Continuing Education Activity

A patellar tendon rupture involves a complete tear of the tendon that runs from the patella's inferior pole to the tibial tubercle. It is typically seen in males in their third or fourth decade of life. It tends to result when a weakened tendon is placed under high tensile forces. These tendon ruptures are best classified into acute versus chronic tears. This type of injury requires prompt diagnosis and surgical repair as the patellar tendon is a part of the extensor mechanism of the knee, which is crucial to the function of the lower extremity. Surgical intervention depends on the timing and location of the rupture. Acute ruptures are amenable to primary repair, whereas chronic ruptures often require tendon reconstruction. This activity describes the causes, evaluation, and management of patellar tendon rupture and highlights the interprofessional team's role in the care of affected patients.

Objectives:

• Review the epidemiology of patellar tendon rupture.
• Describe the typical presentation of a patellar tendon rupture.
• Outline the treatment options available for patellar tendon rupture.
• Summarize how an optimally functioning interprofessional team would coordinate care to enhance outcomes for patients with patellar tendon rupture.

Introduction

A patellar tendon rupture involves a complete tear of the tendon that runs from the patella's inferior pole to the tibial tubercle. It is typically seen in males in their third or fourth decade of life. It tends to result from an overall weakened tendon placed under high tensile forces. These tendon ruptures are best classified into acute versus chronic tears, depending on the time from rupture. This type of injury requires prompt diagnosis and surgical repair as the patellar tendon is a part of the extensor mechanism. The extensor mechanism of the knee is crucial to the function of the lower extremity, including ambulation. It is solely responsible for extending and straightening the knee and resisting knee flexion – a crucial aspect of standing with a flexed knee and, therefore, ambulation.[1] Without a properly functioning knee extensor mechanism, the patient is severely limited functionally.[2] Surgical intervention depends on the timing and location of the rupture. Acute ruptures are amenable to primary repair, whereas chronic ruptures often require tendon reconstruction. 

Anatomy

The knee extensor mechanism is composed of the quadriceps muscle, quadriceps tendon, medial and lateral patellar retinaculum, patella, patellar tendon, and tibial tubercle.[3]

The quadriceps muscle is composed of four separate muscles with different origins but a common insertion point on the patella through the quadriceps tendon.

Quadriceps Muscles with Origins[3]

• Rectus femoris – anterior superior iliac spine and superior acetabular rim
• Vastus lateralis – greater trochanter and lateral linea aspera
• Vastus intermedius – proximal femoral shaft
• Vastus medialis – intertrochanteric line and medial linea aspera

The medial and lateral patellar retinaculum are on their respective sides of the patella and are continuous with the vastus fascia to the tibia and the patella.[3] They are minor patellar stabilizers and, if intact, can provide knee extension and straight leg raising despite a patellar or quadriceps tendon rupture.

The patella is a sesamoid bone. It functions to increase the moment arm from the knee joint axis, thereby increasing the mechanical advantage and quadriceps pull in extension. The patella begins to engage the trochlea at 20 degrees of flexion and is fully engaged by 40 degrees of flexion. Joint reaction forces in the patellofemoral joint can be up to three times the body weight with stair climbing and seven times the bodyweight with deep bending.[4]

The patellar tendon, by definition, is a ligament as it connects bone (patella) to bone (tibial tubercle). The patellar tendon is approximately 30 mm wide by 50 mm long, with a thickness of 5 to 7 mm. The origin on the inferior pole of the patella is juxtaposed on the articular cartilage on the deep side and becomes confluent with the periosteum of the patella anteriorly. The tibial insertion is narrower and invests the entirety of the tibial tubercle, connecting the quadriceps muscles to the lower leg.

Etiology

Tendon rupture usually is the result of underlying tendinosis or a weakened tendon. Chronic inflammation, such as patellar tendonitis, leads to a weakened tendon and can increase the likelihood of tendon rupture. Certain medical conditions can lead to an overall weakened tendon and can also predispose an individual to tendon rupture.

