Osgood Schlatter syndrome

Effectiveness of interventions for treating apophysitis in children and adolescents: protocol for a systematic review and network meta-analysis

Background

Overuse injuries are reported to be more common than acute trauma in children and adolescents, causing pain and reduced function. The most common is apophysitis - a traction injury to the apophysis in growing individuals. The duration of symptoms reported in the literature is between 6 weeks to 6 months or more. The objective of this systematic review and network meta-analysis is to compare the effectiveness and safety of all available treatments for any type of apophysitis in children and adolescents.

Methods/Design

We will conduct a systematic review to retrieve all relevant studies applying a comparative design. Searches will be made in the Cochrane CENTRAL, MEDLINE, EMBASE, CINAHL and SportDiscus databases and via reference searching. The efficacy of treatments will be compared with respect to the outcomes 1) time to pain-free activity and 2) risk of subsequent injury. Risk of bias assessment will be made using revised tool for assessing risk of bias in randomized trials for Randomized trials and Robins-I tool for non-randomized trials. We will explore if different treatment comparisons are sufficiently similar in terms of effect modifiers (transitivity assumption) with the aim to conduct network meta-analyses for randomized and non-randomized studies separately. A treatment hierarchy will be obtained using the surface under the cumulative ranking curve (SUCRA) and mean ranks, visualized using rankograms. We will use the CINeMA software to apply the modified version of Grades of Recommendation, Assessment, Development and Evaluation (GRADE), developed specifically to evaluate the quality of evidence in network meta-analysis.

Discussion

To date the comparative effects of interventions for apophysitis seem to rely mainly on expert opinion. We aim to identify all comparative treatment designs described in the literature and synthesize data when possible. We will use the estimated treatment effects between injury locations to provide guidance in managing apophysitis.

Trial registration

PROSPERO ID number: CRD42018083746.

Electronic supplementary material

The online version of this article (10.1186/s12998-018-0209-8) contains supplementary material, which is available to authorized users.

Osgood-Schlatter Disease Unveiled Under High-frequency Ultrasonogram

Osgood-Schlatter disease is a painful condition, affecting the tibial tuberosity of physically active children with a painful bump that aggravates with repetitive impacts over the affected area during exercise, sports, or even usual daily activities. The condition is usually unilateral; however, bilateral presentation is not unlikely. In addition to clinical features, a unique radiological finding appears worthy in terms of accurate diagnosis. Moreover, ultrasonogram-based pathological changes could appear not only in the tibial tuberosity but also in the patellar tendon. In this study subject, I approached the condition with a high-frequency musculoskeletal ultrasonogram in order to add further information about the ailment in medical literature. The conservative approach was found effective to relieve the patient's problems.

Pathogenic Factors Associated With Osgood-Schlatter Disease in Adolescent Male Soccer Players: A Prospective Cohort Study

Background:

A previous cross-sectional study reported that pathogenic factors associated with Osgood-Schlatter disease (OSD) in adolescent athletes include increased quadriceps muscle tightness, lower leg malalignment, and development of apophysitis in the tibial tuberosity.

Purpose:

To confirm these pathogenic factors associated with OSD in a longitudinal study with regard to physical function and performance.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

In this study, 37 boys (mean age, 10.2 ± 0.4 years) were recruited from 2 soccer teams at an elementary school. This cohort study was conducted over an observation period of 1 year, with measurements recorded at baseline, followed by screening for OSD every 6 months. Variables evaluated at baseline included physical function (morphometry, joint flexibility, and lower extremity alignment), presence of Sever disease, and kicking motion.

Results:

Pathogenic factors associated with OSD in the support leg of adolescent male soccer players included height, weight, body mass index, quadriceps femoris muscle tightness in the kicking and support legs, and gastrocnemius muscle tightness, soleus muscle tightness, and medial longitudinal arch in the support leg. Additional factors included a diagnosis of Sever disease and distance from the lateral malleolus of the support leg’s fibula to the center of gravity during kicking.

Conclusion:

The onset of OSD was found to be affected by many factors, including developmental stage, physical attributes, and pre-existing apophysitis. In particular, a diagnosis of Sever disease and backward shifting of the center of gravity during kicking increased the risk of the subsequent onset of OSD, suggesting that these factors are very important as a possible focus for interventions.

Bony Maturity of the Tibial Tuberosity With Regard to Age and Sex and Its Relationship to Pathogenesis of Osgood-Schlatter Disease: An Ultrasonographic Study

BACKGROUND

Although tensile force on an immature tibial tuberosity is considered the main cause of Osgood-Schlatter disease (OSD), the relationship between bony maturity and the pathogenesis of OSD remains obscure.

PURPOSE

To survey the bone maturation process of the tibial tuberosity by age and sex and clarify its relationship to OSD.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A total of 731 Japanese basketball players aged 6 to 14 years were enrolled in this study. Ultrasonographic examination was performed in all participants (1462 knees) to evaluate the bony maturity of the tibial tuberosity by use of the Ehrenborg classification. The age- and sex-specific prevalence of each stage was investigated, and the prevalence of symptomatic OSD and its relationship with bony maturity were also assessed.

RESULTS

The process of bone maturation occurred 1 to 2 years earlier in female participants compared with male participants. Among female participants, 59.2% were already at the epiphyseal stage (stage E) by 10 years of age, and 47.4% were skeletally mature by 14 years. Among male participants, conversely, only 8.0% were at stage E by 10 years of age, and only 13.8% were skeletally mature by 14 years. The overall prevalence of symptomatic OSD was 6.8% (males, 6.4%; females, 7.2%), and the onset was 1 year earlier in the female participants. The prevalence of symptomatic OSD tended to increase with age and bony maturity, significantly increasing from the cartilaginous stage (stage C) to the apophyseal stage (stage A) (odds ratio, 9.48) and from stage A to stage E (odds ratio, 2.22).

