Patellar Tendinopathy: Physical Therapy for Patellar Tendinitis (2018 Update)

By: Dr. Marc Robinson, PT, DPT, Cert. MDT

Most people refer to pain at the front of their knee as patellar tendinitis. Patellar tendonitis refers to inflammation of the tendon; however, you can still experience pain without inflammation.

Patellar tendinopathy refers to a general problem with the patellar tendon which may or may not be related to acute inflammation of the tendon.

If you experience patellar tendinopathy or patellar tendonitis, you don't care about the technical differences, you just want to get rid of your knee pain!

In this article, I am going to share valuable information to help you recover from patellar tendon injuries and get back to an active life.

First, we will look at the basic structure and function of the patellar tendon. Then, we'll discuss treatment options. At the end of the article, I will provide several solutions to your problem.

Where is the Patellar Tendon Located?

You can feel the patellar tendon in the front of the knee just below the kneecap. It runs from the patella (knee cap) to the tibia where it inserts on a bony structure called the tibial tuberosity.

What Does the Patellar Tendon Do?

The patellar tendon is an important structure that connects the quadriceps muscle to the lower leg.  As the quadriceps contract, the knee will extend.

The patellar tendon is made of strong, connective tissue that can withstand a significant amount of tension. However, excessive tension can lead to pain.

 How Does Patellar Tendinopathy Develop?

An injury occurs to the patellar tendon if there is too much strain on the tendon in a short period of time. Patellar tendinopathy can be thought of as an "overuse injury" or a "poor use" injury.

There are different types of patellar tendinopathy:

Acute patellar tendonitis involves an active inflammation of the patellar tendon which usually heals in 3-6 weeks. (1)

Patellar tendinosis is a chronic condition that involves a thickening of the tendon which usually develops take between 6 weeks and 3 months to develop. The healing process can take longer with patellar tendinosis since the tendon has to repair over time.

In either case, the tendon can be repaired by following a treatment plan implemented by a rehab professional.

How to Rehab Patellar Tendinopathy

 

Early Rehab

Active rest is recommended during the initial stages of patellar tendonitis. It is important to continue with gentle physical activity to promote recovery. Bed rest is not recommended and will likely lead to delayed tendon healing.

A general guideline is to increase your activity level by 10% each week; however, this is a general guideline which may be influenced by the severity of the tendon injury and your overall health. The main objective is to safely progress your activity level until you reach your goals.

Eccentric Exercise

The research shows strong evidence to implement eccentric exercise for tendon recovery.  Eccentric muscle contractions involve lengthening of the quadriceps under tension.  For example, squats involve an eccentric contraction of quadriceps during the lowering phase of the squat.  (2,3,4,5)

The following videos show a progression of eccentric exercises for the patellar tendon.  There is an emphasis on going slow and controlled on the way down to get a better eccentric contraction from the quadriceps.

Eccentric exercise can also be performed on a decline board with a downward angle of 14-30 degrees. The authors of one study recommended bending the knee no greater than 60 degrees on the decline squat to avoid excessive compression on the kneecap. (15)

Stretching

Stretching is also recommended for patellar tendinopathy. The patellar tendon is a continuation of the quadriceps muscle and restrictions in the quadriceps can increase the strain on the patellar tendon.

Static or dynamic stretches can be performed to improve the mobility of the quadriceps. Generally, it is better to perform dynamic stretches prior to exercises and static stretches after exercise.

Soft Tissue Mobilizations

Soft tissue mobilizations will help to improve the mobility of the quadriceps to reduce strain on the patellar tendon.

Soft tissue mobilization may consist of foam rolling, massage, Graston, cupping, flossing, and other techniques which improve blood flow and provide neurological stimulus to the body.

Cross Friction Massage

Cross friction massage is a type of soft tissue mobilization. It involves placing pressure on the patellar tendon with your fingers and moving them back and forth quickly across the patellar tendon.

