At a glance......
- 1 Stages of Patellar Tendinopathy
- 2 Causes of Patellar Tendinopathy
- 3 Symptoms of Patellar Tendinopathy
- 4 Diagnosis of Patellar Tendinopathy
- 5 Treatment of Patellar Tendinopathy
- 6 Physical Therapy for Patellar Tendinopathy
- 6.1 Recovery Phase
- 6.2 Physical Therapy
- 6.3 Maintenance Phase
- 6.4 Physical Therapy
- 6.5 Rehabilitation Exercises
- 7 Prevention of Jumper’s Knee
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Patellar Tendinopathy is a painful condition of the knee caused by small tears in the patellar tendon that mainly occurs in sports requiring strenuous jumping. The tears are typically caused by accumulated stress on the patellar or quadriceps tendon. As the name implies, the condition is common in athletes from jumping sports such as volleyball, track (long and high jump), and basketball. The condition has a male predominance. Contrary to traditional belief, the jumper’s knee does not involve inflammation of the knee extensor tendons.
Jumper’s knee, or patellar tendinopathy (PT), is a chronic overuse injury of the patellar tendon. The prevalence is particularly high in jump sports athletes, such as in elite basketball players and volleyball players, respectively 32% and 45 %. However, also the prevalence among non-elite athletes is substantial and varies between 14.4% and 2.5% for different sports. Athletes with PT are often forced to reduce their training and competition levels because of patellar tendon pain. In some cases, athletes even have to quit their sporting activities. It is without a doubt that this condition can have an enormous impact on sports participation.
Stages of Patellar Tendinopathy
Depending on the duration of symptoms, Patellar Tendinopathy can be classified into 1 of 4 stages
- Stage 1 – Pain only after activity, without functional impairment
- Stage 2 – Pain during and after activity, although the patient is still able to perform satisfactorily in his or her sport
- Stage 3 – Prolonged pain during and after activity, with increasing difficulty in performing at a satisfactory level
- Stage 4 – Complete tendon tear requiring surgical repair
Causes of Patellar Tendinopathy
It is an overuse injury from repetitive overloading of the extensor mechanism of the knee. The microtears exceed the body’s healing mechanism unless the activity is stopped.
- Running – Jumping or bounding are more common overall than Running
- Athletes in jumping sports – High jump, Basketball, Football, Gymnastics
- Pain after Exercise, especially prolonged Exercise and with knee flexion
- Quadriceps tightness or weakness
- Hamstring tightness
- Ankle dorsiflexion muscle weakness (from prior ankle injury)
- Overweight (increased BMI)
- Systemic lupus erythematosus
- Rheumatoid arthritis
- Diabetes mellitus
- Paget’s disease
- Knee local corticosteroid injections and repetitive trauma to the knee extensor tendon
- Leg Length Discrepancy
- Pes Cavus
- Insidious overall onset
- Later – During Exercise and while at rest
- Among the risk factors for patellar tendonitis are low ankle dorsiflexion, weak gluteal muscles, and muscle tightness, particularly in the calves, quadriceps muscle, and hamstrings.[rx]
Symptoms of Patellar Tendinopathy
- Pain and tenderness around your patellar tendon.
- Pain with jumping, running or walking.
- Pain when bending or straightening your leg.
- Tenderness behind the lower part of your kneecap.
- pain below the kneecap, especially during sports, climbing stairs and bending the knee
- A swollen knee joint
- Knee stiffness
- Leg or calf weakness
- Pain when bending the knee
- Strength – Knee extension weakness and Predisposing findings
- Ankle dorsiflexion weakness
- Hamstring tightness
- Heel cord tightness
- Quadriceps muscle tightness
- Pain and decreased depth on single leg decline squat (LR+ 4 and LR- 0.5)
- Extend unaffected knee
- Squat with the affected leg
Diagnosis of Patellar Tendinopathy
- Tenderness to palpation of the patellar tendon, just inferior to the patella, is the hallmark of the diagnosis. A clinical pearl is to palpate the tendon with the knee in extension as opposed to flexion. Palpation in flexion may mask a subtle jumper’s knee.
- The patient may also have swelling of the tendon, and crepitus of the tendon with motion. Patients will also have pain with resisted knee extension.
- A thorough knee exam including palpation of the joint lines, ligamentous and patellar stability and range of motion should also be performed to rule out other pathology.
