Dr Sommer Hammoud answers four questions about patellar tendon injuries, among other things.

[Related information can be found in the Orthopaedia chapter, Disorders of the Extensor Mechanism of the Knee]

ORTHOPAEDIA: Last year, there were three high profile cases of patellar tendon rupture: U.S. women’s national team star forward Mallory Swanson, Edwin Díaz, the star closer for the NY Mets and then Miami Heat guard Victor Oladipo.  What can amateurs --weekend warrior types, especially -- do to minimize their own risk of sustaining this injury?

Sommer Hammoud, MD: First off, I think it’s so important for patients to pay attention to what their body is telling them. Sometimes the message is “take it easy.”  Hopefully, these high profile cases help people remember that. Pain in front of the knee just below the kneecap –“anterior knee pain distal to the patella”, is the technical term–is one such instance where pulling back is the right response. Anterior knee pain distal to the patella  may reflect partial damage to the patellar tendon, and this must be allowed to heal. Rest, ice, and over the counter anti-inflammatories typically help, as they do for most sports related pain. But the treatment that’s particularly effect for patellar tendon disorders is so-called eccentric stretching and strengthening:  that is, stretching the tendon by flexing the knee against active resistance from the quads. Learning and maintaining proper technique is probably best done with a physical therapist.

ORTHOPAEDIA: Have there been any recent advancements in surgical techniques, rehabilitation protocols, or nutrition that have accelerated recovery for athletes recovering from patellar tendon rupture surgery? If not, what are the impediments? But if so, why are athletes like Swanson, Díaz and Oladipo out for so long?

Sommer Hammoud, MD: Unfortunately, for this type of injury and surgery, the recovery is quite long. There are certainly ways to augment a repair structurally, yet these methods have not been shown to accelerate the functional recovery–that is, speed up the “return to play” date. There are some basic biological steps that have to take place for full healing, and they occur in sequence. As students will learn, after repair, special cells called fibroblasts produce collagen­–the main structural protein in tendons– and that alone takes a few weeks to complete. Even then, things are not normal, as the new tissue is not disorganized and is weaker than normal tendon tissue.  Therefore, we need a next phase, so called “tissue remodeling,” when new collagen slowly matures and aligns itself along the lines of stress. This too takes time. But even the processes of biological healing is complete, the injured athlete has to regain muscle strength and neuromuscular control.   With all of that, it’s hard to imagine that we can shave much time off the period of recovery, especially given the risk of re-injury if one comes back too soon.

ORTHOPAEDIA: In your practice, when a patient experiences a tendon tear, do you typically investigate the condition of other tendons in their body as well? In patients like Miami Heat guard Victor Oladipo (who, the newspapers report, has had multiple major tendon injuries), would you ever consider preventative surgery on a tendon-at-risk? What factors contribute to the decision-making process for such interventions?

Sommer Hammoud, MD: Unless there is a strong, recent history of multiple tendon ruptures, which is quite unusual, further investigation is not warranted.  We may get information, but we would not know what to do with it!  To be sure, preventative surgery in the absence of symptoms is not indicated.  And I must stress that phrase, “in the absence of symptoms.” In some instances, as noted above, symptoms are actually a signal of partial damage and a harbinger of complete tears if ignored. Usually, the typical treatment of rest, ice, medication and physical therapy, are sufficient, but at times a procedure such as a debridement (surgically excising damaged tissue) is needed, and in a sense, this is a “preventative surgery” in terms of avoiding additional tearing. I would not consider surgery in an asymptomatic tendon.

ORTHOPAEDIA: According to a recent systematic review there is a “Gender Void” in the sports medicine literature on patellar tendon disorders, with females representing only 2% of cases reported. This void certainly could represent an omission on the part of researchers, a systematic clinicians' error (attributing symptoms to "anterior knee pain" or patellofemoral arthrosis) or a byproduct of studying athletes who play historically male-dominated sports such as football, baseball, wrestling, and hockey. On the other hand, perhaps there is a biological basis for this disparity. What has your clinical experience been, and where do you predict the future trends point?

Sommer Hammoud, MD: My clinical experience indicates that quadriceps tendon ruptures and patellar tendon ruptures happen very rarely in female patients. I think the research appropriately represents what most sports medicine specialists are seeing clinically. That said, it’s absolutely critical that research populations match the treatment populations. If research disproportionately represents one gender, age group, or demographic, it can lead to errors in our very understanding of these conditions. More to the point, only with representative research populations can be sure that our treatments are relevant and effective for everyone who may need them. This is especially vital in sports medicine, where sex-based physiological differences can significantly impact injury risk, presentation, and recovery.