[ musculoskeletal imaging ]

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FIGURE 1. Lateral radiograph of the right knee, displaying
a lucency (arrow) at the distal portion of a large ununited
ossicle.
Copyright © 2017 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
FIGURE 2. Power Doppler sonogram of a long-axis view
of the patellar tendon (blue arrow), with evidence of
inflammation of Hoffa’s fat pad (orange arrow). The left
side of the image is proximal.
FIGURE 3. Sagittal-oblique, T2-weighted, fat-saturated
magnetic resonance image of the right knee showing
Hoffa’s fat pad edema due to a large ununited ossicle
(arrow). Also note the edema within the proximal tibia
donor site and within the distal patellar tendon.

Ununited Bone Ossicle in a Patient

With Patellar Tendinopathy
EMILY B. BEYER, PT, DPT, SCS, M ayo Clinic Sports Medicine Center, Mayo Clinic, Minneapolis, MN.
ELENA J. JELSING, MD, P
 hysical Medicine and Rehabilitation, Mayo Clinic College of Medicine, Minneapolis, MN.
WENDY J. HURD, PT, PhD, SCS, M  ayo Clinic College of Medicine, Mayo Clinic, Minneapolis, MN.
Journal of Orthopaedic & Sports Physical Therapy®

A
40-year-old man presented to
a physician for knee pain when
squatting and in resisted knee ex-
tension. The initial diagnosis was patellar
tendinopathy. Physical therapy treatment
for 6 visits over 12 weeks included quad-
riceps stretching and eccentric single-leg
squats but provided minimal reduction
in pain symptoms. Three months from
the start of treatment, a sports medi-
cine physician was consulted for a sec-
ond opinion on the cause of the patient’s
refractory anterior knee pain. Physical
examination by the consulting physician
revealed full knee flexion and extension
range of motion, with end-range pain,
distal patellar tendon tenderness, and
swelling in the patellar tendon and sur-
rounding soft tissues.
Radiographs revealed a large ossi-
fication adjacent to the tibial tubercle,
consistent with prior Osgood-Schlatter
disease. Lucency in the distal aspect
of the ossification suggested a possible
chronic fracture (FIGURE 1), observed in
approximately 10% of the population.1
Diagnostic ultrasound revealed patellar
tendinopathy, a large ossicle deep to the
distal patellar tendon, and significant
Hoffa’s fat pad thickening and edema
(FIGURE 2). Additional findings from mag-
netic resonance imaging revealed partial-
thickness tearing of the distal patellar
tendon, reactive tendon edema, and a
large ununited fragment of the anterior
tibia (FIGURE 3). Inflammation appeared
to be a result of Hoffa’s fat pad impinge-
ment secondary to the ununited ossicle.
The patient elected conservative treat-
ment over surgical excision of the ossicle.
The original diagnosis of patellar ten-
dinopathy was accurate; however, the
substantial swelling warranted advanced
imaging by the sports medicine physician.
Subsequent treatment to address Hoffa’s
fat pad impingement included activity
modification, a compression sleeve, fat
pad taping, and strengthening exercises.
Following 3 physical therapy visits over
6 weeks, pain was no longer present with
stair or squatting exercises. Health care
providers may consider advanced imaging
in cases of persistent patellar tendon pain
and swelling nonresponsive to tradition-
al conservative treatment strategies.2 t
J Orthop Sports Phys Ther 2017;47(11):885.
doi:10.2519/jospt.2017.7443

References
1. Mital MA, Matza RA, Cohen J. The so-called unresolved Osgood-Schlatter lesion: a concept based on fifteen surgically treated lesions. J Bone Joint Surg Am. 1980;62:732-739.
2. Vaishya R, Azizi AT, Agarwal AK, Vijay V. Apophysitis of the tibial tuberosity (Osgood-Schlatter disease): a review. Cureus. 2016;8:e780. https://doi.org/10.7759/cureus.780

journal of orthopaedic & sports physical therapy | volume 47 | number 11 | november 2017 | 885

47-11 MI Beyer 3.indd 885 10/18/2017 2:32:19 PM