Patellar tendon rupture

Classification	D ICD-10 : S76.1 ; ICD-9-CM : 727.66 ;
External resources	eMedicine : article/1249472 ;

Patellar tendon rupture
Other names	Patellar tendon tear
	Patellar tendon rupture showing a marked distance between the tibial tuberosity and the bottom of the knee cap.
Specialty	Orthopedics
Symptoms	Pain, trouble walking, inability to straighten the knee [1]
Usual onset	Sudden [2]
Types	Partial, complete [1]
Causes	Falling directly on the knee, jumping from a height [1]
Risk factors	Patellar tendinitis, kidney failure, diabetes, steroid use [1]
Diagnostic method	Based on symptoms, examination, medical imaging [1]
Differential diagnosis	Patellar fracture, patella dislocation, quadriceps tendon rupture, muscle strain [2] [3]
Treatment	Rest, physiotherapy, surgery [1]
Prognosis	Good [1]
Frequency	Up to 1 in 10,000 per year [2]

Last updated October 31, 2020

Patellar tendon rupture is a tear of the tendon that connects the knee cap (patella) to the tibia.^[1] Often there is sudden onset of pain and walking is difficult.^[1] In a complete rupture the ability to extend that knee is decreased.^[1] A pop may be felt when it occurs.^[2]

Injury to the patellar tendon generally requires a significant force such as falling directly on the knee or jumping from a height.^[1] Risk factors include patellar tendinitis, kidney failure, diabetes, and steroid or fluoroquinolone use.^[1]^[2] There are two main types of ruptures: partial and complete.^[1] In most cases, the patellar tendon tears at the point where it attaches to the knee cap.^[1] Diagnosis is based on symptoms, examination, and medical imaging.^[1]

Small tears may be treated with rest and splinting, followed by physiotherapy.^[1]^[2] Larger tears typically require surgery within a couple of weeks.^[1]^[2] Outcomes are generally good.^[1] Rates in the general population are not clear; however, in certain high-risk groups it occurs about 1 in 10,000 per year.^[2] They occur most often in those under the age of 40.^[2]

Signs and symptoms

The sign of a ruptured patella tendon is the movement of the patella further up the quadriceps. When rupture occurs, the patella loses support from the tibia and moves toward the hip when the quadriceps muscle contracts, hindering the leg's ability to extend. This means that those affected cannot stand, as their knee buckles and gives way when they attempt to do so.^{[ citation needed ]}

Mechanism

The upper part of the patellar tendon attaches on the lower part of the knee cap, and the lower part of the patella tendon attaches to the tibial tubercle on the front of the tibia. Above the knee cap, the quadriceps muscle via the quadriceps tendon attaches to the top of the knee cap. This structure allows the knee to flex and extend, allowing use of basic functions such as walking and running.^{[ citation needed ]}

Diagnosis

Patellar tendon rupture can usually be diagnosed by physical examination. The most common signs are: tenderness, the tendon's loss of tone, loss of ability to raise the straight leg and observation of the high-riding patella. Radiographically, patella alta can be detected using the Insall and Salvati method when the patella is shorter than its tendon. Partial tears may be visualized using MRI scans.^[4]

Treatment

Patellar tendon rupture must be treated surgically. With a tourniquet applied, the tendon is exposed through a midline longitudinal incision extending from the upper patellar pole to the tibial tuberosity. The tendon is either avulsed (detached) from the lower patellar pole or lacerated. Even so, the continuity and tone of the tendon should be restored, taking into consideration the patellar height.^{[ citation needed ]}

A cast or brace is then put over where the operation took place. The cast or brace remains for at least 6 weeks followed by an unidentified time of rehabilitation of the knee. The usual risks of surgery are involved, including: infection, stiffness, death, suture reaction, failure of satisfactory healing, risks of anesthesia, phlebitis, pulmonary embolus, and persistent pain or weakness after the injury and repair.^{[ citation needed ]}

If the tendon rupture is a partial tear (without the two parts of the tendon being separated), then non-surgical methods of treatment may suffice. The future of non-surgical care for partial patella tendon ruptures is likely bioengineering. Ligament reconstruction is possible using mesenchymal stem cells and a silk scaffold.^[5] These same stem cells have been shown to be capable of seeding repair of damaged animal tendons.^[6] In 2010, a clinical study proved that mechanical loading of the tendon callus during the remodelling phase leads to healing by regeneration.^[7]

Related Research Articles

In humans and other primates, the knee joins the thigh with the leg and consists of two joints: one between the femur and tibia, and one between the femur and patella. It is the largest joint in the human body. The knee is a modified hinge joint, which permits flexion and extension as well as slight internal and external rotation. The knee is vulnerable to injury and to the development of osteoarthritis.

