This ten-year-old female player presented with a four week history of anterior knee pain in her right knee. She developed this during a weekend tournament during which she played multiple games. Since this time she had experienced pain and discomfort that was made worse by activity and improved by rest. She was found to have localised tenderness of the proximal patella tendon with some localised swelling. Her knee and hip examination was otherwise normal.
On the lateral x-ray view there is a small ossicle/ossification centre related to the inferior pole of the patella on the symptomatic right side. There is also minor thickening of the proximal patella tendon. This is not seen on the contralateral left side. An AP x-ray of the affected right knee is normal.
This young player was managed with education, a short period of rest and a gradual re-introduction of physical activity. Her symptoms remained well controlled, but persisted for a further six months. At this point they resolved completely.
Sinding-Larsen-Johansson disease (SLJ) affects the proximal end of the patellar tendon as it inserts into the inferior pole of the patella. It represents a chronic traction injury of the apophysis and similar to Osgood-Schlatter disease (which affects the distal patella tendon at the tibial tubercle). Sinding-Larsen-Johansson disease is seen in active adolescents, typically between the ages of ten to 14 years.
In the majority of cases of traction apophysitis there are no (or very subtle) radiological findings. Thickening of the proximal patellar tendon may be seen on a lateral x-ray image. In some cases there may be stranding of the adjacent portions of Hoffa’s fat pad while dystrophic calcification/ossification may eventually occur in more chronic cases. Comparison x-ray images (where the affected knee is compared with the normal one) can be very useful for paediatric patients. It can be hard to distinguish between normal ossification centres and pathology. Ultrasound images may show thickening or heterogeneity of the proximal patellar tendon. MRI can also be useful in the assessment of these patients. The proximal and deep part of the patellar tendon may appear thickened with high T2/STIR signal while there may also be high signal in the inferior pole of the patella or the adjacent fat pad.
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