Patellar tendon rupture
- It can occur as an acute injury. Patients will have sudden, severe pain in the front of their knee and their knee will buckle. A defect can usually be appreciated in the patellar tendon, though sometimes this is difficult to assess if severe swelling is present. The patient will not be able to perform a straight leg raise, and they will have an extensor lag (lack of full active extension in the setting of full passive extension).
- X-rays will show patella Alta (or high riding patella), and MRI will show the patellar tendon tear. Patients with patellar tendon ruptures should be placed in a knee immobilizer and referred to an orthopedic surgeon for urgent repair.
- It can occur as an acute injury. The patient will have pain over the patella itself. Diagnosis is usually made on an x-ray. Place in a knee immobilizer and refer to an orthopedic surgeon.
Patella chondromalacia (patellofemoral syndrome)
- Presents with anterior knee pain. Pain is particularly bad with going up and downstairs. The pain with this condition is more proximal than with the jumper’s knee, and patients usually have no tenderness to palpation of the patellar tendon on the exam. Most often this is a diagnosis of exclusion.
- Will have pain along the joint line. The pain is usually more lateral or medial than the jumper’s knee, but on occasion, the pain can be in the midline. Patients usually complain of clicking or popping in their knees. An MRI is diagnostic.
Fat pad syndrome
- Inflammation of the fat pad that lies deep to the patellar tendon. Symptoms can be similar to jumper’s knee, but pain is around the tendon, and not on it. This may represent a spectrum of jumper’s knee and not a distinct entity. Regardless, the initial treatment is the same as that for the jumper’s knee.
- Tumors or infections are rare causes of anterior knee pain.
- X-rays are usually negative for patients with jumper’s knee. On occasion, the x-ray can show shadows consistent with soft tissue swelling around the patellar tendon. In chronic cases, the x-ray may show calcifications in the patellar tendon. X-rays are most useful for ruling out concomitant pathology.
- An MRI is usually not necessary in the early stages of the disease when the diagnosis is obvious on clinical exam. For more severe or chronic cases, an MRI can show if there are tears in the patella tendon. MRI’s are also most useful for ruling out concomitant pathology. For patients that cannot obtain an MRI, an ultrasound can also be diagnostic. However, an ultrasound will give limited information on intra-articular pathology.
Treatment of Patellar Tendinopathy
Treatment of Jumper’s Knee
Treatment for jumper’s knee includes
- Rest and take a break from sports
- Taping or wearing a knee support or strap just under the patella
- Sitting with the leg raised
- Massage therapy
- Strengthening and stretching muscles through physical therapy or an at-home exercise program
- Topical Medications – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
- NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Ibuprofen to help with pain and swelling. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include etodolac, aceclofenac, etoricoxib, ibuprofen, and naproxen.
- Calcium & vitamin D3 – To improve bone health and healing tendon. As a general rule, men and women age 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day.
- Glucosamine & Diacerein, Chondroitin sulfate – can be used to tightening the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament.
Jumper’s Knee Surgery
- If your injury is severe and other treatments have failed, you may be required to have surgery. The procedure consists of the doctor making a longitudinal or transverse incision over the patella tendon and then removing the abnormal tissue. After the surgery, it could take anywhere from 6 to 12 months to fully recover and begin training again. You should check with your doctor before beginning rehab and strengthening exercises after surgery.
Physical Therapy for Patellar Tendinopathy
Most patients respond to a conservative management program such as the one suggested below.
- Activity modification – Decrease activities that increase kneecap and upper leg pressure (for example, jumping or squatting). Certain “loading” exercises may be prescribed.
- Cryotherapy – Apply ice for 20 to 30 minutes, 4 to 6 times per day, especially after activity.
- Joint motion and kinematics assessment – Hip, knee, and ankle joint range of motion are evaluated.
- Strengthening – Specific exercises are often prescribed.
- Other sport-specific joint, muscle, and tendon therapies may be prescribed.
- Ultrasound or phonophoresis (ultrasound delivered medication) – may decrease pain symptoms. A special brace with a cutout for the kneecap and lateral stabilizer or taping may improve patellar tracking and provide stability. Sometimes arch supports or orthotics are used to improve foot and leg stability, which can reduce symptoms and help prevent future injury.
The treatment of jumper’s knee is often specific to the degree of involvement.
- Stage I, which is characterized by pain only after activity and no undue functional impairment, is often treated with cryotherapy. The patient should use ice packs or ice massage after terminating the activity that exacerbates the pain and later again that evening. If aching persists, a course of regularly prescribed anti-inflammatory medications should be administered for 10 to14 days.
