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Table of Contents
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Disease Summary
Osgood Schlatter's Disease is classified as an osteochondritis (inflammation of a bone and its associated cartilage) or apophysitis (inflammation of a bony outgrowth that is still attached to the bone) injury. The injury site is located at the epiphyseal plate of the tibial tuberosity. Quadriceps muscle contraction causes the patellar tendon to pull on its attachment to the tibial tuberosity. The body responds to this repetitive strain on the tibial tuberosity by laying down bone at the site of the avulsion of the tibial tuberosity from the tibia to prevent separation. Patients with this condition will be adolescents participating in athletic activity presenting with anterior knee pain that gets worse after activity and improves with rest, a palpable bump over the tibial tuberosity not proportional to the unaffected knee, possible knee musculature strength imbalances, tightness in some of the knee musculature, and possible inflammation around the knee or tibial tuberosity.1,2
Guide To Physical Therapy Practice
Practice Pattern
Pattern 4E: Impaired Joint Mobility, Motor Function, Muscle Performance, and Range of Motion Associated With Localized Inflammation3
Goals
The Guide suggests that over the course of two to four months a patient presenting under this pattern will be able to demonstrate optimal joint mobility, muscle performance, motor function, and range of motion to allow normal functional involvement in home, work, school, community, and leisure activities that the patient was involved in prior to this condition.
Expected Number of Visits
The Guide suggests six to twenty four visits for this episode of care. Note that it is anticipated that 80% of patients under this pattern will achieve their goals and expected outcomes in this amount of time. Frequency of visits is up to the clinical decision making of the physical therapist based on patient presentation.
Intervention
Note: The interventions below are suggested by The Guide for patients presenting under this practical pattern. All interventions may not be appropriate for Osgood Schlatter's Disease or all patients. Continue below for specific interventions for Osgood Schlatter's Disease.
| Intervention | Examples |
|---|---|
| Aerobic Capacity/Endurance Conditioning | Aquatic programs, gait/locomotion training, increasing workload over time |
| Balance/Coordination/Agility | Neuromuscular education, perceptual training, vestibular training |
| Body Mechanics/Postural Stabilization | Postural awareness/control training, body awarness training |
| Flexibility Exercises | Muscle lengthening, stretching, range of motion |
| Gait and Locomotion Training | Gait training |
| Relaxation Techniques | Breathing strategies, relaxation techniques |
| Strength/Power/Endurance | Active assistance, active, and resistance exercises |
| ADL Training | Dressing, toileting, bathing, home activities |
| Injury Prevention | Education, activity limitation |
| Manual Traction | Cervical or lumbar manual traction |
| Massage | Connective tissue massage, therapeutic massage |
| Mobilization/Manipulation | Soft tissue, spinal/peripheral joints |
| Passive Range of Motion | Therapist performed |
| Modalities | |
| Medication Delivery | Iontophoresis |
| Electrical Simulation | EMS, TENS, NMES, FES, HVRC |
| Cyrotherapy | Cold packs, ice massage, vapocoolant sprays |
| Hydrotherapy | Whirlpool, contrast bath, pools |
| Light agents | Infrared, laser |
| Sound agents | Phonophoresis, ultrasound |
| Thermotherapy | Dry heat, hot packs, paraffin |
| Compression Devices | Taping, bracing |
Evidence Based Treatment of OSD
Relieving Pain
Due to the etiology of Osgood Schlatter's Disease, complete pain relief generally only occurs when the epiphyseal plate of the tibial tuberosity closes around the age of nineteen.4 Pain can be diminished using ice, limiting physical activity, the use of oral anti-inflammatory medications, knee padding/taping, and physical therapy for stretching and strengthening.4 Specifically for the physical therapist, pain relief can be brought about by the following ways:
- Ice applied over the anterior knee after activity for about 30 minutes has been shown to be effective in decreasing pain that is self-reported after athletic activity.5
- Limitation of physical activity for six to eight weeks with a gradual return to full participation over another six to eight week period has been shown to be effective in reducing pain for these patients.6
- Physical load restriction through taping techniques and braces to decrease patellar loading are also effective in reducing pain when worn during and after activity.6 Taping techniques include patellar tendon offloading and McConnell taping. Specific instructions for performing these techniques can be found below in the taping section. Cho-Pat braces have been used for this disease; however, research has not been done to see if it is effective in this patient population.
- Low intensity quadriceps stretching has been shown to decrease pain along with strengthening of the vastus medialis oblique have been show to decrease pain for these patients.6
Note: Research by Gerulis et al6 has shown that limitation of physical activity, physical load restriction, and conservative treatment are more effective than physical load restriction and activity limitation alone.6
Injection of a solution of 1% lidocaine with a 12.5% dextrose has been investigated for treatment of Osgood Schlatter's Disease to reduce pain. Results of a study by Topol et al7 show that return to sport with no symptoms occurred more frequently in patients treated with the lidocaine and dextrose injections than patients treated with just lidocaine injection or usual treatment. These researchers also indicated that in their study population asymptomatic sport participation was more common in the patients injected with the lidocaine and dextrose at a one year followup than patients injected with just lidocaine or the usual treatment.7
Increasing Strength
Low-intensity quadriceps strengthening has been shown to be most effective in the initial stages of treatment.4 High-intensity exercises should be introduced gradually as pain decreases, more activity is tolerated, and the quadriceps get stronger.4 If these high-intensity exercises are incorporated too fast pain can be recreated or intensified.
