Any physiotherapist working with academy footballers will know that these players are at risk of overuse injuries due to their immature musculoskeletal systems (1). However, it is imperative that therapists can confidently identify when the players require a therapeutic intervention rather than dismissing their symptoms as ‘growing pains’.
It has been found that 5% of all injuries in football academies are due to overuse (1), as some young footballers will partake in high volumes of physical activity. These children can potentially be playing football at school, club and national levels as well as participating in physical education at school and other organised sports.
Although professional football has been found to be associated with a relatively high incidence of injury (1), it should be not be assumed that children are miniature adults and it should be noted that some of their injuries are unique to the growing years. So when injuries are similar we should still consider the additional effects of growth spurts on these structures and this is when challenges can occur.
Osgood-Schlatters is a traction apophysitis that is most common in male athletes aged 13-14 years old, and can be bilateral in up to 50% of cases (2). Girls tend to be affected aged 10-11 years old. Unfortunately the exact incidence and prevalence of the condition is unknown.
Although the general anatomy (eg ligaments, muscles) of the knee is the same in children and adults there are some significant differences related to the ‘growth plates’ that makes children prone to bony injuries rather than ligamentous or muscular damage.
- Where the musculotendinous unit inserts
- Vulnerable to traction injuries as muscle and tendon growth may be slow relative to bone growth
- The actual site of bony growth
- Inherently unstable and vulnerable to shear forces which can damage bone structure through slips or fractures
Osgood-Schlatters, specifically can be described as an apophysitis, as the symptoms occur where the quadriceps attaches to the tibial tuberosity of the knee. As traction is applied to the tibial tuberosity the apophysis of the tuberosity eventually separates from the tibia. After initial fragmentation at the site, ossification eventually leads to an increase in bone. Thus giving the characteristic prominent tibial ‘bump’.
The athlete suffering from Osgood-Schlatters will often report:
- Mechanism: players often report a gradual onset in anterior knee pain but often symptoms will be exacerbated by pubertal growth spurts.
- Pain Area: the pain is often localised around the tibial tuberosity and patellar tendon. However, be aware that in more severe cases, pain can be distributed rather diffusely if repetitive stress is placed on an immature patellar tendon insertion.
- Aggs: Running, Jumping, Kneeling. Descending stairs
- Eases: NSAIDS, Rest, Activity modification
Diagnosis for this condition tends to be clinical and quite simple. Therefore, much of the objective examination is aimed at identifying potential musculoskeletal and biomechanical contributors to pathology that are amenable to physiotherapy treatment. You will often find:
- A prominent, tender tibial tuberosity
- Quadriceps usually tight
- Dorsiflexion can be reduced (3), and is often associated with loss of calf length.
- There are often other biomechanical contributors present, including excessive pronation, tibial or femoral internal rotation
- See the physiotherapy management section below for how to address these issues.
There are a few differential diagnoses that you should be aware when assessing the young athlete with anterior knee pain, these include:
- Patellofemoral pain syndrome
- Patellar tendinopathy/tendon injury
- Sinding-Larsen-Johansson syndrome
- Osteochondritis Dissecans
- Fat Pad Impingement
- Referral from hip: including Slipped Capital Femoral Epiphysis and Perthes Disease
- Red Flag conditions – infection, malignancy
The use of imaging is not required routinely with this client group as the diagnosis can be made quite simply via a thorough clinical examination. However is symptoms are severe and unrelenting further investigations are merited to rule out other more serious conditions (eg malignancy, infection). Imaging should also be utilised if there are any doubts surrounding a diagnosis of osteochondritis dissecans, slipped capital femoral epiphysis or Perthes Disease.
Standard radiographs can confirm Osgood-Schlatters by revealing heterotropic ossification at the site of the tubercle.
MRI findings will vary dependant on the stage of the condition but can highlight additional soft tissue changes that can occur. These include soft tissue swelling anterior to the tibial tuberosity, loss of the sharp angle to the infrapatellar fat pad, thickening and oedema of the patellar tendon and infrapatellar bursa (2).
