Proximal Patellar Tendinosis And Partial Tearing

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Proximal Patellar Tendinosis And Partial Tearing

Authors, Editors, Case Information Author: Laura Mattson, DO Affiliation: Spectrum Health Department of Orthopedic Surgery Co Author(s): Raul Rosario-Concepcion, MD Senior Editor: Raul Rosario-Concepcion, MD Clinical Vignette: A 15-year-old male basketball player presented for bilateral anterior knee pain for 2 years, insidious in onset, worsening over time, and provoked by running and jumping. Exam showed tenderness to palpation over the inferior pole of both patellae and proximal patellar tendons, with intact extensor mechanisms and no extension lag noted. Type of Probe Used: 3-14 MHz linear array transducer Unlabeled Long Axis View of the Proximal Patellar Tendon Unlabeled Long Axis View of the Proximal Patellar Tendon Labeled Long Axis View of the Proximal Patellar Tendon Labeled Long axis view of the proximal patellar tendon demonstrating thickening and heterogenous echotexture. The proximal patellar tendon measures between 0.8-1cm in thickness versus the more distal, normal appearing tendon which measures 0.4cm. An area of partial thickness tearing is encircled. Adjacent cortical irregularities are appreciated in the inferior patellar pole. Unlabeled Long Axis View of the Proximal Patellar Tendon with Color Doppler Unlabeled Long Axis View of the Proximal Patellar Tendon with Color Doppler Unlabeled Short Axis View of the Proximal Patellar Tendon Unlabeled Short Axis View of the Proximal Patellar Tendon Labeled Short Axis View of the Proximal Patellar Tendon Labeled short axis view of the proximal patellar tendon, demonstrating partial thickness tearing of the central, undersurface fibers. #6 - Video View Video The proximal patellar tendon is scanned in long axis from medial to lateral. The patellar tendon appears thickened and of heterogenous echotexture proximally, with partial thickness tearing of the central undersurface fibers. There are associated cortical irregularities of the inferior patellar pole. #7 - Video View Video The patellar tendon is scanned in short axis from distal to proximal from the level just above the tibial tuberosity to the level just below the inferior pole of the patella. At the proximal-most portion, there is evidence of tendon thickening as well as partial thickness tearing of the central undersurface tendon fibers. Interpretation Image Interpretation: The left proximal patellar tendon was thickened and of heterogenous echotexture, consistent with tendinosis, with associated cortical irregularity of the inferior patellar pole. There was additional evidence of partial thickness tearing of the central undersurface fibers of the proximal patellar tendon with increased vascularity in this region on color doppler evaluation. The left distal patellar tendon appeared normal. Teaching Pearl: When assessing patellar tendinosis and partial tearing, avoid excessive transducer pressure during color or power Doppler imaging because slow-flow neovascularity can be compressed. Power Doppler is more sensitive than color Doppler for low-flow states. Ultrasound evaluation should also define tendon thickening, hypoechogenicity, loss of fibrillar structure, cortical irregularity at the inferior patellar pole, and the size and depth of any partial tear. Return-to-sprt criteria is load tolerance and sport-specific movement-based rather than imaging-based. References: 1. Sunding K, Fahlstrom M, Werner S, Forssblad M, Willberg L. Evaluation of Achilles and patellar tendinopathy with greyscale ultrasound and colour Doppler: using a four-grade scale. Knee Surg Sports Traumatol Arthrosc. 2016;24(6):1988-1996. doi:10.1007/s00167-014-3270-4 2. Ooi CC, Richards PJ, Maffulli N, et al. A soft patellar tendon on ultrasound elastography is associated with pain and functional deficit in volleyball players. J Sci Med Sport. 2016;19(5):373-378. doi:10.1016/j.jsams.2015.06.003 3. Gisslén K, Alfredson H. Neovascularisation and pain in jumper’s knee: a prospective clinical and sonographic study in elite junior volleyball players. Br J Sports Med. 2005;39(7):423-428. doi:10.1136/bjsm.2004.013342
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Authors, Editors, Case Information

Unlabeled Long Axis View of the Proximal Patellar Tendon

Labeled Long Axis View of the Proximal Patellar Tendon

Unlabeled Long Axis View of the Proximal Patellar Tendon with Color Doppler

Unlabeled Short Axis View of the Proximal Patellar Tendon

Labeled Short Axis View of the Proximal Patellar Tendon

#6 - Video

#7 - Video

Interpretation

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