Patella Tendinopathy, also known as Jumper’s Knee, is a common overuse injury affecting the patella tendon which connects the base of the patella (knee cap) to the tibia (shin bone). This condition is predominantly activity related and as per its name sake, commonly affects athletes that perform repetitive jumping.
What is the Patella Tendon?
The patella tendon acts as a pulley for the quadriceps muscle which acts to extend or straighten the knee. When you run, jump and bend the knee, the patella tendon works to absorb and redistribute the force in a spring like action. This elastic nature of the tendon helps to protect the knee joint and facilitate movement.
What happens during Patella Tendinopathy?
Tendons have a high capacity for load. However, if the demand on the tendon becomes greater than the current tendon tolerance, then the tendon may become painful and symptomatic.
As repeated stress is placed on the tendon, micro tears may develop over time. As the volume of stress increases, the tears in the tendon accumulate and can lead to tendon degeneration.
The Tendinopathy Continuum
Tendon pathologies occur as part of a 3 stage continuum.
- 1. Reactive:
- Short-term response where the tendon thickens to reduce stress and increases in stiffness.
- Usually occurs acutely from a sudden increase in load on the tendon
- 2. Tendon Disrepair:
- Can occur when the tendon is not offloaded and cannot return to its normal state
- The tendon has begun to change in structure (becoming increasingly stiff), but these changes are still reversible.
- These changes may now be visible on Magnetic Resonance Imaging (MRI) and Ultrasound scans
- 3. Degenerative Tendinopathy:
- Can occur when a tendon is chronically overloaded
- Structural changes are now irreversible
As tendinopathies may progress over each of these stages, it is important to de-load and manage pain and inflammation as soon as possible. This is to prevent the onset of long-term structural changes to the tendon. These changes can result in complications such as:
- Decreased knee range of motion
- Decreased functional capacity
- Everyday movements may become painful
- Deformities may develop in the muscle
Common Causes
Patella Tendinopathy is a condition where pain develops gradually overtime, and is typically unrelated to a specific traumatic injury. Patella Tendinopathy arises as a result of an increase in load and/or inadequate rest between sessions.
Some examples of load increases include:
- Starting a new activity/ rapidly increasing load
- A one off high-intensity training session or activity that places high demand on the knee
- Inadequate rest between training sessions
Contributing factors may include:
- Muscle tightness over the quadriceps and hamstrings
- Decreased ankle mobility
- Decreased knee bend when landing
Signs and Symptoms
Common signs and symptoms include:
- Pain at the front of the knee
- Morning stiffness
- Pain with squatting
- Pain with prolonged sitting
- Pain with jumping, hopping
- Pain with going up and down stairs
Symptom Characteristics
- Pain and stiffness usually improve with warming-up prior to exercise
- Pain is related to load
Diagnosis
Diagnosis is usually based on a thorough subjective and objective examination, with little emphasis placed on imaging. Many individuals will present with knee pain but have minimal changes present on imaging, whilst others will present without pain but show degenerative changes.
Therefore, diagnosis is based on clinical presentation as there is little correlation between tendon pain, and functional capacity with imaging findings.
Physiotherapy Management
Effective management of this condition occurs in stages. It is important to regularly check-in with your physiotherapist to ensure that the tendon is not being loaded too quickly, and is responding well to each graded increase in capacity. Where each individual starts will be based on their current level of pain and functional capacity.
Load Management
A period of de-loading consisting of rest and/or activity modification may be needed to settle inflammation and reduce pain.
Progressive Strengthening Program
A progressive strengthening program will help introduce load to the tendon in a progressive manner that minimises the risk of further inflammation and pain provocation. The stage and level of rehabilitation needed will be determined by your personal functional goals.
- Isometrics: To improve pain and motor control
- Eccentrics: To improve muscle strength
- Slow-Heavy Concentrics: To improve tendon stiffness and muscle strength
- Plyometrics: To introduce energy release to the tendon
- Faster Loads: To improve capacity for return to sport
Stretching Program
Increasing muscle length through stretching can help to increase knee range of motion and reduce the amount of tension placed on the patella tendon during movement.
Adjuncts to Exercise
Depending on your level of pain and irritability, your physiotherapist may recommend the use of other strategies to help aid with recovery. These include:
- Shockwave: A safe and non-invasive treatment which involves the delivery of high frequency shock waves (sound impulses) which can be effective in reducing pain and promoting soft tissue healing.
- Dry Needling: The use of fine acupuncture-like needles which can be applied directly over the tendon to optimise healing by decreasing local inflammation and increasing blood flow to the area.
- Deep Friction Massage: The use of deep tissue massage over the patella tendon can result to immediate pain relief.
- Non-Steroidal Anti-Inflammatory Drugs (NSAIDs): Can be useful in short-term pain relief. Optimum dosage should be at the discretion of your general practitioner or pharmacist.
References
Charles, R., Fang, L., Zhu, R., & Wang, J. (2023). The effectiveness of shockwave therapy on patellar tendinopathy, Achilles tendinopathy, and plantar fasciitis: a systematic review and meta-analysis. Frontiers in immunology, 14, 1193835. https://doi.org/10.3389/fimmu.2023.1193835
Charnoff J, Ponnarasu S, Naqvi U. Tendinosis. [Updated 2022 Oct 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK448174/
Chaves, P., Simões, D., Paço, M., Silva, S., Pinho, F., Duarte, J. A., & Ribeiro, F. (2019). Deep Friction Massage in the Management of Patellar Tendinopathy in Athletes: Short-Term Clinical Outcomes. Journal of sport rehabilitation, 29(7), 860–865. https://doi.org/10.1123/jsr.2019-0046
Reinking M. F. (2016). CURRENT CONCEPTS IN THE TREATMENT OF PATELLAR TENDINOPATHY. International journal of sports physical therapy, 11(6), 854–866.
Santana JA, Mabrouk A, Sherman Al. Jumpers Knee. [Updated 2023 Apr 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532969/
Stania, M., Król, T., Marszałek, W., Michalska, J., & Król, P. (2022). Treatment of Jumper’s Knee with Extracorporeal Shockwave Therapy: A Systematic Review and Meta-Analysis. Journal of human kinetics, 84, 124–134. https://doi.org/10.2478/hukin-2022-0089