Knee Joint Tendonitis: Types, Symptoms, Treatment- Conservative, NSAIDs, PT, Surgery

Knee joint is involved in walking, standing and shifting weight from sitting to standing position or from supine to standing or sitting position. Several tendons support knee joint. Tendon is a bundle of fibrous tissue attached to bone on one side and muscles on other side.¹ Contraction of muscles pulls tendon and thus the bone to which tendon is anchored results in movement of the bone around the joint. Tendonitis is an inflammation of tendon. Tendonitis often follows injuries or overuse of the tendon and muscles following repeated movements caused by muscle contraction resulting in pull of the tendon.

• Above Patella– Quadriceps Tendon
• Below Patella– Patellar Tendon
• Medial Side Of Knee Joint-Vastus Medialis
• Lateral Side Of Knee Joint–
  1. Vastus Laterali
  2. Iliotibial Band
• Back of Knee Joint–

  

  1. Biceps Femoralis
  2. Semi-Membranous
  3. Semitendinous
  4. Gracialis, Plantaris

• Direct Impact
• Twist and turn of the joint
• Violent extension or flexion of the lower leg

• Tendon Inflammation
• Spread of infections from surrounding cellulitis

• Tendonitis is often seen as a work accident when manual worker consistently use vibrating equipment with legs.
• Driving heavy vehicles or earth moving equipment

• Repeated knee joint motions while driving, cycling, running, and skiing.

• Superficial tendon injury such as scratch or superficial laceration causes mild to moderate pain

• Partial tear of tendon causes moderate to severe pain.
• Partial tear of tendon may heal with scarring of tendon.

• Complete tear of tendon causes severe to very severe pain.
• Complete tear may not heal and may need surgical repair or tendon transplant.

• Age– Most common over age of 40 years.
• Sport Injuries– Knee joint injuries are most often seen in athletes involved in contact sports like football, ice hockey and soccer.
• Occupation– Heavy earth moving equipment operator is at risk of knee joint injury.
• Diet– Calcium or phosphorous deficiency can cause the knee joint injury.
• Physical Exercise– Lack of physical exercise is risky for knee joint injury and tendonitis.
• Alcohol Consumption– Alcohol consumption can cause fall and knee joint injury.

• Pain At Rest– Mild to severe pain at rest.
• Pain With Knee Joint Activities– Moderate to severe intractable pain is felt while walking or standing.
• Onset Of Pain–
  1. Sudden and Severe- Secondary to trauma or injury of the tendon.
  2. Slow and Mild- Seen following repeated knee joint movements resulting in tendon inflammation.
• Location of Pain–
  1. Below Patella- Patellar tendon inflammation is the most common tendonitis observed in elderly and middle aged patients.
  2. Above Patella- Pain is caused by tendonitis of tendon of Quadriceps muscles.
  3. Medial Side Of Knee Joint- Pain is caused by inflammation of tendon of Vastus Medialis muscles.
  4. Lateral Side Of Knee Joint- Pain is caused by inflammation of tendon of Vastus Laterali muscles and Iliotibial Band.
  5. Back of Knee Joint- Pain is caused by inflammation of tendon of Biceps Femoralis, Semi-Membranous, Semitendinous and Gracialis muscles.

• Muscle spasm of thigh and calf muscles are often observed in patients suffering with knee joint tendonitis.
• Pain often radiates to lower leg.

• Joint stiffness causes difficulty in flexion or extension of knee joint.

• Joint movements are restricted.
• Flexion and extension is painful and patient often tries to restrict knee joint movements.

• Severe pain is observed during change of position like sitting to standing or getting in and out of car.
• Anxiety Disorder-Chronic pain may be associated with anxiety disorder resulting in exaggeration of symptoms and further restriction of knee joint activities.
• Depression- Chronic knee joint pain is frequently associated with depression.

• Knee Joint Tenderness– Knee joint examination indicates tenderness and severe pain when deep pressure is applied over inflamed tendon.
• Joint Range Of Motion– Knee joint active and passive movements are restricted. Examiner often fails to achieve assisted optimum passive knee joint flexion because of pain and stiffness of the joint.
• Joint Stiffness– Stiffness observed during passive and active knee joint movement.
• Skin Temperature– Skin temperature over inflamed tendon is often increased and feels warm.
• Muscles Atrophy Of The Thigh And Calf Muscles– Loss of muscle mass or muscle atrophy in thigh and calf muscles are observed in late stages.

