Patellar tendinopathy (PT) is a common condition among athletes characterized by gradually
progressive activity-related anterior knee pain and focal patellar tenderness .
Symptoms are often serious leading to recurrent or long-standing impairment of athletic performance.
Patellar tendinopathy can thus have a major impact on the career of many athletes and for some it is even the reason to end their career prematurely
51 European elite soccer clubs (2,229 players) from three different cohorts,Swedish First League cohort (SWE) and UEFA Champions League cohort (UCL), both playing on natural grass, and Artificial Turf cohort (ART) playing on third generation artificial turfs, were followed between 2001 and 2009. Individual player exposure in training and matches and time-loss injuries were recorded.
In total, 137 patellar tendinopathies were recorded, comprising 1.5% of all injuries
and corresponding to an incidence of 0.12 injuries/1000 hours.
Each season, 2.4% of players were affected
What is Patellar Tendinopathy?
Patellar tendon pathology typically occurs at the enthesis site ( where the tendon enters in the bone ) ; in most cases it occurs at the inferior pole of the patella, but it can occur at the tibial tubercle or at the proximal aspect of the patella in the quadriceps tendon.
The term “tendinopathy” refers to any problem with a tendon, either short- or long-term.
The Patellar tendon transmits force from the Quadriceps muscle down to the tibia when a person walks, runs or jumps, and helps control the position of the Knee when the foot touches back down on the ground (eg, lands).
Patellar tendinopathy results when the demand placed on the Patellar tendon is greater than its ability to function.
The condition can occur after a single incident (acute injury) or after repetitive irritation or "microtrauma" (chronic injury).
Most often, Patellar tendon pain is the result of repetitive trauma to the tendon that can result in chronic Patellar tendinopathy—a gradual breakdown of the tissue—and is most often treated with physical therapy. Please note that we don’t use the term tendonitis because “itis” means inflammation like in a acute ankle sprain. This is more a problem in the architecture of the tendon, a mechanical problem within the tendon and not an inflammatory process.
So in the tendinopathy there are mainly healthy fibers in conjunction with some “abnormal fibers”
Signs and Symptoms
Patellar tendinopathy (PT) is common in jumping sports and in sports with prolonged repetitive stress of the knee extensor apparatus, such as soccer.
The epidemiology of PT in soccer is not well described, and the existing studies are limited by small samples. The evidence is limited regarding risk factors for PT in sports, with many
conflicting results in the literature.
In soccer, only few potential risk factors have been evaluated and data are available mainly from cross-sectional studies.
Some of the suggested intrinsic risk factors are
high body mass
and reduced ankle dorsiflexion
While extrinsic factors include
increased training frequency
high frequency of weight and jump training
Overuse from a high volume , high frequency training ( too much , too quick ) is usually the main factor for developing PT
Landing from a Jump as a Risk Factor
Van der Worp et al concluded that a stiff landing pattern with limited knee motion at landing and a short landing time is associated with patellar tendinopathy. These authors suggested that patellar tendinopathy might be better represented as “lander's knee” rather than “jumper's knee” as the landing from a jump is more likely related to tendon pain than the take-off for the jump. See below a video explaining how to properly train the landing
Physical Therapy Treatment
Research shows that Isometric exercises can help to reduce pain related to patellar tendinopathy and we always start the rehab process with this type of contractions. Down the road you can use them as part of the warm up. Pushing into some pain is OK, as long as it is reducing throughout the exercise. If they work, you should have less and less pain as you repeat the exercise.
Recommended a 3-5 sets of 30-45 sec hold with 1-2 min break in between reps. Daily routine is recommended as well
Isometric means you HOLD the exercises, avoiding any knee movement ( your knee range should not be changing)
Apply submaximal force at the beginning then go to maximal effort .
Isometrics are a good way to start treating PT but Isometrics alone will not do it.
In general a minimum of 12 weeks of gradual loading program is needed to recover from this condition
Rio, Ebonie, et al. "Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy." Br J Sports Med49.19 (2015): 1277-1283. Malliaras, Peter, et al. "Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations." journal of orthopaedic & sports physical therapy 45.11 (2015): 887-898.
Isotonics and Jump Re-education
Isotonic Strengthening - Inclined Board Squats
Once the pain gets better the player needs to start loading the Quadriceps and the Patellar tendon to restore their normal function. We use a decline board for the squat in the treatment of patellar tendon pain.
Addressing Jumping in Physical Therapy with Jump Reeducation and Landing Mechanics...
A consideration regarding intervention for athletes with patellar tendinopathy is addressing the mechanics of jumping. Although there is presently no strong evidence to support or refute jump training for athletes with patellar tendon pain, there is evidence that ground reaction forces in jumping can be decreased with instruction.Whether such training and improvement in the shock absorbing capacity of the lower extremity can affect patellar tendon pain needs to be subjected to further investigation.
Treatment - Patient Education
Educate the soccer player in the importance of loading the joint progressively. For example, return to play in small amounts and with proper rest time in between practices or games. Increase load very slowly and paying a lot of attention to the Pain during these practices and the pain afterwards to decide when to load the joint again.
Patellar Tendinopathy is a complex condition that requires a progressive approach to restore strength in the Quadriceps and in the Patellar Tendon.
Solving this condition requires a comprehensive approach to correct all deficits that can be causing the anterior knee pain .
Research shows that a combination of Hip and Knee Strengthening exercises with landing mechanics for shock absorption is the best approach to PT
Lionel Pannunzio is a Physical Therapist Certified in Sports Injuries. With more than 20 years of experience helping athletes return to their sports after an injury. He is the Owner of White Bay Sports Physical Therapy and Fitness, conveniently located in the beautiful City of Weston, where he treats Soccer Player, Runners and Athletes of all ages
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