patella tendonitis

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INTRODUCTIONThe patellar tendon / ligament joins the kneecap (patella) to the shin bone or tibia (video). 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.

As such this tendon comes under a large amount of stress especially in individuals who actively put extra strain on the knee joint such as those who regularly perform sports that involve direction changing and jumping movements . Jumpers knee is an inflammation of the patellar tendon that attaches from the bottom of the kneecap to the top of the shin bone . Jumpers knee, as it is most commonly referred to, is also known as patellar tendonitis

With repeated strain, micro-tears as well as collagen degeneration may occur as a result in the tendon. This is known as patellar tendinopathy .

CAUSES OF PATELLAR TENDINITISPatellar tendonitis is the condition that arises when the tendon and the tissues that surround it, become inflamed and irritated. This is usually due to overuse, especially from jumping activities. This is the reason patellar tendonitis is often called "jumper's knee."

When overuse is the cause of patellar tendonitis, patients are usually active participants of jumping-types of sports such as basketball or volleyball. Patellar tendonitis may also be seen with sports such as running and soccer. Also, some patients develop patellar tendonitis after sustaining an acute injury to the tendon, and not allowing adequate healing. This type of traumatic patellar tendonitis is much less common than overuse syndromes.

PATHOGENESISExtensor mechanism stress, acceleration/deceleration, jumping/landing, extrinsic overload of the tendon - Microtears within the tendon matrix, rare occurrences of rupture - Patellar impingement theory - Impingement of the inferior patellar pole against the patellar tendon during knee flexion, Often resulting from a long inferior patellar pole

Controversy - Johnson et al. 1996 (JBJS) found impingement of the interior pole at 60 degrees of knee flexion - Schmid et al. 2002 suggested that there was no biomechanical evidence of impingement in their series - Almekinders and Shalaby 1999 found evidence of a long inferior pole in symptomatic patients, but this abnormality did not always correlate to the region of involved tendon - Many surgeons resect the infrapatellar pole during both open and arthroscopic debridement of patellar tendonitis

CLASSIFICATION:(Blazina et al 1973, Roels et al 1978) . - phase I: pain only after activity; - phase II: pain/discomfort during activity, but does not interfere w/ participation; - phase III: pain both during & after participation, which interferes w/ competition; - phase IV: complete tendon disruption.

Symptoms of Jumpers knee Pain with running or jumping especially downhill or downstairs Pain and tenderness around patellar tendon Pain and tenderness behind the knee cap Pain is worse at night Restricted movement and swelling in the area surrounding the injury Prevention of Jumpers knee May be associated with poor Vastus medialis obliquus (VMO) function .

OTHERS CAUSESIntensity and frequency of physical activity. Repeated jumping is most commonly associated with patellar tendinitis. Sudden increases in the intensity of physical activity or increases in frequency of activity also put added stress on the tendon. Being overweight. Additionally, being overweight or obese increases the stress on the patellar tendon, and some research suggests that having a higher body mass index may increase the risk of patellar tendinitis.

Tight leg muscles. Reduced flexibility in your thigh muscles (quadriceps) and your hamstrings, which run up the back of your thighs, could increase the strain on your patellar tendon. Misalignment of your leg. The way your leg bones line up could be off slightly, putting strain on your tendon. Raised kneecap (patella alta). Your kneecap may be positioned higher up on your knee joint, causing increased strain on the patellar tendon. Muscular imbalance. If some muscles in your legs are much stronger than others, the stronger muscles could pull harder on your patellar tendon. This uneven pull could cause tendinitis.

CAUSES OF PATELLAR TENDINOPATHYThis depends on the extent or grade of the injury: Grade 1: Pain only after training Continue training but apply ice or cold therapy to the injury after each training session. Cold therapy can be applied by by ice massage or the use of ice packs. It is important the cold is applied at the point of pain on the tendon. Wear a heat retainer or support. See a sports injury specialist / therapist who can apply sports massage techniques and advise on rehabilitation. An eccentric strengthening programme is generally recommended.

Grade 2: Pain before and after exercise but pain reduces once warmed up. Modify training activities to reduce the load on the tendon. Stop jumping or sprinting activities and replace them with steady running or swimming / running in water if necessary. See a sports injury specialist / therapist who can apply sports massage techniques and advise on rehabilitation.

