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1.  Intratendinous Tophaceous Gout Imitating Patellar Tendonitis in an Athletic Man 
Orthopedics  2011;34(3):223.
Patellar tendon-related pain is common in the athletic patient. When it occurs in skeletally mature patients participating in running, jumping, or kicking sports, the diagnosis of jumper’s knee patellar tendonitis is usually made. If patellar tendon pain is associated with a mass, the differential diagnosis should be broadened to include crystalline arthropathy.
This article presents a case of a highly athletic 45-year-old man with a history of gout, anterior knee pain, and an enlarging mass in the region of the patellar tendon. Conservative management failed, and an excisional biopsy found it to be an intra-tendinous gouty tophus. To our knowledge, only 1 report exists documenting a patellar tendon mass secondary to gout, and no case report exists documenting this problem in an athlete. The interplay between athletics and gout has not been well described. Despite the long-term protective nature of fitness, transient elevations in uric acid associated with athletic endeavors may contribute acutely to manifestations of gout in some athletes. Resultant intra- or extra-articular pathology may present as, and easily be mistaken for, a sports-related injury. Without appropriate medical management, tophaceous deposition may continue to occur and treatment of the resultant mass may require surgical intervention.
PMCID: PMC3784320  PMID: 21410111
2.  Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: a prospective randomised study 
British Journal of Sports Medicine  2005;39(11):847-850.
Background: A recent study reported promising clinical results using eccentric quadriceps training on a decline board to treat jumper's knee (patellar tendinosis).
Methods: In this prospective study, athletes (mean age 25 years) with jumper's knee were randomised to treatment with either painful eccentric or painful concentric quadriceps training on a decline board. Fifteen exercises were repeated three times, twice daily, 7 days/week, for 12 weeks. All patients ceased sporting activities for the first 6 weeks. Age, height, weight, and duration of symptoms were similar between groups. Visual analogue scales (VAS; patient estimation of pain during exercise) and Victorian Institute of Sport Assessment (VISA) scores, before and after treatment, and patient satisfaction, were used for evaluation.
Results: In the eccentric group, for 9/10 tendons patients were satisfied with treatment, VAS decreased from 73 to 23 (p<0.005), and VISA score increased from 41 to 83 (p<0.005). In the concentric group, for 9/9 tendons patients were not satisfied, and there were no significant differences in VAS (from 74 to 68, p<0.34) and VISA score (from 41 to 37, p<0.34). At follow up (mean 32.6 months), patients in the eccentric group were still satisfied and sports active, but all patients in the concentric group had been treated surgically or by sclerosing injections.
Conclusions: In conclusion, eccentric, but not concentric, quadriceps training on a decline board, seems to reduce pain in jumper's knee. The study aimed to include 20 patients in each group, but was stopped at the half time control because of poor results achieved in the concentric group.
PMCID: PMC1725058  PMID: 16244196
3.  Patellar tendinosis as an adaptive process: a new hypothesis 
Background: Patellar tendinosis (PT), or "jumper's knee" is a common condition in athletes participating in jumping sports, and is characterised by proximal patellar tendon pain and focal tenderness to palpation. Hypoechoic lesions observed in the proximal patellar tendon associated with the tendinosis are typically described as being a result of degenerative change or "failed healing". We propose a new model for the development of the hypoechoic lesion observed in PT, in which the aetiology is an adaptive response to differential forces within the tendon.
Methods: We assessed the clinical, histopathological, and biomechanical literature surrounding the patellar tendon and integrated this with research into the response of tendons to differential forces.
Results and conclusions: We propose that the hypoechoic lesion commonly described in PT is the result of adaptation or partial adaptation of the proximal patellar tendon to a compressive load. We postulate that the biomechanics of the patellar–patellar tendon interface creates this compressive environment. Secondary failure of the surrounding tensile adapted tendon tissue may result in tissue overload and failure, with resultant stimulation of nociceptors. We believe that this "adaptive model" of patellar tendinosis is consistent with the clinical and histological findings.
PMCID: PMC1725001  PMID: 15562176
4.  Neovascularisation and pain in jumper's knee: a prospective clinical and sonographic study in elite junior volleyball players 
Background: The nature of tendon neovascularisation associated with pain over time has not been studied.
Objective: To prospectively study the patellar tendons in elite junior volleyball players.
