UT) unit is positioned over the tubercle of the knee which is supported in about 30' of flexion. The sides of the adhesive pad are then taped down to the skin for better contact and to prevent leakage. One cc of dexametha- sone-sodium-phosphate and 1 cc of lidocaine HCI

are injected into the positive electrode. Treatment time is for 20 minutes at up to 5.0 ma. Proper post-treatment application of lotion to both elec- trode sites minimizes the hazard of skin irritation.

Following three treatments with iontophoresis performed every other day, tenderness to palpa- tion is reassessed, and the patient's subjective change in conditions is recorded.

The next phase of treatment addresses tight musculature if found on initial eval~at ion.~~ Heat- ing with hot packs to the anterior and posterior thigh is followed by quadriceps and/or hamstring stretching. Hamstrings are stretched over the side of a plinth (Fig. 4) with the involved knee in full extension and the foot pointing upward (neutral hip rotation). A static stretch of 10 sec is used with the patient instructed to slide his hands down his anterior leg until he feels a stretch either in the posterior thigh or at the hamstrings insertion.

Quadriceps stretching is performed with the patient lying prone, pulling his foot up toward his buttocks. Strain should be felt in the muscle belly, and not at the tenoperiosteal junction. For cases of extreme tightness, a belt may be needed around the dorsal foot (Fig. 5A), whereas patients with less quadricep tightness can be sidelying with the involved leg up, allowing for a greater rectus femoris stretch with passive hip extension (Fig. 56).

Strengthening of the involved limb quadriceps is performed in cases of atrophy secondary to disuse. Isometric quadricep sets, straight leg raises, and short arc quadricep exercises are standard, and are performed only if they are pain free. Exercise concludes with a 5-minute ice mas- sage to the area of the tubercle.

SUMMARY

The symptoms, diagnosis, and conventional forms of treatment for Osgood-Schlatter disease are reviewed. Physical therapy evaluation must concentrate on assessment of tight musculature (quadriceps, hamstrings, calf) as a possible cause of this entity. Treatment concentrates on: I ) de- creasing the pain, 2) improving flexibility, and 3) return to function.

Perhaps the most important part of rehabilita- tion is education of the adolescent and his par- ents, with a reassurance that his condition is temporary and related to the time in his growth when his epiphyseal plates are the weak link of his musculoskeletal system. Activities should be pain limited with instruction in continuation of a

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10 ANTICH AND BREWSTER JOSPT Vol. 7, No. 1

home program with ice massage following. Expla- nation that a prominent tubercle may be present indefinitely ( ~ i ~ . 6), but that pain with activity should cease following the teenage years, may prevent later concerns regarding continued pres- ence of an enlarged tubercle.

The authors would like to thank the other members of the Physical Therapy Research Committee of the Southwestern Orthopaedic Med- ical Group, Inc. for their suggestions and review of the manuscript in its preparation for publication: Matthew C. Morrissey, MS, PT; Celeste Criswell Randall. MS. PT; and Roxie Westbrwk, PT.

The guidance and assistance of Ms. Elizabeth Stone is gratefully appreciated.

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25. Reichmaster J: Injection of the deep infrapatellar bursa for Osgood- Schlatter's disease. Clin Proc Child Hosp DC 3521-24, 1961

26. Rostron PKM, Calver RF: Subcutaneous atrophy following meth- ylprednisolone injection in Osgood-Schlatter epiphysitis. J Bone Joint Surg (Am) 61 :627-628, 1979

27. Scotti DM, Sadhu VK, Heimberg F, O'Hara AE: Osgood-Schlatter's disease, an emphasis on soft tissue changes in roentgen diagnosis. Skeletal Radiol 4:21-25, 1979

28. Smillie IS: Injuries to the Knee Joint, Ed. 5. Edinburgh: Churchill Livingstone. 1978

29. Smillie IS: Diseases of the Knee Joint, Ed. 2. Edinburgh: Churchill Livingstone, 1980 F

30. Stirling RI: Implications of Osgood-Schlatter's disease (abstract). J Bone Joint Surg (Br) 34:149-150, 1952

31. Willner P: Osgood-Schlatter's disease: Etiology and treatment. Clin Orthop 62:178,1969

32. Woolfrey BF, Chandler EF: Manifestations of Osgood-Schlatter's disease in late teen age and early adulthood. J Bone Joint Surg (Am) 42:327-332.1960

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