Grade 3: Pain during activity which prevents you from training / performing at your best. Rest completely from the aggravating activity. Replace it with swimming / running in water (if pain allows). See a sports injury specialist / therapist who can apply sports massage techniques and advise on rehabilitation.

Grade 4: Pain during every day activities which may or may not be getting worse. Rest for a long period of time (at least 3 months!). See a sports injury specialist / therapist who can apply sports massage techniques for patella tendonitis / tendinopathy and advise on rehabilitation. If the knee does not respond to rehabilitation then consult an Orthopaedic Surgeon as surgery may be required.

PREVENTION OF JUMPERS KNEEThe following are some measures that can be taken to prevent jumpers knee: Wear proper fitting shoes that are appropriate for the court If necessary, wear orthotics for proper arch support and joint alignment. Make sure to properly stretch your hamstrings and quadriceps prior to activity Strengthen your quadriceps and hamstrings so they can better withstand the forces of running and jumping. Avoid playing on hard surfaces such as concrete for extended periods of time as this impact can lead to inflammation over time.

TREATMENT OF JUMPERS KNEEFirst and foremost, decrease the frequency and duration of the activity that causes you the most pain. In other words, if it hurts, dont do it. Apply ice for 20 minutes 2-3 times a day for 2-4 days or until pain and inflammation are reduced. If pain persists, see your doctor and maybe they can prescribe an anti-inflammatory or pain medication.

Wear a special brace called an infrapatellar brace around the bottom of the patellar tendon. This will help to prevent overuse by helping the tendon to better absorb impact. Since jumpers knee is a chronic injury due to repetitive stress and overuse, it can last a few weeks to several months depending on your ability to pay attention to the symptoms and take appropriate action early on. Always remember to listen to your body, if something hurts, your best plan of action is to reduce or stop that activity altogether before it develops into something more serious.

Patellar Tendonitis (Jumper's Knee) Rehabilitation ExercisesYou can do the hamstring stretch right away. When the pain in your knee has decreased, you can do the quadriceps stretch and start strengthening the thigh muscles using the rest of the exercises. Standing hamstring stretch: Place the heel of your leg on a stool about 15 inches high. Keep your knee straight. Lean forward, bending at the hips until you feel a mild stretch in the back of your thigh. Make sure you do not roll your shoulders and bend at the waist when doing this or you will stretch your lower back instead. Hold the stretch for 15 to 30 seconds. Repeat 3 times.

Quadriceps stretch: Stand an arm's length away from the wall, facing straight ahead. Brace yourself by keeping the hand on the uninjured side against the wall. With your other hand, grasp the ankle of the injured leg and pull your heel toward your buttocks. Don't arch or twist your back and keep your knees together. Hold this stretch for 15 to 30 seconds. Repeat 3 times. Side-lying leg lift: Lying on your uninjured side, tighten the front thigh muscles on your injured leg and lift that leg 8 to 10 inches away from the other leg. Keep the leg straight. Do 3 sets of 10.

Quadriceps isometrics: Sitting on the floor with your injured leg straight and your other leg bent, press the back of your knee into the floor by tightening the muscles on the top of your thigh. Hold this position 10 seconds. Relax. Do 3 sets of 10. Straight leg raise: Lie on your back with your legs straight out in front of you. Tighten up the top of your thigh muscle on the injured leg and lift that leg about 8 inches off the floor, keeping the thigh muscle tight throughout. Slowly lower your leg back down to the floor. Do 3 sets of 10.

Step-up: Stand with the foot of your injured leg on a support (like a block of wood) 3 to 5 inches high. Keep your other foot flat on the floor. Shift your weight onto the injured leg and straighten the knee as the uninjured leg comes off the floor. Lower your uninjured leg to the floor slowly. Do 3 sets of 10. Wall squat with a ball: Stand with your back, shoulders, and head against a wall and look straight ahead. Keep your shoulders relaxed and your feet 1 foot away from the wall and a shoulder's width apart. Place a rolled up pillow or a soccer-sized ball between your thighs. Keeping your head agains