Tendinopathy

Tendinopathies About The Knee
Diagnosis, Conservative / Surgical Treatment
Chih-Hwa Chen, MD
Department of Orthopaedic Surgery
Taipei Medical University Hospital
Taipei Medical University
Taipei, Taiwan
Tallinn, Estonia
Taipei, Taiwan
• Tendon unit:
• Tendon
• Myotendinous junction
• Enthesis: tendon-bone insertion
• Tendon:
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Endotenon
Peritendon: epitenon / paratennon
Tendon sheath
Bursa
Tendon Disease
• Tendinitis:
• acute tendon injury + inflammation
• Tendinosis:
• chronic tendon injury + degeneration - inflammation
• Tendinopathy:
• chronic tendon injury
• Insertional tendinitis
= Enthesitis
• Paratendonitis
• Tenosynovitis
• Bursitis
Tendinopathy
Pathophysiology
• Disintegrated collagen fibers
• Loss of cell attachment
• Collagen fibers thinner and
loosely organized
• Higher amount of type III
collagen
• Increase proteoglycans,
water content
Tendinopathy
Time - Injury
• Acute: 4 wk
• Subacute: 5 - 12 wk
• Chronic: 12 wk
• Acute on chronic
• Degeneration
Tendinopathy
Mechanism
Tendinopathy
Risk Factors
• Intrinsic risk factors:
• biomechanics, family history, sex,
age
• Extrinsic risk factors
• training errors, sport demands,
occupation, repetitive work
• Medical conditions
• obesity, tight muscles, psoriasis,
high blood pressure, antibiotics
(fluoroquinolones)
Tendinopathy
Additional Features
• Calcification
• Primary / Dystrophic
• Bony change
• Overlaying spur, Insertional spur, Traction spur
• Joint pathology
• OA, ligament injury, chondral tear, meniscus tear
Tendinopathy
Clinical Problems
• Pain on exercising or with
sports activity
• Tenderness and trigger pain
• Unable to normal sports
ability
• Unable to return sports
training, competition, and
performance
Tendinopathies About The Knee
• Anterior knee:
• Patellar tendinopathy
• Quadriceps tendinopathy
• Lateral knee:
• Iliac tibial band tendinopathy
• Popliteus tendinopathy
• Biceps femoris tendinopathy
• Medial knee:
• Pes anserine tendinopathy
• Semimembranous tendinopathy
Patellar Tendinopathy
Anterior
Knee
Jumper’s Knee
Patellar Tendinopathy
Structure
• Epidemiology
• incidence
• Up to 20% of jumping athletes
• Pathophysiology
• mechanism
• repetitive, forceful, eccentric contraction of the extensor mechanism
• histology
• degenerative, rather than inflammatory
• Micro-tears of the tendinous tissue are commonly seen
Patellar Tendinopathy
Contribution Factors
• Physical activity:
• Running and jumping
• Sudden increases or overuse the running
• Tight quadriceps and hamstrings
• Muscular imbalance
• Risk factors:
• Weight, body mass index, waist-to-hip ratio, leglength difference, arch height of the foot,
quadriceps flexibility, hamstring flexibility,
quadriceps strength and vertical jump
performance.
Study
Factor
Risk factor /
Patellar
associated
tendinopathy /
factor
tendon pathology
Comment
Visnes
Cook
Gender
Both
Both
Men at higher risk
Malliaras
Waist circumference
Associated
Pathology
Increased waist circumference associated with
increased pathology
Cook
Imaging abnormality
Risk
Tendinopathy
Adolescents only
Cook
Hamstring length
Associated
Pathology
Less extensible hamstrings associated with pathology
Witvrouw
Hamstring length
Risk
Tendinopathy
Witvrouw
Quadriceps length
Risk
Tendinopathy
Malliaras
Dorsiflexion
Associated
Pathology
Edwards
Altered landing
strategies
Associated
Pathology
Less knee bend at landing, altered hip strategies
associated with pathology
Lian
Jumping ability
Both
Tendinopathy
Better jumping ability associated with patellar
tendinopathy
Culvenor
Fat pad size
Associated
Tendinopathy
Increased fat pad size associated with patellar
tendinopathy
Gaida
Jannsen
Loading
Associated
Tendinopathy
Excess loading associated with patellar tendinopathy
Less extensible hamstrings increase risk of patellar
tendinopathy
Stiffer quadriceps increase risk of patellar
tendinopathy
Reduced dorsiflexion associated with increased
pathology
Patellar Tendinopathy
Diagnosis
• Classification:
• Blazina classification system
• phase I
• pain after activity only
• phase II
• pain at the beginning of activity, disappearing after warm-up, and
reappearing after completion of an activity
• phase III
• persistent pain with or without activities
• deterioration of performance
• unable to participate in sports.
