Received Date : 08-Sep-2016

Accepted Date : 13-Feb-2017

Article type : Original Article
Accepted Article
Anatomical study of the inferior patellar pole and patellar tendon
Short title: The mechanism of patellar tendinitis

Edama M1,2; Kageyama I2; Nakamura M1; Kikumoto T1; Nakamura E1; Ito W1; Takabayashi T1;

Inai T3; Onishi H1

1
Institute for Human Movement and Medical Sciences, Niigata University of Health and

Welfare, Niigata, Japan

2
Department of Anatomy, School of Life Dentistry at Niigata, Nippon Dental University, Niigata,

Japan
3
Department of Rehabilitation, Oguma Orthopedics Clinic, Niigata, Japan

Corresponding author: Mutsuaki Edama, Institute for Human Movement and Medical

Sciences, Niigata University of Health and Welfare, Shimami-cho 1398, Kita-ku, Niigata City

950-3198, Japan

Tel: +81 25 257 4723, Fax: +81 25 257 4723, E-mail: edama@nuhw.ac.jp

ABSTRACT

In this study, detailed investigations of the shape of the inferior patellar pole, the site of the

patellar tendon attachment, and the length and course of the patellar tendon were performed

with the aim of examining the anatomical factors involved in the developmental mechanism of

patellar tendinitis. The investigation examined 100 legs from 50 cadavers. The inferior

patellar pole was classified into three types: Pointed, Intermediate, and Blunt. The attachment
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doi: 10.1111/sms.12858
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 of the patellar tendon to the inferior patellar pole was classified into two types: an anterior and

a posterior. The length of the patellar tendon was measured from the tibial tuberosity to the
Accepted Article
inferior patellar pole. The Pointed Type was seen in 57% of legs, the Intermediate Type in

21%, and the Blunt Type in 22%. Twenty-one legs were the Pointed Type, as well as the

Anterior Type. The patellar tendon was significantly shorter with the Posterior Type than with

the Anterior Type. The Blunt Type also had a significantly shorter patellar tendon than the

Pointed Type. In legs that were both the Pointed Type and the Anterior Type, the inferior

patellar pole and the proximal posterior surface of the patellar tendon impinged during knee

flexion due to the posterior tilt of the patella, suggesting the possibility that this may induce

damage. With the Posterior Type and Blunt Type, on the other hand, the possibility of strong

tensile stress on the tendon fibres of the posterior facet of the inferior patellar pole was

suggested.

Keywords: patellar tendinitis, patellar tendon, inferior patellar pole, tensile load, impingement

INTRODUCTION

Patellar tendinitis is a typical overuse injury from sports such as basketball and volleyball

that involve jumping movements(Hamilton&Purdam, 2004; Peers&Lysens, 2005). It does not

become serious in many cases, but it has a high recurrence rate and is difficult to

manage(Peers&Lysens, 2005). Several effective treatments have been reported(Larsson et

al., 2012; Rodriguez-Merchan, 2013; van Leeuwen et al., 2009; Young et al., 2005), but the

lack of an effective method of prevention is a concern(Hamilton&Purdam, 2004). One reason

for this is that the mechanism by which patellar tendinitis develops is only poorly understood.

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 Representative mechanisms are reported to be a repetitive overload mechanism from

repeated tensile loads and an impingement mechanism, in which the inferior patellar pole and
Accepted Article
the proximal posterior surface of the patellar tendon impinge on each other(Peers&Lysens,

