Original Research

Activity Modification and Knee Strengthening

for Osgood-Schlatter Disease
A Prospective Cohort Study
Michael S. Rathleff,*†‡§ PhD, Lukasz Winiarski,§ MSc, Kasper Krommes,‡k MSc,
Thomas Graven-Nielsen,{ PhD, Per Hölmich,k DrMed, Jens Lykkegard Olesen,‡# PhD,
Sinéad Holden,†‡ PhD, and Kristian Thorborg,k PhD
Investigation performed at Aalborg University Hospital, Aalborg, Denmark, and the Department of
Orthopaedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark

Background: Osgood-Schlatter disease (OSD) affects 1 in 10 adolescents. There is a lack of evidence-based interventions, and
passive approaches (eg, rest and avoidance of painful activities) are often prescribed.
Purpose: To investigate an intervention consisting of education on activity modification and knee-strengthening exercises
designed for adolescents with OSD.
Study Design: Case series; Level of evidence, 4.
Methods: This study included 51 adolescents (51% female; age range, 10-14 years) with OSD. The 12-week intervention consisted
of an activity ladder designed to manage patellar tendon loading and pain, knee-strengthening exercises, and a gradual return to
sport. The primary outcome was the global reporting of change at 12 weeks, evaluated with a 7-point Likert scale (successful
outcome was considered “much improved” or “improved”). Additional endpoints were at 4, 8, 26, and 52 weeks. Secondary
outcomes included the Knee injury and Osteoarthritis Outcome Score (KOOS), objective strength, and jump performance.
Results: Adolescents reported a mean pain duration of 21 months at enrollment. After 12 weeks, 80% reported a successful
outcome, which increased to 90% at 12 months. At 12 weeks, 16% returned to playing sport, which increased to 69% at 12
months. The KOOS subscores of Pain, Activities of Daily Living, Sport and Recreation, and Quality of Life improved significantly (7-
20 points), and there were improvements in knee extension strength (32%; P < .001), hip abduction strength (24%; P < .001), and
jumping for distance (14%; P < .001) and height (19%; P < .001) at 12 weeks.
Conclusion: An intervention consisting of activity modification, pain monitoring, progressive strengthening, and a return-to-sport
paradigm was associated with improved self-reported outcomes, hip and knee muscle strength, and jumping performance. This
approach may offer an alternative to passive approaches such as rest or wait-and-see, often prescribed for adolescents with OSD.
Registration: NCT02799394 (ClinicalTrials.gov identifier)
Keywords: Pediatrics; musculoskeletal; pain; apophysitis

Osgood-Schlatter disease (OSD) is growth-related apophy- OSD is commonly reported to resolve within 12 to 18
sitis of the knee, affecting 1 in 10 athletic adolescents.4 months, despite the lack of data supporting this.6 Recent
While the source of pain in OSD is unclear, adolescents evidence challenges this assumption, 7 and even after
with OSD often report pain localized to the tibial tuberos- “recovery,” adolescents demonstrate negative ultrasound
ity, which is aggravated during knee-loading activities.3,6 findings and impaired function.9 Overall, 60% of those diag-
Clinically, OSD is characterized by localized pain and nosed with OSD at an orthopaedic department within a 6-
swelling at the tibial tuberosity and pain during palpation year period reported OSD-related pain at a median of 4
of the tibial tuberosity.6 Its prevalence is highest in active years’ follow-up. This continued pain was associated with
adolescents,4 with early sport specialization associated impairments in both knee function and quality of life.7 The
with a 4-fold greater relative risk of developing OSD.8 large deficits in strength and function18 appear to persist
after the resolution of symptoms.12,19 Perhaps because of
The Orthopaedic Journal of Sports Medicine, 8(4), 2325967120911106
the previously assumed innocuous nature of the condition,
DOI: 10.1177/2325967120911106 there is a dearth of research evaluating interventions
ª The Author(s) 2020 to reduce symptoms, improve function, and speed up

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1
2 Rathleff et al The Orthopaedic Journal of Sports Medicine

recovery.2 Intervention studies are confined to a random- TABLE 1

ized controlled trial investigating injections and a retro- Inclusion and Exclusion Criteria
spective cohort investigating surgical management.2,21 No
trials or cohort studies have evaluated other management Inclusion criteria
 Pain localized at the tibial tuberosity that increased with
strategies.2 A high degree of sport participation and repeti-
palpation
tive overuse are considered critical in the development of
 Pain on resisted isometric knee extension
OSD,8 and these indications can provide key treatment tar- Exclusion criteria
gets that have never been investigated. The aim of this study  Knee effusion
was to investigate the effect of an intervention consisting of  Patellar instability
education on activity modification and knee-strengthening  Sinding-Larsen-Johansson syndrome
exercises designed for adolescents with OSD.  Concomitant injury or pain in the hip, lumbar spine, or other
structures of the knee (ie, tendinopathy, previous knee
surgery, or patellofemoral pain)
METHODS

