Periarticular Tendinopathies of the Knee

Transcription

1 Periarticular Tendinopathies of the Knee 30 Federico Raggi, Tommaso Roberti di Sarsina, Federico Stefanelli, Alberto Grassi, Cecilia Signorelli, and Stefano Zaffagnini Contents 30.1 Tendonitis of the Quadriceps Tendon Anatomy Pathogenesis: Clinical Presentation Treatment Tendon Rupture Iliotibial Band (ITB) Syndrome The Iliotibial Band Anatomy Pathogenesis and Clinical Presentation Treatment Tendinopathy of the Popliteal Anatomy Popliteus Tendinitis Popliteus Subluxation Popliteus Tendon Rupture Semimembranosus Tendinitis Anatomy Pathogenesis: Clinical Presentation Treatment Tendinitis of the Goose Foot Anatomy Pathogenesis: Clinical Presentation Treatment 322 References 323 There are several knee diseases; the most cases during clinical practice concern meniscal and ligament lesions, but we must remember various disorders related to periarticular tendon inflammation, which can mime different conditions. A correct anamnesis and an accurate physical examination are fundamental to diagnose this kind of pathologies which, if untreated, can often become chronic Tendonitis of the Quadriceps Tendon Anatomy F. Raggi T. Roberti di Sarsina F. Stefanelli A. Grassi C. Signorelli S. Zaffagnini (*) Clinica Ortopedica e Traumatologica II, Laboratorio di Biomeccanica ed Innovazione Tecnologica, Istituto Ortopedici Rizzoli, via di Barbiano, 1/10, Bologna, Italy Dipartimento di Scienze Anatomiche Umane e Fisiopatologia dell Apparato Locomotore, Università di Bologna, Alma Mater Studiorum, Bologna, Italy federico.raggi@studio.unibo.it; tommaso. robertidisarsina@gmail.com; federico.stefanelli@ studio.unibo.it; alberto.grassi@ior.it; cecilia.signorelli@gmail.com; stefano.zaffagnini@ unibo.it The quadriceps tendon originates from the union of the four distal insertions of the femoral quadriceps muscle: the rectus femoris, the vastus lateralis, the vastus medialis, and the vastus intermedius. The most superficial fibers of the tendon, resulting from the rectus femoris, pass ahead the patella and continue with the patellar ligament which insertion is in the tibial tuberosity; the intermediate fibers of the tendon, originated by vastus lateralis and medialis, insert in the edge of the patella; the deep fibers, which originate from ISAKOS 2017 G.L. Canata et al. (eds.), Muscle and Tendon Injuries, DOI / _30 315

2 316 F. Raggi et al. the vastus intermedius, insert in the base of the patella. The tendon function connects the femoral quadriceps muscle, the most voluminous muscle mass of the body, to the patella, to allow the extension of the leg on the thigh, and with the rectus femoris, to flex the thigh on the pelvis Pathogenesis: Clinical Presentation Tendinopathy of the quadriceps tendon concerns especially patients who practice activities that include running, jumping, or however situations where the extensor apparatus is strongly stressed through intense and explosive contractions. The frequency of this disease is lower than the patellar tendinitis; probably the reason is the better vascularization of the quadriceps tendon and the lower mechanical stress which it is subjected during the activities. The main symptom is pain, localized just above the upper pole of the patella. Typically the onset of symptoms is insidious and often associated with a recent increase in physical activity; in some cases the pain can be mild, in others it can be so intense to force the athlete to stop the activities. Objectively, a tumefaction at the upper pole of the patella and pain at palpation in that spot can be observed; the extension of the leg on the thigh against resistance is painful. It s important to evaluate possible bad alignments of the lower limbs, defects of rotation, the tone of the quadriceps, and the motility of the knee. The clinical diagnosis is sufficient if there isn t a strength deficit in the extension of the leg, otherwise it is possible to use X-rays or MRI. Radiographies are often negative, especially in young athletes, while in older patients, there might be calcifications in the context of the tendon or an osteophyte at the upper pole of the patella. The MRI images show signs of tendon degeneration especially at the distal insertion of the quadriceps tendon (Fig. 30.1). Fig Tendinopathy of the distal insertion of quadriceps tendon 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 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,

3 30 Periarticular Tendinopathies of the Knee 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. 317 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 Iliotibial Band (ITB) Syndrome 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.

4 318 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) 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 F. Raggi et al. 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. Resonance can show an alteration of the signal at the distal insertion of the ITB (white arrow) and liquid between the deepest part of the band and the external femoral epicondyle (black arrow) (Fig. 30.2) (Orchard et al. 1996).

