Extensor Mechanism Problems

The extensor mechanism comprises the quadriceps muscle, quadriceps tendon, patella, and patellar tendon. Differential diagnosis of problems in the extensor mechanism is broad, including muscle or tendon rupture, patellar fracture, patellar tendinopathy, patellofemoral syndrome, patellar instability, Osgood-Schlatter's disease, and symptomatic medial plica. Examination of patients with anterior knee pain or extensor mechanism problems should always include a careful evaluation of the lumbar spine and hip to rule out referred pain, as well as assessment of the antagonist hamstring muscles posteriorly. Hamstring tightness can exacerbate problems of tendinosis, patellofemoral syndrome, and instability.

If the patient presents with focal tenderness over the patellar tendon at the distal pole of the patella, or potentially at the quadriceps insertion onto the patella, the likely diagnosis is tendinosis. Numerous studies show that chronic repetitive overuse does not actually lead to inflammation of the tendon itself, but rather to a central degeneration or tendinosis of the fibers of the tendon (Fithian, 2002). Steroid injections into patellar tendinosis are highly discouraged because they may predispose the tendon to complete failure. Treatment protocols for patellar tendinosis, or "jumper's knee," should include hamstring stretching, quadriceps strengthening with eccentric loading, and occasionally the use of a counterforce brace such as a Cho-Pat strap (Fig. 30-27).

Alternative treatments, including deep friction massage, prolotherapy, platelet-rich plasma injections, topical anti-inflammatory drugs, ultrasonic waves, and radiofrequency (RF) probes, show mixed results. Although no RCTs have yet proved their efficacy, these modalities have had some success. Surgical intervention for debridement of the tendi-nosis is uncommon but may be necessary to provide long-term relief. In the skeletally immature patient, tenderness at the distal pole of the patella may represent an avulsion apophysitis called Sinding-Larsen-Johansson disease. If the skeletally immature patient has pain at the insertion of the patellar tendon on the tibia, the most likely diagnosis is an apophysitis of the tibial tubercle, or Osgood-Schlatter's disease. Both problems are more common during active phases of growth and are generally treated conservatively with rest, flexibility exercises, and gradual return to activity. Complete failure or rupture of the extensor mechanism at the patellar or quadriceps tendon requires surgical repair (Ilan et al., 2002).

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