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Quadriceps Tendinosis.

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I am diagnosed with quadriceps tendinosis in my right knee (confirmed with MRI-scan).
This condition is already ongoing for more than three months and seems to get worse. The pain is now continuous whilst in the beginning it was only a few days in the week.
Rest does not help!
I have no clue what to do any more. I visited several doctors and their advices were mixed. From specific training to take full rest.

Category: Orthopedic Surgeon

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Category: Spine Surgeon
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Hello,
Welcome at Doctorspring.
I have read your question with diligence.
From your details, it looks that you may be suffering from tendinosis of tendon of the quadriceps muscle.If you are able to walk or do sports activities and pain comes only after activity then you may get benefit from conservative treatment.This treatment consists of injection of cortisone or a sclerosing agent.
If this does not help you and the pain increases on activity then minor surgeries like arthroscopic shaving,longitudinal splitting of tendon may be helpful for you.
You can discuss these options with your orthopedic surgeon.

I hope this has helped. Please feel free to follow up with any further queries.
With best wishes



Patient replied :

Thanks for your answer. Think your diagnosis of tendinosis of the quadriceps is correct, but I am surprised about your proposed treatment.
Let me explain further.
I have pain most of the time (I don't do sports for months now) and even in my normal activities like walking, I feel some pain (as I indicated in my first email).
My orthopedic surgeon strongly advised again cortisone injections as this will, according to him, destroy my tendons and on a long term not benefit to proper healing and he also strongly dis-encourages surgeon.
Another orthopedic surgeon suggest to take full rest in order to let it heal, but after 3 months of more or less full rest, it does not get better, even worse.
Would appreciate if you can comment on this and whether there's alternative treatment available.



Admin Message : Our peer review team has flagged the Doctors response for including one or more suggestions that are NOT Evidence Based. Kindly ignore the above response from the Doctor. Your consult has been reassigned you can expect a reply from another Specialist MD soon. We are really sorry for the inconvenience.

Dr. Vivek Verman MD
Thank you

Reply:
Hello and thankyou for your query at DoctorSpring.com
From your diagnosis you have quadriceps tendinosis.

Here are a few things you will have to do which have been found to be beneficial in the treatment of tendinosis.
1) You can take Tylenol 3 times a day after food for 5 -7 days. If you have already taken an anti-inflammatory or painkiller tablet, you need not take this.
2) You will require to do Eccentric or heavy load exercises. This is the cornerstone of treatment for tendinosis. You will require to meet a physiotherapist who will guide you on these exercises, as they need to be done under supervision and the muscular exertion has to be monitored as it differs from person to person depending on their pain and fatigability and also the level of function them aim to return to. Your progression will have to be gradual and will have to be monitored.
3) Stretching exercises. This is found to be useful for both symptomatic relief of muscle spasm causing the pain and for corrective lengthening of shortened muscle- tendon units. The therapist will guide you on the stretching exercises. Stretching exercises are being used to prevention and treatment of this condition.
4) You can do warm water fermentation, by dipping a towel in warm water and placing it on the knee. You can do this twice a day as it will help relieve the muscle spasm cause a decrease in your pain.

It make take time for you to recover. Can take upto 3 - 4 months of doing these eccentric load exercises and stretching. Even if your symptoms persist you should not give up on the above physiotherapy exercises. During initial stages of your treatment your symptoms may worsen, and this does not necessarily mean your tendon injury has aggravated. Hence you will have to continue the treatment.

This is your action plan
- Begin with eccentric heavy load exercise program under supervision for 6- 12 weeks. You can use topical analgesic ointments during this time.
- If you felt improvement after 6-12 weeks, continue the exercises for 6 - 12 months
- If no improvement in 6 - 12 weeks your physiotherapist will have to modify the exercise program and adjust the load( exercise)
- If you feel no improvement after 6 months of diligent physical therapy you will require to meet your orthopedic surgeon and consider surgery.
- In addition in the first 5 - 7 days you can take Tylenol if you haven't already taken painkillers and you can do warm water fermentation.

I hope this has helped.
Feel free to follow up.
Thankyou


Patient replied :

Thanks you for your detailed answer.
I have a couple of follow-up questions and would like to have some clarification.

First I would like to have some clarification on some recommendations:

>>
You can take Tylenol 3 times a day after food for 5 -7 days. If you have already taken an anti-inflammatory or painkiller tablet, you need not take this.
>>
I cannot buy Tylenol here. Can you recommend similar medication? Just paracetamol, or ibuprofen?

