Fig. 30.1
Tendinopathy of the distal insertion of quadriceps tendon
30.1.3 Treatment
Treatment is conservative with an initial period of abstention from sports activities, the use of NSAIDs, and physical therapy (cryotherapy, laser therapy, Tecar). Later, muscle strengthening and improvement of elasticity of the tendon are important: particularly recommended in this phase is eccentric exercise of the quadriceps (Fyfe and Stanish 1992).
In most cases symptoms resolve in 2–3 weeks, only rarely it is necessary to perform surgery. Surgical treatment is indicated when conservative treatment has not given results within 3–6 months; the operation consists of the stimulation of tendon bleeding through longitudinal tenotomies.
30.1.4 Tendon Rupture
The rupture of the quadriceps tendon typically concerns subjects older than 40 years, and it’s associated with multiple risk factors including pathological conditions and chronic drug therapies.
Diseases that predispose to rupture of the quadriceps tendon are kidney failure, diabetes mellitus, hyperparathyroidism, rheumatoid arthritis, SLE, gout, and obesity (Shah 2002; Preston and Adicoff 1962; Ribbans and Angus 1989; Cooney et al. 1991).
Drugs involved include statins, local corticosteroid injections, fluoroquinolones, anabolic androgens, and prolonged treatment with systemic corticosteroids.
In these groups, the tendon rupture is usually caused by a minor injury, a fall, an effort descending stairs, or even spontaneous, because there are histological changes of the tendon structure that compromise the mechanical strength (Shah 2002). In most cases the tendon breaks transversally in proximity of the osteo-tendon junction, where it is observed an abnormal distribution of collagen fibers and an increase of the type 3 collagen production by tenocytes (Preston and Adicoff 1962).
In sportsman, complete or partial tears of the quadriceps tendon are rare and not always associated with a history of tendinopathy or previous injuries of the quadriceps. The main damage mechanism consists in an eccentric overload with the knee flexed as in weightlifting or in a direct trauma as in contact sports.
Objectively, characteristic sign of tendon rupture is the inability to extend the leg, although in partial injury, this function can be maintained; in this case it is observable lower strength in the extension against resistance compared to the contralateral knee.
The patient usually is able to walk with stiff limbs and there is a compensatory attitude of hip flexion. In acute phases there is swelling of the knee associated with hemarthrosis; through palpation it is possible to identify a groove at the upper pole of the patella that corresponds to the separation of the tendon at its insertion (Ribbans and Angus 1989).
In cases of complete tendon injury, radiographies show an abnormal patella baja, while in partial lesions, they are negative.
The MRI, in case of complete rupture, confirms the diagnosis by showing in the sagittal projections the discontinuity of the tendon associated with edema of the surrounding tissues, while in the partial ruptures, it is the gold standard for the identification and localization of the lesion.
The treatment of complete ruptures of the tendon is surgical, and the best results are obtained when surgery is performed early, when the tendon is not retracted yet.
The upper pole of the patella and the tendon are freshened to increase bleeding, the tendon is set up by two Krackow sutures using nonabsorbable strand and fixed to the patella through metal anchors or trans-bone holes.
If the tendon is retracted and cannot reach the patella, it can be lengthened by the Codivilla’s technique (Cooney et al. 1991). The technique involves an inverted-V incision about 1.5 cm proximal to the lesion; the two sides of the inverted V are sutured to each other, and the triangular tendon flap is distally overturned and sutured to the patella as reinforcement.
The post operation, in healthy patients who have received early reconstruction, involves the use of a brace for 6/8 weeks, initially blocked in extension, and then increasing the bending of 5°/10° every week. For patients with predisposing diseases or patients undergoing surgery late, rehabilitation must be more cautious and functional recovery expect longer times.
In selected cases of partial rupture in which the lesion affect less than 50% of the tendon, it might be undertaken a conservative treatment by immobilizing the knee with a brace locked in extension for 6/8 weeks.
30.2 Iliotibial Band (ITB) Syndrome
30.2.1 The Iliotibial Band Anatomy
The iliotibial band, or iliotibial tract, originates as common tendon of two muscles, the gluteus maximus and tensor fasciae latae, and then goes down along the thigh thickening the lateral portion of the fascia lata. Near the knees it runs superficially on lateral femoral epicondyle and inserts on the lateral side of the tibia at the tubercle of Gerdy.
