Osgood Schlatter's disease dnbid lecture 2012

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Osgood - Schlatter Disease & Physiotherapy :

Osgood - Schlatter Disease & Physiotherapy Dr. Dibyendunarayan Bid [PT] Senior Lecturer Sarvajanik College of Physiotherapy, Rampura, Surat

Introduction :

Introduction In 1903, Robert Osgood (1873-1956), a US orthopedic surgeon, and Carl Schlatter (1864-1934), a Swiss surgeon, concurrently described the disease that now bears their names. Osgood- Schlatter disease (OSD) is one of the most common causes of knee pain in active adolescents.

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OSD is a traction phenomenon resulting from repetitive quadriceps contraction through the patellar tendon at its insertion upon the skeletally immature tibial tubercle. This occurs in preadolescence during a time when the tibial tubercle is susceptible to strain. OSD should be distinguished from overuse of the patella-patellar tendon junction, which is referred to as Sinding -Larsen-Johansson syndrome (the adolescent equivalent of jumper's knee).

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Radiograph of a patient who is skeletally mature. Note that the tibial tubercle is enlarged and there is an ossicle . A bursa was overlying this.

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OSD is a very common cause of knee pain in children aged 10-15 years. This condition can cause loss of time from athletics; however, it is rarely a cause of permanent impairment or disability. Because of a lack of a precise definition, some practitioners may find differentiating OSD from avulsion fractures of the tibial tubercle to be difficult. If the patient cannot ambulate, an avulsion fractures of the tibial tubercle is more likely because OSD patients typically can ambulate, albeit with pain.

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The onset of OSD is usually gradual, with patients commonly complaining of pain in the tibial tubercle and/or patellar tendon region after repetitive activities. Typically, running or jumping activities that significantly stress the patellar tendon insertion upon the tibial tubercle aggravate the patient's symptoms.

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A sudden onset of pain with no antecedent symptoms in the region of the tibial tubercle should alert the clinician to assess for a possible tibial tubercle avulsion rather than OSD. OSD is a self-limiting condition. In a study by Krause et al, 90% of patients treated with conservative care were relieved of all of their symptoms approximately 1 year after onset of symptoms. [2]

Development of Osgood-Schlatter disease :

Development of Osgood- Schlatter disease In girls younger than age 11 years and in boys younger than age 13 years, the tibial tubercle consists of cartilaginous tissue. The secondary ossification center, or apophysis , of the tibial tubercle develops when girls are aged 8-12 years and when boys are aged 9-13 years. (During this stage of skeletal development, the Osgood-Schlatter lesion may occur.) By the end of the ensuing 2 stages of bony development ( eg , epiphyseal and bony stages), the growth plates of the proximal tibia fuse in males and females (usually when aged 14-18 y), and the OSD usually subsides.

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The most commonly accepted theory regarding the development of OSD is that repeated traction (traction apophysitis ) on the anterior portion of the developing ossification center leads to multiple subacute fractures or tendinous inflammation, resulting in a benign, self-limited disturbance manifested as pain, swelling, and tenderness. The most common long-term long-term ramifications of OSD are pain on kneeling as an adult and the cosmesis of a bony prominence on the anterior knee. Less common complications are the persistence of a painful ossicle requiring surgical excision and a displaced avulsion of a tibial tubercle.

Etiology :

Etiology The cause of OSD is unknown; however, theories suggest that this condition is a result of repeated knee extensor mechanism contraction that causes partial avulsions or microavulsions of the chondrofibro -osseous tibial tubercle. OSD usually occurs in persons involved in sports that require running and jumping.

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During running, gymnastics, and other sports requiring repeated contractions of the quadriceps, an extra-articular osteochondral stress fracture or microavulsion occurs. The proximal area of the patellar tendon insertion separates, resulting in elevation of the tibial tubercle. During the reparative phase of this stress fracture, new bone is laid down in the avulsion space, which may result in a deviated and prominent tibial tubercle.

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When an individual with an injured tibial tubercle continues to participate in sports, more and more microavulsions develop, and the reparative process may result in a markedly pronounced prominence of the tubercle, with longer-term cosmetic and functional implications. A separated fragment may develop at the patellar tendon insertion and may lead to chronic, nonunion-type pain.

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Approximately 50% of patients with OSD relate a history of precipitating trauma. Histologic studies support a traumatic etiology.

Risk factors :

Risk factors Risk factors for OSD include the following: Age between 8 and 15 years Male sex Rapid skeletal growth Repetitive jumping sports

Epidemiology :

Epidemiology Incidence One Finnish study found that OSD affected 13% of athletes. Sex predilection OSD occurs more frequently in boys, with a male-to-female ratio of 3:1, probably because a greater number of boys participate in sports. Age predilection OSD usually is seen in the adolescent years, after a patient has undergone a rapid growth spurt the previous year. Girls who are affected are typically aged 10-11 years but can range from age 8-12 years. Boys who are affected are typically aged 13-14 years but can range from age 12-15 years.

