See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/6576931 Osgood Schlatter syndrome Article in Current Opinion in Pediatrics · March 2007 DOI: 10.1097/MOP.0b013e328013dbea · Source: PubMed CITATIONS READS 87 1,825 5 authors, including: Saurabh Khakharia Daniel Green Weill Cornell Medical College Hospital for Special Surgery 5 PUBLICATIONS 124 CITATIONS 113 PUBLICATIONS 1,261 CITATIONS SEE PROFILE SEE PROFILE All in-text references underlined in blue are linked to publications on ResearchGate, Available from: Daniel Green letting you access and read them immediately. Retrieved on: 16 November 2016 Osgood Schlatter syndrome Purushottam A. Gholvea, David M. Schera,b, Saurabh Khakhariaa, Roger F. Widmanna,b and Daniel W. Greena,b Purpose of review Introduction Osgood Schlatter syndrome presents in growing children In 1903, Osgood [1] and Schlatter [2] separately described (boys, 12–15 years; girls, 8–12 years) with local pain, a painful condition of the anterior tibial tubercle charac- swelling and tenderness over the tibial tuberosity. terized by partial separation of the tongue-like epiphysis Symptoms are exacerbated with sporting activities that of the tibial tuberosity, apparently caused by continued involve jumping (basketball, volleyball, running) and/or on strain placed upon it by the patellar tendon. Osgood direct contact (e.g. kneeling). With increased participation Schlatter syndrome (OSS) involves the tibial tuberosity of adolescent children in sports, we critically looked at the in growing children and presents with local pain, swelling current literature to provide the best diagnostic and and tenderness of the tuberosity. The common age treatment guidelines. of presentation in boys is between the ages of 12 and Recent findings 15 years and in girls is between the ages of 8 and 12 years Osgood Schlatter syndrome is a traction apophysitis of the [3,4]. The occurrence is reported to be greater in boys tibial tubercle due to repetitive strain on the secondary than girls [5,6] and it frequently presents bilaterally ossification center of the tibial tuberosity. Radiographic (20–30%) [7–9]. changes include irregularity of apophysis with separation from the tibial tuberosity in early stages and fragmentation in Etiopathogenesis the later stages. About 90% of patients respond well to Currently it is widely accepted that OSS is a traction nonoperative treatment that includes rest, icing, activity apophysitis of the tibial tubercle due to repetitive strain modification and rehabilitation exercises. In rare cases and chronic avulsion of the secondary ossification center surgical excision of the ossicle and/or free cartilaginous of the tibial tuberosity. The repetitive strain is from the material may give good results in skeletally mature patients, strong pull of the quadriceps muscle produced during who remain symptomatic despite conservative measures. sporting activities. The tibial tuberosity avulsion may Summary occur in the preossification phase or the ossified phase Osgood Schlatter syndrome runs a self-limiting course, and of the secondary ossification center. Once the bone or usually complete recovery is expected with closure of the cartilage is pulled away it continues to grow, ossify and tibial growth plate. Overall prognosis for Osgood Schlatter enlarge. The intervening area may become fibrous, creat- syndrome is good, except for some discomfort in kneeling ing a localized nonunion (separate persistent ossicle), or and activity restriction in a few cases. may show complete bony union with mild enlargement of the tibial tuberosity (Fig. 1). Keywords diagnosis, management, Osgood Schlatter syndrome The theory of traction apophysitis and traumatic avulsion of the secondary ossification center of tibial tuberosity is Curr Opin Pediatr 19:44–50. ß 2007 Lippincott Williams & Wilkins. supported by Ehrenborg and Engfeldt [5,10–12] and Ogden and Southwick [13]. Ehrenborg and Lagergren aDivision of Pediatric Orthopaedic Surgery, Hospital for Special Surgery, New York, b [14] described four radiological stages in the maturation USA and Weill Medical College of Cornell University, New York, USA of tibial apophysis (Fig. 2): cartilaginous stage (aged 0– Correspondence to Daniel W. Green, MD, Associate Professor of Orthopaedic Surgery, Division of Pediatric Orthopaedic Surgery, 535 East 70th Street, Hospital 11 years); apophyseal stage (aged 11–14 years); epiphy- for Special Surgery, New York, NY 10021, USA seal stage, the tibial apophysis coalesces with tibial Tel: +1 212 606 1631; fax: +1 212 774 2776; e-mail: [email protected] epiphysis (aged 14–18 years); and bony stage, the epi- Current Opinion in Pediatrics 2007, 19:44–50 physis is fused (aged > 18 years). On correlating the Abbreviations clinical findings, most OSS cases were seen in the apo- MRI magnetic resonance imaging physeal stage [5]. With work on cadaveric specimens OSS Osgood Schlatter syndrome Ehrenborg [10] suggested that ligamentum patellae fibers are attached distally to the fibrocartilage, which ß 2007 Lippincott Williams & Wilkins has high tensile strength, and hence a traumatic force 1040-8703 causes fracture of the secondary ossification center of tibial tuberosity and not a fracture through the proximal growth plate. 