Methods: The patellar tendons in all students at the Swedish National Centre for high school volleyball were evaluated clinically and by ultrasonography (US) and Power Doppler (PD) sonography.
Results: Altogether 120 patellar tendons were followed for 7 months. At inclusion, jumper's knee was diagnosed clinically in 17 patellar tendons. There were structural changes on US in 14 tendons, in 13 of which PD sonography showed neovascularisation. There were 70 clinically normal tendons with normal US and PD sonography, 24 clinically normal tendons with abnormal US but normal PD sonography, and nine clinically normal tendons with abnormal US and neovascularisation on PD sonography. At 7 month follow up, jumper's knee was diagnosed clinically and by US in 19 patellar tendons, in 17 of which there was neovascularisation. Three of nine clinically normal tendons with structural changes and neovascularisation at inclusion developed jumper's knee. Two of 24 tendons clinically normal at inclusion, with abnormal US but normal PD sonography, developed jumper's knee with abnormal US and neovascularisation on PD sonography. A total of 20 clinically normal tendons with normal US and PD sonography at inclusion developed structural tendon changes and 12 of these also developed neovascularisation.
Conclusions: The clinical diagnosis of jumper's knee is most often associated with neovascularisation in the area with structural tendon changes. The finding of neovessels might indicate a deterioration of the condition.
PMCID: PMC1725252  PMID: 15976162
5.  Can Arthroscopically Assisted Treatment of Chronic Patellar Tendinopathy Reduce Pain and Restore Function? 
Patellar tendinopathy is a common source of pain in athletes, especially those involved in sports with a high incidence of jumping and cutting. Changes in training programs and exercises based on eccentric quadriceps contractions often relieve patients’ symptoms. For athletes unresponsive to this treatment, some authors suggest open and arthroscopic procedures débriding either the tendon alone, or the tendon and bone.
We asked whether an arthroscopically assisted approach to débride not only the tendon, bone, but also the peritenon could relieve pain and allow athletes to return to their former activities.
Patients and Methods
We retrospectively reviewed 23 patients with a history of at least 6 months of painful patellar tendinopathy unresponsive to nonoperative treatment treated with an arthroscopic technique that débrided the tendon, inferior pole of the patella, and peritenon: 22 males and one female. Mean age was 29 years. Patients were evaluated using the anterior knee pain score of Kujala et al. The minimum followup was 12 months (mean, 58 months; range, 12–121 months).
Twelve patients scored 100, one 99, one 98, five 97, two 94, one 90, and one 64. The Kujala et al. mean score was 96 (range, 64–100). All but four patients returned to their former sports activities. We observed no complications.
Arthroscopic treatment can relieve the pain of refractory chronic patellar tendinopathy. Our observations were comparable with those previously reported for open techniques and a high percentage of patients returned to their previous activity level.
Level of Evidence
Level IV, observational study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC3293969  PMID: 21461867
6.  Reconstruction of medial patellofemoral ligament for chronic patellar instability 
Indian Journal of Orthopaedics  2012;46(4):447-454.
Disruption of the capsule, medial patellar retinaculum, and/or vastus medialis obliqus has been associated with recurrent patellar instability. Biomechanical studies have shown that the medial patellofemoral ligament (MPFL) is the main restraint against lateral patella displacement and reconstruction of the MPFL has become an accepted surgical technique to restore patellofemoral stability in patients having recurrent patellar dislocation. We report a prospective series of patients of chronic patellar instability treated by reconstruction of medial patellofemoral ligament.
Materials and Methods:
Twelve patients (15 knees) with recurrent dislocation of patella, were operated between January 2006 and December 2008. All patients had generalised ligament laxity with none had severe grade of patella alta or trochlear dysplasia. The MPFL was reconstructed with doubled semitendinosus tendon. Patients were followed up with subjective criteria, patellar inclination angle, and Kujala score.
The mean duration of followup after the operative procedures was an average of 42 months (range 24–60 months) 10 knees showed excellent results, 3 knees gave good results, and 2 knees had a fair result. The average patellar inclination angle decreased from 34.3° to 18.6°. The average preoperative Kujala functional score was 44.8 and the average postoperative score was 91.9.
MPFL reconstruction using the semitendinosus tendon gives good results in patients with chronic patellar instability without predisposing factors like severe patella alta and high-grade trochlear dysplasia, and for revision cases.
