Patellar tendinitis in the recreational athlete

The use of physical function capacity measures in the management of lower limb tendinopathy: A scoping review of expert recommendations

BACKGROUND

Physical function capacity measures are recommended as outcome measures for people with lower limb tendinopathy.

OBJECTIVE

(i) Explore measures of physical function capacity recommended by experts in lower limb tendinopathy (ii) the context they were used, (ii) identify recommended criteria for exercise progression and return to sport or activity.

DESIGN

Scoping Review.

METHOD

Three databases were searched using keywords for lower limb tendinopathy and physical function capacity to identify studies that outlined a progressive exercise rehabilitation program. A 15-item tool was used for data extraction.

RESULTS

26 studies were included, only eight recommended a physical function capacity measure. There were 10 physical function capacity measures identified for a range of lower limb tendinopathies including patellar (50%), Achilles (13%), proximal hamstring (13%), gluteal (13%), combined patellar and Achilles (13%). Pain was the most common criterion that was used to determine the progression of rehabilitation (96%), with physical function capacity measures rarely used (12%).

CONCLUSION

Physical function capacity measures are used infrequently across expert recommended exercise rehabilitation programs. There remains a high reliance on pain as the criterion for progression of exercises during rehabilitation. There is a need to develop measures of physical function capacity to better inform and progress rehabilitation.

Arthroscopic management of chronic patellar tendinopathy

BACKGROUND

In patients with patellar tendinopathy in whom nonoperative management is unsuccessful, surgery is an option to return to high levels of physical activity. Although open surgery is traditionally advocated, an arthroscopic approach may be safe and effective.

PURPOSE

This study was undertaken to analyze medium- and long-term outcome of 64 patients undergoing arthroscopic surgery for the management of patellar tendinopathy after failing nonoperative treatment.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 64 patients (73 knees), 27 of whom were professional athletes, with patellar tendinopathy refractory to nonoperative management underwent arthroscopic debridement of the adipose tissue of the Hoffa's body posterior to the patellar tendon, debridement of abnormal patellar tendon, and excision of the lower pole of the patella. Preoperative and postoperative evaluation was undertaken using the International Knee Documentation Committee (IKDC), Lysholm knee scale, and Victorian Institute of Sport Assessment-Patella (VISA-P) scores for all patients at 1 and 3 years. No patients were lost to follow-up. Forty-three and 29 patients were similarly assessed at 5 and 10 years, respectively, after surgery. Return to sports and rehabilitation was also assessed.

RESULTS

The IKDC, Lysholm, and VISA-P scores all significantly improved at 1 and 3 years' follow-up. The average preoperative IKDC score of 51.6 improved to 86.4 at both the 1- and 3-year stage. The average preoperative Lysholm score of 52.3 improved to 94.7 at 1-year follow-up and was 95.5 at 3-year follow-up. The average preoperative VISA-P score of 35.3 improved to 69.8 at the 1-year stage and was 70.7 at the 3-year follow-up. These scores remained significantly better for the patients assessed at 5 and 10 years' follow-up. There were no postoperative complications. Nineteen of the 27 professional athletes returned to sports at the same level. Seven patients developed pain after sports within 3 years after the operation, a failure rate of 7 of 73 knees (9.6%). All patients were able to return to sports by 3 months.

CONCLUSION

Arthroscopic surgery for patients with patellar tendinopathy, refractory to nonoperative management, appears to provide significant improvements in symptoms and function, with improvements maintained for at least 3 years. These results suggest that some patients may not be able to achieve their presymptom sporting level; or if they do, they may participate in sports with some degree of residual symptoms. Limited data show that these improvements are maintained for up to 10 years. Early return to sports may also be achieved.

Treating patellar tendinopathy with Fascial Manipulation

According to Fascial Manipulation theory, patellar tendon pain is often due to uncoordinated quadriceps contraction caused by anomalous fascial tension in the thigh. Therefore, the focus of treatment is not the patellar tendon itself, but involves localizing the cause of this incoordination, considered to be within the muscular fascia of the thigh region. Eighteen patients suffering from patellar tendon pain were treated with the Fascial Manipulation technique. Pain was assessed (in VAS) before (VAS 67.8/100) and after (VAS 26.5/100) treatment, plus a follow-up evaluation at 1 month (VAS 17.2/100). Results showed a substantial decrease in pain immediately after treatment (p<0.0001) and remained unchanged or improved in the short term. The results show that the patellar tendon may be only the zone of perceived pain and that interesting results can be obtained by treating the muscular fascia of the quadriceps muscle, whose alteration may cause motor incoordination and subsequent pathology.

