Introduction
Osgood-Schlatter disease (OSD) is one of the primary and most common causes of anterior knee pain in the population of children and adolescents (1). OSD is characterized as traction apophysitis in the tibial tuberosity caused by repetitive strain on the quadriceps femoris muscle (2).
The primary cause of this condition is characterized by stress on the patellar tendon at its insertion point (2). In more recent studies, it seems that the shortening of the rectus femoris muscle may also be a contributing risk factor for the development of OSD (3, 4).
Most symptoms related to OSD appear during the growth phase of adolescents, especially when the body undergoes rapid changes, particularly in physically active children and adolescents who participate in regular sports (1, 5). Pain tends to occur during and after physical activity and may be associated with local swelling. The onset of OSD typically occurs between the ages of 10 and 15 in boys and 8 to 13 in girls. It is also noted that the incidence is more common in boys (10).
The incidence of OSD in adolescent athletes is approximately 10 to 20% (4, 6) and is particularly high in athletes participating in sports that involve jumping, kicking, and running, such as soccer (3, 4, 7).
Risk Factors
It is widely recognized that OSD is associated with sports that involve repeated strain on the patellar tendon at the tibial tuberosity, such as jumping, squatting, kicking, and running (3, 4, 7, 11, 12), especially noted in sports like basketball, volleyball, and soccer (3). It has been observed that athletes participating in soccer activities are more likely to develop OSD in the support leg (the non-kicking leg) than in the kicking leg (3, 4, 8), as there is greater activation of the quadriceps muscle group in the support leg during the kicking motion (9).
Some studies have been conducted to investigate the risk factors for the development of OSD, and it seems that the most commonly accepted ones are:
Shortening of the rectus femoris muscle
Ahortening of the gastrocnemius muscles
Apophyseal Stage
Peak Height Velocity (PHV)
Takei et al (4) - A Recent and Interesting Study:
A recent study conducted by Takei et al (4) observed a positive and statistically significant correlation between the shortening of the rectus femoris muscle, gastrocnemius muscles, and PHV with the development of OSD in adolescents who play soccer (4). This study demonstrated that PHV age +/- 6 months at baseline, apophyseal stage of tibial tuberosity maturity, quadriceps flexibility greater than or equal to 35° at baseline, and decreased gastrocnemius flexibility (less than 0°) in 6 months are the most influential predictive factors for OSD onset on the support leg in 6 months among adolescent male soccer players (table 1) (4).
Table 1: Statistically significant findings of the influence of PHV stage, apophyseal stage, quadriceps femoris and gastrocnemis shortening. Adapted from Takei et al (4)
A) Shortening of the Rectus Femoris Muscle
In agreement with other studies (3), Takei et al (4) concluded that the shortening of the rectus femoris muscle is one of the major risk factors for OSD development. However, this study revealed that a quadriceps flexibility range of 35° was the most appropriate cut-off point for prognostic screening of individuals at high risk of OSD development. These findings suggest that OSD prevention should focus on young athletes whose quadriceps flexibility is greater than 35° (4).
B) Shortening of the Gastrocnemius Muscles
This study also showed that decreased gastrocnemius flexibility (less than 0°) in 6 months was associated with a higher risk of OSD. Other studies (13, 14) had also previously shown this relationship.
C) Apophyseal Stage
In this study, the apophyseal stage was significantly associated with the development of OSD when compared to the epiphyseal stage (4).
D) Peak Height Velocity
This study demonstrated that the prevalence of injury among adolescent soccer players is higher during the 6 months before and after PHV age (4). In line with Sluis et al (15), coaches, fitness trainers, and medical staff should be cautious with training and game loads for players in the 6 months around PHV age to minimize the risk of injury (4, 15).
Diagnosis
Clinical Findings and Physical Examination
Adolescents going through their growth spurt are highly susceptible to musculoskeletal conditions, including OSD. In most cases, a correct diagnosis of OSD in one or both knees can be made through patient history and a comprehensive physical examination. Typically, patients are engaged in regular training programs for leisure or competitive sports. They commonly report anterior knee pain that worsens with frequent physical activity. Pain is exacerbated by repetitive strain on the tibial tubercle during activities like jumping and running, especially with increased load on the knee during flexion (1).
During a physical examination, the affected knee may exhibit mild swelling, tenderness in the tibial tubercle, and possible thickening of the patellar tendon. It's important to rule out any history of trauma and assess for other clinical conditions. Muscle strength and tightness in the hip, quadriceps femoris muscle, hamstring muscles, and core stability should be evaluated to assess for muscle instability (1).
Radiological Findings
In general, a diagnosis of OSD can be made clinically without the need for radiological evaluation. However, knee imaging is recommended to confirm the presence of free ossicles and exclude other conditions like bone injuries, tumors, or infections (1). When ordering radiographic imaging, it should be noted that there is still debate regarding whether tibial tubercle fragmentation is a pathological process accompanying OSD or if it represents a physiological stage of ossification. While ultrasound, MRI, or computed tomography scans can be used, most physicians begin with plain anterior-posterior and lateral radiographs (see Figures 1 and 2) to assess the front aspect of the tibial tubercle and rule out free ossicles (1).
