Changing the way we manage Osgood Schlatter’s
A recent report from Professor Jens Oleson and Dr Sinead Holden from Aalborg University, Denmark suggests that Osgood Schlatter’s (OSD) may not be the self-limiting condition as typically believed.
OSD seems more like juvenile tendinopathy, which means that treatment approaches may need to change [Podcast: https://www.stitcher.com/podcast/talk-medicine-from-bmj/bjsm-british-journal-of-sports-medicine/e/61756747].
Overview: OSD is the most common lower limb osteochondrosis usually occurs between ages of 8–13 years (girls) and 12-15 years (boys). It is is bilateral in 20–30% of children, and can be classified as a non-articular traction osteochondrosis. OSD affects approximately 20% of athletic adolescents, and 4.5% of same-age, non-athletic peers. Frequently, there is history of rapid growth, intense sport participation. Symptoms are aggravated by running and kicking sports.
FIGURE: OSD lateral radiograph with tibial tubercle apophysitis indicated
Evidence: Generally, OSD is managed conservatively, with treatments including, RICER, stretch/strengthen, biomechanics, and modifying sports. However, the evidence is poor, with a recent systematic review finding only one RCT.
New findings: Oleson and Holden found that children with OSD are very active, as are those with patello-femoral (PF) pain. Activity modification is an agreed approach for both conditions, but methods vary.
In their recent study, Oleson and Holden examined three groups of children aged between 10-14 years; OSD n=51, n=150 PF pain, control group. All had an initial 4 weeks rest from all sports, following which a progressive loading approach was implemented to gain return to sport [http://bjsm.bmj.com/pages/wp-content/uploads/sites/17/2019/06/OSD-table.pdf].
The outcome assessment used a global rating of change, self-reported improvement levels, and whether the children had been able to return to playing sports.
The findings are surprising for what has been considered a transient and self-limiting condition. After 1 year, 1 in 3 were not returned to sport. After 2 years, almost 40% still had OSD related pain, and were limited in sports, with lower HRQoL. Retrospectively, after 4 years – 60% were still reporting OSD related pain, similar to an older descriptive report (Krause, 1990).
Interestingly, sonographic examination of the knees found that the children with more severe changes (ie bone, tendon, + bursitis) still had pain after 2 years. The authors posit that US imaging may have prognostic potential.
So what does this mean for clinicians who see children with OSD:
- Good clinical examination
- Clear message to patients: viz. OSD can take time, it’s not just 6 months off sports; it’s not always self-limiting
- Strengthening is advised (especially quads), not just RICER
- Follow up re activity progress/time
- Appreciate that some children with OSD will recover and return to their sports in 6-12 months; others are affected for much longer
- Appreciate the importance of physical activity for health, advise children regarding activity options when OSD imposes limits.
- Cairns G et al; interventions in children and adolescents with patellar tendon related pain: a systematic review. BMJ Open Sport Exerc Med. 2018 Aug 13;4(1):e000383. doi: 10.1136/bmjsem-2018-000383 https://bmjopensem.bmj.com/content/4/1/e000383
- Krause BL et al; Natural history of Osgood-Schlatter disease. J Pediatr Orthop 1990;10(1):65-8.
- Evidence Essentials – Series 2, Monograph 5 https://angelaevanspodiatrists.com.au/evidenceessentials/
TABLE: Five proximal osteochondroses which may coincide with those in the feet.
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Dr Angela Evans AM
PhD, FFPM RCPS(Glasg)