Study Design period, participants were instructed to refrain from pain-

aggravating activities and sport participation. In addition,
This prospective cohort study was pre-registered on participants were instructed to perform knee exercises in
clinicaltrials.gov (NCT02799394) and approved by the the form of static holds and bridges to avoid the loss of
ethics committee of the North Denmark Region (N-2014- muscle strength. This was supported by a load-based activ-
0100). Parental informed consent and participant assent ity ladder and pain monitoring (Appendix 1).
were acquired from all participants. Reporting complies During the second block (weeks 5-12), adolescents were
with the Strengthening the Reporting of Observational instructed to (1) perform a progressive home-based knee-
Studies in Epidemiology (STROBE) statement.5 strengthening program and (2) follow the activity ladder and
progression model for return to sport. Knee strengthening
Recruitment consisted of 3 exercise progression levels (with increasing
levels of difficulty). This also guided adolescents’ progression
Participants were recruited between 2015 and 2017 via on the activity ladder; that is, adolescents had to be able to
local schools and social media. All adolescents with knee perform the squat (progression level 2) within the “OK zone”
pain who responded to a questionnaire distributed to before progressing to step 3 on the activity ladder (Appendix
schools or to posts on social media were telephoned and 1). During each of the visits, the focus was on helping ado-
subsequently invited for a clinical examination. This pro- lescents and their parents understand and manage training
cess was used to recruit participants for this trial (adoles-
loads and pain. The activity ladder and pain monitoring
cents with OSD) and another study on adolescents with
model enabled participants to progress exercises and activ-
patellofemoral pain (NCT0240267314). The clinical exami-
ities between visits (the full intervention, including sets and
nation was conducted by 1 of 2 experienced physical thera-
repetitions for the exercises, can be seen in Appendix 1).
pists (K.K. or L.W.) and did not include radiographs as
A training diary was used to measure adherence to the
inclusion or exclusion criteria. The criteria used to diagnose
strength exercises. Participants who did not return the
OSD were in line with previous literature6,20 (Table 1).
diary were assumed not to have completed any exercises.
Adherence to activity modification was determined by Acti-
Intervention Graph monitors.
The intervention included 4 visits with a physical therapist
over a 12-week period. Parents were required to take part Baseline Demographics
in all 4 visits. The intervention was structured into 2 blocks
(Table 2). Initial load management (weeks 0-4) consisted of Weight was measured by a weighing scale (Seca). Height
a temporary reduction in sport participation. During this was measured with a measuring tape while participants

*Address correspondence to Michael S. Rathleff, PhD, Center for General Practice at Aalborg University, Department of Clinical Medicine, Aalborg
University, Fyrkildevej 7, 1st floor, 9220 Aalborg East, Denmark (email: [email protected]) (Twitter: @michaelrathleff).
†
Center for Sensory-Motor Interaction, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark.
‡
Center for General Practice at Aalborg University, Aalborg, Denmark.
§
Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Aalborg, Denmark.
k
Sports Orthopedic Research Center–Copenhagen, Department of Orthopaedic Surgery, Copenhagen University Hospital, Amager-Hvidovre, Denmark.
{
Center for Neuroplasticity and Pain, Center for Sensory-Motor Interaction, Department of Health Science and Technology, Faculty of Medicine, Aalborg
University, Aalborg, Denmark.
#
Institute of Sports Medicine, Bispebjerg Hospital, Copenhagen, Denmark.
Final revision submitted December 19, 2019; accepted December 23, 2019.
One or more of the authors has declared the following potential conflict of interest or source of funding: This work was supported by the Danish Council for
Independent Research (DFF-4004-00247B) and the TRYG Foundation (grant ID: 118547). Center for Neuroplasticity and Pain is supported by the Danish National
Research Foundation (DNRF121). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Ethical approval for this study was obtained from the Scientific Ethical Committee of the North Denmark Region (N-2014-0100).
The Orthopaedic Journal of Sports Medicine Activity Modification for Osgood-Schlatter Disease 3

TABLE 2
Building Blocks of the Interventiona

Block 1 (0-4 wk) Block 2 (5-12 wk)

