ISSN Versión Online: 2308-0531

Rev. Fac. Med. Hum. April 2021;21(2):449-458.

Facultad de Medicina Humana URP
DOI 10.25176/RFMH.v21i2.3621
CLINICAL CASE

PATELLAR LIGAMENT RUPTURE AS A COMPLICATION OF

POOR APPLICATION TECHNIQUE OF RADIAL PRESSURE
WAVE THERAPY. REPORT OF TWO CASES
ROTURA DE TENDONES ROTULIANOS COMO COMPLICACIÓN DE MALA TÉCNICA DE APLICACIÓN DE ONDAS
DE PRESIÓN RADIAL. REPORTE DE DOS CASOS
Paul Terán-Vela1,a, Walter Insuasti-Abarca1,b, Sussan Llocclla-Delgado2,c, Tania Platero-Portillo3,c,
Diana Martínez-Asnalema4,c, Lilian Abarca-García5,d

ABSTRACT
Patellar tendinopathy is characterized by anterior knee pain located at the lower pole of the patella at the
junction of the patellar tendon. This is often a disabling condition that limits patients' quality of life, affects
their ability to participate in sports, and even hinders their normal daily activities. Extracorporeal shock
wave therapy (ESWT) has been recognized as a promising and safe alternative for the treatment of various
CLINICAL CASE

musculoskeletal disorders – including chronic patellar tendinopathy. However, there is limited evidence
regarding its side effects, in particular ESWT-associated tendon injuries. To the authors' knowledge, this is
the first report demonstrating clinical and radiological evidence of two patients without known risk factors
for partial patellar tendon tears that developed this condition after the application of radial pressure wave
therapy - also known as radial shock wave therapy - for patellar tendinopathy. ESWT must be applied by
properly trained professionals so that specific requirements needed to guarantee an appropriate application
technique, minimize possible adverse effects, and improve patient safety could be met.
Key words: Patellar ligament; Extracorporeal Shockwave Therapy; Tendinopathy; Case reports (source: MeSH
NLM).

RESUMEN
La tendinopatía rotuliana se caracteriza por dolor anterior de la rodilla localizado en el polo inferior de la rótula
en la unión del tendón rotuliano. Esta es, a menudo, una condición discapacitante que limita la calidad de vida
de los pacientes, afecta su capacidad para participar en deportes e incluso dificulta sus actividades cotidianas.
El tratamiento de ondas de choque extracorpóreas (ESWT por sus siglas en inglés) ha sido reconocido como una
alternativa prometedora y segura para el tratamiento de diversos trastornos musculoesqueléticos, incluida la
tendinopatía rotuliana crónica. Sin embargo, existe evidencia limitada con respecto a sus efectos secundarios,
en particular las lesiones de tendones asociadas con ESWT. Según el conocimiento de los autores, este es el
primer artículo que demuestra evidencia clínica y radiológica de dos pacientes sin factores de riesgo que
presentan desgarros parciales del tendón rotuliano después de haber recibido terapia de ondas de presión
radiales, también conocida como terapia de ondas de choque radiales, como tratamiento para la tendinopatía
rotuliana. El tratamiento con ondas de choque debe ser aplicada por profesionales debidamente capacitados
para que se cumplan los requisitos específicos necesarios para garantizar una técnica de aplicación adecuada,
minimizar los posibles efectos adversos y mejorar la seguridad del paciente.
Palabras clave: Ligamento rotuliano; Tratamiento con Ondas de Choque Extracorpóreas; Tendinopatía;
Informes de Casos (fuente: DeCS BIREME).

