What is patellar tendinopathy, and can I get better?

Key Points

1. Patellar tendinopathy is recognised by pain in the front of the knees, and when too much loading on the knees
2. The best form of management is through exercise
3. Patellar tendinopathy rehabilitation can be slow and frustrating. While there are no shortcuts, make sure to avoid common pitfalls such as setting unrealistic rehabilitation time frames

Pain in the front of the knee. Could it be…patella tendinopathy?

I’ve got pain in my knees and it’s hindering me from my sport! Well then, you might have patella tendinopathy. No need to panic though. Let’s find out what patella tendinopathy is first!

Patella tendinopathy typically appears as pain in the front of the knees. The pain can also be brought on when there’s too much loading, such as when we play sports like basketball, volleyball, or tennis. These are sports that require us to put lots of weight on our knees repetitively. Patella tendinopathy occurs more often in younger athletes around 15-30 years, and in men who play sports. 

Why do tendons cause pain?

Tendons connect our muscle to bone. Often when we participate in activities that strain our joints, it can also irritate our tendons by causing inflammation. The wearing down of collagen protein that forms our tendons can eventually lead to tendinopathy. If there is a sudden increase in physical and activity, it would cause pain in our tendons as well. 

What are the other causes of front of knee pain?

Anterior knee pain can be caused by many other structures surrounding the knee. How do we know your pain is patella tendinopathy instead of something else then?

There are several hallmark clinical features that define pain caused by patella tendinopathy. The first feature is pain that presents specifically in the bottom portion of the kneecaps. It is also defined by pain that appears when you put weight on your knees, and disappears when that weight is taken off. There is rarely any pain felt when resting. Patella tendon pain tends to get better with activity as well i.e. the pain will diminish during a game. Patella tendinopathy pain may also be brought on by prolonged sitting, squatting, or stair-climbing. However, these are also features of other pathologies with the knees.

Some pathologies to be differentiated from patella tendinopathy are:

1. Quadriceps tendinopathy
   1. Characterised by pain specific to the quadriceps tendon
   2. Pain brought about with movements that require deep squats such as those commonly seen in volleyball and weight lifting
2. Patellofemoral pain syndrome
   1. Pain when coming down stairs 
   2. Pain upon landing during a run 
3. Medial hamstring tendinopathy
   1. This condition may sometimes present itself as pain in the front of the knee 
   2. Pain is usually elicited when going up the stairs 

How is patella tendinopathy managed?

So… I have patella tendinopathy. What do I do now? Well, the most studied form of intervention is exercise. The two programs developed for patella tendinopathy management are:

1. Decline squat program
   1. Single-leg eccentric squats with an upright torso while standing on a decline board
   2. Perform 3 sets of 15 repetitions, twice a day
   3. Pros:
      1. Concentrates on loading the patellar tendon
   4. Cons:
      1. Might be too aggressive for patients with higher level of irritability
      2. Does not address any other impairments that may exist due to reduced activity caused by patella tendinopathy. 

2. Heavy Slow Resistance (HSR)
   1. Concentric/ eccentric squats + hack squats + leg presses
      1. All exercises performed with both legs
   2. 3-4 sets of each exercise
   3. Pros:
      1. Similar pain and functional outcomes when compared to decline squat program
   4. Cons:
      1. Patient satisfaction significantly greater than those who did the decline squat program

Between these two programs, the HSR is preferred over the decline squat program.

What is the 4-stage rehab process for patella tendinopathy?

Additionally, a 4-stage rehabilitation progression for patella tendinopathy has been proposed based on the available evidence. The aims of the rehabilitation are to develop load tolerance of the patellar tendon, the muscles surrounding the knee, and the entire lower body. It starts first by reducing any activities that require high-load energy storage to prevent aggravating the pain further. Load modification and progressive loading are made after monitoring the pain carefully. At this point, it is important to emphasise that, specific to tendinopathy, some pain during and after exercise is acceptable as long as your symptoms resolve itself fairly quickly after exercise and does not progressively get worse over the course of the loading program. To gauge, a pain score of 3-5 on a 0-10 numeric rating scale, where 0 is no pain, and 10 is the worst pain imaginable, is fine.

The 4 stages of the rehabilitation program are as follows:

1. Isometric loading
   • An isometric quadriceps exercise for 5 repetitions of 45-seconds 
   • Ideal to do  isometric exercises on a knee extension machine
   • Performing these exercises to the full range can be more painful, so make sure you’re not fully straightening your knees when you do perform these workouts
   • Single leg is possible
   • Progress the load based on tolerance
2. Isotonic loading
   • This is initiated when you can perform it with minimal pain
   • Necessary to begin restoring  strength for functional movements
   • The HSR program can be adapted to suit your progress
3. Energy-storage loading
   • At this stage, energy-storage loading will be re-introduced to increase the load tolerance of the patella tendon, and improve power in order to return to sport
   • This stage is initiated after you have achieved good strength and load tolerance
4. Return to sport
   • This stage can be introduced when you’ve completed stage 3, which would have replicated the demands of energy-storage required of your specific sport
   • The exercises performed in stage 3 will be replaced be a graded return to training and eventually competition

What are the aims in each of the stages?

Each stage of the rehabilitation program is to introduce a progression of patella tendon loading, from isometric loading to energy-storage loading. The aim is increase the load tolerance of your patella tendon to withstand the high-load activities required of your sport

What are some common rehabilitation pitfalls?

Fair warning, while it all seems pretty straightforward, rehabilitation of patellar tendinopathy can be a slow and frustrating process for all parties involved. Some common reasons that cause patients to backtrack are:

1. Unrealistic rehabilitation time frames
   • Load progression is based on symptom response. While you may be eager to return to sport, understand that progression can be slow, sometimes taking 6 months of longer
2. Inaccurate beliefs and expectations about pain
   • This can influence the development and management of unresponsive symptoms such as development of fear-avoidance behaviour, which leads to poorer functional outcomes
   • It’s important to know that pain doesn’t necessarily equal to harm
3. Over Reliance on passive treatment
   • While it may be useful to manage pain in order to continue rehabilitation, it should not be a substitute to exercise

Unsure of what to do? Contact us to speak to our Physiotherapist who will be able to ascertain the source of pain and have it addressed early!

DISCLAIMER: These advice and exercises should not replace the need for a consultation with a Physiotherapist especially if your condition doesn’t improve. Therapeutic exercise should be carefully selected to suit your condition.

Ref:
Malliaras, P., Cook, J., Purdam, C., & Rio, E. (2015). Patellar tendinopathy: Clinical diagnosis, load management, and advice for challenging case presentations. Journal of Orthopaedic & Sports Physical Therapy, 45(11), 887–898. https://doi.org/10.2519/jospt.2015.5987