Patellar tendonitis

[Guest guest]

Sherri - will phonophoresis help only the ligaments or will it go so far as to help a meniscus tear?Mark - we thought about a meniscus tear, but could not get a click consistently. I did feel a soft pop medially from time to time, but this did not elicit any pain so I decided it was just an external ligament snap. I have read that a torn meniscus will give a click only 50% of the time so it is still possible. Besides IA block, arthroscopy, and MRI, do you suggest any other methods to determine if it is a meniscal tear? If it is a meniscal tear do you routinely remove the entire meniscus, partial, or consider stem cell therapy?

Laurie - Under what circumstances do you use a splint? I understand building up the support system on the opposite side of the joint, but what's to keep the joint from rolling forward thru the over-stretched joint capsule and cranial side ligaments? Forgive my ignorance and lack of vision. I'm sitting in bed this morning contracting my gastroc and watching my heel pull up and my ankle extend, but it seems that my ankle resists anterior movement because of the tightness of the tissues on that side of the joint. Looking forward to learning what I'm missing. Thanks in advance for your reply.

To all - I didn't realize that the patient's name would appear on the rads and I'm attaching the radiology report and I can't seem to cover up the name on the report. Please ignore this. 

-- Christie Carlo, DVM, CCRT

1 of 1 Photo(s)

[Guest guest]

Hey Rick!So, firstly my thoughts on the thickening - are quite simply that with both the TPLO and TTA, the patellar tendon must be taking on an extra 'work load' to accommodate for the new directional pull of forces subsequent to either osteotomy technique. Some animals may deal with the new changes (and added work load) and 'thicken' in response - then normalize as PERHAPS the tensile strength of the units improves thereby requiring less 'size' of the units... and that some animals 'react' to the changes and/or are less resilient and adaptive to the changes and subsequently become painful during the added work-load phase. (THIS is the mechanism of 'injury' in tendinosis lesions... which is why I suggest that tendinosis be utilized as the descriptive term and/or be added to the thought process in regards to the underlying pathology in the dogs with patellar tendons that are thick and painful on palpation). Indeed ultrasonography or histopathology studies would be invaluable. My main point being, that we cannot ASSUME the pathology to be an 'itis'. We cannot assume inflammation based on 'tenderness on palpation' alone. There are many instances in the body and with various pathologies where this is not true. (So I'm just sayin' - is all)As to the terminology: Tendinopathy encompasses tendinosis, tendinitis, & paratendonitis.Desmopathy would indeed encompass any pathology of a LIGAMENT.And so the argument is: IS the patellar tendon / distal patellar ligament a TENDON or a LIGAMENT? I vote, based on use, function, and structure, that it is a tendon and so I would throw out there that the terms Desmitis, Desmopathy, Desmo-anything (I could not find Desmosis as a definable word in my medical dictionary) would be technically incorrect... and as such would POTENTIALLY lead us down and incorrect path for treatment. Let's say, I'm just thinking out loud on this one!Happy Sunday folks!Laurie

Interesting discussion!

Many of the postop TPLO and TTAs (I don't see many of the later) have an increase thickness appreciated in the distal patellar ligament (commonly referred to as patellar tendon) but I cannot recall the last time that I felt that was of clinical significance. However, if I were to localize pain to that area it would be significant. Two previous ultrasound studies, one on TPLO the other TTA, showed that a high number of postop patients have thickening of this structure that with time improved. The purpose of either study was not to determine clinical significance but the most recent study on TTA, dogs with complications or showing moderate to severe lameness were eliminated from the study and authors stated "the clinical impact of patellar desmopathy appears to be of questionable significance. Two dogs in the study did have histopathology and findings were consistent with patellar tendinosis in people.

However, when I attended TPLO certification course in Eugene, OR, shortly after Barclay Slocum's death, "patellar tendinitis" was described as a common source of postop complications. This complication was one of the factors leading to Dr. Slocum's recommendation of cage rest for 8 weeks postop and no rehab. From what I could learn, Dr. Slocum recognized pain in the patellar ligament area, in a high number of athletic dogs that started swimming very quickly postop, thus leading to his recommendation. I think that it was Dr. Slocum's observation that have led to much of the confusion that exists with this issue today, however, I am certain as innovative as he was, had he lived, he would have a greatly different view on postop rehab.

