DOI: 10.1542/peds.2010-1931; originally published online October 3, 2011; 2011;128;e1121Pediatrics

Francisco Raya, Bradley Dean Fullerton and Hung-wen YehGastón Andrés Topol, Leandro Ariel Podesta, Kenneth Dean Reeves, Marcelo

Hyperosmolar Dextrose Injection for Recalcitrant Osgood-Schlatter Disease  

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of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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Hyperosmolar Dextrose Injection for RecalcitrantOsgood-Schlatter Disease

WHAT’S KNOWN ON THIS SUBJECT: Osgood-Schlatter diseasesymptoms may wax and wane until maturity and affect sportconfidence and participation periodically. Chronic sequelae mayinclude anterior knee pain, kneeling discomfort, or sports limitation.Symptom reduction parallels resolution of patellar tendinopathy byMRI/ultrasound, although ossicles may persist radiographically.

WHAT THIS STUDY ADDS: Small-needle injection of the patellartendon enthesis/tibial apophysis with 12.5% dextrose was safeand well tolerated in adolescents with recalcitrant Osgood-Schlatter disease. Dextrose injection resulted in more rapid andfrequent achievement of unaltered sport and asymptomatic sportthan did usual care.

abstractOBJECTIVE: To examine the potential of dextrose injection versus lido-caine injection versus supervised usual care to reduce sport alterationand sport-related symptoms in adolescent athletes with Osgood-Schlatter disease.

PATIENTS AND METHODS: Girls aged 9 to 15 and boys aged 10 to 17were randomly assigned to either therapist-supervised usual care ordouble-blind injection of 1% lidocaine solution with or without 12.5%dextrose. Injections were administered monthly for 3 months. All sub-jects were then offered dextrose injections monthly as needed. Unal-tered sport (Nirschl Pain Phase Scale � 4) and asymptomatic sport(Nirschl Pain Phase Scale� 0) were the threshold goals.

RESULTS: Sixty-five knees in 54 athletes were treated. Compared withusual care at 3 months, unaltered sport was more common in bothdextrose-treated (21 of 21 vs 13 of 22; P� .001) and lidocaine-treated(20 of 22 vs 13 of 22; P � .034) knees, and asymptomatic sport wasmore frequent in dextrose-treated knees than either lidocaine-treated(14 of 21 vs 5 of 22; P� .006) or usual-care–treated (14 of 21 vs 3 of 22;P� .001) knees. At 1 year, asymptomatic sport was more common indextrose-treated knees than knees treated with only lidocaine (32 of 38vs 6 of 13; P� .024) or only usual care (32 of 38 vs 2 of 14; P� .0001).

CONCLUSIONS: Our results suggest superior symptom-reduction effi-cacy of injection therapy over usual care in the treatment of Osgood-Schlatter disease in adolescents. A significant component of the effectseems to be associated with the dextrose component of a dextrose/lidocaine solution. Dextrose injection over the apophysis and patellartendon origin was safe and well tolerated and resulted in more rapidand frequent achievement of unaltered sport and asymptomatic sportthan usual care. Pediatrics 2011;128:e1121–e1128

AUTHORS: Gastón Andrés Topol, MD,a Leandro ArielPodesta, MD,b Kenneth Dean Reeves, MD,c MarceloFrancisco Raya, PT,d Bradley Dean Fullerton, MD,e andHung-wen Yeh, PhDf

Departments of aPhysical Medicine and Rehabilitation andbOrthopedics, Hospital Provincial de Rosario, Rosario, Argentina;cDepartment of Physical Medicine and Rehabilitation, Universityof Kansas Medical Center, Kansas City, Kansas; dDepartment ofPhysical Therapy, Instituto Universitario del Gran Rosario,Rosario, Argentina; eDepartment of Physical Medicine andRehabilitation, Dell Children’s Medical Center, Austin, Texas; andfDepartment of Biostatistics, University of Kansas MedicalCenter, Kansas City, Kansas

