JUMPERS’ KNEE (Patella Tendonitis)

What is jumpers’ knee / patella tendonitis?
The patellar tendon / ligament join the kneecap (patella) to the shin bone (tibia). This tendon is extremely strong and allows the quadriceps muscle group to straighten the leg.
The quadriceps actively straightens 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.
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With repeated strain, micro-tears as well as collagen degeneration may occur as a result in the tendon.This is known as patellar tendinopathy or Jumpers Knee. It should be distinguished from patella tendonitis as this latter condition indicates an inflammation of the tendon whereas tendinopathy is more about degeneration of the tendon.
For the purpose of this article we have used the term patella tendonitis as well as tendinopathy but strictly speaking tendinopathy is usually the correct term.
What are the symptoms of jumpers’ knee / patella tendonitis?
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  • Pain at the bottom and front of the kneecap especially when pressing in.
  • Aching and stiffness after exertion.
  • Pain when you contract the quadriceps muscles.
  • The affected tendon may appear larger than the unaffected side.
  • May be associated with poor Vastus medialis oblique (VMO) function
  • Calf weakness may be present
What can the athlete can do about patella tendinopathy?
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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 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.
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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 advice on rehabilitation.
If the knee does not respond to rehabilitation then consult an Orthopedic Surgeon as surgery may be required.
Treatment of patella tendinopathy / patella tendonitis
Treatment of patellar tendinopathy 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 tendinopathy. Two modes of treatment may be advised – conservative treatment and surgical treatment
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Conservative (non-surgical) Treatment of patella tendonitis / patella tendinopathy
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This is normally advocated initially after diagnosis of patellar tendinopathy. 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 maximize 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 tendinopathy by restoring enzyme balance in the tendon.
Surgical Treatment of patella tendonitis / patella tendinopathy
This is normally advised as a last resort. Also, there is little convincing evidence to support the use of surgery over conservative treatment for patellar tendinopathy. Surgery either includes excision of the affected area of the tendon or a lateral release where small cuts are made at the sides of the tendon which take the pressure off the middle third.An intensive rehabilitative program is normally advised following surgery. In particular the use of eccentric strengthening exercises may help stimulate healing.
A Sports Injury Specialist or Doctor may:
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  • Prescribe anti-inflammatory medication e.g. ibuprofen.
  • Use ultrasound or laser treatment.
  • Use cross friction massage techniques.
  • Prescribe and supervise a full rehabilitation programme.
A Surgeon can operate.If the injury becomes chronic then surgery is an option. A lateral release of the patella tendon is usually successful.Similar or related knee injuries that are sometimes confused with this injury include Patello femoral pain.
The following guidelines are meant for information purposes only. Always seek professional advice before attempting any rehabilitation.
Aims of rehabilitation
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  •  Reduce initial pain and inflammation.
  • Stretch the quadriceps muscles.
  • Strengthen the tendon and muscles.
  • Gradual return to full fitness.
  • Prevention of recurrence

Reducing pain and inflammation

Rest from all aggravating activities. If you have knee pain during every day activities then expect to rest from training for two weeks. If you only have a little pain after training then modifying training methods (less impact / jumping) for a while may be sufficient.
Apply cold therapy or ice for 15 minutes every hour if it is bad, at least three times a day otherwise.
NSAID’s (Non Steroidal Anti-inflammatory) e.g. Ibuprofen may help in the early stages. Always consult a Doctor before taking medication. Ibuprofen must not be taken by asthmatics.
Wear a heat retainer or knee support. This will protect the tendon and allow it to heal, especially if you have to be on your feet.
Stretching
Gentle stretching is important as soon as pain will allow. Exercises to stretch the quadriceps muscles are particularly important. Hold stretches for around 10 seconds and repeat 5 times. Aim to stretch at least 5 times a day.
Later in the rehabilitation process stretches should be held for longer.
Stretching should continue long after the injury has healed to avoid re-occurrence.
In addition to the quadriceps muscles it is important to stretch the hamstrings, calf muscles and iliotibial band as well.
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Strengthening
  • Strengthening should begin as soon as possible but pain free. Initially you may be only able to manage static contractions of the quadriceps muscles. Strengthening of the calf muscles and hamstring group of muscles is also very important.
  • Progressive ‘eccentric’ resistance exercises are particularly important in rehabilitation of patella tendinosis. This means exercises where the muscle is contracted but lengthening, for example the downwards phase of a squat involves the quadriceps muscles contracting but lengthening at the same time.
  • Strengthening exercises should always be done within a range of movement that is pain free. If you are causing more pain the chances are that you are making the injury worse.
  • Apply cold therapy / ice after exercises to prevent inflammation.
  • A problem that many athletes have when coming back from this type of injury is that they have been deliberately putting weight on the good leg and so have developed abnormal movement patterns. This in itself can lead to further injuries and imbalances. Athletes should be aware of this danger when returning from injury.
  • Be patient! It may take between 6 and 12 months to return to full fitness following a grade 4 injury.

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Return to full fitness
  •  This can begin you have a pain free full range of movement, no swelling, good strength – i.e. you can comfortably manage single leg eccentric squat strength training exercises without pain.
  • A gradual running programme should be started. For example jog 2 minutes, walk 2 minutes, repeat 5 times.
  • When you can comfortably jog for 10 minutes pain free then begin striding and sprinting repetitions – initially at 50% of maximum speed and build up.
  • As the intensity and speed increases pain may result from the tendon. This is often a natural part of the rehabilitation process, however if symptoms do not improve again within a day or so you will need to reduce the workload.
  • It is essential that specific eccentric strengthening exercises are continued throughout the rehabilitation process and not stopped when sports specific training begins.

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Injury Prevention
  •  Do not over-train! Performing too many high impact training act ivies will be too much for the tendon. Look out for the early signs of pain and inflammation after training and act. Do not wait until this injury becomes bad – there is a long rehabilitation period once the injury becomes worse.
  • Identify any biomechanical problems that may increase the risk for example over pronation of the foot, a loose kneecap or a tight iliotibial band. If you are not sure, see professional help and advice.
  • Use eccentric strengthening exercises to make the knee joint strong enough to cope with the demands of the sport. Continue these exercises long after the injury has healed. They should become part of your usual training routine.
  • Stretch the muscles (particularly quadriceps) properly and regularly.
  • Get a regular sports massage to keep muscles and tendons in good condition.

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