Version May 2024
INTRODUCTION — Osgood-Schlatter disease, also known as osteochondritis of the tibial tubercle, was first described in 1903 [1,2]. It is a traction apophysitis of the proximal tibial tubercle at the insertion of the patellar tendon.
The clinical features and management of Osgood-Schlatter disease will be discussed here. Causes of knee pain and the general approach to the diagnosis of knee pain in children and adolescents are discussed separately. (See "Approach to acute knee pain and injury in children and skeletally immature adolescents" and "Approach to chronic knee pain or injury in children or skeletally immature adolescents".)
ANATOMY — Osgood-Schlatter disease is characterized by pain and swelling at the tibial tubercle, the point of insertion of the patellar tendon (figure 1 and picture 1 and figure 2 and picture 2). The patellar tendon arises from the inferior pole of the patella, a sesamoid bone within the quadriceps tendon. The quadriceps muscle is involved in knee extension.
EPIDEMIOLOGY — Osgood-Schlatter disease generally occurs in children 9 to 14 years of age who have undergone a rapid growth spurt. According to a 2022 systematic review of four studies, prevalence among children between the ages of 12 and 15 years (n = 956) was 9.83 percent (95% CI 8.02-11.90) [3]. Among adolescents, the condition develops approximately twice as often in those who are active in sports compared with nonathletes [3,4]. It is bilateral in 25 to 50 percent of cases, although involvement is typically asymmetric [4-6].
Osgood-Schlatter has traditionally occurred most commonly in boys. However, it is becoming more common in girls as their sports participation increases [7]. While the rate was higher in males in the review cited above, there was no statistically significant difference in prevalence between males (n = 474), 11.39 percent (95% CI 8.68-14.60), and females (n = 482), 8.3 percent (95% CI 5.99-11.13) [3]. Osgood-Schlatter typically occurs one to two years earlier in girls than in boys, corresponding to the different timing of the pubertal growth spurt. (See "Normal puberty", section on 'Growth spurt'.)
Risk factors — Osgood-Schlatter occurs most frequently in participants of sports that involve running, cutting (rapid change of direction while running), and jumping (eg, football (soccer), American football, basketball, volleyball, gymnastics, figure skating, ballet) [8,9]. These activities place stress on the tibial tubercle through repetitive contraction of the quadriceps muscle.
PATHOGENESIS — Osgood-Schlatter disease is an overuse injury caused by repetitive strain and chronic avulsion of the secondary ossification center (apophysis) of the tibial tubercle [10-14]. Chronic avulsion causes separation of the proximal patellar tendon insertion from the tibial tubercle, which results in elevation (figure 3). As callous is laid down during healing, the tubercle may become markedly pronounced. (See 'Complications and sequelae' below.)
Other factors that may be related to the development of Osgood-Schlatter disease include a more proximal attachment of the patellar tendon [15], attachment to a broader area of the tibia [15], a history of calcaneal apophysitis (Sever syndrome) [4], and a high-riding patella (patella alta) [16]. Patella alta requires increased force from the quadriceps for full extension, which may contribute to apophyseal stress [16]. However, the temporal relationship between patella alta and Osgood-Schlatter has not been established, and it is possible that patella alta is the effect, rather than the cause, of Osgood-Schlatter [17].
CLINICAL PRESENTATION — Osgood-Schlatter typically occurs in the 13 to 14-year-old boy or skeletally equivalent 11 to 12-year-old girl who has recently undergone a rapid growth spurt [18].
The most common presenting complaint is anterior knee pain that increases gradually over time, from a low-grade ache to pain that causes a limp and/or impairs activity [19]. Pain is exacerbated by direct trauma, kneeling, running, jumping, squatting, climbing stairs, or walking uphill, and is relieved by rest. Involvement usually is asymmetric, although both knees are involved in 25 to 50 percent of cases [4,5,10].
DIAGNOSTIC EVALUATION — The diagnosis of Osgood-Schlatter disease is made by clinical examination. Radiographs are not necessary unless the patient has atypical complaints (pain at night, pain that is unrelated to activity, acute onset of pain, associated systemic complaints) or pain that is not directly over the tibial tubercle. (See 'Imaging' below and 'Differential diagnosis' below.)
