Dr. Justin Arner:
Welcome everyone. I'm Dr. Justin Arner from the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania. Today, I have the distinct pleasure of speaking with my mentor and our partner, Dr. Bradley, who's the clinical professor of orthopedic surgery at the University of Pittsburgh Medical Center, and the longtime head team physician for the Pittsburgh Steelers. Dr. James Bradley is a special person in my life. He operated under my shoulder when I was 17 years old, and I was lucky enough to shadow him, and do research with him. And really got into the field solely because of him. So I'm certainly thankful to continue to learn from him, and work with him. I wanted to speak with Dr. Bradley today about our infographic, which I was again lucky enough to be involved in with also Dr. Chris Kaeding titled Management of Patellar Tendinopathy, which is in press in the Arthroscopy Journal. Welcome Dr. Bradley, and thanks so much for joining me.
Dr. James Bradley:
Oh, thank you for having me.
Dr. Justin Arner:
So tell us, this is a unique topic. How did you get interested in patellar tendinopathy to begin with?
Dr. James Bradley:
Well, the problem was with the athletes just choosing one sport, and not going through different sports. We were having a mini epidemic of proximal tendinopathy, and then there was no real good grading systems, or there was no good guidance, or flow charts to treat it. So we thought it was time for us to do that. We brought Dr. Kaeding in with us who he and I are very similar treatment patterns. He's the head team physician for Ohio State University. So we said together, we'll put our heads together, and see if we can come out with a good scheme.
Dr. Justin Arner:
Yeah. You mentioned that a lot of it's single sports specialization. Tell us a little bit more about the type of patients you typically see with this. Are they certain basketball players, or certain types of athletes?
Dr. James Bradley:
Yeah, typically overuse repetitive explosive activities. 55% of elite male basketball players have some form of tendinopathy, so it's very common.
Dr. Justin Arner:
Yeah. I think one thing is that if you're not looking for it, maybe you don't see it. I've seen quite a few people since you've taught me about this that have been pushed around for a year or two, and never really been diagnosed. You start sometimes with this pathology, with tendinopathy, and maybe progresses to a partial tear, or maybe there are different pathologies, but tell us, do you treat those differently with patients with tears versus tendinopathy?
Dr. James Bradley:
Oh, yeah. Typically, athletes continue to play with mild to moderate symptoms of tendinopathy, which can be aggravated, or then they can lead to partial tears like a continuum. But then when the micro tears, that's a micro injury to the tendon fiber. You get mucinous degeneration. You get necrosis. You get loss of transitional fiber, cartilage, and then there's commonly there's not a lot of inflammation. There's lack of inflammation when you get there.
Dr. Justin Arner:
Yeah. So that's why we call it tendinopathy instead of tendonitis. It's a good point. Tell us a little bit about the treatment options for these folks, and how you approach them.
Dr. James Bradley:
Well, actually the literature is limited. Non-operative we use non-steroidal anti-inflammatories. We use some form of Chopart bracing. We use eccentric PT. There's a 15-year outcome study that 53% of the people that were in that, retired from their sport, so it's not benign. We use extracorporeal shock, which we use Ortho Gold. There's one study out in the literature with 33 patients, and there were significant improvement versus controls at one year, and that was in 2013. Then what happens after that? The next phase is going to injections. So platelet-rich plasma we went to, and we started with leukocyte poor, and then we felt that we needed to aggravate the tendon more by increasing the number of platelets, and the number of monocytes.
So then we used a new system that comes out that will allow us to do that to try to get the engine started if you will. I didn't think poor was enough. Then what happens is the next phase is when these people, when it's torn, and the body's trying to heal it, these neo vessels grow in from the fat pad, and along with them comes the nerve fibers. The neo nerve fibers come with them.
So we have a technique by which you can lay them down. You can take a spinal, or a 14 gauge needle, and slide underneath their patella, and scrape that away under ultrasound sterilely, and then inject platelet rich plasma. I've had some good experience with that, and I've had some good experience that with high level professional athletes, both in the National Baseball League, and in the NFL, or the Major League Baseball League in the NFL. And then finally it's surgical debridement, right? So some people like to do it arthroscopic. I do not. Dr. Kaeding and I both agree that we make an incision over the top of it, and we basically take out the bad tissue, including part of the bone, and then try to force it to heal. Then we're looking at a large study that we're going to combine between our group and OSU.
Dr. Justin Arner:
Yeah, tell us a little bit about how you repair those. It sounds like you take a wedge out, and do you expose the bone to have some good healing elements? The bone marrow, we almost talk about meniscus repairs, and do you put anchors in? And what types of sutures? Do you have preferences regarding those?
Dr. James Bradley:
Yeah, so I make it, I take a five millimeter wedge of bone usually on either side, and in the top, so it is a little cube of bone, and I'll make it probably five millimeters or so, maybe a little wider like we're going to take a patellar tendon graft, but not as long. And then it's like an upside down Christmas tree incision. So I make a triangular starting the base bean at the base of the patella, and then down into a triangle into a point. And then the important thing is you leave that bone out. You just take a portion of it, not the full thickness of the patella.
Then you take tiny little retractors and lift up the patella tendon. Make sure you get the diseased tendon under those areas, and you scrape all the fat away. The fat's going to be adhesed to the bottom of the tendon on either side. Then what I do is I take simple vicryl sutures, interrupted inverted sutures, number ones, and I close the tendon. And I leave the bone alone. I don't put the bone back in. Sometimes if it's a big one, I'll have to use anchors on either side, but that's rare.
