Patellar Tendon Tear

Tendons are sturdy cords of fibrous tissue that attach muscles to bones. The patellar tendon works with the muscles right in front of your thigh to straighten your leg.  Small tears of the tendon will make it difficult to walk and take part in other daily activities. A big tear of the patellar tendon is a disabling injury. It normally requires surgery and physical therapy to regain full knee function. Pay close attention to this important info from Audrain Orthopaedics in Mexico, MO.

Anatomy

The patellar tendon attaches the base of the kneecap (patella) to the top of the shinbone (tibia). It is a ligament that joins with two different bones, the patella and the tibia.

The patella is connected to the quadriceps muscles by the quadriceps tendon. Working together, the quadriceps muscles, quadriceps tendon, and patellar tendon straighten the knee.

Description

Patellar tendon tears may be either partial or complete.

Partial tears. Many tears do not totally disrupt the soft tissue. This is similar to a rope stretched out so far that some of the fibers are frayed, but the rope remains in one piece.

Complete tears. A complete tear will disturb the soft tissue into two pieces.

Whenever the patellar tendon is completely torn, the tendon is separated from the kneecap. Without this attachment, you can't straighten your knee.

The patellar tendon often tears at the place where it attaches to the kneecap, and a bit of bone can break off along with the tendon. Whenever a tear is caused by a medical condition — such as tendinitis — the tear generally occurs in the middle of the tendon.

Cause

Injury

A very strong force is required to tear the patellar tendon, but many individuals in Mexico, Columbia, Moberly, and Jefferson City, MO need to deal with this problem.

Falls. Straight impact to the front of the knee from a fall or other blow is a very common cause of tears. Cuts tend to be associated with this type of injury.

Jumping. The patellar tendon usually tears when the knee is bent and the foot planted, like when landing from a jump or jumping up.

Tendon Weakness

A weakened patellar tendon is more likely to tear. A number of things may cause tendon weakness.

Patellar tendinitis. Inflammation of the patellar tendon, known as patellar tendinitis, weakens the tendon. This may also result in small tears.

Patellar tendinitis is most common in individuals who participate in activities that call for running or jumping. While it's more prevalent in runners, it's sometimes referred to as "jumper's knee."

Corticosteroid injections to treat patellar tendinitis have been linked to increased tendon weakness and increased likelihood of tendon rupture. These injections are usually avoided in or around the patellar tendon.

Chronic disease. Weakened tendons may also be caused by diseases that disrupt blood supply. Chronic diseases which might weaken the tendon include:

•   Chronic renal failure

•   Hyper betalipoproteinemia

•   Rheumatoid arthritis

•   Systemic lupus erythmatosus (SLE)

•   Diabetes mellitus

•   Infection

•   Metabolic disease

Steroid usage. Using medications such as corticosteroids and anabolic steroids has been linked with increased muscle and tendon weakness.

Surgery

Previous surgery around the tendon, such as a total knee replacement or anterior cruciate ligament reconstruction, may put you at greater risk for a tear.

Symptoms

Whenever a patellar tendon tears there is commonly a tearing or popping sensation. Pain and swelling usually follow, and you might not be able to unbend your knee. Additional symptoms include:

•   An indent at the bottom of your kneecap where the patellar tendon tore

•   Bruising

•   Tenderness

•   Cramping

•   Your kneecap might move up into the thigh because it's no longer anchored to your shinbone

•   Difficulty walking due to the knee buckling or giving way

Doctor Examination

Medical History and Physical Examination

Your physician will discuss your general health and the symptoms you're experiencing. He or she will also ask you about your medical history. Questions you might be asked include:

•   Have you had an earlier injury to the front of your knee?

•   Do you have patellar tendinitis?

•   Have you got any medical conditions which could predispose you to a knee or a patellar tendon injury?

•   Have you ever had surgery to your knee, such as a total knee replacement or an anterior cruciate ligament reconstruction?

After discussing your symptoms and medical history, your doctor will conduct a comprehensive examination of your knee. To determine the exact cause of your symptoms, your doctor will test how well you can extend, or straighten, your knee. While this part of the examination can be painful, it is important to identify a patellar tendon tear.

Imaging Tests

To confirm the diagnosis, your doctor may order some imaging tests, such as an x-ray or magnetic resonance imaging (MRI) scan.

X-rays. The kneecap moves out of place whenever the patellar tendon tears. This is often very obvious on a "sideways" x-ray view of the knee. Complete tears can often be identified with these x-rays alone.

MRI. This scan creates better images of soft tissues such as the patellar tendon. The MRI can show the amount of tendon torn and the location of the tear. Sometimes, an MRI is required to rule out a different injury that has similar symptoms.

Treatment

Your doctor will consider several things when planning your treatment, including:

•   The type and size of your tear

•   Your activity level

•   Your age

Nonsurgical Treatment

Very small, partial tears respond well to nonsurgical treatment.

