If you suffer from patellar tendinopathy and you are an athlete or a health professional then this article may be of interest to you. You are probably wondering how to rehabilitate patellar tendinopathy. I invite you to discover the detailed rehabilitation program in 4 steps. They will help you measure the intensity, volume and frequency of your rehabilitation.
What is patellar tendonitis ?
Tendinopathy has always been defined as an inflammation of a tendon due to overuse. However today, several studies have revealed that the term tendinopathy is misused in the health sector. Indeed, the term tendinopathy would be defined rather as the chronic painful symptoms of a sensitive and painful area of a tendon. It could be characterized by the appearance of pain, diffuse and localized inflammation and loss of function. Through histological evaluation of biopsies, intra-tendon microdialysis and technological genetic analysis of the biopsies, it was possible to reveal that there was no evidence of inflammation due to prostaglandins. Therefore, we should no longer speak of inflammation, but rather of a mechanical problem of the locomotor system. But how should we proceed with the rehabilitation of patellar tendinopathies in sportsmen ?
hat happens when you have tendinopathy ?
Biologically, the tendon cells gradually degenerate, leaving a disorder of the collagen fibers and an increase in the collagen-poor cell matrix. This is why neurogenic inflammation occurs.
In other words, you may experience :
- Multiple aches and pains
- A decrease in your joint range of motion in the affected area
- A loss of strength
- A neuromotor deficit
What is the purpose of the patellar tendon ?
A little anatomy...
The patellar tendon is one of the most powerful tendons in the human body. It measures between 4 and 5 centimeters long and 3cm more or less wide. It can be considered an integral part of the knee extensor apparatus, formed by the quadriceps muscle, the patella and the patellar tendon. It is a fundamental structure to support the weight of gravity, to walk, run and jump.
Who can suffer from tendonitis ?
Several profiles can be predisposed to suffer from tendonitis. On the one hand, we have people who are too sedentary, overweight and on the other hand, athletes who are overtraining.
Sedentary people
Factors that may promote its onset:
- Advanced age
- Diabetes mellitus
- High blood pressure
- Dislipidemia
- Rheumatoid arthritis
- Other inflammatory diseases
We also find that environmental conditions, morphological differences (malalignment of the patella, muscular imbalance, decreased flexibility, joint laxity) can be aggravating factors. The patient’s genetic predisposition can play a role in this type of pathology.
Athletes or people in overtraining
Excessive physical activity can be the cause of tendonitis in many cases. Moreover, certain types of effort, because of the constraints exerted on the knee joint, are more likely to cause injuries than others.
Which sport promotes the development of tendonitis ?
All sports that require athletes to jump or run like soccer, basketball, running, hurdling…etc.
Some figures :
In elite jumping: 45% have already suffered from patellar tendinitis
In basketball and volleyball : 45% and 32% of the elite players said they had ever had patellar tendonitis
Similarly, one study reported that more than 50% of elite athletes were forced to retire from their sports. And only 46% of athletes were able to fully return to training and competition without pain after 12 months of supervised rehabilitation.
How to diagnose it ?
1. The pain
Do you suffer from pain in front of your kneecap? A pain that doesn’t stop you before going to your workouts, so unbearable that it prevents you from continuing? Even to the point of affecting you every day for daily tasks. You may even feel this pain while walking, descending the stairs or sitting down. Then I invite you to read on.
Blazina created in 1973 a classification table to link symptoms to assess the status of the injury :
- Pain during activity
- Pain during and after the activity
- Same as above, but the athlete cannot complete the activity
- Tendon rupture
Differential diagnosis
It is the differential diagnosis that will allow us to dissociate patellar tendinitis from other pathologies when we have similar symptoms. Generally, patellar tendinopathy is found following direct trauma. However, an assiduous differential diagnosis is necessary, since other structures such as the bursa, the hoffa fat, the patellofemoral joint can also be associated with direct trauma.
Quadriceps tendonitis :
Pain localized to the quadriceps tendon.
Often associated with movements that require deep knee flexion
Infrapatellar bursa :
Bursa irritation can often be associated with distal patellar tendinitis
Infrapatellar hoffa fat hiperthophia:
Hoffa’s fat pain is not localized to the inferior pole of the patella, rather it presents as a diffuse pain localized to the anterior region of the knee. As a patient, one can feel the pain on final knee extension or digital pressure applied directly on Hoffa’s fat.
The patellofemoral joint :
Yes, the patellofemoral joint can be affected especially in jumping athletes with pain on the anterior aspect of the knee.
Osteochondral lesions located in the lower region of the patella can induce pain similar to patellar tendonitis in the patient. Clinically, a joint effusion can be observed, which does not occur in cases of tendonitis.
The treatments
Rehabilitation through therapeutic exercise
After reviewing several studies, therapeutic exercise has been shown to be effective for optimal recovery from patellar tendonitis. In this treatment, it is essential to constantly monitor the load on the tendon. Listening to yourself and the patient is the key to quantifying the training load on the tendon.
Step 1: isometric loading
It has been shown that 5 rehearsal of 45-second at 70% of maximal voluntary contraction of the quadriceps muscle reduce patellar tendon pain for 45 minutes after exercise.
Exercises that isolate the quadriceps, such as machine knee extensions, are recommended for patellar tendinopathy. In fact, it has been suggested to work with a range of motion between 30 and 60% of the knee. Insofar as the full extension would cause a pinching of the Hoffa fat that could manifest some unwanted pain. As for the resistance, it must be increased as quickly as possible while respecting the pain. The exercise should be performed on one leg only if possible to avoid asymmetrical loads of the lower limbs. Indeed, it is frequent to observe an imbalance, the healthy side protecting the injured side.