1 Centro de Especialidades Ortopédicas, Quito - Ecuador.

2 Instituto de Investigaciones en Ciencias Biomédicas. Universidad Ricardo Palma, Santiago de Surco, Lima - Perú.
3 Facultad de Medicina, Universidad de El Salvador, San Salvador - El Salvador.
4 Departamento de Medicina Física y Rehabilitación, Hospital General Luis Dávila, Tulcán - Ecuador
5 Facultad de Medicina, Pontificia Universidad Católica del Ecuador, Quito - Ecuador.
ª Doctor. Specialist in Orthopedic Surgery and Traumatology, b Medical. Department of Internal Medicine, c Physician, d Student.
Cite as: Paul Terán-Vela, Walter Insuasti-Abarca, Sussan Llocclla-Delgado, Tania Platero-Portillo, Diana Martínez-Asnalema, Lilian Abarca-García.
Patellar ligament rupture as a complication of poor application technique of radial pressure wave therapy. Report of two cases. Rev. Fac. Med.
Hum. April 2021; 21(2):449-458. DOI 10.25176/RFMH.v21i2.3621

Journal home page: http://revistas.urp.edu.pe/index.php/RFMH

Article published by the Magazine of the Faculty of Human Medicine of the Ricardo Palma University. It is an open access article, distributed under the terms of the
Creative Commons License: Creative Commons Attribution 4.0 International, CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/), that allows non-commercial
use, distribution and reproduction in any medium, provided that the original work is duly cited. For commercial use, please contact [email protected]

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INTRODUCTION energy on an applicator and has a more superficial

effect on the tissues(8).
Patellar tendinopathy, also called "jumper's knee"(1),
is characterized by anterior knee pain located at the The Latin American Societies and Associations on
lower pole of the patella at the junction of the patellar Shockwave in Medicine (ONLAT)(9) has made efforts
tendon. This condition is common among athletes to define the risk factors linked to complications
who perform jumping activities with a prevalence after shock wave therapy application. These include:
of around 36% in basketball and volleyball players(2). 1. Diagnostic errors. Prior to the administration of
More often, patellar tendinopathy is related to injuries shock wave therapy, the type of pathology must
produced after repetitive mechanical tension of the be correctly identified - e.g. tendinopathy; calcific
patellar tendon producing an inflammatory response or fibrous tendinopathy; tendon tear; unspecific
with subsequent tendon fiber degeneration. It can pain syndrome.
limit patients' quality of life, affect their ability to
participate in sports, and even hinder their normal 2. Technical errors generated by the operator. The
daily activities. operator must be qualified and trained by the
corresponding scientific societies. In addition, the
On the other hand, patellar ligament rupture is a very
CLINICAL CASE

anatomy, physiology and pathophysiology of the

rare disorder with an estimated prevalence of 0.6% .
disease being treated, as well as the indications
Risk factors that may predispose patients to develop
and contraindications of the therapy, must be
this condition include obesity, being high elite or
completely understood. Lack of knowledge about
amateur athletes with chronic patellar tendinopathy
the type of device and its characteristics is also
(generating repetitive microtraumas over the
classified as a technical error. Knowing the correct
tendon)(3), systemic diseases (e.g., rheumatoid
application technique of shock wave therapy is
arthritis or systemic lupus erythematosus), long-
mandatory, e.g. correct position of the patient
term corticosteroid use, chronic kidney disease,
during the procedure, localization of the site to
fluoroquinolone use(4), elderly, and previous surgical
be treated -which is generally identified under
procedures that disturb the midsubstance or
ultrasonographic guidance-, and establishment
insertion sites of the patellar tendon, such as total
of the ideal energy protocol for each pathology.
knee arthroplasty(5).
3. Adverse effects of the radial wave therapy
Extracorporeal shock wave therapy (ESWT) has been
application such as increased pain, erythema,
recognized as a promising and safe alternative for
bruising, among others. Adverse effect
the treatment of various musculoskeletal disorders
management should be addressed by the medical
– including chronic patellar tendinopathy(6) - due to
personnel.
its practical analgesic effects and ability to promote
tissue remodelling and repair(6-7). There is limited evidence regarding the side effects
of the therapy, in particular ESWT-associated tendon
Currently, there are several shock wave therapy
injuries. In fact, there is only one case in the literature
application devices, and each unit varies in terms of
reporting an Achilles tendon rupture after ESWT(10);
the type of wave it provides - radial or focal - thus
consequently, to the authors' knowledge, this is
determining its use for a specific pathology; however,
the first report demonstrating two cases of partial
the energy provided by the devices is given primarily
patellar tendon tears after the application of radial
on an operator basis, so the risks of applying shock
pressure wave therapy also known as radial shock
waves do not depend on the device used, but on the
wave therapy.
protocol established by the operator.
There are currently two wave types, first, a focal PRESENTATION OF CASES
shock wave that provides a more significant amount
CASE 1
of energy in deep planes generated by piezoelectric,
electromagnetic, or electrohydraulic equipment A 16-year-old previously healthy boy arrived at
that can activate reparative cellular processes even Centro de Especialidades Ortopédicas in Quito
in bone tissue. Second, a radial pressure wave that complaining about intense right knee pain. The
is generated through the kinetic transmission of pain started insidiously three months before when

