Patellar Tendon Repair

A patellar tendon rupture is not an injury that can wait. It is not an injury that improves with rest, physical therapy, or bracing. It is one of the true surgical urgencies in orthopedic surgery — and the window for a straightforward repair is approximately three to four weeks from the moment of injury.

After that window closes, the quadriceps muscle contracts and scars down, pulling the kneecap higher than its normal position. The muscle cannot be stretched back. The tendon cannot be pulled back to the bone. What was a primary repair becomes a complex reconstruction requiring tendon lengthening, quadriceps releases, and potentially graft augmentation — a procedure that is dramatically more difficult, more morbid, and less reliably successful than surgery performed in the acute setting.

If you tore your patellar tendon — or if you are not sure what you tore but you cannot straighten your knee — do not wait for a routine appointment. Call (310) 746-5918 now. This injury needs to be evaluated and treated urgently.

What Is the Patellar Tendon and Why Does It Matter?

The patellar tendon connects the kneecap to the tibial tubercle — the bony prominence just below the knee on the front of the shin. It is the final link in the extensor mechanism: the chain of structures — quadriceps muscle, quadriceps tendon, kneecap, patellar tendon — that allows you to straighten your knee.

The patellar tendon does two things that are essential for basic function. It allows you to actively extend the knee — straightening the leg from a bent position. And when you bear weight on the leg, it keeps the knee from buckling — maintaining the extension needed to walk, climb stairs, and stand from a seated position.

When the patellar tendon ruptures, both of these functions are lost. The quadriceps muscle — now untethered from the tibia — contracts and pulls the kneecap upward. The patient cannot lift the leg off a table with the knee straight. Walking without a brace or support is impossible. The diagnosis is clinical — but it can be confirmed with X-ray and MRI when needed.

The "Empty Merchant Sign" — A New Radiographic Finding Described by Dr. Mirzayan

One of the contributions Dr. Mirzayan has made to the diagnosis of patellar tendon rupture is the description of a new radiographic sign — the Empty Merchant Sign — published in the peer-reviewed literature.

The Merchant view is a specific X-ray taken with the knee bent that shows the kneecap sitting in its groove. In a normal knee, the patella is centered in the trochlear groove on this view. When the patellar tendon has ruptured and the quadriceps has pulled the kneecap superiorly, the groove appears empty — the kneecap is no longer where it belongs. Dr. Mirzayan identified and described this finding as a reliable radiographic indicator of patellar tendon rupture, providing an additional diagnostic tool that can be identified on a simple X-ray before MRI is obtained.

This publication is available here: The Empty Merchant Sign — A New Radiographic Finding in Patellar Tendon Rupture

Why Timing Is Everything: The 3 to 4 Week Window

This cannot be overstated — and it is the most important message on this page.

In the first three to four weeks after a patellar tendon rupture, the quadriceps muscle has not yet fully contracted and scarred. The kneecap is elevated but can still be manually pushed back down toward its normal position. The torn tendon can be mobilized and reattached to the bone under acceptable tension. The surgery is demanding but straightforward — and the outcomes of acute primary repair are excellent.

After three to four weeks, the picture changes dramatically. The quadriceps muscle goes into spasm and the surrounding soft tissues scar down. The kneecap becomes fixed in its elevated position. No amount of gentle traction will bring it back down. To perform a repair at this stage, Dr. Mirzayan must perform quadriceps releases and tendon lengthening procedures to gradually bring the kneecap back toward its normal position — and in some chronic cases, tendon graft augmentation is required to bridge the gap. The surgery is longer, more complex, and the recovery is more difficult and less predictable.

Every week of delay after the injury narrows the options and worsens the outcome. If someone in your family, on your team, or in your care cannot straighten their knee after a fall or a sports injury — treat it as the emergency it is.

Diagnosis

The diagnosis of a patellar tendon rupture is primarily clinical. The patient — typically a man in his 30s or 40s, most commonly injured playing basketball — describes a sudden pop or giving way at the front of the knee, immediate inability to straighten the leg, and pain and swelling below the kneecap. On examination, there is a palpable defect below the kneecap where the tendon should be, the kneecap rides higher than normal, and the patient cannot perform a straight leg raise.

X-rays confirm patella alta — the elevated kneecap position — and may demonstrate the Empty Merchant Sign on the Merchant view. MRI confirms the diagnosis, characterizes the extent of the tear, and identifies any associated injuries. In the acute setting, surgery should not be delayed waiting for MRI if the clinical diagnosis is clear.

