Home » MSK Ultrasound case studies » Knee » Patella tendinopathy and non-union of the ossification centres – Dr Matthieu Sailly (@MedecinsDuSport) Sports Medicine Physician, Switzerland

Patella tendinopathy and non-union of the ossification centres – Dr Matthieu Sailly (@MedecinsDuSport) Sports Medicine Physician, Switzerland

Following on from the recent case I posted on patellar tendinopathy and the role of diagostic MSK Ultrasound, Dr Matthieu Sailly, Sports Medicine Physician at Centre Synergie Medical, Lausanne in Switzerland got in touch and has contributed the following clinical thoughts on patellar tendinopathy and non-union of ossification centres. With a focus on the potential sequel of complaints that may arise  following  non union of the ossification centre.

Tibial tuberosity

Osgood Schlatter disease (OSD) may lead to chronic symptoms in 5 to 12% of the cases depending the literature (1). Distal patellar tendinopathy is not so frequent. This condition is often associated with bone graft harvest following ACL reconstruction or non-union of the ossification centre.

During the endochondral ossification, a part of the ossification center does not fuse properly leading to a definitive non-union. This an example from a young talented basketball player (Figure 1) . He is 18 yo and has a past history of OSD. He is currently symptom free because this is the off season. He reports some pain during kneeling or during direct trauma on this area.

osgoodtake2
Figure 1: Longitudinal view of the patellar tendon on the tibial tuberosity. The tendon looks normal and a non-union defect is seen at the deep portion of the tendon.

Base of patella 

In some cases, proximal patellar tendinopathies are associated with local impingement during knee flexion due to an “aggressive tip of patella” (2). This is illustrated below.

This deformity of the tip of the patella may be related to the non-union of the ossification centre.  This is an example of ballet dancer 19 yo. She complained of a jumper’s knee for 3 months, and was referred to our clinic. The ultrasound scan in clinic demonstrated an ossification defect visible at the deep portion of the tendon that created impingement during knee flexion. The patellar tendon has a hypoechoic signal, loss of fibrillar aspect, Doppler signal. Interestingly the superficial layer of the tendon looks normal.

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Figure 2: Longitudinal view of the patellar tendon on its proximal insertion onto the tip of patella. An ossification defect is visible at the deep portion of the tendon.
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Figure 3: Vascularity demonstrated on power doppler for the proximal portion of the patellar tendon.

During follow-up the deep portion of the tendon remained the  same despite symptoms  improving.

Overall, apophysitis is a common pathology this is often underestimated. Additional studies should look at the long-term consequences and the relation with some insertional tendinopathy during adulthood.

Dr Sailly works at Centre Synergie Medical, Lausanne. You can also follow him on twitter @MedecinsDuSport!

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References

1) Rosenberg ZS, Kawelblum M, Cheung YY, Beltran J, Lehman WB, Grant AD. Osgood-Schlatter lesion: fracture or tendinitis? Scintigraphic, CT, and MR imaging features. 1992 Dec;185(3):853-8

(2) Johnson DP, Wakeley CJ, Watt I. Magnetic resonance imaging of patellar tendonitis. Journal of  Bone Joint Surgery (Br) 1996 May;78(3):452-7

A further article of interest may be this full text from Dr Sailly and colleagues..

Sailly, M., Whiteley, R. & Johnson, A( 2012) Doppler ultrasound and tibial tuberosity maturation status predicts pain in adolescent male athletes with Osgood-Schlatter’s disease: a case series with comparison group and clinical interpretation, British Journal of Sports Medicine.

Carr, J. et al (2001)  Sonography of the Patellar Tendon and Adjacent Structures in Pediatric and Adult Patients, American Journal of Roentgenology, pp-15351539.

For further thoughts on patellar tendinopathy and the use of MSK Ultrasound and MRI view a different article HERE

 

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3 comments

  1. Thanks Matthieu, it’s interesting to see the management strategy of others as tendinopathy is one of those areas where so many approaches shout for primacy! I feel MSK medicine lacks a definitive approach to these!

    Interesting you mention isometric exercises as I’ve always gone for Alfredson’s paradigm involving eccentric loading and am interested in how they both compare concerning the intra-tendinous forces and remodelling. I had a patient with very severe insertional achilles tendinosis with extensive neovascularisation and who had been wrongly doing Alfredson’s protocol concentrically for 8 weeks with severe pain but after only 1 month of switching to eccentric loading (with a complete reversal in pain) the US evidence showed almost complete absence of neovascularisation (although the appearance of the tendinosis was unchanged and the asymptomatic contralateral tendon demonstrated similar changes).

    In those cases where healing is sluggish I go for US guided dry needling of the vessels with paratenon infiltration of long acting anaesthetic although not Otto Chan’s high volume dilatation method (and with strict instructions to off load the tendon initially and slowly rehab under guidance).

    Our NHS clinic currently doesn’t have facility for PRP and, as is the way with such state funded systems, one has to make a very good case to convince commissioners to invest! Even ECSWT is on ‘trial only’ basis within the NHS but I’m hoping our new county wide MSK service will be able to participate with research centres and innovate in the provision of such treatments.

    All the best.

  2. Hey Richard,
    It depends the site: insertional vs corporeal.
    In this case of ballet dancer / insertional tendinopathy, my prefered sequence is
    1. 6 weeks of rehabilitation with restricted training (no landing and deep knee flexion)
    > isometric strengthening, fonctional retraining of landing technique (glut activation)
    > quad strengthening
    > progressive exc
    2. If failure, shock wave therapy (1/week for 6 weeks) for pain management and keep rehabilitation
    3. If failure, (3months rehab in total), ViSAp stagnation and not able to resume dance, I would ask for surgery opinion.
    I am not conviced that Prp may help in this particular case due to the mechanical impingment. (Tip of patella vs deep tendon portion)
    I am using Prp in insertional achilles tendiopathy when bursitsis is present (positive effect on buristis++). Injecting the bursa , the ventral portion of the tendon and the fat pad.
    Matthieu

  3. Richard Collins

    Matthieu, thanks for this. Can I ask how you treated the ballet dancer? Do you have a preferred sequence for managing severe tendinosis with neovascularisation? e.g. eccentric loading first or dry needling/PRP etc…

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