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the patient started practicing basketball at his immobilization followed by several physical therapy
high school. Initially, the patient was evaluated in sessions without improving his symptoms.
another medical facility where he was prescribed Six weeks after receiving the intra-articular
seven radial pressure wave therapy sessions at a corticosteroid injection, the patient was referred
one-week interval with an energy of 5 Bar and a to our clinic, where physical examination revealed
high frequency of 15 to 20 Hz using a BTL-5000 diffuse swelling on the right anterior knee,
SWT POWER equipment, and no anesthesia was significant pain and tenderness over the patellar
administered. Ultrasonography performed before tendon (9/10 in the Visual Analogue Scale), difficulty
the therapy demonstrated complete tendon fiber on leg extension, and a decreased range of motion.
integrity. (Figure 1). Positive Zohler's and Clarke's tests were present,
According to the patient, the first radial pressure representing concomitant signs of grade I patellar
wave therapy session abruptly increased his knee chondromalacia. The Victorian Institute of Sports
pain, making him unable to continue walking. Assessment (VISA-P) score for patellar tendinopathy
As a result, no more ESWT were administered, was 38/100, and the patient's Blazina Scale was IIIb.
and one week later he received an intra-articular Blazina Scale(11) classifies the disease based on five

CLINICAL CASE
injection of 80 mg of methylprednisolone without stages which determine the severity of the injury
sonographic guidance that failed to improve his through symptoms that occur at different levels of
pain. He then underwent a complete right knee joint sport or activity.

Table 1. Blazina Scale.

Classification Symptoms

tage 0 No pain

Stage I Pain after intense sports activity

Stage II Pain at the beginning and after sports activity

Phase III a: Pain during and after activity, but allows regular workouts
Stage III
Phase III b: Pain during and after activity, but unable to perform regular
workouts

Pain during sporting activity unable to participate in sports to a satisfactory

Stage IV
level

Stage V Pain during daily activity. Unable to participate in any sport level

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The VISA-P scale(12) can be applied to quantify contraindicated the use of high intensity laser due to
symptoms, function, and the ability to perform sports the ray´s depth of penetration which can affect the
activities in the context to patellar tendinopathy. patient’s growth plate.
In addition, it can be used to monitor the recovery
CASE 2
of patellar tendinopathy because it allows an early
detection of worsening symptoms. The VISA-P A 25-year-old previously healthy man arrived at
questionnaire consists of 8 items with a score from Centro de Especialidades Ortopédicas in Quito
0 to 100, and 100 is considered a satisfactory result. complaining about intense right knee pain that
started insidiously several months ago after starting
Magnetic resonance imaging of the right knee
playing soccer on weekends. Initially, he sought
performed at our clinic revealed a partial patellar
medical attention in another medical facility where
tendon tear of 3.8 mm, as well as thickening
twenty radial pressure wave therapy sessions on
and edema of its superior portion (Figure 2). In
the right knee were prescribed at a one-day interval
addition, ultrasound elastography demonstrated
with an energy of 4 Bar and a frequency of 10 to
an intrasubstance patellar tendon tear of 4 mm and
15 Hz using a BTL-6000 SWT EASY equipment, and
calcification of its deep portion with a stiffness value
no anesthesia was administered. Ultrasonography
CLINICAL CASE

