Laura GottliebGillian Lieberman, MD

Radiological Findings in Osgood-Schlatter’s Disease

Laura GottliebHarvard Medical School Year IV

Gillian Lieberman, MD

January 2002

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Laura GottliebGillian Lieberman, MD

Agenda

• Define Osgood-Schlatter’s Disease (OSG)• Learn Relevant Knee Anatomy• Identify X-Ray Findings of OSG• Discuss Complications of OSG

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Laura GottliebGillian Lieberman, MD

The Big PictureOsgood Schlatter’s =

An Osteochondrosis

• Predilection for immature skeletons

• Involvement of epiphyseal/apophyseal bone

• Radiologic picture includes collapse, fragmentation, sclerosis, and frequent reossification

Image courtesy of Ferris Hall, MD. BIDMC, Boston, MA.

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Laura GottliebGillian Lieberman, MD

Osgood-Schlatter’s Basics: A Non-articulating Osteochondrosis

Disorder of patellar ligament’s distal attachment at tibial tuberosity

• Results from chronic stress at site of weak attachment causing repeated microtrauma.

• Causes temporary or permanent change in chondrogenesis/osteogenesis.

• Involves no disruption to blood supply but significant soft tissue swelling and pain!

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Laura GottliebGillian Lieberman, MD

Normal Knee Anatomy

From Southmayd W, Sports health. Quickfox 1981; 439.

From Novelline R, Squire’s Fundamental’s of Radiology, 5th ed. Harvard University Press 1997; 60.

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Laura GottliebGillian Lieberman, MD

Apophyseal Growth

From Resnick and Niwayama, Diagnosis of Bone and Joint Disorders, 2nd ed. WB Saunders Co, Philadelphia 1988. 5(84): 3314.

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Laura GottliebGillian Lieberman, MD

Normal Adolescent Knee

Image courtesy of Ferris Hall, MD. BIDMC, Boston, MA

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Laura GottliebGillian Lieberman, MD

Normal Adolescent Knee

Patellar Ligament

Infrapatellar Fat Pad

Apophysis

Image courtesy of Ferris Hall, MD. BIDMC, Boston, MA

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Laura GottliebGillian Lieberman, MD

OSG: The Clinical Picture

• AdolescentsBoys (75%) 10-15yoGirls (25%) 8-12yo

• Localized pain anterior to tibial tuberosity• Pain worsens with activity• Up to 50% have bilateral involvement• Soft tissue swelling without synovial joint

effusion

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Laura GottliebGillian Lieberman, MD

The Case of Adolescent X

Presented to Children’s Hospital• 14 yo male• occasional painful swelling over left tibial

tuberosity• active kid, soccer especially• no known trauma to area

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Laura GottliebGillian Lieberman, MD

DDXUnilateral Knee Pain over Tibial Tuberosity• infection: osteomyelitis• Malignancy or other mass: osteosarcoma, Ewing’s

sarcoma, osteoid osteoma• fracture: complete avulsion of tibial tubercle—includes

apophysis itself• patellar tendonitis = jumper’s knee• Osgood-Schlatter’s disease

In this case they ordered an x-ray to r/o the big, the bad, and the ugly.

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Laura GottliebGillian Lieberman, MD

To X-Ray or Not To X-Ray? The Age Old Question

• Age of patient?• Unilateral?• Other symptoms? e.g. fever, night sweats• Other atypical features? e.g. hx of trauma• Experience and type of clinician matters!

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Laura GottliebGillian Lieberman, MD

Adolescent X Films• Soft tissue swelling

anterior to tibial tuberosity

• Thickening of patellar ligament

• Indistinctness of infrapatellar fat pad

• Bony abnormalities

• SclerosisFrom Children’s Hospital Teaching File 4.535.

Left knee, lateral film

Adolescent X

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Laura GottliebGillian Lieberman, MD

Adolescent X Films Compared to Normal

From Children’s Hospital Teaching File 4.535.

Left knee, lateral film

Adolescent X

Lateral film, normal

Image courtesy of Ferris Hall, MD.

BIDMC, Boston, MA.

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Laura GottliebGillian Lieberman, MD

Adolescent X has classic plain film findings of Osgood-

Schlatter’s Disease. Lets review some other causes for tibial

tubercle pain

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Laura GottliebGillian Lieberman, MD

Known Osteomyelitis vs. Adolescent X

From Children’s Hospital Teaching File 6.253 From Children’s Hospital Teaching File 4.535.

Sclerosis

Cortical erosion

Diffuse involved region

Osteomyelitis

Adolescent X

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Laura GottliebGillian Lieberman, MD

Known Osteosarcoma vs. Adolescent X

From Children’s Hospital Teaching File 4.535.From Children’s Hospital Teaching File 4.321.

Diffuse, homogenously increased density of proximal tibia

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Laura GottliebGillian Lieberman, MD

Classic X-Ray Findings in OSG: Some Practice

Indistinct patellar ligament and fat pad

Fragmentation and sclerosis

From Resnick and Niwayama. Diagnosis of Bone and Joint Disorders, 2nd ed. WB Saunders Co, Philadelphia 1988; 5(84): 3315.

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Laura GottliebGillian Lieberman, MD

Some more practice…

From: gait.aidi.udel.edu/res695/homepage/pd_ortho/

educate/clincase/clcsimge/osgod1.jpg

From Resnick and Niwayama, Diagnosis of Bone and Joint Disorders, 2nd ed. WB Saunders Co, Philadelphia 1988; 5(84): 3316.

