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Osgood-Schlatter Disease (Tibial Apophysitis)

BASICS

Description

  • Syndrome of traction apophysitis and patellar tendinosis, most common in adolescent boys and girls.
  • Presents as pain and swelling over the anterior tibial tubercle.
  • System affected: musculoskeletal
  • Synonym: Tibial tubercle apophysitis

EPIDEMIOLOGY

  • Incidence: Increasing in girls with organized sports; almost equal to boys in the U.S.
  • Prevalence: ~10% in general population aged 12–15; more common in athletes.

ETIOLOGY & PATHOPHYSIOLOGY

  • Traction apophysitis of tibial tubercle due to repetitive strain on the secondary ossification center.
  • Contributing factors: patellar tendinosis, apophyseal microfractures, avulsion injuries.
  • Biomechanical associations: Tight iliopsoas, quadriceps, hamstrings; increased quadriceps:hamstring strength ratio.
  • Highest risk: Jumping/pivoting sports, rapid skeletal growth, weak core muscles.

RISK FACTORS

  • Age: 8–18 years (girls: 8–13; boys: 10–15)
  • Early sport specialization (4× risk)
  • Rapid growth, high BMI, patellofemoral malalignment
  • Overload training, quadriceps/hamstring tightness
  • Repetitive-jumping sports (football, volleyball, basketball, soccer, gymnastics, ballet)
  • Weak core muscles, increased weight

GENERAL PREVENTION

  • Avoid excessive quadriceps loading and heavy deceleration activities.
  • Maintain hamstring and quadriceps flexibility.
  • Reduce early sports specialization; encourage cross-training.

COMMONLY ASSOCIATED CONDITIONS

  • Tight rectus femoris (75%)
  • Hamstring tightness
  • ADD/ADHD (increased risk for other injuries)
  • Sinding-Larsen-Johansson apophysitis, Sever disease

DIAGNOSIS

History

  • Unilateral or bilateral tibial tuberosity pain (30% bilateral)
  • Pain worsened by exercise (jumping, squatting, kneeling)
  • Antalgic gait; pain with sports participation

Physical Exam

  • Knee pain with squatting/crouching
  • Tender, swollen tibial tuberosity
  • Pain with resisted knee extension/kneeling
  • Erythema over tubercle; tight hamstrings/quadriceps
  • Core muscle weakness; single-leg squat reproduces pain

Differential Diagnosis

  • Proximal tibial stress fracture, pes anserinus bursitis, quadriceps tendon avulsion
  • Patellofemoral pain syndrome, chondromalacia patellae
  • Neoplasm, osteomyelitis, tibial plateau fracture
  • Sinding-Larsen-Johansson syndrome, patellar tendonitis, infrapatellar bursitis
  • Osteochondroma, tibial tuberosity fracture, osteosynchondroses, OSD mimickers

Diagnostic Tests

  • Clinical diagnosis; imaging not routinely required
  • X-ray: may show heterotopic calcification/fragmentation at tibial tubercle
  • Ultrasound: shows patellar tendon thickening, bursal effusion, irregular ossification
  • MRI: fragmentation of tubercle and patellar tendon changes in severe cases

TREATMENT

General Measures

  • Frequent ice (2–3×/day, 15–20 min)
  • Rest & activity modification (avoid activities worsening pain/swelling)
  • Physical therapy: quadriceps/hamstring stretching, strengthening, eccentric loading
  • Avoid aggressive stretching if significant pain (risk of avulsion)
  • Orthotics for midfoot pronation, patellar straps/bracing
  • Severe disease: may require longer-term sports restriction

Medication

  • First line: OTC analgesics (acetaminophen, NSAIDs)
  • Second line: Opioids very rarely, short term for severe cases only; corticosteroid injections not recommended
  • Prolotherapy (hyperosmolar dextrose injection): evidence for benefit in RCTs
  • Autologous platelet-rich plasma: shown benefit in case studies

Surgery

  • Rare (<5%): for persistent symptoms, thickened/painful tubercle, or avulsion
  • Options: debridement, excision, bursoscopy, percutaneous screw fixation, reduction wedge osteotomy

ONGOING CARE

  • Return to play when pain controlled
  • Presence of mild pain does not preclude participation
  • Follow-up: monitor symptoms; most resolve with time and rest

PATIENT EDUCATION

  • Symptoms are usually self-limited, resolving within 2 years after skeletal maturity
  • Persistent "knots" on tibial tubercle are common
  • Stretching/strengthening of hamstrings/quadriceps is critical
  • Surgery rarely needed, but generally good outcomes if necessary

PROGNOSIS

  • Self-limited; resolves in most by skeletal maturity
  • Some may have symptoms/pain into adulthood (≥10%)
  • Rare complications: avulsion, ossicle fragmentation, patella alta, osteoarthritis, genu recurvatum

ICD-10 Codes

  • M92.50: Juvenile osteochondrosis of tibia and fibula, unspecified leg
  • M92.51: ... right leg
  • M92.52: ... left leg

Clinical Pearls

  • Most common cause of infrapatellar pain in adolescent athletes.
  • Always consider other serious causes (disc disease, malignancy) in the differential.
  • Treatment = activity modification + stretching/strengthening.
  • Mild pain is not a contraindication to sports participation.
  • ~10% remain symptomatic as adults; persistent disabling symptoms may require surgery.