Patellar and Quadriceps Tendon Repairs

Andrea Tychanski, PT, DPT, SCS, ATC, CSCS

John Cavanaugh, PT, ATC, SCS

Anil S. Ranawat, MD

Dr. Ranawat or an immediate family member has received royalties from Conformis; is a member of a speakers’ bureau or has made paid presentations on behalf of Arthrex, CONMED Linvatec, DePuy Mitek, and Stryker MAKO; serves as a paid consultant to Arthrex, CONMED Linvatec, DePuy Mitek, and Stryker MAKO; has stock or stock options held in Conformis; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research–related funding (such as paid travel) from Saunders/Mosby-Elsevier and Springer; and serves as a board member, owner, officer, or committee member of Current Trends in Musculoskeletal Medicine and the EOA. Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Cavanaugh and Dr. Tychanski.

Introduction

Patellar and quadriceps tendon ruptures are debilitating injuries that usually require surgical repair and physical therapy. The patellar and quadriceps tendons are crucial components of the extensor mechanism of the knee. Knee extension plays an important role in one’s ability to perform basic activities of daily living (ADLs). Most quadriceps tendon injuries occur in individuals around 50 years of age, while the majority of patellar tendon injuries occur in patients around 40 years of age.

Complete patellar or quadriceps ruptures typically present with a palpable infrapatellar or suprapatellar defect and a noticeable effusion. With a patellar tendon rupture, the patella is high riding, while with a quadriceps rupture it may be masked by the swelling. In both cases, assessment of the extensor mechanism will demonstrate an inability to straight leg raise or an extension lag.

Indications and Contraindications

For optimal results, a complete patellar or quadriceps tendon disruption requires surgical repair. Ideal timing for surgical intervention is within 3 weeks following the acute episode. Nonambulators, patients who possess severe comorbidities or have compromised soft tissues in the area secondary to prior trauma, are not candidates for surgery. Patients who have a known history of noncompliance with rehabilitation or have a partial tear without a knee extensor lag during a straight leg raise are best treated conservatively. Some partial quadriceps tendon ruptures may also be treated nonoperatively.

Surgical Procedure

The surgical technique utilized for patellar and quadriceps tendon tears occurring at or near the osteotendinous junction involves a patellar drill hole technique. An anterior incision is made, exposing the extensor mechanism. Interlocking nonabsorbable sutures are passed through the tendonous portion of the torn tendon. Interlocking sutures are then passed through longitudinal transosseous patellar drill holes and tied over a patellar bone bridge. Midsubstance tears are repaired via an end-to-end primary repair utilizing interrupted nonabsorbable sutures. The final step of a surgical repair involves attention to the medial and lateral retinaculum. Tears to either retinaculum are identified and repaired with sutures using a figure-of-eight technique. Following repair, the knee is taken through a gentle range of motion (ROM) from 0° to 60° to assess the tension on the repair.

Postoperative Rehabilitation

Rehabilitation following a quadriceps or patellar tendon repair should be initiated immediately following surgery, although full tensile strength is not achieved until 9 to 12 months from injury. Communication between the physical therapist and surgeon is important to discuss surgical procedure, including the quality of the repaired tissue and any concomitant injuries. In addition, postoperative ROM progression and weight-bearing status is clarified. The surgeon and physical therapist will counsel the patient to expect a gradual and lengthy progression with therapy. The patient is continuously educated regarding the importance of following precautions in order to protect the
repair throughout rehabilitation. A criteria-based functional progression is followed in order to safely advance through postsurgical rehabilitation, and goals are individualized for each patient. Active discussion between the physical therapist, surgeon, and patient is imperative.

Phase 1: Initial Mobilization and Protection of Repair (Weeks 0–4)

Immobilizer or brace in extension
Protected weight bearing with crutches/walker
Quadriceps activation

During the initial phase (0–4 weeks) protection of the repair is essential. The patient is educated regarding proper use of the brace and crutches. The brace is locked in 0° of extension at all times for the first 4 weeks. Ambulation is initially permitted up to 50% weight bearing with a locked brace and crutches; weight bearing is then gradually progressed, as tolerated. The patient is educated to frequently elevate the extremity and apply ice for pain and inflammation management. Use of a combined cryotherapy and compression unit three to five times per day for 20 to 30 minutes at a time is advised for the first 4 weeks postoperatively. Any signs of atypical healing—including signs of infection, repair failure, as well as patient’s degree of compliance to prescribed exercises and activity modifications—should be communicated with the surgeon immediately. Once the surgical incision is completely healed, scar tissue and patellar mobilizations are encouraged. These interventions will aide the mobility of the patella along the trochlear groove, minimize scar-tissue adhesions, and assist with the progression of knee ROM.

Figure 50.1 Photograph of isometric quadriceps activation with a towel roll under the ankle. Hold each contraction for 10 seconds for 10 repetitions, five or more times per day.

Figure 50.2 Photograph of supine straight leg raises with brace locked at 0° of knee extension.

Early activation of the quadriceps muscle is important and is initiated via isometric quadriceps sets with a small towel roll under the knee multiple times per day (Figure 50.1). If the patient demonstrates inhibition of the quadriceps muscle, a neuromuscular electrical stimulation (NMES) unit is utilized to facilitate quadriceps activation. Once the patient demonstrates adequate quadriceps activation, supine straight leg raises with the brace locked at 0° extension are initiated (Figure 50.2). Straight leg raises in all other planes are performed to maintain hip strength. Distal lower extremity strength and flexibility is introduced during this phase. Typical exercises would include ankle plantarflexion with a resistance band and seated calf stretching with a strap (Figure 50.3). Hamstring flexibility
is addressed in the supine position (Figure 50.4). Bilateral weight shifting with upper extremity support on a uniplanar rocker can be initiated in cardinal planes for proprioceptive stimulation.

Figure 50.3 Photograph of seated calf stretching with a strap. Hold each stretch 20 to 30 seconds.

Figure 50.4 Photograph of supine hamstring stretch. Hold each stretch 20 to 30 seconds.

Phase 2: Restoration of Motion and Progression of Weight Bearing (Weeks 4–12)

Progressive ROM
Progression to full weight bearing with a brace and wean as quadriceps control is regained
Proprioception and closed kinetic chain exercise

The second phase of rehabilitation (4–12 weeks) permits gradual increases in ROM, increased use and function of the limb, and progressive weight bearing. Gentle active assistive range of motion (AAROM) is initiated and progressed gradually. Knee flexion ROM is performed in a seated position using the nonsurgical leg for support (Figure 50.5). The patient is educated regarding the fact that ROM should not be forced and should not cause pain. As the patient reaches approximately 90° of knee flexion, gentle overpressure into knee flexion with the nonsurgical leg is applied to further progress ROM. Knee flexion AAROM may also be advanced via supine wall slides, knee flexion stretching on a step (Figure 50.6) and half-moon motion on a low-seated stationary bicycle. When the patient achieves 85° of knee flexion, a stationary short-crank bicycle may be utilized to encourage movement and lubrication of the knee joint (Figure 50.7). The patient can begin cycling on a full-crank bicycle upon achieving 110° to 115° of knee flexion. As the patient approaches 120° of knee flexion, gentle quadriceps flexibility stretching in the supine position may be introduced (Figure 50.8).

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