Osgood-Schlatter Disease

Ross Hauser, MD

A conversation with a concerned parent will usually begin like this. “My son/daughter was just diagnosed with Osgood-Schlatter Disease. They are recommended rest and months of physical therapy. He/she is an elite soccer player and he/she cannot afford to miss that much time off the field. Is there anything you can do?”

Osgood-Schlatter Disease (OSD) is a disorder involving painful inflammation of the bone, cartilage, and/or tendon at the top of the shinbone where the tendon from the kneecap attaches to the shin bone. Young athletes will usually go to the doctor because they have severe knee pain.

• Osgood-Schlatter Disease usually strikes active adolescents at the beginning of their growth spurts.
• Growth spurts can begin any time between the ages of 8 and 13 for girls, and 10 and 15 for boys.
• Sports requiring a lot of jumping, kneeling and squatting make young athletes particularly susceptible, as it is felt that stress on the bone from the tendon tugging on it during activities such as sports, leads to Osgood-Schlatter disease.

“No one seems to know how long the recovery will be or even if this is the right diagnosis.”

Another concern that this parent may express is what we have heard from many parents. “No one seems to know how long the recovery will be or even if this is the right diagnosis.”

An accurate means of diagnosing Osgood-Schlatter disease compounds the problem for clinicians who are not experienced in seeing this disorder.

Doctors writing in the journal Archives of Orthopaedic and Trauma Surgery (1) recognized this problem and called for a heightened awareness of risk factors that could predispose children to Osgood-Schlatter disease. They advised doctors to be alerted to growth or height, body weight, body mass index, tightness of the quadriceps femoris and hamstring muscles, muscle strength during knee extension, and flexion.

Osgood-Schlatter Disease is chronic knee pain

At the end of each of the long bones in the child’s arms and legs is a growth plate made of cartilage. Since cartilage isn’t as strong as bone, stress on the cartilage can cause it to become swollen and irritated. Osgood-Schlatter occurs when the tendon from the kneecap (patellar tendon) pulls very forcefully on the growth plate of the large bone (tibia) below the knee.

The child’s body may try to close that gap by creating new bone growth (a bone spur) or calcification of the tendon where it attaches to the tibia or shin bone, resulting in a bony lump in that area. This lump can be very painful, especially when hit or with activities such as kneeling.

Treating Osgood-Schlatter Disease

The chronic knee pain that results from Osgood-Schlatter disease is usually exacerbated by physical activity, especially running and jumping. As a result, the most common treatment physicians recommend for young athletes is simply rest and cessation from playing sports. Needless to say, although this advice has become accepted practice, it is not popular, especially considering that Osgood-Schlatter disease can last until the bones stop growing. That can be a very long time to wait and not participate in a favorite sport.

Some other possible recommendations include:

• An X-ray to examine the area where the patella tendon attaches to the shinbone, and to look for calcification of the attachment
• Over the counter pain relievers and/or oral anti-inflammatories
• Physical therapy to stretch the quadriceps
• Wearing a pad over the knee for protection
• Wearing a patellar tendon strap to try and keep the tendon from moving during activities.
• Bracing to reduce strain on the tibial tubercle

When the above modalities fail to bring relief and the condition becomes chronic, surgical intervention may be recommended. Surgery often has its complications, and this particular surgery to remove the calcified areas may leave the patient with circulation issues below the knee.

Osgood-Schlatter disease has previously been assumed to be innocuous and to self-resolve with limited intervention. Maybe that is not the case

An August 2021 study from Aalborg University in Denmark, published in the Orthopaedic Journal of Sports Medicine (2) questioned the assumption that all patients with Osgood-Schlatter disease experience quick recovery. Here are the study’s learning points:

• This study included a group of 46 adolescents (aged 10-14 years) diagnosed with Osgood-Schlatter disease who were evaluated for 24 months.
• The primary outcome at 24-month follow-up was whether participants continued to experience Osgood-Schlatter disease-related knee pain.

