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;[4] 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 , trauma (direct or indirect)[5], prolonged use of corticosteroids , previous surgery around the knee joint, obesity[6] 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[2]
- Swelling
- Difficulty with weight-bearing
- Difficulty 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[2]
- An indentation at the bottom of your kneecap where the tendon tore.[7]
- When a tear is caused by a medical condition, like tendonitis, the tendon usually tears in the middle.
Differential Diagnosis[edit | edit source]
- Quadriceps tendon rupture
- Patella fracture
- Tibial tubercle avulsion fracture
Diagnosis[edit | edit source]
Diagnosis of patella tendon tear should be made as early as possible to avoid poor functional outcome with a loss of full knee flexion and decreased quadriceps strength.[8]Accurate diagnosis depends on detailed history, physical examination and radiographic examinations.[2][8]. The history should include the onset of their symptoms, specific location the pain, duration of the pain and symptoms, characteristics of the pain, alleviating and aggravating factors, any radiation of pain, and the severity of their symptoms.
Management[edit | edit source]
The goals are to make an early diagnosis and surgically repair the injured tendon.[5]Surgical management, non surgical management and postoperative rehabilitation are required to ensure satisfactory outcomes.[9]and should not be delayed whenever local and general conditions permit
Surgical Management[edit | edit source]
Surgery remains the best treatment and should not be delayed whenever local and general conditions permit [7]. 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 patella tendon length more complicated. Surgical repair is necessary to reestablish optimal extensor function.
Physical Therapy Management [edit | edit source]
Physical therapy management can be sub divided into: Non surgical treatment and postoperative rehabilitation
Non surgical management is employed in partial patella tendon tear with an intact knee extensor mechanism and it involves immobilization in a cylindrical cast in extension for 6 week. 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]
add appropriate resources here
Clinical Bottom Line[edit | edit source]
References[edit | edit source]
- ↑ 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 2.4 2.5 2.6 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]
- ↑ McGrory JE. Disruption of the extensor mechanism of the knee. The Journal of emergency medicine. 2003 Feb 1;24(2):163-8.
- ↑ 5.0 5.1 Bhargava SP, Hynes MC, Dowell JK. Traumatic patella tendon rupture: early mobilisation following surgical repair. Injury. 2004 Jan 1;35(1):76-9.
- ↑ 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.
- ↑ 7.0 7.1 Ilahiane M, Abdulrazak S, Hassani I, Marzouki A, Boutayeb F. Acute Patella Tendon Rupture A Case Report. Orthopedics and Rheumatology Open Access Journals. 2018;13(2):35-8.
- ↑ 8.0 8.1 Fazal MA, Moonot P, Haddad F. Radiographic features of acute patellar tendon rupture. Orthopaedic Surgery. 2015 Nov;7(4):338-42.
- ↑ Murphy S, McAleese T, Elghobashy O, Walsh J. 222 Bilateral Patellar Tendon Rupture Following Low-Energy Trauma in a Young Patient Without Predisposing Risk Factors. British Journal of Surgery. 2022 Sep;109(Supplement_6):znac269-123.
