Osgood–Schlatter disease
| Osgood–Schlatter disease | |
|---|---|
| Specialty | Rheumatology, orthopedic surgery  |
Osgood–Schlatter disease or syndrome (also known as "knee cancer" and epiphysitis of the tibular tubercle) is an irritation of the patellar ligament at the tibial tuberosity.[1] It is characterized by painful lumps just below the knee and is most often seen in young adolescents. Risk factors include excess weight and overzealous conditioning (running and jumping).
Sinding–Larsen–Johansson syndrome, named after Sven Christian Johansson (1880-1959), a Swedish Surgeon and Christian Magnus Falsen Sindig-Larsen (1866-1930), a Norwegian Physician, is an analogous condition involving the patellar tendon and the lower margin of the patella bone, instead of the upper margin of the tibia. This variant was discovered in 1908, during a winter indoor Olympic qualifier event in Scandinavia. Sever's disease is a similar condition affecting the heel.
Osgood-Schlatter disease occurs in boys and girls aged 9–16[2] coinciding with periods of growth spurts. It occurs more frequently in boys than in girls, with reports of a male-to-female ratio ranging from 3:1 to as high as 7:1. It has been suggested the difference is related to a greater participation by boys in sports and risk activities than by girls. [citation needed]
The condition is usually self-limiting and is caused by stress on the patellar tendon that attaches the quadriceps muscle at the front of the thigh to the tibial tuberosity. Following an adolescent growth spurt, repeated stress from contraction of the quadriceps is transmitted through the patellar tendon to the immature tibial tuberosity. This can cause multiple subacute avulsion fractures along with inflammation of the tendon, leading to excess bone growth in the tuberosity and producing a visible lump which can be very painful when hit. In more detail, activities such as kneeling may irritate the tendon.
The syndrome may develop without trauma or other apparent cause; however, some studies report up to 50% of patients relate a history of precipitating trauma.
In a retrospective study of adolescents, old athletes actively participating in sports showed a frequency of 21% reporting the syndrome compared with only 4.5% of age-matched nonathletic controls.[3] Intense knee pain is usually the presenting symptom that occurs during activities such as running, jumping, squatting, and especially ascending or descending stairs and during kneeling. The pain is worse with acute knee impact. The pain can be reproduced by extending the knee against resistance, stressing the quadriceps, or striking the knee. Pain is mild and intermittent initially. In the acute phase the pain is severe and continuous in nature. Impact of the affected area can be very painful. Bilateral symptoms are observed in 20–30% of patients.
The symptoms usually resolve with treatment but may recur for 12–24 months before complete resolution at skeletal maturity, when the tibial epiphysis fuses. In some cases the symptoms do not resolve until the patient is fully grown. In approximately 10% of patients the symptoms continue unabated into adulthood, despite all conservative measures.[4]
The condition is named after Robert Bayley Osgood (1873-1956), an American Orthopedic Surgeon and Carl B. Schlatter, (1864-1934), a Swedish Surgeon who described the condition independently in 1903.
Treatment
Diagnosis is made clinically,[5] and treatment is conservative with RICE (Rest, Ice, Compression, and Elevation), and if required acetaminophen (paracetamol), ibuprofen and/or Co-Codamol or stronger if in 'acute phase' & (the pain is severe and continuous in nature). The condition usually resolves in a few months, with a study of young athletes revealing a requirement of complete training cessation for 1 week (on average) and gradual resumption of full training by 1 month.[3]
Bracing or use of an orthopedic cast to enforce joint immobilization is rarely required and does not necessarily give quicker resolution. Sometimes, however, bracing may give comfort and help reduce pain as it reduces strain on the tibial tubercle.[6] Surgical excision may rarely be required in skeletally mature patients.[4] In chronic cases that are refractory to conservative treatment, surgical intervention yields good results, particularly for patients with bony or cartilaginous ossicles. Surgery is usually a good idea for patients that will no longer grow but the knee is still affected by Osgood-Schlatters disease. Excision of these ossicles produces resolution of symptoms and return to activity in several weeks. After surgery, it is common for lack of blood flow to below the knees and to the feet. This may cause the loss of circulation to the area, but will be back to normal again shortly. A high pain may come and go every once and a while, due to the lack of blood flow. If this happens, sitting down will help the pain decrease. Removal of all loose intratendinous ossicles associated with prominent tibial tubercles is the procedure of choice, both from the functional and the cosmetic point of view.[7] According to one study, in the great majority of young adults, the functional outcome of surgical treatment of unresolved Osgood-Schlatter disease is excellent or good, the residual pain intensity is low, and postoperative complications or subsequent reoperations are rare.[8]
After symptoms have resolved, a gradual progression to the desired activity level may begin. In addition, predisposing factors should be evaluated and addressed. Commonly quadriceps and/or hamstring tightness is present and should be addressed with stretching exercise.
