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Patellar Tendonitis

I. Description

II. Causes

III. Symptoms

IV. Diagnosis

V. Treatment


Description

The knee joint is the largest joint in the body, housing a complex structure of tendons, ligaments, muscle and bone. Tendons are pliant, fibrous connective tissue structures with slightly more flexible properties than that of ligaments. Tendons connect muscles to bone, but tendons also function like springs, passively regulating forces during movement and providing additional stability. When stretched, tendons behave like other types of soft tissue in the body. Because of their capacity to stretch and the constant forces that are on them, tendons are subject to many types of injuries. There are various forms of tendon injuries due to overuse.

Because the knee performs weight-bearing functions and complex rotational and flexion/extension action, it is particularly vulnerable to injury either from repetitive stress or sudden trauma. These types of injuries generally result in inflammation and degeneration or weakening of the tendons, which may eventually lead to tendon rupture. The patellar tendon is one of two major tendons in the knee, connecting the kneecap to the shinbone (tibia). Because it is connecting bone to bone (a function of ligaments), the patellar tendon is more correctly termed a ligament, but is commonly referred to as the patellar tendon. The patellar tendon assists in extending/straightening the knee, and activities that require excessive or repetitive extension movements can cause tiny micro-tears in the tendon. Normally, the body can repair these micro-tears, but if the activity causing the tears continues, the rate of injury outpaces the body's rate of healing, leading to an inflammation (patellar tendonitis).

Causes

Patellar tendonitis is an overuse injury from repetitive use of the knee's flexing and straightening mechanism, commonly performed in many sports including soccer, rugby, volleyball, track & field, freerunning, tennis, American football, basketball, lacrosse, skateboarding, snowboarding, gymnastics, Olympic weightlifting, powerlifting, rope skipping and kickboxing. It typically affects young athletes. A combination of factors can contribute to patellar tendonitis:
  • High intensity, frequent physical activity, or a sudden increase in activity can place stress on the tendon.
  • Tight leg muscles can lead to reduced flexibility and place additional strain on the patellar tendon.
  • Being overweight- excess weight places additional strain on the tendon.
  • Alignment problems- even a slight misalignment of how the leg bones line up can place strain on the tendon.
  • Patella (kneecap) tracking problems or subluxations (misalignments)- in some individuals, the kneecap or patella may be abnormally positioned, causing the tendon to exert more pressure and leading to overuse.
  • Muscular imbalance- If some muscles in the legs are much stronger than others, the stronger muscles can pull unevenly in comparison to the weaker muscles and lead to tendonitis.
  • Improper biomechanics of the lower extremities can cause an increased load on the patellar tendon. Patients who have continually recurring symptoms without any particular known activity overload may either have problems in the arch of the foot (flat foot) or a mis-aligned ankle joint (talus bone). The latter could be due to a past ankle sprain causing problems higher up in the leg and which is producing more "overuse" of the Patellar Tendon.


Symptoms

Patellar tendonitis symptoms include:
  • Pain in the section between the kneecap and the area where the tendon attaches to the shinbone
  • Sharp pain during physical activity
  • In the beginning stages, pain may not always be present during activity but may only be present when initially beginning a workout, or after an intense workout
  • Pain progresses to persist during activity
  • Pain going up and down stairs
  • A constant ache that can interfere with sleep at night


Diagnosis

Your physician may be able to assess your symptoms and determine that you have patellar tendonitis without involved tests. He or she may simply examine the area in pain, and ask a series of questions to uncover more about your condition. If this does not provide a clear diagnosis, tests may be performed to make the diagnosis or assess the level of inflammation of the tendon. Tests may include:
  • X-rays- A small amount of radiation passes through your body, helping to visualize bone and the surrounding areas, though it is less effective at imaging soft tissues
  • Ultrasound- This test uses sound waves to create an image of your knee, revealing the location of tears in your patellar tendon.
  • Magnetic resonance imaging (MRI)- MRIs produce very detailed images of bones and soft tissues through the use of radio waves and a strong magnetic field. The cost is considerably than that of X-rays or CT scans.
  • Gait analysis- Evaluation of the lower leg biomechanics and ankle & foot motion is imperative to making an accurate diagnosis.
Your doctor will need to rule out other conditions that can cause knee pain similar to patellar tendonitis, such as:
  • Breakdown of the cartilage underneath your kneecap, known as chondromalacia patella
  • Tears in the cartilage (meniscus) that cushions the knee joint
  • Pain behind the kneecap (patellofemoral pain syndrome)


Treatment

Treatment for patellar tendonitis is generally a long process, whether you opt for self-care or require professional care. Expect anywhere from several weeks or months for a non-severe condition, and as long as a year or more to regain full use after surgery. Often, conservative, non-invasive treatments that can be applied at home are effective at pain relief and providing improvement. Surgery is generally required only for cases where the tendon has either ruptured or the tendinitis is so chronic (on-going) that relief is impossible. Seek medical care if pain worsens and does not improve with self-care. Tendonitis pain that persists for over a year should be discussed with your doctor.

