During jumping sports where great amounts of stress are
suddenly placed on the lower extremities of the body, patellar tendinopathy,
best known as jumper’s knee, can be a frequently reported type of injury.
Patellar tendinopathy, or PT, ultimately alters an athlete’s overall performance,
affecting their capacity to jump, land, run and change direction. While their
decline in performance can lead to decreased training tolerance, the symptoms associated
with the condition also often results in missed training days and competition
for a majority of athletes.
For those individuals diagnosed with PT, managing the
condition can be very challenging, especially for athletes during the
competition phase of a season. Because increased amounts of force are
constantly being placed against the tendon, patellar tendinopathy may commonly require
many treatment sessions before it can truly begin to heal. It’s essential to be
patient during the rehabilitation process to achieve a full recovery.
Taking this into consideration, several guidelines may be
followed in order to properly formulate a rehabilitation program to restore the
original state of the individual’s patella tendon and help athletes return to
their regular training routines as soon as possible.
When an individual is experiencing symptoms suggesting the
presence of patellar tendinopathy, a thorough subjective history must be taken
before a clinical examination takes place to help give a more accurate
diagnosis as well as give an understanding of the potential causes and the
severity of the patellar tendinopathy. The injured athlete should be assessed
for past history, as this may help conclude the state the tendon pathology is
in. If said individual presents a long history of tendon pain, the tendon
pathology may have become worse over time. This is best referred to as a
degenerative tendon. Treating the condition may be different according to the
varying stages of the tendinopathy. It’s also important to identify other
possible musculoskeletal injuries which may have contributed to the weakening
of the tendon. For example, a past knee injury may have altered the
individual’s leg structure, weakening the supporting muscles. If the athlete’s
tendon capacity has been previously affected, it may be at risk of developing
further complications. Prior rehabilitation treatment received at the time of
the first injury is also important information for healthcare providers. In
some cases, trauma from an injury after being involved in an automobile
accident can damage the tissues surrounding the knee, leading to symptoms
similar to patellar tendinopathy, or PT.
Physical Assessment
Once the past history evaluation is completed, a healthcare
provider may follow up with a primary diagnosis to further determine the damage
or injury to the tendon, and understand the reasons behind the development of
their PT, before continuing with a physical assessment. Athletes with patellar
tendinopathy, or jumper’s knee, tend to experience specific symptoms, often
located directly over the proximal patellar tendon. The location of pain is
usually stationary. Patellar tendon swelling is a general indication of a
reactive tendon. The inflammation can cause additional pain in the knee.
Careful observation of the athletes muscle strength should be provided
throughout the assessment as muscle atrophy and weakness signals a decreased
capability to withstand pressure on the tendon.
A physical assessment is focused on confirming the initial
assumption, without considering other possible explanations for the damage or
injury of the athlete’s patellar tendon, and conclude the irritability of the
tendon to determine the individual’s level of disability. Tendinopathies are
frequently described to be painful after participating in physical activity,
most notably, after the first day. This assists with the diagnosis of a PT.
Furthermore, imaging using MRI and ultrasound can also be
utilized to identify the presence of a pathology in the tendon. Ultrasound
tissue characterization is used to demonstrate the current state of the tendon
which can help identify the range of the structural pathology. However, the
presence of a PT on imaging does not necessarily show the source of the individual’s
symptoms and further diagnosis may be needed. Management of an injured tendon
may be different depending on the phase of the tendinopathy.
Direct trauma from an injury as a result of an accident,
especially on the knee, can aggravate the condition of the patellar tendon. A
strong blow to this region can lead to pain and soreness. Alternatively, a
tendinopathy occurs when the load being placed against the tendon is too great
for its capacity, often as a result of a sudden and/or substantial change in
pressure. A change or increase in training routines is often a frequent cause
for patellar tendinopathy. Simply modifying your workout routines can allow the
symptoms to resolve on their own, potentially avoiding them in the future. Aggravating
activities for patellar tendons depend on the irritability of the tendon.
Physical activities which usually aggravate patellar tendinopathy include
kneeling, squatting, jumping and in particular landing, changing direction and
decelerating, because these add direct pressure on the tendon.
While the pathology of the tendon may not necessarily offer
a solution, conservative, non-surgical treatment options, such as chiropractic
and physical therapy, can be beneficial for PT. These alternative treatments
focus on managing the symptoms with careful planning and education.
Managing Pain
Getting plenty of
rest is important to rehabilitate the tendon. Nevertheless, the athlete must
make sure to remain physically active because stopping physical activity
completely can decrease the overall capacity of the tendon. The overall
capacity applies to the amount of pressure a tendon is able to endure during
strenuous physical activity. To make sure the athlete doesn’t damage or injure
themselves further while still remaining active, a healthcare professional may
recommend isometric single leg knee extensions and/or single leg decline squats
to help reduce the pain. Five repetitions of these for 10-60 second holds, four-times
per day is a generally approved amount of these, to help individuals with PT.
