Patellar Tendinopathy surgery and treatment options

Ross A. Hauser, MD; Danielle R. Steilen-Matias, MMS, PA-C

Understanding points: People will often come into the office with confusion because they have been diagnosed with patellar tendinosis or with patellar tendinitis. 

My doctors are arguing over my MRI, I need to get a surgery

The problem of chronic patellar tendinopathy is that it is usually not an isolated knee injury. The problem of patella tendinopathy is that is part of a series of problems in the knee caused by knee instability. We will often have people email us describing an injury to the knee. The limitations this is giving them including the inability to perform sports, work without pain, or even just walk up a flight of steps without knee pain. These people also tell us about the confusion in their diagnosis and the true cause of what is causing their pain. Some tell us about the arguments between their doctors as to what their MRI “really,” says. Some people will have a meniscus tear on their MRI and their doctors focus on that, minimizing the potential of a problem with the patella tendon. The longer this goes on, the greater the need to get in line for surgery.

“I do not want to take more time off from working out”

Many people have patellar tendinopathy. They take some anti-inflammatories, look up video exercises, buy tape and knee braces and they go about their way with a chronic nagging injury that they can pretty much control. For others, the situation has progressed to a point of surgical recommendations. Such as these types of stories we hear.

I have been trying to get back to running, I have patellar tendonitis that is not responding. I don’t want to take more time off. The orthopedist I am seeing is prescribing anti-inflammatories, I have been on them for months, stronger doses, I still can’t run. He tells me to rest, I have been resting. I still can’t run. I have had two MRIs. I have patellar tendon inflammation. My doctor and I both knew it but nothing is working for me. Not ice, not yoga, not physical therapy. I am getting quickly out of shape.

Others go something like this.

I am being recommended for surgery. My orthopedist tells me I should have no illusions that I will be the same or better player after surgery. I will just have more better days than worse days. I have no illusions, I play volleyball, I have already had two meniscus procedures and my doctor says the tendinitis is probably a response to my post-surgically weakened knee.

From self-management to doctor’s care. Your knee is not responding.

When someone has knee pain, from whatever source, a self-management program is usually taken before a trip to the doctor. This will include some type of stabilizing brace or knee sleeve and anti-inflammatory medication. Of course, these are only symptom suppression means to keep swelling down and to give the wearer a false sense of security that the brace will hold their knee together. Education is part of the management plan, a person will usually spend a lot of time online trying to find out what is wrong with their knee and the best course of action they can take. The one suggestion most patients with Jumper’s Knee do not want to follow is “REST.”

If you are reading this article, it is likely that here you are, with knee pain that is getting progressively worse, wearing a sleeve on your knee, and a knee that is becoming much less functional. Shutting down your knee and resting seems the best option now.

Rest did not help. Anti-inflammatories are making your knee worse.

After a few weeks of rest, you are back on your knee and nothing has changed. You still have pain, you still have instability. Now perhaps it is time for a trip to the doctor. For some people, they do not go to the doctor. They continue on with more anti-inflammatories because they want to play. These people are going to “suck it up.”

At the beginning of his article, we discussed the difference between tendinitis and tendinosis – this is why it is important to you.

If you would like to learn about When NSAIDs make pain worse and lead to a worsening joint condition, please read our article When NSAIDs make pain worse.

If you are reading this article, perhaps this is what is happening to you now. You are in this situation because you are looking for the quick fix recovery from patellar tendinopathy.

Cortisone injection concerns

A recent paper in the International Journal of Sports Physical Therapy (1) offered this summary of the concerns of ng cortisone for patella tendinopathy.

Cortisone can mutate stem cells and make the tendon weaker.

Research: “no treatments exist for patellar tendinopathy that guarantees quick and full recovery”

This is not what you probably wanted to hear. But let’s look deeply at this. What most researchers warn is that there is no “magic bullet,” single injection or single therapy that will repair this type of knee damage overnight. If you have Jumper’s Knee, you did this type of damage over time, it takes time to repair.

