0:00

Now this is tendinosis

0:01

and it looks like tendinosis anywhere in the body.

0:05

The tendon is thickened signal becomes more heterogeneous.

0:09

There may be some surface fibrillation or fraying,

0:12

and it's not particularly bright on your

0:15

T two weighted images.

0:16

Now, we could argue about this little piece here.

0:19

Maybe there's a micro tear developing.

0:21

Uh, but we can, uh, recognize basically we have a spectrum

0:25

between, uh, tendinosis and, and tears.

0:29

So perhaps there's a little bit of a tear here,

0:31

but the rest of this is all what you expect to see

0:34

with tendinosis.

0:35

He also has some changes related to arthrosis, uh, at the,

0:40

uh, patello, uh, femoral joint.

0:42

So this is very, very common.

0:44

And when you look at tendinosis in the quadriceps,

0:48

unlike tendinosis in some other areas,

0:50

it's often can be hypervascular.

0:53

Um, so if you do ultrasound, uh, you may see some, uh, micro

0:58

angiogenesis, uh, in this area.

1:00

If you give contrast, you may see some enhancement, uh,

1:04

in the, in the quadriceps.

1:06

And that's just a feature of tendinosis in this area

1:09

and why it's often painful.

1:11

Now, this is a patient, uh, with an acute tear.

1:15

Now we don't normally see tears in patients

1:18

unless the tendon is already abnormal.

1:21

It's a very, very strong tendon.

1:23

So the majority of patients

1:25

who develop frank tendon tearing have a background

1:28

of tendonosis of that tendon in the first place,

1:32

only about 10% of quadriceps tears are considered to be due

1:36

to just an acute deceleration trauma.

1:39

About 90% are in patients who have abnormal tendons,

1:44

either due to overuse aging

1:47

and a host of systemic diseases such as diabetes, obesity,

1:53

hyperparathyroidism, et cetera, that are known

1:55

to weaken the tendon and its attachment, uh, to the bone.

2:00

Here are some of the diseases that have been associated

2:03

with quadriceps tendon tears.

2:06

Uh, and this is particularly important when you see tearing

2:11

in women, because in women,

2:14

especially when you have bilateral tearing in women, uh,

2:17

these systemic, uh,

2:18

disorders are found in a significant number of patients.

2:22

So consider these,

2:23

and I especially like to think about hyperparathyroidism.

2:27

We have a large renal failure population,

2:29

and it's certainly very strongly associated with development

2:34

of, uh, quadriceps tears, uh, which which can be bilateral.

2:38

You also wanna think about these more when you are looking

2:41

at a young patient who doesn't have tendonosis, who comes in

2:45

with a quadriceps tendon tear,

2:48

and you can search to see if they have any history

2:50

of steroid use or, or diabetes

2:54

or, uh, one of these other, uh, disorders.

2:57

Now, in terms of description, what we wanna do is to try

3:00

to describe these as well as we can.

3:03

And it's difficult

3:04

because you're dealing with a multi-layered structure.

3:07

So in terms of thickness, thickness goes front to back.

3:12

So this is a partial thickness tear

3:14

because we have intact posterior fibers.

3:18

So again, when you look at the patella,

3:20

the patella tendon is gonna insert along the anterior half.

3:25

The posterior half is covered by this triangular, uh,

3:29

pre femoral, uh,

3:31

by this triangular supra patella, uh, fat pad.

3:34

So as I look at this case, I see

3:36

that the tendon fibers just in front

3:39

of the fat pad are intact.

3:41

So I know that's vastus intermedius.

3:43

And then I go here and I see a thinner bundle

3:46

retracted more approximately.

3:48

That's going to be the rectus,

3:50

and then a thicker bundle located in the middle,

3:53

and that's gonna be the medias and lateral alis.

3:56

The patients may have surprisingly good function, uh,

4:00

with just the intermedius, uh, intact.

4:03

And we like to open up our field

4:05

of view if we're monitoring the exam, uh,

4:08

which unfortunately doesn't happen much of the time,

4:11

but if we do happen to be monitoring it,

4:14

you could open up the field of view, uh, to make sure

4:17

that you got really captured the extent of retraction

4:20

that you have and to be able to assess the muscle quality,

4:24

uh, in these, uh, patients.

4:26

So those are the partial thickness tears involving

4:30

the anterior part.

4:32

And these are common

4:33

because if you look at partial thickness tears,

4:36

the most common component to be torn is the rectus femoris.

4:41

The partial thickness tears

4:42

that are posterior are much more

4:45

challenging for the clinician.

4:46

They're not difficult for us.

4:48

We can see here that the anterior fibers look pretty good,

4:52

but then we have a clump of fibers that are torn

4:56

and retracted,

4:57

and those are the fibers that should be right in front

5:00

of the effect pad.

5:01

That area is irregular, so I know that's vast

5:04

as intermediates, but this doesn't lead to the degree

5:07

of swelling and hemorrhage at the anterior knee,

5:10

that tearing of the anterior fibers does.

5:13

And the patient, again, may have fairly good function.

5:16

So this diagnosis may not be suspected, uh, clinically.

5:21

So Mr is very, very helpful

5:22

and it gives them a really good handle on the size

5:26

of the gap and the quality of the underlying tendon,

5:30

which are important factors

5:31

for deciding whether this can be fixed.

5:34

This is an unfortunate patient

5:36

who had had a patellar tendon tear in the past

5:39

that had been, uh, reconstructed,

5:41

and he presented with repeat pain.

5:44

You can see now we have a full thickness tear.

5:47

All of the layers of the quadriceps are disrupted

5:49

with fluid extravasated from the joint.

5:53

There's a stump of disease degenerated tendon at the upper

5:56

Patella.

5:57

The stump approximately doesn't look too bad.

6:01

We measure this gap,

6:03

tell them this tissue is severely degenerated.

6:05

It's gonna need to be debrided.

6:07

Uh, in this, uh, in this example

6:09

and in this tear, you can see that the change in the patella

6:14

or position, the more extensive the tearing,

6:17

the more changes we'll see in patella position.

6:20

And the typical position changes that'll occur is going

6:24

to be patella baja.

6:26

Not very striking in this case,

6:27

and really difficult to interpret given the previous surgery

6:30

here, that could have led to contracture of that tendon.

6:34

But Baja is the downward migration.

6:37

And the other finding we'll see is that the patella

6:40

will flex so that the space at the top widens

6:44

and the space at the bottom remains the same

6:46

or narrows that flexion.

6:48

Again. It requires a high grade tear for the patella

6:52

to assume this kind of a position.

6:54

Now, in order to call a tear complete, you want

6:57

to be sure it goes all the way from medial to lateral

7:00

as we have in this case.

7:01

So you can chase your sagittal images side to side.

7:05

You can use the other planes.

7:07

And here you can see on the axial images,

7:09

there's nothing left.

7:10

The medial ret inoculum has also been

7:13

disrupted in this example.

7:14

And on our coronals also, we can see

7:17

that the tear is going all the way from medial to lateral,

7:21

and that would be a, uh, complete tear, uh, which is, uh,

7:25

got a big gap in this example and a tendon otic, uh, tendon.

7:29

And this patient required a, uh, reconstruction.