Dr. Justin Arner:
I would imagine that some of these, like you mentioned, they don't look too unhealthy when you look at the anterior surface of the tendon, but probably a big pearl is making sure you get underneath it, and make sure you get that poor tendon underneath. Is that a pearl you would is important?
Dr. James Bradley:
That's a very good pearl, and I use those little tiny hand retractors, so I don't hurt the tendon. I just everted it a little bit, and make sure I get all that disease tissue out of the bottom of that.
Dr. Justin Arner:
Have you had pretty good outcomes with your surgeries that you found?
Dr. James Bradley:
There's really no high quality comparative studies, and some of them, there was no difference in the 2013 international study that was done in KSSTA. There's a systematic review by yourself, and our other partner, our other fellow, Andy Sheen. In 2023, you reviewed in the systematic review 40 studies, return to sport was 88.4%. Return to the same level sport with 76.6, and surgeries definitely improved their PROs.
Dr. Justin Arner:
Yeah, so it seems like it's a good outcomes study. I think there haven't been good studies like you alluded to, comparing open versus arthroscopic. So that 2013 study looked at just debridement arthroscopically versus open. And we don't know the difference, but certainly, it makes sense to me about your plan there. Tell us about your thoughts about just injections with PRP in general. Do you think the scraping really makes the difference? Are you ever just injecting PRP?
Dr. James Bradley:
No, I think it works. There's an AJSM study from 2019, that's Andriolo I believe it was, and it showed promising results in a systematic review and meta analysis. And he took 70 studies of 2,530 patients. Eccentrics helped the most in the short term, less than six months, but multiple PRP injections did best greater than six months. Extracorporal shockwaves and eccentric exercises were the most helpful. So there's another prospective double-blind study by Rodas out in 2021 out of AJSM, and it was a prospective double-blind, randomized controlled trial of leukocyte poor versus BMAC. Both helped, but the tendon looked more normal with bone marrow concentrate.
Dr. Justin Arner:
Yeah, so there's some pretty good studies out there, but certainly not robust literature. And like you said, that seems like PRP in the long term almost like epicondylitis maybe is helpful longer term, and the eccentrics and the shock wave can be helpful too. It's a great point. The small series about patellar tendon scraping and PRP I find really interesting. Tell us how you thought about that, or started doing that. And it really seems like you think that those blood vessels are maybe a big pain generator. Tell us your thoughts about that.
Dr. James Bradley:
So if you look at the Achilles tendon literature, there's some fairly good papers that they scrape the vincula off the achilles tendon, and we use that, and extrapolated that to this. There are very few studies with this patella scraping, but I can tell you what I believe that happens is I believe the body tries to heal it through the fat pad. The vessels come in, and the nerves come with it. And if you can scrape those off and put some platelet rich plasma back there to keep it off, we've been really happy with that. And I'm talking about some high level players here.
Dr. Justin Arner:
Yeah, all different levels. It's I think a great portion in your armamentarium that's not super invasive. Tell us one thing you mentioned at the beginning where people that you decided to go ahead with surgery, tell us which patients you typically see, where are there certain patients where you say, "Well, this person's going to need surgery eventually," that are going to fail non-operative treatment?
Dr. James Bradley:
Yeah. So I use two things from Chris Ahmad's paper back in 2020 in AJSM. So he had a very good study, but basically what I use, once it passes 50% on the lateral of the MRI sagittal, and once it gets 11.5 millimeters on the first axial cut of the distal pole patella, so as soon as you get into the tendon, once that gets about 11.5, in his group, most of those had to go to surgery. So when I see that, I actually just saw two today, when I see that, I will push a little more for surgery because I don't want it to get too big. That's the problem. So I've had fairly good luck when it gets about that size, doing that little technique we do by opening them up, and getting rid of the bad tendon, and then closing them down again, and leaving the bone open.
Dr. Justin Arner:
Yeah, probably, I like the rotator cuff, a bigger tear you would think would probably lead to poor outcomes. So yeah, I think a lot of exciting knowledge here. I just wanted to ask you if you have any closing thoughts about this. I think it's not the sexiest topic, but a common topic that we miss a lot. And I know you and Dr. Kaeding are working on this.
Dr. James Bradley:
So my feeling on that is that's my go-to at the end. And I'm not really an arthroscopic guy taking away tendon and leaving a hole. That to me doesn't make sense to me. I want to repair the tendon.
Dr. Justin Arner:
Yeah, I think it's certainly reassuring that data that you spoke to us about. Thank you so much. I know you're such a busy guy, and it's the middle of the NFL season. Appreciate you taking the time with us today, and I'm honored to continue to learn from you. And I'm sure all the listeners will be really excited to hear all these pearls, which something we don't talk quite as much about. So thanks for your time, and for joining us today.
Dr. James Bradley:
Well, thank you. I think the study that Chris Kaeding and I are going to do put together with your help, I think that's going to answer a lot of these questions, be much more definitive in the long run.
Dr. Justin Arner:
Right. About who needs surgery, and who doesn't.
Dr. James Bradley:
Thank you.
Dr. Justin Arner:
Thank you. Dr. Bradley's infographic titled, Management of Patellar Tendinopathy is in press in the Arthroscopy Journal, and is available online at arthroscopyjournal.org. Thanks so much for joining us. This concludes this edition of The Arthroscopy Journal Podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association, or the Arthroscopy Journal. Thank you for listening. Please join us again next time.
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