One sub-group of Patellafemoral pain that I did not discuss in my previous article about knee pain in runners is Patellar 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.
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 patellar 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.
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:
- @HakanAlfredson (Professor Hakan Alfredson, Umea Sweden)
- @DrPeteMalliaras (Dr Peter Malliaras, Melbourne Australia)
- @BJSM_BMJ (Karim Khan, Vancouver Canada)
- @ProfJillCook (Professor Jill Cook, Victoria Australia)
- @drjrees (Dr Jonathan Rees, Cambridge England)
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.
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 patellar tendinopathy. Br J Sports Med 2011; 45: 1068-76.