CONCLUSION

The tibial tuberosity matures earlier in female participants. The risk of OSD is greater in stage A than stage C and in stage E than stage A. The risk of OSD increases with age in males but not in females.

Minimally displaced tibial tuberosity avulsion fracture in nine skeletally immature large breed dogs

Objective: The objective of this study was to describe the clinical and radiographic features, as well as the treatment and outcome of minimally displaced tibial-tuberosity-avulsion-fractures (MDTTAF).

Materials and methods: Signalment, history, diagnostics, therapy, and outcome were recorded. Follow-up was documented as re-examination, radiographic assessment or telephone conversation.

Results: Nine large breed dogs that were presented with lameness originating from the proximal tibia were included. All showed signs of pain when pressure was applied to the tibial tuberosity. There was no stifle instability or intra-articular disease. The main feature on mediolateral radiographs was a widened tibial-tuberosity-physis with reactive new bone and loss of edge definition of the epiphyseal and metaphyseal margins. Non-surgical treatment was chosen in eight dogs, and surgery in one dog. Radiographic follow-up showed progressive closure of the tibial-tuberosity-physis and healing. Clinical signs resolved at a median of 28 days (range: 14–120).

Discussion: Minimally displaced tibial-tuberosity-avulsion-fractures should be a differential diagnosis in skeletally immature large breed dogs older than nine months of age with signs of subtle pelvic-limb lameness, and signs of proximal tibial pain, but no evidence of stifle joint disease. Thorough clinical examination and critical review of bilateral radiographs are important to diagnose MDTTAF. The outcome in these cases suggests that the prognosis for MDTTAF is excellent. Age and size of the affected dogs in this study differ from an earlier publication that illustrated more severely displaced tibial tuberosity avulsion fractures, occurring mainly in terriers around five months of age.

Treatment of Osgood-Schlatter disease: review of the literature

BACKGROUND

Osgood-Schlatter disease (OSD) is a self-limiting condition which occurs commonly in adolescence.

PURPOSE

The objective of this article is to review published literature regarding pathophysiology, diagnosis and treatment of OSD.

METHODS

A search of the literature was performed on the electronic databases PubMed, Cochrane and SCOPUS databases between 1962 and 2016 for pathophysiology, diagnosis and treatment of Osgood-Schlatter disease.

RESULTS

OSD, also known as apophysitis of the tibial tubercle, is a common disease with most cases resolving spontaneously with skeletal maturity. In pathophysiology, the most accepted theory is repetitive knee extensor mechanism contraction. The pain is localized to the anterior aspect of the proximal tibia over the tibial tuberosity. They may describe a dull ache exacerbated by jumping or stair climbing. Radiological evaluation may indicate superficial ossicle in the patellar tendon. Osgood-Schlatter is a self-limited disease and generally ceases with skeletal maturity. Treatment is usually symptomatic. Adults with continued symptoms may need surgical treatment if they fail to respond to conservative treatment. Surgical procedures include open, bursoscopic and arthroscopic technique. Arthroscopic surgery is beneficial over an open procedure due to early postoperative recovery, no incisional scar in front of the tuberosity that usually causes discomfort in kneeling with a better cosmetic result and the ability to address concomitant intra-articular pathology.

CONCLUSION

Osgood-Schlatter syndrome runs a self-limiting course, and usually complete recovery is expected with closure of the tibial growth plate. Overall prognosis for Osgood-Schlatter syndrome is good, except for some discomfort in kneeling and activity restriction in a few cases. Arthroscopic techniques seem to be the best choice of treatment of unresolved Osgood-Schlatter lesions.

Successful Treatment of Osgood-Schlatter Disease with Autologous-Conditioned Plasma in Two Patients

Osgood–Schlatter Disease (OSD) is a painful, growth-related overuse condition of the tibial tuberosity, leading to inflammation of the patellar ligament at the tibial tuberosity. It primarily affects young adolescents, athletic population, and usually, resolves with age or skeletal maturity. Therapy is usually conservative, with surgery indicated in a minority of cases. For patients with treatment-resistant or refractory OSD, an alternative is the application of autologous platelet concentrate. Here, we describe two cases in which autologous-conditioned plasma therapy was used to treat OSD, and present the treatment protocol developed in our clinic.

Reduction Osteotomy of the Prominent Tibial Tubercle After Osgood-Schlatter Disease

PURPOSE

To evaluate the functional and clinical outcome of a new closing-wedge osteotomy for the prominent tibial tubercle after Osgood-Schlatter disease.

METHODS

Between 2010 and 2014, 7 consecutive adults (mean age, 28.6 years; range, 26-35 years) were treated by closing-wedge reduction osteotomy of a painful tibial tubercle. All patients had prior nonsurgical and surgical treatment. Preoperative and postoperative tubercular prominence, Caton-Deschamps index for patellar height, the Kujala Anterior Knee Pain Scale, Lysholm Knee Score as well as visual analog scale score and Tegner activity scores were recorded.

RESULTS

Mean follow-up after reduction osteotomy was 31.3 months (27-41 months). The bony prominence of the tibial tubercle was significantly reduced (mean 8 mm, P < .001) and the Caton-Deschamps index was lowered from 1.29 to 1.09 (P < .001). From preoperative to last follow-up, the Kujala Anterior Knee Pain Scale increased from 54.71 preoperative to 84.71 (P < .001); the Lysholm Knee Score improved from 72.42 to 94.14 (P < .001); the Tegner activity score increased from 3.1 to 5.7 (P < .001), whereas the visual analog scale significantly decreased from 5.8 to 1.2 (P < .001). No complications were recorded, and all patients were satisfied with clinical outcome.