If you don’t have any machines at home or at the office, it is possible to perform Spanish squats. This is a squat with support of both legs and an angle of 70° – 90° of knee flexion. You can help yourself with an elastic band that you place on the back of the knee (be careful with anterior cruciate ligament).
How many repetitions, at what intensity and resistance should the exercises be performed ?
- 5 repetitions of 45 seconds
- 2 minutes rest between each set of repetitions
- To be performed two to three times a day
- Train to 70% of maximum voluntary contraction as pain allows.
What is important to know to complete this step ?
It is super important to check that the muscle is not shaking throughout the isometric exercises. If the muscle shakes, it is an indication that the load is too high. Don’t despair this stage can last several weeks when the pain irritability level is high. Therefore, it can be combined with exercises such as heel raises to address other strength or flexibility deficits in the affected lower extremity.
Step 2: isotonic loading
This phase can begin when all the exercises mentioned in the previous step have been completed with a minimum pain of 3/10 or less. This phase is important to restore muscle mass and strength through functional ranges of motion. The exercises described below are referred to as HSR or in other words “high load, slow speed exercises”. The exercises in the HSR program include leg press, squats and hack squats.
How many sets, at what intensity and for how long should you perform these exercises ?
- 3-4 sets at a load of 15 RM, progress to a load of 6RM
- Every third day
- It is important to progress with a heavy load according to what can be tolerated
- During the two days of rest, resume the exercises from step 1 to control pain through muscle fatigue and soreness associated with isotonic loading.
- Exercises should continue during rehabilitation and return to sport.
Step 3: Energy storage charge
This phase is fundamental to increase the load tolerance of the tendon and improve the power to return to the field. To begin this stage, we use the following strength and pain criteria :
- Adequate strength: ability to perform 4 sets of 8 repetitions of a single leg press at an intensity of 150% of body weight
- Load tolerance, performing energy storage exercises with minimal pain
As with all steps, individualization and clinical reasoning are necessary in the rehabilitation of patellar tendonitis. The choice of exercises in this step will depend on the demands of your sport or daily activities. The programming of this step requires multidisciplinary work in high level athletes. In order to adequately determine the training frequency, volume, intensity and type of exercise. In this phase, it is possible to include jumping or landing exercises, acceleration, deceleration and change of direction activities according to the sport’s demands.
For example, if you are a jumping athlete, you would work primarily on landings and jumps with a limited height and landing depth. The volume and intensity can be increased as tolerated by the tendon and according to personal goals. Eventually, higher intensity exercises can be added in an attempt to simulate the volume and intensity required by the sport (single leg hops, sport specific hops, block hops like in volleyball…). This process can take several weeks or months depending on the athlete.
For all athletes who do not perform jumps or landings in practice, it is quite possible to direct the training towards accelerations and changes of direction.
How to dose this step ?
Gradually increase the volume and intensity of the exercises so as to progressively reproduce the load required in sports practice.
- 1 time every 3 days
- Maintain the exercises of phase 1 during rest days
Step 4: Resuming sports
The return to sport is scheduled when all the exercises in steps 1, 2 and 3 are well tolerated. Return to competition can be considered when the athlete tolerates the training loads without causing symptoms and has resolved any existing power deficits.
Gradually add training exercises, followed by exercises aimed at reproducing a competition action.
The role of a physical therapist in the management of patellar tendinitis
Our role in the management of a patient or athlete suffering from patellar tendonitis is essential in order to program the rehabilitation individually. We must remember that any treatment of any injury must include the whole body.
Here I have focused mainly on the four phases of analytical recovery of the quadriceps tendon and muscle. However, it is mandatory to work on the other structures that are involved in sports performance. For example, the work of the abdominal muscles and the pelvic floor muscles.
Similarly, maintaining range of motion is important to improve or maintain performance in sports. It can be worked on in several ways, such as neurodynamic mobilization or dynamic stretching.
Without forgetting the work of neuro-muscular control (CNM) and the co-activation of the various muscles involved in the sports task which is essential to obtain 100% of the performance of our sportsman.
Références bibliographique
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- Silva RS, Ferreira ALG, Nakagawa TH, Santos JEM, Serrão FV. Rehabilitation of Patellar Tendinopathy Using Hip Extensor Strengthening and Landing-Strategy Modification: Case Report With 6-Month Follow-up. J Orthop Sports Phys Ther. 21 de septiembre de 2015;45(11):899-909.
- Rutland M, O’Connell D, Brismée J-M, Sizer P, Apte G, O’Connell J. EVIDENCE-SUPPORTED REHABILITATION OF PATELLAR TENDINOPATHY. North Am J Sports Phys Ther NAJSPT. septiembre de 2010;5(3):166-78.
- Malliaras P, Cook J, Purdam C, Rio E. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. J Orthop Sports Phys Ther. noviembre de 2015;45(11):887-98.
- Breda SJ, Oei EHG, Zwerver J, Visser E, Waarsing E, Krestin GP, et al. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. Br J Sports Med. 20 de noviembre de 2020.
- Kulig K, Noceti-DeWit LM, Reischl SF, Landel RF. Physical therapists’ role in prevention and management of patellar tendinopathy injuries in youth, collegiate, and middle-aged indoor volleyball athletes. Braz J Phys Ther. 2015;19(5):410-20.
- Zhang ZJ, Lee WC, Ng GYF, Fu SN. Isometric strength of the hip abductors and external rotators in athletes with and without patellar tendinopathy. Eur J Appl Physiol. agosto de 2018;118(8):1635-40.