Osgood Schlatter's Disease

 

Introduction

Osgood Schlatter's Disease (OSD) is very common in young adolescents, affecting millions of young people a year,  and represents damage to the tendon to cartilage connection on the bony prominence just below the knee cap. If it does not respond quickly to sports limitation, it often leads to substantial alteration of sports ability/participation for a year or more, affecting career development, athlete confidence and self-esteem development and peer relationships for the young athlete. It also causes chronic pain and sports limitations even in adulthood in a substantial number of athletes as well as an obvious deformity.  The OSD study that Dr. Reeves designed and published in conjunction with primary author Gaston Topol in Argentina was directed toward investigating the potential to cure OSD early, to decrease the above consequences.

(For patients: Biomechanics Magazine in the April 2006 issue carried an article explaining Osgood Schlatter Disease and the study in more detail. The article is available in PDF format here.)

 

The Study

On October 3, 2011, the Journal of Pediatrics published results of our clinical trial.

A PDF of the complete study is included here and is able to be shared without copyright concerns with appropriate acknowledgments.

 

A week later a summary was published on Medscape Orthopedics.  Here are those comments:

October 3, 2011 — In athletes with intractable Osgood-Schlatter disease (OSD), dextrose injected over the apophysis and patellar tendon origin appears to be safe and well tolerated and resulted in more rapid and more frequent achievement of unaltered sport compared with usual care, according to new research.

Gastón Andrés Topol, MD, from the Department of Physical Medicine and Rehabilitation at the Hospital Provincial de Rosario in Argentina and colleagues reported their findings online October 3 in Pediatrics.

According to the researchers, OSD is typically described as "a traction apophysitis of the tibial tubercle because of repetitive strain on the secondary ossification center of the tibial tuberosity." Dextrose solution has been found to be safe and effective in areas of damaged ligament, tendon, and cartilage in adults. However, there have been no previous reports specifically in a pediatric population. "The hypothesis was that dextrose injection would be superior to either lidocaine injection or supervised usual care," Dr. Topol and colleagues write.

The study included girls aged 9 to 15 years and boys aged 10 to 17 years with OSD. Investigators treated 65 knees in 54 participants. The study included patients who had anterior knee pain at the tibial tuberosity during a single leg squat. They also must have had pain with a jumping or kicking sport for at least 3 months, after attempting at least 2 months of formal and gently progressive hamstring stretching, quads strengthening, and gradual sport reintroduction.

Patients were randomly assigned to receive 3 months of therapist-supervised usual care or a once-monthly injection of 1% lidocaine solution with or without 12.5% dextrose. Those in the usual-care group met with a physical therapist initially to go over specific stretching and exercises, and then at least once more to confirm proper exercise performance.

At 3 months, "unaltered sport," defined as a score less than 4 on the Nirschl Pain Phase Scale, was more common in both dextrose-treated (21 of 21 vs 13 of 22; P = .001) and lidocaine-treated (20 of 22 vs 13 of 22; P = .034) knees compared with usual care.

By contrast, "asymptomatic sport," defined as a Nirschl Pain Phase Scale score of 0, was more common in knees treated with dextrose compared with the lidocaine-treated knees (14 of 21 vs 5 of 22; P = .006) or those receiving usual care (14 of 21 vs 3 of 22; P < .001) knees.

After 1 year, "asymptomatic sport" continued to be more common in dextrose-treated knees than in knees treated with only lidocaine (32 of 38 vs 6 of 13; P = .024) or usual care only (32 of 38 vs 2 of 14; P < .0001).

"These results suggest that both the duration of sports limitation and the duration of sports-related symptoms may be reducible by dextrose injection in those with recalcitrant OSD," Dr. Topol and colleagues conclude.

The authors note that the current study represents the first study in an exclusively pediatric population and the first in which a tendon attachment on an apophysis was injected.

According to the researchers, elevation of extracellular glucose may promote the production of growth factors that may help damaged tendons. In addition, the authors note that dextrose elevations or a related reduction in insulin levels may downregulate the activity of pain-producing neuropeptides.

The study was not commercially funded. The authors have disclosed no relevant financial relationships.

Pediatrics. Published online October 3, 2011.

 

ABSTRACT:

Topol GA, Podesta LA, Reeves KD, Raya MF, Fullerton BD, Yeh H. Hyperosmolar Dextrose Injection for Recalcitrant Osgood-Schlatter. J Pediatrics.  Originally published online October 3, 2011; DOI: 10.1542/peds 2010-1931

Objective: To examine the potential of dextrose injection versus lidocaine injection versus supervised usual care to reduce sport
alteration and sport-related symptoms in adolescent athletes with Osgood-Schlatter disease.

Patients and Methods: Girls aged 9 to 15 and boys aged 10 to 17 were randomly assigned to either therapist-supervised usual care or double-blind injection of 1% lidocaine solution with or without 12.5% dextrose. Injections were administered monthly for 3 months. All subjects were then offered dextrose injections monthly as needed. Unaltered sport (Nirschl Pain Phase Scale < 4) and asymptomatic sport (Nirschl Pain Phase Scale = 0) were the threshold goals.

Results: Sixty-five knees in 54 athletes were treated. Compared with usual care at 3 months, unaltered sport was more common in both dextrose-treated (21 of 21 vs 13 of 22; P = .001) and lidocaine-treated (20 of 22 vs 13 of 22; P = .034) knees, and asymptomatic sport was more frequent in dextrose-treated knees than either lidocaine-treated (14 of 21 vs 5 of 22; P = .006) or usual-care–treated (14 of 21 vs 3 of 22; P < .001) knees. At 1 year, asymptomatic sport was more common in dextrose-treated knees than knees treated with only lidocaine (32 of 38 vs 6 of 13; P = .024) or only usual care (32 of 38 vs 2 of 14; P < .0001).

Conclusions: Our results suggest superior symptom-reduction efficacy of injection therapy over usual care in the treatment of Osgood-Schlatter disease in adolescents. A significant component of the effect seems to be associated with the dextrose component of a dextrose/lidocaine solution. Dextrose injection over the apophysis and patellar tendon origin was safe and well tolerated and resulted in more rapid and frequent achievement of unaltered sport and asymptomatic sport than usual care.

 

For those with questions about the study, please email Dr. Reeves at DeanReevesMD@gmail.com.