Patellar Tendinopathy by Dr Ciaran Cosgrave
Friday 24th October 2014
Patellar tendinopathy is a condition we see commonly in clinic and can cause athletes from many sports a lot of discomfort and frustration. The Patellar tendon runs from the patella (kneecap) to the tibia (shin) and transmits the force from the quadriceps muscle to the lower leg to allow you to straighten you leg against resistance.
Tendinopathy arises when a tendon is repeatedly loaded with inadequate rest and recovery between loading episodes. This leads to disorganisation of tendon cells and an increase in tendon fluid, blood vessels and nerves. Activities such as landing from a jump and decelerating put increased force through the patellar tendon which is why patellar tendinopathy is more common is sports such as football, basketball and volleyball.
Athletes with patellar tendinopathy usually describe pain in the front of the knee during and after activity. They can often pin-point the tender area just under the patella. Initially symptoms are mild and the athlete will often try to play on for several weeks or months until they seek medical attention.
The treatment for patellar tendinopathy requires a multi-faceted approach.
- Reduce the load – This is a load issue so you must reduce the daily load on the tendon. This can be done by reducing the frequency, duration and intensity of training and competition. Depending on the time of the season it may be necessary for you to continue playing, but you must realise that this reduces the chance of a successful outcome and will increase the time to full recovery.
- Address the biomechanics – The load through the tendon can also be reduced by addressing your biomechanics (the way you move). Many of the patients we see with patellar tendinopathy have a very quadriceps-dominant running and squatting pattern which puts a lot of unnecessary force through the patellar tendon. Changing this pattern to a more glute-dominant movement, focussing on single-leg control exercises and strengthening your posterior chain will help spread the load more globally, significantly off-load the patellar tendon, improve recovery and prevent recurrence.
- Strengthen the tendon – Tendons respond in a positive manner to controlled load with appropriate recovery. All patellar tendon treatment plans should include a programme of isometric and eccentric tendon loading through exercises such as box-squats. This gradually progressive controlled loading stimulates the tendon to repair and heal.
- Medical therapies – There are also a few medical therapies that have proven effective in speeding up recovery from patellar tendinopathy. After the clinical assessment we will often arrange an MRI scan to confirm the suspected diagnosis and also to assess the condition of the tendon.
PRP injection – When a tear is present in the patellar tendon we recommend a Platelet Rich Plasma (PRP) injection. Platelets are the cells in your blood that contain the growth factors and are therefore involved in healing of all tissue. For a PRP injection, we take a 10ml sample of blood from a vein in your arm, spin it in a centrifuge to separate the cells and isolate the platelets. Approximately 3mls of Platelet Rich Plasma is the injected into and around the tear within the patellar tendon. The addition of these growth factors promotes tendon healing and enhances recovery.
ESWT – If the MRI shows patellar tendinopathy but no tear in the tendon we recommend Exracorporeal Shockwave Therapy (ESWT). ESWT transmits shockwaves into the injured tendon which stimulates the release of growth factors leading to increased tendon healing. It also breaks down any calcification which has developed in the tendon.
- Surgery – Most surgeons would agree that surgery should only be considered as a last resort treatment for patellar tendinopathy. The vast majority of cases can be successfully treated by addressing the points outlined above and only a very small percentage of our patients require surgery.
Important points to consider:
- The changes in the tendon seen in patellar tendinopathy have been developing long before you felt symptoms – possibly even months before. It therefore requires time, patience and hard work to reverse these changes. This process can take several months.
- Continuing to participate and play in your sport will continue to aggravate the tendon. This will prolong recovery and reduce the chance of a successful outcome.
- Steroid has been shown to be ineffective in the long term treatment of tendinopathy. Any benefit tends to be temporary and potentially detrimental to the tendon and therefore should not be considered as a viable treatment option.
- The treatment of patellar tendinopathy is multi-faceted. Neglecting one of more of these facets reduces the chances of successful resolution of your symptoms.