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Patellar Tendinopathy as a Chronic Overuse Injury

"Jumper’s knee” is a common overuse injury, often responsible for anterior knee pain. Inside its diagnosis, management, and prevention.

This overview is part of a Chronic Overuse Injuries Primer. View the introduction.
 

History/Pathogenesis

Patellar tendinopathy/patellar tendonitis or “jumper’s knee” is a common overuse injury, often responsible for anterior knee pain, specifically at the proximal attachment point of the patellar tendon. It is characterized by symptomatic degeneration of the patellar tendon with vascular disruption and an inflammatory repair response. Pain typically occurs gradually and progresses due to overload through continued participation in activity. This repetitive loading strains the patellar tendon, leading to multiple lesions within the tendon.

With rest, the lesions are able to heal, but continued strain exceeds the tendon’s capacity to repair, leading to an inflammatory repair response and pain. In younger patients, it typically results from sports that involve repetitive loading of the patellar tendon (jumping and abruptly changing direction), while it can also present in older populations due to excessive strain or weight gain.1-6

Prevalence/Epidemiology

Patellar tendinopathy is primarily seen in athletes from 15 to 30 years old (largely men) who participate in high risk sports. Though more research is needed on the prevalence in various populations, patellar tendinopathy is seen in all age groups, but is dominant in jumping sports.3-4,7

Image courtesy of the authorsReported nocturnal pain, as well as during prolonged sitting, squatting, kneeling, or climbing stairs may be a sign of jumper's knee.

Signs/Symptoms

Anterior knee pain/tenderness at the inferior pole of the patella, patella tendon, and distally toward the tibial tuberosity. Patients often point to an increased tenderness point of specific concentration. Reported nocturnal pain, as well as during prolonged sitting, squatting, kneeling, or climbing stairs. Pain is worsened with repetitive loading maneuvers, especially with jumping/landing, running hills (ascend/descend), and/or resisted leg extensions.

It is important to look at:

  • Weight, body mass index (BMI)
  • Waist-to-hip ratio
  • Leg length difference
  • Arch height of the foot
  • Quadriceps flexibility and strength
  • Hamstring flexibility
  • Jumping/landing biomechanics 3-5,8-10

High Risk Activities for Patellar Tendinopathy: Volleyball, basketball, tennis, football, and other activities that require repetitive patellar tendon loading and jumping.

Related Conditions or Risk Factors: Contributing factors to the pathogenesis of patellar tendinopathy by potentially increasing patellar tendon strain.

Physical Exam

Positive indications for patellar tendinopathy include tenderness noted on the inferior patellar pole or patellar tendon and frequent tightness to the quadriceps, hamstrings, and tensor fascia latae muscles. Clinicians should conduct evaluation of patellar alignment and tracking though the long arc extension, with normal movements making a reverse “C”-pattern as the knee moves through flexion/extension maneuvers. Specifically, pain occurring with ¾ to full squats.

Diagnostic Tests

  • If indicated, evaluate with baseline x-rays, MRI, musculoskeletal diagnostic U/S testing, or bone scan testing, or EMG/NCS testing.

Differential Diagnosis

  • ACL or PCL ligament injury
  • Inflammatory or infectious condition
  • Patellofemoral syndrome
  • Occult lesion
  • Stress fracture

Prevention

  • Dynamic lower body stretching/warmup prior to activity
  • Improving flexibility of quadricep and hamstring groups
  • Strengthening quadricep and hamstring groups
  • Emphasis on proper running, jumping, and landing biomechanics
  • Proper footwear
  • Avoiding excessive overload (ease into training after breaks, injuries, etc.)

Acute Treatment

Clinicians should advise patient on relative rest (decrease speedwork, running hills or stairs, general decrease in overall intensity, duration, and/or frequency); new shoes to control excessive motion if present; analgesia through appropriate doses of NSAIDs together with physical modalities such as ice, ultrasound, iontophoresis, phonophoresis, topical anesthetic skin refrigerants, and electrical stimulation.

Gentle quadriceps/hamstring stretching; counter-force bracing and/or patella taping can be used for short-term treatments to allow athletes to perform pain-free corrective exercises.

Image courtesy of the authorsStrengthening should be part of any long term rehabilitation plan for jumper's knee.

Long-Term Treatment/Rehab 

Following acute pain reduction intervention, strengthening should be progressive, focusing on eccentric loading in a closed chain manner to increase the load tolerance of the tendon.

Upon resolving kinetic chain deficits and making appropriate progressions, sport/task-specific exercises can be utilized to prepare for return to normal activities. Though further research is needed, non-corticosteroid injection therapy and platelet-rich plasma are frequently utilized in the clinical setting; as yet, they have yielded mixed results. If the patient does not respond to nonoperative treatment, surgical intervention has produced very promising outcomes in most patients.

Regenerative medicine techniques are now on the forefront of research and for potential treatments for chronic overuse musculoskeletal/sports injuries. These techniques, such as platelet-rich plasma and stem cell injection options, should be considered on a case-by-case setting for patellar tendinopathy.1,2,5

Practical Takeaways 

  • Patellar tendinopathy/patellar tendonitis or “jumper’s knee” is a common overuse injury, often responsible for anterior knee pain, specifically at the proximal attachment point of the patellar tendon.
  • In younger patients, it typically results from sports that involve repetitive loading of the patellar tendon (jumping and abruptly changing direction), while it can also present in older populations due to excessive strain or weight gain.
  • Signs and symptoms include anterior knee pain/tenderness at the inferior pole of the patella, patella tendon, and distally toward the tibial tuberosity. Patients often point to an increased tenderness point of specific concentration.
  • Following acute pain reduction intervention, strengthening should be progressive, focusing on eccentric loading in a closed chain manner to increase the load tolerance of the tendon.
Additional chronic overuse injuries in this primer:
Last updated on: May 29, 2020
Continue Reading:
Osgood-Schlatter Disease: Knee Injury and Pediatric Pain Management
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