PMCID: PMC3421936  PMID: 22912521
Hamstring tendon; medial patellofemoral ligament; patellofemoral instability
7.  High prevalence of jumper's knee and sonographic changes in Swedish elite junior volleyball players compared to matched controls 
Background: Jumper's knee is a common and troublesome condition among senior volleyball players, but its prevalence among elite junior players compared to matched non-sports active controls is not known.
Objective: To clinically, and by sonography, examine the patellar tendons in elite junior volleyball players (15–19 years) at the Swedish National Centre for volleyball and in matched controls.
Methods: The patellar tendons in the 57 students at the Swedish National Centre for high school volleyball and in 55 age, height, and weight matched not regularly sports active controls were evaluated clinically and by grey scale ultrasonography (US) and power Doppler (PD) sonography.
Results: There were no significant differences in mean age, height, and weight between the volleyball players and the controls. In the volleyball group, jumper's knee was diagnosed clinically and by US in 12 patellar tendons (10 male and two female). In 12/12 tendons, PD sonography demonstrated a neovascularisation in the area with structural tendon changes. In another 10 pain free tendons, there were structural tendon changes and neovessels. In the control group, no individual had a clinical diagnosis of jumper's knee. US demonstrated structural tendon changes in 11 tendons, but there was no neovascularisation on PD sonography.
Conclusions: A clinical diagnosis of jumper's knee, together with structural tendon changes and neovascularisation visualised with sonography, was seen among Swedish elite junior volleyball players but not in matched not regularly sports active controls. Structural tendon change alone was seen in 10% of the control tendons.
PMCID: PMC1725221  PMID: 15849296
8.  Surgery in acute patellar dislocation--evaluation of the effect of injury mechanism and family occurrence on the outcome of treatment. 
A retrospective study was made of 270 patients and 284 knees with acute patellar dislocation treated operatively. The mean follow up time was 4.1 years. Medical history revealed 21.1% of cases with previous dislocations and 15.6% of cases with family occurrence of patellar dislocation. The dislocation resulted from an athletic performance in 41.5% of cases. The sport events most often associated with patellar dislocation were soccer, gymnastics, and ice hockey. All cases were treated with reefing of medial capsule. Release of lateral patellar retinacula was performed in 243 cases. Two cases were treated primarily with the Elmslie-Roux-Trillat procedure. The subjective result of operative treatment was better and the redislocation rate was lower if the injury mechanism was traumatic rather than non-traumatic and if there was no history for family occurrence of patellar dislocation.
PMCID: PMC1332233  PMID: 8808536
9.  The TOPGAME-study: effectiveness of extracorporeal shockwave therapy in jumping athletes with patellar tendinopathy. Design of a randomised controlled trial 
Patellar tendinopathy is a major problem for many athletes, especially those involved in jumping activities. Despite its frequency and negative impact on athletic careers, no evidence-based guidelines for management of this overuse injury exist. Since functional outcomes of conservative and surgical treatments remain suboptimal, new diagnostic and therapeutic strategies have to be developed and evaluated.
Extracorporeal shockwave therapy (ESWT) appears to be a promising treatment in patients with chronic patellar tendinopathy. ESWT is most often applied after the known conservative treatments have failed. However, its effectiveness as primary therapy has not been studied in athletes who keep playing sports despite having patellar tendon pain.
The aim of this study is to determine the effectiveness of ESWT in athletes with patellar tendinopathy who are still in training and competition.
The TOPGAME-study (Tendinopathy of Patella Groningen Amsterdam Maastricht ESWT) is a multicentre two-armed randomised controlled trial with blinded participants and outcome assessors, in which the effectiveness of patient-guided focussed ESWT treatment (compared to placebo ESWT) on pain reduction and recovery of function in athletes with patellar tendinopathy will be investigated. Participants are volleyball, handball and basketball players with symptoms of patellar tendinopathy for a minimum of 3 to a maximum duration of 12 months who are still able to train and compete. The intervention group receives three patient-guided focussed medium-energy density ESWT treatments without local anaesthesia at a weekly interval in the first half of the competition. The control group receives placebo treatment. The follow-up measurements take place 1, 12 and 22 weeks after the final ESWT or placebo treatment, when athletes are still in competition. Primary outcome measure is the VISA-P (Victorian Institute of Sport Assessment - patella) score. Data with regard to pain during function tests (jump tests and single-leg decline squat) and ultrasound characteristics are also collected. During the follow-up period participants also register pain, symptoms, sports participation, side effects of treatment and additional medical consumption in an internet-based diary.
