1
Background
Osteochondrosis of the tibial tubercle was reported for the first time in the early 1900s. Two different physicians reported pain located in the tibial tubercle that occur during sports activities involving jumping and running in active adolescents. This condition was named after Osgood and Schlatter in recognition for their work. The authors explained the syndrome by rapid growth in children and stress transmitted through patellar tendon on the developing tubercle.
The researchers declared that this condition was different from tibial tubercle avulsion fracture and reported that it is due to repetitive microtrauma [ ]. Nowadays Osgood–Schlatter disease (OSD) is considered as a traction apophysitis. The primary cause of this condition is the stress from the patellar tendon at its point of insertion [ , ] ( Fig. 12.1 ).
The retraction of the rectus femoris muscle was also reported to be one of the main factors associated with the presence of OSD in adolescents [ ]. The injury mechanism in adults is usually related to direct impact on the tubercle, rather than contraction of the quadriceps as seen in adolescents [ ].
Pathogenesis of this disease includes a partial loss of continuity of the patellar tendon-cartilage-bone junction at the tibial tuberosity. An inflammatory process starts in the region and results in patellar tendinitis, multiple subacute fractures, and irregular ossification.
If these patients continue sport activities, microavulsions increase over time. This may cause a separated fragment leading to a chronic pain in the front aspect of the knee [ ].
Some studies showed that patients affected by OSD have predisposing anatomical abnormalities at the point of insertion of the patellar tendon and histological studies support the microtraumatic etiology of this condition [ , ].
OSD was originally reported to be more frequent in boys. With the increasing number of young female athletes, this syndrome is now being seen at a similar rate in both genders [ ]. OSD is typically more common between the ages of 8 and 13 years in girls and between 12 and 15 years in boys [ ]. It affects 21% of athletic adolescents, while it is seen in 4.5% of nonathletic controls with the same age [ , ]. The disease can be bilateral in 20%–30% of cases [ ].
The individual’s history and the physical examination are usually sufficient to make a diagnosis of OSD.
Treatment of this condition is mainly conservative.
2
Clinical Study
2.1
Symptoms
Patients complain of pain related to physical activities or sports. This pain is located on the tibial tubercle and distal patellar tendon. It occurs with activities and disappears with rest. It starts as a dull ache gradually increasing with activity. Pain typically improves with rest and will disappear minutes to hours after the culprit activity or sport is stopped.
It is exacerbated particularly by running, jumping, direct knee impact, kneeling, and squatting.
In general, the pain is present with activities involving stress on the knee in flexion, leading to an eccentric quadriceps contraction [ ].
2.2
Physical Examination
During the acute phase of the disease, patients may walk with an antalgic gait.
On physical examination, there is usually tenderness while palpating the tibial tubercle, knee swelling, thickening of the patellar tendon, and enlargement of the tibial tuberosity ( Fig. 12.2 ).
In chronic conditions, a firm mass or bone irregularities are often found during palpation. Acute cases may present with an active knee extension deficit.
There is no sign of effusion or instability, and passive range of motion (ROM) in the knee is usually preserved.
Quadriceps and hamstring muscle retraction is commonly found on examination [ , ].
3
Differential Diagnosis
The differential diagnosis of OSD includes:
3.1
Osteochondritis Dissecans
Pain is rather felt as intraarticular and patients present with a swelling of variable amounts.
3.2
Sinding Larsen Johansson Syndrome (SLJS)
Pain localized to the inferior patellar pole in a young athlete with swelling is suggestive of this condition.
3.3
Patellofemoral Pain Syndrome (PFP)
Pain is provoked by prolonged sitting and while using the stairs. On physical examination, patellar stress tests are positive.
3.4
Avulsion Fracture of the Tibial Tuberosity
A history of knee trauma is usually present.
3.5
Pes Anserinus Bursitis
Typical signs include pain in the medial aspect of the knee and edema of the site of insertion of the pes anserinus.
3.6
Tumor and Infection
Local and general inflammatory signs are suggestive of these conditions.
4
Imaging
4.1
Standard X-rays
Standard radiographs of the knee are requested because they allow the evaluation of the tibial tuberosity.
The lateral radiograph is most helpful in evaluating the insertion of the knee’s extensor system ( Fig. 12.3 ).
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