The ultrasound appearance of the patellar tendon attachment to the tibia in young athletes is conditional on gender and pubertal stage

Ducher, Ga͏ële; Cook, J.; Lammers, Gregory John; Coombs, Peter; Ptazsnik, Ron; Black, J.; Bass, Shona

doi:10.1016/j.jsams.2009.03.003

Cited by 25 publications

(40 citation statements)

References 9 publications

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“…The initial hypothesis described the repetitive traction of the patellar tendon on the distal insertion as the main area of secondary ossification centre fragmentation and transitory necrosis 412 13 This fragmentation has been questioned as a definitive sign of OSD and has subsequently been seen as a normal development of the ATT 14. Fragmentation of the ATT is found in symptomatic as well as asymptomatic knees and therefore cannot be used to discriminate between the normal and abnormal pathology 14–17.…”

Section: Introductionmentioning

confidence: 99%

“…Fragmentation of the ATT is found in symptomatic as well as asymptomatic knees and therefore cannot be used to discriminate between the normal and abnormal pathology 14–17. Subsequent to these studies, Ducher et al 14 developed a maturation staging of the ATT using ultrasonography. Three developmental stages are described, principally in asymptomatic subjects.…”

Section: Introductionmentioning

confidence: 99%

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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

2012

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BackgroundThe pathogenesis of the Osgood-Schlatter's disease (OSD) is still debated. The fragmentation of the ossification centre has been questioned as a definitive sign of OSD and has been seen as a normal development of the anterior tibial tubercle (ATT).ObjectivesIt is unknown if such changes are present in the presumed pathological tendon insertion seen in OSD, nor the relation of Doppler-positive changes to pain on clinical examination.MethodsA prospective analysis was carried out on 20 consecutive symptomatic male athletes (13.9 years±1.3) and a comparison group of asymptomatic subjects. All underwent a comparative clinical assessment and ultrasound with colour Doppler scan on both knees. Subjective pain was recorded with a visual analogue scale (VAS) during provocative manoeuvres: palpation, resisted contraction and single leg squat.ResultsPositive Doppler US (within the distal end of the patellar tendon) was associated with higher pain on palpation (47±24.5 vs 18±11.4, p<0.01) and resisted static contraction (59±20.2 vs 27±12.5, p<0.001) compared with Doppler-negative subjects. No Doppler activity was found in the comparison group. VAS for palpation and resisted contraction of the athletes graded as stage 2 (51.1±22.0 and 60.0±21.2) were significantly higher than stage 3 (17.8±12.0 and 18.9±16.9) and stage 4 (15.0±7.1 and 25.0±7.1; p<0.01).ConclusionsMore painful OSD is associated with the presence of neo-vessels. This may be linked with a particular stage of ATT maturation and applied compressive forces. A Doppler ultrasound scan adds practical information to develop the care plan of the patient.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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

2012

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“…Sequential knee ultrasound imaging of tennis athletes going through puberty has demonstrated that ossicles (separated cartilage that ossifies) within hypoechoic cartilage are common and usually asymptomatic. 2,3 An ossicle may impinge on the patellar tendon, causing long-term impairment of kneeling or running. 4 However, a sequential MRI study of adolescents with symptomatic OSD revealed 100% with patellar tendon pathology and only 32% with ossicle formation.…”

