Osgood-Schlatter diseaseBMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d4534 (Published 01 August 2011) Cite this as: BMJ 2011;343:d4534
- Richard Weiler, specialist registrar in sport and exercise medicine; locum general practitioner 1,
- Michael Ingram, general practitioner2,
- Roger Wolman, consultant in rheumatology and sport and exercise medicine3
- 1Homerton University Hospital NHS Foundation Trust, Homerton Row, London E9 6SR, UK
- 2The Red House Group, Radlett, Hertfordshire
- 3The Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
- Correspondence to: R Weiler
- Accepted 25 June 2011
An active 14 year old boy, accompanied by his father, presents because of persisting knee pain, which is worse during and after sports.
What you should cover
In 1903, Osgood and Schlatter separately described a painful overuse condition affecting the tibial tuberosity. Osgood-Schlatter disease is a common cause of knee pain in children, associated with growth spurts, peaking in boys at about 12 to 15 years and girls at about 10 to 12 years. It is more common in boys than girls and up to 30% of children present with bilateral symptoms.1 Cadaveric and radiological studies have led to the theory that Osgood-Schlatter disease may be caused by forceful contractions of the quadriceps muscles at the proximal tibial apophysis insertion leading to multiple small avulsion fractures.2 This may lead to a firm enlargement of the tibial tubercle over time. The age of onset may be caused by the relative imbalance of strengthening quadriceps muscles compared with the growing bone. It is also associated with a shortened biceps femoris hamstring.1
Diagnosis is clinical and based on history and examination. Patients usually present with a gradual onset of pain localising at the tibial tuberosity, relieved by rest and aggravated by exercise, especially sports involving running and jumping.
Patients can be reassured that the syndrome can be effectively self managed, but will often not fully resolve until the end of the growth spurt.2 However, up to 10% of patients experience persistent symptoms into adulthood, despite conservative measures.3
Ask about the severity and nature of the pain, seeking a history of the relationship with activity, such as aggravation by activity (during or after football, ballet, gymnastics, running or jumping sports, or kneeling, for example) and improvement with rest.
It is helpful when advising prognosis to consider growth stage (such as using height comparison with parents and older siblings and, for girls, whether they have started menstruating), because symptoms typically cease at the end of a growth spurt.
Consider, as with any limb pain in children, other diagnoses, investigation, and urgent referral in the presence of trauma, systemic symptoms (including fever, weight loss, or general malaise), bone or joint pain elsewhere, night pain, pain after rest, or painful examination of the hip or knee joint.4
What you should do
Examination and treatment
Pain can be reproduced at the tibial tuberosity with local palpation and resisted knee extension.
Reassure patient and parents that sporting activity does not have to stop completely and that a reduction in activity may be sufficient to control the pain. Recommend a graded reduction in exercise duration, frequency, and intensity for a limited period, sufficient to resolve or tolerate pain. When pain is tolerable, consider gradual increases in exercise levels, again guided by and titrated to symptoms, adjusting levels, and repeating this process as required.
Paracetamol, non-steroidal anti-inflammatories, and application of ice (10–15 minutes, up to three times a day, including after exercise) to the tibial tuberosity can be offered for pain management.
Physiotherapy can be helpful by stretching, strengthening, and reducing muscle imbalance of the quadriceps, hamstrings, calf muscles, and iliotibial band.
Corticosteroid injections, though sometimes still advocated, are not appropriate, effective, or recommended.
Specialist assessment is recommended for severe or recalcitrant cases and some specialist centres may use short term immobilisation when other treatment has failed.
Emphasise the considerable benefits of physical activity in childhood and throughout life, trying to encourage maintenance of activity below the threshold that induces pain.
For patients who have intolerable symptoms into adulthood, numerous surgical techniques have been described, with variable results. Surgical excision of the bony fragment and/or free cartilaginous material can be considered, where conservative treatment has failed.5
A patient information leaflet may be a useful source of further information for both patient and healthcare professional (see box).
Patient UK information leaflet. www.patient.co.uk/health/Osgood-Schlatter%27s-Disease.htm
East Kent Hospitals University NHS Foundation Trust, quadriceps and hamstring stretches. www.ekhuft.nhs.uk/patients-and-visitors/information-for-patients/a-z-of-patient-information/a/anterior-knee-pain/#Muscle-tightness
For healthcare professionals
Bloom OJ, Mackler L, Barbee J. Clinical inquiries. What is the best treatment for Osgood-Schlatter disease? J Fam Pract 2004;53:153-6
Duri ZA, Patel DV, Aichroth PM. The immature athlete. Clin Sports Med 2002;21:461-82, ix
Gholve PA, Scher DM, Khakharia S, Widmann RF, et al. Osgood Schlatter syndrome. Curr Opin Pediatr 2007;19:44-50; doi: 10.1097/MOP.0b013e328013dbea
NHS Clinical Knowledge Summaries. Osgood Schlatter’s disease.www.cks.nhs.uk/osgood_schlatters_disease/management/which_scenario
Cite this as: BMJ 2011;343:d4534
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer reviewed.