5 30 Periarticular Tendinopathies of the Knee 319 of the posterior fibers of band, in order to reduce the friction with the surface of the epicondyle (Martens et al. 1989) Tendinopathy of the Popliteal Anatomy Fig Edema and tension at the distal insertion of ITB 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. Surgery is necessary few times, only if good results are not obtained after 6 months of conservative treatment. The intervention consists in an inspection and a possible regularization of the bone surface of the lateral femoral epicondyle and s in a V incision Popliteus is a posterior muscle of the leg, the only one which does not reach the foot. It is composed of a muscle-tendon unit placed in the popliteal fossa deep to the plantar and gastrocnemius muscles. His tendon segment originates from the lateral femoral condyle forward the external collateral ligament; his fibers move down and medially and insert, with the muscular portion, on the oblique line and on the posterior face of the tibia. The popliteus muscle is connected to the fibula through the popliteal-fibular ligament that originates in the proximal fibula and ends near the muscle-tendon junction of the popliteus. This ligament is important to control the posterior translation of the tibia, the rotations, and the stability in varus. For this reason, injuries of popliteus tendon can affect the lateral posterior stability of the knee. The popliteus muscle intrarotates the tibia and participates at leg flexion (Noble 1980) Popliteus Tendinitis Tendinitis of the popliteus isn t a frequent pathology; it is an inflammatory process that affects the tendon in its insertion on the lateral femoral condyle. It affects especially runners, and its development is facilitated by running on sloped funds; the tendon is more stressed when the athlete slows down while he s running downhill. The popliteal tendinitis occurs with posterolateral knee pain, and symptoms are triggered by physical activity and, at least in the acute form, stop with rest. An excessive pronation of the foot constitutes a predisposing factor to the development of the disease.

6 320 Physical examination reveals pain with palpation of the tendon that is easier palpable with knee in position 4. The differential diagnosis should be made with lesions of the lateral meniscus or meniscal cysts, ITB syndrome, lateral collateral ligament injuries, and degenerative disorders of the lateral compartment of the knee. The MRI shows an alteration of the signal and edema in the popliteal hiatus (Figs and 30.4) and helps to exclude intraarticular pathologies or tendon rupture. Fig Edema and mild effusion in the popliteal hiatus People affected by the popliteal tendonitis are advised to suspend physical activity and taking NSAIDs at least for 2 weeks. If the symptoms persist, a therapeutic intervention-based infiltration with cortisone is considered. The athletes activities should be corrected avoiding paths on inclined bottoms Popliteus Subluxation F. Raggi et al. Subluxation of the popliteus tendon has been described in young athlete (Ober n.d.). The origin of the disease can be the result of a trauma in varus or hyperextension, or spontaneous. The subluxation of the tendon is appreciable by palpation at 20 and 30 of flexion as a jerk between the lateral femoral epicondyle and the external joint line during the passive extension of the leg associated with a varus stress. The MRI shows in these subjects no specific alterations of the tendon, and arthroscopy is not useful. The differential diagnosis should be made with the presence of a mobile body in the lateral compartment, hypermotility, or a lesion of the lateral meniscus. The treatment involves abstaining from physical activities and the use of NSAIDs. In refractory cases to conservative treatment, it can be performed by a tenodesis, anchoring the popliteal ligament to the proximal half of the lateral collateral Popliteus Tendon Rupture Fig Effusion in the muscle belly of the popliteus The isolated popliteus tendon rupture is an extremely rare event. Usually the tendon rupture is associated with a posterolateral acute or chronic instability due to complex PLC lesions. (Ekman et al. 1994). The rupture can be caused by a trauma of the leg in external rotation with the knee flexed or by a direct trauma, such as a kick received on the lateral side of the knee. The clinic is characterized by pain in the lateral compartment and hemarthrosis, in the absence of clinical signs of joint