KEY WORDSOsgood-Schlatter, tendinosis, apophysitis, enthesopathy,dextrose

ABBREVIATIONSOSD—Osgood-Schlatter diseaseNPPS—Nirschl Pain Phase Scale

This trial has been registered at www.clinicaltrials.gov (identi-fier NCT01300754).

www.pediatrics.org/cgi/doi/10.1542/peds.2010-1931

doi:10.1542/peds.2010-1931

Accepted for publication Jul 11, 2011

Address correspondence to Kenneth Dean Reeves, MD. E-mail:deanreevesmd@gmail.com

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2011 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

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Osgood-Schlatter disease (OSD) is tra-ditionally described as “a tractionapophysitis of the tibial tubercle be-cause of repetitive strain on the sec-ondary ossification center of the tibialtuberosity.”1 Advances in sequentialradiographic examination have helpedto partially clarify pathology. Sequen-tial knee ultrasound imaging of tennisathletes going through puberty hasdemonstrated that ossicles (sepa-rated cartilage that ossifies) within hy-poechoic cartilage are common andusually asymptomatic.2,3 An ossiclemay impinge on the patellar tendon,causing long-term impairment ofkneeling or running.4 However, a se-quential MRI study of adolescents withsymptomatic OSD revealed 100% withpatellar tendon pathology and only32% with ossicle formation.5 Im-provement in patellar tendinosiswas demonstrated in those that be-came asymptomatic, despite persis-tence of nonunion ossicles.5 Hirano etal,6 in another sequential MRI study,found that a partial tear of the second-ary ossification center was in place be-fore patellar tendon swelling butagreed that symptom resolution likelyfollows the resolution of tendonchanges. Thus, althoughrepeatedmicro-avulsion fracturesmaybe thefirst radio-graphic finding and contribute to OSDpain and pathology,6 they do not seem tobe the primary source of pain and dys-function.5,6 Recent MRI and ultrasoundreports are also consistent with a de-scription of OSD as “a tendinopathy/apophysosis of the patellar tendon/tibialtubercle.”7–12

Safety and level A–C evidence of effi-cacy (per US Preventive Services TaskForce criteria) of injection of 10% to25% dextrose in areas of damaged lig-ament, tendon, and cartilage in adultshas been demonstrated in randomizedcontrolled trials in Achilles tendino-sis,13 finger osteoarthritis,14 knee os-teoarthritis,15 lateral epicondylosis,16

sacroiliac joint pain,17 and in case se-ries collections of patients with Achil-les degeneration,18,19 anterior cruciateligament laxity,20 coccygodynia,21 hipadductor and abdominal tendinosis,22

and plantar fasciosis.23 There are noprevious reports of application of dex-trose injection in a strictly pediatricpopulation, nor are there reports of in-jection about an apophysis where, asdescribed, the source of pain andpathomechanism are not yet clear.

The common counsel that parents re-ceive is that OSD is “a self-limited pro-cess that responds favorably to con-servative treatment.”24 The self-limit isclosure of the tibial growth plate, andthus the period of potential symptomscan be considerable.1 A succinct re-cent description of conservative treat-ment includes “rest, icing, activitymodification, and rehabilitation exer-cises.”1 Use of a knee strap may pro-tect the tibia from painful contact, butno prospective trials have been re-ported.25 Symptoms typically wax andwane for months to years.26 Gerulis etal,27 reporting on 178 conservativelytreated adolescents, found a meanrange of 13 to 16.5 months of pain, de-pending on whether load restrictionswere followed. Mital et al28 reportedthat, after a mean of 3.8 years of symp-toms and conservative treatment, 12%of subjects merited surgery. Sixteenyears later, Hussain and Hagroo29 re-ported a 9% surgical rate after a con-servative therapy trial. In young adultsseen for OSD who received conserva-tive treatment only, telephone inter-view data a mean of 9 years after diag-nosis revealed a 60% incidence ofkneeling discomfort and 18% inci-dence of sport limitation because ofpain over the tibial tubercle.30 Air Forcecadets with an OSD history reportedmore frequent anterior knee pain andsignificantly diminished Sports ActivityScale scores than a cohort with no OSDhistory.31 Alteration of primary sport

choice, altered peer group dynamics,self-esteem effects, and occasionalwithdrawal from all competitivesports are effects of OSD that have notbeen measured prospectively. Reas-suring parents and athletes that OSD istime-limited is appropriate, but dis-missing it as benign in effect or brief induration seems to be at odds withavailable literature.

