Quadriceps tendinosis and patellar tendinosis in professional beach volleyball players: sonographic findings in correlation with clinical symptoms

Is There a Relationship Between Quadriceps Tendinopathy and Suprapatellar Plica? An Observational Case Series

Purpose

Chronic painful quadriceps tendinopathy is a relatively rare condition known to be difficult to manage. Conservative management is first-line treatment and if that fails open intra-tendinous revision surgery followed by a long rehabilitation period is used. There is sparse research on etiology and new treatment methods. This observational study aimed to evaluate the intra-articular findings in patients with chronic painful quadriceps tendinopathy resistant to conservative management.

Patients and Methods

Seven male athletes (mean age 33 years, range 22–40) suffering from chronic painful quadriceps tendinopathy in altogether 10 tendons, not responding to conservative management including heavy strength training, were included. Clinical examination and ultrasound scanning were used for diagnosis. Arthroscopy was used for evaluation of the inside of the knee.

Results

In all 10 knees, there were obliterating major plica formations in the suprapatellar pouch.

Conclusion

Obliterating plica formations in the suprapatellar pouch may be involved in the aetiology and pathology in quadriceps tendinopathy.

Current Clinical Concepts: Clinical Management of Patellar Tendinopathy

Patellar tendinopathy is a common, yet misunderstood pathoetiology afflicting a variety of patient populations. This lack of unified understanding affects the capability of clinicians to provide effective treatment interventions. Patients with tendinopathy often report long-term and low to moderate levels of pain, diminished flexibility, and strength, as well as decreased physical function. Load-management strategies combined with exercise regimens focused on progressive tendon loading are the most effective treatment option for patients with patellar tendinopathy. This review will provide an evidence-based approach to patellar tendinopathy, including its pathoetiology, evaluation, and treatment strategies.

An Objective Measure of Patellar Tendon Thickness Based on Ultrasonography and MRI in University Athletes

Ultrasonography and MRI are used for imaging evaluation of patellar tendinopathy, and “thickening of the tendon” is known as one of the characteristic findings. However, there are no evidence-based quantitative criteria to help evaluate this phenomenon. The purpose of this study was to investigate an objective measure of patellar tendon thickness. Patellar tendon thickness was evaluated in 65 elite university athletes using both ultrasonography and MRI. The relationship between tendon thickness and clinical patellar tendinopathy was investigated, and the cutoff value of the tendon thickness was calculated. Of the 129 knees included in the analysis, clinical patellar tendinopathy was found in 16 knees (12.4%). The proximal patellar tendon was significantly thicker in athletes with clinical patellar tendinopathy on both ultrasonography (8.3 mm vs. 5.1 mm; p < 0.001) and MRI (9.9 mm vs. 5.5 mm; p < 0.001). Setting the cutoff value to a thickness of >7.0 mm was an accurate predictor of clinical patellar tendinopathy (ultrasonography: sensitivity 81.3%, specificity 95.6%; MRI: sensitivity 100%, specificity 89.4%). Both ultrasonography and MRI measurement of the proximal patellar tendon thickness reflected the presence of clinical patellar tendinopathy. Defining “thickening of the patellar tendon” as thicker than 7.0 mm on both ultrasonography and MRI therefore has clinical significance.

Relationship of Patellofemoral Angles and Tibiofemoral Rotational Angles With Jumper's Knee in Professional Dancers: An MRI Analysis

Background:

Jumper’s knee is a type of tendinopathy affecting the distal insertion of the quadriceps tendon (25% of cases) or the patellar tendon. It has been shown that frontal-plane measurements, such as genu valgum, genu varum, an increased quadriceps angle, a protuberant tibial tuberosity, patella alta, and short hamstring muscles, may be related to jumper’s knee.

