Patella Tendonitis

PATELLA TENDONITIS

INTRODUCTION The patellar tendon / ligament joins the kneecap (patella) to the shin bone or tibia (video). This tendon is extremely strong and allows the quadriceps muscle group to straighten the leg . The quadriceps actively straighten the knee in jumping to propel the individual off the ground as well as functioning in stabilizing their landing.

As such this tendon comes under a large amount of stress especially in individuals who actively put extra strain on the knee joint such as those who regularly perform sports that involve direction changing and jumping movements . Â Jumper’s knee is an inflammation of the patellar tendon that attaches from the bottom of the kneecap to the top of the shin bone . Â Jumper’s knee, as it is most commonly referred to, is also known as patellar tendonitis

With repeated strain, micro-tears as well as collagen degeneration may occur as a result in the tendon. This is known as patellar tendinopathy .

CAUSES OF PATELLAR TENDINITIS Patellar tendonitis is the condition that arises when the tendon and the tissues that surround it, become inflamed and irritated. This is usually due to overuse, especially from jumping activities. This is the reason patellar tendonitis is often called "jumper's knee."

When overuse is the cause of patellar tendonitis, patients are usually active participants of jumping-types of sports such as basketball or volleyball. Patellar tendonitis may also be seen with sports such as running and soccer. Also, some patients develop patellar tendonitis after sustaining an acute injury to the tendon, and not allowing adequate healing. This type of traumatic patellar tendonitis is much less common than overuse syndromes.

PATHOGENESIS Extensor mechanism stress, acceleration/deceleration, jumping/landing, extrinsic overload of the tendon - Microtears within the tendon matrix, rare occurrences of rupture - Patellar impingement theory - Impingement of the inferior patellar pole against the patellar tendon during knee flexion, Often resulting from a “long inferior patellar pole”

Controversy - Johnson et al. 1996 (JBJS) found impingement of the interior pole at 60 degrees of knee flexion - Schmid et al. 2002 suggested that there was no biomechanical evidence of impingement in their series - Almekinders and Shalaby 1999 found evidence of a “long inferior pole” in symptomatic patients, but this abnormality did not always correlate to the region of involved tendon - Many surgeons resect the infrapatellar pole during both open and arthroscopic debridement of patellar tendonitis

CLASSIFICATION :(Blazina et al 1973, Roels et al 1978) . - phase I: pain only after activity; - phase II: pain/discomfort during activity, but does not interfere w/ participation; - phase III: pain both during & after participation, which interferes w/ competition; - phase IV: complete tendon disruption.

Symptoms of Jumper’s knee Pain with running or jumping especially downhill or downstairs Pain and tenderness around patellar tendon Pain and tenderness behind the knee cap Pain is worse at night Restricted movement and swelling in the area surrounding the injury Prevention of Jumper’s knee May be associated with poor Vastus medialis obliquus (VMO) function .

OTHERS CAUSES Intensity and frequency of physical activity. Repeated jumping is most commonly associated with patellar tendinitis. Sudden increases in the intensity of physical activity or increases in frequency of activity also put added stress on the tendon. Being overweight. Additionally, being overweight or obese increases the stress on the patellar tendon, and some research suggests that having a higher body mass index may increase the risk of patellar tendinitis.

Tight leg muscles. Reduced flexibility in your thigh muscles (quadriceps) and your hamstrings, which run up the back of your thighs, could increase the strain on your patellar tendon. Misalignment of your leg. The way your leg bones line up could be off slightly, putting strain on your tendon. Raised kneecap (patella alta). Your kneecap may be positioned higher up on your knee joint, causing increased strain on the patellar tendon. Muscular imbalance. If some muscles in your legs are much stronger than others, the stronger muscles could pull harder on your patellar tendon. This uneven pull could cause tendinitis.