In current literature, OSD is depictedas a condition involving degenerationof both tendon and apophyseal tissue,as opposed to an isolated inflamma-tion of the apophysis. Dextrose injec-tion has been found to be safe andpotentially effective in treatment ofcartilage and tendon degenerative dis-orders. The purpose of this study wasto examine the potential of dextrose in-jection versus lidocaine injection ver-sus supervised usual care to reducesport-related symptoms in adolescentathletes with OSD. The hypothesis wasthat dextrose injection would be supe-rior to either lidocaine injection or su-pervised usual care.

PATIENTS AND METHODS

Determination of Candidacy

Girls age 9 to 15 and boys aged 10 to 17in the area of Rosario, Argentina, werescreened for anterior knee pain, butonly if they were involved in a jumpingor kicking sport on an organized teamwith a coach. Absence of either patell-ofemoral crepitus or patellar origintenderness was required, as well asreproduction of the exact pain and lo-calization of pain precisely to the tibialtuberosity during a single leg squat.Once confident of the diagnosis, pa-tients were required to have at-tempted at least 2 months of formaland gently progressive hamstringstretching, quads strengthening, grad-ual sport reintroduction, and to havehad pain with sport for at least 3months. At that point, if the patient andguardian demonstrated informed con-

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sent, a random numbers table wasused for assignment to supervisedusual care or to an injection solutiongroup blinded to the subject, guardian,and the treating/evaluating physician.Subjects with 1 or 2 symptomaticknees were accepted, but both kneeswere assigned to the same treatmentif both knees were treated on a singlepatient. The solution for each visit wasprepared by the physician who as-signed the patient, and was preparedin a manner blinded to the patient andthe treating/evaluating physician.

Outcome Measures

The Nirschl Pain Phase Scale (NPPS)(Table 1)32,33 is a 7-level measure ofsport inhibition and sport-relatedsymptoms. NPPS scores of 4 to 7 arelevels where sport is inhibited by pain.Below 4, symptoms of pain, soreness,or stiffness may be present (NPPSscores 1–3) ormay not (NPPS score 0).However the knee in question is unin-hibited with sport. The threshold goalswe chose, on the basis of NPPS scores,were NPPS scores of�4 and 0.

Treatment

All athletes were given pictorial sheetsof gently progressive hamstringstretching and quads strengtheningexercises. Those in the usual caregroup met with a physical therapistwho instructed them individually in thestretching and exercise method, and

provided a video. Then, those in theusual care groups returned at leastonce for 1-on-1 confirmation of properexercise performance and to encour-age compliance. Monitoring to this ex-tent meets or exceeds the amount ofmonitoring that a youth with symptom-atic OSD would typically receive, andthus makes a reasonable usual carecontrol group.

The injection groups received solutionthat always contained lidocaine 1% be-cause, in each session, completenessof injection was determined by com-plete anesthesia of pain with single-legsquat. Injections in the blinded phasesof the study were given at 0, 1, and 2months. Half of injected subjects re-ceived 12.5% dextrose in their injec-tion; half received lidocaine only. Forpurposes of additional discussion, thedextrose/lidocaine group will betermed the “dextrose” group to distin-guish it from the lidocaine-only group.

