Lesioni tendinee del ginocchio

Il tendine quadricipitale

Il tendine (freccia arancione in fig 1A) si forma a livello del terzo distale della coscia per unione delle quattro componenti del muscolo quadricipite (vasto intermedio, vasto mediale, vasto laterale e retto femorale); i fasci costituenti la principale porzione del tendine sono dati dal muscolo retto femorale (superficialmente – freccia gialla) e vasto intermedio (porzione profonda).

Eziopatogenesi

Le lesioni del tendine del quadricipite femorale, comunque rare sono sostanzialmente appannaggio degli sport nei quali l’apparato estensore venga fortemente sollecitato attraverso contrazioni intense ed esplosive. Un tipico gesto sportivo che mette a rischio l’integrità del tendine del quadricipite è costituto dai lavori in accosciata totale che si effettuano reiteratamente in discipline come il sollevamento pesi.

Clinica e diagnosi

Vi è insorgenza immediata di dolore seguito da impotenza funzionale. Il segno patognomonico principale è costituito dal fatto che l’estensione attiva del ginocchio risulta essere inferiore a quella passiva. In caso di lesione completa l’atleta non è in grado di caricare sul lato della lesione. Si registra inoltre emartro, tumefazione e depressione sovrarotulea apprezzabile alla palpazione. Radiograficamente, a testimonianza della rottura tendinea, è evidenziabile una posizione abbassata della rotula.

Trattamento

Per ciò che riguarda le lesioni di tipo parziale, il trattamento è, di massima, di tipo conservativo. Nei casi di rotture gravi, l’indicazione è invece chirurgica e prevede una sutura tendinea seguita da immobilizzazione in estensione per un periodo di quattro settimane, seguita da mobilizzazione protetta con ginocchiera articolare per altre due settimane. La restante parte del programma riabilitativo è incentrata sul potenziamento del quadricipite femorale.

Caso clinico: uomo di 46 anni che improvvisamente accusa doloer alla base rotuleo dopo violenta contrazione del quadricipite nel tentativo di opporsi ad una brusca accellarazione.

Fig. 1 A – Si evidenzia ispessimento e disomogenea struttura della componente distale del tendine quadricipitale con soluzione di continuo della componente prettamente inserzionale superficiale, propriamente del retto (freccia gialla), che risulta deflesso. Si accompagna infarcimento sieroematico dei tessuti peritendinei, scollamento longitudinale tra tendine retto femorale e vasto intermedio. Appare integra la componente tendinea del vasto intermedio fino all’inserzione rotulea (freccia arancione per il tendine e rossa per il ventre).

Fig 2 B – tendine vasto intermedio (freccia aranciona); tendine retto femorale (freccia giallo); come segno indiretto di lesione del tendine si evidenzia aumento della distanza tra il ventre muscolare del vasto mediale e laterale (frecce bianche).

I reperti depongono per lesione parziale del quadricipite costituita da interruzione sub-totale dell’area  inserzionale distale  del retto femorale.

Uomo di 52 aa che vieneal controllo a 2 gg da trauma da caduta con appoggio forzato e  violento sulla gamba destra. si osserva lesione completa del tendine come ben evidenziato nell’immagine sagittale ove risulta interrorro il tendine del vasto intermedio e retto.

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