CAUSES OF PATELLAR TENDINOPATHY This depends on the extent or grade of the injury: Grade 1: Pain only after training Continue training but apply ice or cold therapy to the injury after each training session. Cold therapy can be applied by by ice massage or the use of ice packs. It is important the cold is applied at the point of pain on the tendon. Wear a heat retainer or support. See a sports injury specialist / therapist who can apply sports massage techniques and advise on rehabilitation. An eccentric strengthening programme is generally recommended.

Grade 2: Pain before and after exercise but pain reduces once warmed up. Modify training activities to reduce the load on the tendon. Stop jumping or sprinting activities and replace them with steady running or swimming / running in water if necessary. See a sports injury specialist / therapist who can apply sports massage techniques and advise on rehabilitation.

Grade 3: Pain during activity which prevents you from training / performing at your best. Rest completely from the aggravating activity. Replace it with swimming / running in water (if pain allows). See a sports injury specialist / therapist who can apply sports massage techniques and advise on rehabilitation.

Grade 4: Pain during every day activities which may or may not be getting worse. Rest for a long period of time (at least 3 months!). See a sports injury specialist / therapist who can apply sports massage techniques for patella tendonitis / tendinopathy and advise on rehabilitation. If the knee does not respond to rehabilitation then consult an Orthopaedic Surgeon as surgery may be required.

PREVENTION OF JUMPER’S KNEE The following are some measures that can be taken to prevent jumper’s knee: Wear proper fitting shoes that are appropriate for the court If necessary, wear orthotics for proper arch support and joint alignment. Make sure to properly stretch your hamstrings and quadriceps prior to activity Strengthen your quadriceps and hamstrings so they can better withstand the forces of running and jumping. Avoid playing on hard surfaces such as concrete for extended periods of time as this impact can lead to inflammation over time.

TREATMENT OF JUMPER’S KNEE First and foremost, decrease the frequency and duration of the activity that causes you the most pain. In other words, if it hurts, don’t do it. Apply ice for 20 minutes 2-3 times a day for 2-4 days or until pain and inflammation are reduced. If pain persists, see your doctor and maybe they can prescribe an anti-inflammatory or pain medication.

Wear a special brace called an infrapatellar brace around the bottom of the patellar tendon.  This will help to prevent overuse by helping the tendon to better absorb impact. Since jumper’s knee is a chronic injury due to repetitive stress and overuse, it can last a few weeks to several months depending on your ability to pay attention to the symptoms and take appropriate action early on. Always remember to listen to your body, if something hurts, your best plan of action is to reduce or stop that activity altogether before it develops into something more serious.

Patellar Tendonitis (Jumper's Knee) Rehabilitation Exercises You can do the hamstring stretch right away. When the pain in your knee has decreased, you can do the quadriceps stretch and start strengthening the thigh muscles using the rest of the exercises. Standing hamstring stretch: Place the heel of your leg on a stool about 15 inches high. Keep your knee straight. Lean forward, bending at the hips until you feel a mild stretch in the back of your thigh. Make sure you do not roll your shoulders and bend at the waist when doing this or you will stretch your lower back instead. Hold the stretch for 15 to 30 seconds. Repeat 3 times.

Quadriceps stretch: Stand an arm's length away from the wall, facing straight ahead. Brace yourself by keeping the hand on the uninjured side against the wall. With your other hand, grasp the ankle of the injured leg and pull your heel toward your buttocks. Don't arch or twist your back and keep your knees together. Hold this stretch for 15 to 30 seconds. Repeat 3 times. Side-lying leg lift: Lying on your uninjured side, tighten the front thigh muscles on your injured leg and lift that leg 8 to 10 inches away from the other leg. Keep the leg straight. Do 3 sets of 10.

Quadriceps isometrics: Sitting on the floor with your injured leg straight and your other leg bent, press the back of your knee into the floor by tightening the muscles on the top of your thigh. Hold this position 10 seconds. Relax. Do 3 sets of 10. Straight leg raise: Lie on your back with your legs straight out in front of you. Tighten up the top of your thigh muscle on the injured leg and lift that leg about 8 inches off the floor, keeping the thigh muscle tight throughout. Slowly lower your leg back down to the floor. Do 3 sets of 10.

