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A 13-year-old male patient presents with complaints of bilateral knee pain. He notes that the pain is increased with jumping, squatting or running up a flight of stairs. No other joints are affected. On physical exam, he has tenderness to palpation directly over his tibial tubercles. No effusion is noted. Radiographs are shown in Figures A and B. What is the most likely diagnosis?
Stress fractures of the tibial plateau
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Based on the history and clinical findings, the most likely diagnosis is Osgood-Schlatter disease.
Osgood-Schlatter disease is a traction apophysitis of the tibial tubercle that commonly affects males between the ages of 12-15. Bilateral involvement is found in 20-30% of patients. The condition responds well to conservative measures, including anti-inflammatories, resting, strapping of the tibial tubercle and quadriceps stretching. Ninety-percent of patients will have complete recovery with these measures.
Frank et al. review lower extremity injuries that can affect young athletes. Osgood-Schlatter disease develops as the knee is repetitively flexed and extended. Males are more often affected and complain of swelling, pain and tibial tubercle tenderness. Management involves activity modification, quadriceps stretching and strengthening. Symptoms are predominantly self-limited.
Ghlove et al. review the epidemiology, pathophysiology and management of Osgood-Schlatter disease. They note that the condition commonly affects growing children who are involved with jumping type activities. The majority of patients respond well to nonoperative management.
Figures A and B are AP and lateral radiographs of a knee affected by Osgood-Schlatter disease. On the lateral view, fragmentation of the tibial tubercle can be appreciated. Illustration A is a schematic of the pathoanatomy of this condition.
Answer 1: While Lyme disease can affect the knee, it is likely to produce an isolated knee effusion. Patients often have difficulty with weight bearing or with range of motion.
Answers 2, 4, 5: While these choices could cause knee pain, they are much less likely given the history and radiographic findings.
Frank JB, Jarit GJ, Bravman JT, Rosen JE.
J Am Acad Orthop Surg. 2007 Jun;15(6):356-66. PMID: 17548885 (Link to Abstract)
Gholve PA, Scher DM, Khakharia S, Widmann RF, Green DW.
Curr Opin Pediatr. 2007 Feb;19(1):44-50. PMID: 17224661 (Link to Abstract)
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HPI - A 33 year old male patient presents with a 4 year history of pain over the tibial tubercle of his right knee.
The patient works in construction as a general laborer and states that his pain has become much worse over the past few weeks.
What further imaging, if any, would you order on this patient?