Is patellar tendinitis getting the better of you?
Patellar tendinitis has traditionally been thought of as inflammation of the patellar tendon, which is the tendon that joins the bottom of your kneecap (patella) to your shin bone (tibia). Recent research however, has shown that the patellar tendon does not actually get inflamed (“itis”). It is in fact an injury which is the result of microtears and collagen degeneration within the tendon. As a result the medical terminology has been updated for this condition to patellar tendinopathy to reflect this.
Patellar tendinopathy is usually the result of overuse and increased loading placed on the patellar tendon. It is one of the most common running injuries due to the repetitive loading and stress which is placed on the tendon during training regimes.
Degenerative changes within the tendon will cause runners to experience pain at the front of the knee over the patellar tendon, typically at the bottom of the knee cap. The pain is normally aggravated by activities such as running (especially downhill), going up and down stairs and squatting. It may feel particularly stiff first thing in the morning. The tendon may be tender and thickened compared to the unaffected side.
Runners will be at a higher risk of developing patellar tendinopathy if:
1) They have poor foot biomechanics. Flat feet will lead to poor stability whereas high arches result in poor shock absorption. Both of these foot types can lead to increased loading of the patellar tendon.
2) Their training programme has recently changed, for example an increased training mileage or increased sprints.
3) Not enough rest days are in their training programme.
4) They kneel on their knees frequently, which compresses the patellar tendon.
Patellar tendinopathy does not usually get better on its own, therefore it is important to seek treatment from an experienced physiotherapist before it stops you in your tracks completely.
Physiotherapy management of patellar tendinopathy:
Current research suggests that there are two distinct stages of patellar tendinopathy-
1) The early stage of changes within the tendon, referred to as “reactive tendinopathy.”
2) Further progression of changes leads to a later stage, termed “degenerative tendinopathy.”
It is thus important to get professional help as soon as you feel any symptoms. Your physio should plan an individual treatment regime based on the current stage of your condition. At Apex Clinic, Belfast we have a very high success rate at clearing patellar tendinopathy and from both our clinical experience along with the most recent medical research we recommend the following treatment approach –
1) Soft tissue therapy: Soft tissue therapy/frictions applied to the patellar tendon can be effective when combined with the full treatment regime.
2) A stretching programme: Stretching of any tight leg muscles (which have been identified by assessment) is important, particularly the hip flexors, hamstrings, calves, quads, glutes and iliotibial band. Stretching is important to improve flexibility and thus reduce the load placed on the patellar tendon. Stretching will also encourage a more efficient transfer of load through the tendon while running.
3) A progressive strengthening programme: A specific, progressive eccentric strengthening programme focussing on the quads muscles/patellar tendon is vital in combination with strengthening the hamstrings, calf and glute muscles. All of these muscles work together to support the knee, which should help to reduce the strain on the patellar tendon.
4) A graduated return to running: If you are symptom free day to day you can resume a gentle return to running. A gradual return to your training programme is important to recondition the tendon for running and to help prevent reoccurrence.
5) Correction of any predisposing factors which encouraged the patellar tendinopathy to start: This may include getting orthoses (insoles) and modifying your training programme as advised by your physio.
What if your patellar tendinopathy is still not improving?
In Apex Clinic we see some runners who have followed the above approach elsewhere with little or no improvement in symptoms. Here, it is important to consider if there is another component to the patellar tendon pain which may have been overlooked. It is well known that any tendon in the body requires two main things to remain healthy- a healthy blood supply and a healthy nerve supply.
In most runners, the blood supply to the tendon will certainly be intact however if there is any interference with the nerve supply to the tendon, this may predispose to tendinopathy. Two components which may be contributing to the pain in patellar tendinopathy are-
1) Altered nerve movement (altered neurodynamics):
Poor movement of the nerve which passes by the patellar tendon can lead to the tendon being vulnerable to injury. Specific controlled movements of the nerve will need to be undertaken by a physio experienced in treating nerve pain, to restore free nerve movement. Home exercises will be given to maintain the free nerve movement between treatment sessions.
2) Pain referred from your lower back:
It is possible that pain around the patellar tendon can be referred from your lower back, even if there is no back pain present. In this case, treatment for the patellar tendon is not likely to significantly improve your symptoms. An experienced physio should be able to identify the area of the spine from which the pain is coming from and treat it with manual mobilisation to loosen the affected spinal segment and clear your pain.
In both of these cases, the pain can nearly always be cleared with the correct physio treatment along with addressing any predisposing factors. As with many running injuries, the quicker treatment is started, the less treatment will be required to clear it and the quicker the return to pain-free running.