After being clinically diagnosed the patient should rest for at least 3 days and must try not to use the knee as hard for about 1–2 weeks without any physical activities. If the disease continues to a certain extent where the patient cannot move the joint then they should seek medical advice right away as although this is very rare it can be severely limiting for the patient's sporting future if it does occur. The Strickland Protocol has shown a positive response in patients with a mean return to sport in less than 3 weeks.[9]
Paul Scholes, Danny Welbeck and Mark Winterburn are sportsmen who have recovered from this condition.[10] The French tennis player, Gaël Monfils wears patella bands in an attempt to combat the condition. [11]
References
- ^ Nowinski RJ, Mehlman CT (1998). "Hyphenated history: Osgood-Schlatter disease". Am J. Orthop. 27 (8): 584–5. PMID 9732084.
- ^ Yashar A, Loder RT, Hensinger RN (1995). "Determination of skeletal age in children with Osgood-Schlatter disease by using radiographs of the knee". J Pediatr Orthop. 15 (3): 298–301. doi:10.1097/01241398-199505000-00006. PMID 7790482.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ a b Kujala UM, Kvist M, Heinonen O (1985). "Osgood-Schlatter's disease in adolescent athletes. Retrospective study of incidence and duration". Am J Sports Med. 13 (4): 236–41. doi:10.1177/036354658501300404. PMID 4025675.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ a b Gholve PA, Scher DM, Khakharia S, Widmann RF, Green DW (2007). "Osgood Schlatter syndrome". Curr. Opin. Pediatr. 19 (1): 44–50. doi:10.1097/MOP.0b013e328013dbea. PMID 17224661.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Cassas KJ, Cassettari-Wayhs A (2006). "Childhood and adolescent sports-related overuse injuries". Am Fam Physician. 73 (6): 1014–22. PMID 16570735.
- ^ Engel A, Windhager R (1987). "[Importance of the ossicle and therapy of Osgood-Schlatter disease]". Sportverletz Sportschaden (in German). 1 (2): 100–8. doi:10.1055/s-2007-993701. PMID 3508010.
- ^ O. Josh Bloom and Leslie Mackler (February 2004). "What is the best treatment for Osgood-Schlatter disease?". Journal of Family Practice. 53 (2). PDF version
- ^ Hariri, S.; York, S. C.; O'Connor, M. I.; Parsley, B. S.; McCarthy, J. C. (2011). "Career Plans of Current Orthopaedic Residents with a Focus on Sex-Based and Generational Differences". The Journal of Bone and Joint Surgery. 93 (5): e16. doi:10.2106/JBJS.J.00489. PMID 21368070.
- ^ Strickland JM, Coleman NJ, Brunswic M and Kocken R. (2008). "Osgood-Schlatter's Disease: An active approach using massage and stretching". Presentation at the European Congress of Sports Science Conference. appendix1. ISSN 1536-7290.
{{cite journal}}: CS1 maint: multiple names: authors list (link) - ^ Simply the best. Guardian. 18 May 2008
- ^ Gael could miss French Open. Sky Sports. 21 April 2009