CONCLUSIONS

Closing-wedge osteotomy of the tibial tubercle effectively reduced the bony prominence after Osgood-Schlatter disease and consecutively improved the outcome in terms of knee pain and function. Thus, we can recommend this procedure in selected patients.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Proximal tibial metaphyseal fractures in immature dogs

OBJECTIVE

To describe proximal tibial metaphyseal fractures in immature dogs.

MATERIALS AND METHODS

Medical records of immature dogs with metaphyseal fractures of the proximal tibia were reviewed and data were collected on signalment and history of trauma. Craniocaudal and mediolateral radiographs were evaluated for the determination of the bones fractured, location of the fracture within the bone, fracture configuration, and the presence of fracture segment displacement and angulation.

RESULTS

Eighteen dogs with 22 proximal tibial metaphyseal fractures fulfilled the inclusion criteria. All fractures had a curvilinear, complete fracture of the proximal tibial metaphysis. Displacement was identified in 16 fractures and angulation in 15 fractures. All affected breeds were terrier or small breed dogs less than six months of age. The majority of dogs weighed less than or equal to 5 kg at the time of injury. The most common type of trauma that occurred was a jump or fall from a short distance.

CLINICAL SIGNIFICANCE

Proximal tibial metaphyseal fractures are an uncommon injury that occur in skeletally immature dogs from minimal trauma. Proximal tibial metaphyseal fractures have a characteristic curvilinear fracture configuration that affects mainly small breed dogs with a predominance for terrier breeds.

Apophysitis of the Tibial Tuberosity (Osgood-Schlatter Disease): A Review

Osgood-Schlatter disease (OSD) is a condition in which the patellar tendon insertion on the tibial tuberosity becomes inflamed. It is a well-known condition in late childhood characterized by pain and a bony prominence over the tibial tuberosity. The pain is usually exacerbated by physical activities like running, jumping, and climbing stairs. In the acute stage, the margins of the patellar tendon become blurred in radiographs due to the soft tissue swelling. After three to four months, bone fragmentation at the tibial tuberosity is viewed. In the sub-acute stage, soft tissue swelling resolves, but the bony ossicle remains. In the chronic stage, the bone fragment may fuse with the tibial tuberosity which can appear normal.

The primary goal in the treatment of OSD is the reduction of pain and swelling over the tibial tuberosity. The patient should limit physical activities until the symptoms are resolved. In some cases, the patient should restrict physical activities for several months. The presence of pain with kneeling because of an ossicle that does not respond to conservative measures is the indication for surgery. In these cases, the removal of the ossicle, surrounding bursa, and the bony prominence is the treatment of choice.

Running Injuries During Adolescence and Childhood

The popularity of running among young athletes has significantly increased over the past few decades. As the number of children who participate in running increases, so do the potential number of injuries to this group. Proper care of these athletes includes a thorough understanding of the unique physiology of the skeletally immature athlete and common injuries in this age group. Treatment should focus on athlete education, modification of training schedule, and correction of biomechanical deficits contributing to injury. Early identification and correction of these factors will allow a safe return to running sports.

Correlation between Magnetic Resonance Imaging Characteristics of the Patellar Tendon and Clinical Scores in Osgood-Schlatter Disease

Purpose

This study aims to evaluate magnetic resonance imaging (MRI) findings in young adults with symptomatic Osgood-Schlatter disease (OSD) and compare those in young adults without OSD.

Materials and Methods

We compared MRI findings between young adults with OSD (OS group, n=30) and the equivalent number of young adults without OSD (control group). Visual analog scale scores and Kujala scores were evaluated and correlation analysis was performed in the OS group.

Results

In the OS group, MRI revealed that the patellar tendon was attached to the tibia more widely, resulting in a reduced free tendon portion, and more proximally to the articular surface (p<0.001). The correlation analysis between MRI findings and clinical scores showed statistically significant correlations (p<0.01). In the OS group, 43% presented with patellar tendinopathy or bone marrow edema at the distal attachments.

Conclusions

Compared to the control group, the relatively small free portion and relatively proximal attachment of the patellar tendon were observed with MRI in the OS group. The free portion of the patellar tendon was positively correlated with the clinical scores. Patellar tendinopathy was also frequently encountered in the OS group.

[Clinical examination, imaging and therapy of Osgood-Schlatter's disease]

BACKGROUND

Osgood-Schlatter's disease represents an often seen painful knee illness of temporary duration in adolescent sportsmen, caused by severe stress to the tibial apophysis.

RESULTS

A study in 29 consecutive patients (∅ 12,7 yrs, 77 % male, 67 % non-dominant side affected, 4 patients both knee joints affected, always pain after performance, high sports activity in football, basketball, gymnastics/ballett, 41 % shortening of m. rectus fem.) shows that pure clinical diagnosis is sufficient.

DISCUSSION

Imaging is only necessary in case of suspected concurrent origin, as it does not yield unique results and does not support therapy nor prognosis. Patients reduce their performance on their own. Late pain occurs at the apophyseal protuberance due to local compression. Restrictive recommendations to patients to leave their sport activity are not justified.

Common sports-related musculoskeletal injuries presenting to the emergency department

Young athletes are specialising in sports at a younger age, placing the developing musculoskeletal system under considerable stress. Overuse injuries such as apophysitis are chronic in nature and account for a large proportion of musculoskeletal injuries suffered by young athletes; however, with an increased emphasis on success in sport, tendinopathy and fatigue fractures are now being reported with increasing frequency, in the adolescent population. Correct diagnosis and early protection, rest, ice, compression and elevation therapy is critical, along with supervised rehabilitation an expert in paediatric and adolescent sports medicine. Acute traumatic knee injury and ankle sprain account for most acute injuries. Although most are soft tissue in nature, radiography may be useful in specific situations before early initiation of protection, rest, ice, compression and elevation therapy. These injuries will also require follow-up by an expert in paediatric and adolescent sports medicine to confirm the diagnosis and instigate ongoing rehabilitation and/or orthopaedic referral. Many of these injuries are preventable and due consideration should be given to simple prevention strategies.

Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations

Synopsis The hallmark features of patellar tendinopathy are (1) pain localized to the inferior pole of the patella and (2) load-related pain that increases with the demand on the knee extensors, notably in activities that store and release energy in the patellar tendon. While imaging may assist in differential diagnosis, the diagnosis of patellar tendinopathy remains clinical, as asymptomatic tendon pathology may exist in people who have pain from other anterior knee sources. A thorough examination is required to diagnose patellar tendinopathy and contributing factors. Management of patellar tendinopathy should focus on progressively developing load tolerance of the tendon, the musculoskeletal unit, and the kinetic chain, as well as addressing key biomechanical and other risk factors. Rehabilitation can be slow and sometimes frustrating. This review aims to assist clinicians with key concepts related to examination, diagnosis, and management of patellar tendinopathy. Difficult clinical presentations (eg, highly irritable tendon, systemic comorbidities) as well as common pitfalls, such as unrealistic rehabilitation time frames and overreliance on passive treatments, are also discussed. J Orthop Sports Phys Ther 2015;45(11):887-898. Epub 21 Sep 2015. doi:10.2519/jospt.2015.5987.

Long-term athletic development, part 2: barriers to success and potential solutions

The first installment of this two-part commentary reviewed existing models of long-term athletic development. However, irrespective of the model that is adopted by practitioners, existing structures within competitive youth sports in addition to the prevalence of physical inactivity in a growing number of modern-day youth may serve as potential barriers to the success of any developmental pathway. The second part of this commentary will initially highlight common issues that are likely to impede the success of long-term athletic development programs and then propose solutions that will address the negative impact of such issues.

Precise risk factors for Osgood-Schlatter disease

INTRODUCTION

A number of studies have examined the risk factors for Osgood-Schlatter disease (OSD). Studies on risk factors have not necessarily accurately demonstrated the risk factors of this disease because they were not prospective cohort studies or the populations in the studies were not categorized by the skeletal maturation of the tibial tuberosity. We can identify the precise risk factors for OSD by performing a prospective cohort study of a group of asymptomatic patients in particular times of adolescent using ultrasonography. In the present study, we aimed to investigate the precise risk factors for OSD.

METHODS

For all examinations, we used a 3-stage classification for tibial tuberosity development observed on ultrasonography: sonolucent (stage S), individual (stage I), and connective stages (stage C). Among 150 players with 300 knees, we included 37 male players with 70 knees at asymptomatic stage I on the first examination. We re-examined the included knees 1 year after the first examination and compared 10 knees with OSD (OSD group) and 60 knees without OSD (control group). Height, body weight, body mass index, tightness of the quadriceps femoris and hamstring muscles, muscle strength during knee extension, and flexion were assessed during the first medical examination.

RESULTS

The incidence of OSD was 14.3 % in this 1-year cohort study. A significant difference was found in body weight, quadriceps muscle tightness, and muscle tightness and strength during knee extension between the 2 groups. The precise risk factors for OSD were increased, namely the quadriceps femoris muscle tightness and strength during knee extension and flexibility of the hamstring muscles, using logistic regression analysis.

CONCLUSIONS

This information may be useful for teaching quadriceps stretching in preadolescent male football players with stage I.

A novel microdeletion affecting the CETP gene raises HDL-associated cholesterol levels

We describe a novel, inherited 16q13 microdeletion that removes cholesteryl ester transfer protein (CETP) and several nearby genes. The proband was originally referred for severe childhood-onset obesity and moderate developmental delay, but his fasting lipid profile revealed relatively high levels of high density lipoprotein cholesterol (HDL-C) and relatively low levels of low density lipoprotein cholesterol (LDL-C) for age, despite his obesity. Testing of first-degree relatives identified two other microdeletion carriers. Functional assays in affected individuals showed decreased CETP mRNA expression and enzymatic activity. This microdeletion may or may not be pathogenic for obesity and developmental delay, but based on the lipid profile, the functional studies, and the phenotype of other patients with loss-of-function mutations of CETP, we believe this microdeletion to be antipathogenic for cardiovascular disease.

Assessment of Osgood-Schlatter Disease and the Skeletal Maturation of the Distal Attachment of the Patellar Tendon in Preadolescent Males

BACKGROUND

Osgood-Schlatter disease (OSD) is a traction apophysitis of the tibial tuberosity. Ultrasonography (US) is able to detect pathologic changes, such as cartilage swelling and fragmentation of the tibial tubercle ossification center.

PURPOSE

To compare the US stages of tibial tuberosity development and the physical features and prevalence of OSD in this patient cohort.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Subjects included 238 males (n = 476 joints) with a mean age of 11.4 ± 1.6 years (range, 7-14 years). The tibial tuberosity development on US was divided into 3 stages: the cartilaginous stage (stage C), apophyseal stage (stage A), and epiphyseal stage (stage E). It was then investigated whether the subjects had pain in the tibial tuberosity on application of pressure. Age, height, body weight, body mass index (BMI), heel-buttock distance (HBD, cm), and straight-leg raise angle (SLRA) were evaluated. To confirm the diagnosis of OSD, the participant had to fulfill the following clinical criteria: pain with direct pressure on the tibial apophysis, fragmentation of the bone, and irregularity of the ossification center detected by US.

