KEVIN B. NEWFIELD, D.O., Resident Orthopedic Surgery
RICHARD W. KRUSE, D.O., Attending Orthopedic Surgery
CLINICAL CASE PRESENTATION
THE ALFRED I. DUPONT INSTITUTE
This 11 year old black female presented to Orthopaedic Clinic complaining
of right knee pain . There was no history of trauma. This pain increased
with activity and decreased at rest and had been present for approximately
one year. When asked to localize the pain the patient pointed directly
to the tibial tubercle. A history of Osteomyolitis of the right tibial
shaft at age two was elicited. The suggested cause was a burn of the left
tibia by a curling iron. The infection was treated with IV antibiotics.
PHYSICAL EXAM: Prominence of the right tibial tubercle was noted as
compared to the left. There was no joint line tenderness or effusion. The
right knee had full range of motion with no hamstring or quadriceps tightness.
There was no instability to varus or valgus stress. Lochman and MacMurray
test were negative. There was no pain to palpation over the infrapatellar
ligament and patellar tracking was normal. The tibial tubercle was swollen
and tender to palpation. There was pain with resisted knee extension.
X-RAY: A small area of ossification anterior to the tibial tubercle
and within the infrapatellar ligament was noted.
DIAGNOSIS: Osgood-Schlatters Condition
TREATMENT: The patient was sent for a physical therapy evaluation and
training for stretching and isometric strengthening including a home exercise
program. Antiinflamatories were prescribed. A knee pad was recommended
for sports and kneeling activities. Stretching before and after sports
as well as application of ice was recommended. A follow up appointment
at six weeks was made.
- Etiology thought to be traction apophysitis secondary to repetitive
microtrauma with partial avulsion, inflammation and new bone formation
at the ligament insertion.
- Must differentiate from malignancy, infection, fracture, tendonitis
and Sindling-Larsen- Johansson Disease.
- Should be referred to a "condition" not a "disease."
- Affects children between 10 and 14 years old, more commonly males 3:1,
and is present bilaterally in 25 - 50% of cases.
- Diagnosis is based on clinical signs and symptoms. These include pain,
heat, tenderness and local swelling with prominence at the tibial tuberosity.
- Ossification of the tibial tubercle begins distally between 7-9 years
of age and progresses proximally.
Condition discovered simultaneously by Robert Bayley Osgood (1873-1956)
at Boston General Hospital and Carl Schlatter (1864-1934) in Zurich, in
- The treatment is symptomatic with reduction of stress on the apophysis
as the objective.
- Reduce activities which cause pain in the area of the tibial tubercle.
- Stretching with other physical therapy modalities.
- Knee pads for activity with direct tubercle/knee contact.
- Antiinflamatories (4 to 6 weeks)
- Elastic wrap or neoprene knee sleeve.
- Excision in persistent cases of accessory ossicle.
- No steroid injections. (may cause weakening of the infrapatellar ligament,
scaring and fat necrosis.
OUTCOME & EXPECTATIONS:
- Symptoms should resolve at skeletal maturity when the tibial tubercle
fuses to the main body of the tibia.
- Rarely a separate ossicle fails to unite. Surgical excision provides
predictable pain relief in this situation.
- Reports of tibial recurvatum due to Salter-Harris type 5 injurys with
damage to the anterior portion of the growth plate.
- Tibial tubercle fracture are more common in teenagers with a history
of Osgood-Schlatters condition.
- Canale, S.T., Skeletal Trauma in Children, vol. 3: 2:48, 1994.
- Lynch, M.C., et al,. Tibial Recurvatum as a Complication of Osgood-Schlatters
Disease: A Report of Two Cases. Journal of Pediatric Orthopaedics.
11: 543-544, 1991.
- Staneli, Lynn T., Lovell and Winter's Pediatric Orthopedics. Third
Edition, vol. 2: 763, 1990.
- Wenger, Dennis R. and Rang, Mercer, The Art and Practice of Children's
Orthopedics. 227-229, 1992.
- Wilson, P.D., Robert Bayley Osgood, The Journal of Bone and
Joint Surgery. Vol. 39-A, no.3, June 1957.
- Wiss, D.A. et al, Type III Fractures of the Tibial Tubercle in Adolescents.
Journal of Orthopaedic Trauma. vol 5. no. 4. 475-479, 1991.