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 problem-solving steps required to formulate a rehabilitation program for restoring the load absorption capacity of a grumbling patella tendon.
In 2018, Sweden’s Sofie Skoog was in action during the women’s high jump.
Patellar tendinopathy (PT) affects athletes’ ability to jump, land, change direction, and run. It can lead to a reduced 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 occurs. This helps with an accurate diagnosis and gives an understanding of the potential causes and the severity of the tendinopathy (see table 1).
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 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 hypotheses, and determine the irritability of the tendon, which will ascertain the athlete’s functionality (see table 2).
Question | Clinical Revelance |
Mechanism of injury | Acute trauma from a direct blow to the knee can provoke a reactive response in the PT. A significant blow can be sore and take the PT a while to settle down. Alternatively, the onset of tendinopathy can occur when there is a mismatch between tendon capacity and load placed on the tendon. This happens when there is a sudden and substantial change in load. Questioning the athlete on any new or increases in training loads is essential. Knowing a cause can assist in the management because the new loads can be modified to allow symptoms to be resolved and potentially avoided in the future. |
Past history | Investigating a 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. Management may differ for the different phases of a tendinopathy. Identifying other past musculoskeletal injuries is essential as this may contribute 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 when exposed to a spike in training loads, and they will be at risk of injury to soft tissue structures, such as tendons. Questioning athletes’ rehabilitation, which they complete when injured, is essential. |
Body chart | Athletes with PT are very specific about 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. This assists with the diagnosis. |
Aggravating activities | Painful tendons limit the athlete’s ability to utilize energy storage within a tendon, compromising function. 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 beneficial when tracking the number of decelerations, changes of directions, and high-speed meters to indicate the intensity of a session and loads placed on a tendon. |
Clinical Test | Clinical Relevance |
Observation |
Patellar tendon swelling caused by proliferative cells, which is indicative of a reactive tendon. It is investigating inflammation and an increase in fat pad size, which is associated with PT. This can cause additional pain in the knee. Observing quadriceps musculature size: A muscle with atrophy and weakness is 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 weakness on contraction, confirming patellar tendon involvement. |
SL decline squat 25 degrees wide is | 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 is 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, therapists 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 characterization shows the amount of disorganization within a tendon and can help characterize the extent of structural pathology(1). However, the presence of a PT on imaging does not always mean it is the source of pain, and clinical confirmation is necessary(2). 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 the current phase of recovery.
While the pathology of the tendon may never completely resolve, conservative management of a PT is favorable. The initial treatment goals are pain management, education, and planning.
Pain management
Education
Ongoing management
Programming
Reactive tendon response is the main cause of in-season pain, so the key intervention should be to reduce loads. Load modification can be programmed specifically to relieve tendon pain:
Programming an athlete’s week with PT during the in-season phase can be challenging not only because you’re managing the athlete’s symptoms but also because of other factors, such as recovery from a game and external factors such as match schedules (see table 3).
Mon | Tues | Weds | Thurs | Fri | Sat | Sun | |
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 | |||
Tendon Load | Med | Med | High | Low | Med/Low | High | Low |
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 takes time and depends on the irritability of the tendon (see table 4). A pain level less than 3/10 should be the threshold, and exercises should not progress if this level of pain or higher is present.
Training type | Why | Prescription |
Isometric | Target pain relief and also build tendon capacity. This must continue as an athlete progresses through the program below. |
|
Isotonic max strength | Concentric and eccentric exercise improves tendon capacity by promoting muscle strength and endurance adaptations. Eccentric exercises are more beneficial in tendons with disrepair or degenerative phases because greater forces with repetitive muscle-tendon lengthening may improve the musculotendinous unit’s capacity to absorb the load effectively. |
|
Strength progressions | Strength progressions will address high-load tendon capacity and kinetic chain deficits. | SL step-ups, split squats, front foot elevated split squats, 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 |
|
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). |
|
Kinetic chain strengthening | Strengthening and recruitment considerations of other kinetic chain muscles, particularly the calf and gluteals with lumbopelvic control. This improves lower strength and control to unload the patellar tendon. |
Hip abduction (AB) strength progressions:
Lumbopelvic control progressions:
|
Running progression | Initially, volume was followed by a change of direction and pace, and finally transitioning into training, in particular volumes, maximum velocities, high-speed meters, decelerations, and change of direction. |
Before being able to jog, the athlete must be pain-free walking on stairs and be able to perform the following program AND have a pain score of less than 4 out of 10 pain post-session/next morning when performing an SL decline squat:
The best outcome measure is the athlete’s pain provocation (VAS) during a competition – more specifically, VAS while 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, a vertical jump (single/double leg), and a cross-over hop test. Running sessions should also be measured, quantifying volume, high-speed meters, number of decelerations, and change of direction.
PTs during the competition phase of a season can be challenging to manage. A thorough history must be 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, and 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 keep athletes competing for their season.
Our international team of qualified experts (see above) spend hours poring over scores of technical journals and medical papers that even the most interested professionals don't have time to read.
For 17 years, we've helped hard-working physiotherapists and sports professionals like you, overwhelmed by the vast amount of new research, bring science to their treatment. Sports Injury Bulletin is the ideal resource for practitioners too busy to cull through all the monthly journals to find meaningful and applicable studies.
*includes 3 coaching manuals
Get Inspired
All the latest techniques and approaches
Sports Injury Bulletin brings together a worldwide panel of experts – including physiotherapists, doctors, researchers and sports scientists. Together we deliver everything you need to help your clients avoid – or recover as quickly as possible from – injuries.
We strip away the scientific jargon and deliver you easy-to-follow training exercises, nutrition tips, psychological strategies and recovery programmes and exercises in plain English.