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confidence: 99%

Hyperosmolar Dextrose Injection for Recalcitrant Osgood-Schlatter Disease

Topol¹,

Podestá

Reeves

et al. 2011

Pediatrics

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WHAT'S KNOWN ON THIS SUBJECT:Osgood-Schlatter disease symptoms may wax and wane until maturity and affect sport confidence and participation periodically. Chronic sequelae may include anterior knee pain, kneeling discomfort, or sports limitation. Symptom reduction parallels resolution of patellar tendinopathy by MRI/ultrasound, although ossicles may persist radiographically. WHAT THIS STUDY ADDS:Small-needle injection of the patellar tendon enthesis/tibial apophysis with 12.5% dextrose was safe and well tolerated in adolescents with recalcitrant OsgoodSchlatter disease. Dextrose injection resulted in more rapid and frequent achievement of unaltered sport and asymptomatic sport than did usual care. abstract OBJECTIVE: To examine the potential of dextrose injection versus lidocaine injection versus supervised usual care to reduce sport alteration and sport-related symptoms in adolescent athletes with OsgoodSchlatter disease. PATIENTS AND METHODS: Girls aged 9 to 15 and boys aged 10 to 17 were randomly assigned to either therapist-supervised usual care or double-blind injection of 1% lidocaine solution with or without 12.5% dextrose. Injections were administered monthly for 3 months. All subjects were then offered dextrose injections monthly as needed. Unaltered sport (Nirschl Pain Phase Scale Ͻ 4) and asymptomatic sport (Nirschl Pain Phase Scale ϭ 0) were the threshold goals. RESULTS: Sixty-five knees in 54 athletes were treated. Compared with usual care at 3 months, unaltered sport was more common in both dextrose-treated (21 of 21 vs 13 of 22; P ϭ .001) and lidocaine-treated (20 of 22 vs 13 of 22; P ϭ .034) knees, and asymptomatic sport was more frequent in dextrose-treated knees than either lidocaine-treated (14 of 21 vs 5 of 22; P ϭ .006) or usual-care-treated (14 of 21 vs 3 of 22; P Ͻ .001) knees. At 1 year, asymptomatic sport was more common in dextrose-treated knees than knees treated with only lidocaine (32 of 38 vs 6 of 13; P ϭ .024) or only usual care (32 of 38 vs 2 of 14; P Ͻ .0001). CONCLUSIONS: Our results suggest superior symptom-reduction efficacy of injection therapy over usual care in the treatment of OsgoodSchlatter disease in adolescents. A significant component of the effect seems to be associated with the dextrose component of a dextrose/ lidocaine solution. Dextrose injection over the apophysis and patellar tendon origin was safe and well tolerated and resulted in more rapid and frequent achievement of unaltered sport and asymptomatic sport than usual care. Pediatrics 2011;128:e1121-e1128

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“…Using grey-scale ultrasound imaging, demonstrated that the tibial end of the patellar tendon matures during puberty. The tibial attachment is a cartilage attachment ~1.8 years before PHV, enthesial fibrocartilage immediately after PHV, where a mature attachment is seen ~2 years after PHV 10,11 . Interestingly, the development of pain appears to be related to certain stages of the maturation process of the tibial insertion, suggesting that aberrant loading during maturation can have a negative effect on the tendon attachment 26 .…”

Section: Discussionmentioning

confidence: 99%

“…While tendon development is not solely dependent on peak height velocity and other factors may influence maturation, it does appear that pre and peri PHV are important stages for the transition of the proximal patellar tendon attachment to mature tendon. Prospective research is needed to improve our understanding of how the proximal patellar tendon attachment develops throughout skeletal maturity, and whether the stage of tendon development impacts the risk of developing tendon pathology as has been shown at the distal attachment 10,26 .…”

Section: Discussionmentioning

confidence: 99%

Characterising the proximal patellar tendon attachment and its relationship to skeletal maturity in adolescent ballet dancersCharacterising the proximal patellar endon attachment and its relationship to skeletal maturity in adolescent ballet dancers

Rudavsky

Cook

Magnusson

et al. 2017

MLTJ

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SummaryBackground: It is unknown how and when the proximal attachment of the patellar tendon matures; puberty may be key in ensuring normal tendon formation. The aim of this study was to investigate the features of the proximal patellar tendon attachment at different stages of skeletal maturity, to help gain an understanding of how and when the tendon attachment matures. Methods: Sixty adolescent elite ballet students (ages 11-18) and eight mature adults participated. Peak height velocity (PHV) estimated skeletal maturity. Ultrasound tissue characterisation (UTC) scan was taken of the left knee and analysed for stability of echopattern. An image-based grading scale for greyscale ultrasound was developed to describe the tendon appearance. Anterior-posterior thickness was measured at the inferior pole of the patella, 1 and 2 centimetres distally. Outcomes were compared with skeletal maturity. Results: Mid-portion patellar tendon thickness increased with skeletal maturity (p=0.001 at 1cm and p=0.007 at 2 cm). There was more variance in structural appearance (greyscale classification and UTC echopattern) in pre and peri-PHV participants. Tendon attachment one-year post PHV appeared similar to mature tendons. Conclusions: Early adolescence was associated with highly variable tendon appearance, whereas the tendon appeared mature after PHV. Adolescence may be a critical time for the formation of normal tendon attachment. Level of evidence: IIb individual cohort study.

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The ultrasound appearance of the patellar tendon attachment to the tibia in young athletes is conditional on gender and pubertal stage

Cited by 25 publications

References 9 publications

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

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

Hyperosmolar Dextrose Injection for Recalcitrant Osgood-Schlatter Disease

Characterising the proximal patellar tendon attachment and its relationship to skeletal maturity in adolescent ballet dancersCharacterising the proximal patellar endon attachment and its relationship to skeletal maturity in adolescent ballet dancers

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