What is it?
Patellar tendinopathy results from micro-tearing or degeneration of the proximal attachment of the patellar tendon. Patellar tendinopathy is very common, affecting up to 20% of skeletally mature athletes.
The condition is also referred to as “jumper’s knee” due to the excessive loading of the knee during high repetitive jumping is considered to be the primary risk factor for this condition. The greatest strain on the knee is landing, research states that forces on the tendon double when landing.
Activities that involve rapid acceleration and deceleration are placing a risk on the patellar tendon. Athletes that participate in sports that require forceful jumping like volleyball and basketball are at a higher risk of developing this condition.
Athletes who land with flat feet or those who allow deeper angles of knee flexion are susceptible to this condition. Those who anatomically suffer from foot supination or tend to walk more on the outside of their foot are at a potential risk for patellar tendinopathy.
Symptoms
Symptoms are often chronic without an identifiable onset, and usually reoccur over month or year spans. Symptoms will be provoked and intensified with physical activity. Pain can also intensify when arising from a seated position, squatting, jumping, stair climbing, and running - especially downhill or downstairs.
Two-thirds of patients present with pain at the inferior aspect of the patellar region. Clinicians will usually palpate (touch) the inferior pole of the patella and if there is a reproduction of pain that will indicate patellar tendonitis.
The patient may report some discomfort with full passive (doctor moves for patient) knee flexion or resisted extension. There will also be tenderness on the patellar tendon with palpation of the knee when in a flexed position.
Patients with patellar tendinopathy will often have quadricep and hamstring hypertonicity associated with it. Additionally, quadricep weakness will start to develop.
Bad habits or compensatory mechanisms to protect the knee may result and cause secondary problems within the lower kinetic chain.
Diagnosis
Imaging such as radiographs are unnecessary with this type of condition, unless there is a history of trauma, surgery, or there is joint swelling. Diagnostic ultrasound may be useful for identifying tendinopathy. The use of MRI for diagnosing patellar tendinopathy is questionable. A clinician diagnosis from history and palpation is the best indicator for this condition.
Treatment
The foundation of clinical management of patellar tendinitis includes transverse friction massage, modalities, exercises, and manipulations. A modality that has shown improvement with inflammation is ice. Ice or an ice massage should be utilized at home after activity.
Some athletes may need to decrease training volume and intensity to reduce the excessive load to a sub-pain threshold. However, patients with patellar tendinitis should avoid complete rest, as this could predispose them to recurrence of the condition.
Stretching and myofascial release techniques should be directed to areas of concern which include the hamstrings, quadriceps, gastrocnemius, and the soleus. Additionally areas that may need some myofascial technique applied are the iliotibial band, psoas, piriformis, and the anterior hip capsule. Transverse friction massage or IASTM is shown to immediately reduce pain and improve clinical outcomes by stimulating the healing process.
Manipulation may be used to address restrictions in the ankle, knee, hip, and lumbosacral region.
Rehabilitation of patellar tendinopathy will progress from selective rest to functional re-training. Eccentric style exercises and static stretching is a proven mode of treatment for this condition. Eccentric exercise has been shown to enhance the mechanical properties of degenerate patellar tendons.
Rehabilitation should begin with moderate effort and lower repetitions. Response to the tensile load being put on the tendon can be assessed by the patient’s change in pain at night. An increase in pain at night indicates the current rehab load is too much.
Patellar tendinopathy patients usually demonstrate a diminished quadriceps activation and/or strength. Clinicians will need to assess and address any weakness within the glutes, quadriceps, and hamstring.
Clinicians will counsel the patient about their faulty compensatory mechanisms and retrain the body. They will incorporate a balance centered rehabilitation program in the treatment process, especially for athletes. A balance program will prevent further injuries and enhance sports performance.
Patellar taping or strapping may provide symptomatic relief and short-term functional improvement. Arch supports or orthotics may be recommended to assess arch problems that may be contributing to this condition.
Conservative care has shown to be as effective as surgery for long-term pain relief, ROM, function, tendon force, and quality of life in chronic cases of patellar tendinopathy.