7 30 Periarticular Tendinopathies of the Knee instability. The pain is elicited by asking the patient to intrarotate tibia against resistance or passively externally rotate the tibia at 90 of flexion. MRI is useful to confirm the diagnosis: the tendon appears detached from its femoral insertion, with an irregular profile, and a there is degradation of the signal due to edema surrounding. In most cases there is an osteochondral fragment due to the detachment of the tendon from its femoral insertion which can also be visible with X-rays. The surgery involves the repositioning of the fragment and tendon repair followed by a 4-week period of immobilization with a rigid support Semimembranosus Tendinitis Anatomy The semimembranosus muscle originates from the ischial tuberosity with a flattened tendon which continues in an equally flattened muscle. The muscle fibers descend long the posterolateral portion of the thigh and continue with a tendon, which splits in three parts at level of the knee. The first is directed to the medial condyle of the tibia, posteriorly to the medial collateral ligament; the second goes up on the posterior side of the knee joint capsule, arrives to the lateral femoral condyle, and represents the oblique popliteal ligament; the third is part of the fascia of the popliteal muscle. By its action the semimembranosus muscle extends the thigh on the pelvis, intrarotates the leg, and flexes it on the thigh Pathogenesis: Clinical Presentation The semimembranosus tendinitis includes an isolated primary form, in athletes, and a secondary form due to compensatory overload in patients with osteoarthrosis, meniscal degeneration, or pathologies of the patellofemoral joint (Martens et al. 1989). 321 The inflammatory process that causes the disease often concerns the lower part of the tendon, which inserts in the medial condyle of the tibia. During repeated flexion-extension movements, this portion of the tendon impinges on the medial femoral condyle, the internal tibial plateau, and the tendon of the semitendinosus muscle. This causes irritation of the fibers and consequent degeneration (Veltri et al. 1996). Valgus knee and an excessive pronation of the foot during running predispose to the development of the disease. The patient suffering semimembranosus tendinitis has pain in the posterior-medial compartment of the knee that gets worse during physical activity. Physical examination shows pain with palpation of the posterior-medial knee portion, just below the joint line. The differential diagnosis should be made with lesions or degeneration of the internal meniscus, lesions of the medial collateral ligament, and tendonitis of the goose foot. The last one is different because pain is localized anteriorly and distally. Particularly accurate in diagnosis is the scintigraphy which reveals an abnormal hyperaccumulation posteriorly to the medial tibial condyle, in correspondence of the tendon insertion (Martens et al. 1989). MRI is useful to exclude lesions or degenerative alterations of the internal meniscus Treatment The secondary semimembranosus tendinitis is treated after solving the primary joint disease. The treatment of the primary tendinitis consists in a period of abstention from physical activity, cryotherapy, stretching exercises, and NSAIDs. Surgery is recommended if the conservative treatment has not given the results after at least 3 months. The surgery consists in the isolation of the tendon, the opening of the sheath, and the execution of some longitudinal tenotomies. The insertion site is cut to promote bleeding, and finally the tendon is repositioned and sutured to the posterior side of the medial collateral ligament; in this

8 322 way the contact of the tendon with the internal tibial plateau during flexion-extension of the knee is reduced Tendinitis of the Goose Foot Anatomy The goose foot or pes anserinus is the insertion of the sartorius, gracilis, and semitendinosus muscles. It is located on the anterior-medial side of the proximal tibia, about 5 cm distally from the medial joint line. Its name originates from its structure, which resembles the membrane of goose s legs. Between these tendons and the medial collateral ligament there is an interposed bursa. The three muscles that end in the goose foot are mainly flexors but also participate to the internal rotation of the tibia and control of valgus deviations of the knee Pathogenesis: Clinical Presentation Goose foot tendinitis mainly affects long- distance runners, because it s an overload condition due to repeated rubbing of the tendons on the internal tibial condyle and the medial collateral ligament. It is not clear if the inflammatory process affects the tendon or the underlying bursa; however, the clinical presentation and the subsequent treatment of the two conditions coincides (Cooper 1999). In the rest of the population, the disease mainly affects overweight women between 50 and 80 years, diabetics, and patients with knee arthrosis (Guha et al. 2003; Raj et al. 1988). The knee valgus and flatfeet are risk factors for the development of the disease because they increase the tension of the tendons in their area of common insertion. The clinic is characterized by pain at the medial knee compartment that is typically exacerbated by ascending and descending the stairs or by rising from a chair. Objectively, there is pain with palpation in the anatomic insertion of the goose foot sometimes associated with edema. The diagnosis is essentially clinical; X-rays have little diagnostic significance, except in cases where there are radiographic signs of osteoarthrosis of the medial compartment or an osteophyte. MRI is useful in cases of acute bursitis of the goose foot associated with important presence of liquid in correspondence of the bursa but does not reveal characteristic changes in the majority of symptomatic individuals who have already received a clinical diagnosis. MRI is especially important for the differential diagnosis with lesions of the medial meniscus (sometimes clinically indistinguishable), osteoarthrosis of the medial compartment, semimembranosus tendinitis, or Baker s cyst Treatment F. Raggi et al. The treatment includes resting from sport, cryotherapy, stretching of the posterior muscles of the thigh, and the use of NSAIDs. Laser therapy and ultrasounds are indicated in order to reduce the inflammatory process. Any predisposing conditions such as valgus knee and flatfeet should be corrected, in diabetic patients it is necessary to achieve a better control of glycemic levels, and a weight reduction should be suggested in overweight subjects. If there isn t an improvement of the symptoms after days of rest and use of NSAIDs, a therapeutic intervention-based infiltration with cortisone can be practiced. In some rare cases unresponsive to the conservative treatment it may be necessary to perform a surgical drainage of the anserine bursa.

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