Step-up: Stand with the foot of your injured leg on a support (like a block of wood) 3 to 5 inches high. Keep your other foot flat on the floor. Shift your weight onto the injured leg and straighten the knee as the uninjured leg comes off the floor. Lower your uninjured leg to the floor slowly. Do 3 sets of 10. Wall squat with a ball: Stand with your back, shoulders, and head against a wall and look straight ahead. Keep your shoulders relaxed and your feet 1 foot away from the wall and a shoulder's width apart. Place a rolled up pillow or a soccer-sized ball between your thighs. Keeping your head against the wall, slowly squat while squeezing the pillow or ball at the same time. Squat down until you are almost in a sitting position. Your thighs will not yet be parallel to the floor. Hold this position for 10 seconds and then slowly slide back up the wall. Make sure you keep squeezing the pillow or ball throughout this exercise. Repeat 10 times. Build up to 3 sets of 10.

Knee stabilization: Wrap a piece of elastic tubing around the ankle of your uninjured leg. Tie the tubing to a table or other fixed object. 

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Stand on your injured leg facing the table and bend your knee slightly, keeping your thigh muscles tight. While maintaining this position, move your uninjured leg straight back behind you. Do 3 sets of 10. Turn 90° so your injured leg is closest to the table. Move your uninjured leg away from your body. Do 3 sets of 10. Turn 90° again so your back is to the table. Move your uninjured leg straight out in front of you. Do 3 sets of 10. Turn your body 90° again so your uninjured leg is closest to the table. Move your uninjured leg across your body. Do 3 sets of 10.

Hold onto a chair if you need help balancing. This exercise can be made even more challenging by standing on a pillow while you move your uninjured leg. Resisted knee extension: Make a loop from a piece of elastic tubing by tying it around the leg of a table or other fixed object. Step into the loop so the tubing is around the back of your injured leg. Lift your uninjured foot off the ground. Hold onto a chair for balance, if needed.  

Bend your knee about 45 degrees. Slowly straighten your leg, keeping your thigh muscle tight as you do this.

Do this 10 times. Do 3 sets. An easier way to do this is to perform this exercise while standing on both legs.

TAPING (JUMPER'S KNEE) The following guidelines are for information purposes only. We recommend seeking professional advice before beginning rehabilitation. The aim of this taping is to provide support to the patella tendon or patella ligament and take some of the stress of the patella tendon insertion into the shin bone (tibia).

What is required? 3.8 cm (1.5 inch) non stretch white tape or 5 cm (2 inch) elastic tape. Some athletes may prefer one, some the other depending on amount of support required. Step 1 Sit the athlete on the floor or coach with the knee bent to 90 degrees. A small amount of underwrap may be applied around the knee for comfort and to stop the tape pinching. Or if the leg is particularly hairy then it may be best to shave the leg as well where the tape will be applied.

. Step 2Starting on the outside of the leg pass the tape just under the lower pole (bottom) of the patella and around the back of the knee (image 1). Step 4As the tape passes around the front of the knee it is twisted to give extra support. Continue wrapping the tape around the knee a couple of times. Step 5Apply one third and final wrap around the knee without twisting the tape as it passes under the patella. s

TREATMENT Nonsurgical Treatment In some cases of jumper's knee, the patient may need to stop sports activities for a short period. This gets the pain and inflammation under control. Usually patients don't need to avoid sports for a long time.

To treat jumper's knee, the doctor may prescribe anti-inflammatory medicine to help reduce swelling. A variety of knee straps and sleeves are available that may help keep pain to a minimum. The doctor may also suggest working with a physical therapist. Physical therapy treatments might use ice, heat, or ultrasound to control inflammation and pain. As symptoms ease, the physical therapist works on flexibility, strength, and muscle balance in the knee. Posture exercises can help improve knee alignment. The therapist may also design special shoe inserts, called orthotics, to support flat feet or to correct knock-kneed posture.