Purpose:

To investigate the effects of tibiofemoral rotational angles and patellofemoral (PF) angles on the development of jumper’s knee in professional folk dancers.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

We examined 26 dancers (16 male, 10 female) with knee pain using magnetic resonance imaging (MRI), for a total of 32 knees. Of the knees, 21 with quadriceps tendinopathy (QT) and 7 with patellar tendinopathy (PT) were detected. Using MRI scans, we measured PF angles (PF sulcus angle, lateral PF angle, patellar tilt angle, lateral trochlear inclination angle, lateral patellar tilt angle, and PF congruence angle) and tibiofemoral rotational angles (condylar twist angle, posterior condylar angle, femoral Insall angle, tibial Insall angle, posterior tibiofemoral angle, and angle between the Whiteside line and posterior femoral condylar line) and noted specifics such as patella alta, patella baja, and the Wiberg classification of the patellar shape between the patients with versus without QT and between patients with versus without PT to understand if there was any relationship with tendinopathy.

Results:

No statistically significant difference was observed in age, sex, patella alta, or the Wiberg classification between the QT groups (with vs without) and between the PT groups (with vs without) (P > .05). Having QT was found to be significantly associated with the PF sulcus angle (P = .009), and having PT was found to be significantly associated with the femoral Insall angle (P = .029).

Conclusion:

Jumper’s knee was found to be associated with anatomic variations of the PF sulcus angle and rotation of the patellar tendon in relation to the femur (femoral Insall angle) on axial MRI scans in professional dancers. Unlike those of other athletes, dancers’ knees are exposed more to external rotation forces because of turnout, and this can be the cause of jumper’s knee.

Quadriceps and Patellar Tendon Thickness and Stiffness in Elite Track Cyclists: An Ultrasonographic and Myotonometric Evaluation

Track cyclists are required to perform short- and long-term efforts during sprint and endurance race events, respectively. The 200 m flying sprint races require maximal power output and anaerobic capacity, while the 4,000 m pursuit cyclists demand a high level of aerobic capacity. Our goal was to investigate spatial changes in morphological and mechanical properties displayed using 3D topographical maps of the quadriceps muscle and tendons after 200 m flying start and 4,000 m individual pursuit race in elite track cyclists. We hypothesized a non-uniform distribution of the changes in the quadriceps muscle stiffness (QM_stiff), and acute alterations in quadriceps tendon (QT_thick) and patellar tendon (PT_thick) thickness. Fifteen men elite sprint and 15 elite men endurance track cyclists participated. Sprint track cyclists participated in a 200 m flying start, while endurance track cyclists in 4,000 m individual pursuit. Outcomes including QT_thick (5–10–15 mm proximal to the upper edge of the patella), PT_thick (5–10–15–20 mm inferior to the apex of the patella)—using ultrasonography evaluation, QM_stiff, and quadriceps tendon stiffness (QT_stiff) were measured according to anatomically defined locations (point 1–8) and patellar tendon stiffness (PT_stiff)—using myotonometry, measured in a midway point between the patella distal and the tuberosity of tibial. All parameters were assessed before and after (up to 5 min) the 200 m or 4,000 m events. Sprint track cyclists had significantly larger QT_thick and PT_thick than endurance track cyclists. Post-hoc analysis showed significant spatial differences in QM_stiff between rectus femoris, vastus lateralis, and vastus medialis in sprint track cyclists. At before race, sprint track cyclists presented significantly higher mean QT_thick and PT_thick, and higher QM_stiff and the QT_stiff, as compared with the endurance track cyclists. The observed changes in PT_Thick and QT_Thick were mostly related to adaptation-based vascularity and hypertrophy processes. The current study suggests that assessments using both ultrasonography and myotonometry provides crucial information about tendons and muscles properties and their acute adaptation to exercise. Higher stiffness in sprint compared with endurance track cyclists at baseline seems to highlight alterations in mechanical properties of the tendon and muscle that could lead to overuse injuries.

Back to the roots of rheumatology - Imaging of regional pain syndromes

Musculoskeletal regional pain syndromes (RPS) often lead to patient referrals in general and rheumatological practice. Detailed history taking and clinical examination can, in most cases, reveal the cause for pain and direct the subsequent management of the conditions. Yet, when in doubt, imaging methods, such as ultrasound (US) may support the clinical assessment. This paper reviews the underlying pathologies of some of the most frequently encountered RPS and the role of musculoskeletal US imaging for their diagnosis and treatment. If available, data on diagnostic accuracy and comparisons with gold standards are reported. The article stresses the importance of anatomical and sonoanatomical knowledge for the proper interpretation of the US images, points out the advantages and disadvantages of this imaging tool, and suggests the future research agenda.