The above statement comes from an October 2017 study in the Clinical Journal of Sports Medicine (3from the Center for Sports Medicine at the University Medical Center Groningen in the Netherlands. Here is the whole sentence:

“Currently, no treatments exist for patellar tendinopathy that guarantees quick and full recovery. Our objective was to assess which treatment option provides the best chance of clinical improvement and to assess the influence of patient and injury characteristics on the clinical effect of these treatments.”

These were the treatments they tested:

Participants were divided into 5 groups:

The results:

NO CLEAR BENEFIT to any of those treatments.

We do find that eccentric exercise training offered some degree of relief, however, the more exercise the less benefit (not what an athlete wants to hear), the longer the patient had the symptoms and the patients’ age also presented problems.

Take away points:

The research above continues the work from the University of Groningen researchers. (4Earlier the University medical researchers investigated the impact patellar tendinopathy has on a patient’s sports and work performance. Their findings were published in the journal Research in Sports Medicine.

The Dutch researchers concluded that the impact of Patellar Tendinopathy on sports and work performance is substantial and stresses the importance of developing preventive measures.

 

More research on extracorporeal shockwave therapy

In March 2018, publishing in the British Journal of Sports Medicine, (5) a multi-national team of researchers evaluated extracorporeal shockwave therapy (ESWT) in treating Achilles tendinopathy, greater trochanteric pain syndrome, medial tibial stress syndrome, patellar tendinopathy, and proximal hamstring tendinopathy.

Their findings:

Low-level evidence suggests that ESWT

The conclusion simply suggests,  extracorporeal shockwave therapy may or may not help. Many people get good success with extracorporeal shockwave therapy, however, similar findings were made in an August 2018 study from doctors at the National Taiwan University and Taipei Medical University in Taiwan. They published findings in the journal BioMed Central Musculoskeletal Disorders (6) in London. The suggestion of their findings is that caution is given in providing ESWT to knee soft tissue disorders. ESWT may or may not work for Patellar tendinopathies.


An October 2019 study in the Annals of Translational Medicine (7) also offers this summary:

“The mechanism of action of ESWT is not fully understood, and current research as to its efficacy in treating tendinopathies is conflicting. It is suspected that it can have both analgesic effects along with potential tissue regenerative effects. The efficacy of shockwave therapy is inconsistent, with some research finding no improvements. Other research is promising.”

The main problem with patellar tendinopathy – it is a degenerative disorder rather than an inflammatory disorder – should you have surgery?

If the doctor suggests your problem is due to patellar tendinopathy, you have a problem with the tendon that passes from the quadriceps muscle (the large muscle at the front of the thigh) over the kneecap (patella) to connect to the shinbone (tibia).

What are we seeing in this image?

The patella is pulled and pushed in all directions. It is pulled by the Iliotibial band, it is stabilized in place by the lateral patellar retinaculum and the medial patellar retinaculum. The quadriceps move the patella upwards, the patellar ligament moves it downward. When one of these structures is weakened or damaged through degenerative wear and tear, the knee cap becomes unstable.

The patella is pulled and pushed in all directions. It is pulled by the Iliotibial band, it is stabilized in place by the lateral patellar retinaculum and the medial patellar retinaculum. The quadriceps move the patella upwards, the patellar ligament moves it downward. When one of these structures is weakened or damaged through degenerative wear and tear, the knee cap becomes unstable.

Further recommendations and guidelines for the treatment of patellar tendinopathy were published in The Journal of the American Academy of Orthopaedic Surgeons (8).

As far as the surgical technique goes, doctors from the Department of Orthopedic Surgery and the Department of Physical Medicine and Rehabilitation, Mayo Clinic, Florida State University, and the Florida State University College of Medicine, published their findings in the journal Orthopedics. They found open surgery and arthroscopic techniques achieved similar satisfactory results in 81% of patients, respectively. The average time to return to play was 5.6 months and 5 months, respectively. (9)

The unappealing aspects of Patellar Tendinopathy surgery – Average time to return to play was 5.6 months and 5 months. Second:  If the surgery fails, it is difficult to fix.