Examination — A description of the complete knee examination for children and adolescents is provided separately. (See "Approach to acute knee pain and injury in children and skeletally immature adolescents", section on 'Physical examination'.)
The characteristic examination findings of Osgood-Schlatter disease include tenderness and soft tissue or bony prominence of the tibial tubercle (picture 3) [18]. Pain may be reproduced by extending the knee against resistance, stressing the quadriceps, or squatting with the knee in full flexion [20]. Straight-leg raising usually is painless. Pain that is more prominent in the patellar tendon than the bony prominence is suggestive of patellar tendinopathy (jumper's knee) [21]. (See "Quadriceps muscle and tendon injuries", section on 'Clinical presentation and examination'.)
The hamstrings may be shortened and the quadriceps taut. Quadriceps flexibility is assessed by passively flexing the knee with the patient prone (ie, the Ely test) (figure 4). The range of motion of the knee is not affected, and the knee and patellofemoral joints are stable [20,22]. The remainder of the knee examination is usually normal.
Erythema and warmth of the tibial tubercle, which suggest an acute inflammatory process, require additional evaluation (eg, for osteomyelitis). However, these findings must be interpreted with caution in patients who have used an ace wrap or heating pad before presenting for evaluation [22,23].
Examination of patients with knee pain should include evaluation of range of motion of the hip to make sure that the knee pain is not related to referred pain from pathology in the hip (eg, due to slipped capital femoral epiphysis, Legg-Calvé-Perthes disease) [24]. (See "Approach to hip pain in childhood", section on 'Examination'.)
Imaging — The majority of patients do not require imaging for diagnosis or treatment of Osgood-Schlatter disease.
Ultrasonography has been described as potentially aiding diagnosis, delineating pathogenesis, defining risk factors, and managing patients with Osgood-Schlatter disease [25-31]. However, most patients can be diagnosed and managed without point of care ultrasound.
Plain radiographs are appropriate to help exclude other conditions (eg, tibial apophyseal fracture, tumors, or osteomyelitis) in patients who have atypical features [22-24] (see 'Differential diagnosis' below):
●Erythema or warmth in addition to pain at the tibial tubercle is suggestive of an inflammatory process, such as osteomyelitis. (See "Hematogenous osteomyelitis in children: Clinical features and complications", section on 'Clinical features'.)
●Acute onset of pain (particularly after an injury) may indicate avulsion fracture of the tibial tubercle [32]. (See "Proximal tibial fractures in adults", section on 'Tibial tubercle avulsions'.)
●Pain at night, rest-related pain, mechanical symptoms (catching or locking), associated systemic complaints, and/or tenderness that is not directly localized to the tibial tubercle may indicate tumor, infection, or osteochondritis dissecans. (See "Overview of common presenting signs and symptoms of childhood cancer", section on 'Bone and joint pain' and "Hematogenous osteomyelitis in children: Clinical features and complications", section on 'Clinical features' and "Osteochondritis dissecans (OCD): Clinical manifestations, evaluation, and diagnosis", section on 'Clinical presentation'.)
The radiographic findings of Osgood-Schlatter disease are best depicted on the lateral radiograph. The findings are nonspecific and must be correlated with clinical findings to make the diagnosis. Soft tissue swelling anterior to the tibial tubercle may be the only abnormality (image 1). Other signs may include [8,20]:
●Elevation of the tubercle away from the shaft (image 2)
●Irregularity, fragmentation, or increased density of the tubercle (image 2)
●A superficial ossicle in the patellar tendon
●Calcification within or thickening of the patellar tendon
These findings may be difficult to distinguish from normal variation in the ossification of the tubercle. One or more ossicles may be present but may be normal variants [33]. Changes in the surrounding soft tissues and the infrapatellar fat pad may be more reliable diagnostic features [34].