Knee cartilage damage and concomitant internal derangement on MRI in athletes competing at the Rio de Janeiro 2016 Summer Olympics

•

Cartilage damage is frequently observed on MRI in Olympic Athletes.

•

Patellofemoral cartilage damage is most common and associated with certain sports including volleyball and weightlifting.

•

Meniscal tears are associated with localized cartilage damage.

•

Trend for prevalence of cartilage damage to increase with increasing age of the athlete.

Purpose

To report the MRI patterns of knee cartilage damage and concomitant internal derangement in athletes participating at the Rio de Janeiro 2016 Olympic Games.

Methods

Knee MRIs obtained at the core imaging facility of the International Olympic Committee were blindly, retrospectively reviewed by a board-certified musculoskeletal radiologist for meniscal, ligamentous, and tendon abnormalities. Cartilage assessment was based on the modified Outerbridge criteria.

Results

Of 122 athletes who received a knee MRI, 64 (52.4 %) had cartilage damage. Cartilage damage was more prevalent in the patellofemoral compartment (52 athletes, 42.6 %), followed by lateral (23 athletes, 18.9 %) and medial tibiofemoral compartments (12 athletes, 9.8 %). Patellofemoral cartilage damage was most prevalent in beach-volleyball (100 %), followed by volleyball (8 athletes, 66.7 %) and weightlifting (7 athletes, 70 %). Patellofemoral cartilage damage was most prevalent with quadriceps (8 athletes, 72.7 %) and patellar tendinosis (11 athletes, 61.1 %). Medial and lateral tibiofemoral cartilage damage was significantly associated with medial (8 athletes, 29.6 %) and lateral meniscal tears (16 athletes, 55.2 %), respectively. There was a trend for the percentage of athletes with cartilage damage to increase with age.

Conclusion

The majority of athletes at the 2016 Rio Summer Olympics who had a knee MRI showed cartilage damage. Patellofemoral compartment cartilage damage was most common and frequently observed in certain sports including volleyball, beach volleyball, and weightlifting. Overuse in these sports can contribute to patellofemoral cartilage damage and subsequent development of anterior knee pain. Cartilage damage was also observed with concomitant meniscal tears and older age.

Lower Limb Dominance, Morphology, and Sonographic Abnormalities of the Patellar Tendon in Elite Basketball Players: A Cross-Sectional Study

CONTEXT

Patellar tendinopathy is common in basketball players, and structural ultrasound abnormalities can be found in symptomatic and asymptomatic tendons. Lower limb dominance may also be a critical load factor, potentially leading to overloading of the patellar tendon.

OBJECTIVE

To describe and compare the prevalence by lower limb dominance of patellar tendons with structural and vascular abnormalities and to describe the morphologic measures of tendons without abnormalities among adult male elite basketball players.

DESIGN

Cross-sectional study.

SETTING

Medical center of a professional basketball team in the Spanish league.

PATIENTS OR OTHER PARTICIPANTS

A total of 73 adult male elite basketball players (146 patellar tendons; age = 26.8 ± 4.9 years, height = 198.0 ± 0.1 cm, mass = 95.4 ± 11.4 kg).

MAIN OUTCOME MEASURE(S)

We used ultrasound to screen the patellar tendons for the presence of structural and vascular abnormalities. Tendons were categorized as abnormal if they demonstrated a focal area of hypoechogenicity, thickening, or neovascularization. We also examined the cross-sectional area and thickness of tendons without abnormalities. Prevalence and morphologic measures were compared by limb dominance.

RESULTS

A total of 35 players (48%) had bilateral abnormalities, whereas 21 (28.7%) had unilateral abnormalities. Among the 91 abnormal tendons, 90 (61.6% of 146 tendons) exhibited a focal area of hypoechogenicity, 59 (40.4% of 146 tendons) exhibited thickening, and 14 (9.6% of 146 tendons) exhibited neovascularization. No group differences were detected between the dominant and nondominant limbs. Among the 55 normal patellar tendons, 34 were bilateral (from 17 players) and 21 were unilateral. Approximately 25% (n = 14) of all 55 normal tendons had a cross-sectional area that was greater than 182.8 mm² and a thickness greater than 7.2 mm. Among the 34 bilateral normal tendons, no group differences were observed between the dominant and nondominant limbs for either cross-sectional area or thickness.

