PATELLA TENDONITIS

INTRODUCTION
The patellar tendon / ligament joins the
kneecap (patella) to the shin bone or tibia
(video). 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 .

 Jumper’s knee is an inflammation of the

patellar tendon that attaches from the bottom of
the kneecap to the top of the shin bone .

 Jumper’s knee, as it is most commonly

referred to, is also known as patellar tendonitis
With repeated strain, micro-tears as well
as collagen degeneration may occur as a
result in the tendon.
This is known as patellar tendinopathy .
 CAUSES OF PATELLAR
TENDINITIS
Patellar tendonitis is the condition that
arises when the tendon and the tissues
that surround it, become inflamed and
irritated. This is usually due to overuse,
especially from jumping activities. This is
the reason patellar tendonitis is often
called "jumper's knee."
When overuse is the cause of patellar
tendonitis, patients are usually active
participants of jumping-types of sports
such as basketball or volleyball. Patellar
tendonitis may also be seen with sports
such as running and soccer. Also, some
patients develop patellar tendonitis after
sustaining an acute injury to the tendon,
and not allowing adequate healing. This
type of traumatic patellar tendonitis is
much less common than overuse
syndromes.
 PATHOGENESIS
Extensor mechanism stress,
acceleration/deceleration, jumping/landing,
extrinsic overload of the tendon
- Microtears within the tendon matrix, rare
occurrences of rupture
- Patellar impingement theory
- Impingement of the inferior patellar pole
against the patellar tendon during knee flexion,
Often resulting from a “long inferior patellar pole”
Controversy
- Johnson et al. 1996 (JBJS) found
impingement of the interior pole at 60 degrees of
knee flexion
- Schmid et al. 2002 suggested that there
was no biomechanical evidence of impingement
in their series
- Almekinders and Shalaby 1999 found
evidence of a “long inferior pole” in symptomatic
patients, but this abnormality did not always
correlate to the region of involved tendon
- Many surgeons resect the infrapatellar
pole during both open and arthroscopic
debridement of patellar tendonitis
 CLASSIFICATION
:(Blazina et al 1973, Roels et al 1978) .
- phase I: pain only after activity;
- phase II: pain/discomfort during activity,
but does not interfere w/ participation;
- phase III: pain both during & after
participation, which interferes w/ competition;
- phase IV: complete tendon disruption.
Symptoms of Jumper’s knee
Pain with running or jumping especially downhill
or downstairs
Pain and tenderness around patellar tendon
Pain and tenderness behind the knee cap
Pain is worse at night
Restricted movement and swelling in the area
surrounding the injury
Prevention of Jumper’s knee
May be associated with poor
Vastus medialis obliquus (VMO) function .
 OTHERS CAUSES
Intensity and frequency of physical activity.
Repeated jumping is most commonly associated
with patellar tendinitis. Sudden increases in the
intensity of physical activity or increases in
frequency of activity also put added stress on
the tendon.
Being overweight. Additionally, being
overweight or obese increases the stress on the
patellar tendon, and some research suggests
that having a higher body mass index may
increase the risk of patellar tendinitis.
Tight leg muscles. Reduced flexibility in your
thigh muscles (quadriceps) and your hamstrings,
which run up the back of your thighs, could
increase the strain on your patellar tendon.
Misalignment of your leg. The way your leg
bones line up could be off slightly, putting strain
on your tendon.
Raised kneecap (patella alta). Your kneecap
may be positioned higher up on your knee joint,
causing increased strain on the patellar tendon.
Muscular imbalance. If some muscles in your
legs are much stronger than others, the stronger
muscles could pull harder on your patellar
tendon. This uneven pull could cause tendinitis.
 CAUSES OF PATELLAR
TENDINOPATHY
This depends on the extent or grade of the injury:
Grade 1: Pain only after training
Continue training but apply ice or cold therapy to the
injury after each training session. Cold therapy can be
applied by by ice massage or the use of ice packs. It is
important the cold is applied at the point of pain on the
tendon.
Wear a heat retainer or support.
See a sports injury specialist / therapist who can apply
sports massage techniques and advise on rehabilitation.
An eccentric strengthening programme is generally
recommended.
Grade 2: Pain before and after exercise
but pain reduces once warmed up.
Modify training activities to reduce the load
on the tendon. Stop jumping or sprinting
activities and replace them with steady
running or swimming / running in water if
necessary.
See a sports injury specialist / therapist
who can apply sports massage techniques
and advise on rehabilitation.
Grade 3: Pain during activity which
prevents you from training / performing
at your best.
Rest completely from the aggravating