Magnetic resonance imaging (MRI) has been proposed as a means of classifying staging of Osgood-Schlatter disease, which may help with prognosis, but it is usually not indicated [13,35]. In consultation with an orthopedic surgeon, or sports medicine specialist, MRI may be appropriate for evaluating young adults who are symptomatic beyond the growth period, particularly those patients with severe symptoms refractory to conservative treatment.
Because other imaging modalities can provide similar or better information regarding the status of the apophysis with no or less radiation, computed tomography imaging is not indicated in patients with Osgood-Schlatter disease.
DIFFERENTIAL DIAGNOSIS — Osgood-Schlatter is one in a spectrum of conditions that cause anterior knee pain in children and adolescents [20,36].
Bone tumors (eg, Ewing sarcoma, osteogenic sarcoma, osteoid osteoma, osteoblastoma, eosinophilic granuloma, and enchondroma) and subacute osteomyelitis of the proximal tibial apophysis rarely cause anterior knee pain in children and adolescents [37,38]. These conditions usually have associated features that are absent in patients with Osgood-Schlatter (eg, pain at night, rest-related pain, erythema and/or warmth over the tibial tubercle, fever and other systemic complaints). Patients who have such atypical features should undergo imaging as part of the initial evaluation. (See 'Imaging' above.)
Other conditions that cause anterior knee pain in children and adolescents include:
●Stress fracture of the proximal tibia
●Quadriceps tendon avulsion
●Avulsion fracture of the tibial tubercle
●Peripatellar tendinopathy
●Sinding-Larsen-Johansson (traction apophysitis at the inferior pole of the patella that typically occurs in boys aged 9 to 11 years)
●Plica syndrome (inflammation of the synovial folds)
●Hoffa disease (impingement of the infrapatellar fat pad)
●Idiopathic anterior knee pain
Tenderness over the tibial tubercle usually distinguishes Osgood-Schlatter from the above conditions, in which such tenderness is rarely present. The exception is avulsion fracture of the tibial tubercle, in which there is generally a history of acute injury [32]. The evaluation of patients with anterior knee pain that is not localized to the tibial tubercle is discussed separately. (See "Approach to acute knee pain and injury in children and skeletally immature adolescents" and "Approach to chronic knee pain or injury in children or skeletally immature adolescents".)
MANAGEMENT — The management of Osgood-Schlatter disease has not been studied in randomized controlled trials [39]. Observational studies suggest that most patients respond to nonsurgical treatment and that those with persistent symptoms may benefit from surgical therapy (eg, ossicle excision) [4,5,10,40-42].
Nonsurgical treatment — Osgood-Schlatter disease typically is a benign and self-limited condition. Symptoms generally resolve once the growth plate is ossified. The usual course is 6 to 18 months, during which symptoms may wax and wane [24,43]. However, some patients may have prolonged pain that may interfere with sports participation and quality of life. (See 'Prognosis' below.)
Conservative measures are the mainstay of therapy. Conservative measures for Osgood-Schlatter disease include control of pain and swelling, continuation of activity, and physical therapy (to strengthen the quadriceps and improve quadriceps and hamstring flexibility). The efficacy of these measures for patients with Osgood-Schlatter has not been evaluated in randomized trials [39]. The recommendations below are based upon observational studies and clinical experience [4,5,10,40-42].
Pain control — Measures to control pain and swelling may include the application of ice, administration of analgesics and/or nonsteroidal (image 1) antiinflammatory drugs (NSAIDS) for a limited duration (eg, three to four days), and the wearing of a protective pad over the tibial tubercle.
The application of ice to the involved area after participating in sports activity may be helpful in reducing pain and swelling [39]. During periods of symptom exacerbation, ice should be applied for 20 to 30 minutes at a time at least twice per day.
Analgesics (eg, acetaminophen) or nonsteroidal antiinflammatory medications (eg, ibuprofen) may help to control the pain.
