Patellar tendinopathy also knows as jumpers’ knee is an overuse injury that presents as pain at the front of the patella (the inferior pole of the patella to be specific). The tendon connects the quadriceps muscles (thigh muscle) to the bone at the top of your shin (known as the tibia). It is particularly common in sports that involve large contractions of the quadriceps muscle such as jumping (like the action of riding on a see-saw) or sudden changes of direction with the prevalence of this condition in elite volleyballers and basketball players found to be over 40%. Patellar tendinopathy is thought to develop when the tendon is loaded beyond its capacity and can be diagnosed using a combination of patient history, clinical signs and imaging studies. Physiotherapy is the primary treatment and aims to improve the individual’s ability to tolerate load through an appropriate exercise program.
When the patellar tendon is subjected to regular episodes of high-intensity activity, the tendon can become overloaded resulting in pain. When an individual increases their volume (total workload per session), frequency (number of sessions per week) or intensity of activity (or combinations of these variables) too quickly the tendon’s load tolerance may be exceeded. The more the patellar tendon is repeatedly exposed to this activity and when the tendon not allowed sufficient recovery time it typically results in incomplete tendon healing, and a weak thickened tendon or better known as a tendinopathy. Historically, the term “tendonitis” was used to diagnose these injuries however as you may have realised by now, I have only used the word tendinopathy to describe this injury. To clear things up the term “tendinitis” (“itis” meaning inflammation) and “inflamed tendon” are no longer used. Why? There is actually no inflammatory process occurring in a tendinopathy.
So how do I know if I have patella tendinopathy?
Often it will present with the following features:
- Pain over the bottom of the knee cap (inferior pole of the patella)
- Sudden increase in activity/exercise
- Warm up phenomenon – pain after prolonged rest but warm ups and eases with activity (e.g. morning stiffness but warms up within an hr)
- Increased pain after the activity
- Pain made worse by increased levels of activities such shallow to deep squat, vertical jumping, walking downstairs, decline squat
- Thickening of patella tendon
- Imaging with ultrasound and magnetic resonance can identify the pathology
Common risk factors associated with patella tendinopathy include:
- Sport involving repetitive, knee extension such as running, squatting and jumping
- Sudden changes in activity levels such as starting a new sport and increasing frequency, intensity or duration of exercise too quickly
- Inadequate preparation for sport whereby the tendon id not able to handle the increased demands of the sport. Correct warm up and cool down as well as strength training can prevent a tendinopathy
- Age – most commonly from ages 15-30
- Gender – most commonly seen in men
- Muscular imbalances such as muscle weakness or tightness
- Tendinopathy has also associated with increased weight (high BMI), high cholesterol, diabetes and other metabolic conditions.
So how do I manage patella tendinopathy?
Patella tendinopathy is treated using a 4-stage rehab program with the main aim of correctly re-loading the tendon. Correct management is crucial for patella tendinopathy to ensure the best outcomes. Physiotherapy is often very successful in treatment of patella tendinopathies through a graded and gradual exercise program as well as manual therapy techniques. Stage 1 consists of isometric loading – this means a muscle contraction in which the length of the muscle does not change (for example holding a wall squat for 30 seconds). Isometrics are used because they have been proved to provide pain relief in tendinopathies, but also are a perfect modifying the load to allow the tendon to heal. These exercises will target the quadriceps muscle which contracts to straighten the knee and often involves a 45 second hold x 5 reps up to 3x/day.
Stage 2 involves isotonic loading – this means a muscle contraction in which the length of the muscle changes (for example completing 10 squats without holding the position). Isotonic involves two types of exercises which include concentric and eccentric. This is often hard to explain so I will do so using an example. Think about when you do a bicep curl you move the weight from starting position with the weight sitting at waist height to the finishing position where the weight comes to chest height – this is defined a concentric whereby the muscle shortens. If we think about when the weight moves from chest height back down to waist height this is considered eccentric as the muscle is lengthening (under tension). Studies suggest that a combination of eccentric, concentric and plyometric training – which is in our next phase – is most beneficial in the treatment of patella tendinopathy. In stage 2 the aim is to restore muscle bulk and strength by progressively increasing load on the tendon.
In stage 3 we move towards plyometric. You might be thinking what is that? Essentially, it’s a fancy way of saying energy storage or simply “jump training”. In this phase movements become more sport specific and exercises can vary from jumping, landing, changing direction, cutting, accelerating and decelerating. The aim is to rebuild sufficient strength in the tendon and prepare the body for eventually returning to sport where jumping based movements are often performed. Stage 4 or the final stage is all about returning to sport and maintenance to prevent the risk of re-injury. Return to sport should occur when full training is tolerated without increase in symptoms. Match based scenarios and functional training to mimic games should be completed in this phase.
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Written by Will Lewis (Physiotherapist)