0196-6011/85/0701-0005$02.

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THEJOURNAL
OF ORTHOPAEDIC
AND SPORTS
PHYSICAL
THERAPY
Copyright 0 1985 by The Orthopaedic and Sports Physical Therapy Sections of the
American Physical Therapy Association

Osgood-Schlatter Disease: Review of

Literature and Physical Therapy
Management

Journal of Orthopaedic & Sports Physical Therapy

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T. J. ANTICH, MS, PT,* CLlVE E. BREWSTER, MS, PT

Osgood-Schlatter disease is a traction apophysitis of the tibial tubercle, the weakest

link of the extensor mechanism of the adolescent. Conventional medical treatment
includes plaster casting, injections of various anti-inflammatories, and surgical
removal of painful ossicles in resistant cases. While not a very common condition,
Osgood-Schlatter disease is being seen with increasing frequency in teenage
athletes, especially basketball players (Antich, Lombardo, J Orthop Sports Phys Ther
7: 1-4, 1985.) With a focus on muscular tightness as a possible causative factor,
physical therapy evaluation is outlined, followed by techniques for pain control and
stretching exercises for the quadriceps and hamstrings. Ice massage is advocated
as a way for the athlete to treat postexertional discomfort in the area of the tubercle.
The patient and his or her parents must be assured that while residual deformity may
remain, disappearance of symptoms coinciding with closure of the apophyseal plate
is often the end result.

Osgood-Schlhtter disease is defined as a separation of the tibial tubercle apophysis from the
proximal end of the tibia. This lesion may have a
history of trauma, or may present without a significant recognizable injury. KatzI4 classifies this
entity as a nonarticular osteochondrosis involving
the quadriceps muscle/tendon insertion secondary to excessive muscle pull. Citing the same
mechanism of increased quadriceps pull on the
adolescent tubercle, Smillie28describes OsgoodSchlatter disease as a traction epiphysitis. Dorland's Medical Dictionary gives as a synonym
"apophysitis tibialis adolescentium," while
Christie4 states that the radiographically evident
bone changes make it a disease entity. He adds
that poor epiphyseal nourishment during a time of
rapid growth can lead to the onset. However,
LaZerte and Rapp'sI7 histological studies of nine
specimens indicate no evidence of primary aseptic
necrosis in any of the tubercles examined.
Increased stress on the weak link of the adolescent knee extensor mechanism accounts for
the symptoms experienced by those patients with
this ~ e s i o n . ' ~An
. ' ~initial
~ ~ ~injury can be furthered
Department of Physical Therapy, Southwestern Orthopaedic Medical
Group, Inc., 501 E. Hardy Street, Suite 200, Inglewood, CA 90301.

by continuing minor t r a ~ m a t a ~or' . heterotopic

~~
calcification and ossification in the patellar liga~~~
ment can occur secondary to o ~ e r u s e . " Instances of tibial tubercle fracture have been reported subsequent to violent quadriceps contract i o n . ' ~The
~ ~ imbalance in the cross-sectional area
of the quadriceps muscle bulk to the area of
insertion7 also creates a great concentration of
force on. a small area.
HISTOLOGY

Microscopic examination of bony ossicles removed at surgery indicates that the separation is
due to increased tension over a small area of
tendon insertion. All nine cases studied by LaZerte and RappI7 demonstrated an anterior cortical bone defect of the tubercle, in addition to
increased vascularization of the infrapatellar tendon surrounding the ossicles.
DIAGNOSIS

Osgood-Schlatter disease is easily recognized

in the adolescent with complaints of pain which is
localized to the area of the tibial tubercle. Discomfort is usually generated with running,21 kneeling,2321
ascending or descending stair^,'^^^' and is

