Knee Pain

All About Patellar tendinitis: Jumper’s Knee

Every athlete has experienced pain in the knees at some point. The stress of repetitive motion in running or cycling, sprinting up and down a basketball court, football field or back and forth on a tennis court puts a lot of wear and tear on one of the bodies biggest joints. A little soreness from time to time is normal, but sever pain could mean the onset of jumper’s knee or patella tendinitis.

Patella What…?

The patellar tendon connects the kneecap (patella) to the shinbone (tibia). Its very important job is to help your muscles extend your knee to say, kick a ball, run hill intervals or jump in the air for a rebound.

Patellar tendinitis (or PT for short in case) commonly afflicts athletes who play sports that involve frequent jumping like basketball or volleyball, hence the name jumper’s knee. It is not limited to those types of athletes however.

What A Pain In The Knee

If you are an athlete or very active, pain in your knees is not something you are unfamiliar with. It possible you won’t even realize you have a problem until you start engaging in physical activity. After an intense workout you might feel some discomfort in the knee and not realize this is a common first symptom of PT. Often times the pain from PT will subside after a few minutes of physical activity, like during your warm up, so it’s not unusual for athletes to dismiss the pain and continue doing the very thing that is causing it.

So the pain goes away a few minutes after you start your workout and if it returns later, you will most likely write it off to being hardcore. This kind of neglect is the worse thing you can do because you are only exacerbating the problem. If you don’t take action, though, the pain can increase.

Besides pain, other early symptoms of jumper’s knee are swelling beneath the kneecap and an unstable feeling in the joint. Left untreated, eventually patella tendinitis will start to interfere with your daily activities and make climbing the stairs or getting out of your Lazy Boy difficult.

It’s time to call your doctor and treat the symptoms of PT right away if you want to avoid worse, more permanent damage to the tendon, surgery.

A Stress Mess 

Your doctor will tell you that patella tendinitis is an overuse injury. The stress inflicted on the patellar tendon from repetitive jumping, running, or bending your knees in pursuit of personal glory causes tiny tears to develop in the tendon. There are other risks factors that can lead to PT. If you have tight leg muscles, which reduces flexibility in your quadriceps (quads) or hamstrings (hammies) you increase the stress on the patellar tendon.

An injury unrelated to your knee could cause a muscle imbalance to occur. Say a stress fracture in your ankle or hip pain, which alters your run gait or the way you move in anyway. You can also become muscularly unbalanced if you are always engaging activities that keep your muscles in one plane of motion like cycling or running. The quads and calves may become overdeveloped leaving you with weaker hammies or hip abductors.  The resulting uneven pull on your tendons can cause tendinitis.  When the imbalance starts to wear on the patellar tendon and those tiny tears start to multiply inflammation and pain are the result.

Athletes and other really active types are usually their own worst enemy because they are conditioned to “push through the pain.” However, being “hardcore” and ignoring the painful warning signs you body screams at you can make the tears in your tendon larger and larger until it can no longer perform it’s job and suddenly your sleeping on the coach because your bedroom is on the second floor.

Other symptoms of PT are pain before, during and after your workouts. Swelling, the knee joint locking up, and instability. If taking a few days off from your more strenuous workouts, RICE (rest, ice, compression and elevation) doesn’t relieve the symptoms, then you have a problem.

Patellar tendinitis is just one stop away from the more sever pain train called patellar tendinopathy, which is degeneration of the tendon, so get yourself to a doctor right away.

All About Patellar tendinitis: Jumper's Knee

Be A Boy/Girl Scout

You’ve heard the motto, “always be prepared, right? That is a good one to heed before you see your doctor for debilitating knee pain. Before you head to your appointment you can find some relief from your symptoms with rest (duh) and ice. This will not fix the problem, if you just return to the sports and activities that caused the problem too soon.

Your family doctor might do an exam and then refer you to a sports medicine specialist and this is really the best way to go. These doctors have advanced training in diagnosing and treating musculoskeletal problems.

Tell your doctor in great detail all the symptoms you are having, when the pain first started, not just when you couldn’t make it up the stairs anymore. Have a list of all your past sports injuries and medical conditions you have been diagnosed with and all the medications, including supplements you are taking when you go to your appointment.

Be sure to note any injuries you may have sustained to other parts of the body, and not necessarily while doing something sporty. If you twisted your ankle trying to avoid stepping on the cat or wrenched your back loading your daughter’s Girl Scout Cookies into the back of the mini-van don’t keep it to yourself. These seemingly unrelated injuries, might be related, after all, so don’t disregard them.

Examination Station

So what should you expect during your examination? Since pain from PT is usually concentrated on the front of your knee, a little bit below your kneecap, the doctor will probably start there. He/she will apply pressure to different areas of the knee to determine your pain center and level and see if it is anywhere else around the knee.