The problem with surgery for the athlete are three-fold,

This is what a paper from the University of Salerno and the University of London suggested in the journal Sports Medicine and Arthroscopy Review.

  1. Many patients respond well to conservative treatment, but about 10% of them do not.
  2. In these cases, surgery is indicated.
  3. In a small percentage of patients, surgery is unsuccessful. This group of patients presents a major challenge, as options are limited. (10)

I was a very active woman. In the past year, I underwent arthroscopic knee repair

Many people have patella arthroscopic surgery with outstanding results. These are typically not the patients we see in our office. we see people like this:

I was a very active woman. In the past year, I underwent arthroscopic knee repair. I had a torn meniscus that needed repair and medial meniscus repair and patella debridement for my patellar tendinopathy. I was very happy with the surgery initially because I was able to return to my activities within six months. However a month into my return to activities I had significant knee pain. My knee swelled up. I could not run, I could barely walk. Steps and inclines became impossible.

Non-surgical bio-treatments Prolotherapy and PRP Therapy

Before we look at the research and explanation discussing the use of injection techniques such as Prolotherapy, Platelet Rich Plasma, and Stem Cell Therapy. Let’s look at a paper from the Rubin Institute for Advanced Orthopedics, Sinai Hospital, Baltimore. It was published in the journal Annals of Translational Medicine,(11) October 2019.

In this paper, various methods of treating common knee injuries are discussed. One section has very good information on the concept of the patella and the importance of keeping the patella where it should be in the knee.

“Patellar taping is commonly used in conjunction with manual and exercise therapies in the management of Patellofemoral pain syndrome. Taping is predominately used to help decrease pain. Other studies show it can also help with patellar alignment and muscle activation. As patellar hypermobility has been shown as a predisposing factor for developing Patellofemoral pain syndrome, taping can be indicated to promote patellar positioning and decrease pain. . . .Overall, the effects of taping, are conflicting, with some studies showing no benefit and others unsure of the mechanisms of improvements noted. The positive changes including decreased pain and improved VMO (vastus medialis obliquus, the muscle above the knee used to extend the leg at the knee and to stabilize the patella) function is only short-term but can be helpful with acute management of symptoms with functional activity.”

The goal of tape or brace or surgery is to get the patella back into place.

Prolotherapy treatment options

Prolotherapy is the injection of a simple sugar solution, hypertonic dextrose, into and around specific important structures in the knee to stimulate their repair. Many studies have documented Prolotherapy treatments effectiveness

Prolotherapy is a multiple injection technique that is demonstrated in the video below. The treatment stimulates healing and repair of the tendon attachments, the knee ligaments and addresses problems of the cartilage that sits behind the knee cap and in the trochlear groove. When more significant degenerative damage has occurred, we may utilize Platelet Rich Plasma Therapy, the use of your own blood platelets reintroduced into the knee. Ross Hauser, MD discusses a case of 70% tear treated with stem cell therapy and Prolotherapy.

Most recent research

A November 2020 study in the Journal of Experimental Orthopaedics (12) examined the use of Prolotherapy and Sclerotherapy injections. A note of understanding. At one time Prolotherapy and Sclerotherapy were used as somewhat synonymous terms. They are however not the same treatment. Prolotherapy injections center on the joints with the repair of the tendon, ligaments, and cartilage. Sclerotherapy focuses on the blood vessels and is considered an excellent treatment for varicose veins.

In this study, the researchers noted that: “Sclerotherapy and Prolotherapy are, among a wide range of conservative treatment options, two promising therapies and have shown positive results in other tendinopathies. Since the treatments’ efficacy and safety are still not defined, this review sought to answer questions on recommendations for use in clinical utility, safety, and how to perform the injection in the most effective way.”