X-Ray is performed to rule out fracture and dislocations of the wrist joint.

• Isolated tendon swelling or tear is observed in special MRI targeted to evaluate soft tissue.
• Rule out fracture of wrist joint.
• Rule out dislocation of wrist joint.
• Diagnose blood clots or soft tissue swelling associated with tendonitis or tendon tear.

• Rule out fracture of wrist joint.
• Rule out dislocation of wrist joint.

• White Blood Cell Count (WBC)– WBC count is increased in infected or septic knee joint arthritis. WBC count is normal in tendonitis.
• Erythrocyte Sedimentation Rate (ESR)– ESR is increased in septic arthritis or cellulitis. ESR is also increased in knee joint pain caused by rheumatoid or psoriatic arthritis. ESR is normal in most of the tendonitis patient.
• Rheumatoid Factors (RF)– RF is increased in patients suffering with rheumatoid arthritis and normal in patient suffering with isolated tendonitis.
• Citrulline Modified Proteins (Anti-CCP)– Increase in rheumatoid arthritis.
• HLA-B27 Genetic Marker– Test is negative in tendonitis. But test is positive in inflammatory knee joint diseases caused by Psoriatic knee joint, Ankylosing Spondylitis and Reiter’s Syndrome.

• Rest
• Exercise of forearm and hand muscles
• Heat or cold therapy

• NSAIDs– Motrin, Naproxen and Celebrex
• Opioids– Opioids are prescribed when NSAIDs are ineffective in relieving pain.
  1. Short Acting Opioids- Vicodin, Lortab and Norco
  2. Long Acting Opioids- Oxycontin, MS Contin and methadone
• Antidepressant Analgesics– Prescribed when patient is unable to take NSAIDs and opioids because of side effects or inadequate pain relief. Neuropathic pain is often treated with antidepressant analgesics.
• Antiepileptic Analgesics– Prescribed to treat neuropathic pain and pain not responding to opioids, Neurontin and Lyrica.

• NSAIDs– Ibuprofen, Naproxen, Daypro or Celebrex
• Corticosteroids– Prednisone tablets or corticosteroid injection around tendon

Muscle relaxants are prescribed for muscle spasm and muscle pain. Following muscle relaxants are prescribed to treat muscle spasm caused by knee joint tendonitis.

• Baclofen
• Flexeril
• Skelaxin
• Robaxin

Indications for physical therapy (PT) for knee joint tendonitis is as follows-

• Pain
• Muscle spasm
• Joint stiffness
• Joint instability

• Maintain muscle tone
• Prevent muscle atrophy
• Reduce pain.

• Light or deep massage therapy
• Helps to improve blood circulation
• Rapid recovery from inflammatory disease

• Joint or tendon swelling is treated with cold therapy.
• Stiff joint movements are treated with heat therapy.
• Heat therapy includes infra red light treatment.

• Reduces pain and
• Improves circulation.

Interventional pain therapy is an invasive treatment, which involves insertion of needles or equipment (pump) to inject medications or equipment (stimulator) to stimulate nerve.

• Tendon injection is performed in surgical center.
• Injections in few cases are performed under sedation depending on procedure and patient’s apprehension regarding needle.

• Insertion and placement of spinal cord stimulator to stimulate spinal cord.
• Insertion of nerve stimulator to stimulate peripheral nerve.

• Delivers pain medication in Cerebrospinal Fluid (CSF).
• Catheter is placed in CSF and connected to pump
• Pump delivers pain medications stored in reservoir.
• Quantity of medications delivered intrathecally is controlled by computer device placed within the pump.
• Pump function is controlled by external controller.

• Tendonitis– No surgical treatment
• Tendonitis Caused By Tendon Tear– Tendon Suture- Torn tendon is brought together and sutured.
• Tendonitis Associated With Tendon Separation From Attachment– If the Tendon is separated from its attachment then the tendon is repositioned and sutured to periosteum of the bone at nearest position.
• Tendon Transplant– Severe tendonitis may cause severe tendon damage. Lacerated and torn tendon often looses length and becomes short. Tendon from other location is excised and attached to injured tendon.

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