The TOPGAME-study is the first RCT to study the effectiveness of patient-guided ESWT in athletes with patellar tendinopathy who are still in training and competition.
Trial registration
Trial registration number NTR1408.
PMCID: PMC2831826  PMID: 20144188
10.  Surgical Treatment of Chronic Patellar Tendinitis in a Collegiate Football Player 
Journal of Athletic Training  1995;30(4):342-344.
In the competitive athlete, there are many causes of anterior knee pain, one of which is patellar tendinitis. Repetition of explosive movements can cause microtrauma to the tendon and its insertion, resulting in patellar tendinitis and occasional tearing, either partial or total. Due to its refractory nature, the treatment of this disorder can be quite frustrating to all involved. A 20-year-old collegiate football player with patellar tendinitis was treated conservatively for more than 2 years. Despite aggressive training regimens, including quadriceps stretching, eccentric strengthening, and therapeutic modalities, the athlete was unable to participate at his preinjury level. Physical examination of his knee revealed inflammation and crepitation. Radiographs demonstrated an avulsion fragment from the inferior pole of the patella and magnetic resonance imaging showed cystic degeneration of the tendon. These findings confirmed the diagnosis of chronic patellar tendinitis. The patient underwent surgical debridement of the patellar tendon without complications. His postoperative rehabilitation was divided into three phases: passive range of motion, active strengthening, and sport-specific activities. At 14 weeks post-surgery, the athlete was able to return to his previous level of activity without pain. Follow-up 30 weeks postoperatively revealed no return of symptoms. At 40 weeks postsurgery, the athlete was participating at his preinjury level. This case report demonstrates the successful outcome of the surgical treatment of chronic patellar tendinitis, which was unresponsive to conservative treatment, in a competitive collegiate football player.
PMCID: PMC1318006  PMID: 16558360
11.  Infrapatellar Straps Decrease Patellar Tendon Strain at the Site of the Jumper’s Knee Lesion 
Sports Health  2011;3(3):296-302.
The impetus for the use of patellar straps in the treatment of patellar tendinopathy has largely been based on empirical evidence and not on any mechanistic rationale. A computational model suggests that patellar tendinopathy may be a result of high localized tendon strains that occur at smaller patella–patellar tendon angles (PPTAs).
Infrapatellar straps will decrease the mean localized computational strain in the area of the patellar tendon commonly involved in jumper’s knee by increasing the PPTA.
Study Design:
Controlled laboratory study.
Twenty adult males had lateral weightbearing and nonweightbearing radiographs of their knees taken with and without 1 of 2 infrapatellar straps at 60° of knee flexion. Morphologic measurements of PPTA and patellar tendon length with and without the straps were used as input data into a previously described computational model to calculate average and maximum strain at the common location of the jumper’s knee lesion during a simulated jump landing.
The infrapatellar bands decreased the predicted localized strain (average and maximum) in the majority of participants by increasing PPTA and/or decreasing patellar tendon length. When both PPTA and patellar tendon length were altered by the straps, there was a strong and significant correlation with the change in predicted average localized strain with both straps.
Infrapatellar straps may limit excessive patella tendon strain at the site of the jumper’s knee lesion by increasing PPTA and decreasing patellar tendon length rather than by correcting some inherent anatomic or functional abnormality in the extensor apparatus.
Clinical Relevance:
The use of infrapatellar straps may help prevent excessive localized tendon strains at the site of the jumper’s knee lesion during a jump landing.
PMCID: PMC3445162  PMID: 23016021
infrapatellar straps; patellar tendon strain; patellar tendinopathy; patella–patellar tendon angle; computational model
12.  Re-revision of a patellar tendon rupture in a young professional martial arts athlete 
A 27-year-old professional martial arts athlete experienced recurrent right knee patellar tendon rupture on three occasions. He underwent two operations for complete patellar tendon rupture: an end-to-end tenorrhaphy the first time, and revision with a bone-patellar-tendon (BPT) allograft. After the third episode, he was referred to our department, where we performed a surgical reconstruction with the use of hamstring pro-patellar tendon, in a figure-of-eight configuration, followed by a careful rehabilitation protocol. Clinical and radiological follow-ups were realized at 1, 3, and 6 months and 1 and 2 years postop, with an accurate physical examination, the use of recognized international outcome scores, and radiograph and MRI studies. As far as we know, this is the first paper to report a re-revision of a patellar tendon rupture.