Vastus medialis oblique (VMO) strengthening has been researched in patients with patellofemoral pain syndrome; however, the specific effectiveness of exercises specifically for VMO activation has not been researched for patients with Osgood Schlatter's Disease. Due to the etiology of this disease, abnormal patellar tracking may increase or change the force exerted on the tibial tuberosity by the patellar tendon during quadriceps contraction. Because of this and depending on the reason for patellar traction problems, VMO strengthening may help decrease pain in these patients. Coqueiro et al8 determined that the vastus lateralis (VL) muscle shows greater electrical activation in patients with knee pain pathologies during double-leg semisquat exercise with maximum hip adduction isometric contraction suggesting that the VL is compensating for VMO weakness.8 However, this research also showed a greater activation of the VMO during double-leg semisquad exercise with maximum hip adduction than with the double-leg semisquat exercise alone suggesting activation of the VMO is enhanced with hip adduction.8 The following image shows one way to enhance isometric hip adduction during squat exercises.
Image Source: http://www.health24.com/fitness/Exercises/16-1339-1345,20035.asp
Improving Range of Motion
Stretching should include the hip flexors, hip extensors, hip adductors, hip abductors, hip external rotators, hip internal rotators, knee flexors (including the gastrocnemius), knee extensors, and the iliotibial band. Stretching should initially be performed statically at a low intensity to prevent pain before progressing to dynamic or PNF stretching. A duration of at least thirty seconds with three repetitions is recommended at least once per day to increase range of motion.9 It should be noted here that stretching as an intervention for Osgood Schlatter's has not been studied in isolation; therefore, the effectiveness is not evidence-based for this patient population.
Decreasing Swelling
Swelling associated with this condition can be decreased through cryotherapy, anti-inflammatory medication use (NSAIDS), and activity limitations. The effectiveness of these interventions in isolation have not been researched in this patient population; however, activity limitation in conjunction with physical load restriction and conservative treatment has been shown to be more effective than physical load restriction alone.6 The use of cryotherapy to decrease swelling and inflammation has long been established in the research for many conditions and should be utilized in this patient population after any activity.
Functional Activities
As mentioned above, physical load restriction is important to decrease pain in this patient population. Functional activities need to be evaluated to ensure proper form when lifting or any other activity that involves knee flexion to recognize when unnecessary stress is being placed on the knee. Activities such as kneeling and squatting should be limited or modified especially in the early stages of rehabilitation to again prevent unnecessary force on the knee joint. Modifications for kneeling if it is required by the patient can include using pads specific for knee support during kneeling that are commercially available. These should be available around the home or with the patient if the patient needs to kneel to reach something on a low shelf or other activities requiring kneeling. Kneeling on a pad should be encouraged over maintaining a squatting position for these activities to prevent compressive forces on the knee.
Image Source: http://www.mechanicomfort.com
Home Exercise
Home exercise programs should include stretching and strengthening exercises that are being done in the clinic for rehabilitation. Stretching should be done daily while strengthening exercises should be done on days the patient does not go to the clinic for rehabilitation. The patient should be provided with education on activity restriction as well as an appropriate program to ice the knee at home.
Modality Use
Suggested modalities for treatment of Osgood Schlatter's include iontophoresis, electrical stimulation (EMS, TENS, NMES), cyrotherapy, hydrotherapy (whirlpool, contrast bath), light agents (infrared, laser), sound agents (ultrasound), and thermotherapy. Research has not been done on the patient population with Osgood Schlatter's disease to determine the effectiveness of any of these modalities in treating this disease. TENS use may decrease pain and should be given depending on the specific patient. NMES may be used in isolation or with exercise to maximize VMO contraction; however, this also has been been researched for this patient population. The importance of ice or other cold modality use has already been discussed. Clinicians should use extreme caution in the application of modalities that will increase heat in the area such as light agents, continuous ultrasound, some forms of hydrotherapy, and thermotherapy due to potential increases in blood flow to the area that may enhance the inflammatory response. Remember that inflammation due to the avulsion of the tibial tuberosity from the tibia exacerbates the pain associated with this condition. This occurs every time the quadriceps are contracted; therefore, heat modality use should be considered with caution for this condition until pain has resolved.
Taping
Patellar Tendon Unloading Technique
This technique has not been researched in this patient population; however, patients report that it helps decrease their pain. There are many ways to do this technique. The video below depicts one method to unload the patella using tape. Below the video, you will find an alternative way to perform this technique.
Step 1: The tape is applied with the knee flexed. The tape starts by going circumferentially around the patellar tendon or the area between the inferior pole of the patella and the tibial turberosity. A small amount of pre-wrap in the popliteal fossa prevents pinching.
Step 2: The tape is passed around the circumference of the knee once.
Step 3: The tape is twisted over the patellar tendon.
Step 4: The tape is twisted several times in order to make a thick band of twisted tape of the patella.
Step 5: The tape is passed around the circumference of the knee again.
Step 6: The twisting is repeated as done on the previous strip.
Step 7: The tape is passed around the circumference of the knee again to finish the tape job.
McConnell Taping
The effectiveness of McConnell Taping has not been researched for this patient population; however, use of this taping technique alone has been attributed to improved knee flexion range of motion and decreased pain with activity.10
Special Instructions & Considerations
Patients should be cautioned against lidocaine and dextrose injections due to potential adverse effects. These include but are not limited to postinjection pain, pain with injection, itching, burning, local pain, overall pain, local tenderness and swelling, hematoma, gastrointestinal discomfort, vertigo, rash, local irritation, nausea, weakness, paresis, and decreases in tendon force generating capacity with injections over time.11
Summary
Activity limitation, physical load restriction, ice application, stretching of lower extremity musculature, and strengthening of the quadriceps (specifically the VMO) in combination have been show to decrease pain and inflammation associated with Osgood Schlatter's Disease. Exercises should be prescribed based on patient deficits and patient presentation.
