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case
Young Soccer Player With Anterior Knee Pain
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BACKGROUND Parents bring their 12-year-old
son to the urgent-care clinic with a chief complaint of right knee
pain. The patient states that he has been having pain in the front
part of his knee since he began the soccer season 3 months ago. His
team has played well, and he proudly states that he had scored 5
goals over the season, a personal record. The boy is concerned about
the pain because he does not want to disappoint his team by being
unable to play. On further questioning, he states that the pain is
present “all the time” but that “it gets worse when I am running.”
Resting helps alleviate the pain. His parents have not given him any
medications for the pain except acetaminophen (Tylenol). The
patient’s medical history is noncontributory. On physical
examination, the patient’s vitals signs are as follows: temperature
98°F; heart rate, 72 beats per minute; respiratory rate, 12 breaths
per minute; blood pressure, 188/78 mm Hg. Physical examination
reveals a healthy 12-year-old boy in mild distress. He walks with a
limp when asked to climb onto the examination table. Findings on
head and neck examination are normal, as are those on auscultation
of the heart and lungs and on abdominal examination. Evaluation of
the right lower extremity demonstrates full range of motion of all
joints, including the knee. Strength is normal, and he has no
evidence of trauma, such as erythema or bruising. The McMurray and
Lachman maneuvers, the anterior and posterior drawer tests,
assessment of internal and external rotation, and varus and valgus
stress tests on the right knee joint all yield unremarkable results.
No patellar subluxation is identified;
however, he has a point of focal tenderness immediately over
the inferior pole of the patella. The right hip is normal. Radiographs
of the bilateral knees are obtained. What is the
diagnosis?
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***** HINT *****
Two very similar entities should be considered on the basis of physical examination findings.
***** ANSWER *****
Sinding-Larsen-Johansson disease: Lateral
radiographs demonstrate calcifications inferior to the inferior pole of
the patella in the expected location of the patellar tendon, as well as
minimal soft-tissue swelling over the calcifications. These findings
indicate Sinding-Larsen-Johansson disease. In 1921 and 1922,
Sinding-Larsen and Johansson independently described this syndrome. It
occurs in children and adolescents aged 10-14 years and clinically
manifests as tenderness and soft tissue swelling over the inferior pole of
the patella. Radiographs demonstrate osseous fragmentation, as shown here.
Initial reports erroneously described the disorder as an apophysitis or
osteochondritis. The findings have been shown to be traumatic in origin,
and the pathogenesis is closely related to that of Osgood-Schlatter
disease. The disease is now believed to be related to a traction
phenomenon resulting in tendinitis of the proximal attachment of the
patellar tendon. Tendinitis is followed by calcification or ossification.
Patellar fracture or avulsion can occur but are infrequent.
Osgood-Schlatter disease results in radiographic findings similar to these,
but it occurs at the distal insertion of the patellar tendon on the anterior tibial tubercle.
Patients with Sinding-Larsen-Johansson disease present with focal tenderness over the inferior pole of the patella
that activity aggravates. The initial radiographic changes are classic. The calcifications
are usually incorporated into the inferior pole of the patella, and the
natural course of the condition is 3-12 months. Follow-up radiographs often show normal findings.
Most patients do not require surgical treatment, and the disease is managed symptomatically. It
may also respond to quadriceps-strengthening exercises. In rare cases, debridement of the patellar tendon may be
necessary if the disease does not respond to nonoperative management.
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Authors:
Adam W. Chandler, MD, University of New Mexico Hospital
Residency, Department of Radiology, Albuquerque Gautam Dehadrai, MD, Staff
Physician, Department of Radiology, Veterans Administration Hospital,
Albuquerque, NM
References:
Chang AK. Osgood-Schlatter Disease. eMedicine journal
[serial online]. February 10, 2005. Available at:
www.emedicine.com/emerg/topic347.htm. Accessed November 14, 2005. Ozonoff MB.
Pediatric Orthopedic Radiology. 2nd ed. Philadelphia, PA: WB Saunders 1992:
371-2. Resnick D. Diagnosis of Bone and Joint Disorders. 4th ed. Philadelphia,
PA: WB Saunders; 2002: 3729-30, 3714-8. Wheeless’ Textbook of Orthopedics.2005.
Data Trace Publishing Company. Available at: www.wheelessonline.com. Accessed
November 14, 2005
eMedicine Editor:
Rick Kulkarni, MD, Attending Physician, Director of
Informatics, Department of Emergency Medicine, Olive View - UCLA Medical Center,
Assistant Professor of Medicine, David Geffen School of Medicine at UCLA
Source
http://emedicine.com
Jan 2006
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