Posts tagged patellar tendinopathy
PRP Effects On Tendon Injury Attributed To Post Injection Physical Therapy

Patellar tendinopathy is one of the more common sports medicine conditions seen in our Boulder Physical Therapy clinic. This condition causes increased pain along the front of the knee just beneath the knee cap and leads to pain with jumping, running, and squatting activities. Current medical evidence has described an absence of inflammatory cells and instead we find an increase in cells responsible for tendon repair. These immature cells are initially laid down in a disorganized pattern and require progressive, optimal loading through exercise to reach a mature, healthy state. In addition to exercise some physicians have advocated for PRP injections into the injured tendon in an effort to accelerate the healing process, but well constructed research trials have not been conducted and this treatment is still considered experimental. A recent research trial examined the effectiveness of PRP for patellar tendinopathy.

A well done randomized controlled trial in the American Journal of Sports Medicine examined the effectiveness of PRP vs. placebo (saline) in patients with patellar tendinopathy (> 6 months of symptoms) (Scott et al. 2019). Patients were randomized to one of three injection groups under ultrasound guidance leukocyte rich PRP, leukocyte poor PRP, and saline. Each group then received 6 weeks (3 times per week) of supervised Physical Therapy including heavy slow strength training (concentric and eccentric loading). Patients were folllowed up at 6,12,36, and 52 weeks. Authors found an improvement in all three groups but no difference in pain, function, or recovery between the three groups. If PRP added to the recovery we should have seen a superior effect of PRP and PT vs. saline and PT, but because all groups were similar we can attribute this change in function to the Physical Therapy strengthening program. This evidence supports our current view on the limited benefits of injections for tendon pain. Patients are encouraged to use a Physical Therapy exercise program consisting of progress, loading exercises to accelerate their recovery from tendon injury.

Rupture Of Knee Tendon After PRP Treatment

Platelet Rich Plasma (PRP) is becoming a popular treatment for muscle strains, arthritis/cartilage injuries, and tendinopathies, but the evidence behind its’ use is limited. Specifically there is a lack of large human trials with randomization to both placebo injections and alternative treatments. Consistent with alternative treatments PRP’s clinical utilization is outpacing the evidence leaving many more questions than answers. To date there is insufficient research to advocate for injections into injured tendons and in some cases (corticosteroid) authors have argued the risks outweigh the benefits. A recent research article highlights a risk of PRP.

A case report published in the Clinical Journal of Sports Medicine highlights a risk on the utilization of PRP for sports injuries (Redler et al. 2018). Authors describe a single patient with a degenerative patellar tendinopathy treated with a series of 4 PRP injections. Upon subsequent surgical examination authors reported a complete rupture in the patellar tendon with significant degeneration is the surrounding tendon. Although the results of this report must be taken in consideration due to its’ methodology, including a single patient, the authors state this report questions both the effectiveness and safety of using this injection in patients with severe tendinopathy.

When will my knee tendinitis get better?

Knee tendinopathy, either in the quadriceps or patellar tendon, is a common source of knee pain among jumping athletes, but can occur in non jumping athletes or the general population as well. This overuse injury is caused by repetitive sub maximal loading of the knee through a bending range of motion. If the loading is faster and/or greater than the tendon’s capacity to tolerate this tensile loading pattern, tendinopathy can occur leading to pain and decreased knee function. Our current understanding of these tendon injuries has moved from passive care (rest, anti inflammatories) to an active Physical Therapy approach focused on optimal loading of the tendon to promote remodeling and healing of the injured tissues. A new article sheds light on when patients can expect to recover from their knee tendinopathy.

van Ark and colleagues randomized 29 volleyball and basketball players with patellar tendinopathy to a 4 week full range of motion or isometric exercise program (Am J Phys Med Rehab. 2018). Patients were assessed for symptoms and function, as well as, each player underwent a baseline and 4 week ultrasound scan of the injured tendon. Interestingly, although players reported decreased pain and improved function after the exercise program, no structural changes were detected in the injured tendon. This study is consistent with the research on achilles tendinopathy which demonstrated improved clinical symptoms after 8-12 weeks of Physical Therapy treatment, but continued healing of the injured tendon up to 12 months after the onset of symptoms.

Physical Therapy exercises are the gold standard treatment for tendinopathy but should be continued after resolution of symptoms for optimal recovery of the tendon.

