Osgood Schlatters describes knee pain typically found in young athletes, aged 9 -16, at the front of the knee. Traction apophysitis of the tibial tuberosity, that is a mouthful, which translates from medical jargon as traction caused by the patellar tendon at the front of the shin bone. It refers to the injury of the growth plate of the tibia, which can happen during a growth spurt and the repetitive strain from the strong pull of the quadriceps muscle during sporting activities. Osgood Schlatters is a very annoying pain and limits your ability to run, jump, hop, land, and accelerate due to the pain.
The condition is named after American orthopaedic surgeon, Robert Osgood, and Swiss surgeon, Carl Schlatter, who described the symptoms associated with the injury in 1903.
Osgood Schlatters Disease occurs in adolescents, aged 9 – 16 years, which coincides with periods of growth spurts where height, and attitude, increase in a short period of time. It occurs more frequently in boys, with a male to female ratio of 3:1. Symptoms may occur bilaterally, both sides, at the same time. As though puberty, transitioning to high school and acne isn’t enough of a challenge during this age, Osgood Schlatters can hamper your sporting performance too. The pain progressively gets worse over time.
What structure is affected by Osgood Schlatters Disease?
If you follow the “route” down the front of your leg you will find the quadriceps muscle from the hip crease all the way down to your kneecap. The quadriceps muscle is a family of four muscles, teardrop-shaped, at the front of your thigh. The quadriceps muscle attaches to the patella, or kneecap, via the patellar tendon. The patellar tendon encloses the kneecap and inserts onto the tibia, shin bone. The patellar tendon is mostly known for the site where your knee reflex is tested, by gently tapping the tendon with a reflex hammer. The kneecap enhances the pulley system and force that the quadriceps muscle can generate to straighten the knee to, let’s say, kick a ball.
If you have not reached skeletal maturity you still have a growth plate where the patellar tendon inserts onto the shin bone, making this attachment site quite venerable to injury. Boys reach skeletal maturity between the ages of 14-16 and girls between the ages of 12-14. This growth plate is made up of cartilage, similarly to your nose and ears.
What role does the patella play in Osgood Schlatters Disease?
The kneecap increases the leverage that the quadriceps muscle has, up to 50%! This enhanced design enables a greater force generation when straightening the knee. More leverage, more power. Which comes in handy when kicking a ball or jumping to lift the entire body weight to shoot a goal or clear a hurdle.
This force is directed through the patellar tendon. Tendons attach muscle to bone in our bodies. Think of it as a big cable with loads of strands that is bolted into a wall. When you have not reached skeletal maturity your patellar insertion site is cartilaginous, your wall is soft.
How does Osgood Schlatters Disease happen?
Children’s bone differ from adult bone. The cartilage of the growth plate has the capacity to grow and increase in length. These processes are controlled by hormones, diet and activity. During a growth spurt, the cartilage and bone grow much faster than muscles and tendons. Just like your clothes will not fit anymore, your muscles are adjusting to your “new” height, luckily your muscles are able to change and “fit” again. However, tendons takes much longer to lengthen. This leads to strong forces on the small anchor site of the quadriceps tendon at the front of the shin.
Repetitive stress, with exercise, at the patellar tendon insertion, also leads to pulling of the tibial growth plate. Remember the cable bolted to the wall, now imagine that cable being pulled repeatedly with great force. When this tension is too forceful or repetitive, the growth plate gets irritated. This repetitive shearing, compression or twisting disrupts the epiphyseal growth plate. Swelling, redness and changes in the physeal areas occurs. If healing is not allowed to take place, it will influence the bone’s ability to grow. Pain & swelling, and even tears in the tendon may follow, essentially your cable starts to snap and the wall crumbles. This may cause an increased bony prominence where the tendon inserts as the body attempt to heal.
Symptoms of Osgood Schlatters Disease
How bad is my Osgood Schlatters?
Osgood Schlatters Disease is self limiting, which means that it needs much better monitoring and recovers faster when handled correctly. For someone young and passionate about their sport, this can feel like an eternity, as it can easily take a few months to heal. Treat your body with respect if you wish it to serve you well into old age. Ben Morgan, Danny Welbeck and Gael Monfils all suffered from Osgood Schlatters Disease in the past and succeeded to achieve amazing careers in their chosen sport.
If the patellar tendon is stressed repeatedly through exercise, micro trauma may cause small tears or even increased bony protuberance of the shin bone, which causes a visible lump on the shin that can be very painful. This will also be very sore when kneeling directly on the knee. Repetitive injury to the tendon can lead to weakness and eventually a complete tear of the tendon.
The risk to cause an avulsion fracture, where the tendon pulls away from a small part of the shin bone, is also higher with repetitive strain.
Could this traction on the growth plate delay attachment of the metaphyseal plate, can the bone attach skew, can the bone grow into the tendon?
