Patellar tendon tear
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Definition[edit | edit source]
Patella Tendon tear is an extremely disabling injury resulting in an inability to extend the knee.[1] The tear can be partial, with only some fibers torn, or complete tear of the tendon that runs from the patella's inferior pole to the tibial tubercle.[2]It is common in men who are in their 30's and 40's[1][2]
Clinically Relevant Anatomy[edit | edit source]
The patella tendon, is a ligament as it connects bone (patella) to bone (tibial tubercle). It is approximately 30 mm wide by 50 mm long, with a thickness of 5 to 7 mm. The origin on the inferior pole of the patella is juxtaposed on the articular cartilage on the deep side and becomes confluent with the periosteum of the patella anteriorly. The tibial insertion is narrower and invests the entirety of the tibial tubercle, connecting the quadriceps muscles to the lower leg.[2]
Etiology[edit | edit source]
Patella tendon tear can be caused by an underlying weakened tendon. Inflammatory conditions; tendonitis and some certain medical conditions; Systemic lupus erythematosus, Rheumatoid arthritis,Chronic renal disease, Diabetes mellitus can lead to weakened patella that can predispose an individual to tendon tear.[2]
Other factors such as mechanical stress, prolonged use of corticosteroids , previous surgery around the knee joint, obesity[4] can predispose an individual to patella tendon tear.
Characteristics/Clinical Presentation[edit | edit source]
Individuals with patella tendon tear presents with the following;
Infra patella knee pain
swelling
difficulty with weight-bearing
Diifficulty straightening the leg.
They may report an audible “pop” or the sensation of their knee giving way during an event with a sudden quadriceps contraction with the knee in a flexed position
An indentation at the bottom of your kneecap where the tendon tore.
When a tear is caused by a medical condition, like tendonitis, the tendon usually tears in the middle.
Differential Diagnosis[edit | edit source]
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Diagnostic Procedures[edit | edit source]
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Outcome Measures[edit | edit source]
Most patients undergoing early primary repair achieve nearly full return of knee motion and extension strength, although persistent quadriceps atrophy is common. Patients who underwent a delayed repair have greater persistent quadriceps atrophy.
A total recovery of a patellar tendon rupture takes about 6 months normally, but many patients reported that they required 12 months before reaching their goals.
Examination[edit | edit source]
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Medical Management[edit | edit source]
The treatment depends of the age, the activity level and the size of the tear of the patient.
Surgical repair reattaches the torn tendon to the kneecap. It’s better that the repair is performed early after the injury. An early repair, within 2 to 6 weeks, may prevent the tendon from scarring and tightening in a shortened position. In delayed diagnoses, more than 6 weeks after the rupture, quadriceps contracture and fibrous adhesions make the surgical repair and restoration of the patellar tendon length more complicated. Surgical repair is necessary to reestablish optimal extensor function.
Physical Therapy Management[edit | edit source]
Nonsurgical treatment of a patellar tendon tear
This kind of treatment takes place by patients with a small, partial tear.
Immobilization is important in this treatment. Incomplete lessions are treated with a cylindrical cast in extension for 6 weeks. This will keeps your knee straight to help it heal. Crutches are used to help you in avoiding putting all of your weight on your affected knee. As heeling progresses, the amount of flexion allowed by the brace may be increased. Exercises to strengthen the quadriceps muscles can be done. In addition straight leg raises can be executed. When the brace is unlocked, the patient can exercise with a higher range of motion and more strengthening exercises will be done to restore the strength and range of motion.
Postoperative rehabilitation of a patellar tendon tear
Classic rehabilitation involves the use of a cylinder cast for 6 weeks. The patient is allowed to bear weight as tolerated with crutches in the cast. Active flexion to 45° with passive extension may be started short after the operation, as well as isometric quadriceps and hamstring exercises. After 6 weeks the patient is converted to a control-dial hinged knee brace. The brace begins at 0 to 40 degrees and advanced to 10 degrees per week over the next 6 weeks. In this period, progressive quadriceps, hamstring strengthening and gait training are also performed. The brace is discontinued when the patient has adequate quadriceps function and 90 degrees of motion. Resistive strengthening and continued range-of-motion activities may be done after the brace is discontinued. When the patient has an adequate quadriceps control, isokinetic exercices and sport-specific functional rehabilitation may be started.
Rehabilitation should focus on regaining range of motion and quadriceps control, followed by increasing muscle mass and sport-specific functions.
It’s generally accepted that the knee should be immobilized in extension postoperatively for the tendon to heal without tension on the repair. Therefore, 6 weeks of immobilization in a cylinder cast was done routinely by many surgeons with generally good results.
More and more surgeons are starting passive knee motion immediately after surgery, controlled movements early after the repair. An early range of motion would reduce the risk of stiffness and the need for secondary manipulation.
The timeline for physical therapy and also the type of exercises will be individualized to the patient. It’s based on the type of tear, surgical repair, medical condition, and the specific needs of the patient.
Resources[edit | edit source]
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Clinical Bottom Line[edit | edit source]
References[edit | edit source]
1. R. Wilkerson and S. J. Fischer, “Patellar Tendon Tear”, orthoinfo.aaos.org, February 2016. [Online]. https://orthoinfo.aaos.org/en/diseases--conditions/patellar-tendon-tear (Level of evidence: 5)
2. Tommaso Bartalena, Maria Francesca Rinaldi, Patellar tendon rupture: radiologic and ultrasonographic findings, Western Journal of Emergency Medicine – jun 2009
3. http://emedicine.medscape.com/article/1249472-overview#a0102
4. Jerome G. Enad, Patellar tendon ruptures, Southern medical journal – v92 n6 pg563-566 jun 1999
5. Michael I. Greenberg, Greenberg's text-atlas of emergency medicine, pg 527
6. Nicola Maffulli, Per Renström, Wayne B. Leadbetter, Tendon injuries: basic science and clinical medicine - pg172-175
7. Peter T. Simonian, Brian J. Cole, Sports injuries of the knee: surgical approaches – pg175-181
8. Giles R. Scuderi, Alfred J. Tria, The Knee: A Comprehensive Review - pg313-322
- ↑ 1.0 1.1 Gilmore JH, Clayton-Smith ZJ, Aguilar M, Pneumaticos SG, Giannoudis PV. Reconstruction techniques and clinical results of patellar tendon ruptures: Evidence today. The Knee. 2015 Jun 1;22(3):148-55.
- ↑ 2.0 2.1 2.2 2.3 Hsu H, Siwiec RM. Patellar tendon rupture. InStatPearls [Internet] 2021 Jul 25. StatPearls Publishing.
- ↑ nabil ebraheim. Anatomy Of The Patellar Tendon - Everything You Need To Know - Dr. Nabil Ebraheim. Available from: http://www.youtube.com/watch?v=H9QXILgB9Mw [last accessed 23/12/2022]
- ↑ Macchi M, Spezia M, Elli S, Schiaffini G, Chisari E. Obesity increases the risk of tendinopathy, tendon tear and rupture, and postoperative complications: a systematic review of clinical studies. Clinical orthopaedics and related research. 2020 Aug;478(8):1839.