The patella, also known as the kneecap, is a flat, circular-triangular bone which articulates with the femur and covers and protects the anterior articular surface of the knee joint. The patella is found in many tetrapods, such as mice, cats and birds, but not in whales, or most reptiles.

Attenuated patella alta is an extremely rare condition affecting mobility and leg strength. It is characterized by an unusually small knee cap (patella) that develops out of and above the joint. Normally, as the knee cap sits in the joint, it is stimulated to growth by abrasion from the opposing bones. When not situated properly in the joint, the knee cap does not experience such stimulation and remains small and undeveloped. Note that the cartilage under and around the kneecap is eight times smoother than ice, so "abrasion" may not be the best term.

The anterior cruciate ligament (ACL) is one of a pair of cruciate ligaments in the human knee. The 2 ligaments are also called cruciform ligaments, as they are arranged in a crossed formation. In the quadruped stifle joint, based on its anatomical position, it is also referred to as the cranial cruciate ligament. The term cruciate translates to cross. This name is fitting because the ACL crosses the posterior cruciate ligament to form an “X”. It is composed of strong fibrous material and assists in controlling excessive motion. This is done by limiting mobility of the joint. The anterior cruciate ligament is one of the four main ligaments of the knee, providing 85% of the restraining force to anterior tibial displacement at 30 degrees and 90 degrees of knee flexion. The ACL is the most injured ligament of the four located in the knee.

Osgood–Schlatter disease (OSD) is inflammation of the patellar ligament at the tibial tuberosity (apophysitis). It is characterized by a painful bump just below the knee that is worse with activity and better with rest. Episodes of pain typically last a few weeks to months. One or both knees may be affected and flares may recur.

Anterior cruciate ligament reconstruction is a surgical tissue graft replacement of the anterior cruciate ligament, located in the knee, to restore its function after an injury. The torn ligament can either be removed from the knee, or preserved before reconstruction an arthroscopic procedure. ACL repair is also a surgical option. This involves repairing the ACL by re-attaching it, instead of performing a reconstruction. Theoretical advantages of repair include faster recovery and a lack of donor site morbidity, but randomised controlled trials and long-term data regarding re-rupture rates using contemporary surgical techniques are lacking.

Patellar tendinitis, also known as jumper's knee, is an overuse injury of the tendon that straightens the knee. Symptoms include pain in the front of the knee. Typically the pain and tenderness is at the lower part of the kneecap, though the upper part may also be affected. Generally there is not pain when the person is at rest. Complications may include patellar tendon rupture.

The medial collateral ligament (MCL), or tibial collateral ligament (TCL), is one of the four major ligaments of the knee. It is on the medial (inner) side of the knee joint in humans and other primates. Its primary function is to resist outward turning forces on the knee.

The knee examination, in medicine and physiotherapy, is performed as part of a physical examination, or when a patient presents with knee pain or a history that suggests a pathology of the knee joint.

The stifle joint is a complex joint in the hind limbs of quadruped mammals such as the sheep, horse or dog. It is the equivalent of the human knee and is often the largest synovial joint in the animal's body. The stifle joint joins three bones: the femur, patella, and tibia. The joint consists of three smaller ones: the femoropatellar joint, medial femorotibial joint, and lateral femorotibial joint.

Cruciate ligaments are pairs of ligaments arranged like a letter X. They occur in several joints of the body, such as the knee joint and the atlanto-axial joint. In a fashion similar to the cords in a toy Jacob's ladder, the crossed ligaments stabilize the joint while allowing a very large range of motion.

The patellar ligament is the distal portion of the common tendon of the quadriceps femoris, which is continued from the patella to the tibial tuberosity. It is also sometimes called the patellar tendon as it is a continuation of the quadriceps tendon.

The tuberosity of the tibia or tibial tuberosity or tibial tubercle is an elevation on the proximal, anterior aspect of the tibia, just below where the anterior surfaces of the lateral and medial tibial condyles end.

The unhappy triad, also known as a blown knee among other names, is an injury to the anterior cruciate ligament, medial collateral ligament, and meniscus. Analysis during the 1990s indicated that this 'classic' O'Donoghue triad is actually an unusual clinical entity among athletes with knee injuries. Some authors mistakenly believe that in this type of injury, "combined anterior cruciate and medial collateral ligament disruptions that were incurred during athletic endeavors" always present with concomitant medial meniscus injury. However, the 1990 analysis showed that lateral meniscus tears are more common than medial meniscus tears in conjunction with sprains of the ACL.

The knee bursae are the fluid-filled sacs and synovial pockets that surround and sometimes communicate with the knee joint cavity. The bursae are thin-walled, and filled with synovial fluid. They represent the weak point of the joint, but also provide enlargements to the joint space. They can be grouped into either communicating and non-communicating bursae or, after their location – frontal, lateral, or medial.

