Patellar Tendinopathy

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Definition/Description

Patellar tendinopathy, also called Jumper’s knee, is a clinical condition of gradually progressive activity-related pain resulting from overuse of the knee.It is a syndrome with micro tears and collagen degeneration in the patellar tendon also due to overuse but non- inflammatory . The term tendinosis should be used as a histopathological and not a symptomatic description. It affects both recreational and elite athletes who run and jump as p.e. in volleyball and basketball. Patellar tendinopathy occurs more frequently in those mature adolescents or adults, ranging from ages 16-40 years. 

• Patellar tendinitis should also be distinguished from Osgood-Schlatter’s disease which is a form of osteochondritis.
• Adolescents growing fast in a short time can be affected by the Sinding-Larsen-Johansson disease.

Clinically Relevant Anatomy

 The knee joint consists three bones, the femur, the tibia, the fibula and also the patella which is a sesamoid. The quadriceps muscles are connected to the patella with a shared tendon and there is also a tendon that connects the bottom of the patella to the tibia, called the patellar tendon. This tendon is extremely strong and allows the quadriceps muscle group to straighten the leg. The patellar tendon is made of tough string-like bands. These bands are surrounded by a vascular tissue lining providing nutrition to the tendon. The patellar tendon is also a ligament.

Epidemiology /Etiology

 These are the most common causes of patellar tendinitis:

• a rapid increase in the frequency of training,
• sudden increase in the intensity of training,
• transition from one training method to another,
• repeated training on a rigid surface,
• improper mechanics during training,
• genetic abnormalities of the knee joint, and/or
• poor base strength of the quadriceps muscles.
  

Physiological background

Acute tendinitis involves an active inflammatory process, often occurring following an injury, which if treated, properly heals in 3-6 weeks. 
Chronic patellar manifest itself after 6 weeks – 3months. These changes include absence of inflammatory cells in the tendon, a tendency toward poor healing, and decreased quality and disorganization of collagen fibers, both of which may lead to decreased tensile strength. Additonally, neovascularization, the growth of new vasculature in areas of poor blood supply, is common in chronic tendinopathy and may contribute to pain perception. The relationship between pain perception and neovasularization is not clearly understood, it is believed that increased levels of the neurotransmitter glutamate may play a role.    

Causes 

There is a higher prevalence noted in sports with high impact ballistic loading to the knee extensors. Microtrauma can occur when the patellar tendon is subjected to extreme forces such as rapid acceleration – decelaration, jumping, and landing.  Drastic changes in frequency and or intensity of training may also lead to overuse training errors. Intrinsic factors such as strength or flexibility may play a role. However the primary causes appear to relate to the extrinsic factors of overuse, improper training surfaces, insufficient foot-wear or inappropriate equipment.  

Characteristics/Clinical Presentation

Pain is the first symptom of patellar tendinitis. The pain usually is located in the section of the patellar tendon . During physical activity, it may feel sharp especially when running or jumping. After the workout it will feel like a dull ache. There is swelling and tenderness in and around the patellar tendon. The knee will often feel ‘tight’ when moved towards flexion.

The purpose of the evaluation is to differently diagnose between condition affecting the patella. We can use the Kennedy Scale to evaluate a chronic patellar tendinopathy  :

1. Phase 1: pain after activity
2. Phase 2: pain at the beginning and after activity
3. Phase 3: pain at the beginning, during and after activity, but the performance is not affected
4. Phase 4: Pain at the beginning, during and after activity, and the performance is affected

Thickness of the tendon may be noted also in all stages. Pain in the patellar tendon may be reproduces with resisted knee extension.
The symptomatic evaluation should include history, age and any recent growth spurts, location of pain, and special tests.

Diagnostic Procedures

The signs and symptoms of patellar tendinitis are fairly easy to detect. The athlete will complain of:

• pain in the area of the tendon,
• the knee will often feel "tight,"
• pain will be experienced early in the workout and after the workout is completed,
• there may be some subtle swelling of the tendon, and
• the athlete may feel that the tendon is "squeaking."

The key physical finding in patellar tendinopathy is tenderness at the inferior pole of the
patella or in the main body of the tendon when the knee is fully extended and the quadriceps relaxed. When the knee is flexed to 90 degrees, thus putting the tendon under tension, tenderness significantly decreases and often disappears altogether.

Differential Diagnosis

Knee pain is a common presenting complaint with many possible causes. Therefore it is important to identify the different disorders. Each have a different patterns that can help to identify the underlying cause more efficiently.

Anterior knee pain

• Patellar subluxation or dislocation
• Tibial apophysitis (Osgood shlatter)
• Jumpers knee (patellar tendonitis)
• Patellofemoral pain syndrome (chondromalacia patellae)

Medial knee pain

• Medial collateral ligament strain
• Medial meniscal tear
• Pes anserine bursitis
• Medial plica syndrome

Lateral knee pain

• Lateral collateral ligament sprain
• Lateral meniscal tear
• Iliotibial band tendonitis

Posterior knee pain

• Popliteal cyst (Baker’s cyst)
• Posterior cruciate ligament injury
  

Examination

Two clinical signs can be performed to assess patellar tendinitis  .

In the “passive extension – flexion sign” the patient lies supine on the examination table. The anterior aspect of the extended knee is palpated to define the point of maximal tenderness.

