Patella Tendon Pain

I was talking to a colleague a few weeks ago, who works with volleyball players, and he was telling me that a “positive pain” culture exists with his athletes and the coaching staff. He commented that most members of the team and coaching staff believed that if the athletes didn’t have patella tendon pain, they were not training or playing hard enough.

I do completely understand that some injuries will occur despite best attempts to minimise them, but it’s really disappointing to hear that certain types of injuries in sporting circles are considered a “badge of honor”, when there is a HUGE body of evidence now that exists for the optimal treatment of tendon pain and appropriate load management strategies. I won’t go into load management again as I have covered it fairly extensively in my last 2 blogs, but I will reinforce this:

If your training loads are too high, too low, or your training loads have rapidly spiked, you will get injured and your performance will suffer.

After hearing about my colleague's experience with volleyball players, I thought it would be appropriate to blog about patella tendon pain and provide the readers out there with some up-to-date, evidence-based treatment and management strategies that we should be employing when treating someone with the condition.

Patella tendon pain (or patella tendinopathy), is one source of anterior knee pain. Unlike PFJ pain (see previous blog), which is characterised by diffuse pain underneath the patella, patella tendon pain is localised to the “inferior pole” of the patella (see picture below).

It is aggravated by activities such as jumping, landing and kicking, and is almost always alleviated with the cessation of the aggravating activity. As expected, it is very common in jumping sports such as basketball, volleyball, high jump, triple jump, but also tennis and soccer. It is a very debilitating condition in jumping athletes with previous research indicating that 1/3 of athletes presenting with the condition were unable to return to sport within 6 months, and another study showed that over ½ of athletes with the condition were forced to retire from sport (1).

In the past, the main approach to treat patella tendon pain was eccentric strengthening exercises on a decline board 2x per day, 7 days per week (see picture below).

However there is actually very little high-quality research that supports its use (2). Based on the prescription of the eccentric exercise program, it doesn’t surprise me either, as it takes 72 hours for tendons to recover from a session of heavy eccentric exercise! For a competitive athlete, this is not ideal and would definitely impact on their ability to train and play.

What research is telling us now is that there are less aggravating/irritating (and more evidence-based) ways to treat patella tendon pain, for both the in-season athlete, and the patient/athlete who has chronic patella tendon pain. For ease of reading, I have summarised the most recent and clinically relevant studies below:

In-season athletes (3):

- Isometric exercise vs isotonic exercise (participants encouraged to train and play as normal throughout the trial). 4 week program, conducted 4x per week.

- Results: No differences between groups after the 4 week trial and both showed significant improvements in pain and function.

- Clinical importance: athletes can continue to train and play as normal by simply adding in extra exercises into the weekly schedule that positively effect both pain and performance.

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In-season athletes [endif]--(4):![endif]--

[endif]--- 6 in-season volleyball players performed a series of isometric quadriceps exercises prior to training.

- Results: Pain reduced significantly in each of the players for at least 45mins post intervention.

- Clinical importance: isometric exercise may be used as an analgesic option, and it allows the player to perform at their best with almost no pain for at least 45mins (Might be a whole game of basketball, or volleyball!).

Chronic pain patients [endif]--(5):![endif]--

[endif]--- 3 groups: Heavy, slow resistance (HSR) training group (progressive gym program, 3x per week) VS usual eccentric protocol VS cortisone injection group (2 injections at week 0 and week 4).

- Results: All groups improved pain and function scores in the first 12 weeks (no significant differences between the 3 groups). Cortisone group however worsened in pain and function from week 12 to 6 months, whereas the other 2 groups remained stable.

- Clinical importance: HSR group only had to train 3x per week vs 14x per week (usual eccentric protocol). It also had excellent outcomes at 6 months, and it also had the highest satisfaction rate of all the groups at the 6 month follow-up mark. title="Malliaras, 2015 #437"1, 2).

So there you have it, a very strong evidence base that suggests that we should be changing the way we treat our patients with patella tendon pain, especially the in-season competitive athlete. For anyone interested, the following references are a great resource, and very comprehensive reading, for the appropriate management of patella tendon rehabilitation (1, 2). And finally, this blog produced by Prof. Jill Cook and the Latrobe SEM group is a great 10-point plan for both clinician and patient in HOW NOT TO TREAT and manage all lower limb tendon complaints (including patella tendon).![endif]--[endif]--

As always please feel free to share this blog and spread the knowledge. Also please let me know if you think I have missed the mark on this topic, or if you have any other hot tips that you use to treat patella tendon pain.

References

1. Malliaras P, Cook J, Purdam C, Rio E. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. The Journal of orthopaedic and sports physical therapy. 2015 Nov;45(11):887-98. PubMed PMID: 26390269. Epub 2015/09/22. eng.

2. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports medicine (Auckland, NZ). 2013 Apr;43(4):267-86. PubMed PMID: 23494258. Epub 2013/03/16. eng.

3. van Ark M, Cook JL, Docking SI, Zwerver J, Gaida JE, van den Akker-Scheek I, et al. Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-season? A randomised clinical trial. Journal of science and medicine in sport / Sports Medicine Australia. 2015 Dec 7. PubMed PMID: 26707957. Epub 2015/12/29. Eng.

4. Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British journal of sports medicine. 2015 Oct;49(19):1277-83. PubMed PMID: 25979840. Epub 2015/05/17. eng.

5. Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scandinavian journal of medicine & science in sports. 2009 Dec;19(6):790-802. PubMed PMID: 19793213. Epub 2009/10/02. eng.

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All the best and have a great and active day!