Adam Smith discusses the various causes of posterior ankle impingement syndrome, its clinical presentation, and goes onto describes both conservative and operative treatment options. Posterior ankle impingement syndrome (PAIS) is a common ankle injury in athletes who participate in sports that involve repetitive and/or forced plantar flexion(1). It is a painful condition. which limits end... MORE
Jumpers knee: an in-season management approach
Patellar tendinopathy is a common injury in jumping sports, especially when loads are high or suddenly increase. With this in mind, Luke Heath guides the practitioner through the problemsolving steps required to formulate a rehabilitation program for restoring the load absorption capacity of a grumbling patella tendon…
Patellar tendinopathy (PT) affects an athlete’s performance ability to jump, land, change direction and run. It can lead to a reduction in tolerance of training and competition load, and eventually a decline in performance, resulting in missed training and competition.
Managing PT during the competition phase of a season can be frustrating. High loads are continually placed on the tendon, and the condition can be frequently slow to respond to treatment interventions. It is important to be realistic and not expect a full recovery of the tendon during this in-season phase.
When diagnosing athletes with suspected PT, a thorough subjective history must be taken before a clinical examination takes place. This helps with not only an accurate diagnosis, but also gives an understanding of the potential causes and the severity of the tendinopathy. Critical questions to ask are shown in Table 1 below.
Once a thorough subjective history has been completed, a clinician should have a primary diagnosis, understand how irritable the tendon is, what phase the tendon is in and reasons as to why the PT is present. This will help guide a physical assessment.
A therapist assessing the athlete should already have a strong primary diagnosis based on the subjective history. The priority of the physical examination is to confirm the primary hypothesis, exclude other potential hypothesis and to determine the irritability of the tendon, which will ascertain the functionality of the athlete. Table 2 outlines the best current thinking on examination procedures.
|Table 1: Subjective history questions|
|Question||Relevance of question|
|Mechanism of injury||Acute trauma from a direct blow onto the knee can provoke a reactive response in the PT. A significant blow can be very sore and take the PT a while to settle down. Alternatively, the onset of a tendinopathy can occur when there is a mismatch between tendon capacity and load placed on the tendon. This occurs when there is a sudden and/or substantial change in load. It’s important to question the athlete on any new or increases in training loads. Knowing a cause can assist in the management because the new loads can be modified to allow symptoms to resolve, and potentially avoided in the future.|
|Past history||Investigating a past history is relevant, as this may determine what phase the tendon pathology is in. If an athlete has a long history of tendon pain, it can be assumed that worsening tendon pathology is present. This is referred to as tendon dysrepair or a degenerative tendon(1). Management may differ for the different phases of a tendinopathy.
Identifying other past musculoskeletal injuries is important as this may be contributing to the tendon being subjected to increased loads. For example, a past injury to a knee may have left an athlete with lower limb weakness, and out of sport for a considerable time. The athlete’s tendon capacity will be affected and when exposed to a spike in training loads and they will be at risk of injury to soft tissue structures, such as tendons. Questioning on athletes rehabilitation they completed when injured is of considerable importance.
|Body chart||Athletes with PT are very specific as to where their symptoms are located and often point directly to the proximal patellar tendon. This location of pain does not move.|
|24-hour behaviour||Tendinopathies are often painful after activity and especially the next day(3). This assists with the diagnosis of a PT.|
|Aggravating activities||Painful tendons limit the athlete’s ability to utilise energy storage within a tendon, and this compromises function(4).
Aggravating activities for patellar tendons depend on the irritability of the tendon. Activities usually include direct pressure on the tendon such as kneeling, squatting, jumping and in particular landing, changing direction and decelerating.
Reviewing training and the demands of a training session is very important. Global positioning system (GPS) data can also be very helpful whilst tracking the number of decelerations, change of directions, and high-speed metres indicate the intensity of a session and loads placed on a tendon.
|Table 2: Examination procedures for PT diagnosis:|
|Clinical test||Clinical relevance|
|Observation||Patellar tendon swelling caused by proliferative cells, which is indicative of a reactive tendon. Investigating inflammation and increase in fat pad size, which is associated with PT. This can cause additional pain in the knee.
