patellar tendinopathy. normal anatomy distal pole of patella superior facet tibial tuberosity
TRANSCRIPT
Patellar Tendinopathy
Normal Anatomy
• Distal pole of patella
• Superior facet tibial tuberosity
Normal Anatomy
• Collagen– Parallel– Crimped– Tensile strength
• Ground Substance– Proteoglycans (PG)– Glycosaminoglycan (GAG)
tail– Hydrophillic– Compressive strength
Mechanism of Injury
• Tendon is over or under loaded
• Results in some tissue degradation
• Repair is attempted
• Insufficient time or load
• Tendon degenerationCook and Purdam, 2008
Mechanism of Injury
Magnusson et al, 2008
Pathophysiology
• Increased tenocyte activity
• Increase ground substance
• Collagen deterioration
• Neovascularisation
• Nerve sprouting
Pathophysiology
• Reactive– Inflammatory markers– Minimal tissue
degradation– ?Reversible structural
change
• Degenerative– Disorganised tendon– Decrease Type 1 collagen– Increase Type 3 collagen
Maffuli et al, 2000
Pathophysiology
Cook et al, 2001
Pathophysiology
• Cortical changes may be present
• “All or nothing” response to loading
• Neural compromise
• Radiculopathy
PathophysiologyTranscranial Magnetic Stimulation
Pathophysiology
Reactive Degenerative
Symptoms Irritable Stable
History Recent load change Stable load
Age Young Older
US Reactive (acute)Degenerative (acute on chronic)
Degenerative likely
Pathology Reversible Irreversible
Principles Settle tenocytes Stimulate tenocytes
Associated Pathologies
• Inferior pole– PFPS– Fat pad– Sinding-Larsen-Johnansson Disease
• Tibial Tuberosity– Osgood-Schlatter’s Disease– Infrapatellar bursa– Pes anserinus
Subjective
• Usually atraumatic• Local pain• Night pains• ?History of lower limb injury• Reported change in loading• Lag between load and symptoms• Some initial pain, reduces and returns after
exercise
Objective
• Observation– Spine alignment– Tendon thickening– Muscle bulk
• ROM– Full ROM
• Strength– Kinetic chain
Malliaras and Cook, 2011
Objective
• Neural– Femoral nerve
• Palpation– Local tenderness– Pinpoint location
Objective
• Movement Patterns– Single leg stance– Squat and single leg
squat
• Biomechanics– Femoral torsion– Tibial torsion
Special Tests
Standing Active Quads Sign– Palpate in standing– Locate point tenderness– Unilateral stand– 30 degrees knee flex– Decrease symptoms on
palpation
Passive Ext-Flex Sign– Palpate in supine– Leg in extension– Locate Point tenderness– Passive 90 degrees knee
flex– Decrease symptoms on
palpation
London Hospital Test
Further Investigation
• US Scan
• MRI
• Hypo-echoic more likely pain
Should always be a clinical diagnosis!
Malliaras et al, 2010
Management
• Reduce pain
• Increase load tolerance
• Improve function
• Time
• ?Improve structure
Conservative - Management
Load Modification• Reactive
– Address load– Correct biomechanics
• Degenerative– Correct biomechanics– Loading strategies– Isometric– Conc/Ecc
Conservative
• Isometric– 4-5 reps 3-4 per day– 40-60 sec hold– High load– Little or no pain
• Mechanotransduction• Minimal movement• Tendon Loading– No matrix stimulation
Conservative
• Eccentric– Leg extension– Leg press– Split Squat– Squat
• S&C
• Sport specific
Conservative - Management
• Adjuncts– Acupuncture– Deep transverse frictions– Joint mobilisations– Shockwave– Soft tissue massage– Taping and strapping
Surgical - Management
• Injections– High Volume– Steroid– PRP
• Debridement
• Shockwave
References• Birch HL. (2007). Tendon matrix composition and turnover in relation to
functional requirements. Int J Exp Path. 88; 241-248
• Cook JL, Khan KM, Purdam CR. (2001). Conservative treatment of patellar tendinopathy. Physical Therapy in Sport. 2; 54-65
• Cook JL, Purdam CR. (2008). Is tendon pathology and continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 43; 409-416
• Maffuli N, Ewen S, Waterston S, Reaper J, Barrass V. (2000). Tenocytes from ruptured and tendinopathic achilles tendons produce greater quantities of type III collagen than tenocytes from normal achilles tendon. Am J Sports Med. 28; 499-505
References• Magnusson SP Langburg H, Kjaer M. (2010).The pathogenesis of
tendinopathy: balancing the response to loading. Nat Rev Rheumatol. 6; 262–268
• Malliaras P, Purdam C, Maffuli N, Cook J. (2010). Temporal sequence of greyscale ultrasound changes and their relationship with neurovascularity and pain in the patellar tendon. Br J Sports Med. 44; 944-947
• Malliaras P, Cook J. (2011). Changes in anteroposterior patellar tendon diameter support a continuum of pathological changes. Br J Sports Med. 45; 1048-1051
• Warden SJ. (2003). Patellar tendinopathy. Clinical Sports Medicine. 22; 743-759