PMCID: PMC3427702  PMID: 22008978
Patellar tendon rupture; Re-revision surgery; Rehabilitation protocol
13.  Recalcitrant Infrapatellar Tendinitis and Surgical Outcome in a Collegiate Basketball Player: A Case Report 
Journal of Athletic Training  2001;36(2):174-181.
To present the history, surgery, rehabilitation management, and eventual functional and surgical outcomes of a collegiate basketball player with recalcitrant jumper's knee.
A 21-year-old, male collegiate basketball player had a 2-year history of anterior knee pain.
Differential Diagnosis:
Injuries that often mimic symptoms of infrapatellar tendinitis include infrapatellar fat pad irritation, Hoffa fat pad disease, patellofemoral joint dysfunction, mucoid degeneration of the infrapatellar tendon, and, in preadolescents and adolescents, Sinding-Larsen-Johannsson disease.
After conservative treatment failed to improve his symptoms, the athlete underwent surgical excision of infrapatellar fibrous scar tissue and repair of the infrapatellar tendon.
This patient's case was unique in 3 distinct ways: (1) outcome surveys helped me to understand how this injury affected various aspects of this patient's life and how he viewed himself as he progressed through rehabilitation; (2) a modified functional test was used to help determine whether the athlete was ready to return to sport; and (3) the athlete progressed rapidly through rehabilitation and returned to competitive athletics in 3 months.
This patient was able to return to sport without functional limitations. The surgical outcome was also considered excellent.
PMCID: PMC155530  PMID: 12937459
jumper's knee; tendinitis; tendinosis; rehabilitation
14.  Normal clinical and ultrasound findings indicate a low risk to sustain jumper's knee patellar tendinopathy: a longitudinal study on Swedish elite junior volleyball players 
Jumper's knee patellar tendinopathy is well known to be a common and difficult injury in volleyball. Knowledge about its aetiology and pathogenesis is sparse.
To prospectively follow clinical status, tendon structure and vascularity in elite junior volleyball players.
22 volleyball players (44 patellar tendons) beginning their first grade at the Swedish National Centre for high school volleyball were continuously evaluated clinically and by ultrasonography (US) and power Doppler (PD) over the 3 school years.
At inclusion, there were 44 tendons being assessed. Jumper's knee was diagnosed clinically in eight patellar tendons (seven of eight had structural changes and vascularity on US+PD). There were 27 normal (clinical and US+PD) tendons. At 3 years, there were 36 tendons still being assessed. Four individuals (eight tendons) had been excluded. Jumper's knee had developed in 2 of 25 (2 were excluded) tendons that were normal (clinical and US+PD) at inclusion. Jumper's knee (clinical and US+PD) was also present in six tendons.
Normal clinical tests and ultrasound findings at the start indicated a low risk for these elite junior volleyball players to sustain jumper's knee during three school years with intensive training and playing.
PMCID: PMC2658958  PMID: 17127723
15.  Reproducibility and clinical utility of tendon palpation to detect patellar tendinopathy in young basketball players 
Background—Palpation is an important clinical test for jumper's knee.
Objectives—To (a) test the reproducibility of palpation tenderness, (b) evaluate the sensitivity and specificity of palpation in subjects with clinical symptoms of jumper's knee, and (c) determine whether tenderness to palpation may serve as a useful screening test for patellar tendinopathy. The yardstick for diagnosis of patellar tendinopathy was ultrasonographic abnormality.
Methods—In 326 junior symptomatic and asymptomatic athletes' tendons, palpation was performed by a single examiner before ultrasonographic examination by a certified ultrasound radiologist. In 58 tendons, palpation was performed twice to test reliability. Tenderness to palpation was scored on a scale from 0 to 3 where 0 represented no pain, and 1, 2, and 3 represented mild, moderate, and severe tenderness respectively.