Diagnosis of Osgood Schlatters
We are able to make an accurate diagnosis of your Osgood Schlatters. Our physiotherapists are skilled at testing the structures involved, to determine the degree of severity and guide you in your treatment. We are able to address any contributing factors and work on the stability of other joints involved, like your hips or core. The following imaging may be of use to confirm Osgood Schlatters Disease diagnosis.
X-ray
X-rays will show bone, alignment and joint space, but not the patellar tendon. Comparison of both knees can be done to compare the patellar insertion sites and the tibial growth plate. This will also rule out any other pathology. It is important to remember that children are resilient and heal much quicker than adults. If a child complains of unrelenting pain not improved by rest, medication or treatment it should be investigated.
MRI
This costly investigation can only be ordered by a specialist and is not the first image of choice. Your orthopaedic surgeon is likely to order an MRI if you sustained a traumatic injury. On magnetic resonance image the muscle, tendon and bone will be visible.
Why are my Osgood Schlatters symptoms not going away?
If you are caught in a cycle of pain with exercise, improvement with rest, pain with exercise, improvement with rest, you need to get your knee assessed. There can be other factors contributing to your Osgood Schlatters symptoms. We will do a biomechanical assessment to determine what factors are contributing to your problem.
Hip and lumbar stability are essential for endurance and knee muscle control. For example, if your outer hip muscles, the Gluteus Medius muscle, allows the hips to drop sideways when you run, almost like a catwalk model, excessive and unnecessary strain is placed on the inner knee muscle, Vastus Medialis muscle, to counter the knee moving inwards.
If your ankle is stiff, again the quadriceps muscle needs to work harder to counterbalance this, when you are squatting, jumping, landing or running. We are experts at dissecting movement patterns that help or worsen your problem. Our physiotherapists will identify and fix these imbalances during your Osgood Schlatters treatment.
A big problem we see with Osgood Schlatters symptoms
Unrealistic expectation of treatment, from the patient, but a child or adolescent can be forgiven this, and the parents or coach. There is no quick fix, there is no magic machine or medicine. Your patellar tendon can only heal so fast. A growth spurt and an increase in training load may be too much for it to handle. Unfortunately, in some cases, hard decisions need to be made regarding participation in certain events. Do not make it harder than it already is by challenging time and your body’s physiology.
Osgood Schlatters treatment
As physiotherapists, we are able to assess the quadriceps muscle length and strength, determine if there is inflammation present and any contributing factors that might be the cause of the injury. You can expect climbing a stair or two, squats and being put through your paces. We need to reproduce your pain in the assessment to make the correct diagnosis.
Osgood Schlatter Disease heals with physiotherapy treatment. A vital part of Osgood Schlatters treatment is resting from aggravating activities. That means giving the fraying cable enough time to actually repair, and repair well enough to take the load that your sport requires it to handle. Once the pain has settled you will begin loading the structures gradually. We will address any and all contributing factors during your Osgood Schlatters treatment, you can trust us to guide you every step of your recovery.
Phases of rehabilitation
1st Phase: Protection and initial healing
Protect
A lot of go-getters tend to push through their pain, even walking with a limp. Osgood Schlatters can be so debilitating that it is even painful to take a step with your sore leg. The quadriceps muscle contracts with every step you take. Rest and use crutches to keep the load off of your knee. The aim is to prevent a cycle of continuous inflammation and pain.
Elevate
Elevating your knee higher than your heart will help ease and prevent any further swelling. You can use this time icing the patellar tendon too. Wrap ice cubes in a wet towel or use frozen veg directly on the front of the knee for approximately 5 minutes at a time as often as you can. Not only will this prevent swelling, but also ease the pain.
Avoid anti-inflammatory medication
Avoid using anti-inflammatory medication continuously. Indigestion, stomach pain, bloating, nausea, vomiting, diarrhoea and constipation are just some of the side effects you may experience with long term use. If you have severe pain consult with your GP or pharmacist for a suitable alternative. Once your Osgood Schlatters symptoms are under control, you can decrease the use of your medication and eventually stop taking it completely.
Education
Make sure you get all information the information regarding your worries and concerns, from the person that is treating you. It is important to understand what you should and shouldn’t do. You can make better decisions if you are informed. Your body knows best, so trust your intuition and avoid too many types of treatments at once.
2nd Phase: Establish pain free range of movement
During your examination, we will establish what you are able to do, and what you should avoid. We identify factors that contribute to your symptoms, specific to your case and address these factors as your Osgood Schlatters treatment progresses. You are safe to move in your pain free range and our exercises will be targeted between these boundaries of your pain, for example only bending the knee to 20 degrees. We will make use of strapping to limit your movement within these ranges. The aim is that, with time, your pain-free range of movement improves and painful movements become less intense.
3rd Phase: Tissue healing
We monitor the progress of healing of the patellar insertion site on the tibia. We track the formation of scar tissue at the site of irritation during your Osgood Schlatters treatment. On a cellular level, we’re able to accelerate tissue healing using laser and ultrasound. As healing takes place, we want to see not only improvement of your pain, but also improvement in the quadriceps muscle’s ability to contract and stretch and a decrease in irritation at the tibial attachment.
