Sinding-Larsen-Johansson disease (also known as patellar tendinopathy) is an inflammatory condition of the patellar tendon attachment to the kneecap. It results from overuse of the knee joint and predominantly affects athletes and young people.
What is Sinding-Larsen-Johansson disease?
Sinding-Larsen-Johansson disease is a chronic degenerative inflammation in the knee joint. It originates from the site where the patellar tendon attaches to the lower tip of the patella. The patellar tendon absorbs stresses that act on the knee joint. Overuse can cause irritation or inflammation of the patellar tendon at its attachment. Symptoms include severe pain on exertion as well as restricted movement. In advanced stages, the disease can lead to tendon rupture or necrosis of the patella with detachment of bone fragments. The disease is named after the Norwegian physician Christian Magnus Falsen Sinding-Larsen and the Swedish physician Sven Christian Johansson. They first described the disease independently in 1921 and 1922, respectively.
Causes
The main cause of Sinding-Larsen-Johansson disease is overuse of the knee joint. Frequent or prolonged heavy tensile stress on the patellar tendon can lead to inflammation, especially if the stress is unfamiliar. Risky are primarily jumping sports, rapid changes of direction in running and abrupt stop-and-go movements. Accordingly, Sinding-Larsen-Johansson disease frequently affects basketball and volleyball players, long and high jumpers, tennis and soccer players. But joggers, skiers and weightlifters are also at risk. But the complaints are not always based on an external cause. Internal causes include a raised patella, congenital ligament weakness and reduced extensibility of the muscles in the region of the knee joint. Genetic influences also cannot be ruled out. Furthermore, deformities of the pelvis, spine, or feet may lead to Sinding-Larsen-Johansson disease.
Symptoms, complaints, and signs
The leading symptom of the disease is severe pain in the area of the knee joint, more specifically below the kneecap. In some cases, redness or swelling also occurs. The knee joint is sensitive to pressure and mobility is limited. Stretching the leg is painful. After physical exertion, the pain is particularly pronounced. In advanced stages, the pain initially disappears shortly after the start of exercise, but recurs after exercise. Later, the pain persists even at rest. In 20 to 30 percent of patients, the symptoms occur on both sides. Since these symptoms can indicate various diseases of the knee joint, an early visit to the doctor is advisable for clarification and to initiate appropriate therapy.
Diagnosis and course of the disease
As part of the diagnostic process, the first step is a medical history discussion. The physician inquires about the patient’s complaints, possible previous illnesses and lifestyle habits, including sports activities. This is followed by a physical examination. In the case of Sinding-Larsen-Johansson disease, a pressure pain can be detected at the level of the lower tip of the patella. Stretching the leg is possible only with pain. If the examination confirms the suspicion of Sinding-Larsen-Johansson disease, the next step is an ultrasound examination, magnetic resonance imaging (MRI) or X-ray examination. These procedures map changes in the bone structure of the knee joint, the tendon and the surrounding structures. This allows the degree of inflammation to be seen. Sinding-Larsen-Johansson disease can progress through four different degrees (classification according to Roels et al., 1978). Initially, pain occurs only after exertion. If the degree of inflammation increases, the pain occurs at the beginning of an exertion but then disappears temporarily, only to return after the exertion has ceased. If it continues to worsen, the pain persists beyond exertion in everyday situations and at rest. Lastly, rupture of the patellar tendon occurs. Necrosis of the patella may also occur. If Sinding-Larsen-Johansson disease is diagnosed and treated early, the prognosis is very good. Otherwise, there is a risk of chronicity of the pain.Even after healing, avoid excessive stress on the tip of the patella.
Complications
Due to Sinding-Larsen-Johansson disease, the affected person primarily suffers from very severe and stabbing pain that occurs directly at the patient’s kneecap. The pain results in severe limitations in everyday life and also in restricted movement. Usually, the affected regions are swollen and the pain intensifies when pressure is applied to the area or when the knee is moved. Similarly, the pain in the knee may take the form of pain at rest and thus also affect the sleep of the affected person. This results in sleep disturbances, fatigue and general irritability of the patient. The quality of life of the affected person is significantly reduced and limited by Sinding-Larsen-Johansson disease. Complications usually occur if the knee continues to be loaded. This can also result in irreversible damage to the knee. In most cases, treatment does not require surgery and complications do not occur. The symptoms themselves can be limited by therapies. The life expectancy of the affected person is also not affected by Sinding-Larsen-Johansson disease. Thereby, a positive course of the disease occurs in most cases.
When should one go to the doctor?
If knee discomfort occurs after athletic activities or heavy physical exertion, adequate rest and sparing should be given. If there is significant relief of discomfort or complete recovery after rest or a restful night’s sleep, a doctor is not needed. In these cases, there is an overload that is healed independently by the body’s self-healing mechanism. If the complaints continue unabated or increase in intensity, a doctor should be consulted. A visit to the doctor is also advisable if pain or impairment of the knee joint develops immediately with the onset of movement. If the affected person suffers from a decrease in physical performance or resilience, a check-up visit to a doctor is advisable. If poor posture or incorrect loading of the body occurs, a doctor is needed. If athletic activities can no longer be performed as usual, if tenderness develops, or if sensory disturbances occur in the knee, medical attention is needed. If there is an inability to fully extend or bear weight on the knee, there is a health disorder that needs to be treated. Irregularities in blood flow, changes as well as discoloration of the skin appearance and abnormalities in behavior should be presented to a physician for evaluation.