The next step is probably some imaging tests. An X-ray, will not show a patellar tendon problem, but could reveal bone issues that might be contributing to the it.  An ultrasound will use waves to create an image of your knee so that your physician can see exactly if and where you have tears in your tendon. An MRI is rolling out the big guns, but it will give you the most complete, detailed image of your knee and tendon, revealing even the tiniest tears.

Jumpers knee has four categories or grades:

Grade one: The pain is only present after training or a workout. This is when you stop engaging in strenuous physical activity, elevating the leg, apply ice and take it easy for a couple of days.

Grade two: Pain is experienced before and after strenuous activity but it goes away after a warm up. All of the above, but more frequently.

Grade three: The pain is always present and starts to inhibit your performance. At this point it is probably a good idea to seek medical treatment.

Grade four: The pain is present all the time and inhibits normal everyday activities (stairs, standing after prolonged sitting) You are in trouble and on your way to permanent damage that rest, pain relievers and ice can’t fix.

Good News and Bad News

The bad news is, you have patellar tendinitis. The good news is you only have patellar tendinitis, not the more sever tendonopathy. The even better news is, there are a lot of non-surgical, minimally invasive treatments that you can try that will probably clear up the problem.

First, you can take a pain reliever and anti-inflammatory like ibuprofen (brand names are Advil or Motrin). For longer-term relief try naproxen (Aleve).

Next you need to do a variety of physical therapies to get rid of PT symptoms and strengthen the knee since it and the tendon have weakened when surrounding muscles attempted to compensate for your injury.

Therap-knee

Stretching is key. You should already be stretching after intense workouts, but if you haven’t now is the time to adopt a very good habit of doing so. Regular, steady stretches will reduce muscle spasms, cramps, and lengthen leg muscles that can become knotted and tight from constantly contracting during prolonged strenuous physical activity.

Some standing stretches you can try are:

  • Hamstring stretch – Place your foot on something flat, stable and only hip high.  Fully extend your knee and then bend slowly forward until you feel a stretch in the back of your thigh and knee. Hold it for at least 20 seconds.
  • Quadricep Stretch – Hold on to something sturdy and stable for balance. Then lean backwards slightly while bringing your foot up towards your gluteus maximus (buttocks). Pull your foot as close to your glute as possible keeping your knees together so that you feel the stretch in the front of your thigh
  • Calf Stretch – A foot or two away from a wall, lean into it placing your hands or forearms against while keeping first one foot and then the other flat so that you feel a stretch down the back of your calf
  • IT Band (iliotibial band) – Since this band runs down the side of your leg and is in direct contact with your knee it is important to stretch it. You can use a foam roller to apply pressure and stretch it or do a standing stretch. Cross your right foot over your left and shift you weight to the left foot Next rock you hips gently back and forth until you feel a stretch down the side of your leg. Switch legs.

There is a right way and a wrong way to stretch. Do not bounce during your stretches. Ease into them and hold them for several seconds at just the point where you feel tension and maybe slight discomfort.  Before you begin the stretches warm up your muscles with five minutes of light cardio such as a spin bike or just marching in place.

Ice and compression can be especially beneficial in reducing inflammation and pain. Putting an ice pack on the knee on a regular basis will reduce swelling and increase the knee’s mobility. You can also try some kind of knee support like a jumpers knee support strap (infrapatellar strap) that encircles the leg just below the kneecap. This changes the angle of the tendon against the kneecap, thus changing the distribution of the force away from the tendon, and directs it through the strap instead.

Eccentricities

Strengthening exercises are the next step in rehabilitating your knee. Muscular imbalances may leave crucial leg muscles weak which will increase strain on the patellar tendon. Eccentric stretches are muscle-tendon contractions such as lowering your leg slowly while you extend your knee.

You can typically lower more weight than lift it, which is part of the concept behind eccentric exercises. For example, it is easier to lower the dumbbells in a squat. It is crucial to perform the exercises with proper form and under the guidance of a trainer if you are not well versed in doing those kinds of exercises.

Good old fashion lunges, with lighter weights to start, that you can gradually add to, also help rehabilitate your knee without putting added stress on the tendon. Be sure to use good form and perform the movements slowly at first. Some other really good strengthening exercises for PT are wall squats, and step ups.

More Good News

For an athlete being forced into a prolonged period of inactivity can feel like torture. The good news is with PT you don’t necessarily have to cease and desist from all training.

It is a good idea to stop doing whatever it was you were doing at the onset of the knee pain and take a couple of days off. Use that time to apply frequent ice packs to the injured area, wear a compression sleeve if you have it and do lots and lots of stretching.

To keep up your cardiovascular fitness you can go swimming. This will work your upper body and core, challenge your heart and lungs but not put any additional stress on your injured knee. Only do free style flutter kicks, not breaststroke swimming, though, because of the way it distends your knee.