A single leg squat and palpation wereused to mark the most distal and prox-imal areas of pain/tenderness. Injec-tions were given with a 27-gauge nee-dle beginning at the most distal pointof tenderness, with gentle insertion to

bony depth, and then injecting 1⁄2 mL.Injections were repeated at�1 cm in-tervals, moving proximally for a total of3 to 4 midline injections (Fig 1). Theproximal 1 to 2 injections were deep tothe patellar tendon and on the tibiaabove the tuberosity. To avoid injectingthe fat pad, the needle was angled to-ward the tibia, and depth was usually�1.25 cm. Five minutes later, a singleleg squat was repeated to detect anyadditional pain areas, typically medialor lateral to the midline injections.Those areas were injected until pain-less single leg squat was achieved. Be-cause pain reduction may precede fullhealing, subjects received treatmenton 3 occasions even if they becamepain-free.

Acetaminophen was advised if neededfor postinjection discomfort. Athleteswere advised not to run or kick for 1week after the first injection, and torun as tolerated after the first week.They were advised not to run or kickfor 3 days after both the second andany subsequent injections. Usually,they started playing sports with com-petition if doing well after the secondinjection. Note that many athletes with

TABLE 1 NPPS Scores Ranging From 0 forComplete Remission to 7 forContinuous Pain That Disturbs Sleep

0 No pain or stiffness before, during, orafter sport

1 Stiff/sore after sport for�24 h2 Stiff/sore before and after sport

relieved by warm-up3 Pain during sport but sport not

altered4 Pain alters sport; nonpainful ADL5 Pain alters sport and painful ADL6 Pain prevents sport and alters ADL7 Pain prevents sport, alters ADL, and

alters sleep

ADL indicates activities of daily living.

FIGURE 1Anteroposteror photograph of knee showing injection points starting over themost distal area of painon the tibial tuberosity and moving proximally in 1-cm increments to the most proximal painful pointwith pressure. The black square represents the attachment of the patellar tendon to the tuberosity orits fragments.

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an NPPS score of 3 were used to play-ing with pain; these athletes were en-couraged to engage in a sportingactivity only if the activity was not ac-companied or followed by pain duringthe period of treatment.

As an incentive for study participation,and to potentially avoid sports drop-out, all study participants that did notreach an NPPS score of 0 could chooseto receive dextrose injection after 3months (the point at which the actualinjectant was revealed to the treatingphysician and patient). This was of-fered monthly until 12 months after ei-ther elimination of symptoms or pla-teau of improvement. Athletes werenot required to receive dextrose injec-tion if they were satisfied with theirstatus at 3 months. The athletes wereseen in clinic at 6 months and 1 year tobe sure that those that reported no

pain or stiffness were indeed asymp-tomatic when performing a single legsquat, and to update contact informa-tion and minimize potential for datadropout.

Ethics and Analysis

Human subject consent process,method approval, and monitoringwere conducted via the Comité de In-vestigación y Docencia del HospitalProvincial de Rosario. Assent was ob-tained via guardian or parent. A formalgroup size calculation was not per-formed. Our plan for enrollment wasto reach a minimum of 20 cases ineach group, on the basis of a previ-ous study using a similar injectiontreatment.22 Data were analyzed us-ing SPSS 18 (SPSS Inc, Chicago, IL).Analysis of variance was used tocompare changes in NPPS scores be-

tween groups. Tukey’s posthoc pro-cedure was performed to controltype I error for multiple (ie, dextrose,lidocaine, and usual care) groupcomparisons. The � level of the studywas set at .05. A Fisher’s exact testwas used to compare the likelihoodof achieving an NPPS score of �4and 0 between groups.

RESULTS

Demographics and GroupSimilarity

Enrollment was from September 1,2005, through October 2, 2008. The to-tal enrollment was 65 knees in 54 ath-letes (Fig 2). Data collection was com-plete to 1 year. The ages of athletestreated ranged from 10 to 17 (mean:13.3) years. The enrollees, consistentwith soccer club composition in the re-gion, consisted predominantly of boys(51 boys of 54 athletes enrolled). Ananalysis of variance for each variable(age, pain duration, and NPPS scorefor each of the groups at the time ofrandomization) revealed that the dis-tribution for each variable was thesame for each group.

