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CASE REPORT

Sinding-Larsen Johanssen Syndrome - Case Report   

 Zarogianni Chrysoula*, Tsiamis Christos, Zarogianni Sofia     

* Health Center of Elassona, Larissa, Greece

Address for Correspondence:

Dr.Zarogianni Chrysoula
12 , Marathonos str, 6626, Sykies,                                  Thessaloniki, Greece.
Telephone    :     0030 6945 766 806
Ε-Μail  : drtsiamischristos@yahoo.gr  

 

Abstract:

Introduction :  Sinding-Larsen Johanssen Syndrome represents one of the less common causes of anterior knee pain. It refers to an inflammation of the lower pole of the patella at the site of origin of the patellar tendon. It is characterized by tenderness, warmness and swelling over the lower pole of the patella and also pain with activity. It is considered to be the junevile equivalent of patellar tendinopathy.

Purpose : To describe a case of  an adult male with Sinding-Larsen Johanssen Syndrome.

Patient and Method : A 34 years old male who came in the ď First Aids ď Department of the Elassona Health Center complaining of right knee pain with activity, especially when straightening the leg against force.

Conclusion : Sinding-Larsen Johanssen Syndrome is a very rare cause of patellofemoral pain, the diagnosis of which is difficult and it can be confirmed only by the paraclinical investigations such as X-Rays, Ultrasonography and MRI.

J.Orthopaedics 2007;4(4)e4

Keywords:

Anterior Knee Pain, Patellar Tendinopathy, Patellar Fragmentation, X-Rays, MRI.
 index.htm

Introduction:

   The term Sinding-Larsen Johanssen Syndrome refers to an inflammation of the kneecap ( patella ) at its lowest point. This is the site of origin of the patellar tendon. There is traction on the kneecap at this point due to action of the large, powerful thigh muscle ( quadriceps ). It can be followed by calcification, ossification or frank inferior pole avulsion fractures that produce one or more distinct ossicles.

The injury is usually due to repeated stress or vigorous exercise.

  The most common symptoms and signs include tenderness, warmness and soft tissue swelling over the lower pole of the patella and also pain with activity, especially when straightening the leg against force ( such as with stair climbing, jumping, deep knee bends or weight lifting ) or following an extended period of vigorous exercise. In more severe cases, appears pain during less vigorous activity [ 1, 2 ].

   Radiographic findings include osseous fragmentation of the patella and varying amounts and shapes of calcification at the junction of the patella and the ligament [3 ].

   Initial treatment consists of relieving the pain by resting for a few days and also stretching and strengthening exercises and modification of activities. Specifically, kneeling, jumping, squatting, stair climbing and running on the affected knee should be avoided. Administration of Non-Steroidal Anti-inflammatory Drugs ( NSAIDís ) may be necessary and in severe cases a cast is used. In rare cases, operative debridement  of necrotic intratendinous tissue may be needed.

Case Report:

       A 34 year old man came to the ďFirst AidsĒ Department of the Elassona Health Center in Elassona, Larissa, Greece complaining of Right Knee pain with activity, especially when straightening the leg against force.

       The clinical examination of the patient revealed a diffuse tenderness and soft tissue swelling over the lower pole of the affected patella. The rest of the physical examination has shown no-remarkable findings.

       The X-Rays examination of the knee joints revealed tripartite patella in the right lower limb. Ultrasound examination have shown fragmentation of the affected patella and also proximal patellar tendonitis with thickening of the tendon and heterogenous hypoechogenicity within. Magnetic Resonance Imaging ( MRI ) Findings involve focal thickening of the right proximal patellar tendon and also sparing of the anterior component of the tendon ( typical of chronic patellar involvement ) and also tripartite patella ( right ).

The diagnosis was: Sinding-Larsen Johanssen Syndrome and the treatment of the patient was including the following: NSAIDís were administrated to relieve the pain and also rest and avoiding vigorous exercise were recommended but there was no-significant improvement of the patientís situation. Thatís why the patient undergone an operative debridement  of necrotic intratendinous tissue and in combination with rest and application of a small cast, its situation is much better and after 4-5 months he started an exercise program ( 6 months duration ) in order to restore strength.

 Figure : A Young male with Sinding-Larsen Johanssen Syndrome Ė Tripartite Patella

Discussion:

       Some of the most common causes of anterior knee pain are the following: Chondromalacia Patella, Osteoarthritis of the patellofemoral joint, Osteochondritis Dessicans, Patellofemoral Dysplasia, Subluxation of the patella, Dislocation of the patella, Synovial Plica Syndrome, Tendonitis, Bursitis, Fat Pad Syndrome, Stress Fractures of the patella, Osgood Schlatter Disease and the Sinding-Larsen Johanssen Syndrome [ 1, 2, 4, 5, 6, 7, 8 ].

