Clinical Diagnosis and Management of Osgood-Schlatter Disease
The most appropriate next step is to obtain X-rays of the right knee. This 15-year-old basketball player presents with classic Osgood-Schlatter disease (traction apophysitis of the tibial tuberosity), but radiographs are necessary to confirm the diagnosis, rule out more serious pathology such as tibial tuberosity avulsion fracture, and establish a baseline before initiating conservative treatment 1, 2.
Why Radiographs Are Indicated
Radiographs should be obtained because this patient has focal bony tenderness over the tibial tuberosity, which meets Ottawa knee rule criteria for imaging 1, 2. While the clinical presentation strongly suggests Osgood-Schlatter disease, several critical conditions must be excluded:
- Tibial tuberosity avulsion fracture can present identically to Osgood-Schlatter disease in adolescent athletes, particularly basketball players who perform repetitive jumping activities, and requires surgical fixation rather than conservative management 3
- Osteochondritis dissecans or other bone lesions may present with similar symptoms and require different management strategies 4
- The ACR Appropriateness Criteria explicitly state that radiographs are usually appropriate as the initial imaging study for patients ≥5 years with focal tenderness 4
Recommended Radiographic Views
Order a minimum of two views 1, 2:
- Anteroposterior (AP) view of the knee
- Lateral view with knee at 25-30 degrees flexion to best visualize the tibial tuberosity and any apophyseal irregularity or fragmentation 4, 1
The lateral view is particularly important as it will show characteristic findings of Osgood-Schlatter disease including irregularity of the apophysis with separation from the tibial tuberosity in early stages and fragmentation in later stages 5.
What to Expect on Radiographs
If Osgood-Schlatter disease is confirmed, radiographic changes typically include 5, 6:
- Irregularity of the tibial tubercle apophysis
- Separation of the apophysis from the tibial tuberosity
- Superficial ossicles in the patellar tendon
- Fragmentation in more advanced cases
Management After Radiographic Confirmation
Once radiographs confirm Osgood-Schlatter disease and exclude fracture, approximately 90% of patients respond well to nonoperative treatment 5. This includes:
- Activity modification with reduction (not complete cessation) of jumping activities like basketball 5, 6
- Ice application after activities, particularly ice massage to the tibial tuberosity 7, 8
- NSAIDs for symptomatic pain relief 5, 6
- Quadriceps and hamstring stretching exercises, as muscular tightness is a causative factor 7, 8
- Reassurance that this is a self-limiting condition that typically resolves with skeletal maturity (closure of the tibial growth plate) in 12-24 months 5, 6, 7
Critical Pitfalls to Avoid
Do not skip radiographs and immediately prescribe NSAIDs, even though the clinical presentation is classic for Osgood-Schlatter disease 1, 2. Missing a tibial tuberosity avulsion fracture would result in inappropriate conservative management of a condition requiring surgical fixation 3.
Do not obtain hip radiographs as the first imaging study—the focal tenderness is clearly localized to the tibial tuberosity, not referred from the hip 4, 1.
Do not perform arthrocentesis—there is no joint effusion on examination, and the pathology is extra-articular (at the tibial tuberosity apophysis), not intra-articular 9.
Physician judgment should supersede clinical guidelines when appropriate, but in this case the guidelines clearly support obtaining radiographs first 4.