4th Phase: Eccentric Muscle Strength
Now the fun begins! Eccentric loading means that we load the muscle while it lengthens. With the downwards movement of a squat, the quadriceps muscle lengthens with control. You will be given these exercises to do at home. By the end of this phase of your Osgood Schlatters treatment, you should be able to slowly sit down on a low chair without any pain.
5th Phase: Regain full range of movement
To regain full range of motion of your knee is a very important component of your Osgood Schlatters treatment. We will use myofascial release techniques and deep dry needling during treatment to increase the length of the quadriceps muscle. This decreases the load being placed through the pulley system at the patellar tendon attachment. On completion of this phase, you should be able to bend the knee fully and stretch the quadriceps muscle by drawing your heel to your buttocks.
6th Phase: Concentric Muscle Strength
Concentric loading means that we load the muscle while it shortens, like the upwards movement of a squat or kicking a ball. During this phase of your Osgood Schlatters treatment, you will work on strengthening not only your quadriceps muscle but your hamstrings, buttock and calf muscles too. Repeated contraction of muscles, improves their strength. Stronger muscles have the capacity to work harder for longer. We will progress your exercises by adding resistance, doing more repetitions and building your overall strength. On completion of this phase, you should be able to climb a stair without pain.
7th Phase: Muscle control, stability and technique
During this phase of your Osgood Schlatters treatment, we address all those contributing factors so that the pain doesn’t come back. Be it weak hip stabilisers or poor technique during training, we will address it all to get you back to what you love doing.
8th Phase: Balance, speed, power & proprioception
Now that you’ve worked through the different phases of your Osgood Schlatters treatment, we want to improve the power and speed of your quadriceps muscle contractions. You need to be able to do activities with precise balance, high load, and speed to ensure that your knees are able to keep up with the demands of your body. Your physiotherapist will guide you to return to normal activities but will also challenge you past your normal boundaries to determine how your body reacts to different forces. Ultimately we prepare you to return to participating in your sport. You may begin jogging again during this phase.
Whatever must be done – we’ll get you there. Running, sprinting or jumping and much more.
9th Phase: Sport specific training
This is the final stage of your Osgood Schlatters treatment. Depending on your sport, your physiotherapist will tailor specific exercises to further improve your strength and endurance. A successful outcome is when you understand your condition, know how to prevent flare-ups and can participate at full power and speed, not to mention the benefits of minimizing your chance of future injury.
Healing time for Osgood Schlatters Disease
As all bodies are different and we are working with a growing/changing body, recovery time is completely different for each person. The quicker you stop growing, the quicker there is less load on your tendon, the quicker your symptoms will settle. Generally, symptoms subside within two years of onset. This is also greatly dependent on how strenuous exercise regime is followed. With physiotherapy Osgood Schlatters treatment, we aim to reduce this healing time to approximately six to eight weeks. There can be flare ups as you continue to grow.
If not managed well or neglected symptoms can become chronic. This can cause patellar tendinitis and long term disability, where you are unable to participate in your sport or do weight bearing exercise in general. This includes jogging, jumping, squats, lunges and stair climbing.
Other medical treatment for Osgood Schlaaters Disease
Your GP can prescribe analgesic medication when needed to reduce the pain. This should not be seen as a free pass to continue exercise and training when the pain is less because of the medication. Please use medication responsibly.
A podiatrist referral may be needed if your feet are contributing to the problem. Insoles may be designed to support your arch when training.
In case of an avulsion fracture of the tibia, a brace will be needed to limit movement that can be prescribed by an orthotist.
You may consider a maintenance rehabilitation program from a biokineticist.
Surgery for Osgood Schlatters Disease
Surgery is the last resort if conservative Osgood Schlatters treatment has been unsuccessful. If an ossicle, a very small bone, forms in the tendon it can be surgically removed. Please remember that even this is not a quick fix and you will need extensive rehabilitation after surgery to regain tendon elasticity and strength. Your rehabilitation may take up to 8 weeks.
- Jumper’s Knee (Patellar tendinitis)
Inflammation of the patellar tendon, without injury to the growth plate or cartilage, is known as jumper’s knee.
- Sinding-Larsen-Johanssen Syndrome
This condition affects the patellar tendon attachment at the patella, not the tibia. You will feel pain just below the knee cap, not the front of the shin. This usually occurs after a traumatic injury that led to tendon rupture.
- Hoffa’s Syndrome
Injury to the fat pad that causes impingement of the fat pad between the femur and patella each time that the knee is extended. The pain is sharp and sudden and easily reproducible by straightening your knee.
- Synovial Plica Injury
Impingement of the synovial membrane, the membrane that surrounds the knee joint, usually on the inside of the knee after injury. Pain is sharp and easily reproducible with a specific movement.
- Tibial Tubercle Fracture
A traumatic event, where the knee was forcefully extended, like kicking or jumping or impact from another player, which leads to immediate pain, tenderness and weakness. You may feel unable to weight bear and experience a lot of pain when walking.