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JOSPT Vol. 7, No. 1

ANTICH AND BREWSTER

Fig. 1 . A, Lateral view in a 12-year-old male exhibiting separation of the tubercle; 13,ossicle embedded within the infrapatellar
tendon at its insertion in a 13-year-old male.
I

patella alta in their series of 185 knees utilizing

relieved with rest.l4 Weakness of the quadriceps2'
and Peel method of measuring
and pain on resisted knee e ~ t e n s i o n ~are
~ ~ ~ the
~ ~ Blackburne
'
common signs, as is an enlarged t ~ b e r c l e . ~ . ~ 'patellar position. The mean index of knees with
Osgood-Schlatterdisease was 0.99, as compared
D'Ambrosia and MacDonald6report reproduction
73 normal knees with a mean of 0.84.
to
of pain with passive knee flexion, which Jakob et
Differential
diagnosis of this entity includes osa1.12attribute to a hypertrophiedquadriceps group
teogenic
sarcoma
of the proximal tibia2' and osexhibiting decreased flexibility.
teomyelitis
of
the
tubercle secondary to contuRadiographic examination is considered nec~
i
o
n
D'Ambrosia
.
~
and MacDonald6 emphasize
essary in confirming this diagnosis in the adolesthe
need
to
perform
a thorough examination on
cent with knee pain. In more severe cases, sepadults
with
previous
histories
of Osgood-Schlatter
aration and fragmentation of the apophysis may
disease
and
report
arteriovenous
fistula as the
be seen32as well as irregular ossification of the
cause
of
knee
pain
in
one
individual.
t ~ b e r c l e ' ~(Fig.
. ~ ' 1). In milder cases without radiographic bony changes, soft tissue swelling, esCONVENTIONAL MEDICAL TREATMENT
pecially of the infrapatellar fat pads2' may be the
only evidence of this disease. Mital and Matza2'
A wide range of treatment philosophy exists,
check for a decreased "sharpness" in the angle
with some belief that no treatment is needed other
formed by the tibial apophysis and the infrapatellar
than for pain relief.3.'4Improvement occurs spontendon. Patella infera, as defined by the Insalltaneously in 1-2 years with or without treatment,
Salvati patellar height-to-patellar tendon ratio,
the only sequela being residual deformity of
was seen in a group of 20 patients with OsgoodLimitation of activity is
the tibial t ~ b e r c l e . ~
Schlatter disease (mean = 1.21
0.15).'6 This
r e c ~ m m e n d e d ~ ~ ~ ' with
~ ~ ~ Willne?'
. ~ ~ , ~ ' . more
~'
position was determined to be significantly lower
specifically restricting running and stairs for 12
(P < 0.05) than a group of 80 normals (mean =
weeks, and walking barefoot before the age of
1.OO k 0.11). Conversely, Jakob et a1.12 reported
15. Attributing the problem to lower extremity

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JOSPT JulylAug 1985

OSGOOD-SCHLATTER DISEASE

malalignment involving marked foot pronation and

genu valgum, he advised decreasing the use of
loafers and sneakers, and prescribed "Oxford
shoes with a firm inner shank and 3116 inch inner
heel wedges." Complete relief of symptoms in 65
of 78 patients is reported in 6 weeks, with the
remainder becoming pain free in 12 weeks.31
Bowers2 recommends use of salicylates and
local ice application, as needed, to control pain.
Conservative treatment to decrease quadriceps
l . ~restriction
~
of motension on the t u b e r c ~ e ~and
tion via immobilization from 6 to 8 weeks22to 3
'
feels
months2' is suggested. ~ i c h e l i , ~however,
that casting is not indicated in the presence of a
tight, weak quadriceps group.
Injection of the tubercle with hydrocortisone15
or with lidocaine HCI combined with hydrocort i ~ o n e , ~de~amethasone,~~
'
triamcino~one,~or
methy~prednisolone,~~
may be employed if restriction of activities and immobilization are not successful. Kelly15utilized up to three hydrocortisone
injections and reported 52 to 72 patients having
relief after one injection. Eight and 9 more were
improved after two and three injections, respectively, while 3 of the 72 did not respond to injection.
Levine and ashy yap'^ advocate use of an infrapatellar strap during activities to decrease the pull
of the quadriceps against the tibial tubercle and
report improvement in 92% of patients treated
(Table 1).
Quadriceps stretching into knee flexion with hip
extension is used to stretch the muscle group and
decrease tension on the apophysis. While Katz14
states that "rarely is the pain severe enough to
require plaster-cast immobilization," 12/~of Mital
and Matza's groupz2underwent surgical removal
of painful ossicles with instantaneous relief of
symptoms.
COMPLICATIONS

