Sinding Larsen Johansson Syndrome

Article by John Miller

What is Sinding Larsen Johansson Syndrome?

sinding-larsen-johansson syndrome

Sinding Larsen Johansson Syndrome is a juvenile osteochondrosis that disturbs the patella tendon attachment to the inferior pole of the patella.

Sinding Larsen Johansson syndrome is an inflammation of the bone at the bottom of the patella (kneecap), where the tendon from the shin bone (tibia) attaches. It is an overuse knee injury rather than a traumatic injury.

What Causes Sinding Larsen Johansson Syndrome?

In the skeletally immature or adolescent athlete, Sinding-Larsen-Johansson syndrome most likely results from a traction injury of the knee extensor mechanism at the junction of the patellar ligament and the inferior pole of the patella. This juvenile traction osteochondrosis is similar to Osgood-Schlatter syndrome.

Strong repetitive quadriceps contractions are thought to cause a traction force on the inferior pole, disrupting the immature bone. There is a higher incidence in active children during the adolescent growth spurt.

As a child grows, bones go through different stages of development.

  1. The patella pole is initially cartilaginous (cartilaginous stage). 

  2. It then enters the apophyseal stage when the secondary ossification center (apophysis) appears.

  3. The unity of the proximal tibial epiphysis with the tibial apophysis marks the epiphyseal stage.

  4. Lastly, when the growth plates fuse, the bony stage has been reached.

Children are most susceptible to Sinding-Larsen-Johansson syndrome when their bones are in the (2nd) apophyseal stage. During this phase the apophysis is unable to withstand high tensile forces. When presented with strong, repetitive muscle contractions, micro-fractures occur at the immature area. 

A potential cause for Sinding-Larsen-Johansson syndrome may be the lack of growth of the quadriceps in comparison to the femur. During a growth spurt in a child, the lengthening of the muscle is unable to keep up with the lengthening of the rapidly lengthening femur, resulting in increased tensile force on the patella.

Sinding-Larsen-Johansson Syndrome is more likely in active children who participate in sports that involve running, twisting, and jumping, such as basketball, football, volleyball, soccer, tennis, figure skating, and gymnastics.

What the Symptoms of Sinding Larsen Johansson Syndrome?

Localised pain, swelling or tenderness is felt at the front of your knee - at the base of your patella (kneecap), where the patella tendon inserts into the patella.

Patients are typically active boys aged 10 to 13 years but can also affect active girls a couple of years younger. Symptoms are usually:

  • Worse with exercise, stair climbing, squatting, kneeling, jumping and running.
  • Cause you to limp after exercise (as the condition progresses).
  • May be unilateral or bilateral.
  • Is relieved by rest

What is the Symptom Progression?

While a mild case of Sinding Larsen Johansson syndrome can resolve within a few weeks, severe cases must be professionally managed to avoid growth plate damage. The pain and swelling symptoms can potentially last for years. Longstanding Sinding-Larsen-Johansson syndrome can result in an avulsion fracture of the patella tendon, which can severely affect your ability to walk or run.

Fortunately, Sinding Larsen Johansson Syndrome is very successfully managed via physiotherapy.

How is Sinding Larsen Johansson Syndrome Diagnosed?

Sinding Larsen Johansson Syndrome is normally diagnosed clinically by your physiotherapist or doctor. Knee X-ray can show calcification or ossification at the junction between the patella and the patella ligament. MRI scan will exclude most other musculoskeletal injuries.

Treatment for Sinding Larsen Johansson Syndrome

Physiotherapy assessment and treatment is a proven benefit for Sinding-Larsen-Johansson syndrome sufferers. Left untreated most patients will fully resolve their symptoms within 3 to 18 months (Duri et al 2002). With the good management, most athletes will be able to return to their sport within 6 to 14 weeks (Iwamoto et al 2009).

Phase 1 - Knee Load Management

  • Immediate restriction of high impact activities such as jumping and running.
  • Low impact activities eg. cycling, cross-trainer, water running or swimming are usually fine.
  • Use an infrapatella knee strap to dissipate forces away from the site of Sinding-Larsen-Johansson syndrome. (Duri etal 2002) An example of a Sinding-Larsen-Johansson syndrome brace can be found at this link: http://bit.ly/186YgaR 
  • Kinesiology taping may provide both pain relief and load reduction at the site of pain and injury. 
  • Only on rare occasions severe Sinding-Larsen-Johansson syndrome may require crutches.

Consult with your physiotherapist for the best advice specific to your knee.

Phase 2 - Anti-inflammatory Treatment

Ice & Electrotherapy

A combination of ice treatment, electrotherapy and a home tens unit will reduce pain and improve the healing rate. This usually hastens the recovery rate of sufferers. Ice is useful at home or after exercise. (Michlovitz et al 2007)

Phase 3 - Functional Training

Rest is also important in the management of Sinding-Larsen-Johansson syndrome and relief of pain. It is best to discuss your exercise workload with your physiotherapist for advice on how to best manage your return sport while respecting your injury.

