Navigating Patellar Tendinopathy: Insights and Treatment Strategies

 

Dear subscribers,

We're thrilled to introduce the inaugural edition of the Patellar Tendinopathy Insights Newsletter. If you're here, you likely share an interest in understanding and managing the challenges posed by patellar tendinopathy. Whether you're an athlete striving for peak performance, a fitness enthusiast dedicated to your regimen, or simply someone seeking to comprehend and conquer this condition, you're in the right place.

In this newsletter, we'll delve into the world of patellar tendinopathy, exploring its causes, symptoms, and the most up-to-date insights into effective treatment strategies. From amateur athletes to professionals, this condition can affect anyone who places repetitive strain on their knee joint. Our mission is to equip you with knowledge that empowers you to take charge of your health and wellbeing.

In our ongoing exploration of knee health, we find ourselves at a crucial crossroad: accurate diagnosis. Before embarking on the journey of treatment, it's imperative to ensure that the issue at hand is indeed jumpers knee. To guide you through this pivotal process, we present an in-depth look into the distinguishing characteristics of Jumper’s Knee (Patellar Tendinopathy), Patellofemoral Pain, and Infrapatellar Fat Pad Syndrome.

 

Jumper’s Knee (Patellar Tendinopathy) Characteristics:

• Localized Pain Under the Kneecap: A distinctive pain beneath the kneecap that tends to intensify as activity begins and lingers the day after.
• Activity-Responsive: Pain tends to "warm up" with increased movement and becomes more pronounced.
• Speed-Linked Pain: Pain escalates as activity speed increases.
• Painful Movements: Jumping, landing, and abrupt changes in direction trigger discomfort.
• Primary Occurrence in Young Jumping Men: Typically observed in elite male jumpers who consistently exert high force through their patellar tendon.
• Pain Beyond Activity: Long car rides and prolonged sitting can also incite pain.

 

Jill Cook, a renowned expert, wisely notes, “We see a lot of patellofemoral pain masquerading as a tendon pain.”

 

Patellofemoral Pain Characteristics:

• Spreading Pain: Discomfort that extends beyond localized areas.
• Weight-Bearing Pain: Pain experienced while bearing weight.
• Knee Flexion Discomfort: Pain during knee flexion.
• Diverse Trigger Activities: Unlike Jumper's Knee, pain can manifest during low tendon load activities such as walking, running, cycling, lunging, and squatting.
• Frequently in Females: Research indicates a higher prevalence among females (Vora et al., 2018).

 

Without even talking about :

• Infrapatellar Fat Pad Syndrome
• Quadriceps tendinopathy
• Plica
• Sinding-Larsen-Johansson syndrome
• Osgood-Schlatter syndrome

 

Imagine the patellar tendon as a robust band, like a strong rope, linking your muscles to your bones. This design allows it to handle substantial loads while still being able to stretch and recoil (like a spring) to help with movement around your knee joint.

Starting at the kneecap (patella) and extending down to the shinbone (tibia), the patellar tendon is a continuous thread connecting the quadriceps muscle to the shinbone. Despite appearances, the kneecap doesn't actually split the tendon into two; it's a seamless connection that works as one unit. It's like a team effort where the quadriceps muscle generates force that's transferred through the tendon to assist in movements like jumping and extending the knee.

Tendons are composed of different layers, much like the threads in a fabric. The building blocks are collagen fibers, which are like tiny ropes that give the tendon stiffness to handle the loads. Imagine these collagen fibers aligning in the direction of the tendon, giving it strength. Over time, these fibers can change due to various factors, potentially leading to issues.

As we age, the sliding ability between the layers of the tendon lessens. This sliding is essential for energy storage and release during movements. When this function declines, the tendon becomes more susceptible to injuries. While concerns about aging are somewhat unwarranted, a closer look at the collagen fibers themselves reveals their importance in maintaining tendon health.

The majority of the tendon's composition is made up of organized Type I collagen, providing stiffness and strength. This is complemented by other components like proteoglycans, glycosaminoglycans, and elastin, which contribute to the development of the tissue. When these elements go awry, imaging shows irregularities that might indicate tendon issues.

Blood flow to tendons might be low, but it meets the tendon's metabolic needs. Nerves mainly target the outer portions of the tendon, and special sensors called Golgi Tendon Organs help monitor and regulate the tension in the muscle-tendon junction.

By understanding the patellar tendon's structure and dynamics, we equip ourselves with knowledge that can guide us toward better knee health and movement.

Think of tendons as versatile elastic bands. They adapt their behavior based on how quickly they're stretched. In fast movements, like jumping or sudden direction changes, tendons work like a spring-loaded sheet. When muscles contract and pull, the tendon stores energy like a rubber band. As the muscle relaxes, the tendon releases that stored energy, aiding in movement.

In activities that demand quick knee movements, like jumping or rapid direction shifts, the patellar tendon acts like an elastic band. During a jump, the tendon stretches as you descend, storing energy. As you ascend, that stored energy is released, propelling your knee forward. This also happens when changing direction swiftly.

