Tuberosity tibiae avulsion, which primarily affects children and adolescents, is a partial or complete avulsion of the tibial plateau. If the articular surface is also affected, it is a case of joint surface co-involvement. Then it is called an avulsion fracture.
What is a tibial tuberosity avulsion ?
This diagnosis, related to children and adolescents, is a total or partial avulsion of the tibial tuberosity, lat. tuberositas tibiae, in connection with a current sporting or joint-loading experience. If the articular surface is also involved, the term avulsion fracture is used. The term avulsion refers to a violent avulsion. In young domestic dogs, the term is used synonymously with “apophyseal necrosis of the tiberositas tibiae” in reference to aseptic disease of the affected bone. Formation of necrosis and subsequent detachment of the tibial bump is seen, which is referred to as tibial tuberosity avulsion. There is a similarity to Osgood-Schlatter disease in humans. Although the name is identical, it should be avoided because of some differences in relation to the dog.
Causes
In humans, spontaneous or sustained athletic activity is the most common cause. The joint is not or no longer able to cope with the load, resulting in overload and eventually joint damage. Existing joint arthrosis can also be responsible as a triggering symptom. The same applies to existing metabolic diseases such as gout and osteoarthritis. Diabetes mellitus and chronic inflammation such as polyarthritis are also known triggers. Certain sports such as volleyball and basketball, but also tennis and badminton, put strain on the entire joint and muscle mechanism. This is also true for weightlifting, soccer, road cycling, weightlifting and bodybuilding. As extrinsic (from the outside) occurring factor is responsible first of all a high jump frequency. This is followed by violent and unaccustomed loads. A too hard training floor promotes the risk of injury. Intrinsic (from within) injury factors include age. Thus, statistically, symptoms increase from the age of 15. If there is a leg length discrepancy, the shorter leg is less affected than the longer leg.
Symptoms, complaints and signs
The pain is load-dependent but does not occur only during running (running training). Actually, any movement that exerts a strong to very strong tension on the thigh muscles can be responsible for further pain from mild to very severe. In the initial stage, the pain occurs at the beginning and end of a load. If the injury progresses, the pain is constant. And not only during athletic exertion, but also during everyday activities such as climbing stairs, driving a car, or sitting up after prolonged periods of sitting. The angle at which the joint is located is also decisive for the intensity of the pain. Not infrequently, a chronic development is observed. Load peaks with stronger to severe pain then often alternate with symptom-free periods. Active extension against resistance is also painful. Only in 20 to 30 percent does a bilateral injury of this type occur.
Diagnosis and course of the disease
Sonography (ultrasound), MRI (magnetic resonance imaging), or projection radiography provide information about the actual condition of the affected joint. It is quite typical that no complete detachment of the tibia occurs. Bony fragments do not occur in the attachment of the patellar ligament, in contrast to Osgood-Schlatter disease. Three types can be classified according to Pfeil et al:
- Type I shows a displacement of the tibial tuberosity of less than 2 mm. In addition, there is a minimalized apophyseal surface.
- In type II, the apophyseal fracture shows a displacement of more than 2 mm.
- If type III exists, the apophysis is already widely displaced and there is an elevation of the patella. In addition, there is a step formation in the knee joint.
The classifications for the three types according to Watson-Jones are:
Type I represents an avulsion of the apophysis, but without damage to the tibial epiphysis. In type II, the epiphysis is cephalad elevated and incomplete. Type III shows that the proximal base of the epiphysis is displaced into the joint with the fracture line.
Complications
Tuberosity tibiae avulsion primarily causes very severe pain in the affected person. This pain occurs primarily during running or walking, but may also manifest as pain at rest. The patient may also have trouble sleeping and may become irritable. Often, the pain from the tuberosity tibiae avulsion also spreads to the neighboring regions. Physical activities or sporting activities are thus no longer possible for the patient without further ado. The patient’s joints are also permanently damaged by the complaint, so that movement restrictions may occur. If tuberosity tibiae avulsion already occurs in a child, the condition leads to significantly delayed development and thus also to disorders and complaints in the patient’s adulthood. Treatment of tuberosity tibiae avulsion is not associated with complications and can usually take place with the help of medication. The discomfort acquire thereby alleviated, however, the affected persons are dependent on a long-term intake of these medications. Various exercises can also have a positive effect on the course of the disease. Tuberosity tibiae avulsion usually does not negatively affect or reduce the patient’s life expectancy.