• phase IV
• complete rupture of the patellar tendon
Patellar Tendinopathy
Diagnosis
• Symptoms
• Insidious onset of anterior knee pain
at inferior border of patella
• initial phase
• pain following activity
• late phase
• pain during activity
• pain with prolonged flexion ("movie theater
sign")
• Associated with increased training
load, sports activity
• Acute exacerbations
Patellar Tendinopathy
Diagnosis
• Physical exam
• inspection
• may have swelling over tendon and lower pole of patella
• palpation
• tenderness at inferior border of patella
• provocative tests
• Basset's sign
• tenderness to palpation at distal pole of patella in full extension
Patellar Tendinopathy
Diagnosis - Ultrasound / MRI
Patellar Tendinopathy
Conservative Treatment
• Blazina stages I, II
• Medication:
• NSAIDs
• Physical therapy:
• Eccentric muscle training
• Transverse friction massage
• Modification of activity:
• Improvements in training techniques
• Patellar tendon strap
Patellar Tendinopathy
Conservative Treatment
• Local treatment modality:
• Shock wave therapy
• Low-intensity pulsed
ultrasound (LIPUS)
• Hyperbaric oxygen
• Magnets
• Phonophoresis
• Iontophoresis
• Local injection:
• Steroid infiltrations
• Hyperosmolar dextrose
Patellar Tendinopathy
Conservative Treatment
• Biological agents injection:
• platelet-rich plasma
• Autologous tenocyte
• autologous bone marrow stem cells
• Ultrasound-guided percutaneous
needling
Patellar Tendinopathy
Conservative Treatment - Rehabilitation
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Activity modification:
Cryotherapy:
Joint motion and kinematics assessment:
Stretching:
Strengthening:
Sport-specific proprioceptive training and plyometric
Ultrasonography or phonophoresis
patellofemoral brace
McConnell taping
Patellar Tendinopathy
Conservative Treatment - Rehabilitation
Phase of rehabilitation
Pain management
Aim of treatment
Reduce pain
Intervention
Isometric exercises in mid-range as tolerated. Reduce
loading and activity modification
Strength progression
Improve strength
Heavy slow resistance as tolerated (isotonic)
Functional strengthening
Progressive resistance exercise program, functional
tasks, address movement patterns, kinetic chain and
endurance training as required
Increase speed of muscle contraction, lower the
number of repetitions
Increase power
Energy-storage/stretch- Develop stretch-shorten cycle Plyometric exercises, graded gradually
shorten cycle
Training sport-specific
Drills specific to sport including endurance training
Maintenance
Management of symptoms
and prevention of flare ups
Education, continue strength training and manage
loading as tolerated
Patellar Tendinopathy
Surgical Treatment
• Failure of conservative
treatment
• Percutaneous patellar
tenotomy
• Debridement and resection of
degenerative tendon issue
• Drilling of holes in the inferior
patellar pole
• Resection of the inferior
patellar pole
Quadriceps Tendinopathy
Anterior
Knee
Quadriceps Tendinopathy
Structure
• Quadriceps tendon is a thick tendon extending to
the patella made up of contributions from all four
quadriceps muscles.