On the flip side, in slow and controlled movements, tendons behave differently. Imagine holding a wall sit position – your quadriceps muscles slowly shorten while the patellar tendon gently lengthens. This gradual lengthening is called "tendon creep," and it's like the tendon's way of adapting to sustained loads. It's as if the tendon is saying, "I got this," and becomes more fluid to accommodate the stress.

In sports, tendons are essential for resisting and transmitting forces from muscles to bones. The way they're shaped tells a lot about their function. For example, the patellar tendon is incredibly resilient, while the Achilles tendon is adept at handling high loads. In activities that involve jumping, landing, and changing direction, the patellar tendon steps up to meet the challenge.

Understanding how the patellar tendon responds to different types of movements empowers us to make informed decisions about training and recovery. In our next issue, we'll delve into practical tips for keeping this vital tendon in optimal health.

 

Why resting is not always the answer!

I personally see a lot of athletes, and one question I ask every patient on their initial evaluation is, "What have you been doing at home?" The most common answer is, "Nothing."

Many people tell me that when they felt pain, weeks and even months ago, they just ran or exercised through it until it got bad enough that they could not do their sport anymore. So, they rested for two weeks, four weeks, two months, then they went back to their sport and the pain came back. Sometimes, the pain comes back worse. No matter how long they rested, the pain returned and sometimes worse and, in more spots, then it was before they took time off. Most often, when there is pain there is inflammation or swelling. Even though you may not be able to see a marked increase in fluid to the area, there may still be swelling. Rest allows the swelling to decrease. It allows the painful stimulus to subside. It allows any compensation patterns to diminish and it gives your body a break. The first couple times when you start back in, it may feel good. But over time you return to the old compensation patterns and you begin to experience the pain you once felt and sometimes even worse. While you rested and did nothing, the remainder of your muscles began to weaken and this has made for a more precarious situation then you were once in. Not only are you dealing with an injury but now you are starting to have de-conditioned muscles.

Tendons connect compliant muscle to stiff bone. Because this is a difficult connection to make, the mechanics of tendon change on each end. Near the muscle, the tendon is more compliant (stretchy). Near the bone, the tendon is stiffer.

In a 2017 study, Keith Baar explained that injuries account for more than 70% of time away from sports. She also explained that 5-weeks of immobilization (rest) caused the entire tendon gets stiff. The protective, ‘shock absorber’ mechanics on the muscle end were no longer present. This risks future injury to the muscle (Baar, 2017).

Rest degrades tendon: In tendon cell cultures “an absence of load induced markers of degradation” (Docking & Cook, 2019).

Rest destroys structure: “Rest is bad for tendons. Tendons must have load on them virtually every day to maintain structure.” – Jill Cook

Tendons have something known as load capacity. This is the tendon’s ability to handle the load of sport or practice without injury or pain. Load capacity (broad person-level change) is similar to the ‘Mechanostat Point’ (local tissue-level change). The point increases with application of load and decreases with absence of load (Docking & Cook, 2019). Rest causes maladaptation and the curve to shift to the left.

Rest destroys tendon strength: “If you bed rest somebody, within two weeks you’ve completely destroyed the mechanical strength of the tendon.” – Jill Cook

Resting decreases function of tendon. Training is the only way to maintain or potentially improve tendon function.

 

What do we do when there is pain in exercise?

What if a barbell back squat hurts, what if jumping hurts, what if changing direction hurts, what if playing basketball hurts?

Often athletes have such a bad pain they just rest and ice, but this is bad for the structure of the patellar tendon and bad for its function, just like I mentioned in the first part of the introduction.

 

Pain 24h later matters more than pain in training

Pain 24h later matters more than pain during the session, but if you are worried about pain during the session pain of 3-5/10 during the session is acceptable

You will always know the next day. The human body is smart enough, the tendon will tell you by being more painful whether it responded good or bad to the training loads.

If this is the case, be disciplined and simply use less load or change the range in which you were training. let's say you need to perform a Spanish squat hold and you went close to 90° , you know it's too early for this. Next session, simply change the angle and see how your knee reacts the next day.

 

Supplements & nutrition

No one likes to be out of action due to injury, but with the right nutrition and rehabilitation program, you can be back on your feet in no time.

Including essential nutrients in your diet can help rebuild healthy and flexible tendons and ligaments and complement physical therapy.

Collagen peptides have been proven as a nutrition solution to support strong and flexible tendons and ligaments in athletes, contributing to high performance and fast return-to-training. Recent studies have helped to fine tune dosage recommendations and nutrient combinations to enhance its effectiveness. As the body produces lower-quality and volumes of collagen as we age, master athletes may benefit from prophylactic collagen supplementation.

Collagen is one the major structural protein and building blocks made within your body. Collectively, collagen comprises 30% of the body’s protein as amino-acids, specifically glycine, proline, hydroxyproline and arginine. Collagen provides structure and acts like a glue to your skin, hair, skeleton, tendons, muscles, ligaments, corneas, teeth and blood vessels.

