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Clinically Relevant Anatomy
The patella tendon / ligament joins the kneecap (patella) to the shin bone or tibia. This tendon is extremely strong and allows the quadriceps muscle group to straighten the leg. The quadriceps actively straighten 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. 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 (tendinitis) as this condition indicates an inflammation of the tendon whereas tendinopathy is more about degeneration of the tendon.
- Pain at the bottom and front of the kneecap especially when pressing in or palpating (see assessment).
- 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 obliquus (VMO) function
- Calf weakness may be present
Jumpers knee can be categorised into four grades of injury:
Grade 1: Pain only after training
Grade 2: Pain before and after training but pain eases once warmed-up
Grade 3: Pain during training which limits your performance
Grade 4: Pain during every day activities
This injury may seem like a niggling injury that is not that serious. Many athletes continue to train and compete on it as it may not be a debilitating injury and recovers after a short period of rest. However, neglecting jumpers knee can lead to chronic tendinopathy which can be difficult to treat and may require surgery.
This depends on the extent or grade of the injury. A more severe injury may require longer rest and may result in surgery.
- H/o running, jumping, kicking, climbing.
- Symptoms localised to the patella tendon.
- Tenderness of palpation of tibial tuberosity or along the patella tendon and inferior pole of the patella.
- Crepitis in tendon with ROM.
- Single leg hop increases symptoms in tendon.
General Advice for a patient:
- Rest from training
- In mild to moderate cases, adaptation of training to reduce impact and jumping activities may be suitable.
- Apply cold therapy for pain relief if needed.
- Wear a knee support, or jumpers knee strap to reduce pain and ease the strain on the tendon.
- See a sports injury specialist who can apply sports massage techniques to the tendon and advise on a rehabilitation program.
- Eccentric strengthening is usually recommended.
- If the knee does not respond to conservative treatment, surgery may be required.
- 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:
Conservative (non-surgical) treatment
- 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 maximise 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 tendinopathies by restoring enzyme balance in the tendon.
- 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 health professional or physiotherapist may:
- 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 – see surgery for patella tendinopathy.
- If the injury becomes chronic then surgery is an option. A lateral release of the patella tendon is usually successful.