CONCLUSIONS

The prevalence of abnormal tendons was high among adult male elite basketball players, and bilateral presentations were more frequent. Structural abnormalities were most common.

Quadriceps tendinopathy: a review-part 1: epidemiology and diagnosis

Overuse injuries of the extensor mechanism of the knee are common in both athletes and non-athletes and usually occur during activities associated with repetitive loading, stress, and knee extension. Historically, they have been labeled as Jumper's knee due to the high prevalence seen in the athletic community. In many published reports, the name "patellar tendinopathy" is used to describe this disorder of the quadriceps tendon at the patellar insertion, and the names are often used interchangeably. Numerous reports have been published describing extensor mechanism injuries in athletes, but there is a paucity of studies that focus on quadriceps tendinopathy. In addition, there is no universally accepted classification system for tendon pathology. Therefore, we performed a comprehensive literature review of these studies. This review consists of 2 parts. In the first part we review: (I) epidemiology and (II) diagnosis of quadriceps tendinopathy in the athlete as well as the general population. In the second part we discuss: (I) classification; (II) prognosis; and (III) treatment results.

Musculoskeletal ultrasound: athletic injuries of the lower extremity

Athletic injuries of the lower extremities are commonly encountered in clinical practice. While some pathology can be diagnosed on physical exam, others are a clinical dilemma with nonspecific symptomatology. In these situations, ultrasound imaging can be utilized as an exceptional diagnostic tool, offering unique advantages over other imaging modalities. This article will review the imaging characteristics of commonly encountered athletic injuries of the lower extremity.

Open Repair of Quadriceps Tendon With Suture Anchors and Semitendinosus Tendon Allograft Augmentation

Quadriceps tendinopathy in an increasingly recognized diagnosis can lead to quadriceps tendon rupture, especially in the older population. It can be caused by repeated micro trauma or also predisposed by systemic diseases such as diabetes mellitus and connective tissue disorders that can in turn lead to extensor mechanism deficits. Although a trial of conservative treatment is advocated, operative treatment should be performed in cases of persistent pain, extension deficit, or complete rupture of the tendon. The purpose of this Technical Note is to describe in detail a procedure for open repair of a quadriceps tendon, with significant degeneration due to quadriceps tendinopathy, using suture anchors and semitendinosus tendon allograft augmentation.

Patellar tendinopathy: preliminary surgical results

Background:

Calcific deposits (CaDs) may be related to chronic postoperative pain and may affect function after patellar tendon surgery.

Study Design:

Cross-sectional.

Hypothesis:

We hypothesized that patients with CaDs (+CaDs) would rate lower than those without (−CaDs) on measures of knee function and quality of life.

Methods:

Patients completed the Tegner Lysholm Knee Scoring Scale (Lysholm), Knee Injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee Subjective Knee Form (IKDC), and the Tegner Activity Level Scale. Sixteen postsurgical and 16 age-matched controls were tested. Patients +CaDs were 5.6 years older than those patients −CaDs and had 4.2 years of longer elapse since surgery. Bilateral patellar tendons were examined for CaDs with musculoskeletal ultrasound imaging. One-way analysis of variance was used to determine if differences existed among patients +CaDs and −CaDs and healthy controls. Hierarchical logistic regressions were used to determine which variables best predicted the presence of CaDs.

Results:

CaDs were found in 44% (7 of 16) of postsurgical patients, who scored lower than controls on all dimensions of the Lysholm, KOOS, and IKDC. Patients +CaD had lower KOOS scores than controls (symptoms, activities of daily living, and quality of life). Age and time since surgery were both moderately related to the presence of CaDs, and both correctly predicted 71% of patients +CaDs.

Conclusion:

Calcific deposits were found in the patellar tendon of 44% of postsurgical patients, who rated themselves lower on all subjective measures of knee function and quality of life following surgery. Age is an important factor for developing CaDs postsurgery.

Clinical Relevance:

Calcific deposits may be present in patellar tendons following surgery, but their direct role in functional or clinical limitations remains unknown.