Prognosis :

Prognosis The prognosis in OSD is excellent. OSD usually resolves by the time the patient is aged 18 years, when the tibial tubercle apophysis ossifies. In approximately 10% of patients, however, the symptoms continue unabated into adulthood despite all conservative measures. This may be from residual enlargement of the tuberosity or from ossicle formation in the patellar tendon.

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In the study by Krause et al, 90% of patients treated with conservative care were relieved of all of their symptoms approximately 1 year following symptom onset. In some cases, however, discomfort may persist for 2-3 years until the tibial growth plate closes.

Patient Education :

Patient Education Inform patients about activities that aggravate OSD and about the self-limiting nature of the condition.

History :

History The individual's history and a physical examination are usually sufficient to make a diagnosis of OSD. Knee pain usually is the presenting symptom. Patients usually report that the knee pain occurs during activities such as running, jumping, squatting, and ascending or descending stairs. Pain often subsides with rest and activity modification.

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Athletes involved in football, soccer, basketball, gymnastics, and ballet are most commonly affected. Symptoms often are vague and intermittent in onset. Symptoms may develop without trauma or other apparent cause, although approximately 50% of patients give a history of precipitating trauma. The disease is bilateral in 20-50% of patients.

Physical Examination :

Physical Examination The physical examination is very specific, with point tenderness over the tibial tubercle.

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Other physical examination findings may include the following: Proximal tibial swelling and tenderness Enlargement or prominence of the tibial tubercle Reproducible and aggravated pain by direct pressure and jumping (quadriceps contraction) Pain with resisted knee extension (quadriceps contraction) Full range of motion of the knee Hamstring tightness No effusion or meniscal signs Negative drawer test (no knee instability) Normal neurovascular examination No abnormal findings in the hip and ankle joints

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Tenderness to palpation over the proximal tibial tuberosity at the site of patellar insertion may be present. A firm mass may be palpable. Erythema of the tibial tuberosity may be present. Some patients may have quadriceps atrophy.

Lab studies :

Lab studies Laboratory evaluation is not indicated for OSD unless other diagnoses are being entertained. Imaging studies are not required to make a diagnosis of OSD; however, they often are used to rule out osteomyelitis , tumors, and other pathologies. Bone scanning may demonstrate increased uptake in the area of the tibial tuberosity .

Radiographs :

Radiographs Not all patients with OSD need radiography, since the diagnosis is clinical. However, plain films are helpful for ruling out other etiologies, such as neoplasm, acute tibial apophyseal fracture, and infection.

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In addition, radiographs may indicate: Superficial ossicle in the patellar tendon Irregular ossification of the proximal tibial tuberosity Calcification within the patellar tendon Thickening of the patellar tendon Soft-tissue edema proximal to the tibial tuberosity

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The Osgood- Schlatter lesion is best seen on the lateral view, with the knee in slight internal rotation of 10-20°. When radiographs are obtained, the most common finding is that the knee films are normal, especially if the child is in the preossification phase. The acute phase of OSD may reveal a prominent and elevated tibial tubercle with anterior soft-tissue swelling. In severe cases, radiographs may reveal radiodense fragments or ossicles separated from the tibial tuberosity .

Medical Care :

Medical Care Therapy for OSD is conservative. Initial treatment includes the application of ice for 20 minutes every 2-4 hours. Analgesics and NSAIDs may be given for pain relief and reduction of local inflammation. However, NSAIDs have not been shown to shorten the course of OSD. Steroid injections should not be used. Inform the patient to avoid pain-producing activities (e.g., sports that involve excess amounts of jumping).

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Use of a knee immobilizer for a few days may improve compliance, especially in more severe cases. Pads or braces also can be used for support. Once the acute symptoms have abated, quadriceps-stretching exercises, including hip extension for a complete stretch of the extensor mechanism, may be performed to reduce tension on the tibial tubercle. Stretching exercises for the hamstrings, which are commonly tight, may also be performed. Other than the presence of an ossicle that causes pain with kneeling, there are no long-term disabilities or problems associated with this condition.

Braces and Supports:

Braces and Supports Each of these braces add force to the patellar tendon, making it harder to pull away from the Tibial Tuberosity. A quick and cheap brace can also be a piece of prewrap rolled up around the area of the Tibial Tuberosity just slightly proximal to it.

