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Osgood-Schlatter's disease - Management
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What symptomatic treatment of acute pain is recommended?
- To treat acute pain:
- Offer ibuprofen or paracetamol.
- Advise intermittent application of ice packs over the tibial tuberosity.
- Advise that protective knee pads may be useful to relieve pain on kneeling.
Basis for recommendation
Analgesia, ice packs, and knee pads to manage pain
What advice should I give about exercise to someone with Osgood-Schlatter's disease?
- For people who are able to undertake their usual exercise schedule with only minimal symptoms, advise them to continue taking exercise but to seek advice if symptoms deteriorate.
- For people having difficulty tolerating their usual exercise schedule, recommend exercise modification.
- The amount of exercise modification needed to decrease symptoms to an acceptable level will vary from person to person, depending on symptom severity and response to treatment.
- Modify exercise by any or all of the following:
- Reducing exercise duration, frequency, or intensity.
- Changing the type of exercise to ones that avoid or limit the amount of running and jumping requiring powerful quadriceps contractions.
- As symptoms decrease, gradually increase exercise.
- For people who cannot tolerate a modified exercise program, avoidance of activities that provoke pain may be necessary for a limited period until symptoms decrease.
- Once symptoms have decreased to an acceptable level, advise introducing low-impact quadriceps exercises before gradually increasing the intensity of exercise.
- Options include multiple isometric quadriceps contractions, straight-leg raises, or cross-training with such activities as cycling or swimming.
- If symptoms remain settled, advise gradually increasing the intensity of the exercises and combine them with stretching of the quadriceps and hamstrings.
- If symptoms recur, stop exercises or reduce their intensity. Gradually re-establish exercise or increase exercise intensity on the basis of symptoms.
- Consider referral to a physiotherapist to manage rehabilitation, particularly if recovery is slow.
- Corticosteroid injections are not recommended.
Basis for recommendation
Exercise within tolerable limits for people with Osgood–Schlatter's disease
- Expert opinion supports maintaining exercise, even if it is necessary to modify the frequency, duration or intensity so as to be tolerable, because:
- Continuing exercise provides important general health benefits.
- The risk of serious complications, such as rupture, is very small.
- Exercise helps rehabilitation by maintaining knee stability.
[Antich and Brewster, 1985; Bloom and Mackler, 2004; Brukner et al, 2007; Gholve et al, 2007; Rolf, 2007]
Managing people who cannot tolerate a modified exercise programme
- For people with severe symptoms, expert opinion supports:
- A limited period of rest, to allow symptoms to resolve.
- Gradual reintroduction of exercise guided by symptoms, because this is considered to help maintain knee stability without substantially increasing the risk of serious complications, such as rupture.
- Stretching exercises to reduce or prevent muscular shortening, because muscular shortening is thought to contribute to the development of Osgood–Schlatter's disease in some people.
[Antich and Brewster, 1985; Bloom and Mackler, 2004; Brukner et al, 2007; Gholve et al, 2007; Rolf, 2007]
Corticosteroid injections of the tibial tuberosity are not recommended.
- A case series of 54 people with 70 knees affected by Osgood–Schlatter's disease reported the outcome of treating Osgood–Schlatter's disease by local injection of 40 mg methylprednisolone [Rostron and Calver, 1979].
- A significant degree of subcutaneous atrophy and striae around the tibial tuberosity of eight of the injected knees was noted between 2 and 10 months after the injection.
How should I manage people that do not respond to treatment?
- For people whose condition does not improve or deteriorates despite appropriate management:
- Reassess the cause of knee pain.
- Where there is diagnostic uncertainty, refer for specialist assessment.
Basis for recommendation
Referral for people who do not improve or deteriorate
- With appropriate management, it can reasonably be expected that symptoms of Osgood–Schlatter's disease will improve. Deterioration or failure to improve may indicate another cause of symptoms.
How should I manage adults with persistent symptoms?
- For people with symptoms that persist into adulthood:
- Advise protective knee pads to manage pain on kneeling.
- Refer if symptoms are substantially affecting the individual.
Basis for recommendation
Referral for people with symptoms persisting into adulthood
- People with symptoms persisting into adulthood are likely to have symptoms associated with enlargement of the tibial tuberosity or ossicles.
- The effectiveness of surgical interventions to relieve symptoms is supported by expert opinion [Peirce, 2005; Gholve et al, 2007; Davidson et al, 2008] and limited evidence from a case series of 70 surgical treatments in 67 people with persistent symptoms associated with anatomical abnormalities [Orava et al, 2000]. Symptoms were assessed 2 years after surgery. Results were reported to be excellent in 56 people, moderate in nine people, and unknown or poor in five people.
Prescriptions
For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
Paracetamol
Age from 6 years to 11 years 11 months
Paracetamol s/f susp: 250mg to 500mg up to four times a day
Paracetamol 250mg/5ml oral suspension sugar free
Take one to two 5ml spoonfuls every 4 to 6 hours when required for pain relief. Maximum of 4 doses in 24 hours.
Supply 300 ml.
Age from 12 years onwards
Paracetamol tablets: 500mg to 1g up to four times a day
Paracetamol 500mg tablets
Take one or two tablets every 4 to 6 hours when required for pain relief. Maximum of 8 tablets in 24 hours.
Supply 50 tablets.
Ibuprofen
Age from 6 years to 6 years 11 months
Ibuprofen s/f susp: 150mg up to three times a day
Ibuprofen 100mg/5ml oral suspension sugar free
Take 7.5ml three times a day when required for pain relief. Do not exceed the stated dose.
Supply 150 ml.
Age from 7 years to 9 years 11 months
Ibuprofen s/f susp: 200mg up to three times a day
Ibuprofen 100mg/5ml oral suspension sugar free
Take two 5ml spoonfuls three times a day when required for pain relief. Do not exceed the stated dose.
Supply 200 ml.
Age from 10 years to 11 years 11 months
Ibuprofen s/f susp: 300mg up to three times a day
Ibuprofen 100mg/5ml oral suspension sugar free
Take three 5ml spoonfuls three times a day when required for pain relief. Do not exceed the stated dose.
Supply 300 ml.
Age from 12 to 18 years
Ibuprofen tablets: 200mg to 400mg three to four times a day
Ibuprofen 200mg tablets
Take one or two tablets 3 to 4 times a day when required for pain relief. Do not exceed the stated dose.
Supply 56 tablets.
Age from 18 years onwards
Ibuprofen tablets: 400mg three times a day
Ibuprofen 400mg tablets
Take one tablet three times a day when required for pain relief. Do not exceed the stated dose.
Supply 21 tablets.
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