Risk Factors[5][2][6][7]

• Systemic lupus erythematosus
• Rheumatoid arthritis
• Chronic renal disease
• Diabetes mellitus
• Renal dialysis
• Chronic corticosteroid use
• Fluoroquinolone antibiotics
• Corticosteroid injections
• Patellar tendinopathy
• Previous injury
• Overuse injury
• Patellar degeneration

Epidemiology

Disruption of the knee extensor mechanism can occur at different locations within the extensor mechanism chain. The three most common areas of disruption include the patella, the quadriceps tendon, and the patellar tendon.[8] Patella fractures are much more common than tendon ruptures by more than double.[9] Quadriceps tendon rupture tends to be more common than patellar tendon ruptures, especially in individuals over 40 years of age.[10] In the United States, quadriceps tendon ruptures tend to affect 1.3% of the population each year, whereas patellar tendon ruptures tend to affect less than 0.5% of the population each year. Males are more commonly affected than females. The thought behind this is that males are physically stronger and more susceptible to rupture of the extensor mechanism. Additionally, females have greater ligamentous laxity, and hormonal changes due to the menstrual cycle may be protective.

Pathophysiology

Patellar tendon rupture occurs as a result of a tensile overload on the extensor mechanism. This is usually the result of long-standing chronic tendon degeneration.[11] The usual circumstance is the quadriceps muscle suddenly contracts with the knee in a flexed position. This can be seen in cases where an individual was running up a set of stairs, landing from a jump, or suddenly stopping to change directions when running. The greatest amount of force on the patellar tendon is seen when the knee is flexed more than 60 degrees. As a result, the majority of patellar tendon ruptures occur with the knee in a flexed position. Patellar tendon rupture can occur at three distinct locations with a proximal avulsion of the tendon, with or without bone from the inferior pole of the patella being the most common.[6] The strain at the tendon-inferior pole patella interface is three to four times higher than at the midsubstance of the tendon. The other two possible locations for rupture include the midsubstance of the tendon and an avulsion of the patellar tendon from the tibial tubercle.

History and Physical

Patients with an acute patellar tendon tear present to their healthcare provider with the complaint of infrapatellar knee pain, swelling, difficulty with weight-bearing, and difficulty straightening the leg. They may report an audible “pop” or the sensation of their knee giving way during an event with a sudden quadriceps contraction with the knee in a flexed position, such as with jumping sports or missing a step on the stairs. As with any presenting complaint, it is essential to obtain a detailed history of their symptoms. The history of the present illness should include the onset of their symptoms, specific location of their pain, duration of the pain and symptoms, characteristics of the pain, alleviating and aggravating factors, any radiation of pain, and the severity of their symptoms. Patients may report pre-existing pain at the level of the patella or patellar tendon, which may be indicative of underlying tendinosis. Furthermore, a thorough history may reveal an underlying risk factor or predisposition to a tendon rupture.[12]

There are differing opinions on the definition of an acute versus chronic tendon rupture; however, in general, chronic ruptures are those presenting six weeks after injury.

Physical examination of the knee should begin with an inspection. Be sure to evaluate the surrounding skin for any signs of direct trauma. Look for any associated swelling or knee effusion. Patellar tendon ruptures often will be associated with a large hemarthrosis and surrounding ecchymosis. Inspect and evaluate the patellar height and compare the affected and unaffected sides. A patellar tendon rupture will likely be associated with an elevation of the patellar height compared to the uninjured side.

Palpation of the bony and soft tissue structures is an essential part of any knee exam. The palpatory exam can be broken down into the medial, midline, and lateral structures of the knee.

Palpatory Exam - Areas of Focus[13]

Medial Aspect of the Knee

• Vastus medialis obliquis
• Superomedial pole patella
• The medial facet of the patella
• Origin of the medial collateral ligament (MCL)
• Midsubstance of the MCL
• Broad insertion of the MCL
• Medial joint line
• Medial meniscus
• Pes anserine tendons and bursa

Midline Knee

• Quadricep tendon
• Suprapatellar pouch
• Superior pole patella
• Patellar mobility
• Prepatellar bursa
• Patellar tendon
• Tibial tubercle 

Lateral Aspect of the Knee

• Iliotibial band
• Lateral facet patella
• Lateral collateral ligament (LCL)
• Lateral joint line
• Lateral meniscus
• Gerdy’s tubercle 

Patients with a patellar tendon rupture will have a palpable defect below the inferior pole of the patella. They will also have localized tenderness about the infrapatellar aspect of the knee.