RESULTS

The tibial tuberosity was stage C in 195 knees, stage A in 105 knees, and stage E in 176 knees. The subjects' heights, weights, and BMIs significantly increased with advancing development of the tibial tuberosity. The HBD increased in stage E (P < .01). The SLRA was not significantly different among groups. There was fragmentation of the bone and irregularity of the ossification center in 32 knees (6.8%): 0 in stage C, 21 (4.3%) in stage A, and 11 (2.3%) in stage E. Fragmentation of the bone and irregularity were observed significantly more often in stage A (P < .01). On the other hand, there were 10 joints with OSD (2.1%): 0 in stage C, 3 (0.6%) in stage A, and 7 (1.5%) in stage E. OSD was observed significantly more often in stage E than in the other stages (P < .05).

CONCLUSION

The present study showed that the HBD increased from stage A to stage E. The prevalence of OSD was highest in stage E.

MRI of anterior knee pain

Anterior knee pain is the most common knee complaint. It may be due to a variety of soft tissue or osseous abnormalities. Knowledge of the radiologic appearance of the abnormalities allows more accurate diagnosis of the cause of the pain including chondral abnormalities, patellar instability and dislocation, femoral trochlear dysplasia, abnormal patellar location, bipartite patella, various tendinopathies, bursal inflammation, traction apophysitis in pediatric and adolescent patients, and miscellaneous diseases including mediopatellar plica syndrome and Hoffa's disease. Radiographs are often obtained to exclude acute osseous abnormalities, such as fractures. Magnetic resonance (MR) imaging offers superior soft tissue contrast resolution and allows for more accurate evaluation of the underlying etiology and therefore may improve treatment and possible surgical planning.

Football injuries in children and adolescent players: are there clues for prevention?

Football (soccer) is the world's most popular sport with most players being younger than 18 years. Playing football can induce beneficial health effects, but there is also a high risk of injury. Therefore, it is necessary to implement measures for preventing injuries. The present review analyzes and summarizes published scientific information on the incidence and characteristics of football injuries in children and adolescent players to arrive at sound conclusions and valid considerations for the development of injury-prevention programs. A literature search was conducted up to November 2012. Fifty-three relevant scientific publications were detected. Thirty-two studies fulfilled the inclusion criteria for pooled analysis. Additional information from the remaining 21 studies was considered where appropriate to obtain a broader perspective on the injury problem in children and youth football. Training injury incidence was nearly constant for players aged 13-19 years, ranging from 1 to 5 injuries per 1,000 h training. Match injury incidence tended to increase with age through all age groups, with an average incidence of about 15 to 20 injuries per 1,000 match hours in players older than 15 years. Between 60 and 90 % of all football injuries were classified as traumatic and about 10-40 % were overuse injuries. Most injuries (60-90 %) were located at the lower extremities with the ankle, knee, and thigh being mostly affected. The frequency of upper-extremity and head/face injuries was higher in those studies that analyzed match injuries only. The most common injury types were strains, sprains, and contusions (10 up to 40 % each). There is some evidence that the risk of traumatic injuries and, in particular, of sustaining a fracture, contusion, or concussion was higher during match play than in practice sessions. Fractures were more frequent in children younger than 15 years than in older players. About half of all time-loss injuries led to an absence from sport of less than 1 week, one third resulted in an absence between 1 and 4 weeks, and 10 to 15 % of all injuries were severe. Separate data for players under the age of 11 years are almost absent. Maturation status seems to have an influence on injury characteristics, although evidence is not conclusive at this time. Three main areas seem to be of particular relevance for future prevention research in young football players: (1) the substantial number of severe contact injuries during matches, (2) the high number of fractures in younger players, and (3) the influence of maturation status and growth spurts.

Diagnostic Differences for Anterior Knee Pain between Sexes in Adolescent Basketball Players

BACKGROUND

The purpose of this study was to determine if there is a sex difference in the prevalence of specific patellofemoral disorders that cause anterior knee pain in adolescent basketball players undergoing pre-participation screening.

METHODS: SETTING

Biomechanical Laboratory.

METHODS: PARTICIPANTS

A total of 810 (688 female and 122 male) basketball players from a single county public school district.

METHODS: MAIN OUTCOME MEASURES

Prior to the start of three consecutive basketball seasons, participants were evaluated for anterior knee pain. Testing consisted of completion of the Anterior Knee Pain Scale. Those with positive findings completed an IKDC form, a standardized history and a physician-administered physical examination.

RESULTS

Anterior knee pain was noted in 410 of 1620 knees (25.3%). 26.6% of female knees and 18.0% of male knees were affected (p<0.05). Patellofemoral dysfunction (PFD) was the most common diagnosis with an overall prevalence of 6.4% (7.3% females; 1.2% males). Less common were Sinding-Larsen-Johanssen disease (SLJ), 4.8% (5.0% females; 3.7% males), Osgood-Schlatter Disease (OSD) 2.5% (2.3% females; 4.1% males); and plica syndrome 2.3% (2.1% females; 3.3% males). The remaining diagnoses (trauma, fat pad syndrome, IT band and pes anserine bursitis) had a combined prevalence of 1.7% (1.9% females; 1.6% males).

CONCLUSIONS

PFD was significantly more common in females (p<0.05). Anterior knee pain was more common in adolescent female basketball players than in adolescent male basketball players.

LEVEL OF EVIDENCE

Descriptive Laboratory Study. Level 1.

Relationship between the skeletal maturation of the distal attachment of the patellar tendon and physical features in preadolescent male football players

PURPOSE

The aim of this study was to compare ultrasonography stages of the tibial tuberosity development and physical features.

METHODS

This study examined 200 knees in 100 male football players aged 10-15 years. Tibial tuberosity development on ultrasonography was divided into 3 stages: Sonolucent stage (stage S), Individual stage (stage I), and Connective stage (stage C). Age, height, quadriceps and hamstring muscle tightness, and muscle strength in knee extension and flexion were determined. These findings were compared with the respective stages of development.