Results:

• Of these 46 participants, 37% still reported knee pain due to Osgood-Schlatter disease. In this subgroup, the average duration since symptom onset was 42 months.
• More than 1 in 5 participants reported stopping sport due to knee pain, and those who continued to experience knee pain reported significantly worse pain, function, and sports participation scores at follow-up compared with patients with no knee pain.
• Participants with continued Osgood-Schlatter disease-related pain also had a lower health-related quality of life.

Conclusion: “Over one-third of the study participants had knee pain at 2-year follow-up, which was associated with lower sports-related function and health-related quality of life. This questions the assumption that all patients with Osgood-Schlatter disease experience quick recovery.”

Questioning conservative care treatments – immobilization and avoidance of sports

We are developing a theme here in recent research that questions the prognosis and questions standardized treatment methods. A September 2020 study in the journal International Orthopaedics (3) made these assessments of the standardized conservative care options for Osgood-Schlatter Disease.

• The present-day conservative treatment programs are often inadequate for young athletes because they require extremity immobilization and avoidance of sports, and hence the longer duration of rehabilitation. Therefore, the development of safe and effective treatment protocols for young athletes is of great practical importance. (This may be the understatement of the century to the parent or young athlete who was just told to stay away from their sport for 4 to 8 weeks.)

According to the researchers, the aim of the study “was to assess the efficacy and safety of the conservative treatment of Osgood-Schlatter disease in young professional soccer players.” What the researchers were looking at was can you treat Osgood-Schlatter disease without immobilization, stopping sport, or ultimately surgery?

• Twenty-eight players (between 11 and 15 years old) were diagnosed with Osgood-Schlatter disease.
• The average Osgood-Schlatter disease treatment duration was 27 days.
• Bilateral symptoms were observed in 42.9% of cases, and unilateral symptoms in 57.1%.
• Conservative treatment without immobilization was applied to all patients. It included kinesiotherapy for quadriceps muscle lengthening and physiotherapy as well as a gradual increase of physical activity.
  • A total of 35.7% of players reported having discomfort upon resuming regular training, which caused some restrictions in exercise. However, the symptoms resolved spontaneously with time. Surgical treatment or complete avoidance of exercise was not used in any of the patients.

Why did these researchers explore this treatment route? Because there are no real consciences in treatment. A May 2021 study in the journal Physical Therapy in Sport (4) from the University Children’s Hospital of Basel, Switzerland suggested this.

“Certain therapeutic approaches, such as stretching, have apparent efficacy, but no randomized control trials comparing specific exercises with sham or usual-care treatment exists. Carefully controlled studies on well-described treatment approaches are needed to establish which conservative treatment options are most effective for patients with Osgood-Schlatter disease.”

Using painkillers – Doctors issue concerns and warnings

A December 2021 study comes to us from Aalborg and Southern Denmark Universities in Denmark. Published in the medical review Scandinavian Journal of Pain, (5) doctors here express concerns that “the prevalence of pain medication use for adolescent knee pain and factors associated with use are not well understood.” Specifically in adolescents (age 10-19) with longstanding knee symptoms.

• In this paper 323 adolescents (73% female), 84% had patellofemoral pain and 16% had Osgood-Schlatter Disease
  • Twenty-one percent of adolescents reported pain medication use for their knee pain, with no difference in usage between those over vs. under 15 years of age.

The researchers offered these concerns: “Self-reported pain medication use is common in adolescents with longstanding knee pain, even though whether pharmacological therapy is the best pain management option at this young age is debatable. Reliance on pain medication at an early age could potentially hamper the development of healthy pain coping strategies and increase the risk of dependence and misuse later in life. Future studies should assess the safety, efficacy, and risks of long-term use of pain medications for adolescent knee pain.”

Prolotherapy in our experience gets the athlete back many weeks even months before standard physical therapy

We have been using Prolotherapy in the treatment of Osgood-Schlatter for more than 29 years. In the research below you will see studies including a double-blind study that showed that dextrose Prolotherapy significantly reduced the amount of pain Osgood-Schlatter suffered with.

• Prolotherapy injections, by stimulating the repair of the quadriceps tendon and ligament attachments to the tibial tubercle restore strength to this area and the athlete can go back to all their activities
• Prolotherapy in our experience gets the athlete back many, many weeks even months before standard physical therapy.

