Patellar tendinopathy is a painful overuse condition that is common in athletes, particularly those who engage in running and jumping. Symptoms include knee pain during activity, localised tenderness on palpation and reduced function. It is defined as pain from the insertion of the patellar tendon, to the inferior pole of the patella. Patellar tendinopathy is associated with structural changes within the tendon, such as disorganised collagen, increased water, vascularisation and cellularity. The preferred treatments to induce tendon adaptations include loading the patellar tendon.
Unfortunately, management of patellar tendinopathy poses a difficult problem for musculoskeletal clinicians due to the level of disability and chronicity associated with the condition. This blog aims to briefly outline 5 practical methods to manage patellar tendinopathy for you to implement with your patients immediately.
1. Isometric loading
As discussed by Dr. Seth O’Neill in this research review, patellar tendinopathies can occur mid-season for sporting athletes and can impact performance. For some athletes, it may not be feasible or necessary to take time out to rest the tendon during a busy season. Therefore, isometrics may be one such option to provide the athlete with pain relief and maintain a high level of performance.
This might involve setting the patient up in a knee extension machine, and exploring how much knee flexion the patient can tolerate while holding a contraction for a period of time. This study reviewed by Dr. O’Neill set their participants at 30 degrees of knee flexion and held contractions for either 10 seconds or 40 seconds, completing 24 sets or 6 sets, respectively. Both interventions showed a statistically significant reduction in pain, suggesting that load and duration of the hold can be adapted to the athletes preference, time constraints and irritability.
If you’d like to read more about the methods and limitations of this study, I highly recommend checking it out here.
2. Isotonic loading
In another research review by Tom Goom, which you can view here, participants with chronic patellar tendinopathy were randomised into an eccentric exercise group or an isometric, isotonic and plyometric group. The latter group had a larger reduction in pain, higher return to sport and higher satisfaction. Some of the exercises performed by this group included:
- Isotonic leg press
- Isotonic lunges
- Plyometrics such as double leg broad jumps
- Single leg broad jumps
- Forward hops
- Split jumps
However, it is essential that the above exercises are prescribed as part of a progressive outcome based rehabilitation program. For example, some individuals may not be able to complete split jumps until month 6, whereas other individuals may take up to 12 months depending on the severity of pain and dysfunction. Therefore, individualising your treatment program to the individual is essential.
To find out more about the practical applications and limitations of the study, check it out here.
3. Heavy and moderate resistance training
Heavy resistance training was popularised in recent years as a treatment strategy for tendinopathies. In this study that was reviewed here by Todd Hargrove, the authors compared heavy resistance training to moderate resistance training in the treatment of patellar tendinopathy. The heavy group and moderate group performed leg press and leg extensions at 90% and 55% of 1RM, respectively, over a 12 week period. Interestingly, both groups experienced significant improvements but there were no differences between the groups. In terms of practical applications, it again highlights the importance of tailoring your interventions to the specific needs of the patient.
When conducting a needs analysis of what your athlete must perform in their sport, you might adapt the intensity of the rehabilitation exercise to match the demands of their sport, with the peace of mind that you don’t have to use heavy loads or moderate loads to get the adaptations. For example, a powerlifter will need to squat >90% of their 1 repetition maximum (RM) in competition. This means that you can perform sport specific rehabilitation with the athlete (as pain allows) incorporating 90% of 1RM squats, leg presses and leg extensions to improve pain and dysfunction.
In contrast, if you are helping a bodybuilder with patellar tendinopathy, training at 90% of their 1RM may be unnecessary and inappropriate, given that they train at submaximal intensities, and higher training volumes. Therefore, prescribing a load with 55% of their 1RM may yield the same benefits while also being more specific to the demands of their sport.
For more information on the methods and structural adaptations of the tendons seen in this study, check out the review here.
4. Flywheel training or slow resistance training
While the most researched exercise for patellar tendinopathy is the isolated single leg eccentric decline squat, there may also be a role for bilateral progressive resistance training. In this study which was reviewed by Dr. Teddy Willsey here, the authors compared inertial flywheel to heavy slow resistance training for patella tendinopathy.
The inertial flywheel is not something you see in most gyms, but is growing in popularity as a rehabilitation method. It is basically an isoinertial load on the eccentric contraction, based on the speed the user accelerates the wheel concentrically in the prior repetition. It has been shown to facilitate a high eccentric rate of force development, with high loads through the patellar tendon. The heavy slow resistance training group performed tempo repetitions of leg press and squats, where there is an increased time under tension.
After completing the 12 week intervention, both groups had significant improvements in pain and function. The interventions also allowed individuals to work up to 4/10 pain ensuring that this returned to acceptable levels within 24 hours. Both interventions may be appropriate to use with athletes and suggests that not all patella tendinopathy treatment must rely on single leg exercises only. I’d highly recommend digging into the details of this research review here.
5. Platelet-Rich Plasma (PRP)
Of course, it’s not just about loading!
If you’ve been following Physio Network blogs and keeping up to date with the research reviews, you know that there is more to being a musculoskeletal clinician than just exercise (if only it was that simple). We must meet the needs of the athlete and patient in front of us, address their concerns, read their body language and demonstrate compassionate care. Some individuals will want education about why they have pain, some will want an explanation of what is happening within the tendon itself, and others will have questions such as ‘’I saw [insert name of elite athlete] getting PRP for their tendinopathy, where can I get my hands on it?’’.
How do you respond?
Fear not, Dr. Ebonie Rio has you covered with this excellent research review exploring PRP for patella tendinopathy. Groups were either injected with leukocyte-rich or leukocyte-poor PRP or saline into the patella tendon and all participants engaged in heavy slow resistance training. However, at 12 and 52 week follow up, there was no difference between either saline group or PRP.
This means you can explain to the patient that although their favourite athlete swears that the PRP healed their patellar tendinopathy, there is currently no scientific evidence to support the recommendation. (Now you have the pleasure of explaining why we value scientific evidence over anecdotal accounts when the patients asked why they should trust the scientists over their favourite athlete, enjoy!).
This blog highlights the various methods of managing patellar tendinopathy. I hope it was practically useful and that you’ll check out the research reviews for more details that were beyond the scope of this blog. Happy rehabbing!
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