What is the management for a 20-year-old with Osgood-Schlatter disease?

Management of Osgood-Schlatter Disease in a 20-Year-Old

For a 20-year-old with persistent Osgood-Schlatter disease, conservative management has likely failed given skeletal maturity, and surgical excision of the ossicle with tibial tuberosity reduction osteotomy should be pursued, as 91% of adults achieve complete pain resolution with this approach. 1

Understanding the Clinical Context

At age 20, skeletal maturity has been reached, and Osgood-Schlatter disease (OSD) should have resolved spontaneously in most cases. 2 When symptoms persist into adulthood despite conservative treatment, this represents unresolved OSD requiring a different management approach than the typical adolescent presentation. 3, 1

Initial Assessment in Adults

• Confirm the diagnosis by identifying pain localized to the tibial tuberosity, exacerbated by jumping, stair climbing, or kneeling 2
• Obtain radiographs to identify superficial ossicles in the patellar tendon and assess for a prominent tibial tubercle "beak" that causes patellar ligament impingement (present in 71% of surgical cases) 1
• Document functional limitations, particularly with kneeling, forceful knee use, and athletic activities 3, 1

Conservative Management Trial

While most adult cases reaching medical attention have already failed conservative measures, if not yet attempted:

• Apply the "small amounts often" principle when returning to activities, linking exercises to daily activities to ensure compliance 4
• Functional therapy with stretching of the hamstring musculature is preferable to immobilization, as it results in shorter healing duration despite potentially increased ossicle formation 5
• Avoid immobilization, which doubles the duration of complaints and causes muscular atrophy 5

Surgical Indications and Approach

Surgery is indicated when conservative treatment fails and symptoms persist with functional impairment. 3, 1, 2

Surgical Technique

• Use an anterolateral incision over the patellar tendon rather than direct anterior approach to decrease postoperative pain with kneeling 1
• Reflect the patellar tendon medially and remove the ossicle from the posterior surface of the tendon 1
• Perform tibial tuberosity reduction osteotomy in cases with prominent tubercle (needed in 85% of surgical cases) to address the "beak" causing patellar ligament impingement 1
• Consider arthroscopic technique over open procedure for early postoperative recovery, no anterior incisional scar causing kneeling discomfort, better cosmetic results, and ability to address concomitant intra-articular pathology 2

Expected Outcomes

• 91% of patients achieve complete resolution of preoperative pain with surgical treatment 1
• Complete ossification of the tibial tuberosity with fusion to the tibial metaphysis occurs, followed by return of normal leg function 3

Alternative Treatments for Refractory Cases

Autologous-conditioned plasma (platelet-rich plasma) therapy may be considered for treatment-resistant OSD before proceeding to surgery, though evidence is limited to case reports. 6

Common Pitfalls to Avoid

• Do not rely on prolonged conservative management in adults with persistent symptoms, as 26 out of 142 patients (18%) in one series required surgical treatment despite initial conservative attempts 3
• Do not ignore patients who return years later with protruding tibial tubercle, persistent swelling, and soreness with kneeling—these represent failed conservative management requiring surgical intervention 3
• Do not use direct anterior incisions as they cause significant postoperative pain with kneeling 1
• Do not overlook the tibial tubercle "beak" on imaging, as this impingement lesion is present in 71% of surgical cases and requires osteotomy for optimal outcomes 1