activity. Replace it with swimming /
running in water (if pain allows).
See a sports injury specialist / therapist
who can apply sports massage techniques
and advise on rehabilitation.
Grade 4: Pain during every day
activities which may or may not be
getting worse.
Rest for a long period of time (at least 3
months!).
See a sports injury specialist / therapist
who can apply sports massage techniques
for patella tendonitis / tendinopathy and
advise on rehabilitation.
If the knee does not respond to
rehabilitation then consult an Orthopaedic
Surgeon as surgery may be required.
 PREVENTION OF JUMPER’S
KNEE
The following are some measures that can be
taken to prevent jumper’s knee:
Wear proper fitting shoes that are appropriate
for the court If necessary, wear orthotics for
proper arch support and joint alignment.
Make sure to properly stretch your hamstrings
and quadriceps prior to activity Strengthen your
quadriceps and hamstrings so they can better
withstand the forces of running and jumping.
Avoid playing on hard surfaces such as concrete
for extended periods of time as this impact can
lead to inflammation over time.
 TREATMENT OF JUMPER’S
KNEE
First and foremost, decrease the frequency and
duration of the activity that causes you the most
pain. In other words, if it hurts, don’t do it.
Apply ice for 20 minutes 2-3 times a day for 2-4
days or until pain and inflammation are reduced.
If pain persists, see your doctor and maybe they
can prescribe an anti-inflammatory or pain
medication.
Wear a special brace called an infrapatellar brace
around the bottom of the patellar tendon. Â This will
help to prevent overuse by helping the tendon to
better absorb impact.
Since jumper’s knee is a chronic injury due to
repetitive stress and overuse, it can last a few
weeks to several months depending on your ability
to pay attention to the symptoms and take
appropriate action early on. Always remember to
listen to your body, if something hurts, your best
plan of action is to reduce or stop that activity
altogether before it develops into something more
serious.
 Patellar Tendonitis (Jumper's
Knee) Rehabilitation Exercises
You can do the hamstring stretch right away. When the
pain in your knee has decreased, you can do the
quadriceps stretch and start strengthening the thigh
muscles using the rest of the exercises.
Standing hamstring stretch: Place the heel of your leg
on a stool about 15 inches high. Keep your knee straight.
Lean forward, bending at the hips until you feel a mild
stretch in the back of your thigh. Make sure you do not
roll your shoulders and bend at the waist when doing this
or you will stretch your lower back instead. Hold the
stretch for 15 to 30 seconds. Repeat 3 times.
Quadriceps stretch: Stand an arm's length away
from the wall, facing straight ahead. Brace yourself
by keeping the hand on the uninjured side against
the wall. With your other hand, grasp the ankle of
the injured leg and pull your heel toward your
buttocks. Don't arch or twist your back and keep
your knees together. Hold this stretch for 15 to 30
seconds. Repeat 3 times.
Side-lying leg lift: Lying on your uninjured side,
tighten the front thigh muscles on your injured leg
and lift that leg 8 to 10 inches away from the other
leg. Keep the leg straight. Do 3 sets of 10.
Quadriceps isometrics: Sitting on the floor with your
injured leg straight and your other leg bent, press the
back of your knee into the floor by tightening the
muscles on the top of your thigh. Hold this position 10
seconds. Relax. Do 3 sets of 10.
Straight leg raise: Lie on your back with your legs
straight out in front of you. Tighten up the top of your
thigh muscle on the injured leg and lift that leg about 8
inches off the floor, keeping the thigh muscle tight
throughout. Slowly lower your leg back down to the
floor. Do 3 sets of 10.
Step-up: Stand with the foot of your injured leg on a
support (like a block of wood) 3 to 5 inches high. Keep your
other foot flat on the floor. Shift your weight onto the injured
leg and straighten the knee as the uninjured leg comes off
the floor. Lower your uninjured leg to the floor slowly. Do 3
sets of 10.
Wall squat with a ball: Stand with your back, shoulders,
and head against a wall and look straight ahead. Keep your
shoulders relaxed and your feet 1 foot away from the wall
and a shoulder's width apart. Place a rolled up pillow or a
soccer-sized ball between your thighs. Keeping your head
against the wall, slowly squat while squeezing the pillow or
ball at the same time. Squat down until you are almost in a
sitting position. Your thighs will not yet be parallel to the
floor. Hold this position for 10 seconds and then slowly slide
back up the wall. Make sure you keep squeezing the pillow
or ball throughout this exercise. Repeat 10 times. Build up
to 3 sets of 10.
Knee stabilization: Wrap a piece of elastic
tubing around the ankle of your uninjured leg.
Tie the tubing to a table or other fixed object.