There are 16 different types of collagen within the body, all with slightly different roles but 80 – 90 % of the collagen in the body consists of types I, II, and III. Together all forms of collagen serve the same purpose; to help tissues withstand stretching. Although all forms are essential in the body, research tends to focus on types I-III when it comes to athletes.

Additional dietary intake of vitamin C rich foods during rehabilitation may also be beneficial. Good sources include berries, red capsicum, broccoli, kiwi, guava, citrus, rosehip and indigenous foods such as camu camu, goji berry and Kakadu plum.

 

5 step process

Step 1: Stop elastic activities

If there is pain with patellar tendon store-and-release function (e.g. jumping, landing, changing direction), stop those activities.

 

Step 2: Do pain-free isometrics 2 times per day

Exercise examples: leg extension, single-leg leg press, Spanish squat, decline board squat, split squat, rear foot elevated split squat, etc.

Position: A pain-free position. This is usually mid-range. Deep knee flexion with heavy load can be provocative for patellar tendon pain.

Sets: 3-5

Length of hold: 30-45 seconds to failure

Rest: 2 minutes between sets Time between sessions: at least 6 hours

Don't forget: 1 hour before isometric exercises consume 15grams of gelatin or 1 scoop of collagen along with at least 50MG of vitamin C

 

Step 3: Progress to isotonics

Goal: Restore muscle bulk and strength through functional ranges of movement.

 

Step 4: Plyometrics

Plyometrics exercises should be an integral part of any lower extremity rehab or injury prevention program to increase power development and to teach proper absorption movement mechanics.

In this program we are going to focus more on the plyometric progressions for rehab. In particular, looking at progressing the quality, quantity, and the skill of load absorption required to return to your sport.

 

Step 5: Return to play

Time to shine

 

Extra tips

1. Strength train the quadriceps

For individuals who have a background of Jumper's Knee, experts suggest focusing on the quadriceps when working out in the gym. When Jumper's Knee is a factor, the brain might cease to activate the quadriceps effectively. Consequently, compound movements lose their effectiveness in creating the required muscle overload. Among the most effective exercises to concentrate on and enhance the quadriceps are the leg extension and single-leg leg press. Additionally, exercises like split squats, Spanish squats, and slant board squats can be valuable, assuming that the quadriceps can be engaged properly.

For those who do not have a history of Jumper's Knee, prioritizing heavy split squats could be sufficient to enhance the strength and stiffness of the patellar tendon.

 

2. Strength Train the Gastrocnemius & Soleus

Jill Cook discusses how Patellofemoral Pain can arise due to biomechanical concerns related to the hip and the ankle/foot complex. In the case of Patellar Tendinopathy, the underlying problems are located within the quadriceps and calf muscles.

While many interventions for Jumper's Knee concentrate on addressing the diminishment of muscle mass, strength, power, and functionality in the quadriceps, it's worth noting that a similar issue occurs within the calf muscles. To target these concerns, straight leg calf raises are utilized to enhance the gastrocnemius, whereas bent leg calf raises are employed to strengthen the soleus, which plays a crucial role in deceleration.

These exercises align with the isotonic phase of rehabilitation, progressing through escalating levels of intensity (e.g., from 15 repetitions down to 6 repetitions) and increasing volumes (e.g., from 1 to 5 sets).

 

3. In-season, perform isometrics before or after games/training

Before: Isometric exercises (such as 5 sets of 45-second leg extensions) have the potential to swiftly alleviate pain and provide relief for up to 45 minutes afterward. This aspect renders them a valuable choice to consider as part of a pre-game or pre-training routine, particularly when dealing with patellar tendon discomfort.

After: Employing a comparable approach in terms of sets and repetitions post-activity might lead to a reduction in subsequent day's activity-related discomfort. Engaging in a strenuous isometric split squat could potentially yield a positive impact on the strength of the Rectus Femoris muscle when it's under tension, potentially leading to a decrease in pain.

In a separate workout session: Engaging in heavy isometric exercises induces tendon creep and stress relaxation, both of which have the potential to aid in the gradual healing of degenerative tendons over time. Considering there's a recovery period of around 6 hours following activity, it's often feasible to dedicate an additional 5-10 minutes to a specific tendon-focused session on most days.

 

4. Lack of Flexibility at Quadriceps/Hamstrings

Ensure that the ribcage has the capacity to expand and the pelvis can smoothly transition between anterior and posterior tilts. Maintaining a constantly extended posture has adverse effects on the harmonious coordination of muscles in the hamstrings and abdominals, while also constraining hip rotation. Incorporate training that encompasses diverse movements to prevent the ribcage and pelvis from becoming fixed in an exaggerated flared and anteriorly tilted stance.

 

5. Rigid, supinated foot

Implement exercises to restore normal supination and pronation. If you follow me on instragram, you know I am a big fan of the blackboard. Give this a try.

 

6. Poor muscle endurance/strength around the hip and foot/ankle

• Potential Solution for Endurance: Daily isometrics
• Potential Solution for Strength: Progressive resistance on strengthening exercises.