of 5 kPa., whereas the resting normal tendinous fibers

performed before the therapy demonstrated
demonstrated a stiffness value of 1.2 kPa. (Figure 3).
proximal patellar tendon thickness and edema, as
Conservative management was decided considering well as complete tendon fiber integrity with no signs
the patient's age. First, the administration of two 4ml of peritendinous vascularization. (Figure 4).
intratendinous injections of PRO-PRP KIT leukocyte-
After the fifth shockwave therapy session, the
poor platelet-rich plasma using interventional
patient denoted significant pain increase over the
ultrasound was performed. This was followed by
application area, and over the next few days, he was
several physical therapy sessions, and administration
unable to walk or climb stairs, so he decided not
of two low-energy sessions of focal extracorporeal
to continue receiving the therapy and looked for a
shock wave therapy (fESWT) at a one-week interval.
second evaluation at our clinic.
Weeks after treatment, we documented a complete
tendon healing by performing serial ultrasound The patient's physical examination at our clinic
examinations. The pain almost resolved (1/10 in the showed a positive Bassett sign and an extremely
Visual Analogue Scale), and his VISA-P score was painful right knee extension (9/10 in the Visual
88/100, so the patient was able to return to normal Analogue Scale). Furthermore, edema and
activities. ecchymosis were noticed over the patellar region
of the right leg. The Victorian Institute of Sports
It is important to mention that we decided to
Assessment (VISA-P) score for patellar tendinopathy
apply treatments other than physical therapy,
was 37/100, and the patient's Blazina Scale was IIIb.
medication, and rest, because this patient had
previously been treated with various conservative We performed an ultrasound that evidenced a
therapeutic measures that did not show favorable right partial patellar tendon tear compromising
results. In addition, it was also decided to apply approximately 50% of its whole depth surrounded
these "unconventional" treatments due to the large by multiple blood vessels. (Figure 5).
amount of fibrosis and calcification that the patient Using interventional ultrasound, we administered 4
presented in the tendon insertion area for which intratendinous and 10 peritendinous ml of PRO-PRP
both PRP and the use of focal shock waves have KIT leukocyte-poor platelet-rich plasma. Afterward,
shown benefits. On the other hand, it is necessary the patient was advised to use crutches for two
to emphasize that this patient’s age absolutely weeks followed by administration of ten continuous-

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mode 5.00-W-power high-intensity laser (HIL) were focused on stretching of the lower extremity
therapy sessions at one-day intervals over the right musculature, friction massage of the patellar tendon,
patellar tendon using a BTL- high intensity laser- eccentric quadriceps exercises, and strengthening
12W equipment. the hip and knee musculature. The patient achieved
Finally, twenty physical therapy sessions were a complete tissue and functional recovery, and three
prescribed at one-day intervals. The sessions months after treatment, his VISA-P score was 91/100.

CLINICAL CASE
Figure 1. Case 1. Ultrasonography of the right patellar tendon performed before radial pressure wave
therapy application demonstrated complete tendon fiber integrity.

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CLINICAL CASE

Figure 2. Case 1. Magnetic resonance imaging of the right knee approximately seven weeks after radial
pressure wave therapy application revealed a partial patellar tendon tear of 3.8 mm, as well as thickening
and edema of its superior portion.

Figure 3. Case 1. Ultrasound elastography performed approximately six weeks after receiving intra-articular
knee corticosteroid injection demonstrated an intrasubstance patellar tendon tear of 4 mm and calcification
of its deep portion with a stiffness value of 5 kPa.

Figure 4. Case 2. Ultrasonography performed before radial pressure wave therapy application demonstrated
proximal patellar tendon thickness and edema, as well as complete tendon fiber integrity with no signs of
peritendinous vascularization.

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Figure 5. Case 2. Ultrasonography after radial pressure wave therapy application evidenced a right partial
patellar tendon tear which compromised around 50% of its whole depth surrounded by multiple blood
vessels.