• Trilaminar appearance:
• Superficial layer: rectus femoris
• Middle layer: vastus medialis, vastus lateralis
• Deep layer: vastus intermedius
Quadriceps Tendinopathy
Diagnosis
• Pain along the superior pole of the patella, at the insertion
of the quadriceps tendon
• Pain during and post exertional activity
• Localized swelling
• Local tenderness
• Single leg squat decline
Quadriceps Tendinopathy
Diagnosis – Ultrasound MRI
Quadriceps Tendinopathy
Contribution Factors
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Joint stiffness (particularly the hip, knee, ankle or lower back)
Muscle tightness (particularly the quadriceps, hamstrings or calfs)
Inappropriate or excessive training
Inadequate warm up
Muscle weakness (especially the quadriceps and / or gluteals)
Poor pelvic or core stability
Inadequate rehabilitation following a previous quadriceps injury
Poor foot posture or other biomechanical issues
Inappropriate footwear
Medical disease:
• Hyperparathyroidism • calcium pyrophosphate deposition • diabetes mellitus •
steroid induced tendinopathy • fluroquinolone induced tendinopathy • osteomalacia
• chronic renal insufficiency • gout • uraemia
Quadriceps Tendinopathy
Conservative Treatment
• Eccentric exercises
• Stretching
• PRP
• Shock wave therapy
Quadriceps Tendinopathy
Surgical Treatment
• Partial tear of quadriceps tendon
• Necrotic tendon
• Surgical options:
• Arthroscopic debridement
• Arthroscopic guided tenotomy
• Open tenotomy
Iliotibial Band Tendinopathy
Lateral
Knee
Runner’s Knee
Cyclist’s Knee
Iliotibial Band Tendinopathy
Structure
• Tendon within fascia lata from iliac crest pass on lateral
femoral epicondyle into Girdy’s tubercle at proximal tibia
• slides over the lateral femoral epicondyle during repetitive
flexion and
extension of the knee
Iliotibial Band Tendinopathy
Diagnosis
• ITB friction syndrome
• Excessive friction between the iliotibial band and the lateral
femoral condyle
• ITB insertional tendinitis
• Pain and tender at Girdy tubercle
Iliotibial Band Tendinopathy
Diagnosis
• Activities that involve repetitive knee flexion and extension
will incite and aggravate the symptoms located over the
lateral side of the knee.
• Knee Flexed 30 Degrees: ITB Behind Lateral Femoral
Condyle
• Knee Extended: ITB Moves Anteriorly
• - ITB Syndrome: Inflammation Distally In The Bursa
Between ITB And Lateral Femoral Condyle
• Ober’s test
Iliotibial Band Tendinopathy
Diagnosis – Ultrasound MRI
• MRI:
• Distal iliotibial band becomes
thickened and inflamed and
filled with fluid
Iliotibial Band Tendinopathy
Contribution Factors
• Sports:
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Runners or cyclists
Long-distance run
Rapid increase in training distances
Banked surfaces run: beach / shoulder of road
Excessive downhill running
• Stretched ITB:
• Leg malalignment, leg length discrepancy,
excessive foot pronation, pelvic contralateral
downward tilt
• Genu varum or pronated feet
• Iliotibial band tightness
• Muscular weakness of knee extensors,
knee flexors, and hip abductors
Iliotibial Band Tendinopathy
Conservative Treatment
• Reduction of training distance
• NSAIDS
• Stretching ITB
• Strengthen ipsilateral hip abductors
• Correction of mal-alignments
• Utilize proper warm-up and stretching techniques
• Avoidance of aggravating activities
• Orthotics
• Local infiltration of corticosteroid
Iliotibial Band Tendinopathy
Surgical Treatment
• Iliotibial band release
procedures
• Excision of torn fibers
and necrotic tissue
Popliteus Tendinopathy
Lateral
Knee
Popliteal Tendinopathy
Structure
• Surrounds posterolateral
aspect of knee, stabilizer in
flexion by resisting forward
displacement of the femur
on the tibia
Popliteal Tendinopathy
Diagnosis
• Be suspicious of popliteal tendinitis in who present with
atypical posterolateral knee pain
• Discomfort anterior of superior lat. Collateral ligament and
with resisted knee flexion with tibia held in external
rotation
Popliteal Tendinopathy
Contribution Factors
• Cross-country running
• Extensive downhill walking or running
• Long-distance runners and walkers
Popliteal Tendinopathy
Conservative Treatment
• Reduction training distance
• NSAIDS
• Stretching knee flexors
• Electrotherapy
Popliteal Tendinopathy
Surgical Treatment
• Arthroscopic debridement
of torn popliteal tendon