Premature closure of the anterior tibial epiphysis resulting in genu recurvatum has been rep ~ r t e d . ' ~ , ~Conflicting
~,~'
reports of patella
alta'2~2',30and patella infera16 exist, while the
causal or effectual relationship with this disease
TABLE 1
Improvement with infrapatellar stap*
Definite improvement
Some improvement
No improvement
From Levine and Kashyap.lg

79.1%
12.5%
8.3%

is not known. Subcutaneous atrophy in 8 of 70

knees injected with methylprednisolone was seen
in addition to striae formation in the skin overlying
the tubercle.26Patellar tendon avulsions are possible sequellae to Osgood-Schlatter disease and
from 14'' to 26%" of those seen with this fracture
reported previous histories of Osgood-Schlatter
disease.
PHYSICAL THERAPY EVALUATION

In assessing the patient's knee pain, location

(unilateral or bilateral) of pain and its duration is
documented. Whether it is painful during brief
physical activity, or following prolonged activity,
indicates severity. Answers to questions regarding presence or absence of pain while walking,
running, ascending and descending stairs, and
kneeling should be documented for later comparison.
Examining the patient's gait pattern while walking, the therapist looks for an antalgic limp or
other compensatory mechanism to protect the
knee from pain. Special attention should be focused on whether or not the individual flexes the
involved knee during loading response or attempts to maintain full extension, thereby reducing the need for quadriceps activity.
Confirmation of the diagnosis is the first task of
the attending therapist. With the patient supine
with both knees flexed to 90, inspection of the
tubercles is performed. By looking from the side,
a silhouette image of one knee against the other
reveals enlargement of the apophysis, if present
(Fig. 2). Palpation of the tubercle is then performed
and tenderness is assessed as none, slight, mild,
moderate, or marked (Table 2).
Due to the prevalence of Osgood-Schlatter disease during the early adolescent years, at a time
when musculoskeletal pain may be secondary to
the inability of muscles to elongate at the same
rate as bony growth, tightness of knee musculature must be checked. With the patient still supine,
hamstring length is assessed by the examiner's
flexing the hip while maintaining the knee in full
extension. Comparison between involved and uninvolved limbs in unilateral problems, or comparison to normal values in the cases of bilateral
involvement, aids the therapist in deciding
whether or not muscular tightness plays a role in
the conditon.
Knee flexion range of motion, taking into account rectus femoris tightness, is performed with
the patient prone (Fig. 3). The knee is passively

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BREWSTER

JOSPT Vol. 7,No. 1

Fig. 4. Hamstring stretching is performed with a 10-sec static

stretch. Note limited flexibility in this patient with posterior
pelvic rotation (tight lumbodorsal fascia), inability to keep knee
straight (tight hamstrings), and outward rotation of foot (tight
hip external rotators).

Fig. 2. Silhouette appearance of knees flexed to 90 reveals

mild enlargement of left tibia1 tubercle.

TABLE 2
Assessment of tenderness on palpation
Slight
Mild
Moderate
Marked

Only complains of pain after questioning

Voluntarily reports pain on palpation
Withdraws knee from examiner's hand;
may indicate pain verbally
Withdraws knee and attempts to grab
examiner's hand

flexed by the examiner until either the end of range

or pain is encountered. If this stretch begins to
hurt, the patient must be questioned as to the
location of the pain, as this will influence treatment. If pain from this prone stretching is felt in
the area of the infrapatellar tendon or tubercle
area, stretching the quadriceps is contraindicated,
as the pain is caused by further pulling away of
the apophysis. If the strain is felt up in the muscle
belly or at the proximal attachment of the muscle,
quadriceps stretching will be performed as part of
the treatment. The results of muscle tightness
tests along with the location of pain with stretching are recorded.
Manual muscle testing of the knee extensors
and flexors can be performed with the patient
sitting on the end of the plinth with presence or
absence of pain noted. Muscle tone is assessed
in the long sitting position as the patient performs
a quadriceps set. Quadriceps atrophy should be
checked in the form of girth measurements.
PHYSICAL THERAPY TREATMENT

Fig. 3. Assessment of passive knee flexion range of motion

including evaluation of rectus femoris tightness.