The findings: The researchers examined ten previously published papers and found positive results with an increase in functional ability scores and decreases in pain scores in the patients examined. “Among all ten studies, no serious adverse events were reported. Based on this limited set of studies, there seems to be some evidence that Sclerotherapy and Prolotherapy may be effective treatment options to treat pain and to improve function in patients with Chronic Patellar tendinopathy.”

One of my more memorable cases over the course of 30 years doing Prolotherapy and more recently stem cell therapy was a patient who came in and had a 70% tear of their patella tendon.

When you have bone spurs in the knee

What are we seeing in this image?

This image graphically shows what can happen when knee instability is left untreated or improperly treated. The unstable knee in this image has created a large bone spur to help stabilize the knee by limiting the knee’s natural range of motion. Because of the severity of the knee instability, the knee grew itself a very large bone spur. The bone spur became so large it started to rub and fray the patella tendon of this patient to the point of near-total rupture.

This image graphically shows what can happen when knee instability is left untreated or improperly treated. The unstable knee in this image has created a large bone spur to help stabilize the knee by limiting the knee's natural range of motion. Because of the severity of the knee instability, the knee grew itself a very large bone spur. The bone spur became so large is started to rub and fray the patella tendon of this patient to the point of near total rupture.

Research on Prolotherapy and PRP injections

Here is what New York University doctors wrote in the Bulletin of the Hospital for Joint Diseases.

“Due to its common refractory response (non-responsive or difficult to treat) to conservative treatment, a variety of new treatments have emerged recently that include dry-needling, sclerosing injections (Prolotherapy), platelet-rich plasma therapy, arthroscopic surgical procedures, surgical resection of the inferior patellar pole (cutting away tendon tissue at the kneecap), extracorporeal shock wave treatment (as discussed in the other studies cited here), and hyperthermia thermotherapy (exposing the knee to high temperature) in addition to physical therapy.”(13)

Obviously, the list includes treatments that we offer at Caring Medical, Prolotherapy, and Platelet Rich Plasma.

Non-surgical solutions to the problem of chronic and recurrent Patellar Tendinopathy

In Germany, doctors supported the New York University findings. Writing in the medical journal Der Unfallchirurg (English: The trauma surgeon), the German researchers suggested that treatment with platelet-rich plasma showed a significantly better outcome when used correctly. Additionally, treatments such as Extracorporeal shockwave therapy, operative treatment, and sclerotherapy (Prolotherapy) have also shown positive effects. Treatment with corticosteroid injections and with oral non-steroidal anti-inflammatory drugs (NSAIDs) showed positive short-term effects. (14)

Prolotherapy can treat various knee disorders including problems of the tendons. Prolotherapy Injections of a dextrose solution directed at the weakened tendons and involved ligaments. This causes a mild, localized inflammatory response at the injured area which stimulates a string of healing events, which include an increase of blood supply, an influx of reparative cells, and the deposition of collagen cells. When the collagen matures, it will strengthen and tighten the damaged tendons and ligaments.

PRP and Prolotherapy

The most important finding is that PRP injections are statistically better than the control group (ESWT and dry needling) at longer-term (6 months or more) follow-up, suggesting that PRP is an effective and worthwhile treatment for Patellar Tendinopathy.

Doctors at the University of Pittsburgh writing in the Journal of Knee Surgery (15) say athletes and doctors are turning to biomaterials, that is stem cells and blood platelets (PRP therapy). In fact, “They are becoming the mainstay of nonoperative therapy in the high-demand athletic population. The most well-studied agents include platelet-rich plasma (PRP) and stem cells-both of which have shown promise in the treatment of various conditions. Animal and clinical studies have demonstrated improved outcomes for patients with chronic patellar tendinopathy.”