Educational components  Factors contributing to OSD  Importance of adherence

 Risk of OSD  Proper exercise form
 Loading and sport  Monitoring and progressing
 Rationale for treatment
 Increase/decrease of physical activity based
on symptom response
Modalities to gradually increase  Activity modification  Knee exercises (progressing from isometric
knee joint loads  Double-leg bridge holds to lunges)
 Static holds of quadriceps muscle for 10 
30 seconds (daily)
Specific tools introduced  Activity ladder  Activity ladder
 Pain monitoring  Pain monitoring
 Graded return to sport after step 8 has been
reached on activity ladder
a
OSD, Osgood-Schlatter disease.

stood with their back straight against a wall in their bare that measures acceleration, which is filtered and processed
feet. Pain duration was determined by asking the following: to obtain activity counts. These counts are proprietary mea-
“For how long have you experienced your knee pain?” Par- sures used to classify time spent in activities, with different
ticipants reported current and previous sport participation intensities such as sedentary, moderate, and vigorous phys-
(before knee pain) and if they had reduced/stopped sport ical activity according to predefined count thresholds. The
because of pain. ActiGraph GT3Xþ was initialized using ActiLife software
(version 5.0; ActiGraph) and set to record at 30 Hz. Parti-
cipants were instructed to wear the ActiGraph on their
Outcomes wrist for a minimum of 1 week (1) at the time of inclusion,
Self-reported questionnaires were completed by partici- (2) during block 1 of activity modification, and (3) at the
pants at baseline (before the intervention was started) and 12-week follow-up. Data were analyzed using ActiLife
after 4, 8, 12, 26, and 52 weeks. Ultimately, 12 weeks was software to extract time spent in sedentary, light, and mod-
considered our primary endpoint. If needed, parents helped erate to vigorous physical activity. For further information
participants answer the questions. Before the assessment, on data analysis, see Appendix 2.
all questions were piloted in the same age group to ensure Lower Limb Strength. Isometric knee extension and hip
comprehensibility. The primary outcome was self-reported abduction strength were assessed at baseline and 4- and 12-
improvement on a 7-point Likert scale ranging from “much week follow-up. Muscle strength was assessed using a Com-
improved” to “much worse,” with the midpoint being “no mander PowerTrack handheld dynamometer (JTECH
change.” Participants were deemed to have a successful Medical) fixed with a belt to the examination couch. All
outcome if they reported “improved” or “much improved.” strength tests were conducted isometrically and can be
This has previously been used in other studies on adoles- seen in Appendix 1. The average of 3 consecutive measure-
cents with knee pain.17 ments, normalized to body weight and lever length, was
In addition to improvement, the self-reported question- used for analysis. The procedure is identical to previous
naire included the Knee injury and Osteoarthritis Outcome work in adolescents, and it has demonstrated high
Score (KOOS),19 highest degree of pain during the past reliability.13
week measured by a numeric rating scale (ranging from Lower Limb Jumping Performance. Lower extremity
0 to 10, with 0 being “no pain” and 10 being “worst pain jumping performance was used to assess lower limb func-
imaginable”), if they considered themselves to be com- tion at baseline and 4- and 12-week follow-up. This was
pletely free of knee pain at each follow-up, and sports par- done with single-leg vertical and horizontal jumps. To
ticipation (times per week). These questions have measure single-leg vertical jumps, participants first
previously been used in adolescents with knee pain, marked their highest standing reach: While standing with
enabling comparisons.13,17 Health-related quality of life chalk on their fingertips, participants reached as high as
was measured by the youth version of the EuroQol–5 they could and made a mark on a blackboard. Participants
Dimensions with 3 levels (hereafter referred to as EQ-5D- then performed a single-leg maximal vertical jump (their
Y).1 most painful knee) and marked the highest point, landing
Physical Activity. Objective physical activity was mea- on the same leg. Participants had their other hand free and
sured with an ActiGraph GT3Xþ.18 This is a commercially were given a minimum of 1 practice attempt or until they
available 3-axis accelerometer that has been validated for were proficient with the movement. Participants then per-
collecting physical activity data.11 It is a wearable device formed 3 maximal-effort jumps, with the best trial used for
4 Rathleff et al The Orthopaedic Journal of Sports Medicine

Assessed for eligibility between 2015 and 2017 (n=487)

Excluded during phone/email screening (n=142)

Most common reasons were:
•Could not be reached on email or phone (n=98)
•Pain in other locations, not likely to be OSD or PFP (n=29)
•Currently being treated for PFP or OSD (n=4)
•Outside age criteria (n=4)
•Other (n=7)