Whether or not you should continue playing sport is dependent on symptoms. Patients with mild symptoms may be able to continue to play some or all sport. Others may choose to modify their program. In mild cases, it may enough to just limit your physical activity so that the post-exercise pain is only mild and lasts for maximum of 24-hrs. When symptoms become worse it may be necessary to take a short break from your aggravating sports.

Phase 4 - Therapeutic Exercises

Stretching, Massage & Foam Rollers

One of the common reasons for developing Sinding-Larsen-Johansson syndrome is excessively tight quadriceps muscles, ITB, hamstrings, hip flexors and calf muscles. (Iwamoto et al 2009). Your physiotherapist will prescribe specific stretches for you if they assess that you are tight in these muscle groups.

Massage and foam rollers are beneficial especially in the early phase when stretches create pain at the Sinding-Larsen-Johansson syndrome site.

Strengthening

Your muscle control around the knee will usually need to be addressed to control or maintain your symptoms during the active phase of Sinding-Larsen-Johansson syndrome. Your physiotherapist will commonly prescribe or modify exercises for your quadriceps, hamstrings, calves, foot arch and gluteal (buttock) muscles. (Franchesci et al 2007)

Foot Arch Control & Orthotics

Your foot biomechanics or arch control may be inadequate for your intensity of sport. Your physiotherapist can assist both the assessment and corrective exercises for your dynamic foot control. Active Foot Correction Exercises can be beneficial as both a preventative and corrective strategy. More information can be found here: http://bit.ly/1b8CxkF

Occasionally, your foot biomechanics may be predisposing you to torsional stresses that can cause abnormal knee forces, which can cause knee injury. In these instances, foot orthotics may need to be prescribed. There are mixed views on how effective these are, since the foot structure is rapidly changing at this age. Ask your physiotherapist or podiatrist for advice.

Prognosis for Sinding Larsen Johansson Syndrome

Sinding-Larsen-Johansson syndrome is a self-limiting syndrome. Complete recovery can be expected with closure of the patella growth plate. Although symptoms of Sinding-Larsen-Johansson syndrome may linger for months, few patients have poor outcomes with conservative treatment, and surgical intervention is seldom necessary. Corticosteroid injections are not recommended due to case reports of subcutaneous atrophy.

More Information

For a thorough individualised assessment and professionally guided care for your Sinding-Larsen-Johansson syndrome please consult with your physiotherapist.

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Common Treatments for Sinding Larsen Johansson Syndrome

  • Early Injury Treatment
  • Avoid the HARM Factors
  • Soft Tissue Injury? What are the Healing Phases?
  • Sub-Acute Soft Tissue Injury Treatment
  • Active Foot Posture Correction Exercises
  • Gait Analysis
  • Biomechanical Analysis
  • Proprioception & Balance Exercises
  • Agility & Sport-Specific Exercises
  • Medications?
  • Soft Tissue Massage
  • Brace or Support
  • Electrotherapy & Local Modalities
  • Heat Packs
  • Joint Mobilisation Techniques
  • Kinesiology Taping
  • Prehabilitation
  • Running Analysis
  • Strength Exercises
  • Stretching Exercises
  • Supportive Taping & Strapping
  • Video Analysis
  • FAQs about Sinding Larsen Johansson Syndrome 

  • Common Physiotherapy Treatment Techniques
  • What is Pain?
  • Physiotherapy & Exercise
  • When Should Diagnostic Tests Be Performed?
  • Massage Styles and their Benefits
  • How Does Kinesiology Tape Reduce Swelling?
  • How Can You Prevent a Future Leg Injury?
  • How Much Treatment Will You Need?
  • Sports Injury? What to do? When?
  • What are Growing Pains?
  • What are the Common Massage Therapy Techniques?
  • What are the Early Warning Signs of an Injury?
  • What is a TENS Machine?
  • What is Chronic Pain?
  • What is Nerve Pain?
  • What is Sports Physiotherapy?
  • What's the Benefit of Stretching Exercises?
  • When Can You Return to Sport?
  • Helpful Products for Sinding Larsen Johansson Syndrome 

    Taping or a patella tendon support may provide pain relief and load reduction at the painful site. 

    Occasionally foot orthotics may need to be prescribed. There are mixed views on how effective these are, since the foot structure is rapidly changing at this age. Ask your physiotherapist or podiatrist for advice.

    Sinding-Larsen-Johansson Disease

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    Related Injuries

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  • Osgood Schlatter's
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  • Sinding Larsen Johansson Syndrome
  • Stress Fracture
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    Last updated 31-Dec-2013 06:01 PM

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