Updated: 11/18/2018

Osgood-Schlatter Disease

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Snapshot
  • A 15-year-old boy presents to his pediatrician with left knee pain. He denies any trauma to the knee. He plays football for his high school team and attends practice regularly. On physical exam, the tibial tubercle is pronounced and there is tenderness to palpation over the affected area. The patient reports pain upon resisted knee extension.
Introduction
  • Clinical definition
    • describes an apophysitis of the tibial tuberosity
  • Epidemiology
    • demographics
      • male:female ratio
        • more common in males
      • age bracket
        • 12-15 years of age in boys
        • 8-12 years of age in girls
    • risk factors
      • participating in sports
  • Pathogenesis
    • repetitive traction of the apophysis of the tibial tuberosity results in microtrauma and micro-avulsion
      • the proximal patellar tendon insertion separates from the tibial tubercle
        • during healing there is callous deposition that leads to a pronounced tubercle
  • Prognosis
    • self-limiting
    • responds well to conservative management
Presentation
  • Symptoms
    • anterior knee pain
  • Physical exam
    • inspection
      • enlarged tibial tubercle
      • tenderness over tibial tubercle 
    • provocative test
      • pain on resisted knee extension
Imaging
  • Radiographs
    • recommended views
      • lateral radiograph of the knee
    • findings
      • irregularity and fragmentation of the tibial tubercle  
Studies
  • Diagnostic criteria
    • a clinical diagnosis
Differential
  • Sinding-Larsen-Johansson syndrome
    • chronic apophysitis or minor avulsion injury of the inferior patellar pole
  • Osteochondroma of the proximal tibia
  • Tibial tubercle fracture 
  • Patellar tendonitis 
    • also an overuse injury (jumping, running)
    • chronic, episodic anterior knee pain
    • worsened with stairs or prolonged sitting
    • localized tenderness along the patellar tendon, at the inferior pole of the patella
Treatment
  • Conservative
    • analgesics, ice, and physical therapy
      • indication
        • first-line treatment for Osgood-Schlatter disease
  • Operative
    • ossicle resection and/or excision of the tibial tuberosity
      • indication
        • considered in patients who do not respond to conservative managament and after skeletal maturity
Complications
  • Tubial tubericle prominence persists
  • Genu recurvatum
 

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Questions (3)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.OR.4679) A 13-year-old is brought into your office by his father because of left knee pain. The father states that the patient has no medical conditions and that his birth history is normal. He is an avid basketball player and recently started playing for his school's basketball team. On exam, his vitals are within normal limits. There is no erythema or effusion in any of the knee compartments, and the patient has a full range of motion. The patient has full strength on flexion and extension, but does have pain on the tibial tubercle with palpation and resistance to knee extension. A lateral view of his left knee is shown in the radiograph in Figure A. What is the most likely cause of his knee pain? Review Topic | Tested Concept

QID: 107284
FIGURES:
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Tibial tubercle apophysitis

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Patellar tendonitis

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Patellofemoral arthritis

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4

Patellar stress fracture

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5

Tibial stress fracture

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M2 C

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