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TENDINITIS Martens, et al describes patellar or quadriceps tendimitis as achronic overload lesion in the tendon near its insertion, which

occurs in athletes involved in repetitive activities such as running, jumping, bicycling, or kicking. This problem is sometimes called "jumper's knee" and presents with pain and tenderness in the affected area, sometimes accompanied by local edema. Pain is usually felt at the superior aspect of the patella, at the attachment of the. quadriceps mechanism, or most commonly, at the inferior pole of the patella (Fig. 9-10). Treatment is directed at reduction of inflammation and pain and at encouraging healing of the tendon, as discussed in Chapter 1. Rest is important, but immobilization is not necessary in most cases. Usually, avoiding activities that exacerbate pain is sufficient, for a period of up to 14 days, during which the stages of tendon healing described by Stanish, et al take place. Once symptoms are relieved, strengthening begins in carefully controlled increments, gradually increasing tensile forces. The tendon will then able to withstand functional stresses placed on it by normal activities. Pain should be the limiting factor in treatment by exercise once healing is under way. The popliteus tendon can develop tendinitis, especially during severely stressful activities such as running downhill, and pain is felt along the posterolateral aspect of the knee. Treatment is the same as for other tendons (Fig. 9-11). Jumper's knee This occurs commonly in sports such as jumping, basketball, volleyball or weight-lifting whose action requires repeated jumping off one leg [108]. It is associated with a small area of degeneration at the tendon attachment at the lower pole of the patella, characterized by pain and extreme local tenderness. Pain may be present at first only after activity, but in severe degrees it begins during activity and severely limits athletic performance and may be associated with a weakness or giving way of the knee. Clinical signs Pain is reproduced on resisting active knee extension. Crepitus may be present on passive movement of the patellar tendon. Tenderness, usually marked, is found localized at the lower pole of the patella, especially if the patella is pushed distally. Radiographs are normal but are necessary to exclude any patellar abnormality, stress fracture or an elongated lower pole of the patella.

MANAGEMENT 1. Rest. Symptoms are usually brought on by activity, e.g. running, jumping or kicking, and these may need to be curtailed. In younger patients other activities can be substituted but in professional sportsmen this is extremely

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difficult. Anti-inflamatory drugs are given. Physical measures such as heat or ice may help to relieve symptoms. The patella should be mobilized using the techniques described above. Exercises are essential. Isometric quadriceps exercises may be used first, followed by eccentric knee exercises [109]. Injections of corticosteroid may be given around the tender area in the tendon but never into the tendon substance. Extra rest is advised after the injection, which should be given as infrequently as possible and with at least 1 month between each injection. The injections are stopped if symptoms do not improve significantly. Surgery is indicated if conservative measures fail or if tendinitis is recurrent and prevents full participation in sport [110]. Surgical treatment consists of decompression of the tendon and removal of any area of focal degeneration, adhesions around the tendon or an area of chondromalacia. Operation is followed by an intensive programme of rehabilitation and the patient can usually return to full activity.

COMPLICATIONS OF TENDINITIS The patellar tendon may undergo partial or complete rupture. Complete rupture is quite rare and occurs mainly in patients who have had tendinitis for a considerable period of time. An incomplete tear also occurs but is difficult to distinguish from tendinitis alone. Osgood-Schlatter's disease This is associated with repetitive stress leading to tears and partial avulsion of the patellar tendon at its insertion into the tibial tubercle before the apophysis unites [111,112]. It occurs mainly in young active boys aged 9-14 years with a gradual onset of pain and a tender lump over the tibial tubercle. Pain is made worse by running, kneeling and stairs, and is relieved by rest [113]. It tends to run a protracted course over several years before gradually settling as the tuberosity is ossified. MAJOR SIGNS A tender swelling is present over the tibial tubercle and pain is reproduced on resisting active quadriceps extension. Stretching the quadriceps by filly flexing the knee with the hip in full extension reproduces pain and may demonstrate a shortening of the quadriceps. Radiographic changes, produced by separation of the tendon from the tibial tubercle with fragmentation of the apophysis and occasional loose bodies, take some time to develop.

MANAGEMENT This is often difficult as the patient is young and active, and symptoms may not fully resolve until the apophysis is fully united. Pain usually prevents participation in activities requiring running or jumping but complete immobilization of the knee is neither necessary nor practical. Isometric quadriceps

exercises with the knee straight are essential. Gentle carefully controlled stretching and passive movement techniques to the knee may reduce pain and hamstrings are strengthened and stretched. Non-steroidal anti-inflammatory drugs and corticosteroid injections are contraindicated. This condition usually settles after a prolonged time without any additional active therapy, but is apt to recur on return to activity and then requires a careful balance between rest and activity. Surgery remains controversial but removal of loose bony bodies which fail to unite may be necessary. Rarely the patellar tendon may be avulsed [114].