Proximally iliotibial tract serves as insertion to the gluteus maximus and tensor fasciae latae, allowing their function of abductors of the thigh. Distally, from 0° to 20° of knee flexion, it isn’t forward the lateral femoral epicondyle and participates at the extension of the knee; over 30° of flexion, it climbs over the lateral femoral epicondyle and it is positioned posteriorly to it. Under the microscope the iliotibial band is separated to the epicondyle by a highly vascularized adipose tissue, without the evidence of a real bursa (Kannus and Jozsa 1991).
30.2.2 Pathogenesis and Clinical Presentation
The ITB syndrome is a common disorder among athletes, due to inflammation of the most distal tract of the iliotibial band.
The inflammatory process originates from the rubbing of ITB on the lateral femoral epicondyle during repeated flexions and extensions of the knee; the maximum impingement between these structures is between 20° and 30° of flexion, which correspond to the phase of the step when the foot is in contact with the ground (foot strike) (Maffulli et al. 2012).
This pathology concerns especially runners and cyclists, but it is common in all sports with repetitive movements of flexion-extension of the knee.
Many risk factors predispose to the development of the disease and are related to the training mode or to anatomical characteristics.
Rapid changes in the training program, increase of the distance, and running on a slope can trigger symptoms. In particular in the downhill race, the bending angle of the knee decreases during the contact of the foot to the ground, increasing the time spent in the period of maximum impingement (Boublik et al. 2013).
Anatomical factors that cause an increased tension of the ITB, predisposing to the development of the disease, are the varus knee, the excessive internal rotation of the tibia, and the foot pronation during running (Rougraff et al. 1996).
The main symptom is pain, often described as burning, to the lateral side of the knee that sometimes is well localized by the patient at the lateral femoral epicondyle but in other cases is described as widespread lateral pain.
The pain initially occurs at the end of the training or after a race and then stops to rest. If practice is continued, the pain becomes more intense, and it occurs earlier during training and may persist with the rest.
Objectively the patient has pain with palpation of the lateral femoral epicondyle (2–3 cm proximally to the lateral joint line), which is generally showed at 30° of knee flexion. In some cases, with palpation it’s possible to appreciate a jerk sensation during flexion-extension that corresponds to the passage of the ITB above femoral epicondyle. The pain is also caused by asking at the patient to do a lounge with the affected limb.
The Noble’s tests (Muhle et al. 1999) and the Ober’s test (Terry et al. 1986) are useful in the diagnosis of the ITB syndrome.
The Noble’s test consists in extending the patient’s leg, starting from 90° of flexion while exercising a pressure on the femoral epicondyle. The test is positive if the patient has pain at about 30° of flexion.
Ober’s test is performed with patient in lateral decubitus on the healthy side. The examiner, behind, with one hand stabilizes the pelvis, while the other flexes the knee up to 90° and abducts and extends the hip. Held this position for a while, the examiner leaves the limb. If the hip stays abducted and doesn’t reach the neutral position, the test is positive for suffering of the ITB.
The differential diagnoses of this disease include lateral meniscus tears, stress fractures, tendonitis of the popliteal tendon, degenerative disorders of the lateral compartment of the knee, and sciatalgy.
The diagnosis is mainly clinical, MRI may be indicated in cases of refractoriness to conservative treatment, and it is useful in the differential diagnosis.
30.2.3 Treatment
Most patients get well with a conservative treatment consisting in a first phase, which turn off the inflammation of the involved structures, followed by a second one focused on stretching and muscle strengthening. During the first phase, training should be suspended or replaced by activities that do not involve repetitive movements of flexion-extension of the knee (swimming); the use of NSAIDs and application of local ice are recommended. If pain does not regress after several days of treatment, a cortisone injection is indicated.
Once pain is decreased, it’s important to regularly perform specific stretching exercises to stretch ITB, tensor fascia latae, and gluteus.
Moreover, when patients return to practice sport, they must continue stretching exercises and avoid running on dangerous ground and correct eventual pronation of the foot when they run with orthopedic insole.
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