Click here to view next page of this article

New Treatments for Patellar Tendonitis

Patellar tendonitis occurs at the level of the patella, also called jumper’s knee from repetitive jumping. Usually they have pain at the tendon insertion. Treatment once again, physical therapy, ice, rest anti-inflammatory medicines, patellar tendon straps. Most patellar tendonitis happens at the inferior pole of the patella, in adolescence they get Osgood Schlatter’s disease which is a traction epiphysitis at the insertion site. These immature patient’s get these traction injuries because of the issue of what’s strongest in their bodies, tendons and ligaments tend to be stronger than bone, so they pull off the tendon from the bone.

Osgood-Schlatter’s disease, the children are a little bit older, mostly boys 10 to 16 years of age once again with jumper’s. They have pain at the insertion site of the patellar tendon where the patella inserts into the tibial tubercle, treat these initially symptomatically with pain medicine, anti-inflammatories, strapping, in severe situations you sometimes have to cast them. They usually resolve pretty well. Once they reach adult hood, they no longer complain of this tendinitis, but they can have ossicles that are painful, especially in kneeling and in some situations, you have to remove these ossicles.

Overuse injuries can occur in any of the soft tissues, or even hard tissues of the body. About 30 to 50% of all sports practices are related to overuse injuries from repetitive trauma. The injury just overwhelms the soft tissue and failure occurs, so we see all types of athletes whether they are recreational or professional and it happens at all levels. Muscle and tendon injuries, it’s age dependent. Adolescents, their weakest structure in the muscular tendinous extent tends to be at the growth plate. As we become young adults, it’s the ligaments and the soft tissues, muscles and tendons. In older adults it tends to be the bone, and we see more fractures.

Tears can happen within the substance of the tendon, where the tendon attaches to the bone, where the ligaments attach to the bone, or at the muscular tendinous junction. Most common mechanism of injury is excessive amount of stretch. It is usually failure of the musculotendinous junction or the muscle tendon units, it can be an intrasubstance degeneration. Normal physiology, there is a crimp or a wavy pattern to the tendon. Once you exceed approximately 4% of strain on t hat tendon, you lose this wavy pattern, this wavy pattern, the hydrogen binding of the collagen molecules. As your strain increases up to 10%, you can start getting failure of the fibers themselves. Here is an EM of a tendon, you see the crimp pattern, as strain increases, you start getting failure.

Symptoms. Patient’s usually present with pain, swelling, pseudoparalysis, lack of motion, it could be acute, sharp or inability to actively move the joint. The picture on the right, it’s sort of hard to see but you start noticing some swelling just above the knee on the new leg, but it’s hard to determine it. Here, same patient, knee is bent, this is the thigh, here is the patella sitting in the wrong spot, palpating you see a defect directly in the level of the patellar tendon. Radiographs, this can make your diagnosis here, that’s too much of an extent from the patella down to the insertion site. Physical findings, you usually notice tenderness, you can have a palpable defect, there is usually a loss of motion, there is moderate amount of swelling, muscles have very good blood supply and bleed rapidly, ecchymosis is related to that. Plain radiographs are helpful, especially with avulsion type of injuries, or as you see in the patellar tendon x-ray that complete disruption where the patella is riding high. Rarely do you need an MRI to make this diagnosis, but sometimes it’s helpful in diagnostic dilemmas. You can see this fluid, this was actually mucoid degeneration of the patellar tendon in an athlete who was a runner, who continued to have patellar tendinitis despite appropriate nonoperative measures, it never healed properly.

Differential diagnosis is extensive, contusions, muscle injuries, avulsions injuries, tendons in the knee, you see a lot of patellar dislocations, you have to be concerned about that, or nerve injuries. Muscles usually heal, they heal with scar, since the injury happened because they tend to be tight to start with, they are tighter afterwards, once healing has occurred, so if your patient’s start developing muscular tears, they have to do a lot of therapy for stretching so that they are not prepositioning themselves to injury. Tendons, when tendons rupture, they usually require surgery, partial ruptures can be treated nonoperatively, if they have full function especially against resistance. Incomplete ruptures can later on result in complete ruptures. Surgical procedure for tendons, either direct repair or reconstruction, you can do tendon transfers or augment the tendon. On the slot on the right, you can see this is a gentleman that had a disruption of the patellar tendon, here is a tendon that’s flipped over, you see some more pictures of that, but it looks ratty like spaghetti strands. In nonoperative, care, it’s important to minimize the swelling, so when you see these patient’s you ice them, numerous studies have shown, especially with muscle injuries.

You need to stabilize the limb, you need to treat their pain, and if you can document tendon rupture, surgery is usually necessary. Here is that same patient, you can see the knee joint right in here from the disruption of the patellar tendon. Muscles usually take approximately a month to heal, after the month or so, a course of physical therapy rehabilitation is necessary. Tendons can take longer, you can immobilize them for a period of a month or two, then needs a prolonged period of physical therapy. Iliotibial band syndrome you see primarily in runners, they have some risk factors, pronators or people have an excessive amount of femoral anteversion that is putting rotation across the knee, stretching the ITB, at the hip, it’s the snapping hip syndrome, at the knee the iliotibial band runs across the lateral epicondyle and it can also snap. They usually have pain over the lateral femoral epicondyle, especially with hills. Treatment for this is mainly stretching. A lot of the soft tissue stuff you can deal with mainly with a course of physical therapy. 

Bursitis, multiple bursas throughout the knee, the prepatellar bursa, the infrapatellar bursa, you have bursas around the ITB pes tendons on the medial side, they are gastroc and semi-tendinosis. Bursas are fluid filled sacs, they are there to minimize friction, they can get inflamed, they can get septic, more commonly, the reason for sepsis is usually that there has been intervention, either with a needle or a puncture wound from an abrasion. Patient’s usually present with swelling, erythema, tenderness to palpation, you can treat these with aspirations if you are a little aggressive but you have to be concerned , it’s a prime media for infection, for bacteria to grow. Compressive bandages and anti-inflammatories are usually all they need. At the hip, we see greater trochanteric bursitis, this is common in the middle age groups, the runners, the athletes, especially with hills, especially when they are doing uneven surfaces. Their symptoms are usually pain over the top of the greater trochanter, when their hip does a lot of flexion extension as seen in hills. People that pronate cause a lot of rotation at the knee and the hip, and that’s a concern, you need to check feet, especially in runners, look at their feet. Treatment, anti-inflammatories, aspiration, injections, physical therapy, a lot of this stuff resolves if you curtail some of their activities.

The other issue that we get into with these sports related activities is lower leg pain, the classic triad of lower leg pain that becomes a diagnostic dilemma sometimes has a differential between compartment syndrome, shin splints and stress fractures. They happen in healthy, middle aged active people.