Results—Patellar tendon palpation was a reliable examination for a single examiner (Pearson r = 0.82). In symptomatic tendons, the positive predictive value of palpation was 68%. As a screening examination in asymptomatic subjects, the positive predictive value of tendon palpation was 36–38%. Moderate and severe palpation tenderness were better predictors of ultrasonographic tendon pathology than absent or mild tenderness (p<0.001). Tender and symptomatic tendons were more likely to have ultrasound abnormality than tenderness alone (p<0.01).
Conclusions—In this age group, palpation is a reliable test but it is not cost effective in detecting patellar tendinopathy in a preparticipation examination. In symptomatic tendons, palpation is a moderately sensitive but not specific test. Mild tenderness in the patellar tendons in asymptomatic jumping athletes should be considered normal.
Key Words: patellar tendon; ultrasound; palpation; reliability; athletes
PMCID: PMC1724272  PMID: 11157466
16.  Patellar tendon ossification after partial patellectomy: a case report 
Patellar tendon ossification is a rare pathology that may be seen as a complication after sleeve fractures of the tibial tuberosity, total patellectomy during arthroplasty, intramedullary nailing of tibial fractures, anterior cruciate ligament reconstruction with patellar tendon autograft and knee injury without fracture. However, its occurrence after partial patellectomy surgery has never been reported in the literature.
Case presentation
We present the case of a 35-year-old Turkish man with a comminuted inferior patellar pole fracture that was treated with partial patellectomy. During the follow-up period, his patellar tendon healed with ossification and then ruptured from the inferior attachment to the tibial tubercle. The ossification was excised and the tendon was subsequently repaired.
To the best of our knowledge, this is the first report of patellar tendon ossification occurring after partial patellectomy. Orthopaedic surgeons are thus cautioned to be conscious of this rare complication after partial patellectomy.
PMCID: PMC2835709  PMID: 20181137
17.  Medial patella retinaculum plasty for treatment of habitual patellar dislocation in adolescents 
International Orthopaedics  2012;36(9):1819-1825.
The surgical technique, medial patellar retinaculum plasty, can almost restore both static and dynamic stability and verge on anatomical repair for the treatment of habitual patellar dislocation in adolescents.
In accordance with the injury patterns of the medial patellar retinaculum through knee MRI, we repaired different injury sites with this surgical procedure. We reviewed this technique in 16 patients with an average age of 15 years. Retrospective review of charts and radiographs immediately after the surgery up to the latest follow-up (range 12–36 months) was undertaken.
All patients were evaluated clinically and radiologically over an average of 20.7 months. The recovery of knee mobility results were good. No recurrence of patellar instability has been found.
We think this could be a valid technique to treat habitual patellar dislocation in adolescents.
PMCID: PMC3427441  PMID: 22552428
18.  Use of platelet-rich plasma for the treatment of refractory jumper’s knee 
International Orthopaedics  2009;34(6):909-915.
The aim of this study was to evaluate the efficacy of multiple platelet-rich plasma (PRP) injections on the healing of chronic refractory patellar tendinopathy after previous classical treatments have failed. We treated 15 patients affected by chronic jumper’s knee, who had failed previous nonsurgical or surgical treatments, with multiple PRP injections and physiotherapy. We also compared the clinical outcome with a homogeneous group of 16 patients primarily treated exclusively with the physiotherapy approach. Multiple PRP injections were performed on three occasions two weeks apart into the site of patellar tendinopathy. Tegner, EQ VAS and pain level were used for clinical evaluation before, at the end of the treatment and at six months follow-up. Complications, functional recovery and patient satisfaction were also recorded. A statistically significant improvement in all scores was observed at the end of the PRP injections in patients with chronic refractory patellar tendinopathy and a further improvement was noted at six months, after physiotherapy was added. Moreover, comparable results were obtained with respect to the less severe cases in the EQ VAS score and pain level evaluation, as in time to recover and patient satisfaction, with an even higher improvement in the sport activity level achieved in the PRP group. The clinical results are encouraging, indicating that PRP injections have the potential to promote the achievement of a satisfactory clinical outcome, even in difficult cases with chronic refractory tendinopathy after previous classical treatments have failed.
PMCID: PMC2989009  PMID: 19641918
19.  Comparative study between mono-bundle bone-patellar tendon-bone, double-bundle hamstring and mono-bundle bone-patellar tendon-bone combined with a modified Lemaire extra-articular procedure in anterior cruciate ligament reconstruction 
International Orthopaedics  2012;37(2):193-199.