REHABILITATION Nonsurgical Rehabilitation In nonsurgical rehabilitation, the goal is to reduce pain and inflammation. Nonsurgical treatment can help ease symptoms of jumper's knee. Some doctors have their patients work with a physical therapist. Treatments such as heat, ice, and ultrasound may be used to ease pain and swelling.

Therapists also work on the possible causes of the problem. For example, flexibility exercises for the hamstring and quadriceps muscles can help reduce tension in the patellar tendon where it attaches to the patella. Orthotics are sometimes issued to put the leg and knee in good alignment. Strengthening exercises to improve muscle balance can help the kneecap to move correctly during activity. Therapists work with athletes to help them improve their form and reduce knee strain during their sports. When symptoms are especially bad, patients may need to avoid activities that make their pain worse, including sports.

Therapists work with athletes to help them improve their form and reduce knee strain during their sports. When symptoms are especially bad, patients may need to avoid activities that make their pain worse, including sports. When the problem involves the bone growth plate (Sinding-Larsen-Johannson disorder), the symptoms tend to go away slowly over time. This means nonsurgical rehabilitation probably won't cure the problem. Treatments can only give short-term relief.

What is the treatment for patellar tendonitis? Rest The most important first step in treatment is to avoid activities that aggravate the problem. Your body is the best guide to know how much to rest the injured knee--if an activity hurts in the area of the injured patellar tendon, then you should rest from that activity. Anti-Inflammatory Medications Nonsteroidal anti-inflammatory medications (NSAIDs) include a long list of possibilities such as Ibuprofen, Motrin, Naprosyn, Celebrex, and many others. Patellar tendonitis treatment can be improved by these medications that will decrease pain and swelling. Be sure to talk to your doctor before starting these medications.

Stretching Stretching the quadriceps, hamstring, and calf muscles prior to activity is very important once you do resume activities. Getting into a good stretching habit, even once the symptoms resolve, will help prevent a recurrence of the problem. Ice Treatments Icing the area of inflammation is an important aspect of tendonitis treatment. The ice will help to control the inflammation and decrease swelling. By minimizing inflammation and swelling, the tendon can return to its usual state and perform its usual function

Chopat Straps/Braces Occasionally, your doctor will provide a support strap (called an infrapatellar strap or a Chopat strap), a knee brace, or custom orthotics. The benefit of these measures in the treatment of patellar tendonitis is not well known, but some patients find complete relief from using these products.

EXAMINATION - Perform exam with knee in full extension - Bassett Sign: - Tenderness to palpation with knee at full extension and patellar tendon relaxed - Non-tender with knee in flexion and patellar tendon taut - Quadriceps atrophy - Quadriceps and hamstring tightness - Knee effusion is rare - Ligaments usually stable - Various biomechanical derangements may be present on exam - excessive foot pronation; - ie. Malalignment, patellar hypermobility, patella alta/baja, tibial/femoral rotation, etc. - However, no correlation with jumper’s knee exists for these intrinsic factors (Ferretti 1986)

TREATMENT OF PATELLA TENDINOPATHY / PATELLA TENDONITIS Treatment of patellar tendonopathy is slow and may require a number of months of rehabilitation in order to notice a decrease in aggravating symptoms. This may include several months of rest. During rehabilitation the VISA questionnaire may be filled out to monitor the progress of the tendonopathy.

Two modes of treatment may be advised conservative treatment and surgical treatment: Conservative (non-surgical) Treatment of patella tendonitis / patella tendinopathy This is normally advocated initially after diagnosis of patellar tendonopathy. Care must be taken so as to not overload the tendon. Treatment may involve:

Quadriceps muscle strengthening program: in particular eccentric strengthening. These exercises involve working the muscles as they are lengthening and are thought to maximise tendinopathy recovery. Muscle strengthening of other weight bearing muscle groups, such as the calf muscles, may decrease the loading on the patellar tendon. Ice packs to reduce pain and inflammation. Massage therapy-Transverse (cross) friction techniques may be used. Aprotinin injections may help tendinopathies by restoring enzyme balance in the tendon.