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  • Osteochondrosis or traction apophysitis of tibial tubercle
  • Epidemiology
    • demographics
      • male:female ratio
        • more common in boys
      • age bracket
        • boys 12-15y
        • girls 8-12y
    • location
      • bilateral in 20-30%
    • risk factors
      • jumpers (basketball, volleyball)  or sprinters
  • Pathophysiology
    • stress from extensor mechanism
  • Prognosis  
    • self-limiting but does not resolve until growth has halted
  • Tibial tubercle is a secondary ossification center  
    • age <11y, tubercle is cartilaginous
    • age 11-14y, apophysis forms
    • age 14-18y, apophysis fuses with tibial epiphysis
    • age >18y, epiphysis (and apophysis) is fused to rest of tibia
  • Symptoms 
    • pain on anterior aspect of knee
    • exacerbated by kneeling
  • Physical exam
    • inspection
      • enlarged tibial tubercle
      • tenderness over tibial tubercle
    • provocative test
      • pain on resisted knee extension
  • Radiographs
    • recommended views
      • lateral radiograph of the knee
    • findings
      • irregularity and fragmentation of the tibial tubercle  
  • MRI
    • indications
      • not essential for diagnosis
      • diagnosis can be made based on history, presence of tender swelling and radiographs alone
    • findings  
      • soft tissue swelling
      • thickening and edema of inferior patellar tendon
      • fragmentation and irregularity of ossification center
  • Sinding-Larsen-Johansson syndrome    
    • chronic apophysitis or minor avulsion injury of inferior patella pole  
    • occurs in 10-14yr old children, especially children with cerebral palsy
  • Osteochondroma of the proximal tibia  
  • Tibial tubercle fracture  
  • Jumpers knee  
  • Nonoperative
    • NSAIDS, rest, ice, activity modification, strapping/sleeves to decrease tension on the apophysitis and quadriceps stretching
      • indications
        • first line of treatment
      • outcomes
        • 90% of patients have complete resolution
    • cast immobilization x 6 weeks
      • indications
        • severe symptoms not responding to simple conservative management above
  • Operative
    • ossicle excision
      • indications 
        • refractory cases (10% of patients) 
        • in skeletally mature patients with persistent symptoms
  • Complications of cast immobilization
    • quadriceps wasting

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Questions (1)

(OBQ13.21) 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? Review Topic


Lyme disease




Stress fractures of the tibial plateau




Osgood-Schlatter disease




Patellar tendinopathy




Sinding-Larsen-Johansson syndrome



Select Answer to see Preferred Response


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.

Incorrect Answers:
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.


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