2005). With regard to the repetitive overload mechanism, a report from a study using fresh

cadavers supported a mechanism in which there is a greater increase in strain on the anterior

side than on the posterior side of the proximal patellar tendon when the knee is flexed from 0°

to 60°(Almekinders et al., 2002) . However, there are also contradictory reports that the

proximal posterior surface of the patellar tendon is a favoured site for patellar

tendinitis(Shalaby&Almekinders, 1999), and that the patellar tendon is only stretched during

the initial stage of knee flexion(Defrate et al., 2007). With regard to impingement mechanisms,

an influential report from a study using finite element analysis stated that increased strain was

observed with impingement of the inferior pole of the patella on the proximal posterior surface

of the patellar tendon, a common site of damage, when the patella is tilted

posteriorly(Lavagnino et al., 2008). However, there is also a contradictory report that the

shape of the inferior patellar pole has no effect on injury(Schmid et al., 2002). At present,

therefore, the mechanism for the development of patellar tendinitis remains

controversial(Peers&Lysens, 2005).

Possible reasons for this lack of agreement are the small number of anatomical reports on

the patella and patellar tendon(Basso et al., 2001), and that no biomechanical studies of the

patellar-femoral joint have been conducted based on their anatomical

characteristics(MacIntyre et al., 2006; Suzuki et al., 2012). To resolve these problems, the

anatomical characteristics of the patella and patellar tendon need to be elucidated in detail

through basic research.

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 The aim of this study was to conduct a detailed investigation of the shape of the inferior

patellar pole, the site of the patellar tendon attachment, and the length and course of the
Accepted Article
patellar tendon, as well as to examine the anatomical factors in the mechanism for the

development of patellar tendinitis.

SUBJECTS AND METHODS

Cadavers

This investigation examined 100 legs from 50 Japanese cadavers (mean age at death, 80

± 11 years; 56 sides from men, 44 from women) that had been switched to alcohol after

placement in 10% formalin. None showed signs of previous major surgery around the knee.

This study was approved by the Ethics Committee at our institution.

Methods

The dissection of the patella and patellar tendon was done with reference to the report of

Basso et al(Basso et al., 2001). First, the skin, subcutaneous tissue, and fascia around the

knee joint were removed, and the patellar tendon was extracted together with the patella and

tibial tuberosity. Next, the synovial membrane and fatty bodies around the patellar tendon

were carefully removed, and the patella and patellar tendon were dissected. The inferior

patellar pole was classified with reference to the report of Schmid et al(Schmid et al., 2002).

Lateral plain radiographs of the patella were obtained using a three-dimensional X-ray

computed tomography system (3DX Multi-Image Micro CT, Morita, Osaka, Japan), and the

inferior patellar pole was classified into three types: Pointed, Intermediate, and Blunt. The

length of the inferior patellar pole (P), which is a non-articular surface, and the length of the

articular surface of the patella (AS) were measured from the obtained lateral images, and the

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 P:AS ratio was calculated (Johnson et al., 1996) (Figure 1). Image analysis software (Image J,

National Institutes of Health, Bethesda, MD, USA) was used for the measurements on the
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images. The attachment of the patellar tendon to the inferior patellar pole was classified into

two types, an Anterior Type and a Posterior Type (Basso et al., 2001; Schmid et al., 2002).

The patellar tendon length was measured as the length from the tibial tuberosity to the inferior

patellar pole on the posterior surface of the patellar tendon using digital callipers (digital

caliper, Shinwa, Niigata, Japan) (Figure 2). Although the patellar tendon fibre bundles were

strongly fused, they were carefully teased apart into fibre bundles of approximately 2-3 mm

and observed macroscopically to determine the patellar tendon fibre course.

Statistical analysis

Comparisons of inferior patellar pole type and patellar attachment type between men and

women and between left and right were done using the chi-squared test. Comparisons of the

P:AS ratio for the patellar tendon attachment type onto the inferior patellar pole were done

using one-way measures ANOVA and the Tukey-Kramer test. For the patellar tendon length,

comparison between anterior and posterior surfaces was done using the unpaired t-test, and

comparison between the patellar tendon attachment type and inferior patellar pole type was

done using two-way repeated measures ANOVA (type of patellar tendon attachment onto the

inferior patellar pole × type of inferior patellar pole). One-way ANOVA and the Tukey-Kramer

test were then performed for items that showed a main effect. The level of statistical

significance was 5%.

