Angiotensin II receptor blockers (ARBs) and angiotensin-converting enzyme inhibitors (ACEIs) are two such drugs commonly used to treat patients with hypertension. As generic ARBs have hit the market, many providers and patients are turning to ARBs over ACEIs owing to their similar effectiveness and improved tolerability. Evidence suggesting that ARBs have other benefits over ACEIs might really tip the scales in the favor of ARBs. Of note, researchers have postulated that ARBs might play a role in decreasing cognitive decline as a result of vascular changes in both hypertension and dementia.[1] Observational studies and prospective clinical trials have investigated this potential neuroprotective benefit and found slight improvements in cognitive function with ARBs relative to other antihypertensive drugs.[2,3,4,5,6,7,8,9]
Snapshot of Selected Studies
Li and colleagues[3] evaluated the incidence of dementia and the rate of disease progression among hypertensive patients aged 65 years or older (n = 819,491) taking ARBs, lisinopril, or other cardiovascular comparators (eg, beta-blockers, calcium-channel blockers). Patients were followed over a 4-year period, with results adjusted for age, diabetes, stroke, and cardiovascular disease. In patients without a prior diagnosis of Alzheimer disease or dementia, the use of ARBs was associated with a 19% lower risk of developing Alzheimer disease or dementia versus lisinopril; compared with other antihypertensives, the risk was 16% lower for Alzheimer disease and 24% lower for dementia. In addition, ARB use was associated with a significantly lower risk for nursing home admissions and death compared with lisinopril and other antihypertensive drugs.
Goh and colleagues[4] compared the risk for dementia among patients (n = 426,089) receiving therapy with ACEIs or ARBs. Almost all patients were being treated for hypertension, and about 75% were older than 55 years and did not have diabetes. Compared with ACEIs, use of an ARB was associated with an 8% reduction in the risk for dementia in the adjusted analysis. The impact of ARB exposure on dementia diagnoses was most apparent within the first year, as their use was associated with a 40% lower risk for dementia versus ACEIs during this time frame. However, no long-term neuroprotective benefit was observed beyond 3 years of therapy.
More recently, Ho and colleagues[5] examined whether the use of ARBs was associated with improved memory preservation compared with the use of other antihypertensive drugs. A total of 1626 adults without dementia aged 55-91 years were included. Researchers assessed data from three groups: hypertensive patients treated with ARBs, hypertensive patients treated with other antihypertensives, and patients without hypertension. In general, over 3 years of follow-up, hypertensive patients in the non-ARB group had worse cognitive outcomes compared with both normotensive patients and hypertensive patients treated with ARBs, whereas hypertensive patients treated with ARBs had similar improvements in short- and long-term memory compared with normotensive patients. In addition, patients using blood-brain barrier (BBB)–crossing ARBs (ie, valsartan, telmisartan, and candesartan) were compared with those using non-BBB–crossing ARBs. Users of BBB-crossing ARBs had improved long-term memory-related outcomes and a smaller volume of white-matter hyperintensities. The researchers concluded that ARBs, particularly BBB-crossing ARBs such as valsartan, telmisartan, andcandesartan, are probably associated with greater memory preservation and less white-matter volume than other antihypertensive medications.
Potential Neuroprotective Mechanism
To further explain the potential neuroprotective mechanism, recall that the renin-angiotensin-aldosterone system (RAAS) has effects on the pathophysiology of dementia through other mechanisms outside of the effects on cerebral blood flow and vascular resistance. These mechanisms include tau phosphorylation, amyloid metabolism, and oxidative stress. In addition, angiotensin II blocks the release of acetylcholine in cholinergic neurons, adding to the neurodegenerative effect seen in Alzheimer disease.[2] These additional mechanisms help explain why RAAS blockade is superior to blood pressure control alone for improving cognition-related outcomes.
In addition, two types of angiotensin II receptor exist in humans. ARBs only block activity at the damaging angiotensin II receptor type 1 (AT1), whereas ACEIs reduce receptor activity at both the damaging AT1 receptor and the beneficial AT2 receptor. Therefore, some have suggested that ARBs provide a neuroprotective effect for memory, whereas ACEIs may have paradoxical neurotoxicity.[10]
Also of note, a clinical trial is actively recruiting patients aged 65-80 years with a family history of dementia to evaluate the effects of aerobic exercise and pharmacologic treatment (ie, losartan, amlodipine, atorvastatin) on the risk for Alzheimer disease. Hopefully, these results will help to further clarify the benefit of ARBs in memory preservation and dementia prevention.
Multiple studies show a statistical correlation between memory preservation and the use of ARBs in patients with hypertension. And although no large-scale prospective, randomized, controlled studies have defined the magnitude of cognitive decline (or preservation) with ARBs relative to other antihypertensive drugs, it seems prudent to start patients with hypertension or diabetes and a strong family history of dementia on therapy with ARBs versus ACEIs or other antihypertensive drugs. Unfortunately, the widespread recalls of popular ARBs contaminated with the potential carcinogen N-methylnitrosobutyric acid has limited the number of ARBs available for patients initiating or switching to this class. If this issue is resolved, it seems likely that the popularity of ARBs over ACEIs will continue to grow. However, any therapy should be individualized and tempered by other compelling concurrent disease state considerations.
Patellofemoral pain syndrome vs. chondromalacia patellae
Chondromalacia patellae is a term sometimes treated synonymously with PFPS.[3] However, there is general consensus that PFPS applies only to individuals without cartilage damage,[3] thereby distinguishing it from chondromalacia patellae, a condition characterized by softening of the patellar articular cartilage.[1] Despite this academic distinction, the diagnosis of PFPS is typically made clinically, based only on the history and physical examination rather than on the results of any medical imaging. Therefore, it is unknown whether most persons with a diagnosis of PFPS have cartilage damage or not, making the difference between PFPS and chondromalacia theoretical rather than practical.[3] It is thought that only some individuals with anterior knee pain will have true chondromalacia patellae.[1]
Symptoms
The most common symptom of patellofemoral pain syndrome is a dull, aching pain in the front of the knee. This pain—which usually begins gradually and is frequently activity-related—may be present in one or both knees. Other common symptoms include:
Pain during exercise and activities that repeatedly bend the knee, such as climbing stairs, running, jumping, or squatting.
Pain after sitting for a long period of time with your knees bent, such as one does in a movie theater or when riding on an airplane.
Pain related to a change in activity level or intensity, playing surface, or equipment.
Popping or crackling sounds in your knee when climbing stairs or when standing up after prolonged sitting.
The symptoms of chondromalacia patella are usually pain in the front of the knee that is aggravated by going up and down stairs, sitting for long periods of time with the knees bent (such as in a movie) and when doing deep knee bends.
Mechanism
In this syndrome, the pain is usually the result of the kneecap not tracking smoothly in the groove of the femur (the underlying thighbone) when the leg is being bent and straightened. Kneecap pain can be caused by any imbalance or dysfunction of the stabilising forces that keep the kneecap tracking smoothly in this groove, or by damage to the back surface of the kneecap.
Causes
A combination of factors may result in the kneecap not tracking smoothly, including:
Overly tight thigh (hamstring or quadriceps) muscles;
Tightness of the iliotibial band (the strong band of thick tissue running down the outside of the thigh), which pulls the kneecap outwards;
Weakness of the inner thigh muscles (adductors);
Weakness of one of the buttock muscles which stabilise the pelvis, called the gluteus medius;
Weakness or delayed contraction of one of the large quadriceps muscles, such as the vastus medialis obliquus;
Faulty biomechanics, such as excessive pronation (rolling in of the foot during the walking cycle;
Swelling of the joint, due to an injury or wear and tear in the joint, will also cause reduced function in the quadriceps muscles, and this can result in anterior knee pain; and
Osteoarthritis of the patellofemoral joint may cause anterior knee pain.
Often the pain develops as an overuse injury seen in long-distance runners or cyclists, or it may be initiated by a twisting injury to the knee, or even as a result of lunging or squatting.