When should you see a doctor?
Since tuberosity tibiae avulsion cannot heal itself, the affected person must see a doctor to prevent further deterioration and also to prevent further complications. The sooner a doctor is consulted, the better is usually the further course of the disease. A doctor should be consulted in the case of tuberosity tibiae avulsion if the affected person suffers from slight pain in the thighs. This pain occurs for no apparent reason and does not usually disappear on its own. They can also occur in the form of pain at rest and therefore also have a negative effect on the patient’s sleep. The pain may also become more severe with increased exertion. The disease can be detected by a general practitioner. Further treatment is then usually carried out by a specialist. As a rule, this does not result in a reduction in life expectancy, although the further course of the disease itself depends greatly on the exact manifestation of the tuberositas tibiae avulsion.
Treatment and therapy
Type I initially allows for conservative treatment in the form of immobilization and cooling with ice, ice spray, and anti-inflammatory ointments and medications. Stabilizing knee bandages and injection treatments without cortisone (which would cause the tendon to tear) may also follow. Kinesiotape often leads to effective relief. If the tendon is completely torn, surgery becomes inevitable. If the disease is more advanced and has reached Type II or even Type III, osteosynthetic care is required Physiotherapy exercises to optimize the stretching ability of the hip flexor muscles and strengthen the hip extensor muscles are important. Exercise in the form of brisk walking or moderate running is advised for long-term improvement. Long distances, steep climbs and downhill stretches should only be undertaken with extreme caution, as they place too much strain on the diseased joint. Exercise in water, on the other hand, is particularly suitable.
Prevention
Overpronation and negative hip extension should be avoided. Shoes with pronation protection are recommended. Beginners should learn “correct running” slowly under sports therapy guidance and optimize it step by step. Joints as well as the entire musculature should not be trained without a warm-up phase. When training outdoors on cold days, warming ointments and protective clothing can protect against injury because they protect against hypothermia.
Aftercare
After successful treatment of a tuberosity tibiae avulsion, good and comprehensive aftercare is important to prevent long-term sequelae. The goal here should be, on the one hand, to prevent the reoccurrence of a tuberosity tibiae avulsion and, on the other hand, to permanently restore the complete mobility of the knee joint and leg.To achieve the latter, therapy for tibial tuberosity avulsion must be followed by intensive physiotherapy, during which the knee joint and leg are slowly strengthened again and restored to normal load-bearing capacity and mobility. Until this physiotherapeutic treatment is completed, sports should be avoided as far as possible in order not to put excessive strain on the affected leg(s). In order to prevent the recurrence of a tibial tuberosity avulsion, regular check-ups with an orthopedist should also be performed. For this purpose, imaging procedures (X-rays) are used in addition to an external examination. If necessary, the orthopedist can additionally prescribe knee bandages for sports, especially for the leg that is not (yet) affected, to stabilize and relieve the knee joint and thus prevent the symptoms of a tuberositas tibiae avulsion from developing again.
Here’s what you can do yourself
Type I tuberosity tibiae avulsion can be treated with conservative therapy that includes cooling and immobilization. Patients also need to take anti-inflammatory medications. Appropriate self-help measures include cooling, rest, and the use of natural analgesics and anti-inflammatories when appropriate. A walking aid is needed because of the movement restrictions. In severe cases, a wheelchair must be used. The patient should also be supported in everyday life. Physical activities, especially those involving the lower limbs, must be avoided. The physician will also recommend extensive physical therapy. The healing process can be aided by gentle massage, warm baths, and possibly alternative practices from Chinese medicine. Again, the physician must give his or her consent, as complications may arise under certain circumstances. In severe cases, osteosynthetic treatment is necessary. Patients should contact a specialist at an early stage, especially if severe pain or movement restrictions occur. Sports activities may be resumed after completion of the treatment. The exact steps to be taken should be discussed with the specialist and a physiotherapist. Other self-help measures are usually not applicable for tuberosity tibiae avulsion.