RESULTS

The tibial tuberosity was stage S in 27 knees, stage I in 69 knees, and stage C in 104 knees, with right and left sides at the same stage in 95 %. Average age and height significantly increased with advancing tibial tuberosity development. Quadriceps tightness increased with tibial tuberosity development. Hamstring tightness decreased with development. The strength of both knee extension and flexion increased with advancing development, with a greater change seen in knee extension, hamstring/quadriceps ratio: stage C, 0.74; stage A, 0.64; stage E, 0.53.

CONCLUSIONS

Osgood-Schlatter pathogenesis reportedly involves increased quadriceps tightness with rapidly increasing femoral length during tibial tuberosity development. In this study, it was confirmed that quadriceps tightness increased, yet hamstring tightness decreased, suggesting that quadriceps tightness is not due to femoral length alone. Other factors, including muscle strength, may be involved. The study shows that thigh muscle tightness and thigh muscle performance change with the skeletal maturation of the distal attachment of the patellar tendon. These results add new information to the pathogenesis of Osgood-Schlatter disease.

Is there a relationship between attention deficit/hyperactivity disorder and Osgood-Schlatter disease?

PURPOSE

The purpose of this prospective study is to investigate the relationship between Osgood-Schlatter disease (OSD) and attention deficit/hyperactivity disorder (ADHD).

METHODS

Seventy-four children with a diagnosis of OSD were referred to child and adolescent psychiatry department for the evaluation of ADHD. Diagnostic and Statistical Manual of Mental Disorders was used for diagnostic criteria.

RESULTS

Diagnosis of ADHD was made in 56 (75.6 %) out of 74 children.

CONCLUSIONS

Results of this study suggest that ADHD is a significant risk factor for OSD. During the evaluation of a patient with OSD, a thorough history should be obtained about the behavioral symptoms that indicate underlying ADHD. In case of suspicion, these patients should be referred for an additional evaluation by a child psychiatrist.

LEVEL OF EVIDENCE

II.

Avulsion fragmentation of the tibial tuberosity apophysis and associated patellar tendon enthesopathy in a skeletally immature dog

A 9.5-month-old, female entire, 31.3 kg crossbred dog was presented with a 12 week history of moderate weight-bearing right pelvic limb lameness. Radiographic, computed tomographic, and ultrasonographic imaging revealed progressive avulsion fragmentation of the right tibial tuberosity apophysis and a patellar tendon insertional enthesopathy without physeal involvement. Conservative management was successful in achieving a good clinical outcome. A progressive avulsion of the contralateral proximal tibial physes that occurred concurrently resulted in development of an excessive tibial plateau slope angle. The additional development of a moderate left distal femoral varus deformity was surgically corrected. This is the first report of a progressive, traction injury to the tibial tuberosity apophysis in a dog that appears clinically and radiographically very similar to Osgood-Schlatter disease in humans.

Long-term functional and sonographic outcomes in Osgood-Schlatter disease

PURPOSE

To evaluate the sonographic characteristics, functional aspects and life quality of a group of adolescent patients 2 years after having been diagnosed with Osgood-Schlatter disease and compare them with an age-matched healthy control group.

METHODS

The study was conducted on eighteen Osgood-Schlatter patients with unilateral involvement and 14 age-matched healthy controls. The Flaviis classification and patellar tendon characteristics were observed using a GE Logiq 9 scanner. Broad and vertical jump tests were used for jumping performance. The coordination, proprioception, strength and endurance functions were assessed with the Functional Squat System. For the quality of life, the SF-36 questionnaire was used. The Wilcoxon test for the patients' initial and second-year assessment and Mann-Whitney U test for the comparison between the patient and control groups were used.

RESULTS

By the end of second year, 38.9% of the patients had totally recovered. The patellar tendon lengthened, distal diameter and distal area of the tendon had lessened, and no significant difference was observed between patient and control groups (n.s). Improvements were detected for the bilateral broad jump test scores, the quality of life and coordination of the patients after 2 years (p < 0.05). The average power of endurance and the total work of strength were significantly higher in control group (p < 0.05).

CONCLUSIONS

According to the sonography results 2 years after diagnosis, nearly half of the patients had totally recovered. Coordination was the only parameter that improved over the 2-year period. The patient group strength and endurance function remained lower than the control group.

LEVEL OF EVIDENCE

III.

Expected prevalence from the differential diagnosis of anterior knee pain in adolescent female athletes during preparticipation screening

CONTEXT

Anterior knee pain is a common disorder in female athletes with an undefined cause. The relative prevalence of specific patellofemoral disorders associated with anterior knee pain in adolescent females remains undetermined.

OBJECTIVE

To determine the prevalence of specific patellofemoral disorders obtained using the differential diagnosis of anterior knee pain in adolescent female athletes during preparticipation screening.

DESIGN

Descriptive epidemiology study.

SETTING

Preparticipation screening evaluations at a county public school district in Kentucky.

PATIENTS OR OTHER PARTICIPANTS

A total of 419 unique middle and high school-aged female athletes.

MAIN OUTCOME MEASURE(S)

Participants were evaluated by physicians for anterior knee pain over 3 consecutive basketball seasons. Given the longitudinal nature of this study, some participants were tested longitudinally over multiple years.

RESULTS

Over the course of 3 basketball seasons, 688 patient evaluations were performed. Of these, 183 (26.6%) were positive for anterior knee pain. A statistically significant difference was noted in the prevalence of anterior knee pain by school level, with 34.4% (n = 67) in high school-aged athletes versus 23.5% (n = 116) in middle school-aged athletes (P < .05). In the 1376 knees evaluated, patellofemoral dysfunction was the most common diagnosis, with an overall prevalence of 7.3% (n = 100). The only diagnosis shown to be statistically different between age levels was Sinding-LarsenJohansson disease or patellar tendinopathy, with 38 cases (9.7%) in high school-aged and 31 (3.1%) in middle school-aged athletes (P < .05).

