Knee overuse injuries

Question 1

What is patella tendonitis?

Answer 1

• Activity related knee pain associated with focal patellar-tendon tenderness
• aka jumper’s knee
• 20% of jumping atheletes
• more common in adolescents/young adults
  
  • quadriceps tendinopathy > older adults
• risk factors
  
  • poor quadriceps and hamstring flexibility

Question 2

What is the mechanism and histology of patella tendonitis?

Answer 2

• Mechanism
  
  • Repetitive, forceful, eccentric ( lengthen as tehy contract) contraction of the extensor mechanism
• Histology
  
  • Degenerative, rather than inflammatory
  • micro-tear of tendinous tissue are commonly seen

Question 3

Describe the classification of patella tendonitis?

Answer 3

• Blazina
• phase 1= pain after activity only
• Phase 2= pain during and after activity
• Phase 3= persistent pain w or woout activities
• deterioration of performance

Question 4

What is the presentation of patella tendonitis?

Answer 4

Symptoms

• insidious onset of anterior knee pain at Inferior border of patella
• inital phase= pain following activity
• late phase= pain during activity
  
  • pain w prolonged flexion

O/E

• swelling over the tendon
• tenderness inferior border of patella
• Basset’s sign
  
  • tenderness to palpation at distal pole of patella in full extension
  • no tenderness to palpation at distal pole of patella in full flexion

Question 5

What is seen on imaging of patella tendonitis?

Answer 5

• Xray
  
  • maybe inferior traction spur- Enthesophyte
• USS
  
  • thickening of tendon
  • hypoechoic areas
• MRI
  
  • chronic cases
  • tendon thickening
  • increase signal on T1 & t2

Question 6

What is the tx of patella tendonitis?

Answer 6

Non operative

• Ice, rest, activity modification, physio
  
  • most pts
  • stretching of quads/hamstrings
  • eccentric exercise programe
  • taping or chopat’s strap can reduce tension across patella tendon
  • ** corticosteriods CI due to risk of patella tendon rupture**

Operative

• Surgical excision and suture repair as needed- open vs arthroscopic
  
  • for Blazina stage 3 disease
  • partial tears & chronic pain/dysfunction
  • resect angiofibroblastic and mucoid degenerative area
  • follow w bone abrasion at tendon insertion/ suture repair/anchors as needed
  • Post op
    
    • ​inital immobilisation in extension
    • progressive rom & mobilisation exercises as tolerated
    • Wb as tolerated

Question 7

What are the oucomes of surgery for patella tendonitis?

Answer 7

• return to activites is achieved by 80%-90% of athletes
• there may be activity related aching for 4-6 months post surgery

Question 8

Describe quadriceps tendonitis?

Answer 8

• Inflammation of the suprapatellar tendon of the quadriceps muscle
• M>F : 8:1
• more common in adult athletes
• risk factors
  
  • jumping sports: basketball, volleyball, athletics

Question 9

What is the aetiology of quadriceps tendonitis?

Answer 9

• Mechanism of injury
  
  • occurs as the result of repititive eccentric contractions of the extensor mechanism
• Pathology
  
  • microtears of the tendon most commonly at the bone-tendon interface

Question 10

What are the associated conditions of quadriceps tendonitis?

Answer 10

• Jumper’s knee
  
  • patella tendonitis
• Quadriceps tendinossi
  
  • chronic tendon degeneration with no inflammation

Question 11

Describe the anatomy of quadriceps ?

Answer 11

• Quadriceps muscles
  
  • rectus femoris
  • vastus medialis
  • vastus lateralis
  • vastus intermedius
• Quadriceps tendons
  
  • anterior layer= rectus femoris
  • middle layer= vastus medialis, vastus lateralis
  • deep layer= vastus intermedius
• ​blood supply
  
  • ​medial, lateral and peripatellar arcades
• ​innervation
  
  • Muscular branch of femoral n L2, L3 L4

Question 12

What is the presentation of quadriceps tendonitis?

Answer 12

• hx
  
  • overuse
  • increase in athletic demands
• Symptoms
  
  • Pain localised to superior border of patella
  • worse w activity
  • assoc w swelling
• O/E
  
  • knee alignment
  • swelling
  • tenderness to deep palpation at quads tednon insertion at the patella
  • palpable gap would suggest a quads tendon tear
  • Able to actively extend the knee against gravity

Question 13

What is seen on xrays with quadriceps tendonitis?

Answer 13

• Usually normal
• tendon calcinosis in chronic degeneration
• elavuate knee alignment for varus/valgus
• evaluate patellar height ( alta vs baja) - quads rupture
  
  • Install- Salvati method
    
    • normal between 0.8- 1.2
    • <0.8 = patella alta

Question 14

What is the most sensitive imaging modality?

Answer 14

• MRI
  
  • dx of intrasubstance signal and thickening of tendon
• USS - operator and user dependent to detect and localising tendon rupture

Question 15

What is the tx of quads tendonitis?