Extracorporeal shockwave for chronic patellar tendinopathy

BACKGROUND

Chronic patellar tendinopathy is an overuse syndrome with pathologic changes similar to tendinopathies of the shoulder, elbow, and heel. Extracorporeal shockwave was shown effective in many tendinopathies.

HYPOTHESIS

Extracorporeal shockwave therapy may be more effective than conservative treatment for chronic patellar tendinopathy.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 2.

METHODS

This study consisted of 27 patients (30 knees) in the study group and 23 patients (24 knees) in the control group. In the study group, patients were treated with 1500 impulses of extracorporeal shockwave at 14 KV (equivalent to 0.18 mJ/mm(2) energy flux density) to the affected knee at a single session. Patients in the control group were treated with conservative treatments including nonsteroidal anti-inflammatory drugs, physiotherapy, exercise program, and the use of a knee strap. The evaluation parameters included pain score, Victorian Institute of Sports Assessment score, and ultrasonographic examination at 1, 3, 6, and 12 months and then once a year.

RESULTS

At the 2- to 3-year follow-up, the overall results for the study group were 43% excellent, 47% good, 10% fair, and none poor. For the control group, the results were none excellent, 50% good, 25% fair, and 25% poor. The mean Victorian Institute of Sports Assessment scores were 42.57 +/- 10.22 and 39.25 +/- 10.85, respectively, before treatment (P = .129) and 92.0 +/- 10.17 and 41.04 +/- 10.96, respectively, after treatment (P < .001). Satisfactory results were observed in 90% of the study group versus 50% of the control group (P < .001). Recurrence of symptoms occurred in 13% of the study group and 50% of the control group (P = .014). Ultrasonographic examination showed a significant increase in the vascularity of the patellar tendon and a trend of reduction in the patellar tendon thickness after shockwave treatment compared with conservative treatments. However, no significant difference in the appearance, arrangement, and homogeneity of tendon fibers was noted between the 2 groups. There were no systemic or local complications or device-related problems.

CONCLUSION

Extracorporeal shockwave therapy appeared to be more effective and safer than traditional conservative treatments in the management of patients with chronic patellar tendinopathy.

Patellar tendonitis and patellar dislocations

Common sports injuries, such as patellar tendonitis and patellar dislocation, can be treated either surgically or with rehabilitation and physical therapy. Most patients with patellar tendonitis will respond well to conservative measures; however, some recalcitrant cases will require surgical intervention. To date, the literature is not able objectively to identify the patients best suited to surgery. Likewise, in the case of patellar dislocations, it is still unclear which patients respond best to conservative therapy and which respond best to surgical treatment, although evidence continues to accumulate. A practical approach to this problem can be deduced from the available evidence, but more well-designed clinical trials are needed for the establishment of definitive treatment protocols.

Comparison of Rehabilitation Methods in the Treatment of Patellar Tendinitis

Objective:

To compare outcomes of 2 rehabilitation protocols on patellar tendinitis subjects.

Design:

Prospective, randomized, blinded, controlled clinical trial.

Setting:

Outpatient rehabilitation clinic.

Subjects:

Randomized into 2 rehabilitation groups—traditional (n= 10) and ASTM AdvantEDGE (n= 10).

Main Outcome Measures:

Clinical data and self-reported questionnaires collected at 0, 6, and 12 weeks.

Results:

On completion of the 6th week, 100% of the ASTM AdvantEDGE group and 60% of the traditional group had resolved. The unresolved subjects were crossed over to the ASTM AdvantEDGE for additional therapy. At the end of the additional therapy, 50% of the crossover subjects had resolved. The ASTM AdvantEDGE group's clinical outcomes and weekly journals indicated a statistically significant (P= .04) improvement in subjective pain and functional-impairment ratings.

Conclusions:

Findings suggest that ASTM AdvantEDGE resulted in improved clinical outcomes in treating patellar tendinitis.

Arthroscopic treatment of infrapatellar tendonitis

Infrapatellar tendonitis is a chronic overload lesion in the patellar ligament at the attachment to the lower pole of the patella. This lesion is found primarily in athletes who participate in jumping sports. Magnetic resonance imaging or ultrasound can show the extent of tendon pathology. Patellar tendonitis is treated with modification of activities, medications, and therapy. When conservative measures fail, operative debridement has been recommended. Previous reports have described a technique of open debridement of the patellar tendon, followed by an extended period of rehabilitation before returning to sports. Two athletes with persistent infrapatellar tendonitis were treated with an arthroscopic debridement. Both athletes returned to full activities without restrictions within 8 weeks of surgery. Arthroscopic treatment of infrapatellar tendonitis has not been previously described. This technical note describes the technique and two case reports of the arthroscopic treatment of infrapatellar tendonitis.