Osgoods Schlatters Disease - Case Study Example

Osgoods Schlatters disease The proper functioning of the human body, just like the functioning of any other machinery, depends upon the balanced work output. When work increases beyond the compensating capacity of the body, the condition expresses itself in the form of some disease. One such example is the Osgoods Schlatters disease (Kridelbaugh et al 1948). Which is a benign condition affecting the knees of physically active adolescents due to the traction of the apophysis of tibial tuberosity due to repeated strain on the secondary ossification center (Willner 1969). This paper will encompass all the aspects of Osgoods Schlatters disease. For better understanding of the condition, the normal anatomy and functioning of the knee region is considered first. Then the introduction to the disease and its course of progression, its signs and symptoms, clinical presentation and diagnostic strategies are presented. Furthermore, a rehabilitation plan for the disease, including monitoring and evaluation processes is proposed at the end of the paper. Osgoods Schlatters disease is included in the category of bone development disorders called "osteochondrosis" (Irowa 1989). Osgood Schlatters disease or syndrome was first described by Paget in 1891. It is named after American surgeon Robert Bayley Osgood and the Swiss surgeon Carl Schlatter, who working individually described the disease in 1903. This disease is a very common cause of knee pain and inflammation in physically active children, especially those who are going through their growth spurts (Fendall 1997). It affects boys between 12-15 years of age and girls from 8-12 years (Journal of pedriatic orthopedics). Girls are affected at a younger age because their skeleton matures at a younger age than boys. It occurs more frequently in boys than in girls, with reports of a male-to-female ratio ranging from 3:1 to as high as 7:1. This difference in the ratio is thought to be because of greater participation by boys in sports and risk activities than by girls. With the increasing participation of girls in sports activities, the difference in ratio seems to be decreasing (Hines 1983). The athletes are at 20 percent higher risk of having this condition than nonathletes. Also, the condition seems to run in a family. If one child is affected, there is a 30 percent increased chance that another will also suffer from it (Hines 1983). Osgood Schlatters disease is usually temporary and resolves with skeletal maturity. Three bones come together at the knee region, that is: Femur (the thigh bone), Tibia (The shinbone) and patella (Bone of the knee/ kneecap). The Quadriceps muscle on the thigh is responsible for the extension of the knee. It is attached to a tuberosity on the anterior surface of tibia, called tibial tuberosity through the patellar tendon. When the quadriceps muscle contracts, it pulls on the patellar tendon, which results in the extension of the knee. The key determinant of the development of Osgoods Schlatters disease is the level of tension in the patellar tendon (PEĆINA et al 1993). The causes of tension in the patellar tendon can be excessive use of the quadriceps muscle, which results in a constant stretch on the tendon (Bowers 1981, PEĆINA et al 1993). It can also result from the growth spurts which explains the association of the disease with the adolescence (Kujala et al 1985) The bones develop from cartilages by the process of ossification. Each bone may have one or more than one center of ossification. The age at which different ossification centers of a bone unite is different for each bone. A secondary center for the upper end of tibia appears just before birth and fuses with the shaft between 16-18 years of age. The upper epiphysis usually includes the tibial tuberosity. The bone achieves its mature form and strength after all its ossification centers have united. Clearly, overuse before this age, either from excessive sports activity or repeated subacute microtraumas, result in the avulsion of immature tibial tuberosity. This expresses itself in the form of a bump, which is pathologically filled with bone or cartilagenous tissue because the two separated growth plates, one of tibia and the other of tibial tuberosity continue to grow separately. This extra tissue is the cause of swelling and the pain of inflammation (Rapp et al 1958). Other causes that may contribute to the development of Ogoods Schlatters disease include abnormal alignment of the legs. Flat footed or knock-kneed children are most prone because of their larger Q-angle (the sharp angle between quadriceps and patellar tendon). High riding patella (patella alta) is also a contributing factor. Other growth plate abnormalities, also predispose a person to Osgood Schlatters diisease. Among young athletes suffering from severs disease (abnormalities in the back of the heel), two thirds