Introduction
Patellar Tendinopathy (PT) or Jumpers Knee is a common injury in jumping sports that occurs when loads are very high or suddenly increase. It affects an athlete’s performance ability to jump, land, change direction and run. It can lead to a reduction in tolerance of training and competition load and eventually a decline in performance, missing training and competition.
The aim of this article is to guide you through understanding why you have a PT, and how best to manage your grumbling patella tendon.
Diagnosing Your PT
Mechanism Of Injury
Most commonly the onset of a tendinopathy can occur when there is a mismatch between tendon capacity and load placed on the tendon. This occurs when there is a sudden and/or substantial change in training load. It’s important to reflect on any new or increases in training loads. Knowing a cause can assist in the management because the new loads can be modified to allow symptoms to resolve, and potentially avoided in the future.
An easier way to understand a mismatch between tendon capacity and load placed on the tendon is the cup and water analogy. Think of a cup being your tendon capacity and water being the load poured into the cup. Every time you train, your cup gets filled up with load. If you haven’t been doing much training and then all of a sudden you have a spike in training loads, your cup will fill up a lot more and overflow. My cup size is different to your cup size and everyone is different. Lets compare two athletes in the same team. Athlete One is training consistently whilst completing their planned running, strength and fitness in their off-season break maintaining a good sized cup. Versus Athlete Two who went on a 4 week holiday, training his beach muscles only and going on the odd run. Athlete Two’s cup size will be dramatically smaller than Athlete One. So when these athletes come back to do pre-season training, what athlete is more likely to fill up their cup quicker and is at more risk of getting grumbling tendons?
Location of Pain
Athletes with PT have a very specific location of symptoms and often point directly to the proximal patellar tendon (Cook, Rio & Docking, 2014).
24-Hour Behaviour
Tendinopathies are often painful after activity and especially the next day (Rudavsky & Cook, 2014).
Aggravating activities
Aggravating activities for patellar tendons depend on the irritability of the tendon. Activities usually include direct pressure on the tendon such as kneeling, squatting, jumping and in particular landing, changing direction and decelerating.
SL decline squat 25degree wedge
Reported to be the best clinical assessment tool (Cook, Rio & Docking, 2014; and Rudavsky & Cook, 2014). Both pain and quality of squat can be assessed whilst squatting. If quality of the SL squat is affected, the athlete’s ‘spring’ has a poor function and is commonly stiff at the knee, and soft at the ankle and hip (Rudavsky & Cook, 2014). This demonstrates that they cannot absorb load through their patellar tendon.
Further Investigations
Imaging using MRI and ultrasound can identify the presence of pathology in the tendon. MRI and US imaging are the two modalities used in my practice since an acute strain to a tendon should be excluded and the US can help confirm worsening tendon pathology. Management of a tendon differs according to what phase a tendinopathy is in.
Managing Your PT
Whilst the pathology of the tendon may never completely resolve, conservative management of a PT is favourable (Rudavsky & Cook, 2014). If you follow the management plan below, your pain and/or performance will improve.
Pain management
Relative rest is the first priority to unload the reactive tendon and there should not be complete cessation of activities because this will decrease the overall capacity of the tendon (Kountouris & Cook, 2007). The overall capacity refers to the amount of load a tendon can withstand (cup and water analogy) and by resting completely, a de-training effect will occur.
Isometric single leg knee extensions and/or single leg press squats (See Pics Below) should be prescribed for pain reduction. 5 repetitions x 10-45 second holds performed four-times per day. In reactive tendons isometric contractions with moderate-heavy loads has been reported to be effective in reducing pain for hours (Cook & Purdam, 2014; Rudavsky & Cook, 2014; and Cook, Rio & Docking, 2014). Look at these exercises as panadol of the tendon without taking panadol!!
Following the TENDON RECOVERY RULES
It is important that these exercises do not further aggravate the tendon. One of our High Performance Sports Physio’s can prescribe the correct time and appropriate resistance as tolerated by the athlete. If you follow the following rules your pain and performance will improve.
1. In acute/reactive tendons, avoiding any pain is essential to avoid any further aggravation. One of our High Performance Sports Physio’s can diagnose what phase you are in.
2. NO Stretching acute/reactive tendons – no Quad Stretches.
a. See a HP therapist for manual therapy, dry needling or jump on a foam roller to maintain or increase mobility of the hip/knee.
3. No Pain MORE than a 3/10 during, after or the next day
a. Once symptoms have settled its ok to exercise up until a 3/10 Pain.
b. Tendons may feel OK during exercise but may be sore after. This again needs to be less than a 3/10 Pain.
c. Track your pain by: noting pain levels when you first rise and walk in the morning, Perform a SL decline squat on a wedge, perform 3x vertical hops. Best to note these in a pain diary. You will be able to track how well you are going and what your response to training load from the previous day was (Rudavsky and Cook, 2014).
Interdisciplinary Management
Management of tendon pain should be seen as an issue for an interdisciplinary team to solve. As such, it is helpful to discuss the situation with a physician and dietician as they can administer some ibuprofen, high dose of fish oil and green tea (Fallon, Purdam, Cook & Lovell, 2008). This may help decrease tendon pain.
Ice or Heat??
Some athletes like to put heat packs on prior to activity to warm up their tendons.
Icing after activity for up to 20 minutes for an analgesic effect may help reactive tissue around the patellar tendon (such as a fat pad) settle down. This can stiffen up tendons following activity.
Ongoing Management
Managing tendinopathies is about trying to explore the correct balance of un-loading the tendon without causing a detraining effect on the tendon. Daily pain monitoring using a diary as discussed provides the best information about tendon responses to load.
