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A Look at The Pathophysiology and Rehabilitation of Osgood-Schlatter Syndrome
A Look at The Pathophysiology and Rehabilitation of Osgood-Schlatter Syndrome
ABSTRACT
Osgood-Schlatter Syndrome is childhood prone condition known as an Osteochondrosis. This condition tends effect young
athletes participating in sports that involve a lot of running and jumping, such as dance and gymnastics. It tends to
manifests itself in boys between 10-15yrs and 8-13yr girls, usually a time of peak height velocity. The common signs and
symptoms are local pain, swelling and tenderness over the tibial tuberosity on the dominant leg, which makes
participation in sport painful. The condition is self-limiting without complication if sporting activity is stopped and
conservative treatment sought. However this presents serious limitations for serious athletes who must continue to
training. This article aims to educate coaches on the aetiology, diagnosis, and treatment options of the condition, as well as
well discuss the injury prevention and rehabilitation recommendations. It is believed that an appropriate understanding of
this condition by coaches is important in order to be able to effectively implement preventative measures in their training
programs, make appropriate recommendations to athletes, and work closely with health allies (like physiotherapists, GP,
pediatricians) to be able to reduce losses in training time due to OSS.
Key Words: Osgood-Schlatter Disease, injury prevention, overuse injury, knee injury
INTRODUCTION
in the knee/s, ankle/s, and elbow/s joints. OSS is
In 1903, Robert Osgood, a US orthopaedic surgeon, and categorized as a chronic overuse injury (7), which is most
Carl Schlatter a Swiss surgeon, concurrently described the often diagnosed in young athletes (but not entirely
possible pathophysiology of the disease that now bears exclusive), involved in sports that involve a lot of running
their names, Osgood-Schlatter Disease (1). They described and jumping, such as soccer, dance, gymnastics (10). It
it as an avulsion of a small portion of the tibial tuberosity usually manifest itself in boys around 10-15yrs of age, and
caused by a violent contraction of the quadriceps extensor in girls around 8-13yrs of age, often coinciding with growth
mechanism (2) Since then its has been more accurately spurts and peak height velocity (1) The condition is usually
labelled as a syndrome rather then a disease with many unilateral (9), with 25% to 50% of patients developing a
proposed theories to further explain its aetiology (OSD aka bilateral condition (11). There is a close relationship
OSS), such as, degeneration of the patellar tendon, aseptic between the leg preferentially involved in jumping, and
necrosis, infection, (2), trauma, local alternations of the sprinting and it developing OSS (3). Traditional literature
chondral tissue, overpull by the extensor muscles of the suggest that boys are more prevalent to OSS than girls, but
knee, which can result in patella alta, and traction more recent evidence indicates that with more and more
apophysitis, eccentric muscle pull and muscle tightness, girls being involved in sport, there is no longer any
and reduced width of the patella angle (3). It is now significant difference (14).
generally accepted that OSS is an avulsion fracture of the
growing tibial tubercle (4), characterized by pain at the The aim of this article is to examine the available literature
tibial tubercle resulting from repeated stress at the and the current body of knowledge of the pathophysiology
insertion of the patellar tendon due to extensor of OSS, in order to give coaches a better understanding and
mechanism abnormalities (12). prevention methods. By educating coaches to recognise the
possible signs and symptoms of this condition, coaches
OSS is part of a group of conditions called may be able to identify athletes at high/er risk of
osteochondrosis. These are a family of orthopaedic disease developing the condition, and thus be able to plan
that occur in children, and involve areas of significant preventative measures ahead of time. It will also allow for
tensile or compressing stress (5) effecting the growing coaches to take appropriate treatment steps when
epiphysis (growth plate) (13). These conditions often arise symptoms arise during training as well as being able to
©2008 The Gym Press. All rights reserved Gym Coach Vol.2, August, 2008 - 39-
V. Uzunov, Gym Coach, Vol.2 (2008) 39-45 Commentary
Article
effectively work with medical allies like physiotherapists in with its distinct characteristics and pathological alterations
implementing a rehabilitation program for gymnasts who (figure 2).
suffer from this condition.
Normal Stage – MRI is normal but symptoms are present.
Early Stage – MRI show no avulsion at the secondary
ossification centre of the tibial tuberosity, but
DISCUSSION and REVIEW inflammation around the secondary ossification centre is
present. Symptoms are initially not severe, but progresses
Aetiology quickly if no treatment is undertaken
The exact cause and Progressive Stage – Presence of partial cartilaginous
aetiology of OSS is still avulsion from the secondary ossification centre. Patients
debated (2), but there is complain of pain, with obvious swelling of patellar tendon
general consensus in at insertion. Possible thickening of patellar tendon
literature that it is Terminal Stage – Existence of separated ossicles.
probably caused by one Symptoms present for period of time (around several
or more biological, months), tenderness, swelling and pain at tibial tuberosity,
biomechanical, and with possible thickening of patellar tendon at insertion
physiological factors. site. Pain triggered at stopping and turning motion.
These are considered to Patellar tendonitis is a possible secondary pathologic
be: Overpull of the complication due to partial tear of the secondary
extensor mechanism in ossification centre.
the knee, linked with Healing Stage – Osseous healing of the tibial tubercle
abnormalities in patella without separated ossicles. Visible prominence of tibial
position (figure 1) (20), tuberosity, the patellar tendon could still be thickened at
and the extensor machenism made up
of the quadriceps muscle group,
increase external tibial insertion, but not always.
quadriceps tendon, patella, patellar, torsion (3), and possibly
retinaculum, patellar ligament and an an increased Q-angle, Chronic overuse injuries (especially in young athletes)
assortment of other soft tissues in that observed especially in
area. The tibial tuberosity is the make up 30-50% of all paediatric sport injuries in children
associated site of injury in athletes with
flat footed and knock- (16) Overuse injuries occur when tissue is repeatedly
OSS. Image source: John Hoppkins kneed children (46).
Sport Medicine Traction-induced, Figure 2 (below) - A typical case study of OSS progression Figure 2 -
microtrauma to the A typical case study of OSS progression in a active child over a 2.3 years
apophysis, due to period.(A) At 10.1 years old, development of the tibial tuberosity was in
the cartilaginous stage and normal. (B) At 11.3 years old, this image
chronic overuse (12,16), skeletal immaturity, quadriceps showed that a tear had appeared in the secondary ossification center
muscletendon imbalance, hamstring, and calf flexibility (arrow) and development of the tibial tuberosity was in the apophyseal
restriction (14, 7) All these factors are reported in literature stage.(C) After 1 month, the MR image showed an opened shell like
to either cause or predispose growing children to OSS. In a separation (arrow) and the disease had advanced to the progressive
stage. The growth of the tibial tuberosity had entered the epiphyseal
longitudinal study by Atsushi Hirano et al (2002), MRI stage. High signal intensity appeared within the patellar tendon. (D)
was used to track and clarify the nature and course of OSS After 2 months the MR image showed that an anterior avulsed portion
in 285 boys from high level junior soccer teams. They had been separated (arrow). (E) At 12.4 years old, the ossicle had
identified and described 5 stages of the condition, each moved further superiorly (arrow).
ACKNOWLEDGEMENTS
This article is an abbreviated version of original manuscript by Valentin Uzunov (2007). An in-depth look at the pathophysiology and
treatment of Osgood-Schlatter Disease. Research project submission for Massey University. If you would like a copy of the full
unmodified version, contact Valentin Uzunov a
valentin.uzunov@gmail.com
Address for correspondence: Valentin Uzunov, Hataitai Gymnastics, Wellington, New Zealand.
valentin.uzunov@gmail.com