The aim of the study was to compare three different procedures performed by the same surgeon: mono-bundle patellar tendon reconstruction (bone-patellar tendon-bone, BPTB), double-bundle hamstring reconstruction (DBH) and mono-bundle patellar tendon combined with extra-articular reconstruction (Lemaire) (BPTB + L).
A total of 75 patients (25 in each group) were evaluated at a mean follow-up of 25 months. Laxity was assessed pre- and post-operatively with Telos™ stress radiographs (15 kg). The amount of anterior tibial translation (ATT) corrected by the surgery was quantified. Secondary outcomes were International Knee Documentation Committee (IKDC) scores, pivot shift grading, pain complaints, sensory deficits, subsequent surgical procedures, return to sports and patients’ ability to kneel or squat on their affected knee.
Absolute correction of ATT for the internal compartment was not statistically significant [analysis of variance (ANOVA), p = 0.377]. For the external compartment BPTB + L (8.2 mm) showed superiority over DBH (5.6 mm) and BPTB (4.1 mm) (ANOVA, p = 0.0001, Tukey’s test). Kneeling was better in the DBH group (ANOVA, p = 0.0001, Tukey’s test). In 22 patients it felt normal, while only in seven in the BPTB and eight in the BPTB + L groups. Sensory deficits were present in 11 patients from the DBH group, while in 17 in the BPTB and 19 in the BPTB + L groups (ANOVA, p = 0.052). Mean IKDC values, presence of anterior knee pain, subsequent operations, ability to squat and return to sports were not statistically different between groups.
Absolute correction of ATT was not statistically different for the medial compartment, but the patellar tendon reconstruction combined with the extra-articular procedure achieved the best lateral compartment ATT correction. Sensory deficits and kneeling seem to be worse in the groups where the patellar tendon is harvested.
PMCID: PMC3560891  PMID: 23180103
20.  Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players 
Background: Conservative treatment of patellar tendinopathy has been minimally investigated. Effective validated treatment protocols are required.
Methods: This was a prospective randomised controlled trial of 17 elite volleyball players with clinically diagnosed and imaging confirmed patellar tendinopathy. Participants were randomly assigned to one of two treatment groups: a decline group and a step group. The decline group were required to perform single leg squats on a 25° decline board, exercising into tendon pain and progressing their exercises with load. The step group performed single leg squats on a 10 cm step, exercising without tendon pain and progressing their exercises with speed then load. All participants completed a 12 week intervention programme during their preseason. Outcome measures used were the Victorian Institute of Sport Assessment (VISA) score for knee function and 100 mm visual analogue scale (VAS) for tendon pain with activity. Measures were taken throughout the intervention period and at 12 months.
Results: Both groups had improved significantly from baseline at 12 weeks and 12 months. Analysis of the likelihood of a 20 point improvement in VISA score at 12 months revealed a greater likelihood of clinical improvements in the decline group than the step group. VAS scores at 12 months did not differ between the groups.
Conclusions: Both exercise protocols improved pain and sporting function in volleyball players over 12 months. This study indicates that the decline squat protocol offers greater clinical gains during a rehabilitation programme for patellar tendinopathy in athletes who continue to train and play with pain.
PMCID: PMC1725109  PMID: 15665207
21.  Overload syndromes of the knee in adolescents: Sonographic findings 
Journal of Ultrasound  2008;11(4):151-157.
Overload syndromes are caused by repetitive microtrauma, and the knee joint is most frequently affected in adolescents. The reason for this is that the knee joint is engaged in almost all sports activities. Pathologies related to the anterior aspect of the knee are: femoropatellar pain, jumper's knee syndromes, Osgood–Schlatter disease, Sinding-Larsen–Johansson syndrome and patellar stress fractures; to the medial aspect: semimembranous tendon enthesopathy and pes anserinus bursitis; to the lateral aspect: iliotibial band syndrome (runner's knee), popliteus and femoral biceps tendon enthesopathy; to the posterior aspect: fabella syndrome and medial gastrocnemius muscle tendon enthesopathy. Sonography plays a central role in the diagnosis and can also evaluate the evolution of diseases. This method is well accepted by the patients and by their parents, it does not involve exposure to X-rays and it is inexpensive. US imaging should, therefore, be considered a first-line imaging diagnostic technique in functional overuse syndromes of the knee.