In the case of patellar tendinitis, tenderness to palpation of the tendon is most often located at the origin of the tendon at the inferior pole of the patella. Once the point of maximal tenderness is identified, the knee is flexed to 90° and pressure is again applied to the tendon.

For the “standing active quadriceps sign”, the patellar tendon is palpated along its course while the patient stands. The point of maximal tenderness identified. The patient is then asked to stand only on the involved extremity with 30° of knee flexion and the tendon was re-palpated.

In both these tests, the patient should note a marked reduction of tenderness to palpation when the knee is flexed or the quadriceps contract, in order to confirm the diagnosis of patellar tendinitis.

Medical Management

There are different types of treatment used in the medical management of tendon disorders.
Unfortunately, few have a strong evidence base.

Non-steroidal anti-inflammatory drugs The use of non-steroidal anti-inflammatory drugs (NSAID’s) in the treatment of tendinopathy remains controversial both in the acute stage and in the chronic stage. NSAID’s do, however, have an analgesic effect possibly independent of the anti-inflammatory action.

Corticosteroid injections Corticosteroid injections are a commonly administered treatment for tendon disorders. All the usual side-effects of corticosteroids are possible (such as skin atrophy, skin hypopigmentation, postinjection flare of symptoms, infection and possible effects from systemic absorption particularly after multiple injections). There is also the possible effect on the mechanical integrity of the
tendons themselves.

Surgical treatment Very good results were achieved. In the chronic stage the lesions are irreversible and constitute permanent intratendinous lesions. It thus seems logical to excise these lesions from their origin at the apex of the patella and entry into the adjacent tendon.

Physical Therapy Management

Physical therapy for about four to six weeks (3 times a week) is usually recommended. The first step before treatment is rest. It’s important that the patient avoids activities that aggravate the problem. He can take non steroidal anti- inflammatory medications. These will decrease pain and swelling.

The physiotherapist can use ice massage(cryotherapy), electrotherapy, Iontophoresis , and ultrasound to limit pain and to control swelling.

Typical for a tendinitis therapy is to perform deep transverse frictions.

After a five-minute warm up period, an important thing to perform are stretching exercises for the quadriceps. Inflexible muscles, especially inflexible thigh muscles (quadriceps), contribute to the strain on the patellar tendon and to correct any muscle imbalances.

In the second week the physiotherapist will try ‘shock wave therapy’. It helps to regenerate the tendon and stimulates circulation.
After a while as the symptoms allow, strengthening exercises can start. They are very useful for the knee joint and quadriceps. A few examples are:

• Straight Leg Raises
• knee flexion and extension, as well as hip flexion
• squats, calf raises, step-ups

Researchers have discovered that patellar tendinitis responds to a concentric-eccentric program of closed chain exercises for the anterior tibialis muscle. That is the muscle in the lower leg that helps dorsiflex the ankle. For example toe stand and heel position.
Eccentric closed chain exercises are also good for strengthening the quadriceps

After a while the patient can start with proprioceptive exercises.

Next in line are flexibility exercises, those are useful to restart especially running or jumping sports. For less pain and more stability a brace or tape for the patella can be useful. Most braces for patellofemoral problems are made of soft fabric, such as cloth or neoprene. Patella taping may be used to provide support for the patella and knee and to reduce abnormal patella positioning or tracking. One of those techniques is the McConnell taping technique.

After the exercising program it’s good to cool down, stretch and use cryotherapy.

Therapists also design special shoe inserts, called orthotics, to improve knee alignment and function of the patella.

Don’t overdo the own limits in the exercise program.

For people who do high-level sports: coaches, trainers, and therapists can work together to design a training program that allows to continue training without irritating the tendon and surrounding tissues.

If nonsurgical treatment fails to improve the condition, then surgery may be suggested. Surgery is designed to stimulate healing through revascularization .

Rehabilitation

Rehabilitation incorporates three stages ranging from limited partial weight bearing loaded exercise to a sports specific return to play protocol.Most patients with patellar tendinopathy are treated non-operatively. Eccentric exercise has been promoted as an important conservative treatment choice for patellar tendinopathy.

The first stage of rehabilitation includes the initial rehabilitation with controlled rest. The rest is critical in the recovery. The patient should be refrained from a lot of physical activities or he should be abstained from the overuse abuse, and practice controlled exercise without load.
Initial treatment includes absence from jumping, relative rest, stretching of lower extremity musculature, deep transverse friction massage of the patellar tendon, eccentric quadriceps exercises, strengthening of hip and knee musculature, utilization of a patellar orthotic (if needed), and cryotherapy. Prior the initiate the exercise , a warm-up and stretching period is recommended. Soft tissue mobilization is used to reduce pain and fibrotic limitations in tissue found in patellar tendinopathies. Deep transverse friction massage for 5-10 minutes twice daily is recommended to help promote normalized collagen alignment.

In the progression stage, after pain symptoms decrease, the eccentric exercise program should be progressed from partial-weight bearing to full weight bearing, then to weighted resistance using a back pack or weighted vest.

Conclusion A variety of rehabilitation techniques are necessary to assist an individual in returning the recreational en daily living activities. A combination of active rest, education eccentric exercise, progressing the training regime by 10% weekly, and modifying activity have all been found to be effective in tendinopathy treatment.   

Recent Related Research (from Pubmed)

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