Programming
Reactive tendon response is the main cause of pain, so the key intervention should be reducing loads (Cook & Purdam, 2014). Load modification can be programmed specifically to relieve tendon pain:
Periodising an athlete’s week into high, low and medium days, aims to respect the tissue adaptation from demanding sessions where increased elastic loading is present. High elastic loading includes sessions with running and jumping. High days include increased amounts of stretch shortening cycle (SSC), such as field sessions including training where there may be a lot of running, jumping and mechanical load (change of direction, accels and decels). Medium days include specific tendon strength program and/or a less demanding field/running session. Low days include isometric holds only (Rudavsky & Cook, 2014). Programming an athlete’s week with PT during the in-season phase can be challenging not only because you’re managing the athlete’s symptoms but because of other factors such as recovery from a game/competition and scheduling of when players are training. A typical week for a field based sport is outlined below:
Strengthening The Tendon & Lower Body (Kinetic Chain)
The following program takes time and depends on the irritability of the tendon. A <3/10 pain level should be the threshold and exercises should not be progressed if this level of pain is exceeded (Rudavsky & Cook, 2014). See one of our High Performance Sports Physio’s for a program tailored for you. An example of some progressions and tendon load/strengthening modalities is below:
Exit Criteria
Before being able to jog, the athlete must be pain-free walking, on stairs and be able to perform the following and be <4/10 pain post session / next morning on a SL decline squat:
· <3/10 SL decline squats on wedge to parallel (x4reps each side).
· SL calf raises x25 reps each side.
· DL skips (30secs on/off x 5reps).
· Alternate skips (40s on/20s off x 10reps).
· DL jumping/landing progressing to SL hopping/landing sequences. Including forward, lateral and multi-directional hopping.
· If available, running progressions on an Alter-G treadmill progressing from an entry level of 70-100% weight bearing.
· Running must then be calculated and progressive and programming including high, low and medium days as discussed.
Tendon daily monitoring must be completed and be a guide for progressing the athlete through the above exit criteria, running progressions and training.
Summary
PTs can be challenging to manage. It is important to understand why the athlete has a mismatch between tendon capacity and load. Once this has been established, relative rest (not complete rest) and programming of high, low, medium training days must be done to unload the tendon. Acute management aiming to decrease pain is of upmost importance. A focus on isometric exercises for pain relief will help achieve this. If symptoms are respected and monitored daily, this approach to managing PT will hopefully keep athletes competing for their season.
Reference List
Alfredson, H., Forgren, S., Thorsen, K., and Lorentzon. (2001). In vivo microdialysis and immunohistochemical analyses of tendon issue demonstrated high amounts of free glutamate and glutamate NMDAR1 receptors, but no signs of inflammation, in Jumper's knee. Journal of Orthopaedic Research, 19, 881-886. Retrieved from: http://0-search.proquest.com.alpha2.latrobe.edu.au/docview/71171416?OpenUrlRefId=info:xri/sid:summon
Allison, G.T. and Purdam, C. (2009). Eccentric loading for Achilles tendinopathy – strengthening or stretching? British Journal of Sports Medicine, 43(4), 276-279.
Cook, J., Khan, K., Kiss, Z., Purdam, C., and Griffiths, L. (2001). Reproducibility and clinical utility of tendon palpation to detect patellar tendinopathy in young basketball players. British Journal of Sports Medicine, 35, 65–69. doi: doi:10.1136/bjsm.35.1.65
Cook, J.L, and Purdam, C.R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load induced tendinopathy. British Journal of Sports Medicine, 43(6), 409-16.
Cook, J., and Purdam, C. (2014). The challenge of managing tendinopathy in competing athletes. British Journal of Sports Medicine, 48, 506–509. doi:10.1136/bjsports-2012-092078
Cook, J., Rio, E., and Docking, S. (2014). Patellar tendinopathy and its diagnosis. Sport Health, 32(1), 17-20. Retrieved from: http://0-search.informit.com.au.alpha2.latrobe.edu.au/documentSummary;dn=322863309596697;res=IELHEA
Fallon, K., Purdam, C., Cook, J., Lovell, G. (2008). A ‘‘polypill’’ for acute tendon pain in athletes with tendinopathy? Journal of Science and Medicine in Sport, 11, 235—238. doi:10.1016/j.jsams.2007.09.002
Gaida, J., Cook, J., Bass, S., Austen, S., and Kiss, Z. (2004). Are unilateral and bilateral patellar tendinopathy distinguished by differences in anthropometry, body composition, or muscle strength in elite female basketball players? British Journal of Sports Medicine, 38(5), 581–585. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1724954/?tool=pmcentrez&report=abstract
Malliaras, P., Cook, J., and Kent, P. (2007) Anthropometric risk factors for patellar tendon injury among volleyball players. British Journal of Sports Medicine, 41(4), 259–263. doi:10.1136/bjsm.2006.030049
Rudavsky, A., and Cook, J. (2014). Physiotherapy management of patellar tendinopathy (jumper’s knee). Journal of Physiotherapy ,60, 122–129. doi: http://dx.doi.org/10.1016/j.jphys.2014.06.022
Kountouris, A., and Cook, J. (2007). Rehabilitation of Achilles and patellar tendinopathies. Best Practice & Research Clinical Rheumatology, 21(2), 295–316. doi:10.1016/j.berh.2006.12.003
Witvrouw, E., Bellemans, J., Lysens, R., Danneels, L., Cambier, D. (2001). Intrinsic risk factors for the development of patellar tendinitis in an athletic population. A two-year prospective study. American Journal of Sports Medicine. 29,190–195. Retrieved from: http://0-ajs.sagepub.com.alpha2.latrobe.edu.au/content/29/2/190