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Right Knee Pain


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).



What is your diagnosis?

Answer

Osgood-Schlatter 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 adolescents.

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, and tenderness.

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 deformity.

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.



References

  • Cassas KJ, Cassettari-Wayhs A. Childhood and adolescent sports-related overuse injuries. American Family Physician. Mar 15 2006;73(6):1014-1022. [MEDLINE 16570735]
  • Demirag B, Ozturk C, Yazici Z, et al. The pathophysiology of Osgood-Schlatter disease: a magnetic resonance investigation. Journal of Pediatric Orthopaedics. Nov 2004;13(6):379-382. [MEDLINE 15599229]
  • Bloom OJ, Mackler L, Barbee J. Clinical inquiries. What is the best treatment for Osgood-Schlatter disease? The Journal of Family Practice. Feb 2004;53(2):153-156. [MEDLINE 14764303]
  • Duri ZA, Aichroth PM, Wilkins R, et al. Patellar tendonitis and anterior knee pain. The American Journal of Knee Surgery. Spring 1999;12(2):99-108. [MEDLINE 10323501]
  • de Inocencio J. Musculoskeletal pain in primary pediatric care: analysis of 1000 consecutive general pediatric clinic visits. Pediatrics. Dec 1998;102(6):E63. [MEDLINE 9832591]
  • Nowinski RJ, Mehlman CT. Hyphenated history: Osgood-Schlatter disease. American Journal of Orthopedics. Belle Mead, NJ. Aug 1998;27(8):584-585. [MEDLINE: 9732084]

 


 

Link 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).