Partial tears: Acute versus chronic
The term 'partial tear' is used to refer to either of two clinical entities. One use refers to the sudden significantly painful episode, associated with disability, and this corresponds to a substantial tear in collagen of the patellar tendon. This 'acute' partial tear is not dissimilar to a complete 'rupture' of the tendon (Fig 24.18a), except that some tendon remains intact. This is discussed in Chapter 23. If the partial tear is very large, causes major disability, and there is no improvement in 2-3 weeks, early surgery may be justified to promote anatomical realignment of the tendon.
A small partial tear of the patellar tendon (Figure 24.18) may also occur and this is often first diagnosed at ultrasonography. This may be associated with an acute onset of mild to moderate pain over the patellar tendon but it may present as patellar tendinopathy (see above). Alternatively, it may be an incidental finding on ultrasound examination. This type of partial tear represents a degenerative process (tendinosis) and as the histopathology is identical to that of overuse patellar tendinopathy it can be managed as such [35]. The only indication for surgery is failed conservative management.
Less common causes
Synovial plica
The importance of the synovial plica, a synovial fold found along the medial edge of the patella, has been a matter of considerable debate. An inflamed plica may cause variable sharp pain located anteriorly, medially or posteriorly. The patient may complain of sharp pain on squatting. On examination, the plica is sometimes palpable as a thickened band under the medial border of the patella. It should only be considered as the primary cause of the patient's symptoms when the patient fails to respond to appropriate management of patellofemoral syndrome. In this case, and in the presence of a tender thickened band, arthroscopy should be performed and the synovial plica removed.
Osgood-Schlatter disease
Osgood-Schlatter disease is an osteochondrosis (Chapter 35) which occurs at the tibial tuberosity. This is a common condition in girls of around 10-12 and boys of around 13-15 years (but these ages vary) and results from excessive traction on the soft apophysis of the tibial tuberosity by the powerful patellar tendon. It occurs in association with high levels of activity during a period of rapid growth.
Treatment consists or reassurance that the condition is self-limiting and correcting underlying biomechanical abnormalities. Whether or not to play sport depends on the severity of symptoms. Children with mild symptoms may wish to continue to play some or all sport - others may chose some modification of their programs. If the child prefers to cease sport because of pain that should be supported. However, the amount of sport played does not seem to affect the time the condition takes to heal.
Sinding-Larsen--Johansson syndrome
This syndrome is one of the group of osteochondroses found in adolescents (Chapter 35). It is an important differential diagnosis in young patients with pain at the inferior pole of the patella. Treatment is outlined in Chapter 35.
Quadriceps tendinopathy
Pain arising at the quadriceps tendon at its attachment to the patella occurs occasionally, mainly in the older athlete. It is characterized by tenderness along the superior margin of the patella and pain on resisted quadriceps contraction. Treatment follows the same principles as treatment of patellar tendinopathy. Differential diagnosis is suprapatellar pain of patellofemoral joint origin.
This condition responds well to self-applied transverse friction massage to the direct site of pain. Correction of focal thickening in the quadriceps muscle is also required and is achieved with sustained myofascial tension, transverse glides and stretching.
Bursitis
There are a number of bursae around the knee joint. These are shown in Figure 24.19. The most commonly affected bursa is the pre-patellar bursa. Pre-patellar bursitis ('housemaid's knee') presents as a superficial swelling on the anterior aspect of the knee. This must be differentiated from an effusion of the knee joint. Infrapatellar bursitis can also cause anterior knee pain that may mimic patellar tendinopathy but can be differentiated by careful palpation for maximal tenderness.
  Fig. 24.17
Treatment of mild cases of bursitis includes NSAIDs and firm compression bandage. More severe cases require aspiration and infiltration with a corticosteroid agent and local anesthesia, followed by firm compression bandaging and rest for 48 hours. If, despite these measures, there are several recurrences, surgical bursectomy may be required.
Stress fracture of the patella
Stress fracture of the patella is a rare injury that occurs in jumping sports. It may have an insidious onset or an acute onset after a history of chronic knee pain. The clinical findings include intense localized tenderness over the patella. Most patellar stress fractures are of the transverse type; however, lateral longitudinal fractures occasionally occur. It may be difficult to distinguish this fracture radiographically from a bipartite patella; however, the fracture line tends to be more oblique than the bipartite patella.
RECOMMENDED READING
Gresalmer R, McConnell J. The patella: A team approach. Gaithersburg, Maryland: Aspen Publications, 1998
Józsa L, Kannus P. Human tendons. Champaign, Illinois: Human Kinetics, 1997:576.
McConnell J. Patellofemoral pain and soft tissue injuries. In: Magee, Quillan, Zachazewski, ed. Athletic injuries and rehabilitation. New York: Saunders, 1996:
Thomee R, Augustsson J, Karlsson J. Patellofemoral pain syndrome. A review of current issues. Sports Med 1999;28:245-262.
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Partial tears: Acute versus chronic