Range of motion (ROM) testing and muscle strength testing are essential aspects of the knee exam, especially in the setting of a suspected patellar tendon rupture. Patients with an acute patellar tendon rupture will have decreased ROM of the knee due to pain and disruption of the extensor mechanism. There will be a loss of active knee extension, which is the key physical exam finding. If the patellar tendon is the only portion of the extensor mechanism ruptured and the retinaculum is intact, the active extension may be possible, but there will be an extensor lag of a few degrees. Patients will be unable to perform active straight leg raise and also will be unable to maintain a passively extended knee.

Care is necessary to avoid missing a diagnosis of a patellar tendon rupture or any disruption of the extensor mechanism, as delayed diagnosis and treatment affect the outcome. If needed, aspiration of a painful knee effusion followed by an injection of lidocaine may be performed to aid in clinical diagnosis. A patient with an extensor mechanism disruption will be unable to perform a straight leg raise despite adequate local anesthesia. On the other hand, a patient with a painful effusion secondary to a different issue will be able to perform a straight leg raise.

Evaluation

Recommended radiographic evaluation includes anteroposterior and lateral views of the affected knee. In a complete rupture, radiographs may reveal patella alta (superiorly displaced patella). The Insall-Salvati ratio is a quick method to determine patella alta or baja (inferiorly displaced patella) on the lateral knee radiograph. It is defined as the ratio between the length of the patellar tendon and the length of the patella. Ideally, this is measured on a lateral radiograph with the knee flexed to 30 degrees. A normal ratio is between 0.8 and 1.2, with patella alta having a ratio greater than 1.2 and patella baja having a ratio of less than 0.8.[4]

Radiographs also may reveal avulsion fractures or other concomitant knee injuries. An MRI of the knee is an appropriate diagnostic study if a patellar tendon rupture is suspected. It is the most sensitive imaging modality and can differentiate partial from complete tendon rupture. It helps determine the exact location of the rupture, the presence of any tendon degeneration, the position of the patella, and any concomitant intraarticular knee lesions. Ultrasound also may be used as an adjunctive study in the suspected case of acute or chronic patellar tendon rupture. It is effective in detecting and localizing tendon disruption. It is much less expensive than obtaining an MRI and can be more convenient depending on the availability of an ultrasound machine and an experienced user.

Treatment / Management

Treatment for complete patellar tendon ruptures involves surgical repair, as disability from a deficient knee extensor mechanism is high. Although not considered to be a surgical emergency, prompt surgical management of acute patella tendon ruptures is recommended to prevent the need for reconstruction. Nonsurgical treatment for patellar tendon ruptures is only indicated in those instances where the tendon tear is partial, and there is an intact knee extensor mechanism. The other instance in which nonsurgical management should be considered would be for patients who are not surgical candidates due to medical comorbidities. Non-surgical treatment involves immobilization with the knee in full extension with a progressive weight-bearing exercise program.

Surgical treatment includes primary tendon repair or tendon reconstruction.[8] Primary repair is indicated in complete patellar tendon ruptures and in cases in which the tendon ends can be approximated.[14] The location of the tear will dictate the type of repair used. An end-to-end repair will generally be used when the tendon tear is midsubstance. A transosseous tendon repair, with bone tunnels drilled through the patella, will generally be used for a proximal avulsion. A suture anchor tendon repair will generally be used for a distal avulsion. Tendon reconstruction is indicated in severely disrupted or degenerative patellar tendons or in cases in which primary repair cannot be performed. Tendon excursion, adhesion, and degeneration increase as the time from initial injury to surgical repair increases. This can convert a simple primary tendon repair to a more complicated patellar tendon reconstruction. This makes it important to treat patellar tendon ruptures with a sense of urgency. The patellar tendon can be reconstructed from autograft or allograft tissue. There are multiple surgical techniques described for patellar tendon reconstruction.[15][16]