Patients with persistent pain that alters their ability to participate in sports for more than three months may benefit from injection of hyperosmolar dextrose (eg, 12.5 percent dextrose) by a sports medicine specialist or orthopedic surgeon. As an example, in a small blinded trial of 54 young athletes (mean age 13 years) with Osgood-Schlatter disease and persistent pain despite three months of usual care (ie, local pain control, oral analgesics, and strengthening and stretching exercises with gradual sports reintroduction), injection of 12.5 percent dextrose mixed with lidocaine was significantly associated with no symptoms during sports activities at three months and one year when compared to lidocaine injection or usual care [44]. Although these results are encouraging, additional study is necessary to clarify any potential adverse events before this procedure can be routinely recommended.
Glucocorticoid injections generally are not recommended because of case reports of complications, primarily related to subcutaneous atrophy [45].
Wearing a protective pad over the tibial tubercle (an Osgood-Schlatter pad, or a brace with a doughnut pad around the tibial tubercle) may prevent direct trauma to the tender tibial tubercle [24].
Activity continuation — Complete avoidance of sports activity is neither necessary nor recommended [46]. Inactivity can lead to deconditioning and increases the risk of recurrence or other injury after returning to sports participation [24].
Osgood-Schlatter is one condition in which playing with pain is permitted (provided the pain is tolerated and resolves within 24 hours [24]). Activities that require prolonged squatting or kneeling may not be tolerated; for some athletes, a change in position may be necessary (eg, from catcher to outfielder in baseball) [43,47].
Crutches are rarely indicated, and knee immobilizers are contraindicated. Extended periods of casting worsen the ultimate outcome because they lead to atrophy of the quadriceps and hamstring muscles.
Physical therapy — Once pain is adequately controlled, athletes with Osgood-Schlatter disease should participate in a rehabilitative program that includes stretching and strengthening of the quadriceps and hamstring muscles [24,48].
Education — Children and adolescents with Osgood-Schlatter disease and their parents should be educated regarding the anticipated disease course. They should understand that during the course of resolution, there may be unpredictable exacerbations of symptoms that resolve quickly with appropriate management [24,43]. They should also understand that variable amounts of tibial tubercle prominence will persist after symptoms have resolved [47]. (See 'Complications and sequelae' below.)
Follow-up — There is no specific follow-up schedule for patients with Osgood-Schlatter. Patients should follow-up with their primary care provider as regularly scheduled for health maintenance. They should make arrangements to be seen sooner if they have persistent or worsening pain or develop atypical features (a new or different type of pain, pain at night, pain that is unrelated to activity, or associated systemic complaints).
Surgical treatment — Surgical management is reserved for patients who fail to respond to conservative measures; it is generally undertaken after closure of the proximal tibial growth plate [42]. Specific procedures have not been evaluated in randomized trials. In case series, ossicle resection and/or excision of the tibial tuberosity have been beneficial in reducing symptoms [10,42,49-52]. Arthroscopy is favored over an open approach because it decreases the risk of damage to the patellar tendon, permits more rapid return to activity, avoids a scar over the tuberosity that can cause pain with kneeling, and has better cosmesis [53].
PROGNOSIS — Osgood-Schlatter disease typically subsides with the closure of the proximal tibial growth plate at skeletal maturity (usually between 14 and 18 years of age). However, a subset of adolescents may experience prolonged pain that may be associated with diminished athletic function and quality of life [54-56]. Pain that persists after the closure of the growth plate may be related to a residual ossicle [23].
The natural history of Osgood-Schlatter disease was evaluated in a retrospective review of 50 patients (69 knees) for whom no treatments or activity restrictions were recommended [5]. After an average of nine years, 24 percent of patients reported some limitation in activities, and 60 percent had discomfort with kneeling.
COMPLICATIONS AND SEQUELAE — Complications and sequelae of Osgood-Schlatter disease may include persistent prominence of the tibial tubercle, persistent pain, and rarely, genu recurvatum (back knee, hyperextension of the knee) (figure 5) [24].
Variable amounts of tibial tubercle prominence persist after symptoms have resolved [47]. Patients and parents should be informed about this potential cosmetic sequela at the time of diagnosis [24,47].
Pain that persists after closure of the proximal tibial growth plate is uncommon. A residual ossicle is the most common cause; avulsion fracture of the tibial tubercle is another possibility. Plain radiographs of the tibial tuberosity should be obtained if these injuries are suspected.
