Osgood-Schlatter's Disease management protocols and related health options for adolescents

Pain, General | June 12, 2014 | Author: The Super Pharmacist

knee, Pain

Osgood-Schlatter's Disease management protocols and related health options for adolescents

Osgood-Schlatter's Disease is a condition that causes pain in the knee, just below the kneecap. Osgood-Schlatter's is caused by inflammation at the point where the patellar tendon connects to the tibia (the larger, lower leg bone). Osgood-Schlatter's is a condition that almost exclusively affects children between 9 and 14 years old and is usually self-limited. Self-limited, in this case, means that symptoms usually resolve once the child stops growing. Unfortunately, the period between onset and resolution of Osgood-Schlatter's can be quite painful for the child. Thus, management during this period is aimed at reducing symptoms and controlling discomfort. Unfortunately, there is no consensus about the best method to manage this condition.

Pain control

Since the pain of Osgood-Schlatter's disease results from an inflammation of tendon, bone, and cartilage, the most conservative approach to pain control is to apply ice to the affected area. Once symptoms arise, ice should be applied to the affected knee or knees for 20 to 30 minutes at least twice a day.1 In fact, Osgood-Schlatter's is treated like an athletic, patellofemoral injury in children. The acronym for acute treatment of these injuries is RICE:

  • R: Rest
  • I: Ice
  • C: Compression
  • E: Elevation

Note that the “rest” in this management algorithm is only temporary (see below).

Nonsteroidal anti-inflammatory drugs

Nonsteroidal anti-inflammatory drugs or NSAIDs can also be helpful at reducing knee pain. Dosages should be calculated based on the child's age and size. It is important not to exceed recommended dosages of these medications. Children who require near maximal dosages on a regular basis may need to look for other pain management options to reduce the risk of adverse drug reactions associated with NSAIDs. Ibuprofen, naproxen, and paracetamol are considered safe to use in children and adolescents. Parents should avoid giving aspirin to children due to the theoretical risk of Reye’s syndrome. While Reye’s syndrome is an exceedingly rare complication of aspirin use in children who do not have fever, other NSAIDs offer better pain relief than aspirin and are better choices for Osgood-Schlatter's disease.

Should my child stop playing sports?

shutterstock_121427749No. It is not helpful for children with Osgood-Schlatter's disease to stop participating in sports completely. In fact, cessation of sports can lead to deconditioning of the muscles and tendons, so that when the child resumes exercise there is a greater risk for injury or exacerbation of the pain.2 Children should be allowed to “play through the pain” if they can tolerate doing so and if the pain does not last for longer than 24 hours.2 Knee braces, orthotics, or other means to immobilise the leg should not be used. These devices are shown to weaken and decondition the structures surrounding the joint and can actually increase the risk of pain and damage. If the pain does persist for more than a day, some form of activity modification should be considered. For example, longer periods of rest may be needed between periods of activity. It may also be helpful to consider the type of activity being performed. It is often the case that activities that require bending at the knee can exacerbate Osgood-Schlatter's symptoms. Thus, it may be possible to change positions in the sporting team to avoid/minimise symptoms.

Elite athletes

Children who participate in the elite or highly competitive sports may be able to schedule adequate rest periods between practices and competitions. 9 out of 10 adolescent athletes with Osgood-Schlatter's are able to manage their symptoms with a combination of ice, NSAIDs, and slight adjustments to their activities.1

Physical therapy

Certain physical therapy interventions and conditioning exercises may reduce the risk of symptom recurrence.2 Quadriceps strength is associated with good, long-term outcomes in people who have pain in the patellofemoral region.3 These exercises may be performed when the child is not experiencing acute pain in the knees.

Quadriceps strengthening exercises

Quadriceps strengthening without weights Have the child sit in a chair in which the knee is fully supported by the seat of the chair. Without lifting the knee, have the child straighten the leg and hold for 6 seconds. Repeat this 10 times. This exercise should be done in the morning and at night.

Quadriceps strengthening with weights The child can do the same exercise as above but with added resistance. If exercise equipment is available, the child can use light weights. If equipment is not available, small Velcro-affixed weights can be placed around the ankles or the use of resistance bands to provide additional resistance can be used.

Cycling Riding a bicycle or an exercise bike is actually a reasonably good way to strengthen the quadriceps muscles. This and other types of exercise that reduces weight bearing on the knee can be excellent alternatives to maintain or develop the child’s athletic endurance.

Deep knee bends Deep knee bends or squats are more advanced quadriceps-strengthening exercises. These exercises should only be done when the child has been pain-free for at least two weeks and has already performed quadriceps-strengthening exercises without weights.

Quadriceps and hamstring flexibility exercises

Quadriceps While standing, have the child grab the front of his ankle and pull his heel behind his back. The upper leg should point straight down (the knee should face the ground) This stretch should be done for 15 seconds and the leg should be allowed to relax between stretches. The stretch can be repeated two more times.

shutterstock_84252976Hamstrings Straight leg raises will stretch the hamstrings; however, a partner is usually required to get a good hamstring stretch from this position. Have the child lie on his back and lift one leg. A partner or parent can then gently raise the foot towards the head, keeping the leg straight. The partner should move slowly and continuously feel for resistance in the muscle. The muscle should be stretched, but not strained. The child should feel the pull of the muscle being stretched, but the stretch should not be painful. Hold the stretch for 15 seconds (do not pulse; hold constant pressure) and then allow the muscle to relax. The stretch can be repeated two more times.

Surgery

Surgery is considered a last resort in Osgood-Schlatter's disease. It is reserved for children who do not outgrow the pain by the age of 14 (approximately). Surgery is usually performed after the growth plate in the tibia has fused (the bone has stopped growing). Surgery for Osgood-Schlatter's disease includes removing the ossicle (bony outgrowth) that tends to form under the patellar tendon in Osgood-Schlatter's disease. This orthopedic surgery provides favorable results in select patients.4,5,6,7

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REFERENCES:

  1. Bloom OJ, Mackler L, Barbee J. Clinical inquiries. What is the best treatment for Osgood-Schlatter disease? J Fam Pract. Feb 2004;53(2):153-156.
  2. Wall EJ. Osgood-schlatter disease: practical treatment for a self-limiting condition. Phys Sportsmed. Mar 1998;26(3):29-34. doi:10.3810/psm.1998.03.802
  3. Natri A, Kannus P, Jarvinen M. Which factors predict the long-term outcome in chronic patellofemoral pain syndrome? A 7-yr prospective follow-up study. Med Sci Sports Exerc. Nov 1998;30(11):1572-1577.
  4. Binazzi R, Felli L, Vaccari V, Borelli P. Surgical treatment of unresolved Osgood-Schlatter lesion. Clin Orthop Relat Res. Apr 1993(289):202-204.
  5. Flowers MJ, Bhadreshwar DR. Tibial tuberosity excision for symptomatic Osgood-Schlatter disease. J Pediatr Orthop. May-Jun 1995;15(3):292-297.
  6. Orava S, Malinen L, Karpakka J, et al. Results of surgical treatment of unresolved Osgood-Schlatter lesion. Ann Chir Gynaecol. 2000;89(4):298-302.
  7. Pihlajamaki HK, Mattila VM, Parviainen M, Kiuru MJ, Visuri TI. Long-term outcome after surgical treatment of unresolved Osgood-Schlatter disease in young men. J Bone Joint Surg Am. Oct 2009;91(10):2350-2358. doi:10.2106/jbjs.h.01796
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