Patella Tendinopathy: A pain in the knee
Patella tendinopathy, or jumper’s knee, is a condition that results from an inflammation and/or overload of the patella tendon. In the last article, we covered the 3 phases of tendinopathy: Reactive, tendon dysrepair and degenerative tendinopathy. In this article, we will use the same model to cover patella tendinopathy.
Symptoms of Patella Tendinopathy
For tendons, there can exist multiple spectrums of tendinopathy in the same tendon, as the tendon will adapt to different levels of load or stress. What this means for you, is that you might experience a mix of symptoms depending on the spectrum of tendinopathy in the tendon.
For reactive tendinopathy, you will likely experience acute pain at the lower part of the kneecap that increases with activity, or direct trauma. If you continue the aggravating activities, you might find that the pain will increase. For some, there might be pain at the tendon even at rest.
Tendon dysrepair is when there is separation of the collagen and disorganisation within the cell matrix. Tendon dysrepair will occur if the reactive tendon is not rested and allowed to fully rest. What you might experience is that the pain continues with activity, and there might be thickening at the tendon. Tendon thickening happens as an adaptation to too much activity, causing swelling, and subsequently, scarring.
For a degenerative tendon, changes here are usually irreversible. Progression to this stage occurs due to old age, or in younger individuals who continue to overload the tendon.
Who does this condition affect?
This condition affects mostly athletes/active people who do sports that stress the lower limbs, such as volleyball, running, tennis, and football. These sports stress the lower limb muscles and tendons more. On the individual level, if the tendons or muscles are not strong enough to take the demands of your sport, this will result in patella tendinopathy.
For the non-sporting population, when the muscles and tendons get weaker than what our daily activities demand, you might experience the same patella tendon issue similar to the sporting population.
In a nutshell, when the demands of our sport or daily activity exceeds our muscles or tendon’s ability to function, this will result in patella tendinopathy.
Risk factors for Patella Tendinopathy
External risk factors include fatigue, excessive loading during aggravating tasks, or external trauma. If you find that your training intensity, frequency, or activities that involve the knee has suddenly increased, or if you had a long break and are coming back to sports, your chances of improper loading would be higher. This is because your muscles and tendons will need time to adapt to its new sporting demands. Going back to 100% of your previous activity levels after a long break will not give your muscles and tendons proper time to adapt well.
Other factors that will increase the chances of tendinopathy include age, nutrition, medical history, and body fat percentage. As we grow older, natural aging will happen to our tendons. This decreases our tendon’s capacity for activity as we age, thus the chances of improper loading would be higher. For those with diabetes or other medical conditions, this will decrease the overall circulation at the tendon itself, impeding the tendon and muscles’ ability to recover. For those with a higher body fat percentage, the inflammatory markers in the body would be higher, making a flare of pain at the tendon itself more likely.
Physiotherapy treatment for Patella Tendinopathy
The aim of coming to physiotherapy would be to manage your pain, and to work back towards your previous activity levels, and even more! Physiotherapy has been shown to be effective in managing patella tendinopathy, so do give rehab a good shot! Exercise has been shown to increase blood circulation and increase collagen synthesis in tendons. Just like muscles, tendons become stronger with exercise and weaker with rest, just with a slower response time (Silbernagel, 2015). Physiotherapists will be able to guide you through the whole rehabilitation process to make your tendon stronger.
What physiotherapists will do, firstly, is to manage your initial pain. This stage will involve manual techniques, massages, and light resistance exercises. Subsequently, physiotherapists will customise an exercise program just for you, to drive towards your goals. This will include load management and exercise form correction. Proper activity management is essential to ensure that your tendon becomes stronger, which will mean that you likely will be able to return to activities that you previously could not, and maybe even more! Exercise form correction ensures that you are moving better than before, spreading the load evenly on the body.
3 phases of Proper Load Management: Safety, Competency and Strength
Phase 1: Safety
At this phase, the aim is to decrease pain and to start exercises that are safe for the tendon. Some exercises include heel raises and squats. These are foundationally leading up to your goals, so it is very important to work hard on these exercises. You might experience some pain with the exercises, but as long as you are being consistent, and keeping pain within the acceptable zone (figure 4), you are on track to recovery! Within the acceptable zone, your tendons are in the process of getting stronger, more powerful, and ultimately more resilient (Silbernagel, 2015). It is definitely okay to train through some pain, but not too much. If you do feel any other symptoms during, after, and up to 24h after the workout, do let your physio know, and they will further adjust your program to suit your goals!
Phase 2: Competency
At the competency phase, the aim is to build strength, endurance and power, tailoring towards your goals. The types of exercises for this phase might include single leg heel raises, split squats, and light plyometric drills. In this phase, expect the resistance or difficulty to increase, in order to build strength. You will find that the repetitions will decrease, and the resistance, or difficulty of the exercises, increases. A good gauge for this stage that trainers and physiotherapists will use is RIR (repetitions in reserve). Meaning that at the end of an exercise set, you will feel like you are able to do more repetitions. This method of training stresses the tendon just enough to cause good adaptations while avoiding any painful flares.
Phase 3: Strength
At this phase, the aim is to build strength that will translate into increased power and endurance. The types of exercises for this phase might include weighted single-leg squats, box jumps, and sport-specific plyometric drills. For the tendon, this increases its capacity to produce strength. As your tendon strengthens, the spectrum of activity that you will be able to do without pain would be wider. In this phase of training, expect heavier loads, fewer repetitions (3-5 reps) and longer rest periods (>3 mins). Do speak to your physiotherapist or functional trainers to tailor an exercise program to suit your goals!