Bony fragment within ligament

Bony fragment

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Laura GottliebGillian Lieberman, MD

Menu of Tests Used in Osgood-Schlatter’s Disease

• None• X-ray: Standard frontal and lateral projections;

consider special views--internal rotation views

soft tissue density bone density

• CT and MRI: show changes at insertion of patellar tendon

• U/S: shows thickening of patellar tendon near insertion (increased echogenicity)

Don’t overexpose films!

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Laura GottliebGillian Lieberman, MD

CT Images

From uhrad.com/msiarc/msi039.htm.

Mild fragmentation of anterior tibial tubercle at insertion site of patellar ligament

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Laura GottliebGillian Lieberman, MD

MRI Images

Decreased signal in region of tibial tuberosity at insertion of patellar ligament

From uhrad.com/msiarc/msi039.htm.

T1 Sagittal MR Image

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Laura GottliebGillian Lieberman, MD

Complications of Osgood-Schlatter’s Disease

Usually resolves when apophysis fuses with tibial tuberosity.

May see:• Persistent bony fragment/non-union

pain--surgery• Subluxation of patella from weakened distal

insertion point of ligament• Patellar ligament tear• Scar tissue

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Laura GottliebGillian Lieberman, MD

Avulsion Injuries IOld avulsion injury

Sclerosis

From Murray and Jacobson. Radiology of Skeletal Disorders. Longman Group NY 1971; 1(1):142.

From Resnick and Niwayama. Diagnosis of Bone and Joint Disorders, 2nd ed. WB Saunders Co, Philadelphia 1988; 5(84): 3315.

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Laura GottliebGillian Lieberman, MD

Avulsion Injuries II

From Murray and Jacobson. Radiology of Skeletal Disorders. Longman Group Limited NY 1971; 1(1): 143.

Presentation One year laterIrregular and fragmented tibial tuberosity

Abnormally wide apophyseal plate

Prominent tibial tuberosity

Bony fragment

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Laura GottliebGillian Lieberman, MD

Subluxation of patella

From http://www.medmedia.com/oo1/51.htm

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Laura GottliebGillian Lieberman, MD

Patellar ligament tear

Normal Patellar Ligament

Absence of Patellar Ligament

From http://www.medmedia.com/oo1/238.htm Image courtesy of Ferris Hall, MD. BIDMC, Boston, MA.

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Laura GottliebGillian Lieberman, MD

Related disorder of the Patellar Ligament: Sinding Larsen Johansen Syndrome

(SLJS)• d/o of proximal patellar ligament where it

attaches to patella• otherwise the same d/o as OSG!

chronic stress leads to microtrauma and change in chondrogenesis/osteogenesis

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Laura GottliebGillian Lieberman, MD

Sinding Larsen Johansen Syndrome II

From Resnick and Niwayama. Diagnosis of Bone and Joint Disorders, 2nd ed.Publisher info! :3326.

Extraossification area

Fragment of lower pole of patella

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Laura GottliebGillian Lieberman, MD

Treatment of Osgood-Schlatter’s Disease

Rest and relaxno jumping no pushing off no squatting

Reality of AdolescenceWant teens to comply: give them control

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Laura GottliebGillian Lieberman, MD

Other Treatment Options

• NSAIDS• Wraps--ace bandages, neoprene braces• Removable immobilizers, restraints• Cast--mid-thigh to mid-calf• Quadriceps strengthening

Anterior knee strapFrom www.supports4u.com/osgood-schlatters.htm

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Laura GottliebGillian Lieberman, MD

Conclusions

• Osgood-Schlatter’s Disease is a non-articulating osteochondrosis that occurs in the accelerated growth phase of adolescence when distal attachment of patellar ligament is weakest.

• Disease usually disappears when apophysis fuses. Treatment depends on severity of symptoms.

• X-rays are the study of choice and usually reveal: soft tissue swelling: indistinct patellar ligament, blurred fat pad, anterior tissue swellingbony fragmentation focal sclerosis

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Laura GottliebGillian Lieberman, MD

References• Children’s Hospital Pediatric Radiology Teaching Files. The Children’s Hospital,

Boston, MA. • Murray and Jacobson. Radiology of Skeletal Disorders. Longman Group, NY:

1971.• Wenger, Dennis and Mercer Rang. The Art and Practice of Children’s

Orthopaedics. Raven Press, NY: 1993.• Novelline, Robert. Squire’s Fundamentals of Radiology, 5th ed. Harvard

University Press: 1997.• Resnick and Niwayama. The Diagnosis of Bone and Joint Disorders, 2nd ed.,

5(84). WB Sanders, Philadelphia: 1988.• Southmayd, William and Marshall Hoffman. Sports health: The Complete Book

of Athletic Injuries. Quick Fox, NY: 1981.• Staheli, Lynn. Fundamentals of Pediatric Orthopedics, 2nd ed. Lippincott-

Raven, Philadelphia: 1998.• Web Resources:

www.uhrad.comhttp://gait.aidi.udel.eduwww.medmedia.com/oa2www.alldoctors.comwww.allkids.org/Epstein/Articles/Adolescence.htmlhttp://www.medstudents.com.br/orto/orto4.htm

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Laura GottliebGillian Lieberman, MD

AcknowledgementsConsiderable appreciation is owed to the following

people:

• Michael Stella, MD• Daniel Saurborn, MD• Ferris Hall, MD• Gillian Lieberman, MD• Larry Barbaras and Cara Lyn D’amour• Pamela Lepkowski