Dr. Mirzayan's Repair Technique: Button Fixation, Suture Anchors, and FiberTape Internal Brace

The traditional method of patellar tendon repair involves passing sutures through drill holes in the kneecap and tying them above the patella over a bone bridge. This technique is inexpensive and straightforward — but the repair construct is mechanically weak. It relies on suture knots tied over bone, which can loosen, cut through, or fail under the cyclic loading of early rehabilitation. Because of this mechanical weakness, traditional repairs require prolonged immobilization to protect the construct — leading to quadriceps atrophy, stiffness, and a longer, harder recovery.

Dr. Mirzayan uses a technique he has developed that is biomechanically superior to traditional repair and specifically designed to allow earlier, more aggressive rehabilitation — reducing the muscle loss and stiffness that make patellar tendon rupture recovery so difficult.

His technique uses cortical buttons positioned above the kneecap to tension the patellar tendon against the patella, combined with suture anchors placed into the kneecap that carry FiberTape — a high-strength synthetic tape. The FiberTape limbs are passed in an anatomic position to the tibial tubercle, functioning as internal braces that immediately augment and protect the repair construct from the moment of fixation.

This combination — button tensioning, anchor fixation, and FiberTape internal brace augmentation — creates a repair construct that is strong enough to begin earlier range of motion and rehabilitation than traditional repair techniques permit. Earlier motion means less quadriceps atrophy. Less quadriceps atrophy means a faster, more complete recovery of strength and function.

Dr. Mirzayan has developed this technique based on his experience with internal brace augmentation in other high-load tendon repairs and his commitment to optimizing early rehabilitation after patellar tendon reconstruction. While formal publication of this specific technique is in preparation, the principles — button fixation, anchor-based internal brace augmentation, and early motion — are consistent with the current leading edge of extensor mechanism repair.

His outcomes study on patellar tendon repair — which won the Best Poster Award at the American Academy of Orthopaedic Surgeons Annual Meeting in Las Vegas in 2019 — is published here: Patellar Tendon Repair Outcomes — AAOS Best Poster Award 2019

Chronic Patellar Tendon Ruptures: When the Window Has Passed

For patients who present more than three to four weeks after injury — or who were misdiagnosed and have been living with an unrecognized rupture — chronic reconstruction is still possible, but it is a more complex undertaking.

Dr. Mirzayan performs quadriceps V-Y lengthening and releases to gradually mobilize the retracted muscle-tendon unit and bring the kneecap back toward its normal position. In cases where the gap between the torn tendon ends is too large to bridge primarily, allograft tendon augmentation is used to reconstruct the patellar tendon. These procedures are technically demanding and require experience with both the acute and chronic presentations of this injury.

The functional outcomes of chronic repair are meaningful — patients regain the ability to walk, climb stairs, and return to activity — but they are less reliable and require a longer recovery than acute repair. This is the unavoidable consequence of delayed treatment, and it is why urgency at the time of injury is so critical.

What to Expect: Surgery and Recovery

Patellar tendon repair is performed as an outpatient procedure under general anesthesia with a nerve block for postoperative pain control. Patients go home the same day.

With Dr. Mirzayan's augmented repair technique, the construct is strong enough to begin gentle range-of-motion exercises earlier than with traditional repair. The knee is protected in a brace locked in extension for the initial healing phase, with progressive unlocking as healing allows. Quadriceps strengthening begins as soon as the repair is sufficiently healed to tolerate loading. Return to sport — including basketball and other cutting and jumping activities — typically occurs between 6 and 9 months, depending on the extent of the injury and the speed of quadriceps recovery.

Dr. Mirzayan will give you a personalized return-to-sport timeline based on your specific injury, the technique used, and your rehabilitation progress.

Coming from Las Vegas, Phoenix, or Out of State?

Patellar tendon rupture is one of the few orthopedic injuries where the urgency of treatment directly determines the complexity and the outcome of surgery. For patients outside Los Angeles who sustain this injury, the most important first step is getting an accurate diagnosis and understanding the timeline — because every week of delay matters.

Dr. Mirzayan regularly treats patients from Las Vegas, Henderson, Phoenix, Scottsdale, and across the country. For an acute patellar tendon rupture, the conversation about traveling to Los Angeles needs to happen immediately — not after weeks of observation at a local facility.

If you carry a commercial insurance plan — Blue Cross Blue Shield PPO, Aetna, Cigna, United Healthcare, or a self-funded employer plan — you likely have out-of-network benefits that cover a substantial portion of the cost of surgery. Urgent surgical cases are frequently covered at higher reimbursement rates than elective procedures. Dr. Mirzayan's office will verify your coverage and help you understand your benefits before surgery.

Virtual consultations are available for urgent cases — you can submit your imaging and meet Dr. Mirzayan on video within hours to determine whether traveling to Los Angeles is the right next step.