Invited for clinical examination (n=336)

Clinical examination

Most common reasons for exclusion during examination (n=285)

•Suffered from PFP (n=151)
•Did not want to participate in main study, which included activity
modification (n=25)
•Other knee conditions than OSD (n=72)
•Other (n=34)

Included for analysis

•N=51 with Osgood-Schlatter
Inclusion

Figure 1. Flowchart for recruitment of participants. The participants were recruited in parallel for both a study on Osgood-Schlatter
disease (OSD) and patellofemoral pain (PFP).

analysis. Jump height was calculated as the vertical dis- To maximize data availability for the ActiGraph, a gen-
tance between jump reach and standing reach. The eral linear mixed model was used. This enabled the inclu-
single-leg horizontal jump for distance (broad jump) was sion of ActiGraph data from 47 participants over the 3 time
measured as the distance from the tip of the shoe at the points. The model accounted for the within-participant
start position and the heel at the landing position. Each nature by including random effects for participants, with
trial was conducted with a 30-second pause between, and a variance component covariance structure and restricted
pain during testing was recorded. Changes over time are maximum likelihood estimation. The best-fitting covari-
expressed as percentages from baseline for each ance structure for the residuals was a compound symmetry
participant. structure evaluated with the –2 restricted log likelihood
(1234.99) and Akaike information criterion (1238.99). Time
(baseline, 4 weeks, and 12 weeks) was included as a fixed
Sample Size repeated-measures factor, with moderate to vigorous phys-
This was a pilot study with no previous data available on ical activity as the dependent variable. Repeated-measures
which to base the sample size. The sample size was there- analysis of variance (ANOVA) was used to evaluate
fore based on the following rationales: (1) a sample large changes in strength over time (baseline, 4 weeks, and 12
enough to explore outcomes and perform sample size calcu- weeks) for the dependent variables of knee extension tor-
lations for future clinical trials and (2) the ability to capture que and hip abduction torque. Similarly, repeated-
the heterogeneity of the sample in terms of sex and sport measures ANOVA was used to evaluate the effect of time
participation. (baseline and 4, 8, 12, 26, and 52 weeks) on the KOOS and
EQ-5D-Y. In cases where the assumption of sphericity was
violated, the Greenhouse-Geisser correction was used.
Statistical Analysis
All data were visually inspected for approximate normality RESULTS
using a Q-Q plot. The mean ± SD is reported when data
were normally distributed. Nonnormally distributed data Participants
are presented as the median and interquartile range. All
calculations were performed using Stata (version 11; Over the 5-month recruitment period, 51 adolescents with
StataCorp). OSD were enrolled in the study (Figure 1). At enrollment,
The Orthopaedic Journal of Sports Medicine Activity Modification for Osgood-Schlatter Disease 5

TABLE 3
Baseline Demographics (N ¼ 51)a

Value

Age, y 12.7 ± 1.1

Female sex, % 51
Weight, kg 55.8 ± 10.1
Height, cm 165.5 ± 8.4
BMI, median (IQR), kg/m2 20.2 (17.6-22.0)
Previously treated for knee pain, % 35
Difficulty with kneeling, %b 58
Use of pain medication for knee pain, % 12
Physical activity, min, mean (95% CI)c
Sedentary 344.2 (330.3-358.1)
Average light 333.8 (315.7-351.9)
Average moderate 115.5 (106.4-124.6)
Average vigorous 133.1 (117.5-148.7)
Moderate to vigorous 248.7 (225.1-272.2) Figure 2. Proportion reporting a successful outcome (success
Reached WHO minimum physical activity 92
defined as reporting “much improved” or “improved” on the
recommendations per day, %
global rating of change scale). Error bars indicate 95% CIs.
a
Values are reported as mean ± SD unless otherwise indicated.
BMI, body mass index; IQR, interquartile range; KOOS, Knee
injury and Osteoarthritis Outcome Score; WHO, World Health
Organization.
b
Based on participants reporting “moderate” or “severe” diffi-
culties on question 5 of the KOOS Sport and Recreation subscale.
c
Based on available ActiGraph data from 47 adolescents with
Osgood-Schlatter disease; there were missing data from 4 partici-
pants at baseline.

adolescents reported a mean pain duration of 21 ± 12.5

months. There were 18 participants who reported that they
had previously received treatment for their OSD, most com-
monly by a physical therapist (17/18). Baseline demograph-
ics are included in Table 3. Response rates were 88% at the
primary endpoint, 80% at 12-month follow-up, and 96% at
4-week follow-up.

