An 11-year-old girl with
no past medical history presents to the Emergency
Department complaining of pain in her right shin for the
past month, specifically in the area just under her
kneecap. She was recently on vacation and did a lot of
walking, which seems to have worsened the pain. She also
noticed some swelling in the same area for about a week
prior to visiting the Emergency Department. The swelling
and pain have both improved somewhat with the use of
ibuprofen. The patient and her parents deny any trauma to
the area. Additionally, there is no history of fever,
numbness, tingling, weakness, or other bone or joint pain.
On physical examination, the patientís vital signs are
within normal limits, with an unremarkable head and neck,
chest, and abdominal examination. In the extremities, the
patient has intact sensation to light touch in the L3-S1
distribution. She had 5/5 strength in the bilateral hip
flexors, 4/5 strength in the right quadriceps limited by
pain over the tibial tubercle, and 5/5 strength in the
hamstrings, tibialis anterior, gastrocsoleus, and extensor
hallucis longus. She has brisk distal capillary refill.
There is mild soft-tissue swelling (see Image 1) with
localized tenderness to palpation over the right tibial
tubercle. There is no erythema overlying the affected area.
A plain film radiograph was obtained (see Image 2).
is your diagnosis?
disease: The right knee radiograph showed mild
separation of small ossicles from the developing
ossification center of the tibial tuberosity, with
minimal overlying soft-tissue swelling (see Image
3), consistent with Osgood-Schlatter disease.
The patient was instructed to use crutches for
comfort and weight-bearing as tolerated. The patient
was also advised to modify her activities to
decrease the amount of stress on her right knee and
to use over-the-counter analgesics for pain relief.
Follow-up with a pediatric orthopedist was arranged.
In 1903, Robert Osgood, an American orthopedic
surgeon, and Carl Schlatter, a Swiss surgeon,
concurrently described the disease that now bears
their names. Osgood-Schlatter disease is one of the
most common causes of knee pain in active
In girls younger than 11 years and in boys younger
than 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. The most commonly accepted
theory for the development of Osgood-Schlatter
disease is that repeated traction on the anterior
portion of this developing ossification center leads
to multiple subacute fractures or tendinous
inflammation, resulting in a benign self-limited
disturbance that manifests itself as pain, swelling,
Patients present with a history of pain inferior to
the patella at the insertion of the patellar tendon.
Typically, individuals report that physical activity
aggravates the pain, which generally improves with
rest and worsens with activity. Although any
activity may be involved, sports involving jumping
or running are commonly implicated.
The diagnosis of Osgood-Schlatter disease is based
primarily on clinical features. Pain is the most
common presenting complaint. The major physical
findings are visible soft-tissue swelling and
exquisite tenderness to direct pressure over the
proximal tibial tuberosity at the site of patellar
tendon insertion. A firm mass may be palpable in the
involved area. The symptoms are reproducible by
extending the knee against resistance, by stressing
the quadriceps, or by squatting with the knee in
full flexion. The remainder of the knee examination
is usually unremarkable.
Although radiographic abnormalities are frequently
found in patients with Osgood-Schlatter disease,
there are no definitive radiologic criteria for the
diagnosis of the condition.
Most patients respond to conservative care that
consists of rest and avoidance of activities likely
to aggravate the condition. Stretching of the
quadriceps and hamstrings before physical activity
may be helpful. Applying ice after activity may
decrease swelling and pain. Immobilization by
casting or bracing is usually unnecessary, except in
severe cases. Nonsteroidal anti-inflammatory drugs
may be used for analgesia but have not been shown to
decrease the duration of the disease. Steroidal
injections should not be used. When voluntary
limitation of physical activity is unsuccessful, an
alternative approach to treatment includes the use
of either an infrapatellar strap or a knee brace. If
the patient remains symptomatic, a walking cylinder
cast is recommended to immobilize the knee in full
extension for 3-6 weeks. Surgical treatment is
recommended for the relief of recurrent, disabling
episodes that do not respond to conservative
management or for the removal of a cosmetic
Symptoms usually disappear spontaneously within 1
year, although discomfort may persist for 2-3 years
until closure of the tibial growth plate is complete
in late adolescence. Recurrences are common.
Persistent complaints may be secondary to residual
enlargement of the tuberosity or to ossicle
formation in the patellar tendon.
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to further Information on:
For more information on Osgood-Schlatter
disease, see the eMedicine articles Osgood-Schlatter
Disease (within the Radiology specialty), Osgood-Schlatter
Disease (within the Emergency Medicine specialty), Osgood-Schlatter
Disease (within the Orthopedic Surgery specialty), and Osgood-Schlatter
Disease (within the Sports Medicine specialty).