Prolotherapy’s injection technique causes a mild inflammatory response that stimulates the body’s immune system. This boosts blood flow to the damaged areas and causes an influx of reparative cells to come in to heal the weakened tendon attachment and cartilage. It even stimulates the body to lay down collagen, which is what the tendon and cartilage are made of. This new collagen causes a strengthening of the tendon, the tendon attachment, the cartilage, and the weakened soft tissue in the treated area. In short, Prolotherapy gives the body the resources it needs to repair.

Reviewed studies

In our research overview, A Systematic Review of Dextrose Prolotherapy for Chronic Musculoskeletal Pain was published in the journal Clinical Medicine Insights. Arthritis and Musculoskeletal Disorders. We highlighted several studies in patients with athletic injury resulting in tendinopathy unresponsive to conservative treatment.

• In one double-blinded study, young athletes aged 9–17 years with Osgood–Schlatter disease were randomized to dextrose injection, control injection, or to a non-injection (supervised exercise) group. Dextrose Prolotherapy patients had substantially greater pain reduction during sports activity than either group at follow-up, with many pain-free during sport involvement. At one year, 84% of the dextrose-treated knees were pain-free compared to 46% of the lidocaine-treated knees. (6).

That study which appeared in the medical journal Pediatrics also suggests:

• “Our results suggest superior symptom-reduction efficacy of injection therapy over usual care in the treatment of Osgood-Schlatter disease in adolescents. A significant component of the effect seems to be associated with the dextrose component of a dextrose/lidocaine solution. Dextrose injection over the apophysis and patellar tendon origin was safe and well-tolerated and resulted in the more rapid and frequent achievement of unaltered sport and asymptomatic sport than usual care.”(7)

After three injections, at the 6-month and 12-month follow-up visits, significant improvement

This study was published in the medical journal Journal of Foot and Ankle research by doctors at the School of Surgery, University of Western Australia. This research goes on to say:

“The analysis also suggests Prolotherapy injections provide equal or superior short, intermediate, and long-term results to alternative treatment modalities, including eccentric loading exercises for Achilles tendinopathy, Platelet-rich plasma for plantar fasciopathy and usual care or lidocaine injections for Osgood-Schlatter disease.”(8)

An October 2021 study in the journal Archives of Orthopaedic and Trauma Surgery (9) examined the use of hyperosmolar dextrose (Prolotherapy) injection in patients with Osgood-Schlatter disease.

• In this study, the researchers conducted a randomized, double-blind clinical trial involving 70 patients with Osgood-Schlatter disease.
• One group received a hyperosmolar dextrose injection (12.5%), while the other received a saline injection.
• The injections were conducted under ultrasound guidance.

Results:

• The dextrose group outperformed the saline group in improvement in the VISA-Patella (degree of symptoms, functional ability, and the ability to play sports) score from baseline to three months, 6 months; and 12 months.
• The changes in both groups were clinically important, suggesting that both therapies (the saline too) were active treatments.
• The dextrose group improved too rapidly for spontaneous improvement to explain much of this change.

Conclusion: “After three injections, at the 6-month and 12-month follow-up visits, the VISA-Patella (degree of symptoms, functional ability, and the ability to play sports) scores of the two groups were significantly improved; the dextrose group score was better than the saline group score, and there were significant differences between the two groups.

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References

1 Nakase J, Goshima K, Numata H, Oshima T, Takata Y, Tsuchiya H. Precise risk factors for Osgood-Schlatter disease. Arch Orthop Trauma Surg. 2015 Sep;135(9):1277-81. doi: 10.1007/s00402-015-2270-2. Epub 2015 Jul 2. [Google Scholar]
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6 Topol GA, Podesta LA, Reeves KD, Raya MF, Fullerton BD, Yeh H. Hyperosmolar dextrose injection for recalcitrant Osgood-Schlatter Disease. Pediatrics. 2011;128(5):e1121–e1128. doi: 10.1542/peds.2010-1931. [Google Scholar]
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This article was updated December 14, 2021

• Surgery
• NSAIDs
• Cortisone Shots
• R.I.C.E.