Primary Outcome

At the primary endpoint (12 weeks), 80% reported a suc-

cessful outcome (improved or much improved), which
increased to 90% at 12 months (Figure 2).

Self-Reported Knee Pain, Disability,

and Quality of Life

Highest degree of pain during the past week decreased from

a median score of 7 of 10 at baseline to 2 of 10 at 12 weeks (P
< .001) (Figure 3). The KOOS Pain subscore improved 14
points during the first 12 weeks, reaching a mean of 91
points after 12 months (P < .001) (Figure 3). A total of 27
of 45 considered themselves free from knee pain at 12
weeks, which was similar at 12 months (24/43). Partici- Figure 3. Self-reported outcomes from baseline to 12
pants improved 7 to 20 points on the KOOS subscales of months: Knee injury and Osteoarthritis Outcome Score
Activities of Daily Living, Sport and Recreation, and Qual- (KOOS), health-related quality of life (QoL) as measured by
ity of Life from baseline to the primary endpoint (P < .001) the youth version of the EuroQol–5 Dimensions (EQ-5D-Y),
(Figure 3). This was a 9- to 34-point improvement at 12- and highest degree of pain during the past week (numeric
month follow-up (P < .001). Moreover, 38.7% reported rating scale [NRS]). ADL, Activities of Daily Living.
6 Rathleff et al The Orthopaedic Journal of Sports Medicine

TABLE 4
Sport Participation

After Intervention
Before
Intervention 4 wk 8 wk 12 wk 26 wk 52 wk

Participation in sport the previous month, number of positive responses/ 51/51 7/49 4/44 7/43 28/42 27/39
total responses
Current sport participation (training þ competition per week), 4 (3-5) 1 (1-3) 1.5 (1.0-2.5) 1.5 (1.0-2.5) 2 (1-3) 3 (2-4)
median (interquartile range), h/wk

TABLE 5
Compliance With Knee Exercisesa

Days to Exercise Sessions Exercise Sessions

Completion in Total per Week Notes

Block 1 4 wk for all 18 (13-25) 4.5 (3.3-6.3) 13 did not report performing any of the exercises in block 1
Exercise 33.5 (17-53) 15 (8-24) 3.4 (2.9-3.8) 11 did not report performing any of the exercises in
progression 1 progression 1
Exercise 25 (11-34) 11 (5-15) 3.5 (3.1-3.9) 22 did not report performing any of the exercises in
progression 2 progression 2
Exercise 19 (15-27) 9.5 (7-12) 3.4 (3.2-3.6) Only 12/51 reached progression 3 (as documented by their
progression 3 training diary)
a
Values are reported as median (interquartile range). Based on data from 38 training diaries.

moderate or severe difficulty in kneeling at 4 weeks (based significant increases in single-leg horizontal jumps (14%;
on responses to question 5 of the KOOS Sport and Recreation P < .001) and vertical jumps (19%; P < .001).
subscale), which improved to 9.5% at 12-month follow-up.
The EQ-5D-Y index score increased significantly (F3,105 ¼ Use of Medication and Additional Treatments
13.6; P < .001) by 0.13 points at 12 weeks and by 0.23 points
at 12 months (Figure 3). Significant changes from baseline No participants reported using painkillers at the 12-week
are presented in Figure 3 for the KOOS and EQ-5D-Y. follow-up, compared with 12% at baseline (P < .001). There
were 2 participants who reported receiving additional
Physical Activity and Sport Participation treatments between baseline and 12-week follow-up. Addi-
tional treatments, types of treatments, and use of painkil-
At 12 weeks, 16% returned to playing sport, which lers across all time points can be found in Appendix 3.
increased to 67% at 6 months and 69% at 12 months
(Table 4). Satisfaction With Treatment

Physical Activity and Compliance With Exercises At the 12-week follow-up, 71% (32/45) were “very satisfied”
with the results of treatment. None were “very unsatisfied.”
The general linear mixed model showed a significant effect Overall, 43 of 45 (96%) would recommend the intervention
of time (F2,72 ¼ 6.7; P ¼ .002). On average, participants to a friend with the same type of knee pain. Furthermore,
decreased moderate to vigorous physical activity by 15 min- 29% said that they would be “very satisfied” to live with
utes per day (95% CI, –33 to 3; P > .05) during activity their current knee symptoms, while 31% said that they
modification (corresponding to 1 hour 45 minutes per week) would be “very unsatisfied.”
and by 37 minutes per day (95% CI, 27 to 38; P < .001) at 12- At 12-month follow-up, 67% were “very satisfied” with
week follow-up (ie, >4 hours per week). Participants per- the results of treatment. Overall, 43% would be “very
formed the majority of the exercises as prescribed, with a satisfied” to live with the current level of symptoms, while
mean exercise frequency of 3.4 to 4.5 sessions per week 2 (5%) would be “very unsatisfied.” When asked, 38 of 42
(Table 5). (90%) would recommend the intervention to a friend with
similar knee pain.
Hip and Knee Muscle Strength
and Jumping Performance
DISCUSSION
At the 12-week follow-up, there were significant improve-
ments in knee extension strength (32%; P < .001) and hip This is the first study to use an active management strategy
abduction strength (24%; P < .001). Similarly, there were focusing on adolescents’ specific deficits and preferences for
The Orthopaedic Journal of Sports Medicine Activity Modification for Osgood-Schlatter Disease 7

