Sinding-Larsen-Johansson Syndrome

                                 Dr. KS Dhillon

Introduction

The Sinding-Larsen-Johansson syndrome (SLJS) has a pathogenesis that is similar to that of the Osgood-Schlatter disease and the two disorders sometimes occur simultaneously [1]. 

Increased tension and pressure due to repetitive traction by the patellar tendon on the lower pole of the patella (still partly cartilaginous in adolescents) during contraction of the quadriceps muscle causes Sinding-Larsen-Johansson syndrome. This leads to cartilage damage, swelling, and pain, and later to tendon thickening and fragmentation of the lower pole of the patella. It sometimes leads to bursitis, i.e. inflammation of a bursa situated between the tendon and the patella. The syndrome is seen typically in adolescents between 10 and 14 years of age, but most often in males who play sports such as football, running, volleyball, and gymnastics [2,3]. The syndrome is clinically characterized by pain localized to the lower pole of the patella, subpatellar edema, and functional limitation. Ultrasound can show all the manifestations of this disorder i.e swelling of the cartilage, tendon thickening, fragmentation of the lower pole of the patella, and bursitis [4–6]. Treatment is nonoperative with NSAIDs, activity modifications, and physical therapy with most cases resolving over time. 

Epidemiology

It is more common in adolescence. It is located at the patellar tendon insertion on the inferior pole of the patella.

Etiology

It is caused by chronic injury. It has similar pathogenesis as Osgood-Schlatter. Overuse causes traction apophysitis at the lower pole of the patella.

Classification

The Blazina classification for functional limitations associated with patellar

 tendinitis is divided into 3 stages.

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

Clinical Presentation

The patient presents with a history of insidious onset of pain on the anterior aspect of the knee after or during activity. Clinical examination shows tenderness over the inferior pole of the patella. There is swelling over the inferior pole of the patella. Resisted knee extension may elicit pain.

Imaging

Ap and lateral x-rays of the knee are done. Lateral radiographs are most useful.  There may be peripatellar soft tissue swelling or patella alta.  One or several osseous fragments may be present at the inferior pole of the patella.

MRI (magnetic resonance imaging) of the knee will show whether or not edema or inflammation is present over the patella. It will rule out any other internal derangement of the knee.  On MRI, the inferior pole of the patella, proximal and posterior part of the patellar tendon, and surrounding soft tissues are hypointense on T1-weighted MRI sequences and hyperintense on T2-weighted MRI (fat-suppression) sequences.  Ultrasound images are either equally effective or more effective than radiographs, especially when evaluating soft tissue. Ultrasound is proposed as a simple and reliable method for diagnosing knee joint osteochondrosis, especially during the early stages of the disease. Ultrasound is also suitable for periodic follow-up in the course of the disease [7]. On ultrasound, the lower pole of the patella appears fragmented and hypoechoic with swelling of the cartilage, in particular at the insertion of the patella tendon.

Treatment

There is no definite treatment algorithm for SLJS. Pain relief is obtained by resting for a few days. Strengthening exercises with modification of activities are carried out. Non-steroidal anti-inflammatory drugs (NSAIDs) may be necessary. In severe cases, a cast is used for 4 weeks to maintain immobility.  Physiotherapy can also be prescribed.

An average return to sport occurs in 4-14 weeks [5-7]. Treatment is guided by pain and activities.  Crutches may be needed if there is a limp. An experienced physical therapist or athletic trainer can aid in the return to activity or sport.

Surgical debridement to remove the necrotic intratendinous tissue should be the last resort for patients who are resistant to conservative management. The disease is usually self-limiting.

Conclusion

The Sinding-Larsen-Johansson syndrome is characterized by cartilage swelling, the patellar tendon's thickening with calcifications in the advanced stages, fragmentation of the lower pole of the patella, and bursitis affecting a serous bursa situated between the patellar tendon and the patella.

Patients present with pain localized to the lower pole of the patella. In the acute phase, therapy is mainly rest and abstention from sports activity for at least 1–2 months, particularly football and running. The evolution is usually benign with spontaneous recovery. Full recovery usually takes between 12–24 months. When the patella is completely ossified the pain disappears and complications are rare.

References

1. Hagner W., Sosnowski S., Kaziñski W., Frankowski S. A case of Sinding-Larsen-Johansson and Osgood-Schlatter disease in both knees. Chir Narzadow Ruchu Ortop Pol. 1993;58(1):13–15.

2. 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):50–53. 

3. Peace K.A., Lee J.C., Healy J. Imaging the infrapatellar tendon in the elite athlete. Clin Radiol. 2006 Jul;61(7):570–578.

4. De Flaviis L., Nessi R., Scaglione P., Balconi G., Albisetti W., Derchi L.E. Ultrasonic diagnosis of Osgood-Schlatter and Sinding-Larsen-Johansson diseases of the knee. Skeletal Radiol. 1989;18(3):193–197. 

5. 5. Draghi F., Danesino G.M., Coscia D., Precerutti M., Pagani C. Overload syndromes of the knee in adolescents: sonographic findings. J Ultrasound. 2008;11:151–157. 

6. 6. Barbuti D., Bergami G., Testa F. Ultrasonographic aspects of Sinding-Larsen-Johansson disease. Pediatr Med Chir. 1995 Jan-Feb;17(1):61–63.

7. De Flaviis L, Nessi R, Scaglione P, Balconi G, Albisetti, W, Derchi, LE. Ultrasound diagnosis of Osgood-Schlatter and Sinding-Larsen-Johansson diseases of the knee. Skeletal Radiol 1989;18(3);193-197.