What is the best course of treatment for a patient experiencing burning pain from the tibial tuberosity?

Burning Pain from Tibial Tuberosity

Start with a structured 3-6 month trial of conservative management centered on eccentric quadriceps strengthening exercises, activity modification, topical NSAIDs, and cryotherapy, as this approach successfully resolves symptoms in approximately 80% of patients with tibial tuberosity pain. 1

Initial Diagnostic Approach

• Obtain plain radiographs first (anteroposterior and lateral views) to characterize any bony abnormalities, assess for fragmentation at the tibial tuberosity, or identify small osseous fragments suggesting prior trauma 1
• In the acute stage, look for blurred margins of the patellar tendon due to soft tissue swelling; after 3-4 months, bone fragmentation at the tibial tuberosity may appear 2
• The pain typically localizes to the anterior proximal tibia over the tibial tuberosity and is exacerbated by jumping, running, stair climbing, or kneeling 2, 3
• If radiographs are insufficient or clinical concern persists, order CT imaging with metal artifact reduction techniques to evaluate precise anatomical relationships and detect occult pathology 1

Conservative Management Protocol (First-Line Treatment)

Exercise Therapy

• Implement eccentric quadriceps strengthening exercises as the cornerstone of treatment, specifically targeting the vastus medialis obliquus (VMO) to improve patellar tracking and stability 1, 4
• Heavy slow resistance training serves as an evidence-based alternative to traditional eccentric protocols 1, 4
• Continue rehabilitation exercises as part of nonoperative treatment, which is effective in approximately 90% of patients 3

Activity Modification

• Reduce repetitive loading activities that reproduce pain, particularly jumping (basketball, volleyball), running, and stair climbing 1, 2, 3
• Implement relative rest rather than complete immobilization to avoid muscular atrophy and deconditioning 1, 4
• In some cases, restrict physical activities for several months until symptoms resolve 2

Pain Management

• Use topical NSAIDs preferentially over oral formulations to eliminate gastrointestinal hemorrhage risk while providing short-term pain relief 1, 4, 5
• Apply cryotherapy through a wet towel for 10-minute periods for acute pain episodes 1, 4, 5
• Consider oral paracetamol as the first-line oral analgesic if topical measures are insufficient 6

Surgical Intervention Criteria

Surgery is justified only after 3-6 months of well-executed conservative treatment has failed. 1, 4

Specific Indications for Surgery

• Persistent pain with kneeling due to an ossicle that does not respond to conservative measures 2
• Continued symptoms in skeletally mature patients who remain symptomatic despite conservative treatment 3, 7
• Removal of the ossicle, surrounding bursa, and bony prominence is the treatment of choice when surgery is indicated 2

Surgical Technique Options

• Arthroscopic surgery is beneficial over open procedures due to early postoperative recovery, no incisional scar causing discomfort with kneeling, better cosmetic results, and ability to address concomitant intra-articular pathology 7
• Open or arthroscopic excision of abnormal tissue with longitudinal tenotomies to release scarring and fibrosis can be performed 4
• Percutaneous fixation of the tibial tuberosity has been reported in refractory cases, with symptom resolution and return to sport within 6 weeks 8

Critical Pitfalls to Avoid

• Never inject corticosteroids directly into patellar supporting structures or periarticular tissues, as this inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture 1, 4
• Do not proceed to surgery without documenting an adequate 3-6 month trial of properly executed conservative treatment 1, 4
• Avoid complete immobilization, as this worsens outcomes through deconditioning and muscular atrophy 1, 4
• Do not use multiple corticosteroid injections, as they weaken structural integrity despite providing short-term symptom relief 4

Expected Outcomes and Prognosis

• Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment 1, 4
• This condition runs a self-limiting course, and complete recovery is usually expected with closure of the tibial growth plate 3, 7
• Overall prognosis is good, except for some discomfort with kneeling and activity restriction in a few cases 3, 7
• Resolution of symptoms may take several years in some cases, and a proportion of teenagers may be prevented from participating in sport for a prolonged period 8

Follow-Up Protocol

• Serial radiographs are essential to monitor for fragment migration, development of complications, or changes in surrounding bone 1
• If multiple tendons are symptomatic simultaneously, evaluate for underlying rheumatic disease 1, 4