returning to sport. There were high rates of self-reported healthy controls in this age group,13,18 indicating a sus-
successful outcomes (80% at 12 weeks and 90% after 12 tained long-term impact of OSD on quality of life during
months), and knee extension strength reached values sim- adolescence. The management of OSD may therefore need
ilar to those in adolescents without knee pain.18 However, to continue for an extended period of time, and perhaps
only 16% returned to sport after 12 weeks, which increased more focus should be on longer term outcomes. As approx-
to 67% after 6 months. Only 18 of 45 considered themselves imately one-third did not return to sport within 1 year, and
completely free from knee pain at 12 weeks, which was the KOOS Sport and Recreation subscore was 80 points at
similar at 12 months (19/43). This highlights that despite 12 months, focus is needed to further optimize the manage-
the majority of adolescents reporting that they were ment of this long-standing and sport-disabling condition. It
improved, one-third still experienced knee pain and contin- seems relevant to investigate who is at highest risk of a
ued to be impeded in their sport participation. This is poor prognosis and what features categorize these patients.
underscored by the fact that at 12-month follow-up, less Previous research on adolescents with patellofemoral pain
than 50% (43%) responded that they would be satisfied to has shown that characteristics of their pain experience
live with current symptoms. Due to the long symptom dura- (intensity, duration, and frequency of pain), together with
tion at baseline (nearly 2 years), it may be prudent to con- quality of life, were associated with a 2-year prognosis.16
sider this a long-standing condition, which may in some Whether these prognostic factors are also valid for adoles-
cases need ongoing management. However, this study indi- cents with OSD is unclear.
cates that the addition of targeted strength training can Adolescents with OSD have shown approximately 30%
offset some of the previously documented long-term nega- lower isometric knee extension strength compared to their
tive impacts that this condition can have on strength and pain-free peers,18 and deficits may persist after the resolu-
function.9 tion of symptoms.9 Therefore, progressive strengthening
was included in the current study to help offset the sus-
Targeting Sport Participation and Physical Activity tained impact into adulthood that has previously been
documented.20 The exercises were intended to increase
This study targeted sport participation, which is thought to muscle strength and stimulate tissue adaptation around
be associated with the development of OSD.8 The interven- the knee. The exercise levels were guided by the patient’s
tion was delivered to adolescents and their parents to take symptoms and progressed to prepare participants for
into account the unique social and developmental consid- return to sport-specific activities. The intervention
erations of adolescents. It was thought that engaging par- increased strength to the same level as adolescents without
ents may help optimize adherence to the intervention.15 knee pain.18 Theoretically, this should help prepare adoles-
Participants reduced their moderate to vigorous physical cents for the physical demands associated with sport.
activity by 15 minutes per day after 4 weeks and 37 minutes Improvements in jump for height and distance suggest
per day at 12 weeks. This could indicate that it takes time returning to sport-specific activities. Treatments such as
before they learn how to modify physical activity levels and stretching, rest, and other passive modalities that are
how it might help them. Only 16% returned to playing recommended6 neglect this. The strength training compo-
sports at 3 months. This is likely because participants were nent of this intervention may therefore help to ameliorate
required to reach progression 3 of the exercises before these previously documented long-term deficits.
returning to sport. Based on the training diaries, only 12
participants had reached progression 3 by week 12, which Comparison With Previous Studies
should be taken into consideration in future research.
After 12 months, 69% returned to playing sport, although The only randomized trial21 compared an injection of local
with lower weekly participation than before inclusion. This anaesthetic with dextrose with either usual care or local
is in contrast to common expectations from a narrative anaesthetic alone. The dextrose group was also advised to
review that OSD will disappear within 12 to 18 months,6 reduce sport participation. That study found that the dex-
but it fits well with clinical experience. This may indicate trose injection was associated with higher rates of asymp-
that OSD is not as short-lived as described in the literature tomatic sport participation (3/22 in usual care group vs 14/
(which is supported by the number of participants who 21 in dextrose group). Because of the combined injection
were unsatisfied with living with current symptoms and and recommendations on sport participation, it is impossi-
the duration of symptoms at baseline). While the interven- ble to disentangle the effective component of the interven-
tion was designed to help adolescents progressively tion group. The lack of demographic data makes a
increase in exercises and activities before returning to comparison with the current population difficult.
sport, the paradigm may have impeded return to sport The longer term outcomes observed in the current study
because of the requirements that we imposed on them. are in line with those of Kujala et al.10 In that retrospective
Importantly, the contradiction of adolescents reporting study at a sports medicine clinic in Finland,10 patients diag-
to be much improved while being unable to fully participate nosed with OSD were prescribed 2 months of rest as the
in sport requires further research to disentangle and initial treatment. On average, they had 3.2 months of com-
underlines the need for adolescent-specific patient- plete rest from sport because of knee symptoms, and 70%
reported outcome measures. While the EQ-5D-Y index were forced to limit activities for 10.2 months, on average.
score improved over 12 months, the mean score of 0.82 Kujala et al highlighted the potential long-standing nature
points at 12-month follow-up is still lower than that of of OSD and indicated that rest may not be adequate for all
8 Rathleff et al The Orthopaedic Journal of Sports Medicine