Cross friction massage helps to reorganize the alignment of connective tissue fibers to increase strength in the tendon and expedite the healing process. (6)

Hip Strengthening

Strengthening the hips can reduce strain on the patellar tendon allowing the tendon to heal faster.

Initially, it will be beneficial to perform hip exercises lying down to minimize strain on the tendon then you can add resistance using minibands.

Next, you can transition to standing exercises and progressively increase the difficulty with the standing exercises using minibands.

Hip strengthening exercises should be performed throughout all stages of rehab and continued after rehab to promote a pain-free knee.

Taping

The use of KT tape, KinesioTape, Leukotape, or Rock Tape can be applied over the patellar tendon to redistribute pressure on the tendon.

The redistribution of pressure reduces strain and allows the tendon to heal faster (7).

Anti-Inflammatories

NSAIDs (Non-steroidal anti-inflammatories) like Ibuprofen may help to reduce inflammation with acute tendinitis; however, many people do not tolerate NSAIDS due to negative side effects such as stomach cramps. In addition, the long-term use of NSAIDs has been linked to gastrointestinal problems. I do not recommend taking NSAIDs regularly.

An alternative to NSAIDs is Turmeric. Turmeric is part of the ginger family and it is proven by research to be a powerful natural anti-inflammatory. Turmeric extract, not the root, needs to be taken at a high dose (usually greater than 500 mg per day) to obtain therapeutic benefits.

In addition, turmeric is shown to promote healthy joints, improve cognition and memory, kill cancer cells, boost mood, and reduce pain.

Many of my clients have asked me for anti-inflammatory recommendations. I did extensive research and found the majority of turmeric supplements contain a very small amount of turmeric extract, an amount below what is used in most studies.

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Electrical Stimulation

Electrical stimulation applies a mild electrical current to the body. A common form of electrical stimulation is TENS (transcutaneous electrical stimulation) which is used to control pain. It works by masking pain signals sent to the brain.

Electrical stimulation can also be used to stimulate contraction of a muscle. The settings can be adjusted to promote muscle strength and reduce muscle atrophy. Quadriceps weakness and muscle atrophy are common after patellar tendon injuries.

The research is mixed with electrical stimulation. Electrical stimulation is best used in combination with other treatments.

Iontophoresis

Iontophoresis is a non-invasive method of delivering an anti-inflammatory directly over the patellar tendon.

Iontophoresis is similar to electrical stimulation with the addition of anti-inflammatory medication applied to the surface of one of the electrodes. The electrical current helps to transmit the anti-inflammatory through the skin near the location of the injury.

Dexamethasone, a common anti-inflammatory used with iontophoresis has been shown to potentially weaken the tendon. (11) Similar to NSAIDs, it may provide limited benefits with long-term, negative side effects.

Corticosteroid Injections

Corticosteroids such as dexamethasone can be injected directly into the patellar tendon. As we discussed, dexamethasone can weaken the patellar tendon.  (12,13)

Injections may provide short-term pain relief; however, repeated injections can lead to long-term damage of the tendon. In my opinion, corticosteroid injections should be used as a last resort for the management of patellar tendinopathy.

Opioids

The current opioid epidemic is a major public health concern in the United States. Opioids are addictive and habit-forming just like heroin. In addition, opioids can mask the symptoms rather than solve the root cause of the problem.

Generally, prescription opioids should be reserved for severe and intolerable pain. When used responsibly, they can be very helpful in the recovery process.

Ultrasound

Ultrasound uses sound waves to transmit vibration into the patellar tendon to promote healing; however, there is little research to support ultrasound as an effective treatment for patellar tendonitis. A recent systematic review showed that ultrasound provided no significant benefits compared to the placebo. (14)

Rehab professionals should prioritize the treatments that will give you the most benefit in the shortest amount of time. Ultrasound is unlikely to provide such benefits.

Surgery

Surgery is indicated with complete tears of the patellar tendon. The severity of the tear, activity, age of the individual among other factors will determine whether a surgery is indicated.