MR imaging of anterior knee pain: a pictorial essay

Anterior knee pathology is a frequent cause of joint pain and limitation of function and mobility among patients presenting to an orthopaedic department. Proper recognition and treatment of pathologic conditions depend on the knowledge of normal anatomy and of the various abnormalities, which affect this area of the knee and may present with anterior knee pain. A broad array of benign and malignant processes may be manifested as anterior knee discomfort, and this common clinical entity is among the most frequent indications for MR imaging of the lower extremities. Clinical history and physical examination are also of paramount importance. The disorders can be categorized and differentiated primarily according to their location. Traumatic or non-traumatic disorders of the patella, patellar retinacula, quadriceps and patellar tendons and supra or infrapatellar fat pad can be the source of symptoms. This article includes a comprehensive pictorial essay of the characteristic MR features of common and uncommon disorders causing anterior knee pain. For accurate assessment of the aforementioned clinical problem, a radiologist should be able to identify typical MR imaging patterns that contribute in establishing the correct diagnosis and thus tailoring the appropriate therapy. Level of evidence IV.

The extensor mechanism of the knee

Disorders related to the knee extensor mechanism are common and rarely require imaging. Non specific anterior knee pain, fracture, dislocation, overuse tendinopathy and chronic patellofemoral instability are the commonest conditions encountered. Imaging is used in acute trauma, and for the assessment of cases of anterior knee pain resistant to conservative measures. The role of the radiograph is now largely restricted to cases of suspected fracture. Ultrasound is the optimum technique for suspected tendon and bursal pathology and MRI is widely used for the assessment of dysplasia and instability of the patellofemoral joint, including acute dislocation.

Ultrasound in sports medicine: relevance of emerging techniques to clinical care of athletes

The applications of ultrasound in managing the clinical care of athletes have been expanding over the past decade. This review provides an analysis of the research that has been published regarding the use of ultrasound in athletes and focuses on how these emerging techniques can impact the clinical management of athletes by sports medicine physicians. Electronic database literature searches were performed using the subject terms 'ultrasound' and 'athletes' from the years 2003 to 2012. The following databases were searched: PubMed, Web of Science, Cochrane Library, CINAHL, and SPORTDiscus™. The search produced 617 articles in total, with a predominance of articles focused on cardiac and musculoskeletal ultrasound. 266 of the studies involved application of ultrasound in evaluating the cardiovascular properties of athletes, and 151 studies involved musculoskeletal ultrasound. Other applications of ultrasound included abdominal, vascular, bone density and volume status. New techniques in echocardiography have made significant contributions to the understanding of the physiological changes that occur in the athlete's heart in response to the haemodynamic stress associated with different types of activity. The likely application of these techniques will be in managing athletes with hypertrophic cardiomyopathy, and the techniques are near ready for application into clinical practice. These techniques are highly specialized, however, and will require referral to dedicated laboratories to influence the clinical management of athletes. Investigation of aortic root pathology and pulmonary vascular haemodynamics are also emerging, but will require additional studies with larger numbers and outcomes analysis to validate their clinical utility. Some of these techniques are relatively simple, and thus hold the potential to enter clinical management in a point-of-care fashion. Musculoskeletal ultrasound has demonstrated a number of diagnostic and therapeutic techniques applicable to pathology of the shoulder, elbow, wrist, hand, hip, knee and ankle. These techniques have been applied mainly to the management of impingement syndromes, tendinopathies and arthritis. Many of these techniques have been validated and have entered clinical practice, while more recently developed techniques (such as dynamic ultrasound and platelet-rich plasma injections) will require further research to verify efficacy. Research in musculoskeletal ultrasound has also been helpful in identifying risk factors for injury and, thus, serving as a focus for developing interventions. Research in abdominal ultrasound has investigated the potential role of ultrasound imaging in assessing splenomegaly in athletes with mononucleosis, in an attempt to inform decisions and policies regarding return to play. Future research will have to demonstrate a reduction in adverse events in order to justify the application of such a technique into policy. The role of ultrasound in assessing groin pain and abdominal pain in ultraendurance athletes has also been investigated, providing promising areas of focus for the development of treatment interventions and physical therapy. Finally, preliminary research has also identified the role of ultrasound in addressing vascular disease, bone density and volume status in athletes. The potential applications of ultrasound in athletes are broad, and continuing research, including larger outcome studies, will be required to establish the clinical utility of these techniques in the care of athletes.

