**7.9 Surgical treatment**

*Tendons*

**Stage Program**

Stage 1 Adequate warm up Ice after activity

*Program for patellar tendinopathy.*

Stage 2 Addition of period of rest and heat before activity

Stage 3 Addition of prolonged period of rest

**7.6 NSAIDS**

**Table 1.**

not assessed [46].

**7.7 Corticosteroids**

returning to activity.

**7.8 Other medical treatments**

Although the benefits of NSAIDs are dubious, they are the most common drug used for symptomatic relief [43]. Although the use of "anti-inflammatory" medication seems paradoxical for a condition that is essentially degenerative, it is believed NSAIDs might act via mechanisms different from their conventional anti-inflammatory actions [44]. In vitro studies in human cartilage have revealed a variable interaction of NSAIDs with glycosaminoglycans (GAGs) where some have been shown to stimulate and some to inhibit, its synthesis [45]. This mechanism also sheds light on its effect on the synthesis of extra-cellular matrix. In a double blinded placebo controlled study, the use of NSAIDs in tendinopathy, piroxicam did not benefit patients with Achilles tendinopathy however topical ketoprofen reached the target tissue in patients with patellar tendinopathy, but the clinical efficacy was

Physiotherapy(isometric quadriceps exercises and an elastic knee support)

Local anti-inflammatory treatments, including non-steroidal anti-inflammatory drugs (NSAIDs)

Corticosteroids are known for reducing the symptoms arising from the inflamed synovial structures. However the role of corticosteroids remains controversial in management of tendinopathy. According to Jozsa and Kannus [47] steroids are contraindicated in acute phase of tendinopathy and in the late chronic phase of tendinopathy when the tendon degeneration is advanced which may lead to tendon rupture. However it has proved beneficial when diluted with anesthetic for diagnostic reasons and to minimize adverse effects and in conditions where 1–6 week rest period combined with a programme of gradual strengthening is required before

Aprotinin, an 85 amino acid 65 kDa basic polypeptide extracted from bovine lungs has shown to offer better pain relief than steroids at least in short term. However aprotinin which is a strong inhibitor MMP (matrix metalloproteinase) is less effective in insertional tendinopathy as compared to main body [48]. Another non-surgical treatment option includes use of sclerosing agent with chemical irritant (e.g. polidocanol) [8, 49, 50]. These targets the neovascularization and accompanying nerves. The use of platelet-rich plasma injection has been tried in tendinopathy and favorable outcome have been found [51–53]. However still there is no level 1 or level II studies about role of PRP in patellar tendinopathy. The glyceryl trinitrate (GTN) patch [54, 55], which delivers nitric oxide (NO) to pathological tendon which play role in tendon healing. But we still need level1or level II evidence

**62**

to support it.

Patellar tendon surgery is indicated in patients who have failed conservative management more than 6 weeks [56–58]. A variety of surgical procedures have been described such as resection of the tibial attachment of the patellar tendon with realignment, drilling of the inferior pole of the patella, macroscopic necrotic area excision [59], repair of macroscopic defects, longitudinal tenoplasty/tenotomy of the tendon [60] percutaneous longitudinal tenotomy, percutaneous needling [61] and arthroscopic assisted decompression [62, 63] of the tendon, possibly with excision of the inferior pole of the patella however the effectiveness of any single procedure has not been elucidated.
