Patellar Tendinopathy in a College Football Player

Abstract

HISTORY: A 22 year old Division I college football player presents during Spring Football practice with bilateral anterior knee pain. Localizes to lower portion of the patella worsening with deep squats, prolonged sitting and ambulating up and down stairs. No prior history of knee pain or injuries. For a couple of weeks, he has near-daily ultrasound, icing, and quadriceps/patellar tendon stretches with moderate improvement. Continued to have mild symptoms until Fall Football camp when he develops severe pain over the distal patella after a cutting motion. He notices swelling in the area of the pain and complains of associated lower extremity weakness and instability. PHYSICAL EXAM: Examination revealed mild swelling near origin of patellar tendon bilaterally. Full range of motion of both knees noted, but pain with extremes of extension and flexion. Tenderness over the inferior pole of the patella bilaterally. Normal Lachman's, Anterior and Posterior Drawer tests, and no instability with valgus/varus stressing bilaterally. No joint line pain and McMurray's was within normal limits bilaterally. Quadriceps strength was reduced bilaterally, but extensor mechanism appeared intact. Neurovascular exam of bilateral lower extremities was non-focal. DIFFERENTIAL DIAGNOSIS: Patellar tendinosis Patellofemoral syndrome Partial patellar tendon rupture Patellar bursitis Inflammation of the peripatellar fat pad Patellar fracture TEST AND RESULTS: MRI of right knee - Full thickness tear through medial half of patellar tendon at origin, lateral fibers intact. Patellar tendinosis. MRI of left knee - Edema associated with patellar tendon origin with fraying of the tendon. FINAL WORKING DIAGNOSIS: Bilateral Patellar Tendinosis TREATMENT AND OUTCOMES: Bilateral open debridement of patellar tendinosis and partial repair of right patellar tendon. (Surgeries staggered by 6 weeks) Early touch down weight-bearing with crutches. Subsequent progression of rehabilitation focusing on range of motion, quadriceps strengthening (closed chain), and hamstring flexibility. Five months later, the right knee was doing very well but patient was having persistent anterior left knee pain. Underwent local steroid and lidocaine injection over the patella avoiding the tendon. One week later, MRI of left knee revealed persistent patellar tendinopathy. Continued physical therapy with complete resolution of pain after two more months. Subsequently cleared for full activity. Two months later suffered left patellar tendon rupture while performing standing long jumps (eccentric load) during training. Subsequently underwent patellar tendon repair.