Surgical Intervention :

Surgical Intervention If conservative treatment fails, surgical excision of the united painful ossicle is recommended. Removal of ossicle fragmentation in immature patients with an unfused apophysis should be approached with caution, as a resultant recurvatum deformity may occur due to premature fusion of the tibial tubercle. Tibial tubercle avulsions occasionally can occur due to the contracture of the extensor mechanism. Open reduction and internal fixation (ORIF) usually is recommended, depending on the size and displacement of the fragment as well as the phase of apophyseal closure.

Other Treatments :

Other Treatments The American Academy of Orthopaedic Surgeons and the American Academy of Family Practice recommend activity limitation, ice, anti- inflammatories , protective padding, quadriceps/hamstring strengthening, and time in the management of OSD. Corticosteroid injections are not recommended because of case reports of complications, primarily related to subcutaneous atrophy.

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Long-term immobilization is typically contraindicated, because it may result in increased knee stiffness in mild cases, thus predisposing the athlete to additional sports-related injuries. However, if a patient is noncompliant, the clinician may recommend immobilization in a knee brace for a minimum of 6 weeks . The brace should be removed daily, but only for stretching and strengthening exercises.

Physical Therapy :

Physical Therapy The goal of rehabilitation is for the athlete to be able to return to his or her sport as quickly and safely as possible. The physical therapist and the physician determine when the athlete is ready to resume competition, depending on the findings of the clinical examination and functional testing.

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The pain may take up to 6-24 months to resolve . If an individual returns to activity too soon, he or she may worsen the condition. Athletes need to work on improving the flexibility and strength of the quadriceps and hamstring muscles throughout the course of rehabilitation to ensure that they are ready to return to sports.

Acute phase :

Acute phase Several techniques may be recommended by the physical therapist to alleviate discomfort and avert recurrence of the disease. Treatment recommendations are dependent upon the severity of the condition. An infrapatellar strap may be recommended during sports activity. Resting is recommended when pain arises. Ice should be applied to the area for 20 minutes following activity. Stretching of the quadriceps and hamstring muscles helps to prevent the development of OSD. Short-term rest and knee immobilization may be required. Knee braces are used for long-term immobilization (6 wk) in severe cases ( eg , pain persists longer than 24 h following sports activity and/or limits daily activity) or for noncompliant patients with increasing symptoms.

Recovery phase :

Recovery phase The following regimen recommendations for patients with OSD are taken from Meisterling , Wall, and Meisterling . Straight leg raises can be performed as follows: Lie on the floor with the back propped up a few inches with the elbows Bend the unaffected knee to a comfortable position; using adjustable ankle weights with half-pound increments, determine the weight at which 10 raises can be performed on the affected leg Tighten the thigh muscles and lift the affected leg 12 inches, keeping the leg straight Hold for 5 seconds Slowly lower the leg and relax Start with 10 repetitions for each leg When 15 repetitions have been performed comfortably, increase the weight by half a pound and drop back to 10 repetitions Once 15 repetitions again can be performed comfortably, increase the weight again, to a maximum of 7-12 lb

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Short-arc quadriceps exercises can be performed as follows: Lie back with the unaffected knee bent (same as for straight leg raises) Place a few rolled up towels under the affected knee to raise it 6 inches from the floor Tighten the thigh muscles and straighten the leg until it is 12 inches from the floor Hold for 5 seconds Slowly lower the leg and relax Start with 10 repetitions for each leg and increase to 15, using the same ankle weight and repetition progression as for straight leg raises

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Wall slides can be performed as follows: To do wall slides or quarter seats, stand about 12 inches from a smooth wall and lean back against it with the feet shoulder width apart Holding a light dumbbell in each hand with the arms straight down, bend the knees and slowly lower the body 4-6 inches If pain is felt, the body has squatted too far Hold for 5 seconds and then rise up quickly Start with 10 repetitions and increase to 15, gradually increasing the dumbbell weight in the same type of progression as for straight leg raises

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A good rule of thumb with regard to squats and wall slides for patients with patellar pain of any kind is a relative restriction of not flexing the knee beyond 90°.

Medications :

Medications The only medications that need to be prescribed are NSAIDs for pain relief and reduction of local inflammation (any NSAID may be used).

Nonsteroidal Anti-Inflammatory Drugs :

Nonsteroidal Anti-Inflammatory Drugs Short-term NSAIDs may be used for pain relief. Steroids are not recommended for use in this condition. NSAIDs have analgesic, anti-inflammatory, and antipyretic activities. NSAIDs are commonly used for relief of mild to moderate pain. Although the effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen is usually the DOC for initial therapy. Other options include naproxen, flurbiprofen , and ketoprofen . *Drug of choice=DOC

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