       Distinguishing between the possible causes of anterior knee pain can be difficult as their clinical features can be similar. Furthermore, some of these conditions may appear simultaneously as a result of the same biomechanical abnormality or because of overuse or one may occur first and predispose to the other.

       There are a number of important factors to elicit in the history of a patient with general presentation of anterior knee pain. These include the specific location of the pain, the nature of aggravating activities, the history of the onset of the pain and any associated clicking or swelling. The type of activity producing pain also aids diagnosis. The onset of typical anterior knee pain is often insidious, but it may also present after an acute traumatic episode.

       Disorders such as Chondromalacia Patella, Osteoarthritis, Osteochondritis Dessicans, Patellofemoral Dysplasia, Subluxation of the Patella and Dislocation of the Patella are usually associated with various cartilage damage. Disorders associated with usually normal cartilage include Tendinitis, Bursitis, Fat Pad Syndrome, Osgood Schlatter Disease and the Sinding-Larsen Johanssen Syndrome [ 1, 2, 4, 5, 6, 7, 8 ].

       Patellar Tendinitis is an overuse syndrome existing as tendonitis of the Patellar or Quadriceps tendon at either the inferior or superior pole of the patella [ 2 ]. Accordimg to the majority of authors and the international literature, three ( 3 ) main sites of tendonitis are described. The first site is at the attachment of the patellar tendon to the inferior pole of the patella, second at the insertion of the quadriceps tendon at the base of the patella and thirdly at the insertion of the patellar tendon into the tibial tuberosity [ 2 ]. Symptoms include an insidious onset of low-grade aches aggravated by deceleration and acceleration forces. Examination exhibits tenderness and swelling over the tubercle and associated patellar tendon. Diagnosis is mainly via clinical examination as the only constant radiographic feature is swelling (greater than 4 mm) over the anterior tibial articular surface. MRI and Ultrasound can aid in diagnosing the condition. MRI can show patellar tendon thickening and chrinic tendon tear and Ultrasound can help distinguish fragmentation [ 3 ].

Sinding-Larsen Johanssen Syndrome is a similar condition which occurs at the distal pole of the patella. It presents as a traction apophysitis of the distal pole of the patella secondary to overuse. Most commonly it is described as the juvenile equivalent of patellar tendonitis ( but it can also be present in adults like in our case ) [ 1 ]. The condition presents with the same symptoms as Osgood Schlatters Disease except at the opposite location ( Tibial Tuberosity ). 

       It is evident from the literature that there are numerous pathological conditions that can cause patellofemoral pain. The authors believe that confusion arises due to enormity of conditions that mimic one another in terms of symptomatology in the anterior knee region.

History and clinical examination are a crucial factor in formulating a logical diagnosis, but definite diagnosis can be based only in the further investigations which can include : X-Rays, Ultrasound and MRI.

Reference :

1. Greenfield M.A. and Scott W.N. 1994. Patellofemoral Pain. In Scott W.N.
( Ed ) The Knee. Mosby. St. Louis, Baltimore, Boston, London. pp : 391-403.

2. David J.M. October 1989. Jumperís knee. The Journal of Orthopaedic and Sports Physical Therapy. Vol 11 ( 4 ), pp : 137-141.

3. Rask B.P. and Micheli L.J. 1994. The Paediatric Knee. In Scott W.N. ( Ed ) The Knee. Mosby. St. Louis, Baltimore, Boston, London. pp : 229-240.

4. Brukner P. and Kahn K. 1994. Clinical Sports Medicine. Mc Graw-Hill Book Company. pp : 366-400.

5. Merchant A.C. 1994. Extensor Mechanism Injuries : Classification and Diagnosis. In Scott W.N. ( Ed ) The Knee. Mosby. St. Louis, Baltimore, Boston, London. pp : 403-409.

6. Calvo R.D, Steadman J.R, Sterling J.C, Holden S.C and Meyers M.C. 1990. Managing Plica Syndrome of the Knee. The Physician and Sports Medicine. Vol. 18, (7), pp : 64-74.
7. Johnson D.P., Eastwood D.M and Witherow P.J. 1993. Symptomatic Synovial Plicae of the Knee. The Journal of Bone and Joint Surgery. Vol. 75-A, ( 10 ), pp : 1485-1495.

8. Tsirbas A., Paterson R.S. and Keene G.C.R. 1990. Fat Pad Impingement ; A Missed Cause of Patellofemoral Pain ? The Australian Journal of Science and Medicine in Sport. Vol. 23, ( 1 ), pp : 24-26.


 

This is a peer reviewed paper 

Please cite as : Zarogianni Chrysoula : Sinding-Larsen Johanssen Syndrome - Case Report   

J.Orthopaedics 2007;4(4)e4

URL: http://www.jortho.org/2007/4/4/e4

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