Revista de Medicina Desportiva (English) November 2018 - Page 26

presence of an anterior isolated ossicle that corresponds to its ossi- fication center that was previously avulsed. 9-11 disappears and only a prominent anterior tibial tuberosity will be left (Figure 3). 5-8,16,17 Natural history The echography over the patellar tendon, including its tibial inser- tion, can be a good diagnostic test. MRI can be indicated when there are still doubts after clinical evalua- tion. 4,6-8,12,15,19 Etiology It is unknown the etiology os OSS, although there are several studies that associate this pathology to some variations that increase the traction strength of the extensor apparatus over the anterior tibial tuberosity: pronated feet, valgus knees and medial rotation and patella alta. 13-15 The majority of the researchers indicate that OSS is a self-limiting pathology, with spontaneously reso- lution, where 90% of the patients will recover. About 10% of the patients will have the symptoms until adulthood independently of the conservative treatment. 5-7, 16,17 Differential diagnosis Clinical presentation The symptomatology varies from slight local discomfort to incapaci- tating pain. Usually is characterized by a vague gradual increasing pain and a tumefaction located over the tibial tuberosity. On the beginning, there is moderate and intermittent pain. During the acute phase pain is severe, continuous with signifi- cant functional incapacity. The pain worsens after physical exercise, especially if it involves jumps and running, like basketball, volleyball and running, and /or direct con- tact, like kneeling. 16 Pain is often of mechanical type that relieves when there isn’t tension over the extensor apparatus of the knee. So, the typical clinical picture includes a male adolescent, between 12 and 15 years of age, involved on physical exercise, that indicates pain and shows a tumefaction over the anterior tibial tuberosity, gradually onset on nature, that aggravates after physical activity. During the acute phase there is tenderness, tumefaction and prominence on the tibial tuberosity. Pain can be repro- ducible by local palpation and resis- tive knee extension, which is a test that stresses the extension appara- tus of the knee and causes traction on the anterior tibial tuberosity. If the patient is unable to actively extends the knee it must be considered and eventual complete avulsion of the anterior tibial tuberosity or a compromise on the tendinous extension mechanism. After acute phase, pain and tumefaction usually 24 november 2018 www.revdesportiva.pt On all young physical practition- ers with gradual arising knee pain, that worsens during and after sports practice, either unilateral or bilat- eral, it should be considered, besides OSS, the following diagnosis: Sind- ing-Lansen-Johansson syndrome, a similar osteochondrosis that afflicts the lower extremity of the patella bone, the Hoffa syndrome, which is an inflammation of the fat pad under the patellar tendon, and a fracture of the anterior tibial tuber- osity. It also must be considered are the patelofemoral pain, infections and tumors. 18,19 Complementary diagnostic tests The diagnosis of OSS is mainly clinical and rarely the exams are needed. 8 A profile knee X-ray with the lower limb on 10-30° of medial rotation can show the irregularity of the anterior tibial tuberosity, where avulsion can be found on the initial stages, but on the more advanced stages there might exist fragmenta- tion. In some cases, even after fusion and closure of secondary ossification center, it can be detected a unique isolated anterior ossicle (Figure 4). Figure 3 – The lateral view of the knee reveals the prominent tibial anterior tuberosity on an OSS case (arrow). Treatment There aren’t any prospective, con- trolled, randomized studies that evaluated the bet treatment for OSS. Therefore, in the literature only retrospective studies are found about the treatment of this pathol- ogy. The symptomatic treatment is recommended on the early stage. During the symptomatic phase the physical activity should be avoided and the application of local ice, nom-steroids anti-inflammatory drugs and knee brace protectors must be prescribed. Provided the patient can handle it, physical activity shouldn’t be forbitten at all. The patients with moderate pain and without functional impairment should keep regular physical exer- cise associated with nom-steroids anti-inflammatory drugs and knee brace protectors. On those patients with severe pain, associated or not to physical impairment, physical activity should be avoided for a few days. 6,8,13 Physiotherapy and a conditioning and strength rehabilita- tion program are a very important component for the treatment of OSS. They should be implemented right after the acute phase and strength- ening and stretching of the regional muscle involved on the mobility of the knee are recommended. Initially, low intensity isometric exercises are indicated and then exercises with increasing intensity are prescribed. Some studies demonstrate that about 90% of the patients have good results with the application of ice, nom-steroids anti-inflammatory drugs and relative rest. 20-22 However, Figure 4 – A profile knee X-ray revealing the ossicle at the tibial tuberosity, typical changes in the OSS (arrow).