Stand on your injured leg facing the table and bend
your knee slightly, keeping your thigh muscles tight.
While maintaining this position, move your uninjured
leg straight back behind you. Do 3 sets of 10.

Turn 90° so your injured leg is closest to the table.
Move your uninjured leg away from your body. Do 3
sets of 10.

Turn 90° again so your back is to the table. Move
your uninjured leg straight out in front of you. Do 3
sets of 10.

Turn your body 90° again so your uninjured leg is
closest to the table. Move your uninjured leg across
your body. Do 3 sets of 10.
Hold onto a chair if you need help balancing.
This exercise can be made even more
challenging by standing on a pillow while you
move your uninjured leg.
Resisted knee extension: Make a loop from a
piece of elastic tubing by tying it around the leg
of a table or other fixed object. Step into the loop
so the tubing is around the back of your injured
leg. Lift your uninjured foot off the ground. Hold
onto a chair for balance, if needed.
 Bend your knee about 45 degrees.
 Slowly straighten your leg, keeping your thigh muscle
tight as you do this.
Do this 10 times. Do 3 sets. An easier way to do
this is to perform this exercise while standing on
both legs.
TAPING (JUMPER'S KNEE)
The following guidelines are for
information purposes only. We
recommend seeking professional advice
before beginning rehabilitation.
The aim of this taping is to provide support
to the patella tendon or patella ligament
and take some of the stress of the patella
tendon insertion into the shin bone (tibia).
What is required?
3.8 cm (1.5 inch) non stretch white tape or 5 cm
(2 inch) elastic tape. Some athletes may prefer
one, some the other depending on amount of
support required.
Step 1
Sit the athlete on the floor or coach with the
knee bent to 90 degrees.
A small amount of underwrap may be applied
around the knee for comfort and to stop the tape
pinching. Or if the leg is particularly hairy then it
may be best to shave the leg as well where the
tape will be applied.
. Step 2Starting on the outside of the leg
pass the tape just under the lower pole
(bottom) of the patella and around the
back of the knee (image 1).
Step 4As the tape passes around the
front of the knee it is twisted to give extra
support. Continue wrapping the tape
around the knee a couple of times.
Step 5Apply one third and final wrap
around the knee without twisting the tape
as it passes under the patella. s
 TREATMENT
Nonsurgical Treatment
In some cases of jumper's knee, the
patient may need to stop sports activities
for a short period. This gets the pain and
inflammation under control. Usually
patients don't need to avoid sports for a
long time.
To treat jumper's knee, the doctor may prescribe
anti-inflammatory medicine to help reduce
swelling. A variety of knee straps and sleeves
are available that may help keep pain to a
minimum. The doctor may also suggest working
with a physical therapist.
Physical therapy treatments might use ice, heat,
or ultrasound to control inflammation and pain.
As symptoms ease, the physical therapist works
on flexibility, strength, and muscle balance in the
knee. Posture exercises can help improve knee
alignment. The therapist may also design special
shoe inserts, called orthotics, to support flat feet
or to correct knock-kneed posture.
 REHABILITATION
Nonsurgical Rehabilitation
In nonsurgical rehabilitation, the goal is to
reduce pain and inflammation.
Nonsurgical treatment can help ease
symptoms of jumper's knee. Some doctors
have their patients work with a physical
therapist. Treatments such as heat, ice,
and ultrasound may be used to ease pain
and swelling.
