Patellar Tendinopathy

What is Patellar Tendinopathy?

This condition goes by a number of different names, such as Patellar Tendonitis, Patellar Tendinosis, Knee Tendonitis and Jumpers Knee. Physios no longer use the term “Tendonitis”, as in the vast majority of cases we now understand that there is no inflammation (“itis”) present, but rather it is a degenerative condition, where the tendon is suffering from a long term wear and tear process, and no longer has the strength to cope with sports stresses and daily physical activities. 

Knee Pain

Pain is felt within the Patellar Tendon, usually just at the bottom edge of the Patella (kneecap) and is usually worse with ballistic and vigorous leg activities such as jumping and landing, hopping and taking stairs. At its worst, it can be very debilitating and stop sports participation. Usually there is little or no pain at rest.

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How does it develop?

As is generally the case with other tissues in the body, when we are active and use our muscles and tendons consistently, they become strong and resilient. Typically, as we get older, our strength and activity levels decline, and the tendon structure starts to deteriorate. Parts of the tendon lose the capacity to transfer muscle force. 

Now, the tendon is vulnerable to sudden increases in activity, such as a return to sport after a long break, unfamiliar vigorous physical training, work or home activities, or sometimes quite trivial loads for people who are usually less active.

Essentially when we place more stress on the Quadriceps/ Patellar Tendon than it is used to, there is a greater risk of tendinopathy resulting. Pain results when the brain registers the mismatch between tendon strength and the demands on the tendon, as a threat of imminent tissue damage.

Who does it happen to?

As the common name “Jumpers Knee” indicates, Patellar Tendinopathy is quite prevalent in jumping sports such as Volleyball, Basketball, Triple Jump and Netball. It can appear in other sports such as cycling where there are heavy and repetitive demands on the tendon. However, in many cases the condition shows up in older adults who may have participated in these sports in the past, have suffered wear and tear of the tendon over time, then exacerbate the problem with sudden increased loading.

How to identify it?

Many different knee conditions present quite similarly, but there are some key features that indicate the tendon is the problem.
1/ A history of recent increased load on the knee
2/ Pain with vigorous knee activities such as jumping and landing
3/ Pain and / or weakness when performing a Single Leg Squat or Single Leg Decline Squat
4/ Acute tenderness to finger pressure where the tendon joins the Patella

What to do about it?

Physiotherapy modalities such as ultrasound, medium frequency current and friction massage can help with the pain in the short term.

A Patella Tendon Brace or Band can provide relief during sport or activities, as it changes the line of pull of the tendon at the Patella and provides local compression support, However, this is not a good long-term solution as it will also retard blood flow to the tendon which is vital for healing, repair and growth, and it does not address the causes of the problem.

In the acute period, the knee will need “relative rest”, meaning a reduction or cessation of the provocative activities. If the pain is quite strong and easy to set off, you may need to significantly reduce your sports training or physical activity. If the pain is not so bad, reducing the load by a smaller amount may be appropriate. It is very rare to advise complete rest, as this will further weaken the tendon.

Ultimately, the best way to fix Patellar Tendinopathy is with a Progressive Resistance Exercise program. Exercises will initially be less dynamic, often starting with isometrics which provide immediate pain relief  as well as a strengthening effect. These should initially be done daily, to kick start the repair process.

Gradually, the program will need to include more and more difficult, vigorous and ballistic exercises, until eventually you are mimicking the full demands of the sport or original causative activity. While building strength, exercises will be needed 3-4 times per week, and then less frequently after that as you move into a strength maintenance phase. 

How to stop the pain returning?

There are a few considerations to reduce the likelihood of Patellar Tendinopathy recurrence:
1/ Respect the acute/ chronic ratio of activity loading. This means that the sporting or physical activity load on the leg/ tendon should not increase by more than about 10% per week. Remember that loading has many parameters including activity frequency, duration and intensity. If you increase all three of these factors by 10%, the overall increase is over 30%!

2/ If your tendinopathy has settled, it is recommended to continue with a maintenance dose of tendon strength exercise once per week. In an elite sporting environment this may need to be more frequent.  This ensures that the tendon remains strong and resilient and does not suffer from more disuse related deterioration.

3/ See your physio on a periodic basis, to check that your strength measures are being maintained. If they detect any small losses in functional ability, a short burst of treatment and resumption of more frequent exercises may help to avoid a full-blown relapse of symptoms