- In stage II, the patient has pain both during and after activity but is still able to participate in the sport satisfactorily. The pain may interfere with sleep. At this point, activities that cause increased loading of the patellar tendon (for example, running or jumping) should be avoided.
- A comprehensive physical therapy program, as discussed above, should be implemented. For pain relief, the knee should be protected by avoiding high loads to the patellar tendon, and cryotherapy should continue. The athlete should be instructed in alternative conditioning to avoid injury to the affected area.
- Once the pain improves, therapy should focus on knee, ankle, and hip joint range of motion, flexibility, and strengthening. If the pain becomes increasingly intense and if the athlete becomes more concerned about his or her performance, a local corticosteroid injection may be considered. The doctor will explain the pros and cons of these injections.
- In stage III, the patient’s pain is sustained, and performance and sport participation are adversely affected. Though discomfort increases, therapeutic measures similar to those described above should be continued along with not participating in activities that may worsen or prevent recovery from the injury. Relative rest for an extended period (for instance 3 to 6 weeks) may be necessary for stage III. Often, the athlete will be encouraged to continue an alternative cardiovascular and strength-training program.
- If the condition does not improve with treatment, surgery may be considered. Some athletes will not be able to continue to participate in activities that worsen or prevent recovery from the problem.
- Tendon rupture requires surgical repair.
Medical Issues and Complications
- Knee immobilization is not recommended because it results in stiffness and may lead to other muscle or joint problems, further prolonging an athlete’s return to activity.
- Consultation with a physical medicine and rehabilitation specialist or an orthopedic specialist is recommended, particularly for Stage I cases that do not respond to conservative treatment and more severe cases (Stages II, III, and IV). Primary care sports medicine physicians can also be consulted.
- An in-depth, stage-specific description of a conservative therapy program is described above. In brief, in the recovery phase, the athlete and therapist should work to restore pain-free joint range of motion and muscle flexibility, symmetric strength in the lower extremities, and joint sensation. Sport-specific training, including high-level sport-specific exercises, should then be initiated.
- Consultation with a physical medicine and rehabilitation specialist or an orthopedic specialist is recommended, particularly for Stage I cases that do not respond to conservative treatment or more severe cases (Stages II, III, IV).
- Surgical intervention is indicated for stage IV, and refractory stage III tendinopathy as noted above.
An in-depth, stage-specific description of a conservative therapy program is described above. Briefly, once in the maintenance phase, the athlete should complete a sport-specific training program before returning to competition. The physician and physical therapist can assist the athlete in determining when to return to competition based on the patient’s symptoms, current physical examination findings, and functional test results. Once the athlete returns to play, he or she must work to maintain gains in flexibility and strength.
Stretching – Stretch
- (1) flexors of the hip and knee (hamstrings, gastrocnemius, iliopsoas, rectus femoris, adductors),
- (2) extensors of the hip and knee (quadriceps, gluteals),
- (3) the iliotibial band (a large tendon on the outside of the hip and upper leg), and
- (4) the surrounding tissues and structures of the kneecap.
- Lay on a flat surface, like a bench or couch.
- Pull your knee up to your chest with your leg bent at the knee and your hands gripped under the knee.
- Starting with this will prepare you for other stretches.
- In a standing position bring your leg up behind you to hold your toes in your hand.
- Try to keep your knees together and to pull your leg up straight behind you, not to the side.
- You will feel a stretch at the front of the leg.
- Try to hold this position for 10 seconds when you first begin rehab and work up to 30 seconds when inflammation has gone down.
Thera-Band Knee Flexion (Prone)
- Tie the TheraBand Resistance Band into a loop and secure one end close to the floor.
- Lay on your stomach and place the other end of the loop around your ankle.
- Begin with your knee straight and bend your knee against the band.
- Hold and slowly return.
Thera Band Lunge
- Start in a standing position with one leg in front of the other.
- Hold the ends of the TheraBand Resistance Band in each hand while standing in the middle of the band with the front foot.
- Bend the front knee, so the thigh is horizontal while the back knee goes towards the floor.
- Try not to rest your back knee on the floor, instead of hover over it.
- Hold and return to the starting position.
Prevention of Jumper’s Knee
- It’s important to warm up before and cool down after exercising to prevent patellar tendonitis
- Wear shoes that fit well and support your arch
- Gradually increase the intensity of your workouts to reduce your risk of injury.