Call (310) 746-5918 now. Do not wait.

Frequently Asked Questions

How do I know if I tore my patellar tendon?

The classic presentation is a sudden pop or giving way at the front of the knee during a jumping or landing activity — most commonly basketball — followed by immediate inability to straighten the leg. There is typically pain and swelling below the kneecap, and a palpable gap where the tendon should be. The most reliable clinical test is the inability to perform a straight leg raise — lifting the leg off a table with the knee held straight. If you have these symptoms, seek evaluation immediately.

Does every patellar tendon rupture need surgery?

Yes — with rare exceptions. The only patients who do not undergo surgical repair are those whose medical condition makes anesthesia unsafe. In all other patients, surgical repair is essential for restoration of function. Without repair, the extensor mechanism is permanently disrupted — the patient cannot straighten their knee actively and cannot walk without a brace. This is not an injury that heals with conservative treatment.

How urgent is patellar tendon repair?

Extremely urgent. The window for a straightforward primary repair is approximately three to four weeks from injury. After that, the quadriceps contracts and scars, making the surgery significantly more complex. Every week of delay narrows the surgical options and worsens the outcome. If you suspect a patellar tendon rupture, do not wait for a routine appointment — call (310) 746-5918 immediately.

What is the Empty Merchant Sign?

The Empty Merchant Sign is a radiographic finding described and published by Dr. Mirzayan that identifies patellar tendon rupture on a standard X-ray view of the knee. When the patellar tendon ruptures, the quadriceps pulls the kneecap upward out of the trochlear groove — leaving the groove empty on the Merchant view X-ray. This finding can be identified before MRI is obtained and provides an additional diagnostic tool for surgeons evaluating this injury.

Why is traditional patellar tendon repair insufficient?

The traditional technique — sutures passed through drill holes in the kneecap and tied over a bone bridge — produces a mechanically weak construct that requires prolonged immobilization to protect. Prolonged immobilization causes severe quadriceps atrophy and joint stiffness that significantly prolongs recovery. Dr. Mirzayan's technique using cortical button tensioning, suture anchor fixation, and FiberTape internal brace augmentation creates a stronger construct that allows earlier motion and rehabilitation — reducing muscle loss and producing a faster, more complete recovery.

What happens if I waited too long and now have a chronic rupture?

Chronic repair is still possible but significantly more complex. Dr. Mirzayan performs quadriceps lengthening and releases to mobilize the retracted muscle and bring the kneecap back toward its normal position, with allograft tendon augmentation when needed. The outcomes of chronic repair are meaningful but less reliable than acute repair — which is why urgency at the time of injury is so critical.

Do you offer virtual consultations for urgent cases?

Yes. For acute patellar tendon ruptures, Dr. Mirzayan can evaluate your imaging on video within hours to determine whether traveling to Los Angeles is the right next step. Time is critical — call (310) 746-5918 now rather than scheduling a routine appointment.

Does being out-of-network mean I will pay full price out of pocket?

Not necessarily. Many patients with commercial insurance — especially PPO plans and self-funded employer plans — have strong out-of-network benefits, and urgent surgical cases frequently receive higher reimbursement rates than elective procedures. Dr. Mirzayan's office will verify your coverage immediately so you have a clear picture of costs before making any decisions.

About Dr. Raffy Mirzayan

Dr. Raffy Mirzayan, MD is a double-board certified orthopedic sports medicine surgeon with 25 years of experience treating extensor mechanism injuries of the knee, including acute and chronic patellar tendon ruptures. He is the author of a peer-reviewed outcomes study on patellar tendon repair that won the Best Poster Award at the American Academy of Orthopaedic Surgeons Annual Meeting in 2019, and the describer of the Empty Merchant Sign — a new radiographic finding in patellar tendon rupture published in the peer-reviewed literature. His repair technique — using cortical button tensioning, suture anchor fixation, and FiberTape internal brace augmentation — is designed specifically to produce a stronger construct that allows earlier rehabilitation and a faster, more complete recovery of quadriceps strength and function. For patients who have sustained a patellar tendon rupture and understand the urgency of their situation, Dr. Mirzayan offers both the expertise and the availability to treat this injury when it matters most. He practices at DOCS Health in Los Angeles, serves as a Clinical Professor of Orthopaedic Surgery at USC, and welcomes patients from across the United States, including Las Vegas, Phoenix, and Scottsdale, for urgent virtual consultations and in-person care.

DOCS Health | 8436 W 3rd St #800, Los Angeles, CA 90048 | (310) 746-5918 | raffymirzayan.com