Blinded Period (0–3 Months)

In the first three columns of Table 2,means and SDs are listed for the NPPSscore at 0 and 3 months and NPPS im-provement from 0 to 3months for eachgroup. NPPS scores improved more indextrose-treated knees than eitherlidocaine-treated (3.9 vs 2.4; P� .004)or exercise-treated knees (3.9 vs 1.2;P� 0001). Lidocaine was significantlybetter than usual care (2.4 vs 1.2; P�

FIGURE 2Determination of candidacy and study flow. Note the low refusal rate for inclusion and lack of dataloss.

TABLE 2 Mean and SD for NPPS Score at 0 and 3 Months, NPPS Mean Difference From 0 to 3 Months, and NPPS Score at 1 Year in OSD-Affected Knees

Group NPPS Scoreat 0 mo NPPS Score at 3 mo,Mean (SD)

NPPS Difference at 0–3mo, Mean (SD)

NPPS Score at 1 y, NoDextrose Received

NPPS Score at 1 y,Dextrose Received

Mean (SD) n Mean (SD) n Mean (SD) n

Dextrose 4.6 (1.0) 21 0.7 (1.2) 3.9a (.3) — — 0.2 (0.7) 21Lidocaine 4.2 (1.0) 22 1.8 (1.4) 2.4a (.3) 1.2 (1.5) 13 0.4 (0.7) 9Usual care 4.3 (1.0) 22 3.1 (1.6) 1.2a (.4) 2.5 (1.5) 14 0.1 (0.4) 8a Significant differences between all groups and between pairs: all groups (P� .0001); dextrose vs lidocaine (P� .004); dextrose versus usual care (P� .0001); and lidocaine versus usualcare (P� .024).

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.024). Posthoc analysis (Tukey’s proce-dure) confirmed significant improve-ment over usual care for both dextrose(P� .0001) and lidocaine (P� .046).

At the time of enrollment, some kneeswere already performing at an NPPSscore of 3 (pain during sport but unal-tered sport). Randomization was suc-cessful in achieving a near equal as-signment of these knees to each group(ie, 5 of 21 dextrose, 6 of 22 lidocaine,and 6 of 22 exercise-treated). Despitethe expected reduction in statisticalpower to compare intragroup differ-ences in reaching unaltered sport, incomparison to usual care, significantlymore dextrose-treated (21 of 21 vs 13of 22; P � .001) and lidocaine-treatedknees (20 of 22 vs 13 of 22; P � .034)achieved unaltered sport by 3 months(first column of Table 3).

Although unaltered sport wasachieved by �90% of both dextroseand lidocaine-treated athletes by 3months, dextrose-treated knees weresignificantly more likely than lidocaine-treated knees (14 of 21 vs 5 of 22; P�.006) to be asymptomatic with sport(NPPS score of 0) by 3 months (sec-ond column of Table 3).

Open Label Period (3–12 Months)Treatment Results

After the blinded period, 13 of 22lidocaine-treated knees were not in-jected with dextrose because they didwell enough with lidocaine. Of the

usual-care–treated knees, 14 of 22were not injected with dextrose. Sevenknees improved enough, 2 were in ath-letes that quit sport, and 5 were in ath-letes who were disqualified becauseof failure to perform usual careexercises.

Columns four and five in Table 2 listmean NPPS scores at 1 year for groupsthat did not and did receive dextroseinjection, and the third and fourth col-umns in Table 3 list 38 knees that re-ceived dextrose (21 original dextrose,9 lidocaine that switched, and 8 usual-care that switched). Dextrose-treatedknees were significantly more likely tobe asymptomatic with sport by 1 yearthan were lidocaine-treated knees notreceiving dextrose (32 of 38 vs 6 of 13;P � .024), despite the fact that the li-docaine knees not receiving dextrosewere those that respondedwell to lido-caine alone in the first 3 months. Nota-ble is that only 2 of 14 knees treated

with usual care for the entire yearreached an NPPS score of 0 and thatsport drop-out and inability to do exer-cises only occurred in the usual caregroup.

