Sinding Larsen Johansson Syndrome

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Definition/Description

The Sinding Larsen Johansson Syndrome (SLJ) is an osteochondroses and traction epiphysitis affecting the extensor mechanism of the knee. SLJ occurs at the inferior pole of the patella, at the superior attachment of the patella tendon. The tenderness of the inferior pole of the patella is usually accompanied by roentgen graphic evidence of splintering of that pole. Most patients with SLJ also show a calcification at the inferior pole of the patella.^{[1] (Level of evidence 1B)}

The syndrome usually appears in adolescence, during the growth spurt. It’s associated with localized pain which is worsened by exercise. Usually we observe a localized tenderness and soft tissue swelling. There’s also a tightness of the surrounding muscles, the quadriceps, hamstrings and gastrocnemius in particular. This tightness usually results in inflexibilities of the kneejoint, altering the stress through the patellofemoral joint.^{[2] (Level of evidence 2B)}

Clinically Relevant Anatomy

The Sinding Larsen Johansson Syndrome occurs in the knee joint. It is an inflammation of the growth plate at the inferior pole of the patella. At the superior pole of the patella, the quadriceps tendon inserts. The patella tendon inserts at the inferior pole of the patella.

The growth plate of the patella, or apophysis, is consists of cartilage cells. These cells are softer and more vulnerable to injury. Increased tension and pressure on the growth centre causes SLJ.^{[3] (Level of evidence 5)}

Epidemiology /Etiology

SLJ is caused by microtraumata to this area and can be followed by calcification and ossification if the condition becomes chronic. It typically affects children and adolescents between the ages of 10 and 15 years old. However, it can also affect active adults who run for moderate to long distances or are involved in sports that require much jumping or squatting. It is similiar to Osgood-Schlatter's disease of the distal patellar tendon.

Characteristics/Clinical Presentation

US or MRI imaging may show osseus fragmentation of the distal patellar pole, or it may be irregular, with chondral changes and thickening at the insertion of the patellar tendon. Any activity, from normal walking to climbing stairs, may increase the person's pain depending upon the severity of the condition. In less severe cases, a person may not begin to feel pain until after extended activity, such as running for several miles. The pain occurs when straightening the knee against force: deep knee bends, kneeling, jumping, climbing stairs, squatting, running, weightlifting,…^{[4] (Level of evidence 5)} Tenderness to touch, limping and a tender bump in the infrapatellar area are all common signs. Lower extremity neurovascular signs or crepitus in the knee are rare and may be indicative of another pathology.

Differential Diagnosis

Other diseases with similar symptoms to the Sinding Larsen Johansson Syndrome are injury to the infrapatellar fat pad, Hoffa disease, patellofemoral joint dysfunction, mucoid degeneration of the infrapatellar tendon.^{[5] (Level of evidence 1C)}

Diagnostic Procedures

The physiotherapist performs a physical examination of the knee and reviews the patient’s symptoms.^{[3] 
(Level of evidence 5)}

In case of anterior knee pain there are three important tests to perform (in all tests the patient is in supine position)^{[6] (Level of evidence 2A)}

• Patellar Grind Test
• Compression Test
• Extension Resistance Test

Outcome Measures

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Examination

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Medical Management

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Physical Therapy Management

Icing or ice massage, especially right after activity, and referral to an MD for antiinflammatories should be initiated, if not already done.  First and foremost, physical therapists must educate the patient on activity modification. Kneeling, jumping, squatting, stair climbing, and running on the affected knee should be avoided at least for the short term.  A formal posture, gait, running and jumping-landing analysis should be performed to identify any biomechanical insufficiencies. Orthotics may need to be fitted to help stabilize hind foot valgus, overpronation or pes planus problems. Lower extremity strength needs to be tested, especially at the ankle and the hip to find any muscle weaknesses that may be contributing to the overuse syndrome. Core strengthening should be initiated since most of these people are athletes and central stability is required for proper distal mobility.  An adjunct treatment that has been proven beneficial for tendonitis or tenosynivitis problems is the ASTYM system (see below for link to more information on this system).  A safe progression back to sports or high-level activities may happen when each of the following happens in this specific order:

1. The lower kneecap is no longer tender and there is no swelling.
2. The injured knee can be fully straightened and bent without pain.
3. The knee and leg have regained normal strength compared to the uninjured knee and leg
4. Ability to jog straight ahead without limping.
5. Ability to sprint straight ahead without limping.
6. Ability to do 45-degree cuts.
7. Ability to do 90-degree cuts.
8. Ability to do 20-yard figure-of-eight runs.
9. Ability to do 10-yard figure-of-eight runs.
10. Ability to jump on both legs without pain and hop on the injured leg without pain.
    

Key Research

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Resources

www.astym.com/

For a video presentation on SLJ, please click on link below

  http://www.dailymotion.com/video/xa38v7_dr-marshall-discusses-sindinglarsen_sport

References: www.childrensmemorial.org/depts/sportsmedicine/slj.aspx www.kneeclinic.info/problems_other_knee_conditions.php

[1] Medlar, R. C., et al., ‘Sinding-Larsen-Johansson Disease. Its Etiology and Natural History’, Journal of Bone & Joint Surgery, December 1978, vol. 60, no. 8, p. 1113-1116. (Level of Evidence 1B)

[2] Houghton, K. M., ‘Review for the generalist: evaluation of anterior knee pain’, Paediatric Rheumatology, (2007), vol. 5, p. 4-10. (Level of Evidence 2B)

[3] Sinding-Larsen- Johansson Syndrome (distal patella apophysitis)’, internet, (19 november 2010), (http://www.childrensmemorial.org/depts/sportsmedicine/slj.aspx). (Level of Evidence 5)

[4] Demetrious, T. and B., Harrop (red.), Sinding-Larsen-Johansson Disease, internet, 2008, (http://www.physioadvisor.com.au/10246650/sindinglarsenjohansson-disease-physioadvisor.htm). (Level of Evidence 5)

[5] Klucinec, B., ‘Recalcitrant Infrapatellar Tendinitis and Surgical Outcome in a Collegiate Basketball Player: A Case Report’, Journal of Athletic Training, June 2001, vol. 36, no. 2, p. 174-181. (Level of Evidence 1C)

[6] Hagen, K., ‘Anterieure Kniepijn’, Afstudeeropdracht fysiotherapie HvU, 2005, p. 1-8. (Level of Evidence 2A)

Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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