When the knee moves, the kneecap (patella) slides to remain in contact with the lower end of the thigh bone (trochlear groove of the femur). Normally, this motion has almost no friction: the friction between these two joint surfaces is approximately 20% the friction of ice sliding against ice. If the patella and /or femur joint surface (articular cartilage) becomes softened or irregular, the friction increases. Grinding or crepitus that can be heard or felt when the knee moves is the result. This condition in which there is patellofemoral crepitus is called chondromalacia patella or patellofemoral syndrome.
The force, or pressure, with which the patella pushes against the femur is 1.8 times body weight with each step when walking on a level surface. When climbing up stairs, the force is 3.5 times body weight and when going down stairs it is 5 times body weight. When running or landing from a jump the patellofemoral force can exceed 10 or 12 times body weight.
Pressure between the patella and femur is minimized when the knee is straight or only slightly bent. Exercises and activities that require deep knee bending, jumping and landing , pushing or pulling heavy loads and stopping and starting will place very high stresses on the patellofemoral joint and the patellar tendon.
Imaging Studies
See the list below:
Imaging studies usually are not necessary in order for a physician to diagnose or recommend treatment for patellofemoral syndrome (PFS). Imaging studies should be considered for unusual presentations and for persons in whom the syndrome is refractory to conservative management.
Skyline views should be included with anterior-posterior (AP) and lateral radiographic imaging of the knee. Limited positions of flexion are available for such viewing. These radiographs provide more of an indirect observation of what is happening within the articulation.
Lateral patellar tilt and a high-riding patella (patella alta) may be observed.
Osteophytes or joint space narrowing may be identified, suggesting arthritic changes in the articular cartilage. [6]
Nuclear scans are less likely to be of value in defining PFS and are more useful in helping to identify other, less common conditions that may mimic PFS, as outlined in the differential diagnoses. When changes have occurred in the retropatellar cartilage, mild increases in uptake of radionucleotide may be observed. Increased uptake of radionucleotide is not limited to the patella; it may be seen in the proximal tibia, distal femur, or patella. [7]
Computed tomography (CT) scanning and magnetic resonance imaging (MRI)
CT scanning and MRI allow for imaging at various angles of flexion.
CT scanning with the knee in full extension has been demonstrated to more accurately detect patellar subluxation.
Cross-sectional viewing allows more direct visualization of the articulation between the patella and femur.
Schutzer et al identified 3 patterns of malalignment using CT scanning [8] :
Type 1 includes patellar subluxation without tilt.
Type 2 is described as patellar subluxation with tilt.
Type 3 is patellar tilt without subluxation.
Treatment
How is it treated?
Patellofemoral pain syndrome can be relieved by avoiding activities that make symptoms worse.
Avoid sitting, squatting, or kneeling in the bent-knee position for long periods of time.
Adjust a bicycle or exercise bike so that the resistance is not too great and the seat is at an appropriate height. The rider should be able to spin the pedals of an exercise bike without shifting weight from side to side. And the rider’s legs should not be fully extended at the lowest part of the pedal stroke.
Avoid bent-knee exercises, such as squats or deep knee bends.
Other methods to relieve pain include:
Taking nonprescription anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, to decrease swelling, stiffness, and pain. Be safe with medicines. Read and follow all instructions on the label.
Ice and rest. You can also try heat to see if it helps.
Physical therapy exercises. Exercises may include stretching to increase flexibility and decrease tightness around the knee, and straight-leg raises and other exercises to strengthen the quadriceps muscle.
Taping or using a brace to stabilize the kneecap.
Surgery.
Short-term
Initial treatment may involve taping of the kneecap to hold it in a more ideal position to relieve pain. A sports doctor or physiotherapist will be able to show you how to tape the knee correctly to pull it back into alignment.
Simple pain relief medicine such as paracetamol and sometimes a non-steroidal anti-inflammatory drug (NSAID) may also help.
When the symptoms first develop they are best treated by icing the knee for 10-20 minutes after activity.
It is also advisable to avoid any activities that exacerbate the pain.
Long-term
Rehabilitation involving stretching and strengthening exercises for specific muscles to achieve correct balance of the stabilising muscles around the kneecap.
Strengthening of stabilising buttock muscles, that when activating properly, enable the muscles about the knee to function more effectively.
Orthotics are useful for those with biomechanical abnormalities, particularly excessive pronation of the foot (rolling in).
Your doctor or physiotherapist may design an individual exercise programme for you. Such a programme will include a graded increase in activity. It is important to do these exercises on a daily basis to maximise the chance of recovery, which will generally take about 6 weeks.
If there is significant swelling of the knee, further assessment and investigation will be needed.
The best treatment for patellofemoral syndrome is to avoid activities that compress the patella against the femur with force. This means avoiding going up and down stairs and hills, deep knee bends, kneeling, step-aerobics and high impact aerobics. Do not wear high heeled shoes. Do not do exercises sitting on the edge of a table lifting leg weights (knee extension). An elastic knee support that has a central opening cut out for the kneecap sometimes helps. Applying ice packs for 20 minutes after exercising helps. Aspirin, Aleve or Advil sometimes helps.
Patellofemoral Pain Syndrome Treatment
Approximately 90% of patello-femoral syndrome sufferers will be pain-free within six weeks of starting a physiotherapist guided rehabilitation program for patellofemoral pain syndrome.
For those who fail to respond, surgery may be required to repair associated injuries such as severely damaged or arthritic joint surfaces.
The aim of treatment is to reduce your pain and inflammation in the short-term and, then more importantly, correct the cause to prevent it returning in the long-term.
As with most soft tissue injuries the initial treatment is – Rest, Ice and Protection.
Anti-inflammatory medication is often recommended to reduce pain.
Phase 2: Restore Full Muscle Length
It is important to regain normal muscle length to improve your lower limb biomechanics.
A specific stretching program is prescribed in this phase of treatment to address any muscle length issues,
Phase 3: Normalise Quadriceps Muscle Balance
In order to prevent a recurrence, the quadriceps muscle balance and its effect on the patellar tracking will be addressed in this stage via a specific knee strengthening program
Phase 4 : Normalise Foot & Hip Biomechanics
Patellofemoral pain syndrome can occur from poor foot biomechanics (eg flat foot) or poor hip control.
To prevent a recurrence, your foot and hip control will be addressed.
In some instances, you may require a foot orthotics and footwear changes to control abnormal foot and leg biomechanics along with a hip stabilisation program.
Epidemiology /Etiology
PFPS can be due to a patellar trauma, but it is more often a combination of several factors (multifactorial causes): overuse and overload of the patellofemoral joint, anatomical or biomechanical abnormalities, muscular weakness, imbalance or dysfunction. It’s more likely that PFPS is worsened and resistive to treatment because of several of these factors.
One of the main causes of PFPS is the patellar orientation and alignment. (fig.1) When the patella has a different orientation, it may glide more to one side of the facies patellaris (femur) and thus can cause overuse/overload (overpressure) on that part of the femur which can result in pain, discomfort or irritation. There are different causes that can provoke such deviations.
The patellar orientation varies from one patient to another; it can also be different from
Patella Glidings.png
the left to right knee in the same individual and can be a result of anatomical malalignments. A little deviation of the patella can cause muscular imbalances, biomechanical abnormalities … which can possibly result in PFPS. Conversely, muscular imbalances or biomechanical abnormality can cause a patellar deviation and also provoke PFPS. For example:
When the Vastus Medialis Obliquus isn’t strong enough, the Vastus Lateralis can exert a higher force and can cause a lateral glide, lateral tilt or lateral rotation of the patella which can cause an overuse of the lateral side of the facies patellaris and result in pain or discomfort. The opposite is possible but a medial glide, tilt or rotation is rare. Another muscle and ligament that can cause a patellar deviation is the iliotibial band or the lateral retinaculum in case there is an imbalance or weakness in one of these structures. (see table1)
PFPS can also be due to knee hyperextension, lateral tibial torsion, genu valgum or varus, increased Q-angle, tightness in the iliotibial band, hamstrings or gastrocnemius.
