What is jumpers knee / patellar tendinopathy?
The patella tendon / ligament joins the kneecap (patella) to the shin bone or tibia. This tendon is extremely strong and allows the quadriceps muscle group to straighten the leg. The quadriceps actively straighten the knee in jumping to propel the individual off the ground as well as functioning in stabilizing their landing.
Causes
It is an overuse injury from repetitive overloading of the extensor mechanism of the knee. The microtears exceed the body's healing mechanism unless the activity is stopped.
The injury occurs to athletes in many sports including baseball (catcher), bowling, golf (reading putts), football, rugby, volleyball, track & field, freerunning, tennis, American football, basketball, lacrosse, ultimate frisbee, badminton, diving, skateboarding, snowboarding, gymnastics, Olympic weightlifting, powerlifting, and kickboxing.
What are the symptoms of jumpers knee?
- Pain at the bottom and front of the kneecap especially when pressing in or palpating (see assessment).
- Aching and stiffness after exertion.
- Pain when you contract the quadriceps muscles.
- The affected tendon may appear larger than the unaffected side.
- May be associated with poor Vastus medialis obliquus (VMO) function
- Calf weakness may be present
Jumpers knee can be categorised into four grades of injury:
Grade 1: Pain only after training
Grade 2: Pain before and after training but pain eases once warmed-up
Grade 3: Pain during training which limits your performance
Grade 4: Pain during every day activities
Warning!! - This injury may seem like a niggling injury that is not that bad. Many athletes continue to train and compete on it as it may not be a debilitating injury and recovers after a short period of rest. However, neglect jumpers knee at your peril! If left to become chronic it can be very difficult to treat and may require surgery.
What can the athlete can do about patella tendinopathy?
This depends on the extent or grade of the injury. A more severe injury may require longer rest and may result in surgery.
- Rest from training
- In mild to moderate cases, adaptation of training to reduce impact and jumping activities may be suitable.
- Apply cold therapy on a regular basis, especially after any form of exercise.
- Wear a knee support, or jumpers knee strap to reduce pain and ease the strain on the tendon.
- See a sports injury specialist who can apply sports massage techniques to the tendon and advise on a rehabilitation program.
- Eccentric strengthening is usually recommended.
- If the knee does not respond to conservative treatment, surgery may be required.
Treatment of jumpers knee
Treatment of jumpers knee is slow and may require a number of months of rehabilitation in order to notice a decrease in aggravating symptoms. This may include several months of rest.
Two modes of treatment may be advised - conservative treatment and surgical treatment:
Conservative (non-surgical) treatment
This is normally advocated initially after diagnosis of patellar tendinopathy. Care must be taken so as to not overload the tendon. Treatment may involve:
- Quadriceps muscle strengthening program: in particular eccentric strengthening. These exercises involve working the muscles as they are lengthening and are thought to maximise tendinopathy recovery.
- Muscle strengthening of other weight bearing muscle groups, such as the calf muscles, may decrease the loading on the patellar tendon.
- Ice packs to reduce pain and inflammation.
- Massage therapy - transverse (cross) friction techniques may be used.
- Aprotinin injections may help tendinopathies by restoring enzyme balance in the tendon.
Surgical Treatment
This is normally advised as a last resort. Also, there is little convincing evidence to support the use of surgery over conservative treatment for patellar tendinopathy. Surgery either includes excision of the affected area of the tendon or a lateral release where small cuts are made at the sides of the tendon which take the pressure off the middle third.
An intensive rehabilitative program is normally advised following surgery. In particular the use of eccentric strengthening exercises may help stimulate healing.
A Sports Injury Specialist or Doctor may:
- Prescribe anti-inflammatory medication e.g. ibuprofen.
- Use ultrasound or laser treatment.
- Use cross friction massage techniques.
- Prescribe and supervise a full rehabilitation programme.
- A Surgeon can operate - see surgery for patella tendinopathy.
- If the injury becomes chronic then surgery is an option. A lateral release of the patella tendon is usually successful.
Also Don't Forget RICE [Rest, Ice, Compression, Elevation]
At which stage of the rehabilitation process you start will depend on the extend or grade of the injury - click here if you are not sure.
Rehabilitation
Reducing pain and inflammation
- Rest from all aggravating activities. If you have knee pain during every day activities then expect to rest from training for several weeks. If you only have a little pain after training then modifying training methods (less impact / jumping) for a while may be sufficient.
- Apply cold therapy or ice for 15 minutes every hour if it is bad, at least three times a day otherwise.
- NSAID's (Non Steroidal Anti-inflamatory) e.g. Ibuprofen may help in the early stages. Always consult a Doctor before taking medication. Ibuprofen must not be taken by asthmatics.
- Wear a heat retainer or knee support. This will protect the tendon and allow it to heal, especially if you have to be on your feet.
Stretching Exercises
- Gentle stretching is important as soon as pain will allow. Exercises to stretch the quadriceps muscles are particularly important. Hold stretches for around 10 seconds and repeat 5 times. Aim to stretch at least 5 times a day.
- Later in the rehabilitation process stretches should be held for longer.
- Stretching should continue long after the injury has healed to avoid reoccurrence.
- In addition to the quadriceps muscles it is important to stretch the hamstrings, calf muscles and iliotibial band as well.
Strengthening Exercises
- Strengthening should begin as soon as possible provided it is pain free. Initially you may be only able to manage static contractions of the quadriceps muscles.
- Progressive 'eccentric' quadriceps exercises are particularly important in rehabilitation of patella tendinopathy This means exercises where the muscle is contracted but lengthening, for example the downwards phase of a squat involves the quadriceps muscles contracting but lengthening at the same time.
- Strengthening of the calf muscles and hamstring group of muscles is also very important.
- Strengthening exercises should always be done within a range of movement that is pain free. If you are causing more pain the chances are that you are making the injury worse.
- Apply cold therapy / ice after exercises to prevent inflammation.
- A problem that many athletes have when coming back from this type of injury is that they have been deliberately putting weight on the good leg and so have developed abnormal movement patterns. This in itself can lead to further injuries and imbalances. Athletes should be aware of this danger when returning from injury.
- Be patient! It may take between 6 and 12 months to return to full fitness following a grade 4 injury.
Injury Prevention
- Do not over-train! Performing too many high impact training activities will be too much for the tendon.
- Look out for the early signs of pain and inflammation after training and act. Do not wait until this injury becomes bad - there is a long rehabilitation period once the injury becomes worse.
- Identify any biomechanical problems that may increase the risk for example over pronation of the foot, a loose kneecap or a tight iliotibial band. If you are not sure, see professional help and advice.
- Use eccentric strengthening exercises to make the knee joint strong enough to cope with the demands of the sport. Continue these exercises long after the injury has healed. They should become part of your usual training routine.
- Stretch the muscles (particularly quadriceps) properly and regularly.
- Get a regular sports massage to keep muscles and tendons in good condition.