>>
You will require to do Eccentric or heavy load exercises. This is the cornerstone of treatment for tendinosis. You will require to meet a physiotherapist who will guide you on these exercises, as they need to be done under supervision and the muscular exertion has to be monitored as it differs from person to person depending on their pain and fatigability and also the level of function them aim to return to. Your progression will have to be gradual and will have to be monitored.
>>
I will contact a Physiotherapist. Can you give some examples of heavy load and stretching exercises beneficial for healing for this injury I can propose and discuss with the physiotherapist?
>>

>>
You can do warm water fermentation, by dipping a towel in warm water and placing it on the knee. You can do this twice a day as it will help relieve the muscle spasm cause a decrease in your pain.
>>
Can I also use a warm pack? I suppose? Can I also draw the conclusion a coldpack does not help?
>>

>>
It make take time for you to recover. Can take upto 3 - 4 months of doing these eccentric load exercises and stretching. Even if your symptoms persist you should not give up on the above physiotherapy exercises. During initial stages of your treatment your symptoms may worsen, and this does not necessarily mean your tendon injury has aggravated. Hence you will have to continue the treatment.
>>
Questions:
* Despite doing only normal activities, the pain increased the past months significantly and I have problems doing my normal activities like walking and even in rest I feel some pain now. Especially if there’s pressure on the tendon. Do I have to continue doing my normal activities even when this hurts? It gives me the impression my tendon injury will be aggravated further? Should I not take total rest for a period of time?
* I am not intending to do any sports the next period, but I used to cycle to my work (few km’s). Can I continue doing this or do you recommend to stop as it might aggravate my injury (I think the reason for the injury is running and not cycling)?
* So I can expect full recovery of this injury if I do the exercises, stretching and take adequate rest (and a lot of patience)?

Please note the MRI-scan from December last year showed only a mild tendinosis (and at that time I hardly had any pain). Despite not doing any running afterwards, the situation has worsened.
Does it make sense to make a new MRI-scan to confirm the tendinosis? Could you advice on this?

Looking forward to a detailed answer and thanks in advance.


Mild Tendinosis in MRI is not something I would give much weightage.
I was under the impression the diagnosis was confirmed by imaging and Physical examination.

I would like to know where exactly you have the pain. Side of the knees / front / all round ?
Is the pain located just over the knee joint or does it extend further up or down ?
Is there any joint swelling ?
Is the pain worse or better when you wake up ?
What kind of activity makes ur pain worse ?
Any pain over other joints ?

--


Patient replied :

Sorry for the confusion.
The diagnosis was indeed mainly physical examination confirmed later (although not very obvious) by MRI.
I have the pain above my kneecap in the middle (perhaps a slightly to the left).
It does not extend further up and down and no swelling is observed and when you palpate I feel some pain on this location.
My pain is more or less equal over the day. I cannot say that I have less or more pain when I wake up and the pain seems to increase by more or less every normal activity I do.
Especially walking is very uncomfortable and painful. Cycling feels better. I don't know whether I should take complete rest or keep on moving, despite the pain. It worries me that the pain still is increasing, even with my normal daily activities.

I also have chondral degeneration in my right knee, but I have this condition for more than 15 years (and I had no problems the past 10 years as I could do every activity/sport) To paraphrase the analysis of the MRI scan ‘‘The cartilage at the back of the patella shows a focal highgrade defect on the medial side.’
So I don’t know whether this is related or has impact to my tendinosis?
Your answers to my questions from this and my last posting are very much appreciated.


Hello,

In view of the chondral degeneration in the right knee, the diagnosis need to be reconfirmed. Your symptoms are not typical of tendinitis. Infact based on the symptoms alone a diagnosis is not possible. A mild tendinitis in MRI will not account for this level of symptoms.

We need to know whether there is any damage to articular surface, any secondary osteoarthritis, any loose fragments, meniscal injury etc is there. The recommended next investigation would be a diagnostic arthroscopy.

I understand that this can be frustrating and challenging. But you need to be under the care of a Joint Specialist so that a proper diagnosis can be made. It still could be tendinitis but we need to rule out other causes. Treatment has to be planned only after confirming this. in view of these new finds please do not carry on with my recommendations for tendonitis.

Hope this helps
Thank you


Dr. Mukesh Tiwari
Category: Spine Surgeon
Experience: 
Fellowship - Khandaka Hospital, Jaipur
Residency - MS, Rabindranath Tagore Medical College, Udaipur, 2000
Medical School, Internship - MBBS, SMS Medical College, Jaipur, 1995
Dr. Mukesh Tiwari and 4 other Medical Specialists are ready to help you

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