Therapists also work on the possible causes of
the problem. For example, flexibility exercises
for the hamstring and quadriceps muscles can
help reduce tension in the patellar tendon where
it attaches to the patella. Orthotics are
sometimes issued to put the leg and knee in
good alignment. Strengthening exercises to
improve muscle balance can help the kneecap
to move correctly during activity. Therapists work
with athletes to help them improve their form and
reduce knee strain during their sports. When
symptoms are especially bad, patients may need
to avoid activities that make their pain worse,
including sports.
Therapists work with athletes to help them
improve their form and reduce knee strain during
their sports. When symptoms are especially bad,
patients may need to avoid activities that make
their pain worse, including sports.
When the problem involves the bone growth
plate (Sinding-Larsen-Johannson disorder), the
symptoms tend to go away slowly over time.
This means nonsurgical rehabilitation probably
won't cure the problem. Treatments can only
give short-term relief.
What is the treatment for patellar
tendonitis?
Rest
The most important first step in treatment is to avoid
activities that aggravate the problem. Your body is the
best guide to know how much to rest the injured knee--if
an activity hurts in the area of the injured patellar tendon,
then you should rest from that activity.
Anti-Inflammatory Medications
Nonsteroidal anti-inflammatory medications (NSAIDs)
include a long list of possibilities such as Ibuprofen,
Motrin, Naprosyn, Celebrex, and many others. Patellar
tendonitis treatment can be improved by these
medications that will decrease pain and swelling. Be sure
to talk to your doctor before starting these medications.
Stretching
Stretching the quadriceps, hamstring, and calf
muscles prior to activity is very important once
you do resume activities. Getting into a good
stretching habit, even once the symptoms
resolve, will help prevent a recurrence of the
problem.
Ice Treatments
Icing the area of inflammation is an important
aspect of tendonitis treatment. The ice will help
to control the inflammation and decrease
swelling. By minimizing inflammation and
swelling, the tendon can return to its usual state
and perform its usual function
Chopat Straps/Braces
Occasionally, your doctor will provide a
support strap (called an infrapatellar strap
or a Chopat strap), a knee brace, or
custom orthotics. The benefit of these
measures in the treatment of patellar
tendonitis is not well known, but some
patients find complete relief from using
these products.
 EXAMINATION
- Perform exam with knee in full extension
- Bassett Sign:
- Tenderness to palpation with knee at full extension and
patellar tendon relaxed
- Non-tender with knee in flexion and patellar tendon taut
- Quadriceps atrophy
- Quadriceps and hamstring tightness
- Knee effusion is rare
- Ligaments usually stable
- Various biomechanical derangements may be present on
exam
- excessive foot pronation;
- ie. Malalignment, patellar hypermobility, patella alta/baja,
tibial/femoral rotation, etc.
- However, no correlation with jumper’s knee exists for these
intrinsic factors (Ferretti 1986)
 TREATMENT OF PATELLA
TENDINOPATHY / PATELLA
TENDONITIS

Treatment of patellar tendonopathy 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 tendonopathy.
Two modes of treatment may be advised -
conservative treatment and surgical
treatment:
Conservative (non-surgical) Treatment
of patella tendonitis / patella
tendinopathy
This is normally advocated initially after
diagnosis of patellar tendonopathy. 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.