also suffer from Osgoods Schlatters disease. Slinding-Larsen-Johansson disorder (problems at the top of patellar tendon) can precipitate in individuals suffering from Osgoods Schlatters (Traverso et al 1990). The signs and symptoms of Osgood Schlatters disease are primarily clinical. The patient complains of constant aching pain and tenderness over the tibial tuberosity, which worsens during any activity that causes strain on the knee region such as climbing the stairs, running, jumping, kneeling or forced flexion. The pain may be associated with some soft-tissue swelling and localized heat and tenderness (Scotti at el 1979). Mobility may or may not be affected (Out P 1991). The patient often experiences pain while straightening the knee. The condition mostly affects one knee, but at times both the knees may be affected. The above mentioned clinical symptoms point straight to the diagnosis of Osgood Schlatters disease. A detailed history of the patient will reveal the level of the patients physical activity and stress on the knee (Price et al 2004). The diagnosis is confirmed radilogically, by an x-ray or by ultrasonography. The x-ray shows a raised area with irregular bone density in the tibial tuberosity, along with some soft tissue swelling anterior to the tuberosity (King 1935). Ultrasound reveals the thickened distal patellar tendon, that is more echogenic than normal and an anechoic zone of swelling anterior to the tuberosity (Journal of pedriatic orthopedics) In severe cases, bony fragments separated from the tuberosity may be seen. The severity of the condition can be assesed in terms of grades, ranging from grade one to grade three, depending upon the duration of pain: GRADE 1: If pain occurs after activity and resolves within 24 hours. GRADE 2: Pain occurs during and after the activity, but does not limit the activity. It also resolves in 24 hours. GRADE 3: Constant pain. Sports and daily activities are limited. The clinical presentation of the patient that is considered here, is that of a seventeen year old footballer, who trains twice a week fror an hour and a half each session and can play upto two games a week. The athlete experiences pain during and after the activity, which means the severity of his Osgood Schlatters condition is that of grade 2. The treatment strategy and rehabilitation plan for Osgoods Schattlers revolves around resting the affected knee and allowing time for recovery (Willner 1969). The rehabilitation plan varies with the grade of the disease. Grade 1 and 2 are mild and moderate respectively, so they donot require any surgical intervention. Often symptomatic treatment and proper rest is all that is needed. Non-steroidal antiinflammatory drugs relieve inflammation. Cortisone injections are not recommended for Osgoods Schlatters condition. Analgesics are prescribed for treating the pain. Ice packs applied to the knee, for twenty minutes several times a day has proved beneficial. The patients should follow what is famous as "The R.I.C.E regime", which stands for: -Resting the affected knee -Icing regularly -Compressing the knee with the bandage -Elevation of the affected knee Grade 3 Osgood Schlatters requires more intense treatment as it is severe and even recurrent in some cases. All activities that strain the knee have to be aborted and the knee has to be immobilized, knee immobilizer can be used in case of patient non-compliance. Pads and braces can also provide support. In rare cases, when the symptoms donot resolve with skeletal maturity, surgical intervention can be an option (Glynn et al 1983, Wray et al 1982). It involves either excising the raised area of tibial tuberosity by an osteotome or the excision of lose pieces of bone and cartilage only, the latter offers more promising results (Journal of pedriatic orthopedics). Acute phase rehabilitation consists of pharmacotherapy, that is antiinflammatory and analgesic drugs to reduce morbidity and prevent complications. The ease of symptoms marks the start of the recovery phase of rehabilitation, in which the exercises to restore flexibilty, strength and muscle balance are started. The last phase is the phase of maintenance. The pain may take 6 to 24 months to resolve completely. Maintenance phase allows the time for complete recovery by slowly bringing the athlete to his normal activity level step by step by performing exercises that challenge his strength and stamina as he recovers. The rehabilitation plan revolves around resting the knee and performing pain-free flexibility and strengthening exercises to speed up the recovery. The rehabilitation plan requires atleast four to eight week rest period, depending upon the severity of the condition (Meisterling et al 1998). Stretching exercises of quadriceps, lower leg and hip help produce flexibility. These exercises include Hamstring stretch, standing calf stretch, quadriceps stretch, straight leg raise, prone