CONCLUSIONS

Anterior knee pain was present in 26.6% of the adolescent female athletes screened over 3 years. Symptoms of anterior knee pain likely persist after middle school-aged onset and reach peak prevalence during the high school years.

Arthroscopic Excision of a Huge Ununited Ossicle Due to Osgood-Schlatter Disease in an Adult Patient

Introduction:

Surgical excision of the ununited ossicles has been suggested for unresolved sequelae of Osgood-Schlatter disease in adults resistant to conservative measures. We report a case where arthroscopy was used to excise the ossicles. A bird eye view from the superolateral portal was helpful in the arthroscopic procedure for excision of the deep low lesion.

Case Series:

A 32-year-old, male driver had anterior knee pain during walking and sports activity that had been treated conservatively for 3 months. On physical examination, there was a prominent tibial tubercle, but without palpable pain. There was obvious pain when the knee was approaching full extension. On image, a huge ununited ossicle was seen behind the patellar tendon, intruding into the joint space, and there was another two small ununited ossicles beneath the bow-shaped patellar tendon. Arthroscopy was performed through a three portals technique, and a bird eye view was achieved from the superolateral portal. The ossicles were separated from the surrounding soft tissue with a motorized shaver. The small ununited ossicles were removed by use of a grasper. The huge ossicle was removed by use of a motorized bur, and the contouring of the irregular surface of the tibial tubercle was performed. After 3 months, the patient returned to sports activities without any restrictions.

Conclusion:

This report shows that a huge ossicle can cause impingement in anterior knee compartment, and it can be easily removed arthroscopically under assistance of an additional portal.

Doppler ultrasound and tibial tuberosity maturation status predicts pain in adolescent male athletes with Osgood-Schlatter's disease: a case series with comparison group and clinical interpretation

BACKGROUND

The pathogenesis of the Osgood-Schlatter's disease (OSD) is still debated. The fragmentation of the ossification centre has been questioned as a definitive sign of OSD and has been seen as a normal development of the anterior tibial tubercle (ATT).

OBJECTIVES

It is unknown if such changes are present in the presumed pathological tendon insertion seen in OSD, nor the relation of Doppler-positive changes to pain on clinical examination.

METHODS

A prospective analysis was carried out on 20 consecutive symptomatic male athletes (13.9 years±1.3) and a comparison group of asymptomatic subjects. All underwent a comparative clinical assessment and ultrasound with colour Doppler scan on both knees. Subjective pain was recorded with a visual analogue scale (VAS) during provocative manoeuvres: palpation, resisted contraction and single leg squat.

RESULTS

Positive Doppler US (within the distal end of the patellar tendon) was associated with higher pain on palpation (47±24.5 vs 18±11.4, p<0.01) and resisted static contraction (59±20.2 vs 27±12.5, p<0.001) compared with Doppler-negative subjects. No Doppler activity was found in the comparison group. VAS for palpation and resisted contraction of the athletes graded as stage 2 (51.1±22.0 and 60.0±21.2) were significantly higher than stage 3 (17.8±12.0 and 18.9±16.9) and stage 4 (15.0±7.1 and 25.0±7.1; p<0.01).

CONCLUSIONS

More painful OSD is associated with the presence of neo-vessels. This may be linked with a particular stage of ATT maturation and applied compressive forces. A Doppler ultrasound scan adds practical information to develop the care plan of the patient.

Imaging diagnosis-bilateral abnormal ossification of the supraglenoid tubercle and cranial glenoid cavity in an English Setter

An 8-month-old intact male English Setter was presented with bilateral shoulder lameness. Radiographic and CT examinations demonstrated bilateral irregular margination and separation of the supraglenoid tubercle from the scapula, with involvement of the cranial articular surface of the glenoid cavity. After 30 days of cage rest, complete fusion of proximal portions of both supraglenoid tubercles and persistent un-united cranial portions of both glenoid cavities were evident. Histopathologic findings from biopsies of glenoid cavity defects were consistent with osteochondrosis or focal chondrodysplasia.

Relationship between the clinical findings and radiographic severity in Osgood-Schlatter disease

BACKGROUND

Osgood-Schlatter disease (OSD) is one of the common causes of knee pain in active adolescents who play sports. The common age for boys to have OSD is between 12 and 15 years and for girls, between 8 and 12 years. Radiographic studies are helpful in diagnosis and treatment of OSD.

PURPOSE

We examine the age at onset of OSD in detail and investigate the relationship between clinical findings, radiographic bone morphology, and the severity of OSD in adolescents.

RESULTS

The average age at onset of knee pain was 12 years and 6 months - 12 years and 9 months in boys, and 12 years and 1 month in girls. Boys were significantly older than girls at onset. In addition, there were significant relationships between duration from first onset to visit to the clinic, radiographic bone stage, body morphology, and radiographic severity. The patients who delayed their visit to the clinic from the first onset of pain and who were older showed a later bone stage and more radiographic severity grade of OSD. There was significant differences concerning weight and body mass index between severity grade I and III.

CONCLUSION

For the age at the onset of OSD, the mean age of boys was significantly older than that of girls. The patients at a later bony stage had a higher severity grade. The boys and girls with OSD who had less weight or body mass index showed less severity.