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 RESULTS

Inferior patellar pole type

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The Pointed Type was seen in 57 legs (57%), the Intermediate Type in 21 legs (21%), and

the Blunt Type in 22 legs (22%) (Figure 3). In men, the Pointed Type was seen in 39 legs

(70%), the Intermediate Type in 10 legs (18%), and the Blunt Type in 7 legs (12%). In women,

the Pointed Type was seen in 18 legs (41%), the Intermediate Type in 15 legs (34%), and the

Blunt Type in 11 legs (25%), showing a significant difference (P < 0.05). On the right side, the

Pointed Type was seen in 29 legs (58%), the Intermediate Type in 9 legs (18%), and the Blunt

Type in 12 legs (24%). On the left side, the Pointed Type was seen in 28 legs (56%), the

Intermediate Type in 12 legs (24%), and the Blunt Type in 10 legs (20%). No significant

difference was seen.

The P:AS ratio was 0.39 ± 0.02 for the Pointed Type, 0.31 ± 0.02 for the Intermediate Type,

and 0.26 ± 0.02 for the Blunt Type. The Pointed Type was found to have a significantly larger

P:AS ratio than the other two types (vs. Intermediate Type p < 0.05, vs Blunt Type p < 0.01).

Patellar tendon attachment type

The attachment type was the Anterior Type in 46 legs (46%) and the Posterior Type in 54

legs (54%) (Figure 4). In men, it was the Anterior Type in 20 legs (36%) and the Posterior

Type in 36 legs (64%). In women, it was the Anterior Type in 26 legs (59%) and the Posterior

Type in 18 legs (41%). No significant difference was seen. On the right side, it was the

Anterior Type in 24 legs (48%) and the Posterior Type in 26 legs (52%), and, on the left, it

was the Anterior Type in 22 legs (44%) and the Posterior Type in 28 legs (56%). No

significant difference was seen.

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 Relationship between the inferior patellar pole and the site of patellar tendon

attachment
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With the Pointed Type of inferior patellar pole, the attachment was the Anterior Type in 21

legs (37%) and the Posterior Type in 36 legs (63%). With the Intermediate Type, the

attachment was the Anterior Type in 13 legs (62%) and the Posterior Type in 8 legs (38%).

With the Blunt Type, it was the Anterior Type in 12 legs (55%) and the Posterior Type in 10

legs (45%).

Patellar tendon length

The patellar tendon length was 54.9 ± 1.2 mm on the anterior surface and 35.0 ± 0.6 mm

on the posterior surface. The patellar tendon length was significantly shorter on the posterior

surface than on the anterior surface (P < 0.01). The results of two-way repeated measures

ANOVA (type of patellar tendon attachment onto the inferior patellar pole × type of inferior

patellar pole) showed no interaction, and since a significant main effect was seen between

the groups, one-way ANOVA and the Tukey-Kramer test were used. The patellar tendon

length was found to be significantly shorter with the Posterior Type than with the Anterior

Type (P < 0.05), and significantly shorter with the Blunt Type than with the Pointed Type (P <

0.05) (Table 1).

Patellar tendon fibre course

The course of the patellar tendon fibre bundles showed a linear structure in all cases

(Figure 5).

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 DISCUSSION

The present study morphologically clarified the shape of the inferior patellar pole, the site of
Accepted Article
patellar tendon attachment, and the length and course of the patellar tendon. To the best of

our knowledge, there have been no large-scale anatomical studies that elucidated the shape

of the inferior patellar pole and patellar tendon and investigated factors related to the

mechanism of the development of patellar tendinitis from the anatomical perspective.

