We need you! See something you could improve? Make an edit and help improve WikSM for everyone.
Patellar Apophysitis
From WikiSM
Contents
Other Names
- Traction apophysitis of the knee
- Sinding-Larsen-Johansson Disease
- Sinding Larsen Johansson Disease (SLJ)
- Superior Patellar Pole Apophysitis
- Inferior Patellar Pole Apophysitis
Background
- This page describes apophysitis of the inferior pole of the Patella, an overuse injury
- Often referred to by its eponym Sinding-Larsen-Johansson Disease
- Not to be confused with Patellar Pole Avulsion Fracture
- Overall, this disease suffers from a dearth of information in the literature
History
Epidemiology
- Seen in adolescents age 10-14 years of age[1]
- Males > females
- Common in middle school athletes[2]
- More likely to occur during practice than competition
Pathophysiology
- General
- Overuse injury at the inferior pole of patella at the proximal patella tendon attachment
- Repetitive traction on the patellar ligament due to quadriceps contraction causes inflammation of patellar tendon attachment
- Leads to cartilage damage, swelling and pain
- Later to tendon thickening and fragmentation of the lower pole of the patella
- Present in skeletally immature adolescents (age 10-14)
- Considered stress fractures of the apophyseal physis
- Analogous to a nondisplaced Salter Harris 1 fracture
- Etiology
- Regular physical activity
- Excessive physical activity is most common (i.e. overuse)
- Direct trauma to the inferior pole of the patella
Associated Pathology
Pathoanatomy
- Patella
- Largest sesamoid bone of the skeleton
- Patellar Tendon arises from the inferior patella and inserts distally into the tibial tuberosity
- Extensor mechanism: Quadriceps attaches to Patella, Patella Tendon inserts on Tibial Tubercle
- Ossification begins at 3-5 years
- Apophysis at inferior pole of patella
- Opens at age 10, closes at age 14[3]
Risk Factors
- General
- Middle school athletes[2]
- Practice > competition
- Involvement in competitive sport at the age (around 5 or 6 years old) in which the patella begins its ossification
- Sport specialization
- Sports (high demands on the extensor apparatus)[4]
- Football
- Running
- Volleyball
- Gymnastics
- Long Jump
- Karate
- Biomechanical/ Structural[5]
- Short hamstring tendon
- Increased posterior tibial slope
Differential Diagnosis
- Fractures
- Dislocations & Subluxations
- Patellar Dislocation (and subluxation)
- Knee Dislocation
- Proximal Tibiofibular Joint Dislocation
- Muscle and Tendon Injuries
- Ligament Pathology
- Arthropathies
- Bursopathies
- Patellofemoral Pain Syndrome (PFPS)/ Anterior Knee Pain)
- Neuropathies
- Other
- Bakers Cyst (Popliteal Cyst)
- Patellar Contusion
- Pediatric Considerations
- Patellar Apophysitis (Sinding-Larsen-Johnansson Disease)
- Patellar Pole Avulsion Fracture
- Tibial Tubercle Avulsion Fracture
- Tibial Tuberosity Apophysitis (Osgood Schalatters Disease)
- Proximal Tibial Metaphyseal Fracture
- Proximal Tibial Physeal Injury
Clinical Features
- History
- History of insidious onset of pain on anterior aspect of knee
- Duration is weeks to months
- Worse when patella is loaded (running, jumping, sudden stops)[6]
- Physical Exam: Physical Exam Knee
- Tenderness over inferior patella, may extend into tendon
- Swelling over inferior patella, Knee Effusion should be absent
- Range of motion normal or slightly limited in flexion due to pain
- Strength and extension should be intact but painful
- Special Tests
- Jump Test: Pain is easily reproduced with repetitive jumping in examination room
Evaluation
Lateral left knee radiograph with arrow demonstrating loose bony fragments at inferior patellar pole[7]
Radiographs
- Standard Radiographs Knee
- Findings
- May be normal or show spur at inferior pole of patella
- Soft tissue swelling may be noted on lateral view
- Can see calcifications at the origin of the patellar tendon[8]
Focal thickening, increased echogenicity of the right infrapatellar tendon (compared to left). Arrow indicates significant widening, cortical irregularity associated with the apophysis of the patellar apex.[7]
Ultrasound
- General
- Imaging modality of choice as it can identify all pathology associated with the disease
- May follow serially over time to examine for progression/resolution of disease
- Findings[9]
- Cartilage swelling or thickening
- Tendon thickening
- Fragmentation of the lower pole
- Infrapatallar bursitis
- Hyperemic tendon fibers with power doppler
MRI
- If diagnosis unclear
- Help distinguish from from patellar sleeve avulsion
Classification
Unknown Classification System
- Stage 1: Pain occurs after activity
- Stage 2: Pain present while performing activity and persists after activity
- Stage 3: Pain affecting/limiting function during activity
Iwamoto Classification System
- Based on radiographic findings[10]
- Stage 1: Normal findings.