Recommended self-care for patellar tendonitis

  • Knee ice packs- cold therapy products can help soothe inflamed tissues and bring pain relief. Ice the knee for 10-15 minutes as needed but not more than once every hour or as directed by your physician.
  • Patellar knee bands- These bands provide compression around the inflamed tendon and relieve pressure from the patella, potentially helping to reduce pain. They can play an important role in pain-management during your daily activities, and may promote faster healing time.
  • Knee pain gels- These topical analgesics provide temporary, targeted relief that can help during a painful episode. Pain gels also encourage gentle massage of the area upon application, an additional benefit that can help reduce pain.
  • Knee friendly exercise equipment- While resting the knee and avoiding activities that cause pain is advised, engaging in low-impact exercise can actually promote healing, and strengthen muscles that support the patellar tendon. Exercise improves circulation, which can help reduce painful symptoms.
  • Balance boards- Balance boards help to strengthen "core" abdominal muscles, and also utilize the hip abductors. This aids in achieving better stability, balance, and flexibility in the supporting tendons and muscles in the knees and ankles.
  • Massage- Convenient hand-held massagers applied to the knee and surrounding areas may provide soothing, targeted symptom relief, increase circulation, and promote healing of the tendon.
  • Medications- Over the counter medicines like Non-Steroidal Anti Inflammatory (NSAIDs) such as ibuprofen and aspirin are appropriate for providing short-term relief. However, because of the potential side effects, they are not typically advised as a long-term solution.


Lifestyle tips for patellar tendonitis

Following the RICE protocol of Rest, Ice, Compression, and Elevation can be effective at reducing symptoms of patellar tendonitis, and may shorten healing time. Products to assist self care and the RICE protocol include:
  • Rest the knee as much as possible while in pain, avoiding activities that increase pain. However, being completely inactive isn't necessary and in fact, gentle activity can encourage healing by keeping the tendon and surrounding tissues flexible. This can also prevent scar tissue from building up.
  • Improve your technique and form. If you are an athlete, it may benefit you to assess your body mechanics. Corrections to posture or alignment can help prevent pain and injury. Consult a physical therapist, sports medicine professional, or athletic coach for specific tips on improving your form for your condition.
  • Take time to stretch. Tight, inflexible muscles can lead to injury. Stretch when your muscles are gently warmed up, a few minutes into a workout or directly after.
  • Rehabilitative Exercise. Performing knee-friendly exercise may strengthen your patellar tendon and your quadriceps. Eccentric strengthening is a specific type of exercise involving a weight lifting movement that focuses on slowly lowering weight back down to the starting position. Eccentric strength training exercises performed on the quadriceps has been shown in some studies to help treat and prevent patellar tendonitis. To perform an eccentric strengthening exercise, simply focus on making both the lift and descent equal in speed and effort. By slowing the descending part of a weight-bearing lift movement, lengthening of the muscles and tendon is encouraged. For example, during a seated knee extension exercise, slowly lift the weight up (a positive contraction), and slowly return down (a negative contraction), as opposed to quickly returning to the starting position. A physical therapist can recommend more exercises that may help improve your knee function.

Professional care for patellar tendonitis

In some cases when pain persists even after home treatments, the condition may need to be professionally managed. Some options for professional treatments for patellar tendonitis may include:
  • Surgery. If conservative approaches to your treatment have not provided relief after 12 months, you and your physician may consider surgery. Surgery can involve repairing any tears in the tendon or removing any badly damaged parts of your tendon. Post surgery recovery can involve a waiting period of up to 6 months before physical activity can be resumed. However, some cases require a more extensive recovery time even up to 18 months, depending on the severity.
  • Corticosteroid injection. These injections can be administered into the tendon sheath to temporarily reduce inflammation. Cortisol is a natural hormone produced by the adrenal glands that acts as a powerful anti-inflammatory. Doctors use a synthetic cortisol for injections, and this treatment can often provide significant pain relief and help you perform strengthening exercises that would otherwise be too painful to perform.
  • Iontophoresis. Typically administered by a physical therapist, this technique involves applying a topical corticosteroid medication to the inflamed area, and a small device then uses an electrical charge to deliver the medication through the skin.
  • Extracorporeal shock wave therapy. This form of therapy uses sound waves to promote healing of the tendon. Some research suggests that it can be effective in relieving the symptoms of patellar tendonitis.
  • Ultrasound and laser stimulation. These therapies can help to provide pain relief but more research is needed to determine if they can heal the tendon.
  • Chiropractic care. In cases where the condition is stemming from alignment and biomechanical problems, chiropractic care from a Chiropractor specializing in extremity conditions may be a beneficial option in correcting the root of the problem. Alternative therapies for pain management and restoring function to the damaged area may also be applied and incorporated under chiropractic therapy.

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