What is the best approach to managing a high-grade partial-thickness tear involving the proximal patellar tendon?

Management of High-Grade Partial-Thickness Tear of the Proximal Patellar Tendon

Initial conservative management is recommended for high-grade partial-thickness tears of the proximal patellar tendon, with surgical intervention reserved for cases with tear thickness >50% or tendon thickness >11.5mm that fail to respond to conservative measures. 1, 2

Diagnostic Evaluation

• MRI is the gold standard imaging modality for evaluating patellar tendon tears, with high sensitivity (95%) and specificity (95%) for detecting tendon degeneration, partial tears, and chronic tendinopathy 3
• Ultrasound is a useful alternative with high specificity (94%) but lower sensitivity (58%), making it better at confirming rather than ruling out tendinopathy 3
• On axial MRI views, tendon thickness >8.8mm strongly correlates with the presence of a partial tear 1
• Most partial-thickness tears (91%) involve the posterior and posteromedial regions of the proximal patellar tendon 1

Conservative Management (First-Line Approach)

1. Relative Rest and Activity Modification

   • Reduce activities that cause pain while avoiding complete immobilization to prevent muscle atrophy 3
   • Continue activities that do not worsen symptoms 3

2. Pain Management

   • Cryotherapy (ice) for short-term pain relief, applied through a wet towel for 10-minute periods 3
   • NSAIDs for pain relief, though they may not affect long-term outcomes 3
   • Topical NSAIDs may provide pain relief with fewer systemic side effects 3

3. Rehabilitation Protocol

   • Eccentric strengthening exercises are strongly recommended to reduce symptoms, increase strength, and promote tendon healing 3
   • Tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers 3
   • Deep transverse friction massage may help reduce pain 3

4. Adjunctive Therapies

   • Extracorporeal shock wave therapy can be considered as a non-invasive treatment option 2
   • Platelet-rich plasma or bone marrow aspirate concentrate injections may be beneficial, though evidence is still evolving 2
   • Ultrasound-guided percutaneous tendon scraping with needle is an emerging treatment option 2

Surgical Management (For Refractory Cases)

Surgical intervention should be considered when:

• Conservative management fails after 3-6 months 3
• Tendon thickness >11.45mm on MRI 1
• Tear thickness >50% of the tendon 1, 2

Surgical options include:

• Open debridement of unhealthy proximal tendon and bone with closure of healthy tendon using absorbable sutures 2
• Arthroscopic debridement and repair 2
• Suture anchor repair when necessary 2

Outcomes and Return to Sport

• Over 90% of athletes return to sport following either conservative or surgical treatment 4
• Average time to return to sport is approximately 3.9 months 4
• Both open and arthroscopic approaches show favorable outcomes, with arthroscopic treatment potentially allowing faster recovery 5

Important Considerations and Pitfalls

• Avoid corticosteroid injections directly into the tendon substance as they may inhibit healing and reduce tensile strength, potentially predisposing to spontaneous rupture 3
• Complete immobilization should be avoided to prevent muscular atrophy and deconditioning 3
• Failure to recognize tear size and location may lead to inappropriate treatment selection; tears >50% thickness typically require surgical intervention 1
• Regular MRI monitoring of tendon thickness can help guide treatment decisions and predict response to conservative therapy 1