Answer 15

Non operative

• Activity modification, nsaids, physio
  
  • mainstay of tx
  • rest until pain is improved
  • physio to start with rom and progress to eccentric exercises
  • cortisone injections CI due to risk of quads tendon rupture

Operative

• quads tendon debridment
• v rarely required

Question 16

Describe Semimembranosus tendonitis?

Answer 16

• Most common in male athletes
• pt in 30yrs
• report of increase in endurance activites
• Pain in posteromedial knee
  
  • may radiate to thigh/distal medial calf
  • maybe exacerbated by down stairs/deep flexion
• tenderness to palpation at tibial insertion
• passive deep flexion of knee/ internal rotation of tibia at 90o may increase pain
• MRI helpful for dx

Question 17

What is the tx of Semimembranosus tendonitis?

Answer 17

• Non operative
  
  • Physio
    
    • mainstay of tx
    • usually responds to strecthing and strengthening of hamstrings
  • Steriod injection
    
    • used as adjunct

Question 18

What is prepatella bursitis?

Answer 18

• Swelling and inflammation of anterior knee
• aka house maids’s knee
• **most common bursitis of the knee
• location
  
  • bursa anterior to patella
• `Risk factors
  
  • kneeling
  • common in wreslers- concern septic arthritis
• ​Pathophysiology
  
  • ​maybe septic or aseptic
  • 20% septic

Question 19

Describe the anatomy of the prepatellar bursa?

Answer 19

• A potential space
• function is to enhance gliding of tissue over patella

Question 20

What is the presentation of prepatella bursitis?

Answer 20

• Often hx of kneeling
• Symptoms
  
  • Pain
  • swelling
• O/E
  
  • can be warm to touch, esp if septic

Question 21

What study would help identify if prepatella bursitis was septic or aseptic?

Answer 21

• Aspiration w gram stain and culture

Question 22

What is the tx of prepatella bursitis?

Answer 22

• Non operative
  
  • Compressive wrap, NSAIDS, +/- aspiration & immobilisation for 1 wk
    
    • most cases
    • corticosteriod is contraversial
• Operative
  
  • Bursal resection
    
    • rare
    • open vs arthroscopic

Question 23

What iliotibial band friction syndrome?

Answer 23

• A condition characterised by excessive friction between the iliotibial band and lateral femoral condyle
• comprised 2-15% of all overuse injuries of knee region
• common runners, cyclists- repetitive knee flexion/extension
• risk factors
  
  • training errors
    
    • change in intensity
    • poor shoe support
  • anatomical factors
    
    • genu recurvatum/genu varum
    • LLD
    • excessive foot pronation
    • weak hip abductors
    • tight ITB
  • Biomechanical
    
    • disparity between quads and hamstring strength
    • increased landing forces
    • increased angle of knee flexionat heel strike

Question 24

What is the pathophysiology of iliotibial band syndrome?

Answer 24

• mechanism of injury
  
  • ITB repetitivel shifted towards & backwards across lateral femoral condyle causing
    
    • friction, ITB tensioning and inflammation
    • impingement zone= 30 degrees of knee flexion

Question 25

Name any associated conditions with iliotibial band syndrome?

Answer 25

* Patellofemoral syndrome * tightness of ITB * Medial compartment OA ​ * Greater trochanteric pain syndrome * alters mechanics of ITB

Question 26

What is the prognosis of iliotibial band syndrome?

Answer 26

* 50-90% ot will improve with 4-8 wks of non op modalities

Question 27

Describe the anatomy of ITB?

Answer 27

* Origin * continuation of tensor fascia lata * Inserts * Gerdy's tubercle * Innervation * Sup gluteal nerve L1-3 * Primary synergistic muscle * Hip abductors

Question 28

What is the presentation of iliotibial band syndrome?

Answer 28

* **Pain over lateral femoral condyle** * usually relieved by rest * O/E * **pain reproduced w single leg squat** * ***Ober's test*** * provcatio test * lateral w sytomatic side up w knee flexed to 90 * hip is brought from flexion & abduction into extension and adduction * positive if pain, tightness or clicking over ITB

Question 29

What is seen on imaging of iliotibial band syndrome?

Answer 29

* Bone patholgy * medial joint space narrowing * patellar malignment * fx * MRI * rule our soft tissue pathology in same region

Question 30

What is the tx of iliotibial band syndrome?

Answer 30

* Non operative * **rest, ice, nsaids, corticosteriod injections** * intial tx to reduce pain/swelling * **Physio & training modification** * stretch ITB, lateral fascia and gluteal muscles * deep transverse friciton message * change shoes every 300-500 miles * Operative * **Excision of cyst, bursa or lateral synovail recess** * failed non op mx * soft tissue pathology * arthroscopic vs open * **Elipitical surgical excision of ITB** * failed non op with chronic pain * open technique * lateral femoral incision * expose post portion of ITB over lateral femoral condyle * incise 2x4cm ellipse of band tissue * **Z plasty of ITB** * in refractiry cases