CLINICAL CASE
DISCUSIÓN patient with a history of chronic calcific Achilles
tendinopathy experienced Achilles tendon rupture
Multiple evidence supports the use of extracorporeal
two months after being treated with ESWT. The study
shockwave therapy (ESWT) as effective and safe
concluded that despite ESWT is generally considered
in treating patellar tendinopathy. Liao et al.,(13) in a
safe, physicians should be aware of potentially
recent meta-analysis of randomized controlled trials
significant complications such as tendon tears.
evaluating the efficacy of extracorporeal shock wave
therapy for knee tendinopathies and other soft tissue It is worth mentioning that none of our patients had
disorders, concluded that ESWT exerts a positive any of those risk factors. They also had pre-therapy
effect on the treatment success rate, pain reduction, patellar tendon ultrasonography that demonstrated
and range of motion restoration in patients with knee complete tendon fiber integrity; hence, we can
soft tissue disorders. Similarly, Van Leeuwen et al.,(7) only conclude that their patellar tendon ruptures
in a review of the literature involving seven studies in were produced as iatrogenic consequences of
which more than two hundred patients with patellar poor application technique of radial pressure wave
tendinopathy were treated with ESWT, concluded therapy.
that this treatment seems to be a safe and promising Even though the patients’ histories differ from
alternative for this tendinopathy with a positive the ones who develop patellar tendinopathy, it
effect on pain and function. Lastly, Wang et al.,(14), is worth mentioning that the patients’ symptoms
in a randomized controlled clinical trial evaluating started to develop right after a sudden increase in
the efficacy of extracorporeal shockwave therapy their physical activities - they started to practice a
compared to conservative treatment for chronic new sport -. This precipitated change in physical
patellar tendinopathy, found positive outcomes in activity may have contributed to the development
90% of patients in the study group compared to only of patellar tendinopathy. In this context, it is well
50% of patients in the control group. Furthermore, established that progressing physical loading, high
recurrence of symptoms occurred in only 13% of intensity training, or repetitive loading too fast may
patients in the study group and 50% in the control contribute to the development of this condition(16).
group. In addition, it is possible that an interaction between
Concerning the side effects of the therapy, even various intrinsic and extrinsic factors with the genetic
though Furia et al., have reported some mild side make up of our patients could have increased their
effects as a consequence of ESWT such as ecchymosis, likelihood to develop tendinopathy(17).
petechiae, slight swelling, and temporary reddening Another aspect to consider is that in the first
of the skin(15), there are very few reports in the case the patient’s age made the diagnosis of
literature demonstrating severe complications like patellar tendinopathy less feasible; however,
the ones seen in our patients. complementary exams like plain radiographs,
At date, there is only one previous study reporting a MRI and ultrasonography failed to confirm other
tendon rupture after ESWT(10). In this case, a female causes of patellar tendon pain, e.g. Sinding Larsen

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Johansson Syndrome. doses that enhance tissue repair mechanisms(19). In

addition, studies which investigated the effects of
Even though there is enough evidence supporting
PRP in vitro and in vivo, demonstrated benefits that
the use of ESWT for the treatment of patellar
include improved cellular remodeling and decreased
tendinopathy, we have identified health providers'
healing time(20).
lack of expertise as a major risk factor for ESWT
side effects(18). As mentioned previously, risk factors Finally, in the second case, we administered ten
may play an essential role in developing patellar continuous-mode 5.00-W-power high-intensity
tendon rupture, but several studies suggest that laser (HIL) therapy sessions at one-day intervals.
this condition is often the result of direct trauma There is evidence supporting HIL effectiveness in
over the tendon among healthy individuals such as inhibiting pain pathways in the nervous system as
our patients(3). When radial pressure wave therapy well as the production of anti-inflammatory effects
is used, tendinopathies are treated with an energy by locally stimulating blood and lymph circulation,
between 4 and 5 Bar, and a low frequency ranging which leads to reduced edema and increased blood
from 6 to 10 Hz.(6) at a one-week interval. However, supply. Both effects are produced by the generation
in the first case, in addition to inappropriately using of heat in the diseased tissue - an increase of
a high frequency of 15 to 20 Hz., the patient’s age approx. 2°C–3°C- and the mechanical stimulation
CLINICAL CASE