Tensiomiografia utilizada para a avaliação de jogadores de vôlei de praia de alto nível

OBJETIVO: Esta investigação tem por objetivo coletar dados sobre rigidez muscular, as propriedades mecânicas e contráteis dos músculos utilizando a TMG em jogadores de vôlei de praia de alto nível, assim como demonstrar a utilidade deste método para a avaliação dos músculos responsáveis pela flexão e extensão do joelho. MÉTODOS: A investigação foi conduzida com um grupo de 24 jogadores de vôlei de praia os quais participaram do Torneio Europeu Nestea - Master Espanhol realizado nas Ilhas Grâ-Canárias em maio de 2009. O método de estudo utilizado foi comparação de casos individuais de vários atletas com a finalidade de verificar a utilidade deste método em esportes. Os músculos analisados foram: vasto lateral (VL), vasto medial (ML), reto femoral (RF) e bíceps femoral (BF). RESULTADOS: As informações coletadas nos certificam sobre o alto grau de utilidade deste método para avaliação da rigidez muscular e equilíbrio entre estruturas musculares de atletas. Contudo, a validade e reconstrução dos resultados estão condicionadas a um severo protocolo de avaliação. Além disso, os seguintes critérios devem ser considerados: individualidade (o perfil do atleta) e especificações (características do esporte). CONCLUSÕES: A aplicação da TMG em jogadores de alto nível revela a existência de importantes diferenças dependendo de suas funções em jogo (defesa, bloqueio ou alternância entre ambas as posições), as ações técnicas, a posição em quadra (direita-esquerda) e o histórico de lesões médicas.

Enthesitis of the direct tendon of the rectus femoris muscle in a professional volleyball player: A case report

Enthesitis of the direct tendon of the rectus femoris muscle is a rare pathology which mainly affects professional athletes, and it is caused by overuse and repetitive microtrauma. Athletic jumping and kicking exert a great stress on the direct tendon of the rectus femoris muscle, and volleyball and football players are therefore most frequently affected. Enthesitis may occur suddenly causing pain and functional impairment possibly associated with partial or complete tendon injuries, or it may be a chronic condition causing non-specific clinical symptoms.We present the case of a professional volleyball player who felt a sudden pain in the left side of the groin area during a training session although she had suffered no accidental injury. The pain was associated with impaired ipsilateral limb function. Tendon rupture was suspected, and magnetic resonance imaging (MRI) was performed. MRI showed a lesion at the myotendinous junction associated with marked inhomogeneity of the direct tendon. Ultrasound (US) examination confirmed the presence of both lesions and allowed a more detailed study of the pathology.This is a typical case of enthesitis which confirms that MRI should be considered the examination of choice in hip pain, particularly when the patient is a professional athlete, thanks to its panoramic visualization. However, also US is an ideal imaging technique for evaluating tendon injuries thanks to its high spatial resolution, and it can therefore be used effectively as a second line of investigation.

Evaluation of the patellar tendon in transtibial amputees: a preliminary sonographic study

This study aimed to provide sonographic imaging of the patellar tendon (PT) - one of the main weight bearing structures for prosthetic use - in transtibial amputees. Thirteen males, who had been under follow-up for unilateral traumatic transtibial amputations, were enrolled. After physical examination of the limb, pain was evaluated by visual analogue scale and Leeds Assessment of Neuropathic Symptoms and Signs. Sonographic evaluations were performed by using a linear array probe (Aloka UST-5524-7.5 MHz) on both sides. Measurements pertaining to the contralateral limbs were taken as controls. In three subjects (23.1%), two with a silicone liner and one with a pelite liner, cortical irregularities were detected at the tibial insertion of the PT on the amputated sides. PTs were found to be thicker on the amputated sides when compared with those of the contralateral sides (p = 0.03), and this increase in thickness correlated with disease duration (r = 0.67, p = 0.01). Overall, our preliminary results imply that after transtibial amputation, PTs of the amputated sides tend to become thicker by time. These findings need to be complemented with future studies. In this regard, sonography seems to be promising for imaging the soft tissue problems of the stump.