What is the recommended treatment for a 26-year-old male with a mountain biking injury, presenting with increased swelling to the knee, patella alta, and an Insall-Salvati ratio of 2, concerning for patellar tendon injury?

Management of Patellar Tendon Injury in a 26-Year-Old Male Mountain Biker

Immediate surgical consultation is strongly recommended for this patient with patella alta and an Insall-Salvati ratio of 2, which strongly suggests a complete patellar tendon rupture requiring prompt surgical repair.

Clinical Assessment and Diagnosis

• The patient's presentation is highly concerning for patellar tendon rupture:

  • Recent mountain biking injury (2 days ago)
  • Increased knee swelling
  • Patella alta on X-ray
  • Insall-Salvati ratio of 2 (normal is ≤1.2)

• Patella alta is a key radiographic finding in patellar tendon ruptures 1

• An Insall-Salvati ratio of 2 (significantly above the normal upper limit of 1.2) strongly suggests complete or high-grade partial patellar tendon rupture

Immediate Management

1. Avoid weight-bearing activities that cause pain 2
2. Apply cold therapy (ice with water in a damp cloth) for 20-30 minutes, 3-4 times daily for pain and swelling 2
3. Consider compression wrap for comfort while awaiting definitive treatment 2
4. Urgent orthopedic consultation for surgical evaluation

Rationale for Surgical Management

• Patellar tendon ruptures represent the final stage of tendinopathy from repetitive microtrauma or acute injury 3
• Prompt surgical management is key to regaining normal function of the extensor mechanism 1
• The prognosis after patellar tendon rupture depends largely on the interval between injury and repair, with early surgery recommended for optimal results 3
• Patients with patellar tendon thickness >11.5 mm and/or >50% tear thickness on axial MRI are less likely to improve with nonoperative treatment 4

Surgical Approach

• Repair typically involves:
  • Reapproximation of the ruptured tendon ends
  • Repair of torn extensor retinacula
  • Placement of reinforcing cerclage suture 3
• Modern techniques use nonabsorbable high-strength sutures or suture tape in running locking fashion along the injured tendon, secured to the patella with bone tunnels or suture anchors 5
• Biomechanical testing shows no significant difference between transosseous and anchor techniques in load to failure, though anchors may have less gap formation at the repair site 5

Post-Surgical Rehabilitation

• Rehabilitation can typically begin immediately after surgical repair with:
  • Protected weight-bearing in an orthosis
  • Safe-zone knee passive range of motion
  • Avoidance of active extension 5
• After 6 weeks, rehabilitation can progress to:
  • Full range of motion exercises
  • Concentric strengthening program 5
• Most patients fully recover within 3-6 months with appropriate treatment 6

Cautions and Pitfalls

1. Avoid delay in surgical consultation: Delayed repair risks compromised outcomes including loss of full knee flexion and decreased quadriceps strength 3
2. Do not miss bilateral injuries: While this patient has unilateral findings, bilateral patellar tendon ruptures can occur
3. Consider MRI for complete evaluation: MRI can confirm the diagnosis and evaluate the extent of the tear 4
4. Be aware of risk factors: Patellar tendon ruptures may be associated with systemic illness, fluoroquinolone therapy, or chronic degeneration within the tendon 1

Follow-up Recommendations

• Close monitoring of surgical site healing
• Adherence to rehabilitation protocol
• Gradual return to activities based on functional milestones
• Assessment of criteria for return to sport: pain resolution, full ROM, strength symmetry >90% compared to uninjured side, and successful completion of sport-specific functional tests 6