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.
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.
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.
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.
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.
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.
For more information, please feel free to ask Dr. Jimenez or contact us at 915-850-0900 .
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By Dr. Alex Jimenez
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