In Fig 3 the effect of switching to dex-trose injection is depicted by graphingthe mean NPPS score to 12 months. Li-docaine and usual-care knees thatwere treated with dextrose injectionbeginning at 3 months approximatedthe same level of improvement by 6months as those initially treated withdextrose, whereas those lidocaine andusual-care–treated knees not injectedwith dextrose plateaued.

Of the dextrose-treated knees thatreached an NPPS score of 0, 3 kneeswere later injected after direct contu-sions to the knee, and again reachedan NPPS score of 0. The mean numberof dextrose injections received until 12months was 2.0 for lidocaine-first-then-dextrose-injected knees, and2.4 for usual-care-first-then-dextrose-injected knees. Knees receiving dex-trose injection only were required toreceive a minimum of 3 injections, andthe mean number of dextrose injec-tions received was 3.8.

DISCUSSION

Synopsis of Key Findings

At the conclusion of 3 months of kneetreatment with dextrose injection, 21of 21 knees functioned unaltered withsport, 14 of 21 were asymptomatic

TABLE 3 Three-Month and 1-Year Outcomes for Dextrose-Injected, Lidocaine-Injected, and Usual-Care–Treated Subjects

3-mo NPPS Scoreof�4

3-mo NPPS Scoreof 0

1-y NPPS Scoreof�4

1-y NPPS Scoreof 0

Dextrose, n/N 21/21 14/21 38/38a 32/38Lidocaine, n/N 20/22 5/22 12/13 6/13Usual care, n/N 13/22 3/22 10/14 2/14Dextrose vs lidocaine, P .488 .006 .518 .024Dextrose vs usual care, P .001 �.001 .008 �.0001Lidocaine vs usual care, P .034 .698 .139 .005

Numbers achieving NPPS scores of �4 (unaltered sport) and an NPPS score of 0 (asymptomatic sport [ie, no pain, nosoreness, and no stiffness before, during, or after sport]) in each group and Fisher’s exact test result for significance ofdifferences between pairs.a After 3 months, 9 lidocaine-treated and 8 usual care–treated knees switched to receiving dextrose, for a total of 38 (21�9� 8) knees that received dextrose injection.

FIGURE 3Comparison of NPPS scores from 0 to 12 months in the dextrose group compared with the lidocainegroup on the left and usual care on the right. The different course for those who chose to receivedextrose after 3 months is shown.

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with sport, in contrast with 13 of 22and 3 of 22 usual-care–treated knees,respectively. At 1-year follow-up, 38 of38 dextrose-treated knees functionedunalteredwith sport, and 32 of 38 wereasymptomatic with sport comparedwith 10 of 14 and 2 of 14 usual-care–treated knees. Those athletes thatdropped sport or were unable to per-form OSD exercises were only from theusual care group. These results sug-gest that both the duration of sportslimitation and the duration of sports-related symptomsmay be reducible bydextrose injection in those with recal-citrant OSD.

Consideration of PossibleMechanisms and Explanations

Traumatic needling (percutaneousneedle tenotomy) has been proposedfor use in tendinosis.34,35 Although aneedling effect and subtendinous/in-tratendinous fluid infusion may con-tribute to the clinical benefit in thisstudy, trauma was minimized via useof a 27-gauge needle, with 3 to 6 gen-tle entries through a tendon, andonly light bone contact. Given identi-cal needling technique in both dex-trose and lidocaine groups in thisstudy design, a unique quality of dex-trose must account for its superiorefficacy.