Sometimes the pain and discomfort is localized in the knee, but the source of the problem is somewhere else. A pes planus (pronation) or a Pes Cavus (supination) can provoke PFPS. Foot pronation (which is more common with PFPS) causes a compensatory internal rotation of the tibia or femur that upsets the patellofemoral mechanism. Foot supination provides less cushioning for the leg when it strikes the ground so more stress is placed on the patellofemoral mechanism.
The hip kinematics can also influence the knee and provoke PFPS. A study has shown that patients with PFPS displayed weaker hip abductor muscles that were associated with an increase in hip adduction during running.
Table 1
Muscular etiologies of PFPS
Etiology
Pathophysiology
Weakness in the quadriceps
It may adversly affect the PF mechanism.
Strengthening is often recommended.
Weakness in the medial quadriceps
It allows the patella to track too far laterally.
Strengthening of the VMO is often recommended.
Tight iliotibial band
It places excessive lateral force on the patella and can
also externally rotate the tibia, upsetting the balance
of the PF mechanism.
This can lead to excessive lateral tracking of the patella.
Tight hamstrings muscles
It places more posterior force on the knee, causing
pressure between the patella and the femur to increase.
Weakness of tightness in the hip muscles
Dysfunction of the hip external rotators results in
compensatory foot pronation.
Tight calf muscles
It can lead to compensatory foot pronation and can
increase the posterior force on the knee.
Activity modification
As overuse of the knee is a primary contributing factor to patellofemoral syndrome, activity modification is one way to reduce further damage to the knee and prevent a recurrence of the condition.
People who experience patellofemoral syndrome may wish to reduce or avoid activities that include repetitive high-impact actions, such as:
running
jumping
kneeling
squatting
lunging
going up and down stairs or other steep inclines
sitting for long periods of time
Examples of low-impact exercises that put less strain on the knees include:
swimming
cycling
water aerobics
using elliptical machines
STRENGTHENING VASDUS MEDIALIS
The Clamshell
A common and simple exercise to help keep the gluteals conditioned includes something called the ‘clamshell’. While lying on one side bend both knees to 90 degrees, and keep the feet in alignment with the hips. While keeping the pelvis still (belly button pointing slightly downward) and your feet together, raise the top knee. Completing 20 repetitions for three sets should make you feel as if someone poked you in the middle of your back pocket. Check out this brief video to make sure your technique is good:
Patellar tendinitis is characterized by inflammation and pain at the patellar tendon (the tendon below the kneecap). This structure is the tendon attachment of the quadriceps (thigh) muscles to the leg, which is important in straightening the knee or slowing the knee during bending or squatting. Patellar Tendonitis is typically a grade 1 or 2 strain of the tendon. A grade 1 strain is a mild strain. There is a slight pull without obvious tearing (referred to as microscopic tendon tearing). There is no loss of strength, and the tendon is the correct length. A grade 2 strain is a moderate strain, which involves tearing of tendon fibers within the substance of the tendon or at the bone-tendon junction. The length of the tendon is usually increased, and there is decreased strength. A grade 3 strain is a complete rupture of the tendon.
Anatomy and Pathology
The patellar tendon originates from the anterior aspect of the extensor hood, inferior to the patellar apex. The distal portion of the patellar tendon inserts on the tibial tubercle. The patellar tendon is a monotonous band of fibrocartilaginous tissue.3 Though Jumper’s Knee was once referred to as patellar tendonitis, it is now well established in histopathologically and biochemically analyzed tissue samples excised from the patellar tendons of patients with acute symptoms of Jumper’s Knee that inflammatory cellular infiltrates are absent.4,7 This confirms that the mechanism of disease in Jumper’s Knee is that of a degenerative tendinopathy (tendinosis)5,6 rather than that of an inflammatory tendinitis. In the setting of patellar tendinopathy associated with jumper’s knee, the area of abnormal signal intensity on MRI corresponds to a region of tenocyte hyperplasia, angiofibroblastic tendinosis, loss of coherent collagenous architecture and microtears.4 With more advanced disease, macrotears and frank discontinuity may ensue. Rarely, an avulsion fracture at the apical patellar enthesis may be found.
Clinical Diagnosis
Patellar tendinosis may be classified into four stages of injury. They are as follows:
Stage 1: Pain after activity, without functional impairment
Stage 2:
Pain at beginning of activity
Pain disappears after warm-up and reappears with fatigue, but still able to perform satisfactorily
Stage 3:
Pain during and after activity that impairs function
Patient unable to participate in sports at their prior level
To evaluate for the presence of injury, the following test can be conducted:
Ask the patient to lie on unaffected side on a treatment table.
Passively flex the patient’s knee.
A positive sign for jumper’s knee is present if the patient feels pain at 120 degrees passive knee flexion or anytime during resisted knee extension.
Common Signs & Symptoms of Patellar Tendonitis
Pain, tenderness, swelling, warmth, or redness over the patellar tendon, most often at the lower pole of the patella (kneecap) or at the tibial tubercle (bump on the upper part of the lower leg)
Pain and loss of strength (occasionally) with forcefully straightening the knee (especially when jumping or when rising from a seated or squatting position) or bending the knee completely (squatting or kneeling)
Crepitation (a crackling sound) when the tendon is moved or touched
MRI Evaluation
The ability of MRI to acquire multiplanar images, in concert with its high soft tissue contrast, makes MR imaging the most effective diagnostic modality in the evaluation of Jumper’s Knee. T1, proton density and/or T2-weighted sagittal and axial sequences are employed to evaluate the patellar tendon. Coronal sequences are of limited value due to volume averaging artifacts and the non-orthogonal slice orientation. On MR images, the normal patellar tendon demonstrates homogenous low signal intensity (4a). Exceptions to this rule occur proximally, where the posterior margin of the tendon may show thin, linear, intermediate signal intensity striations, and distally, where mildly increased signal intensity may be noted at the triangle proximal to the tibial tubercle enthesis. A normal patellar tendon should not exceed 7mm in AP diameter.4,9 The tendon is semilunar to half round in geometry, with a convex anterior border. A constant feature is that of a well-defined posterior border (5a).
4
Figure 4:(4a) A T1-weighted sagittal image in a patient with a normal patellar tendon reveals a homogeneously low signal intensity appearance to the tendon (arrows), which appears symmetrical in appearance throughout its course.
5
Figure 5:(5a) A proton density-weighted axial view demonstrates the normal semilunar appearance of the patellar tendon, with a convex anterior border (arrow) and well-defined posterior rim.
With Jumper’s Knee, the most reliable MRI finding is focal proximal 3rd tendon thickening with an associated increase in AP diameter greater than 7mm.9 Focal T2 hyperintensity within the proximal tendon is most commonly seen involving the medial one-third of the tendon (6a),4 and may extend to involve the central third of the tendon. Mild, subtle tendonopathy may not affect the entire A-P diameter of patellar tendon (7a). More severe tendinopathy demonstrates full thickness involvement by intrasubstance signal and T2 hyperintensity (8a,8b). In addition, an indistinct posterior tendon border may also be seen. Edema may be present within the adjacent Hoffa’s fat pad, with irregular T2 hyperintensity replacing normal fat signal. Partial thickness (9a,10a) and complete tears may also occur (11a,11b).
6
Figure 6:(6a) A water-excitation double-echo steady-state sagittal image in a patient with mild Jumper’s Knee demonstrates focal proximal tendon thickening and increased signal intensity (arrow), with sparing of anterior tendon fibers.
7
Figure 7:(7a) The corresponding axial image reveals that the area of focal tendinosis preferentially involves medial tendon fibers (arrow), a typical finding in early Jumper’s Knee.
8a
8b
Figure 8:Marked, diffuse tendinosis (arrows) is readily apparent throughout the patellar tendon on (8a) a T2-weighted sagittal image and (8b) fat-suppressed proton density axial images in a patient with severe Jumper’s Knee. Note the somewhat indistinct posterior border and the loss of semilunar morphology of the patellar tendon (arrow) on the axial view.
9
Figure 9:(9a) Typical soft-tissue thickening and edema (arrow) are seen within the proximal patellar tendon on this T1-weighted sagittal image of a patient with Jumper’s Knee.
10
Figure 10:(10a) A fluid-filled split (arrow) compatible with a partial tear is seen within the proximal tendon on the corresponding fat-suppressed proton-density weighted sagittal image.
11a
11b
Figure 11:(11a) T1-weighted and (11b) fat-suppressed proton density-weighted sagittal images in a basketball player who sustained an acute injury reveal marked edema about the patellar tendon with a fluid filled gap (arrows) at the central tendon, compatible with a complete rupture. The retracted proximal and distal ends (arrowheads) are markedly thickened, indicating severe tendinosis. The vast majority of patellar tendon ruptures occur in patients with pre-existing patellar tendinosis.
Patellar Tendonitis Causes
Strain from a sudden increase in amount or intensity of activity or overuse of the quadriceps muscles
and patellar tendon
Direct blow or injury to the knee or patellar tendon
Patellar Tendonitis Risk Increases With:
Sports that require sudden, explosive quadriceps contraction (jumping, quick starts, or kicking)
Running sports, especially running down hills
Poor physical conditioning (strength and flexibility, such as with weak quadriceps or tight hamstrings)
Flat feet
Patellar Tendonitis Preventive Measures
Appropriately warm up and stretch before practice or competition
Allow time for adequate rest and recovery between practices and competition
Maintain appropriate conditioning:
Cardiovascular fitness
Thigh and knee strength
Flexibility and endurance
To help prevent recurrence, taping, protective strapping or bracing, or an adhesive bandage may be needed for several weeks after healing is complete
Wear arch supports (orthotics)
Expected Outcome
Patellar Tendonitis is usually curable within 6 weeks if treated appropriately with conservative treatment and resting of the affected area.
Possible Complications
Prolonged healing time if not appropriately treated or if not given adequate time to heal
Recurrence of symptoms if activity is resumed too soon, with overuse, with a direct blow, or when using poor technique
Untreated, tendon rupture requiring surgery
Possible Complications
Eccentric Quadriceps and Patellar Tendon Exercises
I describe my eccentric exercise protocol below. I developed it through trial-and-error over the past 1-2 years. It is what has worked for me to eliminate knee pain related to longstanding patellar tendinopathy.
Unlike prior eccentric exercise protocols I experimented with, this protocol has not led to relapses in my knee pain. Through trial-and-error, I discovered that if too much weight is added too soon, eccentric exercises can lead to flare-ups in symptoms, particularly increased pain. So, I caution anyone who embarks on eccentric exercises to use a proper protocol. Furthermore, I highly recommend that prior to starting eccentric exercises that you consult an appropriate medical specialist and a good physical therapist.
The exercises should not be done in the early stages when one still has inflammation. They are recommended once the inflammation of tendinitis has gone away, but the pain remains.
I developed my protocol after reviewing the medical literature on using eccentric exercise to treat patellar tendinopathy. However, the articles in most cases were not very precise on the exact protocols used and left out some important details. I had to fill in the details through my own trial-and-error over the past couple of years. In late 2005 I started on my first self-designed program of eccentric exercises. However, after a number of weeks of doing the exercises, my pain increased and I stopped doing the exercises. Then, in mid-2006, I started my second program of eccentric exercise, but my pain started to increase again after a month and I again temporarily stopped the exercises. During the first few weeks of the two programs, the exercises seemed to somewhat reduce my daily knee pain. However, as I continued to add weights in each case, I eventually ran into problems. While I did not have more-than-usual knee pain doing the exercises, my pain began to increase significantly during the day in the following 1-3 days just before stopping the programs. I was determined to come up with a protocol that would not lead to a relapse.
As I look back on my data from the first two programs, I firmly believe the problem was that I added weight to the backpack too quickly. So, the protocol I now use corrects this problem.
These are key aspects to the protocol that has worked for me:
— I do the exercises ONCE a day and AT NIGHT before going to bed. I discovered that when I did the exercises in the morning, I had greater, annoying knee pain during the day. However, when I did the exercises before going to bed, the tendon and surrounding muscles had time to rest over night. I do not endorse protocols that call for doing the exercise in the morning. I also do not believe the exercise needs to be done twice a day to be effective.
— For the first 2 months, I did the eccentrics on the slant board without using any weights in a backpack.
— For the first two weeks, I used BOTH legs together to do the eccentric squats. I ramped up from 1 set of 10 repetitions to 3 sets of 15 repetitions over that period. By squating with both legs at the same time, you will be putting much less force on the bad knee compared to doing a single-leg squat.
— After that, I stopped the two-leg squats and began performing one-leg squats (i.e., performing squats with the bad-knee leg.) I began with 10 repetitions and added only 1 or 2 repetitions per day. When I built up to 45 repetitions over four weeks, I stayed at 45 repetitions for another couple of weeks. Again, all of this was without any weights in a backpack. (Every 15 repetitions I considered a set. I usually took a 5-20 second break between each set.)
— When doing the one-legged squats, I’d recommend the following, which is not shown in the video, and which was not part of my original protocol. It will help you to focus more of your bad leg’s energy on the eccentric portion of the movement, and less on the concentric part: Once You Are At The Bottom Of The One-Legged Squat (In Other Words, The Point Of Maximum Squat, Just When You Are About To Return Up To Standing) Come Up To Standing With BOTH Legs.
— During month 3, I introduced weights into a backpack that I wore while doing the eccentric exercises on the slant board. I started with 1/2 pound. Then, every 4 days I would add another 1/2 pound into the backpack. (1/2 pounds weights can be obtained from ankle weights that use 1/2-pound inserts.) THIS STEP IS VERY IMPORTANT. IT IS WHAT CAN MAKE THE DIFFERENCE BETWEEN HAVING SUCCESS OR FAILURE WITH ECCENTRIC EXERCISE. Weight must be added S-L-O-W-L-Y over time.
— There will be the temptation to add weights more quickly. DON’T DO IT. You may find that in the early weeks of doing the eccentric exercises they are helping to reduce pain. You may believe that you can add weights at a faster pace because of this improvement. Through trial-and-error, I learned the hard way not to add weights any faster than 1/2 pound every 4 days. After a period of time, after adding weights, if you find your pain rising in the four days after increasing the weight increment, I would not increase weight further. You may need to stop altogether or for a few days or a week or more. You may need to reduce weight in the backpack. When you resume, you may need to stay on the same weight for more than 4 days.
— Even if your pain is not rising in the days after adding weight to the backpack, you may still decide to hold off adding weight for more than 4 days if you are not absolutely comfortable with adding additional weight. For example, when I got to 15 pounds, I stayed at that level for 8 days before I went to 15 1/2 pounds. I wanted to be able to do the 45th repetition at 15 pounds fairly easily before proceeding to 15 1/2 pounds.
Please double click the forward button to start video:
https://www.youtube.com/watch?v=eIQW8VnEABc
— Weights should continue to be added over time at the same rate described. It is not clear what the upper limit of weights should be, however. A number of research protocols seem to suggest 20-25 pounds as a possible upper limit. However, the upper limit will likely be different for each person depending on a variety of factors — age, general health, one’s own weight, general physical abilities, etc… I believe one will be able to see improvement well before getting to 20 pounds, however, and I cannot say I endorse going all the way to 20 pounds. It is very possible that for some people 10 pounds (or less) may be as far as you should go. It is also not clear when to stop the exercises altogether. A number of research protocols suggest that after a period of months of doing the exercises every day that the exercises be continued for another year, but not necessarily each day. This is one part of my protocol that is not yet nailed down.
— The slant board I use has roughly a 25-degree angle. (If you have a slant board with less angulation, you can increase it with a thin piece of wood. But you would need to review some trigonometry so you don’t raise the angle too much!)
— I DO NOT subscribe to those protocols that say you should experience higher-than-typical pain while doing the eccentric exercise. If you have significantly more pain while doing the exercise, you should stop. You may have ramped up your weights or reps too fast in prior days. You should take off a couple of days from the eccentrics and consult with your physical therapist and/or doctor.
— I attempted to do the eccentric exercises every day. However, there were times when I had a bad cold, or my pain was temporarily elevated, or I was away from home. On average, I took off 1 day out of every 18 days.
— IT IS VERY IMPORTANT TO KEEP A DAILY LOG BOOK. The log book should include the number of repetitions and the amount of weight being used that day. Additional information, such as your pain score on a scale from 0 to 10 and other notes can be added.
— I generally tried to limit other kinds of exercise when doing the eccentric protocol. On occasion, I did go bicycling. However, when bicycling I used very easy gears, a higher cadence, and avoided hills. For the first 2-4 months, I’d limit significant exercise. (If you swim, I’d avoid the breaststroke.)
— I stretch on a daily basis. After doing the eccentric exercise each day, I also roll my IT-band and quadriceps on a “foam roller.”
— I do not apply ice after doing the eccentric exercises. (In my first two programs of eccentric exercise I religiously iced, but did not do so for the protocol described here after I determined that icing may not have been providing any benefit.)
— I set up my slant board with chairs or other large objects to the left and right of the slant board. This is so I could lightly brush my hands against these objects to maintain balance while doing the eccentric exercises. It is important to maintain balance while doing the exercises. However, I did not want to hold firmly to any object given that it could have negated the effects of the weight in the backpack. So, I maintained my balance by lightly brushing my hands against objects on either side of the slant board.
— Once on the slant board, I squat down to a count of 2 to 3, and then rise up from the squat more quickly. It is the downward part of the exercise that is the eccentric phase. The move back up should be steady and smooth, not explosive.
— A number of medical journals use a 12-week protocol. However, my protocol is at least twice as long. Through trial-and-error I found that doing too much too soon can lead to relapses, which will ultimately lead to needing to take time off before starting again. If there is a relapse, then the total time required may be substantially longer.
— To remind oneself to do the exercises, place a note by your bed.
Stretching exercises
Patellar Tendonitis Symptoms
Symptoms of patellar tendonitis largely involve pain and tenderness in the area surrounding the kneecap. Any activity that places additional stress on the kneecap, like squatting or kneeling,l produce more severe pain. If untreated, these signs of patellar tendonitis will only grow worse and will begin to interfere with normal activities like climbing stairs.
Understanding how to heal patellar tendonitis begins by differentiating between the acute and chronic forms of the injury.
Acute Patellar Tendonitis
Acute patellar tendonitis results from a single accident or incident, causing symptoms almost immediately. Acute cases are most common in athletes.
Chronic Patellar Tendonitis
The chronic form of the condition may be easy to overlook, as symptoms develop gradually, allowing the patient to continue regular activity, causing further damage. If untreated, chronic patellar tendonitis will develop symptoms as severe as its acute counterpart.
Patellar Tendonitis Treatment
Treatment for patellar tendonitis can focus on treating immediate pain or addressing the underlying cause. By approaching the problem from both sides, you will both heal your patellar tendonitis and enjoy a manageable recovery process.
The best treatment for patellar tendonitis in the short term is simple rest. Short-term pain relief is important to your daily life, before finding a long-term cure for patellar tendonitis. Avoiding heavy physical activity will allow the tendons to repair themselves in a matter of days or weeks. Boost the effectiveness of this patellar tendonitis cure by incorporating hot and cold therapy and reducing swelling with patellar tendonitis taping or a compression sleeve.
Compression sleeves reduce inflammation and improve circulation to encourage healing. ( See Product)
Once your immediate symptoms are under control, explore long-term solutions for treating patellar tendonitis:
Patellar Tendonitis Exercises
Exercises for patellar tendonitis in the knee are one way to strengthen muscles for a faster and healthier recovery process. In addition to speeding recovery, physical therapy for patellar tendonitis will protect against future injury.
Adjust the intensity of the patellar tendonitis stretches below to fit your own needs and limitations. Pushing yourself too hard can worsten the condition, leaving you in a worse place than when you started.
Speak to your doctor before attempting the following stretches for patellar tendonitis.
Calf Stretch
Stand about 18 inches from a wall. Take one step forward with your uninjured leg and place both palms flat on the wall. From this position, lean forward and bend your injured leg slightly until you feel a stretch in your calf.
Quad Stretch
The quads are essential to a functioning knee joint, which makes quad stretches key patellar tendonitis physical therapy exercises. Standing, bend your injured leg at the knee. Use your hand to pull the ankle upward toward your hips, stabilize yourself against a wall if necessary. Lean forward to stretch the muscle. You should feel a slight burning sensation in your upper leg.
Hamstring Stretch
The hamstring is one of the most commonly injured leg muscles, so hamstring stretches are a crucial part of your patellar tendonitis recovery exercise regimen. Stand and lean forward to touch your toes while keeping your knees locked. Reach down as far as you are able.
Eccentric Exercises for Patellar Tendonitis
The best physical therapy exercises for patellar tendonitis include a fair share of eccentric training. Begin in a standing position, using a slant board if you have one available. Perform an eccentric decline squat by extending your uninjured leg forward and squatting slowly on your injured leg. Use a wall or chair for support if necessary. Return to standing position, and repeat 5 to 10 times.
Testing flexibility – A good place to start is testing the flexibility of the hip flexor and quadriceps muscles. This can be tested by performing the Thomas test.
Sit on the end of a couch and pull the knee up to your chest. Holding this position, lay back onto the couch. The thigh of the free leg should be horizontal. If it rides up, this indicates possible tight hip flexor muscles (Rectus femoris or Iliopsoas). The shin of the free leg should hang vertically. If not then this may indicate tight Quadriceps muscles.
Quadriceps stretch – The quads can be stretched in either the standing or laying position. In standing you can hold onto something for balance if you need to or try holding your ear with the opposite arm. Aim to keep the knees together and pull the leg up straight not twisted. You should feel a stretch at the front of the leg which should not be painful. In the early acute stages of treatment hold stretches for around 10 seconds. Later on when the inflammation has gone stretches should be held for around 30 seconds. Repeat 3 times and stretch at least 3 times a day.
Hip flexor stretch – This exercise stretches the iliopsoas muscle and rectus remoris. Place one knee on the floor and the other foot out in front with the knee bent. Be careful to use on a mat or padding under the painful knee so at not to aggravate the injury. Push your hips forwards and keep your back upright. You should feel a stretch at the front of the hip and upper thigh. Hold for 10-30 seconds. Repeat 3 times and stretch at least 3 times a day. This exercise stretches the Rectus Femoris and Iliopsoas muscles which flex the hip. Be careful if lifting the leg up leaving only the knee on the floor. If it is painful at the knee do not do it. Ensure there is plenty of padding to avoid injuring the knee.
Strengthening exercises
Strengthening exercises are a very effective part of healing patella tendinopathy or jumpers knee. But knowing which exercises to do and when to do them is essential.
Strengthening exercises should begin as soon as pain allows and be gradually progressed over a period of 6 months or more. Exercises can be separated into three phases. As a guide phase 1 lasts for the first 3 months of rehabilitation and here the aim is to increase the strength and strength endurance. Phase 2, from 3 months to 6 months can begin to increase the power and speed endurance and from 6 months onwards more sports specific rehabilitation is appropriate.
It is likely that even the more serious patella tendon injuries can begin with isometric or static contractions of the quadriceps muscles. Strengthening for the calf raises is also important and can be done without much strain on the patella tendon at all. The athlete should progress to single leg eccentric squat exercises as soon as possible. Applying ice or cold therapy after performing the exercises can help avoid any pain and inflammation.
Isometric quad contractions – this exercise is likely to be possible very early in the rehabilitation program. The athlete contracts the quadriceps muscles, holds for a few seconds and relaxes. This can be done in the standing position, seated or lying face up or face down, whatever is most comfortable although standing is probably more relevant.
Initially begin with 3 sets of 8 repetitions holding for 5 seconds and build up to 4 sets of 12 repetitions holding for 10 seconds. If it is painful during, after or the next day then reduce the load. Athletes with good quadriceps bulk should aim to progress onto single leg eccentric squats as soon as possible.
Single leg extension – the leg extension machine can be used to strengthen the quadriceps muscles if doing full weight bearing exercises is still painful. It is a step on from isometric exercises but not likely to trigger the same kind of pain that single leg drop squats may.
Begin with 3 sets of 10 repetitions with light resistance concentrating on the last few degrees of motion as the leg straightens as this is the range of motion which works the vastus medialis on the inside of the knee more. Do no more on the good leg than you are able to do on the injured leg. Gradually increase the resistance when 3 sets of 10 or 12 reps become comfortable. Progress to single leg eccentric squats as soon as pain allows.
Eccentric squats – this is probably the most important exercise to get right in the treatment of chronic patella tendinopathy. The athlete can begin with double leg squats but should pregress as soon as possible onto single leg squats.
The exercise is performed by squatting down very slowly and more quickly up. Try to use the good leg to aid the upwards movement rather than load the injured knee. The aim is to load the tendon and muscle eccentrically which happens on the downwards phase of the squat. When performing single leg eccentric squats both legs can be used during the upwards phase so the load is purely concentrated on the eccentric or downwards phase.
Eccentric squat exercises can be performed on a slant board or with a half foam roller to raise the heels. This has the effect of reducing the element that the calf muscles contribute to the exercise and increasing the load on the quadriceps muscles.
Begin with 3 x 10 repetitions each day and gradually increase to 3 x 15 repetitions before increasing the load or weight. Stick with a particular load level until they can be done very comfortably. If any pain is felt during, after or the next day then take a step back. Applying ice after can help with pain and inflammation.
Play eccentric squat video (double leg only demonstrated here)..
Lunge – the lunge exercise should begin as soon as pain allows and is a more demanding exercise which brings increasing power and speed into the exercise. It is more likely this exercise will be introduced around 3 months into the rehab program but each athlete will be different.
The athlete stands with one leg in front of the other and bends the front knee so the thigh is horizontal while the back knee goes towards the floor. This can be made easier by not going quite so low with the front leg. Begin with 1 set of 8 repetitions building to 3 sets of 15 reps. A weights bar across the shoulders can be used to increase the load.
Step back exercise – this exercise is more suitable for the later stages of rehabilitation when the athlete is attempting to return to more specific sports training. The athlete steps back and then in one movement steps back onto the step. This is a more explosive, plyometric exercise related to the specific demands of sport. It works the calf muscle eccentrically as well as the knee during the stepping back phase and plyometrically as they push off.
Alternate so both legs are exercised and do not do any more on the good leg than you can achieve with the injured leg.
There has been a lot of published work on the benefit of eccentric exercises and in my practice I have seen significant benefits to the athletes I treat.
The key to the rationale behind eccentric drills is that they are the best way of promoting tendon remodelling: the regrowth and reordering of collagen tissue in place of the oedematous (fluid filled) degenerative tissue typical of tendinosis.
The athlete needs to be taught eccentric exercises (See table 1). A 45-degree slope is required and (at a later stage) a weights bar. Initially the athlete stands straight on the slope, then flexes his/her knees to 90 degrees, returning to a straight position again (see illustration below left).
Table 1: Decline squat progressions
Stage
Exercise
No of legs
1
Two legs, 90 degree squat, no slope
2
2
Two legs, 90 degree squat on 45 degree slope
2
3
Single leg for squat phase (eccentric); two legs
return phase (concentric), on slope
1.5
4
10kg bar; single leg for squat phase, two legs
return, on slope
1.5
5
Single leg only throughout, on slope
1
The movement down must be done slowly (to a count of three) and the return can be done quickly (to a count of one). When away from home the slope can be replaced by the edge of a curb or step so that opportunities can be taken whenever possible to do the drills.
The number of repetitions is determined by the amount of discomfort felt in the patellar tendon. I advise athletes to stop a sequence of repetitions when they perceive an ache in the patellar tendon of 3/10, using the scale described above. The rationale for this is to stimulate the patellar tendon eccentrically to a fixed (symptomatic) level each day, but without such a high score as to produce pain and further damage. I suggest to athletes that they can do these repetitions as often as possible every day and many achieve the repetitions two to four times a day.
The exercise sequence can be progressed as shown in table 1. For some athletes stage 1 is too easy and they cannot bring on any discomfort in the patellar tendon. For others, the ratelimiting factor is quadriceps fatigue and for this reason they can use two legs in returning to the standing position (see stages 2 to 4).
As the stages progress the athlete will be able to increase the number of repetitions they can perform before the symptoms come on at a discomfort level of 3/10. There will be some days when the athlete can manage more repetitions than others, but normally they will be able to move on to the next stage after two to four weeks – so improvement in this condition is usually measured in months, not weeks.
The rate of progression will vary from athlete to athlete, dependent in large part on how often they perform the exercises. If more pain occurs in the tendon, the athlete should be advised to rest for two to three days and then drop back one stage in the rehab exercise progression.
Other rehab considerations
Alongside the eccentric exercises, it is important to address other possible contributory factors, such as:
Every knee has a medial and lateral meniscus which are C-shaped pieces of fibrocartilage that absorb stress and act as cushions between the bones at the knee. At birth, the meniscus is not C-shaped, but discoid (round like a discus).
With growth and walking, the discoid meniscus evolves into its normal C-shape. In some children, the lateral meniscus continues to stay discoid with growth.
Incidence
present in 3-5% of population
location
usually lateral meniscus involved
25% bilateral
Classification
Watanabe Classification
Type I
• Incomplete
Type II
• Complete
Type III
• Wrisberg (lack of posterior meniscotibial attachment to tibia
Presentation
Symptoms
pain, clicking, mechanical locking
most common presentation is a 6 to 8-year-old child with a “snapping” or a “clicking” in their knee as they walk.
often becomes symptomatic in adolescence.
also possible for the onset to occur in early adolescent years when a child’s sporting activities increase.
In some instances, as the child grows older, the click increases and may cause recurrent locking, where they are unable to straighten or bend their knee fully. This will commonly also manifest as pain in the knee.
Physical exam
mechanical symptoms most pronounced in extension
Imaging
Radiographs
recommended views
AP and lateral of knee
findings
widened joint space due to widened cartilage space (up to 11mm)
squaring of lateral condyle with cupping of lateral tibial plateau
hypoplastic lateral intercondylar spine
MRI
indications
study of choice for suspected symptomatic meniscal pathology
findings
diagnosis can be made with 3 or more 5mm sagittal images with meniscal continuity (“bow-tie sign”)
sagittal MRI will show abnormally thick and flat meniscus
coronal MRI will show thick and flat meniscal tissue extending across entire lateral compartment
Treatment
Nonoperative
observation
indications
asymptomatic discoid meniscus without tears
Operative
partial meniscectomy and saucerization
indications
pain and mechanical symptoms
meniscal tear or meniscal detachment
technique
obtain anatomic looking meniscus with debridement
repair meniscus if detached (Wrisberg variant)
Traditionally, the treatment for stable or unstable discoid meniscus is an open total meniscectomy. But recent research has proved that a partial meniscectomy of normal shaped menisci, was shown to increase the contact stresses in proportion to the amount of removed meniscus. Total meniscectomy of a non-discoid meniscus often leads to osteoarthritis. Keeping in mind the negative effect of a meniscectomy on the normal functionality of the knee, the goal in treatment planning should be preservation of meniscal tissue[11].
Discoid meniscus with no symptoms or physical signs should not be treated surgically. Still it’s important to do a periodic follow-up for early detection of any deterioration and appropriate treatment planning.Nowadays, arthroscopic partial meniscectomy is the treatment of choice for symptomatic stable, complete, or incomplete discoid meniscus. As mentioned above removal of the entire meniscus speeds degenerative change within the joint, so the current standard therapy is to remove the abnormal central portion and preserve a rim of meniscus to maintain the biomechanical benefits
Treatment
Traditionally, the treatment of choice for symptomatic stable or unstable discoid lateral meniscus was open total meniscectomy. The residual meniscal tissue that had been left after partial meniscectomy was considered abnormal and was, therefore, supposed to be resected as well [9, 15, 24, 25]. The menisci serve as load distributors and shock absorbers and play a role in joint stability as well as in synovial fluid distribution and cartilage nutrition. Better understanding and documentation of the importance of the menisci to normal articular function has led to preservation of stable meniscal tissue as part of treatment planning.
Partial meniscectomy of normal shaped menisci, was shown to increase the contact stresses in proportion to the amount of removed meniscus [49]. Following total meniscectomy, the contact area was decreased by 75% while contact stresses increased by 235% [49]. The lack of normal meniscal fibrocartilage arrangement in discoid menisci types 1 and 2 may play a roll in load changes after partial meniscectomy of lateral discoid meniscus, but no data supporting it has yet been published. A meniscus-deficient knee carries a high risk of early cartilage degeneration and early degenerative changes. Total meniscectomy of a non-discoid meniscus often leads to osteoarthritis [50–54]. Bearing in mind the detrimental effect of meniscectomy on the knee’s function, the goal in treatment planning should be preservation of meniscal tissue.
Incidentally found discoid lateral meniscus with no symptoms or physical signs should not be treated surgically. A periodic follow-up for exclusion of symptoms and a physical examination enables early detection of any deterioration and appropriate treatment planning.
Snapping knee with no other symptoms and no radiographic signs of accompanying articular lesions can be followed-up and then treated should it become symptomatic. A patient may become symptomatic due to instability of the meniscus, a new tear of the ill-defined meniscus, or as the result of accompanying findings, such as osteochondral lesions to the lateral joint compartment.
Arthroscopic partial meniscectomy (saucerization) is the treatment of choice for symptomatic stable, complete, or incomplete discoid lateral meniscus [8, 30, 55]. The width of the remaining peripheral rim is an important feature to consider when meniscectomy is performed. Most authors agree that the width of the remaining peripheral rim should be between 5 mm and 8 mm to prevent impingement and instability of the remaining part of a discoid lateral meniscus that may lead to future secondary meniscal tear [55, 56]. If a meniscal tear is present, partial central meniscectomy in conjunction with suture repair of the peripheral tear can be effective treatment [57] (Fig. 3a–c).
Arthroscopic demonstration of complete lateral discoid meniscus. a Wide medial edge of the lateral meniscus. The arthroscopic probe points the small tibial plateau part not covered with the meniscus (LM lateral meniscus). b Demonstration of the wideness …
The reparability of the lateral discoid meniscus cannot be reliably predicted from imaging studies, even MRI [58], and can best be decided on intraoperatively. Klingele et al. [59] reported that 28.1% of arthroscopically evaluated discoid lateral menisci had peripheral rim instability; therefore, the planning and preparation of surgery should include anticipation of a possible need for meniscal stabilization by suturing.
Motoric and radio frequency tools are used for meniscal reshaping. When meniscal instability is found clinically or arthroscopically, stabilization of the meniscus should be considered providing that the meniscal tissue quality allows it. We usually use an inside-out technique for meniscal suturing and use the all-inside meniscal devices for augmentation.
Type-III unstable lateral discoid menisci can be reattached to the posterior capsule and complete meniscectomy should be condemned.
Finally, despite technical improvements in arthroscopic surgery, arthroscopic procedures for treatment of discoid meniscus are considered technically difficult due to the abnormal size, height, and quality of the discoid meniscus [28, 30].
Treatment outcome
Meniscectomy of the lateral meniscus harbors a detrimental effect on the lateral knee. A retrospective review of patients who underwent arthroscopic partial lateral meniscectomy for lateral meniscus tears demonstrated that early results for partial lateral meniscectomy could be quite good, but that significant deterioration of functional results and decreased activity level can be anticipated [60]. The results of total or near-total meniscectomy of non-discoid meniscus in pediatric patients are poor, with the risk of early arthrosis [52, 53].
There has been a trend toward choosing meniscal preservation procedures for treating discoid lateral meniscus. Aichroth et al. [28] reviewed 52 children with 62 discoid lateral menisci and an average follow-up of 5.5 years. The children’s average age at operation was 10.5 years and the mean delay in diagnosis was 24 months. Of knees with symptomatic torn discoid menisci, 48 underwent open total lateral meniscectomy, 6 had arthroscopic partial meniscectomy, and 8 with intact discoid menisci were left alone. The reported outcomes were 37% of the knees with excellent results, 47% with good results, 16% with fair results, and no poor results. Early degenerative changes were seen in the lateral compartment in three knees of older patients (over 16 years of age) with a follow-up period of 11, 13, and 18 years after total meniscectomy. The authors concluded that arthroscopic partial meniscectomy should be recommended only when the posterior attachment of the discoid meniscus is stable and that total meniscectomy is indicated for the Wrisberg-ligament type of discoid meniscus with posterior instability.
Washington et al. [61] reported good or excellent results in 13 of 18 knees of patients with a mean age of 17 years (8–28 years). Radiographs of 9 knees (8 patients with a mean age of 15 years; 7–26 years) showed evidence of slight narrowing of the joint space in only 3 of them.
Raber et al. [62] reviewed the results of total meniscectomies performed in 17 knees (14 children) for discoid lateral meniscus at a mean follow-up of 19.8 years (range 12.5–26.0 years). They found that 10 of these knees had clinical symptoms of osteoarthrosis. Plain radiographs were available for 15 knees and 10 showed osteoarthritic changes.
Aglietti et al. [63] reported 10-year follow-up results of arthroscopic meniscectomies for symptomatic discoid lateral menisci in 17 adolescents. They found no correlation between the type of meniscectomy (partial or total) and the clinical and radiographic results. Development of radiographic changes, such as minor osteophytes in the lateral compartment of 8 knees and less than 50% narrowing of the lateral joint space, was found in 11 knees. The reported clinical results were excellent or good in 16 of their 17 patients.
It should be emphasized that excellent or good clinical reports after a 10-year follow-up in this age group calls for a critical appraisal. The follow-up period puts those patients in their mid-to late twenties. In the face of the reported high incidence of ominous premature radiographic arthritic changes in this and the other series, a longer follow-up period is needed.
Currently, the indications and results of treatment options, such as meniscal transplantation for knees with a history of discoid lateral meniscectomies and meniscectomy, have not yet been conclusively defined. There is some experience in performing allograft meniscal transplantation for those cases but no reports have appeared in the literature thus far. Heightened awareness of the clinician to the possibility of discoid meniscus, its variable presentations and complications, and management considerations may improve therapeutic outcome.
Understanding PML and the JC Virus in Multiple Sclerosis
Before AIDS epidemic, PML was considered a rare complication of the middle-aged and elderly patients with lymphoproliferative diseases and incidence of PML in pre-AIDS era was considerably low (0.07%) [12]. It is now a commonly encountered disease of the CNS in patients of a variety of different age groups with AIDS and ~5% of HIV patients develop PML. It is now defined as an AIDS-associated illness. In addition, recent studies indicate that the highly active retroviral therapies (HAART) against HIV infections considerably reduced the virulent behavior of HIV virus, however, the same does not hold for JCV infections. In other words, the incidence of PML did not significantly change between the pre-HAART and post-HAART era [13]. More interestingly, PML has also recently been described in patients with autoimmune diseases such as multiple sclerosis and Crohn’s disease, who were treated with specific monoclonal antibodies. These antibodies (natalizumab and efalizuma) target several surface molecules (α-integrin) on B and T cells and prevent their entry into brain, skin and gut. Rituximab, another monoclonal antibody, targets the CD20 surface molecule on B cells and causes their depletion through complement-mediated cytolysis.
PML and the JC virus have been in the headlines a lot lately following the death of a person taking Tecfidera. Today I want to focus on PML, the JC virus, and how it effects those of us with MS. This is obviously one of the scariest medication side effects for us, and it is very important to know the what it is, it’s risk factors, and how it is detected.
PML stands for progressive multifocal leukoencephalopathy- ok lets just stop right there and breakdown that mouthful…
Progressive- steadily getting worse
Multifocal- in many areas
Leuko- white (in this case referring to white matter in the brain)
Encephalopathy- disorder or disease of the brain
So before even reading anything else you already know that this is a disease that afflicts multiple areas of white matter in the brain, and that it gets worse over time. But what causes it?
PML is in a category called “opportunistic infections”. These are infections that generally pose no threat to a person with a normal immune system, but love to rear their ugly heads in people with weakened immune systems. They are most frequently seen in chemotherapy patients or people with HIV because they are severely immunocompromised. Although it is much rarer, they can also occur in people with MS who are on drugs that weaken their immune systems. You may already know that Tysabri poses the greatest risk for developing PML. However, PML developed in one person taking Gilenya, and one person taking Tecfidera recently died of complications from a PML infection.
The JC virus (John Cunningham virus) is the infection that leads to PML. This virus behaves much like other common viral infections such as herpes and the chicken pox. When you get the chicken pox the virus never leaves your body, and later in life it may flare up again and cause a condition called shingles. Similarly, people who have been infected with herpes always have the virus lurking in their nervous systems. During times of stress it will become active and an outbreak of sores will occur, but unless an active outbreak is occurring there are no outward signs of the virus. The JC virus is fairly common, and is passed easily from person to person. However, since it’s an opportunistic infection healthy people never have any complications from it. When you introduce medications that weaken the immune system, like Tysabri does, your body no longer fights off viruses the way it used to. This gives the dormant JC virus the chance to become active. Once it is active there is a chance that it can cross through the blood-brain-barrier and cause PML. This causes severe damage to the white matter of the brain, and can even lead to death.
All of that information is fairly terrifying right? Well, here’s some good news! We can easily test to see if you have been exposed to the JC virus, which tells us if you are at risk for developing PML. A blood test called the JCV Antibody ELISA test is routinely done on anyone thinking about going on Tysabri. If you test negative, meaning you don’t carry the JC virus, we continue to test for it every 6 months while you are taking Tysabri because you can be exposed to the virus at any time. If you do test positive we also get an index value, which gives us even more information about how likely you are to get PML. A low index value indicates a very low risk, and a higher number indicates a greater risk. All that being said, PML is by no means a common side effect. However, when it does happen it is very serious, so we as providers aren’t willing to take any chances! During the first year of taking Tysabri your risk is very low, but it increases after two years. Additionally, being treated with immunosuppressants in the past puts you at a higher risk for developing PML. We look at all of these risk factors, and use that information to decide whether Tysabri is safe for you or not. The benefit of Tysabri is that it lowers relapse rates by 81%, and disability progression by 64% so we have to weigh its effectiveness against the relative risk of contracting PML, which I’ve summarized for you below:
Because PML attack the myelin, just like MS does, the symptoms should sound familiar. They include confusion, difficulty talking, weakness, memory loss, and loss of balance and coordination. If PML is suspected a MRI of the brain will be done, and a lumbar puncture can confirm the diagnosis. PML is treated in the hospital, and the goal of therapy is to remove all traces of the virus from your body.1-6
Picking medications is a very personal decision, and should be discusses in detail with your neurologist. It is imperative to weigh the risks versus benefits very carefully, and to understand the medications and their side effects. Being well informed is the first step to being your own best advocate!
Diagnosis
Although PML lesions, caused by both lytic infection of oligodendrocytes and neuronal loss, can be detected by magnetic resonance imaging (MRI) system [33], some other CNS related viral infections may make this diagnosis difficult. Therefore, detection of JCV in the brain samples of PML patients in large numbers would be strong evidence for the full diagnosis of the disease. There are a number of techniques for the identification of the virus as the causative agent of PML, including immunocytochemistry and nucleic acid methods. Antibodies against JCV were employed earlier; however, the specificity of this method was always in question due to cross-reactivity with other viral proteins. Nucleic acid methods, such as in situ hybridization of JCV DNA were successfully performed on tissue samples obtained from various PML patients [34]. However, the polymerase chain reaction (PCR) has been proven to be the most reliable method for detecting JCV DNA in PML cases. PCR can easily be used to test cerebrospinal fluid (CSF) for infectious JCV. In a recent study, it has been shown that as low as 10 copies of viral DNA in CSF can be detected using quantitative PCR technology [35].To support this finding, in another recent study, 168 suspected PML cases over 10 years have been reviewed retrospectively and it turned out that majority of the samples that are diagnosed as JCV positive using PCR come from HIV positive patients [36], which highlights the importance of HIV infection in JCV reactivation.
Enliva is a new active supplement containing 3 specifically selected and patented strains of beneficial bacteria – Lactobacillus Plantarum (CECT 7527, 7528,7529). Enliva is intended for use by healthy patients not yet requiring prescription medication, who are seeking to maintain healthy cholesterol through diet and exercise. Enliva is specifically formulated to support these activities to help maintain normal cholesterol levels. Enliva is a once-a-day complementary medicine that may help to maintain normal cholesterol levels in healthy individuals in two ways; Increasing the use of cholesterol by the liver: the enzymes from Lactobacilli in Enliva have been shown to promote the breakdown of bile salts. Once broken down, bile salts are not available for use by the body and are removed. To replace the lost bile salts, the liver takes cholesterol from the blood to make new bile salts. Reducing the amount of cholesterol absorbed from the diet: The bacteria in Enliva has also been shown to absorb cholesterol which is then removed in normal digestive waste.
HDL,LDL, cholesterol
mmol/L to mg/dL / by 0.0259 to get mg/dL
mg/dL to mmol/L * by 0.0259 to get mmol/L
HDL,LDL, cholesterol
mmol/L to mg/dL / by 0.0259 to get mg/dL
mg/dL to mmol/L * by 0.0259 to get mmol/L
Triglycerides
mmol/L to mg/dL / by 0.01129 to get mg/dL
mg/dL to mmol/L * by 0.01129 to get mmol/L
EXAMPLE 1 DAD
Cholesterol 4.2 mmol/L 162.16 mg/dL
Triglyceride 0.8 mmol/L 70.85 mg/dL
HDL 1.11 mmol/L 42.85 mg/dL needs to be >60mg/dL
LDL 2.7 mmol/L 104.24 mg/dL needs to be <70mg/dL
Chol/HDL Ratio 3.8 mmol/L
EXAMPLE 2 MUM
Cholesterol 7.6 mmol/L 293.43 mg/dL
Triglyceride 1.7 mmol/L 150.57 mg/dL
HDL 1.71 mmol/L 66.02 mg/dL needs to be >60mg/dL
LDL 5.1 mmol/L 196.91 mg/ dL needs to be <70mg/dL
Chol/HDL Ratio 4.4 mmol/L
LDL’s
Bad Fats and promote atherosclerosis (narrowing of the arteries)
An LDL level of less than 100 mg/dL is optimal for CAD prevention,
A level of 70 mg/dL or less is now recommended for persons with existing heart disease
HDL’s
Good Fats and promote opening up of the arteries
> 50 mg/dL (≈ 1.3 mmol/L) man or >60 mg/dL (≈ 1.6 mmol/L) in a woman a reduced risk of atherosclerosis.
>75 mg/dL (≈ 2 mmol/L) man or woman is associated with a very low risk of atherosclerosis.
Less than 40 mg/dL (≈ 0.8 mmol/L) in a man <50 mg/dL (≈ 1 mmol/L) in a woman increases the risk.
TRIGLYCERIDES
Reduction of triglycerides to 60 mg/dl.
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