Patella Tendinopathy
Background:
Patella Tendinopathy is often referred to as ‘Jumpers Knee’. It is an overuse condition that commonly affects high level athletes who participate in jumping sports. Tendinopathy occurs when the tendon is overloaded by repeat ‘spring-like’ activity overtime with poor rest between sessions. The role of the patella tendon is to generate energy storage and release during powerful and explosive movements, such as jumping. If the tendon has minimal rest time then tendon remodelling can’t occur, resulting in a pathology whereby the tendon’s mechanical properties can change.
Epidemiology:
In terms of prevalence, it has been found that up to 22% of elite athletes may experience Patella Tendinopathy at some point of their career. Some of the main sports that have a high prevalence of Patella Tendinopathy are basketball and volleyball, given the requirement of fast explosive jumping, pivoting, or landing.
Clinical features:
One of the key features of Patella Tendinopathy is localised tenderness at the distal pole of the patella. Pain is load associated and worsens when demand is placed on the knee extensors during energy storage and release activities. Commonly, the pain can ‘warm up’ with repeated loading and then return once the activity ceases and the muscles cool down. There is often pain on stairs, squatting and following extended periods of sitting. Following the standard tendinopathy pattern, pain can often be worse first thing in the morning.
Assessment:
A thorough assessment of all lower limb joints should be conducted. The assessment should include functional tests, palpation, muscular endurance tests, range of motion and progressive energy storage and release loading. Ultrasound can demonstrate tendon thickening, however MRI is the gold standard for diagnosing tendinopathies.
Treatment:
Treatment should begin with education on the nature of tendinopathies and the importance of load management. Avoiding aggravating activities as much as possible is recommended. Setting an early understanding that rehabilitation for tendons can be slow and lengthy is important. Rehabilitation involves progressive loading of the tendon and musculoskeletal unit. Pending how irritable the tendon is will determine where to start with exercise prescription. It is important to continue loading the tendon, however within an acceptable range of pain ideally below 4/10. Monitor for pain during activity and for up to 48 hours post. Focusing on quadricep and posterior chain strength is crucial in the early stages. As this foundation is built, progressive introducing single leg loading and plyometric based exercises can be introduced. The final stage of rehabilitation is sport-specific training and eventually return to sport when deemed appropriate.
Current evidence:
An RCT conducted in 2021 (Breda et a. 2021) explored the effectiveness of progressive tendon loading compared to eccentric exercises for individuals with Patella Tendinopathy. Of the 76 patients included, pain scores were significantly higher (P < 0.05) in the progressive loading group. Within the progressive loading group, 43% of individuals returned to sport, compared to 27% of the eccentric exercises group.
A 2021 Systematic Review and Network Metanalysis explored the effectiveness of different treatment strategies for Patella Tendinopathy. The 37 included RCT’s revealed the ineffectiveness of shockwave therapy and proved that isometric based exercises proved to be as useful as isotonic exercises for immediate short term pain relief. Topical gylercyl trinitrate and hyaluronic acid injection combined with eccentric exercises, as well as moderate slow resistance exercises, revealed the greatest probability of treatment effective. This however is based on very low quality evidence. Exercise should remain the first line of treatment however these alternative methods may be explored as adjuncts if load management and exercise proves to be ineffective.
If you are experiencing Patella Tendinopathy, book in for an assessment and treatment plan with one of our physiotherapists.
References:
Breda, S.J., Oei, E.H., Zwerver, J., Visser, E., Waarsing, E., Krestin, G.P. and de Vos, R.J., 2021. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. British journal of sports medicine, 55(9), pp.501-509.
Challoumas, D., Pedret, C., Biddle, M., Ng, N.Y.B., Kirwan, P., Cooper, B., Nicholas, P., Wilson, S., Clifford, C. and Millar, N.L., 2021. Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies. BMJ open sport & exercise medicine, 7(4), p.e001110.
Malliaras, P., Cook, J., Purdam, C. and Rio, E., 2015. Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. journal of orthopaedic & sports physical therapy, 45(11), pp.887-898.
Nuhmani, S., Ahsan, M., Bari, M.A., Malhotra, D., Al Muslem, W.H., Alsaadi, S.M. and Muaidi, Q.I., 2022. Patellar Tendinopathy—Does Injection Therapy Have a Role? A Systematic Review of Randomised Control Trials. Journal of Clinical Medicine, 11(7), p.2006.