Alfredson36 noted increased numbersof small veins (neovessels) in areas ofpainful tendinosis and demonstratedlarge numbers of small sympathetic fi-bers (a potential source of pain) inneovessel regions. A reduction in neo-vascularity has been demonstrated af-ter 25% dextrose injection in Achillestendinosis, but staining for a sympa-thetic nerve fiber count has not beenperformed.18,19

Repair of soft tissue such as liga-ment and cartilage is accomplishedby regenerative polypeptides, calledgrowth factors, which are producedlocally.37 Growth factors require sus-

tained glucose metabolism to pro-mote cell survival, and glucose can-not be transported into the cellwithout transporter proteins thatare stimulated by growth factors.38,39

Elevation of extracellular glucosepromptly elevates levels of trans-forming growth factor �, connectivegrowth factor, vascular endothelialgrowth factor, insulin-like growthfactor, and fibroblast growth fac-tor.38–44 Genes for growth factor pro-duction are activated within 20 min-utes of human cell exposure to 0.45%glucose (normal extracellular level is0.1%).45 Studies on glucose effects onneuropeptides are limited thus far, butthere are indications that either dex-trose elevations or a related reductionin insulin levels downregulate the ac-tivity of the transient receptor poten-tial vanilloid type 1 (TRPV1) receptorwhich reduces production of pain pro-ducing (substance P) and degenera-tive (calcitonin gene-related peptide[CGRP]) neuropeptides.46–48

Comparison With Relevant FindingsFrom Other Published Studies

Improved tendon organization afterdextrose injection has been shown byinterval ultrasound in the Achilles ten-don18,19 and plantar fascia23 in consec-utive case series. The ability of dex-trose to tighten loose connectivetissue without direct contact was sug-gested by a pilot study using anteriorcruciate ligament machine measure-ment and simple intra-articular dex-trose injection.20 Another study onsports-altering tendinosis (adductorand abdominal insertions) in eliterugby and soccer athletes resolvedcareer-threatening chronic groin painin �90% of athletes.22 The speed andsuccess rate for return to sport in theadductor/abdominal tendinosis studywere the same as that reported withfar more expensive surgical interven-tions. In this OSD study, similar efficacywas demonstrated, but it also repre-

sents the first study in an exclusivelypediatric population, and the firststudy in which a tendon attachment onan apophysis was injected.

Limitations of the Study

Failure to use a validated measureof symptoms of tendinopathy, suchas the Victorian Institute of SportAssessment-Patella score,49 with anestimated minimally clinically impor-tant difference, was a significant limi-tation of this study. Although the usualcare (supervised exercise) group wasa reasonable control, they had alreadytried exercise. Nevertheless, some inthe exercise group did well with theclose therapist supervision.

Clinical and Research Implications

Screening at soccer club level identi-fied 5.7% of athletes who failed usualcare for OSD. This “early” identificationstill found quite chronic symptomswith a median of 8 (range: 3–72)months of anterior knee pain.

Tolerance of small needle injectionwas demonstrated in this age group,and, because of the nonviscous natureof dextrose, 27- to 30-gauge needlesshould make treatment practical forother conditions in this age group,such as Sever’s disease. Less than 10%of athletes required acetaminophenafter injection.

Although designing and conducting asimilar RCT in this age group would bedifficult, we hope that additional con-secutive patient studies with follow-uplasting several years will be pursued,given the safety and outcomes demon-strated by this study.

CONCLUSIONS

Dextrose or lidocaine injection overthe apophysis and patellar tendonorigin was safe, well tolerated, andresulted in more rapid and more fre-quent achievement of unalteredsport than did usual care in athletes

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with intractable OSD symptoms. Dex-trose injection resulted in morerapid and frequent achievement ofasymptomatic sport than either lido-caine injection or usual care. Those

athletes that dropped sport or wereunable to perform OSD exerciseswere only from the usual care group;this finding merits additional pro-spective study.

ACKNOWLEDGMENTSWe thank Ana Saionz for support andencouragement and Richard Kammerfor assistance in primary literatureaccess.

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DOI: 10.1542/peds.2010-1931; originally published online October 3, 2011; 2011;128;e1121Pediatrics

Francisco Raya, Bradley Dean Fullerton and Hung-wen YehGastón Andrés Topol, Leandro Ariel Podesta, Kenneth Dean Reeves, Marcelo

Hyperosmolar Dextrose Injection for Recalcitrant Osgood-Schlatter Disease  

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