PMCID: PMC3552786  PMID: 23396316
Sonography; Knee; Overload syndromes
22.  Recurrent dislocation of the extensor carpi ulnaris tendon 
Five patients with recurrent dislocation of the extensor carpi ulnaris (ECU) tendon resulting from an athletic injury were treated by reconstruction of the ECU tendon sheath, and each had a satisfactory result. Two types of disruption of the fibro-osseous sheath were found. In two cases in which the fibro-osseous sheath ruptured radially, the torn sheath lay on its ulnar groove beneath the ECU tendon. These patients were treated by direct suture of the sheath over the ECU tendon. In three cases in which the fibro-osseous sheath ruptured ulnarly, the torn sheath lay superficial to the ECU tendon. These patients were treated by reconstruction of the sheath using a piece of the extensor retinaculum. We believe that surgical reconstruction of the fibro-oseous sheath of the ECU tendon should be considered for symptomatic dislocation of the ECU tendon, even in an acute case. 

PMCID: PMC1756093  PMID: 9631228
23.  Reconstruction of a ruptured patellar tendon using ipsilateral semitendinosus and gracilis tendons with preserved distal insertions: two case reports 
BMC Research Notes  2013;6:361.
Acute patellar tendon ruptures with poor tissue quality. Ruptures that have been neglected are difficult to repair. Several surgical techniques for the repair of the patellar tendon have been reported, however, these techniques remain difficult because of contractures, adhesions, and atrophy of the quadriceps muscle after surgery.
Case presentation
We report the cases of 2 Japanese patients (Case 1: a 16-year-old male and Case 2: a 43-year-old male) with patellar tendon ruptures who were treated by reconstruction using semitendinosus-gracilis (STG) tendons with preserved distal insertions. Retaining the original insertion of the STG appears to preserve its viability and provide the revascularization necessary to accelerate healing. Both tendons were placed in front of the patella, in a figure-of-eight fashion, providing stability to the patella.
Both patients recovered near normal strength and stability of the patellar tendon as well as restoration of function after the operation.
PMCID: PMC3844589  PMID: 24010848
24.  Giant cell tumor of the tendon sheath: A rare case in the left knee of a 15-year-old boy 
Oncology Letters  2012;3(3):718-720.
Localized forms of giant cell tumors are defined as giant cell tumors of the tendon sheath (GCTTS). GCTTS arises from the synovium of a joint, bursa or tendon sheath, and 85% of the tumors occur in the fingers. GCTTS in the knee is extremely rare. We report an unusual case of a 15-year-old boy who presented with an occult growing swelling and a 2-month history of infra-patellar pain in the left knee. Magnetic resonance imaging (MRI) demonstrated a well-circumscribed soft tissue mass in the infra-patellar fat pad posterior to the patella tendon. Excision biopsy was performed by surgical removal. Histopathological examination revealed that it was GCTTS. During the follow-up period, his recovery was propitious and there was no recurrence. Owing to its few and non-specific symptoms, and local recurrence varying from 9 to 44%, its proper, early diagnosis and appropriate treatment is necessary. The purpose for which we report the case is to emphasize the possibility of GCTTS where there is a mass with non-specific symptoms such as infra-patellar pain of the knee, and to avoid misdiagnosis where possible.
PMCID: PMC3362500  PMID: 22740982
giant cell tumor; knee; tendon sheath; diagnosis; histopathology; magnetic resonance imaging
25.  Combined rupture of the patellar tendon, anterior cruciate ligament and lateral 
Hippokratia  2011;15(2):178-180.
Simultaneous rupture of both the patellar tendon and the anterior cruciate ligament is a relatively rare injury. Its diagnosis can easily be missed during the initial examination. Treatment options include immediate repair of the patellar tendon with either simultaneous or delayed reconstruction of the ACL. We present the case of a combined rupture of the patellar tendon, the anterior cruciate ligament and the lateral meniscus in a 38-year old recreational martial arts athlete after a direct kick on his left knee. A two-stage treatment approach was performed with an excellent functional outcome.
PMCID: PMC3209685  PMID: 22110304
patellar tendon; anterior cruciate ligament; rupture; repair

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