Biceps Femoris Tendinopathy
Lateral
Knee
Biceps Femoris Tendinopathy
Structure
• Origin:
- long head: ischial tuberosity
and the sacrotuberous ligament
- short head: lateral lip of linea
aspera, lateral supracondyle of
femur
• Insertion:
- lateral sides of the head of the
fibula, lateral condyle of the tibia
and the deep fascia on the lateral
side of the leg
• Action:
- flexion and lateral rotation of
the leg at the knee, extends,
adducts and laterally rotates the
thigh at the hip
Biceps Femoris Tendinopathy
Diagnosis
• Tenderness at the site where the tendon enters the bone
• Swelling at the site where the tendon enters the bone
• Pain with resisted flexion of the knee
• Stiffness of the knee after physical activity or exercise
• Tightness of the hamstring muscles resulting in limitation
of hip flexion
Biceps Femoris Tendinopathy
Contribution Factors
• Lower extremity muscle imbalances
• Decreased lower body flexibility
• Obese or overweight
• Advanced age
• Malalignment abnormalities of the leg
• Excessive running
Biceps Femoris Tendinopathy
Conservative Treatment
• Rest
• Ice
• Massage therapy
• Eccentric exercise
• NSAID
• Ultrasound therapy
• Electrotherapy
• Taping
Biceps Femoris Tendinopathy
Surgical Treatment
• Surgery is rarely necessary
• Insertional necrotic tissue
excision
Pes Anserine Tendinopathy
Medial
Knee
Pes Anserine Tendinopathy
Structure
• The tendinous aponeurosis of the
sartorius, gracilis, and
semitendinosus
• Per anserinus bursa: located
directly beneath this aponeurosis
and lies on top of the underlying
superficial medial collateral
ligament
Pes Anserine Tendinopathy
Diagnosis
• Burning Localized Pain When Running
• Pain slowly developing on the inside of your knee and/or in
the center of the shinbone, approximately 2 to 3 inches
below the knee joint.
• Pain increasing with exercise or climbing stairs
Pes Anserine Tendinopathy
Diagnosis – Ultrasound MRI
Pes Anserine Tendinopathy
Contribution Factors
• Tight hamstrings, inadequate stretching, previous
hamstring injury, hamstring orientation training
programme
• Excessive genu valgum and weak vastus medialis
• Running with one leg higher than the other
• Running on a slope or crowned road
Pes Anserine Tendinopathy
Conservative Treatment
• Stretching Hamstrings,
• NSAID
• Rest when acute local infiltrations
• Orthotics
• Wrapping an elastic bandage around the knee to reduce
any swelling or to prevent swelling from
• Leg stretching exercises: hamstring stretch, standing calf
stretch, standing quadriceps stretch, hip adductor stretch,
heel slide, quadriceps isometrics, hamstrings
• Local steroid injection
Pes Anserine Tendinopathy
Surgical Treatment
• Pes anserine bursitis
Semimembranosus Tendinopathy
Medial
Knee
Semimembranosus Tendinopathy
Structure
• Originates from the lateral aspect of the ischial tuberosity,
runs down the posteromedial aspect of the thigh, inserts at
the posteromedial aspect of the knee
Semimembranosus Tendinopathy
Diagnosis
• Symptom and Sign:
• Pain along the posteromedial corner of the knee
• Strenuous and repetitive activities can elicit pain
Semimembranosus Tendinopathy
Diagnosis
• Pain, tenderness, and/ or inflammation over posterior side
of the thigh or medial side of the knee.
• Pain that worsens during and after exercise that involves
use of the knee or hip joints
• A crackling crepitation when the tendon is moved or
touched
Semimembranosus Tendinopathy
Diagnosis
Semimembranosus Tendinopathy
Contribution Factors
• Activities that involve repetitive and/or strenuous use of
the knee and hip
• Distance running, triathlon, race walking, weightlifting, or
climbing).
• Running down hills
• Poor strength and flexibility
• Failure to warm-up properly before activity
• Flat feet
• Improper knee alignment with bowed knee
Semimembranosus Tendinopathy
Conservative Treatment
• Relative rest from painful activities
• Pain-relieving modalities
• NSAID
• Physical therapy with hamstring strengthening and
stretching
• Proper shoe fit to prevent over pronation
Semimembranosus Tendinopathy
Surgical Treatment
• Recalcitrant cases of SMT after failure of conservative
treatment
• SM-rerouting procedure:
• Places the SM tendon adjacent to the posterior border of the MCL
• Relieve the chronic irritation of the SM tendon at the posterior
medial corner