In human anatomy, the quadriceps tendon works with the quadriceps muscle to extend the leg. All four parts of the quadriceps muscle attach to the shin via the patella, where the quadriceps tendon becomes the patellar ligament. It attaches the quadriceps to the top of the patella, which in turn is connected to the shin from its bottom by the patellar ligament. A tendon connects muscle to bone, while a ligament connects bone to bone.

A patellar dislocation is a knee injury in which the patella (kneecap) slips out of its normal position. Often the knee is partly bent, painful and swollen. The patella is also often felt and seen out of place. Complications may include a patella fracture or arthritis.

Quadriceps tendon rupture Tear of the tendon that runs from the quadriceps muscle to the top of the knee cap

A quadriceps tendon rupture is a tear of the tendon that runs from the quadriceps muscle to the top of the knee cap.

Posterolateral corner injuries of the knee are injuries to a complex area formed by the interaction of multiple structures. Injuries to the posterolateral corner can be debilitating to the person and require recognition and treatment to avoid long term consequences. Injuries to the PLC often occur in combination with other ligamentous injuries to the knee; most commonly the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). As with any injury, an understanding of the anatomy and functional interactions of the posterolateral corner is important to diagnosing and treating the injury.

Medial knee injuries are the most common type of knee injury. The medial ligament complex of the knee is composed of the superficial medial collateral ligament (sMCL), deep medial collateral ligament (dMCL), and the posterior oblique ligament (POL). These ligaments have also been called the medial collateral ligament (MCL), tibial collateral ligament, mid-third capsular ligament, and oblique fibers of the sMCL, respectively. This complex is the major stabilizer of the medial knee. Injuries to the medial side of the knee are most commonly isolated to these ligaments. A thorough understanding of the anatomy and function of the medial knee structures, along with a detailed history and physical exam, are imperative to diagnosing and treating these injuries.

References

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 "Patellar Tendon Tear". OrthoInfo - AAOS. February 2016. Retrieved 7 July 2018.
1 2 3 4 5 6 7 8 9 Bracker MD (2012). The 5-Minute Sports Medicine Consult. Lippincott Williams & Wilkins. p. 446. ISBN 9781451148121.
↑ "Knee Extensor Injuries - Injuries and Poisoning". Merck Manuals Consumer Version. Retrieved 5 November 2018.
↑ Insall and Salvati Method Wheeless Online accessed 22 July 2015
↑ Fan H, Liu H, Wong EJ, Toh SL, Goh JC (August 2008). "In vivo study of anterior cruciate ligament regeneration using mesenchymal stem cells and silk scaffold". Biomaterials. 29 (23): 3324–37. doi:10.1016/j.biomaterials.2008.04.012. PMID 18462787.
↑ Long JH, Qi M, Huang XY, Lei SR, Ren LC (June 2005). "[Repair of rabbit tendon by autologous bone marrow mesenchymal stem cells]". Zhonghua Shao Shang Za Zhi = Zhonghua Shaoshang Zazhi = Chinese Journal of Burns (in Chinese). 21 (3): 210–2. PMID 15996290.
↑ Massoud EI (December 2010). "Repair of fresh patellar tendon rupture: tension regulation at the suture line". International Orthopaedics. 34 (8): 1153–8. doi:10.1007/s00264-009-0879-x. PMC 2989072 . PMID 19809813.

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[OI2016-1] 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 "Patellar Tendon Tear". OrthoInfo - AAOS. February 2016. Retrieved 7 July 2018.

[Bra2012-2] 1 2 3 4 5 6 7 8 9 Bracker MD (2012). The 5-Minute Sports Medicine Consult. Lippincott Williams & Wilkins. p. 446. ISBN 9781451148121.

[3] "Knee Extensor Injuries - Injuries and Poisoning". Merck Manuals Consumer Version. Retrieved 5 November 2018.

[4] Insall and Salvati Method Wheeless Online accessed 22 July 2015

[5] Fan H, Liu H, Wong EJ, Toh SL, Goh JC (August 2008). "In vivo study of anterior cruciate ligament regeneration using mesenchymal stem cells and silk scaffold". Biomaterials. 29 (23): 3324–37. doi:10.1016/j.biomaterials.2008.04.012. PMID 18462787.

[6] Long JH, Qi M, Huang XY, Lei SR, Ren LC (June 2005). "[Repair of rabbit tendon by autologous bone marrow mesenchymal stem cells]". Zhonghua Shao Shang Za Zhi = Zhonghua Shaoshang Zazhi = Chinese Journal of Burns (in Chinese). 21 (3): 210–2. PMID 15996290.

[7] Massoud EI (December 2010). "Repair of fresh patellar tendon rupture: tension regulation at the suture line". International Orthopaedics. 34 (8): 1153–8. doi:10.1007/s00264-009-0879-x. PMC 2989072 . PMID 19809813.

Classification	D ICD-10 : S76.1 ICD-9-CM : 727.66
External resources	eMedicine : article/1249472