This study found that the inferior patellar pole was the Pointed Type and the patellar

attachment was the Anterior Type in 21 legs. Considering that, in a previous study, posterior

tilt of the patella was seen as a problem involved in the “impingement mechanism”(Lavagnino

et al., 2008), it is thought that impingement is more likely to occur with the Pointed Type than

with the Blunt Type inferior pole, and with the Anterior Type than with the Posterior Type

patellar tendon attachment site. In a study using MRI(Schmid et al., 2002), however, there

was reported to be no significant difference in the shape of the inferior patellar pole between

a patellar tendinitis group and a control group. They did find that the proximal patellar tendon

was significantly thicker in the patellar tendinitis group, and significantly more people in the

group had the Posterior Type attachment. Similarly, in another MRI study(Johnson et al.,

1996), no significant difference was reported in the P:AS ratio between a patellar tendinitis

group and a control group, but the proximal patellar tendon was significantly thicker in the

patellar tendinitis patients. Since the proximal portion of the patellar tendon is reported to be a

common site of patellar damage in patellar tendinitis patients, and thickening is also useful in

diagnosis(Peers&Lysens, 2005), it may be that this is a secondary manifestation. Both of

these MRI studies were retrospective(Johnson et al., 1996; Schmid et al., 2002), however,

and a prospective study that considers the type of inferior patellar pole and the type of

patellar attachment appears to be needed.

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 The results of the present study with regard to bilateral and sex differences showed a sex

difference only in the type of inferior patellar pole. No previous studies have reported sex
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and bilateral differences in the structure of the patella and patellar tendon. A prospective

cohort study reported that the incidence of patellar tendinitis was 21.1% in men and 10.8% in

women(Backman&Danielson, 2011). No significant difference was seen, but it tended to be

more common in men. Consequently, a prospective study of whether differences in inferior

patellar pole structure are a risk factor is needed in the future.

The results for patellar tendon length showed that the posterior surface of the patellar

tendon was significantly shorter than the anterior surface. The posterior patellar tendon

length was found to be significantly shorter with the Posterior Type than with the Anterior

Type attachment. It was also found to be significantly shorter with the Blunt Type than with the

Pointed Type inferior pole. A previous study using fresh cadavers reported the Posterior

Type in 6 of 22 knees(Almekinders et al., 2002), and since the patellar tendon length on the

posterior surface of the inferior patellar pole, which is a common site of patellar tendinitis, is

shorter than the anterior surface, it may be that this site is more susceptible to repeated

tensile stress. This suggests the possibility that, when the patella is tilted posteriorly, strong

tensile stress is applied to the tendon fibres of the posterior surface of the inferior pole of the

patella with the Posterior Type and Blunt Type morphology.

In investigating the mechanism of the development of patellar tendinitis, many reported

studies have examined the strain on the patellar tendon when the knee joint is flexed. In a

study using optic fibre in healthy adult subjects(Dillon et al., 2008), tendinous forces were

reported to be stronger on the posterior surface than on the anterior surface of the proximal

patellar tendon during knee movement. In a study using fresh cadavers(Basso et al., 2002),

it was reported that, when the knee joint was flexed with the application of uniform tension

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 on the quadriceps muscle, the strain increased more on the posterior fibres than on the

anterior fibres with knee flexion of 60° and 90°. However, in another study using fresh
Accepted Article
cadavers(Almekinders et al., 2002), the strain was reported to increase more on the anterior

surface than on the posterior surface in the proximal patellar tendon when the knee joint was

flexed from 0° to 60°. Differences in subjects and study methods may have been factors in

these different findings, but it is also possible that the results were affected by differences in

the patellar tendon attachment site and in the length of the patellar tendon, as in the results

of the present study.