44 Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Osgood Schlatter syndrome Gholve et al. 45 Figure 1 Pathogenesis of an Osgood Schlatter lesion (a) Appearance of the secondary ossification center of tibial tuberosity. (b) Fragmentation of the bony ossification center. (c) Complete healing and fusion of the apophysis with prominent tuberosity. (d) Ununited free ossicle. Adapted and modified from [4]. Ogden and Southwick [13] further expanded this work. patella infera in skeletally immature adolescents with They studied autopsy specimens of proximal tibiae of OSS. They explained increased stress on tibial tuberosity children aged from few days to 16 years. Histological due to the short length of the patellar ligament. Willner analysis of the tibial tuberosity growth plate revealed [18] reported pronated feet, genu valgum and internal three zones that gradually merge into one another. The rotation in all 78 patients with OSS. Demirag et al. [19], in proximal zone is analogous to the upper tibial growth their magnetic resonance imaging (MRI) study, com- plate and is formed of short cell columns. The middle pared patellar tendon insertion of 15 OSS patients with zone is made of fibrocartilage (high tensile strength) with that of 15 normal adolescents. Their study showed that interposed layers of hyaline cartilage. The distal zone is the patellar tendon was attached more proximally and formed mainly of fibrous tissue. As the tuberosity matures had broader insertion above the tibial physis in OSS as through the apophyseal to epiphyseal stages, the most compared with the controls. Gigante et al. [20] studied the important change is distal migration of the short cell relationship between OSS and torsional abnormalities of columns replacing fibrocartilage. Based on these findings the lower limbs. They measured rotational profiles on Ogden and Southwick suggested OSS to be caused by the computed tomography scans in 20 control knees and developing secondary ossification center’s inability to 21 knees affected with OSS. A significantly increased withstand the forces from the patellar tendon, resulting condylomalleolar angle and external tibial rotation was in avulsion of the center and later formation of extra bone found in patients with OSS. Despite all the above reports, between the fragments. none of these variations have been universally accepted as etiological factors for lack of sufficient evidence. Pathological or normal variants of anatomy also have been suggested as etiological factors. Aparicio et al. [15] Clinical features and natural history reported an association between OSS and patella alta Boys become symptomatic between the ages of 12 and in their radiological study. Jacob et al. [16] reported 15 years and girls between the ages of 8 and 12 years [3,6]. 125 patella alta in 185 knees with OSS. Almost all patients Bilateral symptoms are observed in 20–30% of patients in their series healed, and they believed rectus femoris [7–9]. Kujala et al. [21] in a study of 389 adolescent contracture caused the patella alta. Contradicting the athletes reported OSS in 21% of those actively par- above findings, Lancourt and Christini [17] reported ticipating in sports, as compared with only 4.5% in Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 46 Orthopedics Figure 2 Ehrenborg and Lagergren radiological stages in matu- and continuous in nature. Pain exacerbates after sporting ration of tibial tuberosity activity involving jumping (basketball, volleyball, running) and/or on direct contact (e.g. kneeling) [4]. Physical examination reveals tenderness, local swelling and prominence in the area of the tibial tuberosity (Fig. 3). Pain can be reproduced with extension of the knee against resistance. Once the acute phase heals, the pain and tenderness subside, and the only positive physical finding may be an anterior mass. Most investi- gators [3,4,6,22–24] claim spontaneous resolution and self-limiting nature of the symptoms, with recovery expected in about 90% of patients. Symptoms, however, may continue to wax and wane for 12–24 months before complete resolution. In approximately 10% of patients the symptoms continue