Observing quadriceps musculature size If a muscle has atrophy and weakness, they are less likely to withstand loads.
|Palpation||Tenderness is usually located on the inferior pole of the patellar.|
|Isometric muscle tests||Quadriceps isometric muscle testing – pain and/or weakness on contraction, confirming patellar tendon involvement.|
|SL decline squat 25 degree wide||Reported to be the best clinical assessment tool. Both pain and analysis of the kinetic chain can be assessed using this test. If kinetic chain function affected, the athlete’s ‘spring’ has a poor function and is commonly stiff at the knee, and soft at the ankle and hip. This demonstrates that they cannot absorb load through their patellar tendon.|
|Differential diagnosis||To distinguish between patella-femoral joint (PFJ) pain and patellar tendon pain, you can tape the PFJ and see if the decline squat pain changes. If the pain is reduced, it usually means the tendon is not the pain source. The location of PFJ can be more diffuse and not as specific.|
Imaging using MRI and ultrasound can identify the presence of pathology in the tendon. Ultrasound (US) tissue characterisation shows the amount of disorganisation within a tendon and can help characterise the extent of structural pathology1. However the presence of a PT on imaging does not always mean it is the source of pain, and clinical confirmation is necessary2. MRI and US imaging are the two modalities used in my practice; an acute strain to a tendon should be excluded and the US can help confirm worsening tendon pathology. Management of a tendon differs according to what phase a tendinopathy is in.
Whilst the pathology of the tendon may never completely resolve, conservative management of a PT is favourable. The initial treatments goals are aimed at pain management, education and planning.
- Relative rest is the first priority to unload the reactive tendon. However, there should not be complete cessation of activities because this will decrease the overall capacity of the tendon3. The overall capacity refers to the amount of load a tendon can withstand and by resting completely, a de-training effect will occur.
- Isometric single leg knee extensions and/or single leg decline squats should be prescribed for pain reduction: 5 repetitions x 10-60 second holds performed fourtimes per day. In reactive tendons, isometric contractions with moderateheavy loads has been reported to be effective in reducing pain for hours4 5 6.
- It is important that these exercises do not further aggravate the tendon, so prescribe the correct time and appropriate resistance as tolerated by the athlete. In reactive tendons, avoiding any pain is essential to avoid any further aggravation. In tendons in the dysrepair or degenerative phases, exercising into pain of a less than 3-4 out of 10 on the visual analogue scale (VAS) is appropriate. Morning pain, single leg decline squat on a wedge and 3x vertical hops should be used to monitor pain and response to load on a daily basis every morning.
- Icing after activity for 20 minutes for an analgesic effect may help reactive tissue around the patellar tendon (such as a fat pad) settle down.
- Athletes must be educated on the importance of resting the tendon and not pushing past 3/10 pain on VAS whilst in the reactive phase of a tendinopathy, because symptoms will worsen. The athlete should be educated about how tendons may feel okay during training but may sore the next day. Progressions in loads should be calculated, not to be aggressive and risk a flare up of symptoms – eg planning and measuring the amount of decelerations in a running program.
- Avoid stretching the tendon, through doing quadriceps stretches. Compressive loads can further aggravate a tendon7. Soft tissue massage and/or acupuncture through the quadriceps and hip flexors can be utilised alternatively to maintain knee and hip ROM.
- Interdisciplinary management: management of tendon pain should be seen as an issue for an interdisciplinary team to solve. As such, it is helpful to discuss the situation with a physician and dietician as they can administer some ibuprofen, high dose of fish oil and green tea. This may help decrease tendon pain8.
- Managing tendinopathies in-season is about trying to explore the correct balance of unloading the tendon without causing a detraining effect on the tendon. Daily pain monitoring as discussed provides useful information about tendon responses to load. Use of the VISA-P (Victorian Institute of Sport questionnaire) may also be useful.
Reactive tendon response is the main cause of in-season pain, so the key intervention should be aimed at reducing loads. Load modification can be programmed specifically to relieve tendon pain:
- Programming should periodise an athlete’s week into high, low and medium-load days, to respect the tissue adaptation from demanding sessions where increased elastic loading is present.
- High-load days include increased amounts of stretch shortening cycle (SSC), such as field sessions including training where there may be a lot of running, jumping and mechanical load.
- Medium-load days include specific tendon strength program and/or a less demanding field/running session.
- Low days-load include isometric holds only.
Programming an athlete’s week with PT during the in-season phase can be challenging not only because you’re managing the athletes symptoms but also because of other factors such as recovery from a game and external factors such as match schedules. A typical week is outlined below in Table 3.
|Table 3: Typical in-season programming|
|Description||LOAD-BEARING WEIGHTS (Optional depending on irritability of tendon)||TRAIN (optional on irritability of tendon)||TRAIN / LOAD-BEARING WEIGHTS||OFF||TRAIN||PLAY||OFF|
|Specifics||Medium tendon loading|
|Lighter training session||Main training session / Key load-bearing lift - high tension loading||Isometrics only||Very light team run pre-game||Recovery focus / Isometrics only|
Strengthening the tendon and kinetic chain
During the competition phase of the season it is hard for symptomatic PT to become completely symptom free and to achieve strength gains. The following program in Table 4 takes time and depends on the irritability of the tendon. A less than 3/10 pain level should be the threshold and exercises should not progressed if this level of pain or higher is present.
