Patella Tendinopathy – What Runners Need To Know

Apr 30, 2013   //   by Brad Neal   //   Injury & Rehab Information  //  5 Comments  //  Affiliate Disclosure  

One sub-group of Patellafemoral pain that I did not discuss in my previous article about knee pain in runners is Patella Tendinopathy. That is because we felt that it is a broad enough topic to warrant a full article, which is presented here.  One slight difference to my previous posts, this is designed purely to demystify this complex area for suffers/patients, but comments from other clinicians are obviously welcome at the bottom of the blog.

Terminology

The term Tendinopathy came about in the early 2000’s as a replacement for the historic Tendinitis, as the examination of problematic tendons consistently showed minimal to no inflammatory markers. Remember that it is just a diagnostic term and that you do not need to get caught up in medical semantics. In fact, the topic of inflammation is currently back on the research agenda, with this very recently published paper proving very popular (Rees et al, 2013).

Get an Accurate Diagnosis

A true diagnosis is obviously prudent for all areas of medicine, but especially so in a Tendinopathy. In an ideal world, this will be done with a real-time ultrasound scan, as this will allow us to apply the diagnostic criteria put forward by Cook & Purdham in 2009, which for me is still the best way to then decide upon any subsequent treatment modalities.

What I like to do is give my patients a diagnosis of either ‘Reactive’ or ‘Degenerative’ Tendinopathy, the treatment for which will differ significantly. An ultrasound scan also allows us to screen for any differential diagnoses; such as a full/partial tear, a Paratendinitis or a Calcific Tendinopathy being common examples.

Select the Right Loading Method

There are many methods of loading suggested in the literature – eccentric, concentric, isometric; which one is right for you?

I must advocate that a Physiotherapist direct your tendon loading because (as an example) a degenerative patella tendon should respond well to eccentric loading but it will usually significantly worsen a reactive tendon. However, optimal loading can be a very powerful tool in rehabilitating patella tendinopathy, the long-term mechanism of which is attributed to a phenomenon known as ‘mechanotransduction’ (Repair through Loading) (Khan & Scott, 2009).

Exercise Caution with Injections

There are a plethora of injections on the market to treat tendinopathy but beware – systematic review level evidence (the best we have) usually finds minimal difference between all of them (Van Ark et al, 2011). This suggests to me a mechanism that is not consistent with what substance is injected, but that is a separate topic.

The only injection that I currently advocate in my clinical practice is ‘Polidocanil’, a sclerosing agent designed to destroy the rouge blood vessels (neovessels) encountered with most degenerative tendons. Please avoid any injection involving corticosteroid, as this can increase your chances of tendon rupture significantly.

Surgical Intervention

Any orthopaedic surgeon worth his salt should be very reticent to get involved with any tendinopathy. This is not something you should even contemplate unless your symptoms are recalcitrant and have failed to respond to adequate conservative management for a minimum of six months.

My close colleague Professor Hakan Alfredson (a world renowned tendon specialist from Sweden), has developed a revolutionary minimalist ‘scraping’ technique for the patella tendon which is showing excellent follow up data when applied to degenerative tendons and this is what I would advocate if conservative management fails.

Optimise Your Training & Biomechanics

As with any musculoskeletal injury, how often and with what quality you move is paramount in your recovery. Tendons rarely respond well to total rest, but ensure that your clinician and coach communicate regularly to get your training levels correct. Seek the advice of a Physiotherapist or Biomechanics Coach to ensure that your running form is strong and that you are structurally balanced and robust.

Tendon Experts in Social Media

Consider following this list of expert clinicians for further information relating to all aspects of Tendinopathy:

  1. @HakanAlfredson (Professor Hakan Alfredson, Umea Sweden)
  2. @DrPeteMalliaras (Dr Peter Malliaras, Melbourne Australia)
  3. @BJSM_BMJ  (Karim Khan, Vancouver Canada)
  4. @ProfJillCook (Professor Jill Cook, Victoria Australia)
  5. @drjrees (Dr Jonathan Rees, Cambridge England)

Final Messages

I hope that you’ve found this information useful. I’ll happily answer any further questions in the comments section below.