hip extension as well as the techniques for knee stabilization. The stretching exercises that require hamstrings and calf muscles can be started right away, Rest of the exercises named above should be started when the acute pain subsides (Yatsuka et al 1992) 1. Hamstring stretch on the wall: Hamstrings are the muscles of the back of the thigh. The patient should lie straight on his back, with the legs stretched in front of him. The hip region lies close to the doorway. The injured leg has to be raised and rested against the wall on the door frame. The position is to be maintained for 30 to 60 seconds, until the patient feels a stretch in the back of the thigh. This stretch should be performed thrice on one leg, then the leg is switched and the steps are repeated with the other leg. 2. Standing Calf Stretch: This exercise relieves the tension in calf muscles. The patient should stand, facing the wall. Place his hands on the wall in front of him. The healthy leg is drawn forward, so that the distance between the two legs becomes 18 to 20 inches. The injured leg has to be kept straight. Slowly lean into the wall, by slightly bending the leg that is in front. The patient will feel a stretch in the calf muscles. The steps have to be repeated thrice with each leg. This exercise should be performed several times a day because of its direct tension relieving effects on the knee. 3. Quadriceps Stretch: The patient should stand an arms length from the wall. The side of his body should be towards the wall. The injured leg should be on the outside. Place the inside hand on the wall for support. With the other hand, hold the ankle of the leg affected by Osgood Schlatters disease and slowly raise it above, until it reaches the hip level. This position should be held for 30 seconds and the steps should be repeated thrice. The patient should take care not to bend the back while performing this exercise. Of all the exercises, the quadriceps strengthening exercises are the safest, easiest and the most important ones that aid in better recovery. 4. Straight Leg Raise: For this leg raise, the patient has to lie on the floor on his back, with both legs straight out in front of him. The healthy leg has to be bent, with the foot lying flat on floor. The affected leg is slowly raised, the toes pointing inwards towards the body, this will straighten up the knee. This exercise tightens the muscles on top of the thigh. Make sure the the leg is just 6 to 8 inches off the floor. The maximum time duration for the straight leg raise is 10 seconds. Repeat this exercise 20 times. 5. Prone Hip Extension: For this exercise, the patient has to lie on his stomach, the back should be kept straight. The hips are sqeezed together and with the help of gluteal muscles and the muscles of the back of the thigh, using the insertions in knee, the injured leg is raised 5 to 8 inches off the floor for 5 seconds. The exercise should be repeated 10 times in 3 sets. To sum it up, Osgood Schlatters condition is more like a benign pathology than a serious disease. It is a self limited process of inflammation of the knee joint and often, all that is required for the recovery is proper rest and patient compliance for the good of his own health. If handled properly and on time, serious pain and discomfort can be avoided. It is always better to slow down, or even stop for a while to aid the recovery, and then move onto the healthy and active life, rather than hastening it up and landing into long term complications. Bibliography: 1. BOWERS KD JR. (1981). Patellar tendon avulsion as a complication of Osgood-Schlatters disease. The American Journal of Sports Medicine. 9. 2. FENDALL, R. S. S. G. (1997). Osgood-Schlatters disease: an osteopathic perspective. Thesis (M. Osteo. Sc.)--Royal Melbourne Institute of Technology, 1997. 3. GLYNN MK, & REGAN BF. (1983). Surgical treatment of Osgood-Schlatters disease. Journal of Pediatric Orthopedics. 3, 216-9. 4. HINES, S. K. E. (1983). Risk factors of Osgood-Schlatters Disease: a case-control study to examine the relationship of trauma, season of the year of onset of symptoms, maturational stage, and rate of gain of lean body mass with incidence of Osgood-Schlatters Disease. Thesis (M.S.)--University of Maryland, 1983. 5. IROWA GO. (1989). 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Clinical Orthopaedics and Related Research. 62. 18. WRAY DG, & MUDDU BN. (1982). Operative treatment for longstanding Osgood-Schlatters disease. Journal of the Royal College of Surgeons of Edinburgh. 27, 200-3. 19. YATSUKA, T., TORISU, T., & TAKAMI, H. (1992). Hamstring Stretching Exercise for Anterior Knee Pain, Osgood-Schlatters Disease and Plica Syndrome. 20. ZRIG, M., ANNABI, H., AMMARI, T., TRABELSI, M., MBAREK, M., & BEN HASSINE, H. (2008). Acute tibial tubercle avulsion fractures in the sporting adolescent. Archives of Orthopaedic and Trauma Surgery. 128, 1437-1442. Read More