Approach to the active patient with chronic anterior knee pain

The diagnosis and management of chronic anterior knee pain in the active individual can be frustrating for both the patient and physician. Pain may be a result of a single traumatic event or, more commonly, repetitive overuse. "Anterior knee pain," "patellofemoral pain syndrome," and "chondromalacia" are terms that are often used interchangeably to describe multiple conditions that occur in the same anatomic region but that can have significantly different etiologies. Potential pain sources include connective or soft tissue irritation, intra-articular cartilage damage, mechanical irritation, nerve-mediated abnormalities, systemic conditions, or psychosocial issues. Patients with anterior knee pain often report pain during weightbearing activities that involve significant knee flexion, such as squatting, running, jumping, and walking up stairs. A detailed history and thorough physical examination can improve the differential diagnosis. Plain radiographs (anteroposterior, anteroposterior flexion, lateral, and axial views) can be ordered in severe or recalcitrant cases. Treatment is typically nonoperative and includes activity modification, nonsteroidal anti-inflammatory drugs, supervised physical therapy, orthotics, and footwear adjustment. Patients should be informed that it may take several months for symptoms to resolve. It is important for patients to be aware of and avoid aggravating activities that can cause symptom recurrence. Patients who are unresponsive to conservative treatment, or those who have an underlying systemic condition, should be referred to an orthopedic surgeon or an appropriate medical specialist.

Bursae around the knee joints

A bursa is a fluid-filled structure that is present between the skin and tendon or tendon and bone. The main function of a bursa is to reduce friction between adjacent moving structures. Bursae around the knee can be classified as those around the patella and those that occur elsewhere. In this pictorial essay we describe the most commonly encountered lesions and their MRI appearance.

Hyperosmolar dextrose injection for recalcitrant Osgood-Schlatter disease

OBJECTIVE

To examine the potential of dextrose injection versus lidocaine injection versus supervised usual care to reduce sport alteration and sport-related symptoms in adolescent athletes with Osgood-Schlatter disease.

PATIENTS AND METHODS

Girls aged 9 to 15 and boys aged 10 to 17 were randomly assigned to either therapist-supervised usual care or double-blind injection of 1% lidocaine solution with or without 12.5% dextrose. Injections were administered monthly for 3 months. All subjects were then offered dextrose injections monthly as needed. Unaltered sport (Nirschl Pain Phase Scale < 4) and asymptomatic sport (Nirschl Pain Phase Scale = 0) were the threshold goals.

RESULTS

Sixty-five knees in 54 athletes were treated. Compared with usual care at 3 months, unaltered sport was more common in both dextrose-treated (21 of 21 vs 13 of 22; P = .001) and lidocaine-treated (20 of 22 vs 13 of 22; P = .034) knees, and asymptomatic sport was more frequent in dextrose-treated knees than either lidocaine-treated (14 of 21 vs 5 of 22; P = .006) or usual-care-treated (14 of 21 vs 3 of 22; P < .001) knees. At 1 year, asymptomatic sport was more common in dextrose-treated knees than knees treated with only lidocaine (32 of 38 vs 6 of 13; P = .024) or only usual care (32 of 38 vs 2 of 14; P < .0001).

CONCLUSIONS

Our results suggest superior symptom-reduction efficacy of injection therapy over usual care in the treatment of Osgood-Schlatter disease in adolescents. A significant component of the effect seems to be associated with the dextrose component of a dextrose/lidocaine solution. Dextrose injection over the apophysis and patellar tendon origin was safe and well tolerated and resulted in more rapid and frequent achievement of unaltered sport and asymptomatic sport than usual care.

Prevalence and associated factors of Osgood-Schlatter syndrome in a population-based sample of Brazilian adolescents

BACKGROUND

Osgood-Schlatter (OS) syndrome is a disease of the musculoskeletal system often observed during the bone growth phase in adolescents. HYPOTHESIS/ PURPOSE: Demographic and anthropometric factors and those linked to the practice of sports may be related to the prevalence of OS. The aim of the present study was to describe the epidemiologic profile and associated factors of individuals with OS syndrome in a population-based sample of Brazilian adolescents.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

A cross-sectional study was conducted with 956 adolescent students (474 boys, 482 girls) from 2008 to 2009 enrolled in the school system of Natal, Brazil. The age ranged between 12 and 15 years (13.7 ± 1.04 years). Tests were performed to assess the anthropometric and clinical aspects related to OS. To confirm the diagnosis of OS syndrome, the participant had to fulfill all the following clinical criteria: pain with direct pressure on the tibial apophysis; aforementioned pain before, during, and after physical activities; enlargement or prominence of the tibial apophysis; pain with resisted knee extension; and pain from jumping.

RESULTS

The prevalence of OS in the sample was 9.8% (11.0% of boys and 8.3% of girls; boys, 13.5 ± 1.07 years; girls, 13.6 ± 1.01 years). The results showed that 74.6% of the students suffered from muscle shortening. Multivariate analysis using logistic regression showed that the factors associated with the presence of OS were the regular practice of sport activity (odds ratio, 1.94; 95% confidence interval, 1.22-3.10) and the shortening of the rectus femoris muscle (odds ratio, 7.15; 95% confidence interval, 2.86-17.86).

CONCLUSIONS

The regular practice of sports in the pubertal phase and the shortening of the rectus femoris muscle were the main factors associated to the presence of OS syndrome in the students.

Overuse injuries in youth sports

Although youth sports participation is beneficial on many levels, it is also associated with an increased risk of injury. Risk factors for injury in children and adolescents include the presence of growth cartilage, existence of muscle imbalance, and pressure to compete despite pain and fatigue. Overuse injuries, such as patellofemoral pain, Osgood-Schlatter disease, calcaneal apophysitis, Little League elbow, Little League shoulder, spondylolysis, and osteochondritis dissecans, are common injuries in organized sports. However, proper education, supervision, and training can help reduce the risk of these injuries and facilitate early intervention.