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Identifying Causes of Patellar Tendon Pain Among Jumping Athletes

Patellar tendinopathy (tendonitis) is a common sports medicine overuse injury most commonly found in jumping (volleyball, basketball) athletes.  This injury has been found in up to 40% of these athletes secondary to the repetitive forces applied to their tendons during their respective sports.  Repetitive loading, without adequate rest, is often found to be the cause of these symptoms, but abnormal loading patterns also play a role.  Changes in dynamic knee alignment due to strength, coordination, and mobility impairments can place the knee at an abnormal angle in preparation for these jumping or landing movements.  A recent research paper looked to identify impairments of flexibility and strength among jumping athletes.

Mendonca and colleagues studied the flexibility and strength of 192 professional basketball and volleyball athletes (JOSPT. 2018). The authors placed athletes in one of two groups based on the presence of patellar tendinopathy (n = 59). The key examination techniques which helped identify those with or without tendinopathy included ankle and leg alignment, hip mobility, and hip external rotation and abduction strength. The study highlights the importance of examining the hip and ankle joint in athletes with patellar tendinopathy. Consistent with the majority of knee diagnoses, hip weakness is one of the strongest correlates with knee pain.

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Short or Long Duration Isometrics Equally Effective For Patellar Tendinopathy

Patellar Tendon pain, also known as jumper's knee, is a painful condition most commonly seen in athlete's engaged in jumping sports such as track and field, basketball, and volleyball.  Common causes of this condition include training errors (too much too soon) and underlying weakness in the quadricep and hip musculature.  The gold standard of treatment for this condition involves the application of sub maximal loading through Physical Therapy exercises to promote healing (remodeling) of the tendon.  In short, doing too little is as bad as doing too much.   Exercise begins to heal the injured tissue through a process called mechanotransduction and without it tissues remain in an immature, weakened condition.  In the knee, promising research is being conducted showing the immediate and short term benefits of isometric loading (45-60 seconds), but new research suggests patients may benefit from shorter loading times.  

In the Clinical Journal of Sports Medicine, Pearson and colleagues randomized patients with patellar tendinopathy to one of two groups (2018).  Patients were placed in either a short duration (24 sets of 10 seconds) or long duration (6 sets of 40 seconds) isometric loading program at 85% of their maximum voluntary contraction.  As you can see from the prescriptions time under load (240 seconds) was balanced between groups.  Authors reported the short duration isometric loads were as effective as the longer duration isometric loads as long as the time under tension was equalized.  This study provides more flexibility to both patients and Physical Therapists when treating patellar tendinopathy.  The take home message is one size does not fit all and tendons should be optimally and progressively loaded over time based on the individual.

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Patellar Tendonitis (tendinopathy) Treatment Using Isometric Exercise

Patellar tendonitis (tendinopathy) is common among jumping athletes requiring repetitive jumping, landing, and squatting movements.  This overuse injury was thought to have a inflammatory component (ex. tendonitis) but more current research supports the term tendinopathy.  This term indicates a disruption in tendon fiber characteristics and alignment leading to a loss of its' tensile strength.  Resting an injured tendon often leads to further disorganization of the tendon and pain.  Conversely, individualized, progressive loading of the tendon (exercise) provides the tissue a stimulus to repair itself along the lines of stress.  This remodeling process can take up to 1 year to complete although patients often feel better and return to sport in 8-12 weeks.  


New research has highlighted the effectiveness of specific exercise programs to both immediately reduce patellar tendon pain and facilitate a return to prior levels of activity.  Rio and colleagues initially demonstrated the effectiveness of isometric (no change in muscle length) contractions on a slant board in patients with patellar pain (Br J Sp Med 2015, Clin J Sport Med 2017).  Patients who performed these exercise holds (5 reps x 45 seconds) saw an average 7 point reduction in pain on a scale of 10.  In both studies, Rio showed this exercise was more effective than isotonic exercise for pain reduction.


van Ark and colleagues continued this line of research among in season athletes with patellar tendon pain (J Sci Med Sport 2016).  They randomized 29 patients to either a 4 day a week isotonic or isometric training program over the course of 4 weeks.  Interestingly, the authors made no adjustments to these in season athletes training programs.  The authors found both groups reduced their pain, but no differences were found between groups.  This study highlights the importance of isometrics if an athlete is unable to tolerate a complete repetition on their injured tendon.  In our Boulder Physical Therapy practice we often start with isometric contractions before progressing to exercises through the available range of motion (isotonic) as the patient's symptoms improve.

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