Before being able to jog, the athlete must be pain-free walking, on stairs and be able to perform the following programme AND have a pain score of less than 4 out of 10 pain post session/next morning when performing a SL decline squat:
- Decline SL squats on wedge to parallel (x 4 reps each side) with a pain score of less than 3/10;
- SL calf raises – x25 reps each side;
- DL skips (30 secs on/off x 5reps);
- Alternate skips (40 secs on/20 secs off x 10reps);
- DL hopping/landing progressing to SL hopping/landing sequences (including forward, lateral and multi-directional hopping);
- Running progressions on an Alter-G treadmill (if available) progressing from an entry level of 70-100% weight bearing;
- The introduction of running must be calculated, progressive and programmed to include high, low and medium days as discussed;
- Tendon daily monitoring must be completed and be a guide for progressing the athlete through the above exit criteria, running progressions and training.
|Table 4: Programme to strengthen tendon and kinetic chain|
|Isometric||Target pain relief and to also build tendon capacity. |
Must continue as an athlete progresses through the below program.
|-10-60s x 5 reps
-Completed pre-post training
-Completed on ‘low days’
|Isotonic max strength||Both concentric and eccentric exercise improves tendon capacity by promoting muscle strength and endurance adaptations. Eccentric exercises have been found to be more beneficial in tendons with dysrepair or degenerative phases because greater forces with repetitive lengthening of the muscletendon may improve the capacity of the musculotendinous unit to affectively absorb load.||-SL knee extension / SL decline squats on a Smith machine (Figure 1)
-4-6reps x 4-5sets
-Mod-heavy loads Ideally
-3x/ week (on the back of field sessions (high days) and/or on medium days
|Strength progressions||Strength progressions will address high-load tendon capacity as well as kinetic chain deficits.||SL step-ups, split squats, front foot elevated split squat, stepping lunges and multi-directional lunges.|
|Landing||Landing re-education encourages landing distribution and absorption of loads across all three segments on the kinetic chain(1).||-DL landing and progressing to SL landing in horizontal and vertical planes of movement.
-Altitude landings from varying heights
|Stretch-shortening cycle||Absorption and production of load occurs|
here, which is the main function of a tendon.
Forms the basis for return to running and
training (See exit criteria below).
|DL skipping 30s on/of x5reps.
-Alternate-leg skipping 30-40s on/30-20s off x 5-8reps
-DL jumps and SL vertical/forward/lateral/ multi-directional hopping
-Repetitive hurdle jumps (Figure 2)
|Kinetic chain strengthening||Strengthening and recruitment|
considerations of other kinetic chain
muscles, particularly the calf and gluteals
with lumbopelvic control.
This is done to improve lower strength and
control to unload the patellar tendon.
|-SL Calf raises 10-15reps x 3-4 sets (bodyweight)
-Hip abduction (AB) strength progressions:
-Hip AB in side lying (Figure 3) Side lying planks with hip AB (Figure 4)
-Hip AB in standing with bands
-Banded crab walks
-Pilates reformer: Hip AB (Figure 5) and ice skaters (Figure 6)
Lumbopelvic control progressions:
-Running man on foam (Figure 7) & box
|Running progression||Initially volume, followed by change of direction, change of pace and finally transitioning into training. In particular volumes, maximum velocities, high-speed metres, decelerations and change of direction.|
The best outcome measure is the athlete’s pain provocation (VAS) during competition – more specifically VAS whilst performing specific activities such as decline squatting, hopping, jumping, running, changing direction and decelerating. Outcome measures specific to strength gains are increases in thigh circumference measured by DEXA scan or tape measure and by an increase in weight lifted, reps and sets. Quantifying lower limb power is achieved by measuring a single-leg hop for distance, vertical jump (single/double leg) and a cross-over hop test. Running sessions should be also be measured, quantifying volume, high speed metres, number of decelerations, and change of directions.
PTs during the competition phase of a season can be challenging to manage. It is important that a thorough history is taken to understand why the athlete has a mismatch between tendon capacity and load. Once this has been established, relative rest (not complete rest) and programming of high, low, medium training days must be done to unload the tendon. Acute management aiming to decrease pain is of utmost importance. A focus on isometric exercises for pain relief will help achieve this. If symptoms are respected and monitored daily, this approach to managing PT will hopefully keep athletes competing for their season.
- Sport Health 2014; 32(1), 17-20
- Journal of Physiotherapy 2014; ,60, 122–129
- Best Practice & Research Clinical Rheumatology 2007; 21(2), 295–316
- Sport Health 2014; 32(1), 17-20
- Journal of Physiotherapy 2014; ,60, 122–129
- British Journal of Sports Medicine 2009; 43(6), 409-16
- British Journal of Sports Medicine 2009; 43(6), 409-16
- Journal of Science and Medicine in Sport 2008; 11, 235—238