In a one-year study of patients who decided on non-surgical PRP treatments to get them back to their sport, European doctors found that all 20 patients in their study benefited from one injection of PRP coupled with a standardized eccentric rehabilitation (exercise). They concluded: “This study confirms that a local injection of PRP coupled with a program of eccentric rehabilitation for treating a chronic jumper’s knee, improves pain symptoms and the functionalities of the subjects’ knee up to 1 year after injection.”(16)

The most important finding in our meta-analysis is that PRP injections are statistically better than the control group (ESWT and dry needling) at longer-term (6 months or more) follow-up suggesting that PRP is an effective and worthwhile treatment for Patellar Tendinopathy.

Doctors in the United Kingdom writing in the journal Knee Surgery and Related Disease (17) released their study in which they state: “The most important finding in our meta-analysis is that PRP injections are statistically better than the control group (ESWT and dry needling) at longer-term (6 months or more) follow-up suggesting that PRP is an effective and worthwhile treatment for Patellar Tendinopathy.”

Multiple Injections of PRP may hold the answer

Doctors at The Rizzoli Orthopaedic Institute in Italy published their paper: Nonsurgical Treatments of Patellar Tendinopathy: Multiple Injections of Platelet-Rich Plasma Are a Suitable Option: A Systematic Review and Meta-analysis. It appeared in the March 2018 issue of the American Journal of Sports Medicine. (18)

What they were looking for was the evidence on nonoperative options to treat chronic patellar tendinopathy: Three treatments came to the forefront as the most studied: They are mentioned in the research above:

  1. eccentric exercise,
  2. extracorporeal shockwave therapy (ESWT),
  3. and platelet-rich plasma (PRP).
    1. Single and multiple PRP injections were evaluated separately.

CONCLUSION:
“Eccentric exercises may seem the strategy of choice in the short-term, but multiple PRP injections may offer more satisfactory results at long-term follow-up and can be therefore considered a suitable option for the treatment of patellar tendinopathy.”

In December 2018, doctors at the University of Connecticut Health Center published this summary on the effect of PRP on Patellar tendinopathy in the journal Current Reviews in Musculoskeletal Medicine. (19)

The summary of their findings suggested:

A quick word on Patellar Tendinopathy and ligament weakness

To address this, a series of injections are placed at the tender and weakened areas of the patella tendon and knee ligaments. These injections contain a proliferant to stimulate the body to repair and heal by inducing a mild inflammatory reaction. The body heals by inflammation, and Prolotherapy stimulates this healing. As the ligaments tighten and the patella tendon heals, the knee structures function normally rather than moving out of place. When the knee functions normally, the pain goes away.


Summary and contact us. Can we help you?

We hope you found this article informative and it helped answer many of the questions you may have surrounding your knee problems and knee instability.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

This is a picture of Ross Hauser, MD, Danielle Steilen-Matias, PA-C, Brian Hutcheson, DC. They treat people with non-surgical regenerative medicine injections.

Brian Hutcheson, DC | Ross Hauser, MD | Danielle Steilen-Matias, PA-C

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References:

1 Reinking MF. Current concepts in the treatment of patellar tendinopathy. International journal of sports physical therapy. 2016 Dec;11(6):854. [Google Scholar]
2 Zhang J, Keenan C, Wang JH. The Effects of Dexamethasone on Human Patellar Tendon Stem Cells: Implications for Dexamethasone Treatment of Tendon Injury. Journal of orthopaedic research: official publication of the Orthopaedic Research Society. 2013 Jan;31(1):105. [Google Scholar]
3 van Rijn D, van den Akker-Scheek I, Steunebrink M, Diercks RL, Zwerver J, van der Worp H. Comparison of the Effect of 5 Different Treatment Options for Managing Patellar Tendinopathy: A Secondary Analysis. Clin J Sport Med. 2017 Oct 10 [Google Scholar]
4 De Vries AJ, Koolhaas W, Zwerver J, Diercks RL, Nieuwenhuis K, Van Der Worp H, Brouwer S, Van Den Akker-Scheek I. The impact of patellar tendinopathy on sports and work performance in active athletes. Research in Sports Medicine. 2017 Apr 9:1-3. [Google Scholar]
5 Korakakis V, Whiteley R, Tzavara A, Malliaropoulos N. The effectiveness of extracorporeal shockwave therapy in common lower limb conditions: a systematic review including quantification of patient-rated pain reduction. Br J Sports Med. 2018 Mar 1;52(6):387-407. [Google Scholar]
6 Liao CD, Xie GM, Tsauo JY, Chen HC, Liou TH. Efficacy of extracorporeal shock wave therapy for knee tendinopathies and other soft tissue disorders: a meta-analysis of randomized controlled trials. BMC musculoskeletal disorders. 2018 Dec;19(1):278. [Google Scholar]
7 Mellinger S, Neurohr GA. Evidence based treatment options for common knee injuries in runners. Annals of translational medicine. 2019 Oct;7(Suppl 7). [Google Scholar]
8 Figueroa D, Figueroa F, Calvo R. Patellar Tendinopathy: Diagnosis and Treatment. J Am Acad Orthop Surg. 2016 Dec;24(12):e184-e192. [Google Scholar]
9 Stuhlman CR, Stowers K, Stowers L, Smith J. Current Concepts and the Role of Surgery in the Treatment of Jumper’s Knee. Orthopedics. Nov 1 2016;39(6):e1028-e1035. doi: 10.3928/01477447-20160714-06. [Google Scholar]
10 Maffulli N, Giai Via A, Oliva F. Revision Surgery for Failed Patellar Tendinopathy Exploration. Sports Med Arthrosc. 2017 Mar;25(1):36-40. [Google Scholar]
11 Mellinger S, Neurohr GA. Evidence-based treatment options for common knee injuries in runners. Annals of translational medicine. 2019 Oct;7(Suppl 7). [Google Scholar]
12 Morath O, Beck M, Taeymans J, Hirschmüller A. Sclerotherapy and prolotherapy for chronic patellar tendinopathies – a promising therapy with limited available evidence, a systematic review. J Exp Orthop. 2020 Nov 9;7(1):89. doi: 10.1186/s40634-020-00303-0. PMID: 33165667.
13 Christian RA, Rossy WH, Sherman OH. Patellar tendinopathy – recent developments toward treatment. Bull Hosp Jt Dis (2013). 2014;72(3):217-24. [Google Scholar]
14Horstmann H, Clausen JD, Krettek C, Weber-Spickschen TS. Evidence-based therapy for tendinopathy of the knee joint: Which forms of therapy are scientifically proven? Unfallchirurg. 2017 Mar;120(3):199-204.  [Google Scholar]
15 Kopka M, Bradley JP. The Use of Biologic Agents in Athletes with Knee Injuries. J Knee Surg. 2016 Jul;29(5):379-86. doi: 10.1055/s-0036-1584194. Epub 2016 May 20. [Google Scholar]
16 Kaux JF, Bruyere O, Croisier JL, Forthomme B, Le Goff C, Crielaard JM. One-year follow-up of platelet-rich plasma infiltration to treat chronic proximal patellar tendinopathies. Acta Orthop Belg. 2015 Jun;81(2):251-6. [Google Scholar]
17 Dupley L, Charalambous CP. Platelet-Rich Plasma Injections as a Treatment for Refractory Patellar Tendinosis: A Meta-Analysis of Randomised Trials. Knee surgery & related research. 2017 Sep;29(3):165. [Google Scholar]
18 Andriolo L, Altamura SA, Reale D, Candrian C, Zaffagnini S, Filardo G. Nonsurgical Treatments of Patellar Tendinopathy: Multiple Injections of Platelet-Rich Plasma Are a Suitable Option: A Systematic Review and Meta-analysis. The American journal of sports medicine. 2018 Mar 1:0363546518759674. [Google Scholar]
19 Kia C, Baldino J, Bell R, Ramji A, Uyeki C, Mazzocca A. Platelet-rich plasma: Review of current literature on its use for tendon and ligament pathology. Current reviews in musculoskeletal medicine. 2018 Dec 1;11(4):566-72. [Google Scholar]

This article was updated January 8, 2021

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