Physiotherapy Management of Osgood Schlatters Disease
Conservative management involves a significant amount of education of players, parents and coaching staff, as their co-operation is often required during the implementation of the player’s rehabilitation.
- Regular icing of the knee post activity for pain relief.
- Painkillers/NSAIDs as required.
- Stretching of tight quadriceps (however, during the acute stages this may not be possible due to pain at end of range flexion in which case stretching would be delayed).
- Activity modification is often required to allow the player to continue participating in sport, and this can involve altering the number of training sessions attended or cutting down the time the player is permitted to play during matches.
- In very severe cases total rest from physical activity may be advocated. However, the prescription of an appropriate exercise program is required to reduce muscle atrophy and loss of function.
- Correcting biomechanical contributors is essential. This may include tightness and weaknesses present in surrounding musculature. For tightnesses consider the calf, hamstring and quadriceps. Regarding weaknesses assess the pelvic stabilisers, medial quadriceps, extrinsic and intrinsic foot musculature.
- In some cases poor foot posture may need to be addressed, consider these options for controlling excessive pronation.
- Taping techniques/bracing may provide some symptomatic relief (see videos below)
Surgical Management of Osgood Schlatters Disease
Although the majority of players with Osgood-Schlatters will recover successfully using a conservative approach, there may be the rare occasion (less than 2% of all cases (5)) where a player will require a surgical approach to treatment. It has been suggested that players who remain symptomatic even with 10 weeks of rest (4) or whose symptoms persist after skeletal maturity(5) would benefit from the surgical removal of the symptomatic ossicles in an attempt to produce the resolution of persistent symptoms
Weiss et al (5) report that 75% of all patients who underwent surgery were able to return to their preoperative level of function. However, it should be noted that this particular study did only have a small sample size (15 patients – 16 knees), so the results should be interpreted with caution.
Outcomes of Osgood Schlatters Disease
Ultimately Osgood-Schlatters in a self limiting condition, which generally resolves when a player achieves skeletal maturity. It has been suggested that greater than 90% of patients respond well to the conservative management techniques discussed above. If managed carefully, it should not require the player to avoid all physical activity. However coaches and therapists need a team approach to adjust the players activity levels to allow them to participate in sport.
About the Author
This was another great guest post by UK Physiotherapist Laura Chimimba. Laura graduated from Glasgow Caledonian University in 2006, and since graduation has had the opportunity to work at various levels of football. She has been involved with the treatment and rehabilitation of players from amateur, professional youth academy and elite level women/girls players. She is currently the Head Physiotherapist at Stenhousemuir FC. In addition to her sports coverage, Laura also works within the NHS and in private practice at Move Well Physiotherapy near Falkirk. This allows her to work closely with a variety of Orthopaedic and Sports Medicine Specialists. Furthermore, Laura has continued to further her education and has recently began a MSc in Sport and Exercise Medicine. Fortunately for her patients, and you as the reader, she continually strives to enhance her clinical skills and stay up to date with current evidence based practice.
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Gerbina, PG (2006) Adolescent Anterior Knee Pain, Operative Techniques in Sports Medicine, Vol 14, pp203-211
O’Keefe, SA, Hogan, BA, Eustace, SJ & Kavanagh, EC (2009) Overuse Injuries of the knee, Magnetic resonance Imaging Clinics of North America, Vol 17 (4), pp725-739
Price, RJ, Hawkins, RD, Hulse, MA & Hodson, A (2004) The Football Association medical research programme: an audit of injuries in academy youth football, British Journal of Sports Medicine, Vol 38(4), pp466-471
Sarcevic, Z (2008) Limited ankle dorsiflexion as a predisposing factor to Morbus Osgood Schlatter?, Knee Surgery, Sports Traumatology, Arthroscopy, Vol 16(8), pp726-728
Weiss, JM, Jordan, SS, Anderson, JS, Lee, BM & Kocher, M (2007) Surgical treatment of unresolved Osgood-Schlatter disease: ossicle resection with tibial tubercleplasty, Journal of Pediatric Orthopaedics, Vol 27(7), pp844-847
Photo Credit: elibaseball