Tendon pain is common presentation amongst athletes, especially runners. It’s an injury we believe we treat with great success with our combined approach at Pure Sports Medicine and Kinetic Revolution. If you are struggling and need our assistance then please don’t hesitate to get in touch.

References

Cook, J & Purdham, C. Is tendon pathology a continuum: a pathology based model to explain the clinical presentation of load induced tendinopathy. Br J Sports Med 2009; 43: 409-16.

Khan, K & Scott, A. Mechanotherapy: how physical therapists prescription of exercise promotes tissue repair. Br J Sports Med 2009; 43: 247-251.

Rees, J et al. Tendons – time to revisit inflammation. Br J Sports Med 2013; Article in Press.

Van Ark, M et al. Injection treatments for patella tendinopathy. Br J Sports Med 2011; 45: 1068-76.

About The Author

Brad is a Specialist Musculoskeletal Physiotherapist from Pure Sports Medicine in London, based in Canary Wharf. He completed his BSc in Physiotherapy at the University of Hertfordshire in 2006 and a subsequent MSc in Advanced Musculoskeletal Physiotherapy at the same university in 2011. He has experience in both the NHS and private sectors of health care alongside a career in various professional sports.

His clinical interest lies in the field of Biomechanics, Patellofemoral Pain (PFJP), Tendinopathy and other overload pathologies. Academically he is a PhD candidate at Queen Mary, University of London on the topic of hip strengthening and running re-education for PFJP.

 

Facebook Comments

5 Comments

  • Another good write up Brad.

    For clinicians reading this, here is the link to the Khan & Scott article (http://bjsm.bmj.com/content/43/4/247.full).

    I’m not sure where or when I first came across this one, but it was fantastic to see some very sound reasoning that made some sense out of the approach that all good sports rehab physios usually find themselves leaning towards through experience rather than hard evidence. That is, tending towards exercise rather than rest! It also gives weight to the use of myofascial techniques away from sites of patholgy to effect changes in those structures.

    On a completely different line of thought it would be interesting to consider the effects of diet on the ‘neovessels’ mentioned above as there is interesting works coming out regarding ‘anti-angiogenetic’ (ie stop growing blood vessel) foods in studies on tumor growth etc. There is also an interesting study regarding chronic achilles pathology (sorry no link) and the effect of omega oils and antioxidant supplements on return to sport times. Perhaps you could dig a little on this topic and present something on nutrition and healing for your next installment!?

  • Thanks Brad for the informative article!

    What would be be the differences in the common presentations of a reactive verses degenerative tendinopathy? And what aspects of a patients history would lead us to believe it is one over the other?

    Thanks,
    Paul

    • Paul,

      Many thanks for the comment. If you are (as your name suggests) a new graduate then my advice would be to read the Cook & Purdham paper from 2009 cited within the article. If you cannot access the full version on the BJSM website then please reply and I will email you the full text. Please come back to me when you have read the paper with any further questions.

      Cheers,

      Brad

  • Brad – interestng article – my soft tissue therapist ‏@CamSportMassage tweeted me the link – I have been struggling for a few years with either a Patella tendon tendinopathy or a fat pad issue (medical opinion is divided re the cause – seen 3 specialists over the years) and am currently trying to manage conservatively by soft tissue manipulation to take the pressure off the knees. Up until now I was not aware of the 2 types of tendinopathy – are you able to mail me the Cook & Purdham paper as you offered above – I cannot access it. I then may go back round the specialist route – this time to @drjrees as I live in Cambridge, who you name above who seems an expert in the field – Rgds, Ian

  • Any useful subjective/objective differentiators between patella tendinopathy and patellofemoral pain?

Leave a comment. Ask us a question...