made the use of radial pressure wave therapy of nociceptors and other nerve terminals(21-22).
contraindicated. Likewise, in the second case, Consequently, HIL has emerged as a reliable, safe,
the therapy was applied erroneously at one-day and effective treatment option in the treatment of
intervals. In regard to this matter, Leal et al.,(6) in a various musculoskeletal conditions (23).
review about the use of extracorporeal shock wave
The main limitation of our report is its retrospective
therapy for chronic patellar tendinopathy, suggest
nature. Since the patients received radial shock wave
a maximum of five sessions should be applied for
therapy in other medical centers, we were unable to
the treatment of this tendinopathy when radial
collect valuable information regarding the number
pressure wave therapy is used; thus, in both cases,
of shocks used, or the precise site of radial pressure
the protocols were breached.
wave therapy application.
It is worth mentioning a brief description of the
treatments we used in order to help achieve a CONCLUSION
complete tissue and functional recovery in our
This report demonstrates the potentially harmful
patients.
effects of radial pressure wave therapy for patellar
In the first case, we administered two low-energy tendinopathy in two otherwise healthy individuals.
sessions -0,10mJ/mm2- of focal extracorporeal shock As stated earlier, none of our patients had risk factors
wave therapy (fESWT) at a one-week interval. The that could have compromised their patellar tendon
use of fESWT is well recognized for providing high- integrity; therefore, traumatic partial patellar tendon
quality energy over tissues leading to activation of ruptures following a poor application technique of
reparative cellular processes; thus, promoting tissue radial shockwave therapy are the most consistent
repair and neovascularization(6-8). In addition, there is diagnosis.
far more evidence recommending the use of fESWT to
It is important to mention that we were able to
treat patellar tendinopathy compared to radial shock
evaluate the patients relatively shortly after they
wave therapy(6-8-14). This means that even though
developed their patellar tendon tears, so we could
an inappropriate shock wave therapy application
appropriately confirm the diagnosis clinically and
protocol can lead to severe adverse effects as the
radiologically.
ones observed in our patients, the appropriate use
of ESWT can definitely lead to positive outcomes. As we detailed in a previous report, ESWT must be
applied by professionals certified by the International
Regarding the use of poor leukocyte platelet rich
Society for Medical Shockwave Treatment (ISMST) or
plasma, there is a lot of emerging evidence supporting
by the Latin American Societies and Associations on
its effectiveness in patellar tendinopathy. Many
Shockwave in Medicine (ONLAT). Therefore, specific
studies suggest that it promotes tendon healing
requirements needed to guarantee an appropriate
through the delivery of platelet-derived growth
application technique, minimize possible adverse
factors and bioactive molecules in hyperphysiologic
effects, and improve patient safety could be met.

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More research is required to clarify the the scientific evidence provides in order to establish
pathophysiological mechanisms involved in tissue appropriate treatment protocols for each particular
injury after ESWT. patient. When focal shock wave therapy is used
for the treatment of patellar tendinopathy, it is
More research is required to clarify the
recommended to use an energy between 0.10mJ
pathophysiological mechanisms involved in tissue
/ mm2 and 0.25mJ / mm2, and and frequency of
injury after treatment with radial pressure waves
4 to 7 Hz with one week intervals - 3 sessions on
when there is application technique failure.
average- (6,13).
It is essential to follow the recommendations that

Authorship contributions: The authors participated Interest conflict: The authors declare that they have
in the genesis of the idea, project design, data no conflicts of interest in the publication of this article.
collection and interpretation, analysis of results and Received: January 02, 2021
preparation of the manuscript of this research work.
Approved: February 14, 2021
Financing: Self-financed.

CLINICAL CASE
Correspondence: Walter Insuasti Abarca.
Address: Centro de Especialidades Ortopédicas. Av, Mariana de Jesus OE7-02 y Nuño de Valderrama. Edificio CITIMED. Consultorio 511. Quito - Ecuador.
Telephone number: +593983115501
E-mail: [email protected]

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