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 difficult. 2. Anti-inflamatory drugs are given. 3. Physical measures such as heat or ice may help to relieve symptoms. 4. The patella should be mobilized using the techniques described above. 5. Exercises are essential. Isometric quadriceps exercises may be used first, followed by eccentric knee exercises [109]. 6. 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. 7. 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.