You can also ride a stationary recumbent or upright bike, just be sure to position the seat a little higher or farther back and keep the tension very light. You also ride your regular bike outside, but may need to move your saddle higher and always stay in an easy gear. Of course if you feel any pain in your knee, stop exercising and take some more downtime.

What The Doctor Orders

If your symptoms persist or get worse despite rest, ice, stretching and strengthening exercises, your doctor can help. He/she will probably start with the least invasion procedures that will have minimal side effects.

One option for reducing inflammation and relieving PT pain is Inotophersis. A corticosteroid is spread on the skin of your knee, especially just beneath it. Then a device with a very low electrical charge is used to push the medication past the skin into the inflamed tissue below.

A corticosteroid injection is using a syringe to administer a cortisone medication to reduce inflammation directly into the affected area. This can rapidly reduce joint pain and restore full function to your knee almost immediately. There is a very low risk of allergic reaction, so discuss that with your doctor first, but generally this treatment is quick, and has relatively few side effects. However some patients report that the injections are painful. The injections can only be repeated every three months because there is an increased risk of joint damage if you do more than that.

Platelet-rich plasma injections have also been used to treat the symptoms of persistent patellar tendinitis.  The plasma is injected into people with PT in hopes that it will promote new tissue formation and heal the damage tendon. RPR, as it’s known, is a relatively new procedure but is showing great promise in using cutting edge technology and the body’s own natural ability to heal itself.

Last Resort

If the damage to the tendon is so bad that nothing has worked to relieve the pain and returned your knee and you back to normal activities then it’s time to consider surgery.  It really is a last resort and is rarely need to treat anything but the worst cases of patellar tendinitis which by the time surgery is being considered it’s become tendinopathy.

Those who can benefit from surgery have damaged or torn the tendon to the point that has started to degenerate.  Thanks to technology, surgery can be minimally invasive and still get great results.

During surgery the doctor will attempt to repair the worst of the tears in the tendon. If the tendon has ruptured and needs to be reattached this is done by passing the tendon through holes drilled in the kneecap. Sometimes graft tissue is necessary to ensure the tendon is the right length.

There is a new surgical procedure that is less invasive. Using ultrasound, doctors can perform what is called longitudinal tenotomies (cutting the tendon) which will stimulate a healing response in the uninjured part of the tendon. It’s generally treated as an outpatient surgery, too.

As is the case with almost any surgery there are risks and complications that you need to consider. The most common problem associated with patellar tendon surgery is weakness and a loss of motion.  Scar tissue can accumulate and cause stiffness in the joint and some patients will never regain full range of motion in the knee. Post-surgical physical therapy and rehabilitation are crucial in keeping this from happening.

Infection has also been reported. Any time a wound is created in the body there is risk of germs and bacteria getting into the tissue. The risk of infection is particular high in patellar tendon repair surgery. Surgeons will make every effort to minimize the risk by using sterile surgical techniques and give the patient a dose of antibiotics to prevent infection.  If a patient does develop a post-surgical infection this can slow down the healing process.

Embolus or blood clots are also a serious risk of surgery for a damaged tendon. Usually blood clots form in vessels that have been damaged by surgery, obstructing them. However they can migrate to other areas of the body and a prevent blood from reaching vital organs like the lungs, heart and brain.

Of course there is always a risk of a bad reaction to anesthesia. While this is rare it is something you should discuss with your doctors before you undergo surgery to repair your patellar tendon.

Perhaps the worst part about undergoing surgery for PT is the prolonged time ti takes to recover, anywhere from six to nine months. You will not be able to bend your knee for at least five or six weeks after surgery. After a couple of weeks you may be able to stand on your leg but must absolutely not bend the recovering knee.

After surgery it is critical that patients begin physical therapy and rehabilitation to restore range of motion and strengthen the muscles.  This will be prescribed by  your doctor after about six to eight weeks. It can be a pretty grueling process and will require patience and diligence in following your physical therapists instructions, applying ice to reduce swelling, using compression and elevating your leg as much as possible.

If you stick to the post surgical recovery plan and intense physical therapy it is possible to have a complete recovery. To avoid the pain and misery of patellar tendinitis prevention is your best friend. Do not play through or push past pain. As soon as you notice knee pain take a break from whatever your doing, apply ice to the area and rest.

Keep all the muscles in your leg strong by conditioning and strengthening all the different muscle groups. Strong thigh muscles are essential for avoiding tendon damage. Regularly doing wall squats, one leg squats and other eccentric exercises will also help prevent the onset of PT.

Improve your form.  Whatever your sport of workout of choice, be sure you do it with proper form. Wear well fitting shoes, learn how to lift weights properly, make sure you are stretching correctly, not bouncing through the stretch and always warm your muscles up before you stretch them.

With a few lifestyle changes and vigilance when it comes to monitoring pain you can avoid the pain of jumper’s knee and keep on keeping on.

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