Immobilization. Your physician may suggest you wear a knee immobilizer or brace. This will keep your knee straight to help it heal. You will most likely need crutches to help you stay away from putting all of your weight upon your leg. You can expect to be in a knee immobilizer or brace for 3 to 6 weeks.

Physical therapy. When the initial pain and swelling has settled down, physical therapy may start. Specific exercises can restore strength and range of motion.

While you're wearing the brace, your physician may suggest exercises to reinforce your quadriceps muscles. Straight-leg raises are often prescribed. As time goes on, your doctor or therapist will unlock your brace. This will enable you to move more freely with a greater range of motion. You will be prescribed more strengthening exercises as you heal.

Surgical Treatment

Most people need surgery to regain knee function. Surgical repair reattaches the torn tendon to the kneecap.

People who require surgery do better if the repair is performed soon after the injury. Early repair may prevent the tendon from scarring and tightening into a shortened position.

Hospital stay. Although tendon repairs are occasionally done on an outpatient basis, most people do stay in the hospital at least one night after this operation. Whether or not you will have to stay overnight will depend on your medical needs.

The surgery may be performed with regional (spinal) anesthetic which numbs your lower body, or with a general anesthetic which will put you to sleep.

Procedure. To reattach the tendon, sutures are put in the tendon and then threaded through drill holes in the kneecap. The sutures are tied at the top of the kneecap. Your doctor will cautiously tie the sutures to get the correct tension in the tendon. This will also make sure the position of the kneecap closely matches that of your uninjured kneecap.

New Technique. A recent development in patellar tendon repair is the use of suture anchors. Surgeons affix the tendon to the bone utilizing small metal implants (called suture anchors). Using these anchors means that drill holes in the kneecap are not necessary. This is a new technique, so data is still being collected on its effectiveness. Most orthopaedic research on patellar tendon repair involves the direct suture repair with the drill holes in the kneecap.

Considerations. To provide extra protection to the repair, some surgeons use a wire, sutures, or cables to help hold the kneecap in place while the tendon mends. If your physician does this, the wires or cables may need to be removed during a later, scheduled operation.

Your physician will discuss your need for this extra protection before your operation. Occasionally, surgeons make this decision for added protection during surgery. It is then that they see the tendon shows more damage than anticipated, or the tear is more extensive.

If your tendon has shortened too much before surgery, it's going to be difficult to re-attach it to your kneecap. Your surgeon may have to add tissue graft to lengthen the tendon. This often involves using donated tissue (allograft).

Tendons often shorten if over a month has passed since your injury. Severe damage from the injury or underlying disease can also make the tendon too short. Your surgeon will discuss this extra procedure with you before surgery.

Complications. The most common complications of patellar tendon repair include weakness and loss of motion. Re-tears occasionally occur, and the repaired tendon can detach from the kneecap. Also, the position of your kneecap may differ after the procedure.

As with any surgery, the other possible complications include infection, wound breakdown, a blood clot, or anesthesia complications.

Rehabilitation. Following surgery you'll need some sort of pain management, including ice and medications. About 2 weeks after surgery, your skin sutures or staples will be taken out in the surgeon's office.

Probably, your repair will be protected with a knee immobilizer or a long leg cast. You might be allowed to put your weight on your leg with the use of a brace and crutches (or a walker). To begin, your physician may recommend "toe touch" weight bearing. This is whenever you lightly touch your toe to the floor, putting down just the weight of your leg. By two to four weeks, your leg can usually bear about 50% of your weight. After four to six weeks, your leg ought to be able to handle your entire body weight.

Over time, your doctor or therapist will unlock your brace. This enables you to move more freely with a greater range of motion. Strengthening exercises will be added to your rehabilitation plan.

In some instances, an "immediate motion" protocol (treatment plan) is recommended. This is a more aggressive approach and not appropriate for all patients. Most surgeons protect motion in early stages following surgery.

The exact timeline for physical therapy and the type of exercises prescribed will be individualized to you. Your rehabilitation plan will be based on the type of tear you have, your surgical repair, your medical condition, and your needs.

Complete recovery takes around half a year. Many patients have reported that they required a year before they reached all their goals.

Outcomes

Most people are able to return to their past occupations and activities after recovering from a patellar tendon tear. A lot of people report stiffness in the affected leg. Most regain nearly equal motion compared to the uninjured leg.

If you are an athlete, your surgeon will probably want to test your leg strength before giving a go-ahead to return to sports. Your doctor will compare your leg strength utilizing some functional knee testing (such as hopping). The goal is that your strength be at least 85-90% of your uninjured side. In addition to leg strength, your surgeon will assess your leg's endurance, your balance, and if you're having any swelling.

Your return to competitive status will be addressed very carefully with you by your surgeon.

If you've got any questions about patellar tendon tear or any other part of orthopedic medicine, go to Audrain Orthopaedics in Mexico, MO.