adolescents suffering from OSD. Overall, 50% of their sam- 4. de Lucena GL, Santos Gomes dos C, Guerra RO. Prevalence and
ple continued to experience mild tenderness at the tibial associated factors of Osgood-Schlatter syndrome in a population-
based sample of Brazilian adolescents. Am J Sports Med. 2011;
tuberosity even after complete ossification, and 15 of 50
39(2):415-420.
reported pain at the patellar tendon or at the inferior pole 5. Elm von E, Altman DG, Egger M, et al. The Strengthening the Report-
of the patella.10 ing of Observational Studies in Epidemiology (STROBE) statement:
guidelines for reporting observational studies. J Clin Epidemiol.
Limitations 2008;61(4):344-349.
6. Gholve PA, Scher DM, Khakharia S, Widmann RF, Green DW. Osgood
This was a noncontrolled study, and specific treatment effects Schlatter syndrome. Curr Opin Pediatr. 2007;19(1):44-50.
7. Guldhammer C, Rathleff MS, Jensen HP, Holden S. Long-term prog-
cannot be disentangled from the natural course of the condi-
nosis and impact of Osgood Schlatter 4 years after diagnosis: a retro-
tion. However, the long-term duration of pain complaints at spective study. Orthop J Sports Med. 2019;7(10):2325967119878136.
baseline indicates that a quick natural resolution of symp- 8. Hall R, Barber Foss K, Hewett TE, Myer GD. Sport specialization’s
toms is unlikely. Adolescents were diagnosed with OSD at association with an increased risk of developing anterior knee pain in
study commencement. It is unclear if adolescents with con- adolescent female athletes. J Sport Rehabil. 2015;24(1):31-35.
tinued reports of knee pain at 12-month follow-up still had 9. Kaya DO, Toprak U, Baltaci G, Yosmaoglu B, Ozer H. Long-term
OSD-related knee pain only or if they reported additional functional and sonographic outcomes in Osgood-Schlatter disease.
Knee Surg Sports Traumatol Arthrosc. 2013;21(5):1131-1139.
pain complaints (as in 15/50 patients from Kujala et al10).
10. Kujala UM, Kvist M, Heinonen O. Osgood-Schlatter’s disease in ado-
Because of the lack of adolescent-specific patient-reported lescent athletes: retrospective study of incidence and duration. Am J
outcome measures for knee pain, we used outcomes that we Sports Med. 1985;13(4):236-241.
believed were meaningful to this population and enabled 11. Migueles JH, Cadenas-Sanchez C, Ekelund U, et al. Accelerometer
external comparisons. We included 2 functional tests: jump data collection and processing criteria to assess physical activity and
for height and jump for distance. The reliability of these 2 other outcomes: a systematic review and practical considerations.
tests is not known for this population. Knee kinematics was Sports Med. 2017;47(9):1821-1845.
12. Pihlajamäki HK, Mattila VM, Parviainen M, Kiuru MJ, Visuri TI. Long-
not measured, and it is unclear how knee kinematics might
term outcome after surgical treatment of unresolved Osgood-
have changed during the course of the intervention. Schlatter disease in young men. J Bone Joint Surg Am. 2009;
91(10):2350-2358.
13. Rathleff CR, Baird WN, Olesen JL, Roos EM, Rasmussen S, Rathleff
CONCLUSION MS. Hip and knee strength is not affected in 12-16 year old adoles-
cents with patellofemoral pain: a cross-sectional population-based
This study implemented an intervention of activity modifi- study. PLoS One. 2013;8(11):e79153.
cation, pain monitoring, progressive strengthening, and a 14. Rathleff MS, Graven-Nielsen T, Hölmich P, et al. Activity modification
return-to-sport paradigm in 51 adolescents with OSD. The and load management of adolescents with patellofemoral pain: a pro-
subjective and objective measures of knee function and spective intervention study including 151 adolescents. Am J Sports
sporting activity improved over 12 months, and 69% of ado- Med. 2019;47(7):1629-1637.
15. Rathleff MS, Rathleff CR, Holden S, Thorborg K, Olesen JL. Exercise
lescents returned to playing sport after 12 months. This
therapy, patient education, and patellar taping in the treatment of
may offer an alternative to passive approaches, which adolescents with patellofemoral pain: a prospective pilot study with
include rest and avoidance of painful activities, but future 6 months follow-up. Pilot Feasibility Stud. 2018;4:73.
studies should aim to improve the management of adoles- 16. Rathleff MS, Rathleff CR, Olesen JL, Rasmussen S, Roos EM. Is knee
cents with OSD and their return to sport and quality of life. pain during adolescence a self-limiting condition? Prognosis of patel-
lofemoral pain and other types of knee pain. Am J Sports Med. 2016;
44(5):1165-1171.
SUPPLEMENTAL MATERIAL 17. Rathleff MS, Roos EM, Olesen JL, Rasmussen S. Exercise during
school hours when added to patient education improves outcome for
Appendix 1 is available at http://journals.sagepub.com/doi/ 2 years in adolescent patellofemoral pain: a cluster randomised trial.
Br J Sports Med. 2015;49(6):406-412.
suppl/10.1177/2325967120911106.
18. Rathleff MS, Winiarski L, Krommes K, et al. Pain, sports participation,
and physical function in 10-14 year olds with patellofemoral pain and
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The Orthopaedic Journal of Sports Medicine Activity Modification for Osgood-Schlatter Disease 9