So I am somewhat of the opinion that Marc initially described separating tendinitis from tendinosis. With the limited information that is available there does appear to be a rather common postop thickening of this tendinous structure that is properly defined as a ligament since it connects the patellar to the tibial tuberosity ( the patella is described as a sesamoid bone and is encased in the tendon of the quadriceps). This thickening appears to be of little clinical significance in most cases and limited data indicates a non-inflammatory issue. Since this appears to resolve without therapy it would falsely make one think that many therapies may have validity. On the other hand if pain is in and around the structure in the postop period an inflammatory problem, tendinitis cannot be ruled out. Diagnostic ultrasound may provide some information to assist in differentiation.

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Laurie,

Regarding normenclature I consider tendon strain, tendinitis and tendinosis all to fit properly under the heading of tendinopathies, and desmitis would fit under the heading of desmopathy, is that correct?

Rick Wall

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RADIOGRAPHIC AND ULTRASONOGRAPHIC EVALUATION OF THE PATELLAR LIGAMENT FOLLOWING TIBIAL TUBEROSITY ADVANCEMENT

KAROLIN KU ̈ HN, STEFANIE OHLERTH, MARIANO MAKARA, MICHAEL HA ̈ SSIG, TOMAS G. GUERRERO

Effect of tibial tuberosity advancement (TTA) on the patellar ligament has not been described. Our purpose was to evaluate the patellar ligament radiographically and ultrasonographically before and after a TTA. Twenty-one stifles (20 dogs) were evaluated preoperatively (T0), and at six (n1â„418) (T1) and 16 weeks (n1â„417) (T2) postTTA. Radiographically, proximal and distal thickness of the patellar ligament was assessed and a ratio to the total length of the ligament was calculated to compensate for the magnification. Ultrasound evaluation included measurements of the transverse thickness and cross-sectional area at three different levels, as well as a subjective score of ligament changes. In comparison with T0, all radiographic and ultrasonographic measure- ments increased significantly, 6 weeks postoperatively (P ô°ƒ 0.04), and did not change 16 weeks postoperatively compared with T1. The subjective score worsened significantly from T0 to T1 and T0 to T2 (Po0.0001), and improved significantly from T1 to T2 (P 1â„4 0.02). Larger cage size was associated with a more severe increase in radiographic proximal thickness to total length ratio and ultrasonographic middle transverse area at both follow-up examinations (P ô°ƒ 0.02). Dogs in which arthrotomy was not performed appeared to have ultra- sonographically less changes. In conclusion, patellar desmopathy was a common postoperative sequel to TTA. Surgical trauma, arthrotomy, perfusion injury, complete vs. partial cranial cruciate ligament rupture, larger tibial advancement, postoperative activity or altered insertion angle of the patellar ligament at the tibial tuberosity are suggested causes, that should be elucidated in a larger study cohort. r 2011 Veterinary Radiology & Ultrasound, Vol. 52, No. 4, 2011, pp 466–471.

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Laurie Edge-, BScPT, MAnimSt(Animal Physio), CAFCI, CCRTCo-Owner,The Canine Fitness Centre Ltd.Calgary, AB, Canadawww.caninefitness.comCEO,Four Leg Rehab Inc.Past-Chair,The Animal Rehab DivisionThe Canadian Physiotherapy Associationwww.animalptcanada.comInstructor,The Canine Rehab Institutewww.caninerehabinstitute.comGuest Lecturer,Faculty of Veterinary MedicineThe University of Calgarywww.vet.ucalgary.caVice-President,International Association of Physical Therapists in Animal PracticeWorld Confederation for Physical Therapywww.wcpt.org

[Guest guest]

Christie,I am miffed by this. I have yet to see a case or consult a case postop TTA pat. tendonitis-p not sure why you are seeing them Freedman VMD CCRTVIN Associate Editor Orthopedics

 

I believe I am seeing some patients with patellar tendonitis. The leg that is affected is the leg that previously had a TTA. I am seeing these patients at various times post-sx up to almost a year later. I am not finding iliopsoas or sartorius pain. Only pain with palpation on or beside the patellar ligament on the cranial aspect of the stifle joint. ROM seems ok, but just sore mostly with flexion.

I have been treating these with laser therapy, exercise restriction, and pain medications (NSAIDs, Tramadol, Gabapentin) and then when improvement is seen gradually adding weight bearing exercises and increasing into strength over time. This would be a similar protocol for iliopsoas strains.

Other ideas or suggestions?

Christie Carlo, DVM, CCRT

-- Regards,