It is beneficial to have surgery within 3 weeks of a patellar tendon rupture to improve recovery.

Summary

You can recover from patellar tendonitis by following a personalized exercise program. The program can be personalized based on your individual needs.

As you can see from the treatment options discussed above, exercise is the most important factor in the recovery process. It will provide the most long-term benefits and help you get back to an active life.

If you need a personalized exercise program, fill out this quick application form to work with me. This is the most effective option to recover quickly. Apply here.

If you want a few simple exercises to strengthen the hip/knee then I recommend you order the Evercore minibands. You will get 7 different resistance bands for hip strengthening and access to 10 instructional exercise videos using the minibands! Order here.

If you are looking for a comprehensive fitness program to lose weight, gain muscle, or live healthier then we offer personalized nutrition and exercise programs from highly skilled and experienced professionals who want to see you succeed! If you are dealing with injuries, this program will help you reach your goals without making the injury worse. Click here to learn more.

 

References

1. Rutland, M., O’Connell, D., Brismée, J.-M., Sizer, P., Apte, G., & O’Connell, J. (2010). EVIDENCE–SUPPORTED REHABILITATION OF PATELLAR TENDINOPATHY. North American Journal of Sports Physical Therapy : NAJSPT5(3), 166–178.

2. Jonsson P Alfredson H. Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: a prospective randomised study. Br J Sports Med. 2005;39(11):847-850.

3. Frohm A Saartok T Halvorsen K Renstrom P. Eccentric treatment for patellar tendinopathy: a prospective randomised short-term pilot study of two rehabilitation protocols. Br J Sports Med.2007;41(7):e7

4. Young, M. A. (2005). Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. British Journal of Sports Medicine,39(2), 102-105. doi:10.1136/bjsm.2003.010587.

5. Saithna A Gogna R Baraza N Modi C Spencer S. Eccentric exercise protocols for patella tendinopathy: Should we really be withdrawing athletes from sport? A systematic review. Open Orthop J. 2012;6:553-557

6. Brosseau L Casimiro L Milne S, et al. Deep transverse friction massage for treating tendinitis. Cochrane Database Syst Rev. 2002(4):CD003528

7. de Vries A Zwerver J Diercks R Tak I van Berkel S van Cingel R van der Worp H van den Akker-Scheek I. Effect of patellar strap and sports tape on pain in patellar tendinopathy: A randomized controlled trial. Scand J Med Sci Sports. 2015. 10.1111/sms.12556

8. McGriff-Lee N (2003) Management of acute soft tissue injuries. Journal of Pharmacy Practice; 15: 1, 51-58.

9. Mishra D et al (1995) Anti-inflammatory medication after muscle injury. Journal of Bone and Joint Surgery; 77: 10, 1510-1519.

10. Hertel J (1997) The role of nonsteroidal anti-inflammatory drugs in the treatment of acute soft tissue injuries. Journal of Athletic Training; 32: 4, 350-358.

11. Zhang J Keenan C Wang JH. The effects of dexamethasone on human patellar tendon stem cells: Implications for dexamethasone treatment of tendon injury. J Orthop Res. 2012.

12. Paavola M Kannus P Jarvinen TA Jarvinen TL Jozsa L Jarvinen M. Treatment of tendon disorders. Is there a role for corticosteroid injection? Foot Ankle Clin. 2002;7(3):501-513.

13. Shrier I Matheson GO Kohl HW 3rd. Achilles tendonitis: are corticosteroid injections useful or harmful? Clin J Sport Med. 1996;6(4):245-250.

14. Desmeules F, Boudreault J, Roy JS, et al. The efficacy of therapeutic ultrasound for rotator cuff tendinopathy: A systematic review and meta-analysis. Phys Ther Sport. 2015 Aug;16(3):276–84.

15. Zwerver J Bredeweg SW Hof AL. Biomechanical analysis of the single-leg decline squatBr J Sports Med. 2007;41(4):264-268.