All cases in the present study showed a linear structure for the course of the patellar

tendon. In the Achilles tendon (AT), a site of common injury in sports along with the patellar

tendon, a characteristic twisted structure has long been reported(Cummins et al., 1946;

Edama et al., 2015; Edama et al., 2016; Szaro et al., 2009). In recent years, the functional

role of this twisted structure (Bojsen-Moller&Magnusson, 2015; Dean et al., 2007) and the

possibility that it contributes to the occurrence of injuries such as AT injury (Lersch et al.,

2012) have attracted attention. One could speculate, therefore, that a similar characteristic

structure exists for the patellar tendon that attaches to the patella (MacIntyre et al., 2006;

Suzuki et al., 2012), which has complex three-dimensional movement. However, all

specimens in the present study showed a linear structure.

The present study was a morphological examination of the shape of the inferior patellar

pole, the patellar tendon attachment site, and the length and course of the patellar tendon,

but it has several limitations. First, the specimens used in this study were from cadavers of

elderly people with a mean age of 80 ± 11 years, and second, this study investigated the

patellar tendinitis developmental mechanism based only on the morphological characteristics

of the patella and patellar tendon.

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 PERSPECTIVE

Previous reports included studies that created 3D models with MRI(Defrate et al., 2007),
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studies using finite element analysis(Tyler et al., 2002), and studies using strain gauges with

fresh cadavers, among others(Almekinders et al., 2002; Dillon et al., 2008). None of them,

however, considered the type of inferior patellar pole shape or the attachment site and length

of the patellar tendon. This may be one reason why there is still no uniform agreement on the

mechanism of the development of patellar tendinitis. The results of the present study suggest

the possibility that the developmental mechanism differs depending on structural differences,

and that development occurs with a combination of two mechanisms: a repetitive overload

mechanism from repeated tensile load; and an impingement mechanism in which there is

impingement between the inferior patellar pole and the posterior surface of the proximal

patellar tendon. Future biomechanical studies with the present findings as background data

are needed.

ACKNOWLEDGMENTS

This study was supported by a Research Activity Young B Grant (20632326) from the Japan

Society for the Promotion of Science (JSPS) and a Grant-in-Aid program from Niigata

University of Health and Welfare (H27B04).

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Legends

Figure 1. The method of measurement of the length of the non-articular inferior pole

and the

length of the articular surface of the patella

P: The non-articular inferior patellar pole

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 AS: The length of the articular surface of the patella
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Figure 2. Measuring the length of the patellar tendon, right side.

A: front side. B: back side. 1: patella. 2: patellar tendon. 3: tibial tuberosity. 4: inferior patellar

pole. 5:

The inferior aspect, patellar tendon length, from the inferior patellar pole to the tibial tuberosity.

6: The

posterior aspect, patellar tendon length, from the inferior patellar pole to the tibial tuberosity.

Figure 3. Type classification of the Inferior patellar pole, right side, lateral view.

A-C：Lateral view of the patella.

a-c： X-ray lateral view of the patella.

Figure 4. Attachment classification of the patellar tendon on the patella, right side,

posterior

view.

Anterior Type: Adheres to the anterior aspect of the inferior patellar pole.

Posterior Type: Adheres to the posterior aspect of the inferior patellar pole.

White arrow: Patellar tendon fibre attachment to the inferior patellar pole

Figure 5. Methods of fine dissection of each fibre bundle, the right patellar tendon.

A: front side. B: back side. 1: patella. 2: patellar tendon. 3: tibial tuberosity. 4: inferior patellar

pole.

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 Table 1. Attachment patellar tendon length by type.

Values represent means ± SE. *p < 0.05.

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Table 1. Attachment patellar tendon length by type

Pointed Intermediate Blunt

Type Type Type Total
Anterior 37.5 ± 1.4 35.0 ± 1.5 35.6 ± 36.3 ±
Type 2.0 0.9
＊
35.3 ± 0.9 32.4 ± 1.5
Posterior 30.0 ± 33.8 ±
Type 36.1 ± 0.7 34.0 ± 1.1 3.0 0.8
＊

Total 33.0 ± 35.0 ±

1.8 0.6
Values represent means ± SE. *p < 0.05.

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