Treatment and therapy
To counteract the spread of inflammation, therapy should be initiated as soon as possible. Regeneration is protracted, lasting up to one year. Nevertheless, conservative therapy is sufficient in about 90 percent of cases. The most important thing is to take it easy on the affected knee joint. Regular stretching of the thigh muscles reduces the tension in the area of the kneecap. Further treatment depends on the degree of the disease. Warm or cold compresses, physiotherapy and manual therapy are general measures that positively influence the course of the disease. Electrostimulation, ultrasound and shock wave treatment are also used successfully. Naturopathic therapies such as homeopathy, phytotherapy and treatment with Schuessler salts can further support healing. The goal of all these treatments is to promote regeneration by activating local metabolism and stimulating regional circulation. Relaxation of the thigh muscles reduces traction forces on the kneecap. Furthermore, anti-inflammatory drugs and painkillers help. If conservative therapy methods are not sufficient, surgery in the form of arthroscopy is performed. Common procedures include removal of inflammatory tissue or parts of the patellar tendon, denervation of the area around the tendon, release of the patellar tendon from the tip of the patella, and removal of dead bone tissue.
Outlook and prognosis
The prognosis for Sinding-Larsen-Johansson disease is generally considered favorable. A prerequisite for this is that patients receive a prompt start to treatment. Depending on the extent, conservative or surgical measures are used.Compliance with recommended rules of conduct over the next three to twelve months is essential for recovery. These include rest, cooling, taking painkillers and physiotherapy. Only in the context of consistent implementation can a final cure be achieved. If treatment is not started, long-term movement restrictions and pain regularly result. Although this does not shorten the patient’s life, the quality of life suffers considerably in some cases. In practice, Sinding-Larsen-Johansson disease is diagnosed more frequently in men than in women. After treatment of Sinding-Larsen-Johansson disease has been completed, certain types of sports should be avoided. The amount of physical exertion should also be significantly reduced. This is the only way to ensure freedom from symptoms of the patellar tendinitis. The treating physician talks to his patient about sports activities practiced and makes recommendations. Adherence to the advice improves the prospect of lifelong freedom from symptoms. Their implementation is the sole responsibility of the patient.
Prevention
To prevent overuse of the patellar tendon, it is especially important to warm up well before sports and to stretch the muscles regularly. When starting a new sport, the load on the knee joint should be increased slowly. There must be sufficient time for regeneration between sports units. In case of malalignment, orthopedic insoles reduce the risk of developing Sinding-Larsen-Johansson disease. If pain occurs in the area of the knee joint, the load should be reduced immediately.
Follow-up
Aftercare for Sinding-Larsen-Johansson disease focuses primarily on sparing the affected knee joint. The regeneration phase goes on for a longer period of time, usually about twelve months. In severe cases, regeneration can take up to two years. If symptoms persist after completion of therapy, abstention from sports activities is indicated. If the patient is symptom-free or has only mild symptoms, light sports activities can be resumed. Rarely, treatment with analgesics is necessary. Taking painkillers, such as paracetamol, is possible for a short time. For pain after physical activity, cooling compresses applied to the affected area will relieve pain. The compresses are then applied for about 20 minutes. Sports that are easy on the knee, such as cycling or swimming, are suitable during the recovery phase. The resumption of sporting activities takes place in small steps. A build-up training for the thigh extensor (quadriceps) supports the further regeneration. Future overloading of the joints promotes the recurrence of Sinding-Larsen-Johansson disease. Pain in the knee and hip should be clarified with the treating physician to avoid a relapse. Malalignment in the hip, ankle or knee joints is treated in parallel with patellar tendinopathy to relieve pressure on the knee joint. This requires the use of orthopedic insoles. Only in a few severe cases is there no improvement in symptoms despite rest. Then the inflamed tendon material is removed in an operation.
What you can do yourself
Since Sinding-Larsen-Johansson disease is a disease with physical causes, everyday management and self-help are aimed at mitigating the symptoms. The inflammation associated with the disease can be alleviated primarily by cooling. In this way, pain symptoms are combated. In addition, affected patients should refrain from physical exertion through sports in order not to run the risk of aggravation. On the other hand, patients should not forgo exercise. Physiotherapeutic exercises are a good way to maintain motor skills and prevent the muscles from deteriorating. For example, it is advisable to exercise the thigh extensor, as this muscle is most likely to be affected by Sinding-Larsen-Johansson disease. In addition, if the pain is severe, sufferers can turn to medications that have an anti-inflammatory or analgesic effect. Paracetamol is a good choice for this purpose. However, a doctor should be consulted if the medication is taken regularly, in order to avoid side effects or consequential damage from taking painkillers. In addition, the affected joint should not be placed in a position of rest.On the one hand, if carried out over the long term, gentle postures can lead to deformities and, on the other hand, accelerate muscle degeneration. For those affected, it is advisable to make everyday life as normal as possible.
