Review Question - QID 220028

The patient has quadriceps tendinosis, as demonstrated on his ultrasound imaging studies in Figure A. First-line treatment for this problem is activity modification with physical therapy focusing on eccentric exercises.

Quadriceps tendinopathy represents inflammation of the suprapatellar tendon of the quadriceps muscle associated with activity-related anterior knee pain. The diagnosis is typically made clinically with tenderness to palpation at the quadriceps tendon insertion at the superior pole of the patella and can be confirmed on ultrasound as a thickening of the normal tendon, though this modality is both operator and user-dependent. Treatment is generally nonoperative with rest, ice, activity modifications, and physical therapy to focus on hamstring, quadriceps, and core strengthening. Surgery can be considered as a treatment option for patients who have failed nonoperative measures for a minimum of 3 months.

King et al. provide a two-part review of quadriceps tendinopathy. The authors start by reviewing the epidemiology and diagnosis, completing the second part of the review with the classification, prognosis, and treatment of the pathology. The authors note that quadriceps tendinopathy is an important cause of anterior knee pain, with diagnostic imaging for quadriceps tendinopathy diagnosis revealing morphologic changes of localized tendon thickening, hypoechoic areas, and increased vascularity. They conclude by stating that injections of PRP and sclerosing agents such as polidocanol have shown good outcomes in patients who have failed non-operative treatment, while arthroscopic and open surgical procedures have also shown good outcomes in patients with more severe symptoms who have failed non-operative treatment.

Dragoo et al. published a double-blind, randomized controlled trial using platelet-rich plasma as an adjunct treatment to PT and US-guided dry needling (DN) for patellar tendinopathy. The authors included 23 patients and found at a mean 26-week follow-up that there were no treatment failures in the PRP group and no adverse events were reported. Recruitment was stopped because interim analysis demonstrated statistically significant and clinically important results. They concluded that a therapeutic regimen of standardized eccentric exercise and ultrasound-guided leukocyte-rich PRP injection with dry-needling (DN) accelerates the recovery from patellar tendinopathy relative to exercise and ultrasound-guided DN alone, but the apparent benefit of PRP dissipates over time.

Figure A represents ultrasound imaging of a patient with quadriceps tendinopathy, showing a thicker, more hypoechoic tendon with positive power doppler flow signals compared to the normal tendon shown in Figure B. Normal quadriceps tendon width on ultrasound is between 2-3cm.

Incorrect Answers:
Answers 1 and 2: Operative management is considered for severely symptomatic patients with recalcitrant pain despite a minimum of 3 months of non-invasive treatment methods. This patient has only had one month of symptoms and has not yet tried a formal, guided physical therapy program despite his high activity level.
Answer 3: Leukocyte-rich PRP has been shown to be efficacious for patellar tendinopathy, as above, not leukocyte-poor PRP. Despite this, it is not considered a first-line treatment.
Answer 5: A "jumper's" knee strap is a patellar tendon strap that is used for patellar tendinopathy, not quadriceps tendinosis.