APPENDIX 1 APPENDIX 3
Patient Education Leaflet Used During the Study Use of Painkillers and Additional Treatmentsa
(English Translation)
No. of Participants
See the Supplemental Material published separately online.
4 wk (n ¼ 48)
Physical therapy 2
APPENDIX 2 Treatment (type not specified) 2
Pain medication 3
Analysis of ActiGraph Data
8 wk (n ¼ 44)
The ActiGraph is a commercial 3-axis accelerometer, Physical therapy 1
validated for collecting physical activity.2 Participants Treatment (type not specified) 3
wore the ActiGraph on the wrist of their nondominant Pain medication 1
arm, and data were analyzed using ActiLife. Raw data 12 wk (n ¼ 43)
were converted into files with a 10-second epoch length Treatment (type not specified) 2
for subsequent validation of wear time and classification Pain medication 0
26 wk (n ¼ 42)
of intensity. Nonwear time was defined as bouts of
Physical therapy 3
60 minutes of consecutive zero counts, allowing
Treatment (type not specified) 3
interruptions of up to 2 consecutive nonzero counts Pain medication 0
(100 counts/min). Adolescents were told to record the 52 wk (n ¼ 41)
type of activity missed by the ActiGraph during non- Physical therapy 2
wear. A valid day was defined as 600 valid wear-time Body Self Development System 1
minutes per 24 hours, and 4 valid days was the minimum Craniosacral therapy 1
requirement for analysis. The Evenson et al1 cut points Pain medication 0
were used for categorizing sedentary (0-100 counts/min), a
Sample sizes refer to the number of participants who
light (101-2295 counts/min), moderate (2296-4011 counts/
responded at each time point.
min), and vigorous (4012 counts/min) physical activity, as
per previous research in children and adolescents.2 The
time spent in consecutive sedentary bouts of 10 minutes
was used to calculate the average weekly sedentary time.
In addition, variables were computed to indicate whether
participants met the World Health Organization’s weekly
physical activity recommendations (ie, >150 minutes of
moderate to vigorous physical activity or >75 minutes of
vigorous activity).

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other outcomes: a systematic review and practical considerations.
Sports Med. 2017;47(9):1821-1845.