What is the treatment approach for patients with severe patellar tendinitis who have not responded to conservative treatments, possibly requiring surgery?

Surgical Management of Patellar Tendinitis

Surgery for patellar tendinitis should only be considered after 3-6 months of well-managed conservative treatment has failed to provide symptom relief. 1

Conservative Management First

Before considering surgical intervention, patients should undergo comprehensive conservative treatment including:

1. First-line treatments:

   • Eccentric exercise therapy (cornerstone of rehabilitation)
   • Activity modification
   • NSAIDs for pain control
   • Physical therapy with stretching exercises

2. Second-line treatments:

   • Corticosteroid injections (local site)
   • Deep transverse friction massage
   • Sport-specific exercises

Conservative management should be attempted for at least 3-6 months before considering surgical options, as recommended by the American College of Rheumatology 1.

Surgical Indications

Surgery may be appropriate when:

• Symptoms persist despite 3-6 months of comprehensive conservative treatment
• Patient has marked functional limitations affecting quality of life
• Imaging confirms significant tendon pathology
• Patient is motivated to comply with post-surgical rehabilitation

Surgical Approach

The surgical procedure typically involves:

1. Diagnostic arthroscopy to evaluate the knee joint and rule out other pathologies
2. Open repair consisting of:
   • Excision of degenerated tendon tissue
   • Longitudinal tenotomies to release areas of scarring and fibrosis
   • Stimulation of healing response in the pathological area of the patellar tendon 2

Operative findings typically show marked fibrotendinous degeneration, which is confirmed by pathology reports 2.

Surgical Outcomes

Research shows promising results for appropriately selected patients:

• 86% of patients achieved excellent results in one study with 3.6-year follow-up 2
• Most professional and collegiate athletes were able to return to previous level of competition

Post-Surgical Rehabilitation

Rehabilitation following surgery should progress through several stages:

1. Range of motion (early phase)
2. Progressive strengthening
3. Flexibility training
4. Sport-specific exercises
5. Cardiovascular conditioning
6. Gradual return to play 3

Important Considerations

• Patient selection is critical: While 86% of patients in one study achieved excellent results, there is still limited evidence for identifying which patients will respond best to surgery 2, 4
• Rehabilitation is essential: Post-surgical management is as important as the procedure itself for successful outcomes 3
• Return to sport timeline: Expect a gradual progression, with full return typically taking several months
• Special populations: Diabetic patients and those with rheumatoid arthritis may require modified approaches 1

Potential Risks

• Surgical complications (infection, bleeding)
• Persistent pain or stiffness
• Need for additional procedures
• Delayed return to activity
• Incomplete resolution of symptoms

Conclusion

While eccentric training and other conservative measures remain the first-line treatment for patellar tendinitis 5, surgical intervention can be effective for carefully selected patients with chronic, recalcitrant symptoms. The decision for surgery should be made after thorough discussion of risks, benefits, and expected outcomes, with realistic expectations for recovery timeline and return to activity.