In the acute stage of OSD, the margins of the patellar tendon may appear blurred due to soft tissue swelling. After 3-4 months, signs of bone fragmentation become visible. In the subacute stage, soft tissue swelling subsides, but bony ossicles may still be visible on radiographs. The chronic stage is defined by the fusion of the bone fragment with the tibial tuberosity (1, 17).
Conservative Management and Treatment
Given that symptoms typically improve over time, the secondary ossification center tends to ossify, and around 80% of patients usually recover, the standard treatment for OSD is conservative (18, 19). Rathleff et al. (20) reported high success rates among OSD patients (80% at 12 weeks and 90% after 12 months), with 16% returning to sports after 12 weeks and 67% after 6 months (20).
Several treatment hypotheses have been proposed in the literature, although the level of evidence is relatively low. Within these hypotheses, we should highlight strategies such as:
Decreasing and dosing physical activity (18, 21)
Application of ice (18)
The use of knee orthoses (22)
Stretching of the leg extensor musculature (23, 24)
Education (30)
Knee-strengthening exercices (30)
Reducing or eliminating activities like jumping, running and changing directions until symptoms improve (25)
Core stabilization exercices (26)
Extracorporeal shockwave therapy (27)
Warm-up and cool-down exercices before and after training and competition (28)
When symptoms appear and OSD is diagnosed, you can immediately reduce sports activity and, particularly, adjust the load of jumping, running, and changing directions (18, 21, 25). These activities can be replaced with moderate physical activities that don't put strain on the patellar tendon, such as swimming and cycling (25).
From the early stage, it appears to be important to work on the athlete's core, as increased core stabilization is associated with decreased peak torque in knee flexion during the stance phase of running (29). Furthermore, increased core stabilization is also linked to better functionality in jumping actions (18, 29).
In certain cases, if available, you may advise your athlete to use a knee orthosis in the initial phase for training and possibly playing to reduce the tractional load on the patellar tendon (22).
Moderation and modification of physical exercise (18, 21, 25), combined with athlete education (30), and the gradual implementation of knee-strengthening exercises as well as core stabilization exercises (26), appear to be the most effective approach in the treatment and management of OSD (18, 26, 30).
However, the level of scientific evidence regarding the conservative treatment of OSD is quite low, and thus, further studies are needed to clarify the effects of interventions, particularly regarding specific exercises.
Final Considerations
OSD is a significant condition primarily observed in young males between the ages of 10 and 15. This condition can limit activity and should be taken seriously, with the entire multidisciplinary team in agreement regarding its management.
Despite being a relatively common condition in adolescent athletes, few studies have been conducted to clarify its causes and the key risk factors involved. Thanks to the study conducted by Takei et al. (4), we now know that in adolescents who play soccer, there appears to be a direct relationship between the muscle flexibility of the rectus femoris and the gastrocnemius muscles and the development of OSD, as well as the apophyseal stage at which the athlete is and the PHV. These findings are important for all physiotherapists and other healthcare and sports professionals who work with adolescent teams or athletes, as they clearly indicate factors to be assessed in our athletes and possibly corrected to reduce the risk of developing OSD.
Finally, with regard to conservative physiotherapy treatment, the available scientific evidence is quite limited and of low quality, with a focus on modifying physical activity, education, and using exercises to strengthen the lower limbs and the athlete's core.
Further studies are needed regarding OSD, especially concerning conservative treatment of the condition.
Bibliographic References
1. Ladenhauf, H. N., Seitlinger, G., & Green, D. W. (2020). Osgood-Schlatter disease: a 2020 update of a common knee condition in children. Current opinion in pediatrics, 32(1), 107–112
2. Demirag B, Ozturk C, Yazici Z, Sarisozen B (2004) The pathophysiology of Osgood–Schlatter disease: a magnetic resonance investigation. J Pediatr Orthop B 13(6):379–382
3. de Lucena GL, dos Santos Gomes C, Guerra RO (2011) Prevalence and associated factors of Osgood–Schlatter syndrome in a population-based sample of Brazilian adolescents. Am J Sports Med 39(2):415–420
4. Takei S, Torii S, Taketomi S, et al. Developmental stage and lower quadriceps flexibilities and decreased gastrocnemius flexibilities are predictive risk factors for developing Osgood-Schlatter disease in adolescent male soccer players. Knee Surg Sports Traumatol Arthrosc. 2023;31(8):3330-3338.
5. Nakase J, Goshima K, Numata H, et al. Precise risk factors for Osgood– Schlatter disease. Arch Orthop Trauma Surg 2015; 135:1277–1281
6. Haines M, Pirlo L, Bowles KA, Williams CM (2022) Frequencies of lower-limb apophyseal injuries in children and adolescents: a systematic review. Clin J Sport Med 32:433–439
7. Bezuglov EN, Tikhonova AA, Chubarovskiy PV, Repetyuk AD, Khaitin VY, Lazarev AM et al (2020) Conservative treatment of Osgood-Schlatter disease among young professional soccer players. Int Orthop 44(9):1737-1743
8. Gaulrapp H, Nührenbörger C (2022) The Osgood-Schlatter dis[1]ease: a large clinical series with evaluation of risk factors, natural course, and outcomes. Int Orthop 46(2):197–204
9. Brophy RH, Backus SI, Pansy BS, Lyman S, Williams RJ (2007) Lower extremity muscle activation and alignment during the soccer instep and side-foot kicks. J Orthop Sports Phys Ther 37:260–268
10. Gholve, P.A.; Scher, D.M.; Khakharia, S.; Widmann, R.F.; Green, D.W. Osgood Schlatter syndrome. Curr. Opin. Pediatr. 2007, 19, 44–50.
11. Itoh G, Ishii H, Kato H, et al. Risk assessment of the onset of Osgood– Schlatter disease using kinetic analysis of various motions in sports. PLoS One 2018;
12. Chang GH, Paz DA, Dwek JR, Chung CB. Lower extremity overuse injuries in pediatric athletes: clinical presentation, imaging findings, and treatment. Clin Imaging 2013; 37:836–846
13. arcević Z (2008) Limited ankle dorsifexion: a predisposing factor to Morbus Osgood Schlatter? Knee Surg Sports Traumatol Arthrosc 16:726–728
14. Watanabe H, Fujii M, Yoshimoto M, Abe H, Toda N, Higashiyama R, Takahira N (2018) Pathogenic factors associated with Osgood– Schlatter disease in adolescent male soccer players: a prospective cohort study. Ortho J Sports Med 6:2325967118792192
15. van der Sluis A, Elferink-Gemser MT, Brink MS, Visscher C (2015) Importance of peak height velocity timing in terms of injuries in talented soccer players. Int J Sports Med 36:327–332
16. Blankstein A, Cohen I, Heim M, et al. Ultrasonography as a diagnostic modality in Osgood–Schlatter disease. A clinical study and review of the literature. Arch Orthop Trauma Surg 2001; 121:536–539.
17. Sailly M, Whiteley R, Johnson A. Doppler ultrasound and tibial tuberosity maturation status predicts pain in adolescent male athletes with Osgood– Schlatter’s disease: a case series with comparison group and clinical interpretation. Br J Sports Med 2013; 47:93-97.
18. Corbi F, Matas S, Álvarez-Herms J, et al. Osgood-Schlatter Disease: Appearance, Diagnosis and Treatment: A Narrative Review. Healthcare (Basel). 2022;10(6):1011
19. Kartini C., Wayan-Suryanto D.I. Osgood-Schlatter disease: A review of current diagnosis and management. Curr. Orthop. Pract. 2022;33:294–298
20. Rathleff MS, Winiarski L, Krommes K, et al. Activity Modification and Knee Strengthening for Osgood-Schlatter Disease: A Prospective Cohort Study. Orthop J Sports Med. 2020;8(4):2325967120911106
21. Vaishya R., Azizi A.T., Agarwal A.K., Vijay V. Apophysitis of the Tibial Tuberosity (Osgood-Schlatter Disease): A Review. Cureus. 2016;13:e780.
22. Yen Y.-M. Assessment and Treatment of Knee Pain in the Child and Adolescent Athlete. Pediatr. Clin. N. Am. 2014;61:1155–1173.
23. Bezuglov E.N., Tikhonova A.A., Chubarovskiy P.V., Repetyuk D., Khaitin V.Y., Lazarev A.M., Usmanova E.M. Conservative treatment of Osgood-Schlatter disease among young professional soccer players. Int. Orthop. 2020;44:1737–1743.
24. Launay F. Sports-related overuse injuries in children. Orthop. Traumatol. Surg. Res. 2015;101:S139–S147.
25. Ladenhauf H.N., Seitlinger G., Green D.W. Osgood-Schlatter disease: A 2020 update of a common knee condition in children. Curr. Opin. Pediatr. 2020;32:107–112.
26. Sasaki S., Tsuda E., Yamamoto Y., Maeda S., Kimura Y., Fujita Y., Ishibashi Y. Core-Muscle Training and Neuromuscular Control of the Lower Limb and Trunk. J. Athl. Train. 2019;54:959–969.
27. Lohrer H., Nauck T., Schöll J., Zwerver J., Malliaropoulos N. Extracorporeal shock wave therapy for patients suffering from recalcitrant Osgood-Schlatter disease. Sportverletz. Sportschaden. 2012;26:218–222.
28. Herrero-Morín J.D., Fernández-González N., Gutiérrez-Díez C., Pérez-Menéndez M.T., Fernández-Fernández E.M. Enferme dad de Osgood-Schlatter en un adolescente deportista. Arch. Argent. Pediatr. 2017;115:445–448
29. Chaudhari A.M.W., VAN Horn M.R., Monfort S.M., Pan X., Oñate J.A., Best T.M. Reducing Core Stability Influences Lower Extremity Biomechanics in Novice Runners. Med. Sci. Sports Exerc. 2020;52:1347–1353.
30. Krause J.B., Williams A., Catterall A. Natural history of Osgood-Schlatter disease. J. Pediatr. Orthop. 1990;10:65–68.
コメント