Residual ossicles in the patellar tendon occur in approximately 10 percent of children and adolescents with Osgood-Schlatter disease [10,19]. Residual ossicles may be associated with symptoms that persist after closure of the proximal tibial growth plate (eg, pain with activity or direct pressure) [23]. Ossicle excision can be curative [10]. (See 'Surgical treatment' above.)
Persistent pain that is not associated with a residual ossicle may indicate avulsion fracture of the tibial tubercle, particularly in athletes involved in jumping sports [57]. Tibial tubercle fractures occur more commonly among teenagers with a history of Osgood-Schlatter disease [58] but remain uncommon [58,59]. A causal relationship has not been demonstrated [8].
Genu recurvatum is a rare but serious complication of Osgood-Schlatter disease [60,61]. It results from premature fusion of the anterior part of the upper tibial epiphyseal plate.
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: Osgood-Schlatter disease (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Definition and pathogenesis – Osgood-Schlatter disease is an overuse injury seen in older children and adolescents. It is caused by repetitive strain and chronic avulsion of the secondary ossification center of the tibial tubercle. (See 'Pathogenesis' above.)
●Risk factors – Osgood-Schlatter occurs most frequently in participants of sports that involve running, cutting, and jumping, especially children and adolescents who have recently undergone a rapid growth spurt. (See 'Risk factors' above.)
●Clinical presentation – The most common presenting complaint is anterior knee pain that increases gradually over time; the pain is exacerbated by direct trauma, kneeling, running, jumping, squatting, climbing stairs, or walking uphill, and is relieved by rest. (See 'Clinical presentation' above.)
●Diagnosis – The diagnosis of Osgood-Schlatter is made clinically. The characteristic findings are tenderness and soft tissue or bony prominence of the tibial tubercle in a patient with an otherwise normal examination (including range of motion of the hip). (See 'Examination' above.)
Imaging is not necessary to confirm the diagnosis in individuals with characteristic features but may be necessary to exclude other conditions in patients with atypical complaints, such as pain at night, rest-related pain, acute onset of pain (especially after trauma), associated systemic complaints, or pain that is not directly over the tibial tubercle. (See 'Imaging' above.)
●Management – For children and adolescents with Osgood-Schlatter disease, we suggest the following conservative measures (Grade 2C) (see 'Nonsurgical treatment' above):
•Cold therapy (eg, applying ice) to the tibial tuberosity after participating in sporting activities. (See 'Pain control' above.)
•Analgesics or nonsteroidal antiinflammatory drugs of limited duration (no longer than 3 to 4 days) as needed for pain. Patients with persistent pain that alters their ability to participate in sports for more than three months may benefit from injection of hyperosmolar dextrose (eg, 12.5 percent dextrose) by a sports medicine specialist or orthopedic surgeon. (See 'Pain control' above.)
•Continued sports participation, provided that the pain can be tolerated and resolves within 24 hours. (See 'Activity continuation' above.)
•Physical therapy to strengthen the quadriceps and stretch the quadriceps and hamstrings. (See 'Physical therapy' above.)
Neither immobilization of the knee nor cessation of activity are appropriate.
Children and adolescents with Osgood-Schlatter disease and their parents/caregivers require anticipatory guidance regarding the expected waxing and waning disease course, the typical duration of the disease, and its sequelae. (See 'Education' above.)
●Complications – Complications and sequelae of Osgood-Schlatter disease may include persistent prominence of the tibial tubercle, persistent pain (usually related to a residual ossicle), and genu recurvatum. Patients who have pain that persists after closure of the proximal tibial growth plate and is related to bony or cartilaginous ossicles may benefit from surgical excision. (See 'Complications and sequelae' above and 'Surgical treatment' above.)
●Prognosis – Osgood-Schlatter disease typically is a benign and self-limited condition, although a significant subset of patients may experience prolonged pain that may be associated with diminished athletic performance and quality of life. Symptoms generally resolve once the growth plate is ossified. (See 'Prognosis' above.)
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