What is patella tendinopathy?
The most common cause of patella tendon pain is patella tendinopathy, also known as jumper’s knee. The patella tendon is a large strong tendon that runs from the patella (kneecap) to the shin bone and helps to transmit large forces through the thigh when we run and jump. A healthy patella tendon will deal perfectly well with exercise, however if the tendon is overloaded by excessive exercise, it can become aggravated and painful. The tendon microstructure maladapts and some of the collagen fibres become weak and degenerative. Patella tendon rupture are very rare but do happen as do avulsion fractured of the tendon from the shin bone in young people both of which require surgery.
How do we diagnose patella tendinopathy?
This will depend on your symptoms but typically there will be a history of increased loading, such a going from running 3 days a week to 5, or starting a new sport or playing on a hard surface. The tendon will be a bit sore with sports but can settle down again afterwards. It will typically be stiff and sore first thing in the morning and might be sore climbing stairs or getting up after sitting for a while.
It will usually be tender to touch just off the bottom edge of the patella and we can see the thickened and painful tendon if we perform an ultrasound scan. If you have developed knee pain increasing your running you need a Run Fit assessment…
What treatment is there for patella tendinopathy?
Patella tendon pain can be highly variable within the different stage of tendinopathy, and we need to adapt our treatment and loading to the pain not the stage of pathology. All tendons can take minimum 3 months to improve, sometime longer.
The pain model of patella tendinopathy
Is the pain irritable or stable? How does the pain behave after loading with the 24-hour response? If it’s irritable it needs relative rest, let it settle, remove offending load, use isomeric exercises at a low intensity for analgesia. Consider anti-inflammations. If it’s stable move through general S and C phases of heavy slow resistance as per the Kongsgaard protocol. I might also be useful to have a course of shockwave on the tendon.
The pathology model of patella tendinopathy
This model suggests we treat the type of tendon injury based on Cook and Purdham’s tendon pathology continuum. If there is a reactive tendon it requires relative rest, ice and Ibuprofen (which is a tenocyte inhibitor), speaking with a physio to assess and correct and biomechanical issues, use isometric exercises for pain modulation and be less aggressive with strengthening the tendon.
If there is tendon disrepair progress from isometrics to concentric / eccentrics to plyometrics exercises and complete general lower limb S and C as per the Kongsgaard protocol) to strengthen the glutes, quads, hamstrings and calf. One could also use shockwave therapy which is very effective for patella tendinopathy or consider trialling GTN patches.
If there is tendon degenerative, then we manage it as per tendon disrepair but can be more aggressive with loading and do heavy isometrics. Patella tendons responds well to heavy load as a long as the symptoms stable. Perform heavy slow resistance 3-4 times a week. Use leg extension, leg press, squats, split squats, step ups, hopping and jumping progressions. Avoid deeper flexion to limit irritating the tendon. Generally, the Alfredson decline board squats programme is obsolete.
Ultrasound guided injections for patella tendinopathy
Steroid injections are not recommended for tendon problems. We know they will have a short-term effect such as settling pain, however they can have a long term negative effect. Two other types of ultrasound guided injection for patella tendinopathy include high volume injections and PRP.
High volume injections involve injection saline and a local anaesthetic into the tendon sheath to strip off any blood vessels and nerves that have grown into the painful tendon. PRP injections involve taking some of your blood and spinning it it a centrifuge to produce the PRP, this can be injected into the tendon to promote healing. The injections are adjuncts to load management and strengthening and the research is mixed as to their effectiveness so they should be used cautiously. It’s important to note that tendon pain can improve or resolve however pathological imaging can remain.
Ultrasound guided injections for patella tendon pain
If you’re suffering from patella tendon pain contact us today.