- Stage 2: Irregular calcifications at the inferior patellar pole.
- Stage 3: Coalescence of calcifications.
- Stage 4A: Incorporation of calcifications into patella.
- Stage 4B: Coalesced calcified mass separate from the patella
Management
Nonoperative
- Mainstay of treatment, usually self limited
- Activity modification
- Abstain for 1-2 months minimum
- Consider replacing with swimming, other sports that dont use quadriceps muscle as much
- NSAIDS
- Physical therapy
- Improve hamstring, quadriceps and heel cord flexibility
- Patellar Tendon Counterforce Strap
- May provide relief, can be worn as needed
- Consider biomechanical evaluation if not improving
- Look for knee twisting, valgus moment
- Neuromuscular deficits
- Contraindicated
Operative
- Indications
- Refractory to nonoperative treatment
- Technique
- Debridement of damaged tissue/stimulation of healing response
Rehab and Return to Play
Rehabilitation
- Needs to be updated
Return to Play
- Full recovery typically takes 12-24 months
Complications and Prognosis
Prognosis
- Generally considered a self-limiting condition
- Full recovery typically takes 12-24 months
- Symptoms often resolve completely when ossification of the patella is complete[11]
Complications
- Rare
- Delayed return to sport
See Also
- Internal
- External
- Sports Medicine Review Knee Pain: https://www.sportsmedreview.com/by-joint/knee/
References
- ↑ Valentino M, Quiligotti CRM. Sinding-Larsen-Johansson syndrome: a case report. J Ultrasound. 2012;15:127–129.
- ↑ 2.0 2.1 Foss, Kim D. Barber, Greg D. Myer, and Timothy E. Hewett. "Epidemiology of basketball, soccer, and volleyball injuries in middle-school female athletes." The Physician and sportsmedicine 42.2 (2014): 146-153.
- ↑ Atanda Jr, Alfred, Suken A. Shah, and Kathleen O'brien. "Osteochondrosis: common causes of pain in growing bones." American family physician 83.3 (2011): 285-291.
- ↑ Iwamoto J, Takeda T, Sato Y, Matsumoto H. Radiographic abnormalities of the inferior pole of the patella in juvenile athletes. Keio J Med 2009 Mar;58(1):50e3.
- ↑ López-Alameda, S., et al. "Sinding-Larsen-Johansson disease: analysis of the associated factors." Revista Española de Cirugía Ortopédica y Traumatología (English Edition) 56.5 (2012): 354-360.
- ↑ Browne, Gary J., and Peter LJ Barnett. "Common sports‐related musculoskeletal injuries presenting to the emergency department." Journal of paediatrics and child health 52.2 (2016): 231-236.
- ↑ 7.0 7.1 Malherbe, Kathryn. "Traction apophysitis of the knee: A case report." Radiology case reports 14.1 (2019): 18-21.
- ↑ A G Orthopaedic radiology: a practical approach. 3rd ed. Lippincott Williams & Wilkins.
- ↑ Draghi F, Danesino GM, Coscia D, Precerutti M, Pagani C. Overload syndromes of the knee in adolescents: sonographic findings. J Ultrasound 2008;11:151e7.
- ↑ Iwamoto J, Tsuyoshi T, Sato YMH. Radiographic abnormalities of the Inferior pole of the Patella in Juvenile athletes. Keio J Med. 2009;58(1):50–53.
- ↑ Freedman DM, Kono M, Johnson EE. Pathologic patellar fracture at the site of an old Sinding-Larsen-Johansson lesion: a case report of a 33-year-old male. J Orthop Trauma 2005 Sep;19(8): 582e5
Created by:
John Kiel on 30 June 2019 20:33:03
Authors:
Last edited:
4 October 2022 15:56:57
Categories: