Percutaneous tendon-fat pad separation can treat patellar tendinopathy in season
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Patellar tendinopathy is commonly encountered in athletes who participate in high-impact sports. This condition can be frustrating for athletes and clinicians.
Despite a breadth of treatment options including physical therapy, platelet-rich plasma (PRP) injections, sclerosing agents and extracorporeal shockwave therapy (ESWT), symptoms frequently continue and athletes are usually not satisfied with extensive time lost from sports participation. Further complicating treatment for these patients is the limited number of interventions that can be administered “in season” that will result in a minimal disruption to the athlete’s competitive season. For example, physical therapy, PRP and ESWT often take months to reduce symptoms. Sclerosing agents can be challenging to acquire depending on the clinic setting. There is a need for a simple, minimally invasive intervention that quickly reduces pain, minimizes recovery time, is easily applied in any clinic setting and allows an early return to competition. Percutaneous tendon-fat pad separation (PTFPS) may fill this treatment gap.
Tendon-fat pad separation was popularized by Hakan Alfredson, MD, PhD, for midportion Achilles tendinopathy. It was referred to as tendon “scraping.” Given the favorable safety profile and high rate of return to sport for the technique, this is now being employed to treat athletes with patellar tendinopathy. The target of the procedure is to disrupt the neovascularity and painful neonerves that infiltrate the tendon from the fat pad. These pathologic neurovascular structures can be disrupted mechanically by a large-bore needle. The technique can be performed in the office under local anesthesia and does not violate the tendon structure, thus allowing for a rapid and safe return to athletic activity.
Technique setup, steps
Procedure setup and technique are performed in the office (Figures 1 and 2). The knee is flexed to 30° using a bolster with the patient in the supine position. The tendinopathic area is localized using ultrasound. After identifying the region of increase tendon thickness and increased Doppler signal, the area is prepped in the usual sterile fashion. Ultrasound is used to guide the procedure. Following sterile preparation at the proximal patellar tendon origin, a 25-gauge, 1.5-inch needle is used to inject 5 mL 1% lidocaine under the skin and between the patellar tendon and Hoffa’s fat pad. A skin wheal is created at the lateral border of the pathologic portion of the patellar tendon, and then a poke incision is made with an 11-blade. A 14-gauge 2-inch needle is attached to a syringe with 5 mL 1% ropivacaine and is advanced lateral-to-medial and placed between the tendon and fat pad. The needle bevel is turned anteriorly so the posterior surface faces the tendon.
Source: Michael R. Baria, MD, MBA
Taking care not to enter the tendon itself, the needle is used to separate the fat pad from the tendon in the sagittal plane by using gentle posterior-directed forces. Once the fat pad has been pulled away from the tendon surface, the needle is moved in a semicircular fashion in the coronal plane until the needle moves freely across the tendon and the ropivacaine can be injected under low resistance.
The entire procedure takes less than 5 minutes. The needle entry site is cleaned with alcohol and covered with Steri-Strips (3M) and Tegaderm (3M). No sutures are required.
Following the procedure, all patients are able to ambulate immediately without weight-bearing precautions. Patients can expect mild soreness at the site for 24 to 48 hours.
Rehabilitation, follow-up
Using the progression described by Alfredson for midportion Achilles tendinopathy, patients were permitted to walk during the first week, bike during the second week and return to running and full loading of the knee by the third week. Under the supervision of a certified athletic trainer or physical therapist, cut-pivot progression was permitted as tolerated after successfully returning to running.
Clinical outcomes
Nine patients underwent PTFPS. Three were lost to follow-up in our clinic. Of the six patients who followed up, five had primary patellar tendinopathy and one had ongoing pain despite previous open debridement. At 1 month, four patients attended their follow-up visit; three of the four patients experienced clinical improvement evidenced by crossing the minimal clinically important difference (MCID) threshold on the Victorian Institute of Sport Assessment-Patellar Tendon (VISA-P). These patients all engaged in competitive sport and returned to sport by 1 month without major complications.
