Patellar Tendinopathy

This article originally appeared in the February/March 2006 issue of "FitPro Network". It is reprinted here with permission.

Paul Wright is the director of Get Active Physiotherapy and Health Services, which has clinics inside Fitness First clubs in Australia. He is a senior lecturer for the Australian Institute of Fitness and a featured presenter at many national and international health and fitness conventions. Paul has also released a series of DVDs specifically for fitness leaders, covering knee, shoulder, and lumbar spine injury prevention and rehabilitation, Swiss ball for rehabilitation, and advanced resistance training. For more information visit the Get Active website at www.getactivephysio.com.au.

Pain in the anterior aspect of the knee is a frequent complaint for patients attending physiotherapy, sports physicians and also personal trainers. Pain and discomfort in this region can be due to conditions such as patello femoral syndrome, fat pad impingement, various bursitis irritations, or commonly, patellar tendinopathy.

Terminology
Patellar tendinopathy has been referred to in the past as ‘jumper’s knee’ as the condition was often associated with repetitive impact sports such as basketball, volleyball and high impact aerobics. This term has gone out of favour as the condition can, and often does, occur in individuals who do not participate in these high impact activities. The other term previously used for this condition was ‘patellar tendinitis’ in reference to the previously held theory that the pain felt in the patellar tendon was due to an inflammatory process. It is now believed that there is a fundamental change to the structure of the injured patellar tendon that is more closely associated with tendon degeneration than active inflammation – thus the term patellar tendinopathy is the most accurate label for the condition.

Signs and symptoms
The typical presentation for patellar tendinopathy is where the patient complains of a gradual onset of anterior knee pain aggravated by jumping and landing activities, as well as loaded quadriceps exercises such as leg extensions. The condition is often clinically graded on a one to four scale, where a grade one has pain only after activity, through to a grade four, where the pain occurs during everyday activities and is worsening or progressing.

The pain is usually localized to the inferior pole of the patella; however, there can also be pain and tenderness in the midsection of the tendon. Factors that may contribute to the development of this condition include an increase in high impact activity, a change in footwear or running surface, poorly prescribed footwear, decreased recovery time between sessions, excessive pronation, alack of ankle dorsi flexion, and tight muscles, particularly quads, hamstrings and calves.

Management
As with all episodes of pain it is essential the client is examined by a physiotherapist or sports physician as soon as possible. The medical professional will evaluate the extent of the injury, determine an accurate diagnosis and chart the most appropriate management strategy to return the client to full function. An accurate and rapid diagnosis is especially important in cases of patellar tendinopathy as this condition often co-exists with patello femoral pain, which can lead to other compensations in the ankle, knee, hip and lumbar spine.

The keys to successful rehabilitation of patellar tendinopathy are a well constructed and progressive rehabilitation plan, and an understanding of the importance of reducing the tendon load. The primary methods used to reduce tendon load include a minimization of the amount of high impact jumping and sprinting, and reducing the total weekly training volume.

Local physiotherapy treatment will involve tendon massage, regular icing, stretching, and biomechanical correction, with appropriate footwear and orthoses (if required). However, even with early management, this condition can still take between two and six months to completely resolve.

An important component of the rehabilitation process is the need for an effective strengthening program to restore pre-injury function. The majority of exercises should be performed pain free with close attention being paid to any post-exercise pain, and especially increased pain the morning after a rehabilitation session–the need for appropriate strengthening must be balanced with possible aggravation of symptoms.

A handy exercise used in the strengthening program for patellar tendonopathy is the drop squat. This simple squatting exercise is performed with the heels slightly raised off the floor to place more stress on the patellar tendon. The drop squat can be progressed to a single leg version and ultimately resistance can be slowly added by having the patient hold dumbbells. The eccentric phase of this exercise is considered to be the most important in effective post injury rehabilitation. Ice is usually applied after each session.

The progression of the strengthening program should always be overseen by the treating physiotherapist or sports physician, as re-injury and poor recovery are often caused by over enthusiastic patients and premature return to sport.

Source: Australian Fitness Network