For reactive tendons, isometric contractions with mild to moderate amounts of
pressure are believed to effectively reduce the symptoms for hours. Before
attempting any of the above exercises, it’s important to consult your
healthcare professional to properly determine the correct time and appropriate
resistance of each exercise for every individual athlete to prevent other
complications.
With reactive tendons, avoiding any pain trigger is crucial
towards preventing further aggravation of the condition. For tendons affected
with degeneration, single leg decline squats on a wedge followed by three vertical
hops should be utilized to supervise the athlete’s pain and response to the
added stress on a daily basis. Also, applying ice therapy after physical
activity for about 20 minutes will help reduce the inflammation and swelling
around the affected region of the patellar tendon.
Educating the Athlete
An athlete should be well educated on the significance of
rest on their injured tendon and how essential it is for them to not push past
3 out of 10 on the visual analogue scale, or VAS, for their pain symptoms,
especially during the reactive stage of a tendinopathy or the symptoms may
worsen. Mild soreness the next day after engaging in the recommended physical
activity is normal. Moreover, the individual should be educated to gradually
increase the amounts of pressure they place on their tendon. Suddenly and
quickly raising the load could risk a flare up of symptoms. Likewise, avoid
stretching the tendon through quadriceps stretches. Compressing the tendons
once patellar tendinopathy has developed can further aggravate the condition. Soft
tissue massages and/or acupuncture through the quadriceps and hip flexors may
be used instead to maintain the range of motion of the knee and hip.
In some cases, a healthcare professional may recommend
over-the-counter medications, such as ibuprofen, to help relieve the symptoms.
In other cases, a physician and dietician can discuss the use of a high dose of
fish oil and green tea to help improve the athlete’s symptoms.
Managing the symptoms of an athletes patellar tendinopathy
is primarily focused on achieving the correct balance of rest and continuing
fitness during recovery. Closely observing the injury provides the necessary
information regarding the tendon’s response to the added pressure and stress
throughout the rehabilitation process.
Training Programming
The athlete’s training programming should be heavily
monitored during the competition season to ultimately reduce the amount of
stress and pressure being placed against the tendon. The main goal is to modify
the individual’s training routines to reduce the load being placed against the
affected tissues. The new programing should cycle an athlete’s week into high,
low and medium load days to allow the tendon capacity to adjust to the challenging
workouts.
High-load days can involve heightened quantities of stretch
shortening cycles, or SSC, including training routines with plenty of running
and jumping.
Medium-load days can involve specific tendon strengthening
exercise routines and/or moderate running and jumping activities.
Low-load days should involve isometric holds only.
Programming an athlete’s training week once diagnosed with
patellar tendinopathy can be challenging, not only because the individual’s
symptoms are being monitored, but because other athletic factors, including
match schedules and overall recovery periods after a game, can often be
difficult to manage on their own.
While an athlete is engaging in physical activity training
routines during the competition phase of the season, it is difficult for the
pain and discomfort associated with PT to ease entirely in order to gain
strength. Specialized programs for many athletes can take time depending on the
level of damage or injury to the tendon. A less than 3/10 pain level should be
the athletes limit at this time and exercises should cease if this level of
pain or higher is present.
Exit Criteria
To start jogging after being diagnosed with PT, the athlete
should no longer experience any pain while walking and they should be able to implement
the following program while experiencing a score of less than 4 out of 10 level
of pain after engaging in the recommended training session: four repetitions on
each side of decline SL squats on wedge where the pain ranges less than 3 out
of 10; SL calf raise repetitions of 25 on each side; 30 second on/off DL skip
repetitions of 5; 40 second on/20 second off alternative skip repetitions of
10; DL hopping/landing progressing to SL hopping/landing sequences including forward,
lateral and multi-directional hopping; and running progressions on a treadmill,
if available, starting gradually from an entry level of 70 to 100 percent weight
bearing.
As previously mentioned, once the athlete begins to
introduce running into their training routines, it must be closely monitored
and programmed to include high, low and medium days.
In conclusion, patellar tendinopathies can be challenging to
manage for athletes during the phase of a competition season, therefore it’s
important to take a thorough history check of the individual to understand the cause
of the injury. Once diagnosed, relative rest and a high, low, medium
programming modification of training days should be established to relieve the
stress on the tendon. Properly managing the symptoms of PT are crucial towards
the athlete’s recovery. By focusing on a series of isometric exercises, pain
relief can be achieved. If the symptoms of the condition are monitored and
properly cared for on a daily basis, the athlete has a higher chance of
ensuring they continue to compete for their season without further aggravating
their jumper’s knee.
By Dr. Alex Jimenez