At an average final follow-up of 13.5 ± 6 months, five of six patients crossed the MCID threshold without the need for additional treatment. The average improvement in the VISA-P score was 53 ± 24.2 points. No major complications occurred in the long term. Review of the medical record demonstrated that two of the three patients lost to follow-up ultimately underwent patellar tendon surgery for ongoing pain and activity restriction.
Discussion
Our small case series provides the initial clinical experience that PTFPS may be a safe, effective and simple intervention to treat patellar tendinopathy. Because it is minimally invasive and does not violate tendon structure, it allows for a rapid return to sport with minimal pain after the procedure and minimal risk of tendon rupture upon return to full loading activities.
Many of the non-surgical options have a delayed time to symptom relief. ESWT and PRP can take months to relieve symptoms. Although sclerosants, like polidocanol, have a similar target to the tendon-fat pad separation (disruption of neovessels), it can be difficult to obtain the sclerosing agents in some clinical settings. The tendon-fat pad separation requires only an ultrasound, needles and common local anesthetics. This makes it accessible to most sports medicine clinics, reduces the cost of the procedure and minimizes the risk of adverse events because no additional medications are administered.
High-volume image-guided injections (HVIGI) are the most similar procedure to what we presented here. In HVIGI, a mixture of anesthetic, saline and steroid is injected into the same tendon-fat pad interface. This procedure disrupts neovessels because the large amount of fluid distends the interface, thereby causing vessel disruption. While this reduces symptoms for patellar tendinopathy, the use of steroid heightens the risk of adverse events like patellar tendon rupture. Given that we use the PTFPS technique for in-season athletes, we recommend against using steroids in this population. Additionally, the HVIGI technique requires injection volumes of 40 mL, which increases patient discomfort. The PTFPS technique requires only 10 mL of anesthetic, minimizing discomfort after the procedure and potentially allowing an earlier return to activity.
Setting proper expectations for long-term outcomes for patients who undergo this procedure is important. We noted that while PTFPS helps in-season athletes return to play, their symptoms often return. This is indicated in our work by two of the three patients lost to follow-up in our clinic who required surgical debridement. Therefore, when we discuss the procedure, we communicate to patients that while we hope the pain relief is long term, the main goal is to reduce symptoms through the competitive season. A more definitive treatment, such as surgery, may then be performed later when a longer recovery time is available to the patient.
Conclusion
Tendon-fat pad separation may be a safe and technically simple intervention that can reduce patellar tendon pain and facilitate an early return to sport for in-season athletes. Patients may expect pain relief soon after the procedure, but symptoms may require additional treatment at the conclusion of the competitive season. Larger studies are necessary to determine return to sport rates and the possible need for additional treatments.
- References:
- Alfredson H. Br J Sports Med. 2011;doi:10.1136/bjsm.2010.081216.
- Baria MR, et al. (2020). Ultrasound-guided Percutaneous Tendon Scraping: A Novel Technique for Treating Patellar Tendinopathy. Techniques in Orthopaedics. Publish Ahead of Print. 1. 10.1097/BTO.0000000000000471.
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- For more information:
- Michael R. Baria, MD, MBA, is assistant professor in the department of physical medicine and rehabilitation. Christopher Kaeding, MD, is professor in the department of orthopaedics. They can be reached at Sports Medicine Research Institute, The Ohio State University, 2835 Fred Taylor Drive, Columbus, OH 43202. Baria’s email: michael.baria@osumc.edu. Kaeding’s email: serena.smith@osumc.edu.
- Daniel R. Lueders, MD, a physical medicine and rehabilitation physician at Burke and Bradley Orthopedics and University of Pittsburgh Medical Center, can be reached at 200 Delafield Road, Medical Arts Building 200, Suite 4010, Pittsburgh, PA 15215; email: luedersdr2@upmc.edu.
- Timothy L. Miller, MD, FAAOS, can be reached at 2835 Fred Taylor Drive, Columbus, OH 43202; email: timothy.miller@osumc.edu.
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Bahr R, et al. J Bone Joint Surg Am. 2006;doi:10.2106/JBJS.E.01181.
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