Autograft and Allograft Tissue Options

• Semitendinosus
• Gracilis
• Ipsilateral or contralateral central quadriceps tendon-patellar bone
• Achilles tendon with a bone block

Differential Diagnosis

• Quadriceps tendon rupture
• Patella fracture
• Tibial tubercle avulsion fracture

Prognosis

Overall, there are good to excellent outcomes reported with patellar tendon ruptures that undergo surgical repair promptly. Poor outcomes, complications, and failures are typically associated with missed or delayed diagnosis, delayed treatment, or technical errors during surgery.

Complications

• Re-rupture
• Residual extensor mechanism weakness
• Residual extensor lag or inability to fully extend the knee
• Knee stiffness
• Quadriceps atrophy
• Infection

Postoperative and Rehabilitation Care

The post-operative rehabilitation protocol will vary based on the surgeon, but the following is a general guideline.[17]

Weeks 0 through 2

• Goal – protect surgical repair of the tendon
• Weight-bearing as tolerated with crutches and knee brace locked in full extension
• The operating surgeon determines ROM allowances based on the quality of repair

Weeks 2 through 6

• Goal – continue protecting surgical repair of tendon, normalize gait with crutches and knee brace
• Continue weight bearing as tolerated with crutches and knee brace locked in full extension
• Begin passive ROM from 0 to 90 degrees of knee flexion, no active quadriceps extension
• The operating surgeon determines ROM allowances based on the quality of repair

Weeks 6 through 12

• Goal – normalize gait on a flat surface, wean crutches, the knee brace may be opened to allow flexion, begin active quadriceps contraction
• Gradual progression of weight bearing with knee flexion, avoid weight-bearing in knee flexed past 70 degrees
• Active ROM of knee
• Progressive light squat, leg press, core strengthening, and other physical therapy exercises and modalities

Weeks 12 through 16

• Goal – normalize gait on all surfaces without a brace, full ROM, single-leg stance with good control, and squat to 70 degrees of flexion with good control
• Begin non-impact balance and proprioceptive drills
• Continue with physical therapy exercises, quad, and core strengthening

Weeks 16 and Longer

• Goal – good quad control, no pain with sport or work specific movement, including impact activity

Return to Sport Criteria

• Dynamic neuromuscular control with multiplane activities, without pain or swelling

Deterrence and Patient Education

Patients need to understand the surgery to be performed, and more importantly, the necessity for strict adherence to surgical follow-up processes, particularly physical therapy. Non-surgical cases will also require strict therapeutic adherence. Laxity in performing both scheduled and home therapeutic exercises can lead to lifelong loss of function. Expectations also need to be set depending on the patient's age, level of conditioning pre-injury, and both work and daily activities. With successful surgery and patient commitment to postsurgical care, the patient can achieve a good outcome.

Enhancing Healthcare Team Outcomes

Diagnosis and management of patellar tendon rupture are best performed with an interprofessional team that includes therapists and orthopedic nurses. Clinicians should be aware that treatment of patellar tendon rupture depends on the integrity of the tendon. Treatment for complete patellar tendon ruptures involves surgical repair, as disability from a deficient knee extensor mechanism is high. Although not considered to be a surgical emergency, prompt surgical management of acute patella tendon ruptures is recommended to prevent the need for reconstruction. Nonsurgical treatment for patellar tendon ruptures is only indicated in those instances where the tendon tear is partial, and there is an intact knee extensor mechanism. Orthopedic specialty nursing staff can play an integral role in conservative and surgical treatment/management, monitor patient progress, coordinate medication with the pharmacist, and keep the clinicians informed of status changes.

All patients should be enrolled in rehabilitation to regain joint function and muscle strength. The outlook for most patients is excellent.