Of primary concern to the therapist treating

Osgood-Schlatter disease is relief of pain in the
area of the tubercle. lontophoresis is the modality
of choice, and a trial period of not more than three
treatments should be undertaken.'. l o Use of an
anti-inflammatory medication and local anesthetic
helps decrease swelling and pain.
We feel the benefits of iontophoresis are: 1)
Inhibition of pain from the electrical current used;
2) method of administering medication without
injecting the tendon/muscle junction, thus avoiding the possibility of associated tendon damage;

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JOSPT JulylAug 1985

OSGOOD-SCHLATTER DISEASE

Fig. 5. A, Quadriceps stretch position for individuals with

extreme tightne*; B, advanced quadriceps stretch position
which increases rectus femoris stretch across the anterior hip.

are injected into the positive electrode. Treatment

time is for 20 minutes at up to 5.0 ma. Proper
post-treatment application of lotion to both electrode sites minimizes the hazard of skin irritation.
Following three treatments with iontophoresis
performed every other day, tenderness to palpation is reassessed, and the patient's subjective
change in conditions is recorded.
The next phase of treatment addresses tight
.~~
musculature if found on initial e v a l ~ a t i o n Heating with hot packs to the anterior and posterior
thigh is followed by quadriceps and/or hamstring
stretching. Hamstrings are stretched over the side
of a plinth (Fig. 4) with the involved knee in full
extension and the foot pointing upward (neutral
hip rotation). A static stretch of 10 sec is used
with the patient instructed to slide his hands down
his anterior leg until he feels a stretch either in the
posterior thigh or at the hamstrings insertion.
Quadriceps stretching is performed with the
patient lying prone, pulling his foot up toward his
buttocks. Strain should be felt in the muscle belly,
and not at the tenoperiosteal junction. For cases
of extreme tightness, a belt may be needed
around the dorsal foot (Fig. 5A), whereas patients
with less quadricep tightness can be sidelying with
the involved leg up, allowing for a greater rectus
femoris stretch with passive hip extension (Fig.
56).
Strengthening of the involved limb quadriceps
is performed in cases of atrophy secondary to
disuse. Isometric quadricep sets, straight leg
raises, and short arc quadricep exercises are
standard, and are performed only if they are pain
free. Exercise concludes with a 5-minute ice massage to the area of the tubercle.
SUMMARY

Fig. 6. Residual deformity in a 28-year-old male with neither

pain nor functional limitations of the left knee.

3) localization of treatment required for the size

of this particular lesion.
The active pad of the PhoresoP (Motion Control, Salt Lake City, UT) unit is positioned over the
tubercle of the knee which is supported in about
30' of flexion. The sides of the adhesive pad are
then taped down to the skin for better contact
and to prevent leakage. One cc of dexamethasone-sodium-phosphate and 1 cc of lidocaine HCI

The symptoms, diagnosis, and conventional

forms of treatment for Osgood-Schlatter disease
are reviewed. Physical therapy evaluation must
concentrate on assessment of tight musculature
(quadriceps, hamstrings, calf) as a possible cause
of this entity. Treatment concentrates on: I ) decreasing the pain, 2) improving flexibility, and 3)
return to function.
Perhaps the most important part of rehabilitation is education of the adolescent and his parents, with a reassurance that his condition is
temporary and related to the time in his growth
when his epiphyseal plates are the weak link of
his musculoskeletal system. Activities should be
pain limited with instruction in continuation of a

10

ANTICH AND BREWSTER

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home program with ice massage following. Explanation that a prominent tubercle may be present
~ .but that pain with activity
indefinitely ( ~ i 6),
should cease following the teenage years, may
prevent later concerns regarding continued presence of an enlarged tubercle.
The authors would like to thank the other members of the Physical
Therapy Research Committee of the Southwestern Orthopaedic Medical Group, Inc. for their suggestions and review of the manuscript in
its preparation for publication: Matthew C. Morrissey, MS, PT; Celeste
Criswell Randall. MS. PT; and Roxie Westbrwk, PT.
The guidance and assistance of Ms. Elizabeth Stone is gratefully
appreciated.

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JOSPT Vol. 7, No. 1

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