Dr Gerhard Coetzer 1999061854 Patient No 1 – 2012 Patella Tendinosis

1. Dr Gerhard Coetzer1999061854Patient No 1 – 2012Patella Tendinosis

2. COMPLAINT • 26 Year old male patient complaining of pain in his left knee. • Pain present when running.

3. FURTHER HISTORY • He is a recreational athlete training for the Iron Man 70.3 Triathlon. • Complaining of pain after approximately 5 – 10 minutes of running. • Pain is sever enough to make patient stop. • Pain is anterior and inferior to the Patella. • Complaining of calf pain before knee pain starts • What changed?? • Started running longer and harder

4. FURTHER HISTORY (cont) • BMI of 18 • No medical history • No family history • Previous rugby injury to left knee with lateral collateral ligament sprain (2000)

5. CLINICAL EXAMINATION • Full range of movement of left knee. • No visible effusion. • Painful palpation of the inferior pole of the patella. • Pain with Hot Test • All ligaments intact • Negative Grind Test

6. CLINICAL EXAMINATION (cont) • Differential Diagnosis • PFJ pain • Patellar tendinosis • Partial tear of Patellar tendon • Did McConnel taping, patient still had pain with functional exercise. • PFJ excluded. • Did Ultra Sound, no partial tear found.

7. SPECIAL INVESTIGATION • Ultra Sound done • MRI scan not done • Although these are the recommended test, the tests do not have 100% sensitivity and specificity for Patellar Tendinosis.

8. 3 STAGE SUMMARY • Clinical • Patient presenting of 2 week history of pain in the anterior aspect of the knee • Personal • Patient is scared that he will have to pull out of the race due to pain • Forfeit R1 300, 00 entry fee • Contextual • 26 year old recreational athlete with Patellar Tendonitis 3 weeks before Iron Man 70.3

9. PROBLEM LIST • Active • Reduce pain, reduce load and analgesia for pain relief. • Passive • Starting a rehabilitation programme for the patient after the race.

10. PLAN • Avoid aggravating activity • Analgesia for pain • Not enough time for rehabilitation before the race

11. PROGRESSION • Patient completed the race but with severe pain and difficulty. • Rested patient for a week after the race. • Pain settled, moved to the lateral joint line of left knee on re-examination. • Final diagnosis- Lateral meniscus tear

12. DISCUSSION

13. DISCUSSION • Patellar Tendinitis is not an inflammatory reaction, but rather a degenerative tendinitis and should be referred to as Patellar Tendinosis.

14. ANATOMY • Macroscopic • Normal tendon is seen as white and glistening • The tendon of Patellar Tendinopathy has a soft, yellow brown tissue adjacent to the lower pole, called mucoid degeneration.

16. CLINICAL FEATURES • It is important to reproduce the patients pain with examination. • Must differentiate between PFJ and Tendinosis • Another aid is the VISA questionnaire.

18. SPECIAL INVESTIGATION • Diagnostic Ultra sound and MRI are the investigation of choice. • These tests do not have 100% sensitivity and specificity for the condition. • Ultra sound you look for neo-vascularisation and increased diameter of the Patellar Tendon.

24. STRENGTHENING EXERCISE • Prof Jill Cook from Australia says to treat any tendinopathy you must first load the tendon and get it strong. • Different types of exercise has been tried • A recent study that was published reported a 60% VAS and 86%VISA score improvement (Romero-Rodriguez et al, 2010).

25. LOAD REDUCTION • Load reduction can be done through decreasing the amount of jumping per session or by reducing the sessions per week(Brukner P, Khan K, 2008).

26. CORRECT BIOMECHANICS • Correct Biomechanics is also necessary to improve Patellar Tendinopathy. • Decreased range of motion in the ankle can contribute to Patellar Tendinopathy because the calf absorbs +- 40% of the loading energy. • Biomechanical analysis must include both functional and anatomical abnormalities.

28. SOFT TISSUE THERAPY • Although there is insufficient evidence to show that Soft Tissue Therapy is effective, it is still a popular choice of treatment. • It includes transverse friction, digital ischemic pressure and miofacial release. • A study by Alessandro Pedrelli, suggested that pain can be significantly reduced after miofacial manipulation of the quadriceps muscle facia(Pedrelli et al, 2009).

29. SOFT TISSUE THERAPY (cont) • Extra-corporeal shock wave therapy is also being sued for the treatment of Patellar Tendinosis. • There is still no conclusive evidence that I am aware of that it improves the condition, but the pilot study published by Zwerver in 2010, concluded that there was a good reduction in pain(Zwerver et al, 2010).

30. PHARMACOTHERAPY • Iontophoresis with cortisone improve outcome phonophoresis. • There seems to be some evidence that suggest that sclerosing injections significantly improves pain in patients with long standing Tendinopathy(Kampa & Connell, 2010). • In a case study by Brown and Sivan , ultra sound guided platelet rich injections also improved symptoms(Brown & Sivan, 2010). • 2 other studies reported an 80% reduction in pain

31. SURGERY • There is currently no evidence that surgical intervention provides a better outcome than conservative treatment. • Surgery is not a quick fix. • Surgery is only indicated after quality conservative treatment has failed. • Although surgery will alleviate symptoms, the patient is unlikely to return to previous level of competition. (60% - 80% likelihood)

32. LEARNING EXPERIENCE • It is important to differentiate PFJ pain and Patellar Tendinosis. • Ultra sound can be helpful in the diagnosis. • There is no quick fix and the patient should be made aware of the duration of the rehabilitation. • Must be able to reproduce patient symptoms during examination.

33. THANK YOU

34. REFERENCES • Zwervera J, Dekkera F, Pepping G. Journal of Back and Musculoskeletal Rehabilitation, 2010, Vol 23, pg 111–115. • Kampa RJ, Connell DA. Treatment of tendinopathy: is there a role for autologous whole blood and platelet rich plasma injection, IJCP, International Journal of Clinical Practice, 2010, Vol 64 & 13, pg 1813–1823. • Pedrelli A, Stecco C, Day JA. Treating patellar tendinopathy with FascialManipulation, Journal of Body work and Movement Therapies,2009, Vol 13, pg73–80. • Brown J, Sivan M. Ultrasound-guided Platelet-rich Plasma Injection for Chronic Patellar Tendinopathy: A Case Report, American Academy of Physical Medicine and Rehabilitation, 2010, Vol 2, pg 969-972. • Romero-Rodriguez D, Gual G, Tesch PA. Efficacy of an inertial resistance training paradigm in the treatment of patellar tendinopathyin athletes: A case-series study, Physical Therapy in Sport, 2011, Vol 12, pg 43-48. • Brukner P, Khan K. Clinical Sports Medicine, 2008, Vol 3, pg508 – 532.