What is the likely diagnosis and recommended management for an active adolescent (10‑15 years old) presenting with pain and swelling over the tibial tuberosity that worsens with running, jumping, or kneeling?

Osgood-Schlatter Disease

Diagnosis

Osgood-Schlatter disease is a traction apophysitis of the tibial tuberosity presenting in active adolescents (boys 12-15 years, girls 8-12 years) with pain, swelling, and tenderness over the tibial tuberosity that worsens with running, jumping, or kneeling. 1, 2

Clinical Presentation

• Pain localized to the tibial tuberosity that is exacerbated by activities involving jumping (basketball, volleyball), running, or direct contact such as kneeling 1, 3
• Visible bony prominence and swelling over the tibial tuberosity 3
• Pain with resisted knee extension due to quadriceps contraction pulling on the patellar tendon insertion 1
• Tenderness on palpation of the tibial tubercle 1

Radiographic Findings (if obtained)

• Early stage: Irregularity of the apophysis with blurred margins of patellar tendon due to soft tissue swelling 1, 3
• Later stages: Fragmentation of the tibial tuberosity with separation from the main bone 1, 3
• Chronic stage: Persistent ossicle or fusion with tibial tuberosity 3
• MRI is useful only when diagnosis is uncertain, not routinely needed 4

Risk Factors to Identify

• Quadriceps and hamstring muscle tightness, particularly rectus femoris shortening which alters knee biomechanics 2
• Increased body weight 2
• Muscle weakness during knee extension 2
• High-impact sports participation during growth spurts 2

Management

Conservative treatment successfully resolves symptoms in over 90% of patients and should include activity modification, ice application, stretching exercises, and NSAIDs for short-term pain relief only. 1, 5, 2

Acute Phase Management (First 2-4 Weeks)

• Relative rest from aggravating activities including running, jumping, and kneeling until pain subsides 1, 3
• Ice application through a wet towel for 10-minute periods to reduce pain and inflammation 6
• NSAIDs for short-term pain relief (2-3 days maximum) as prolonged use may delay healing 6
• Activity modification: The patient should limit but not completely eliminate physical activities 3

Rehabilitation Phase (Weeks 2-12)

Stretching exercises are the cornerstone of treatment and prevention:

• Quadriceps stretching to reduce traction forces on the tibial tuberosity 5, 2
• Hamstring stretching to improve flexibility and reduce compensatory quadriceps strain 2
• Progressive strengthening exercises as pain allows 5

Return to Activity Guidelines

• Gradual return to sports when pain-free with daily activities 1
• Avoid high-impact activities (jumping, sprinting) until symptoms completely resolve 1, 3
• Continue stretching exercises even after symptom resolution to prevent recurrence 2
• Expect 3-6 months for complete resolution in most cases 1

Common Pitfalls to Avoid

• Do NOT inject corticosteroids into the tibial tuberosity area, as this inhibits healing and reduces tissue strength 6
• Do NOT use NSAIDs beyond 2-3 days as they may delay bone and soft tissue healing despite providing symptomatic relief 6
• Do NOT allow return to full sports participation while still symptomatic, as this prolongs recovery 1, 3
• Do NOT overlook stretching exercises, which are essential for both treatment and prevention 5, 2

Surgical Indications (Rare)

Surgery is indicated only in skeletally mature patients with persistent pain despite 6+ months of conservative treatment. 1, 3

• Surgical procedure: Excision of the ossicle, surrounding bursa, and bony prominence 3
• Timing: Only after growth plate closure (skeletal maturity) 1, 3
• Indication: Persistent pain with kneeling or activity that does not respond to conservative measures 3

Prognosis

• Self-limiting condition that resolves with closure of the tibial growth plate 1
• Over 90% respond to conservative treatment 1, 2
• Some patients may have residual discomfort with kneeling even after resolution 1
• Bony prominence may persist but is typically asymptomatic 3