Patellar Tendinopathy

Historically the term tendinitis has been used to describe tendon pain, thickening, and impaired function while the term tendinosis has been used to describe changes in tendon structure [1]

Terminology

A consensus statement of tendon researchers published in 2019 agreed that the term tendinopathy should be used to describe persistent tendon pain and loss of function related to mechanical loading e.g., running, jumping, and changing directions [1]. The term tendinopathy emphasises pain and function and does not imply a particular pathological process [1]. Partial or full thickness tendon tears may represent a separate clinical entity from tendinopathy and may require different management; however, further research is needed to differentiate tendinopathy from tendon tears in order to direct treatment [1].

Aetiology

Patellar tendinopathy causes pain over the anterior knee and a loss of tendon function that affects participation in sport [2]. An acute or chronic increase in forces on the patellar tendon can cause patellar tendinopathy [3-5]. Systematic review and meta-analysis on the epidemiology of patellar tendinopathy reported that patellar tendinopathy occurs in 18.3% of athletes but only 0.1 % of the general population. Patellar tendinopathy is the most common in athletes who are participating in volleyball (24.8%), basketball (20.8%) and football (6.1%) [6]. Patellar tendinopathy is also more common in non-elite athletes (19.9%) compared to elite athletes (16.7%), male athletes (17%) compared to female athletes (11.2%), and athletes who are ≥18 years old (21.3%) compared to athletes who are <18 years old (10.1%)  [6].

Assessment

Clinical diagnosis of patellar tendinopathy includes signs of load-related tendon pain and positive pain provocation tests that indicate pain localised to the patellar tendon, often at the proximal or distal tendon insertions [2, 7-9]. Athletes often report improvement in symptoms of patellar tendinopathy during sports participation, which is known as a warm-up effect, and an increase in tendon pain and stiffness after sports participation and the following morning [10].

However, it is not known if these features are exclusive to patellar tendinopathy. Assessment of patellar tendinopathy should include a shared decision between healthcare professionals and athletes on when their participation in training and/or sport needs to be modified or when they need to be removed from participation in training and/or sport.

Modification or removal of athletes from participation in sport can result in psychological distress and de-conditioning that may increase an athletes risk of injury when returning to sport [11, 12]. It can also impact the success of a sporting team/club as the availability of athletes for selection in games/matches has been shown to affect the performance of a team/club [13, 14].

Current evidence suggests that athletes with patellar tendinopathy can follow a pain guided activity model that allows athletes to continue participating in sport if their patellar tendon pain is not >5/10 on a numerical pain rating scale during participation in sport, after participation in sport, and the morning after participation in sport [15, 16]. Patellar tendon pain and stiffness is also not allowed to increase week to week.

If an athlete’s participation in sport is causing severe patellar tendon pain and/or reducing their compliance with their treatment protocol, then modification of their participation in training and/or sport or removal from participation in training and/or sport may be required. Assessment of patellar tendinopathy should also include measurement of quadriceps muscle strength, active knee extension and ankle dorsiflexion range of motion [17, 18], and analysis of jumping and landing biomechanics, which should focus on ankle, knee, and trunk biomechanics [19].

Treatment

First line care for patellar tendinopathy includes education on the condition and self-management (e.g., how much tendon loading activity the tendon has the capacity to perform without exacerbating tendon pain), exercise based treatments such as eccentric exercise, moderate or heavy slow resistance training, or progressive tendon loading exercise [20-23], and modification of jumping and landing biomechanics to increase ankle dorsiflexion, knee flexion, and trunk flexion range of motion, which is hypothesised to decrease forces on the patellar tendon [19]. The goal of exercise based treatment is to improve symptoms of patellar tendon pain, promote tendon healing, and improve function of the muscle-tendon unit [10].

Athletes with patellar tendinopathy report high levels of satisfaction with exercise-based treatments; however, some athletes experience persisting or recurring symptoms [20-23]. Athletes with persisting or recurring symptoms may consider shockwave treatment or invasive treatments such as hyaluronic acid injections, sclerosing polidocanol injections, platelet rich plasma injections, intratissue percutaneous electrolysis, or surgery [24-26].

A consensus of tendinopathy researchers and patients agreed that patients rating of their condition, disability (patient-rated pain and disability due to the pain, usually relating to tendon-specific activities or tasks), participation (patient rating of the level of participation or engagement across areas of their life), quality of life, pain on loading or activity and pain over a specified period of time, as well as their level of function and physical function capacity (e.g., quantitative measures of physical tasks) and psychology (e.g., pain self-efficacy, pain catastrophisation, kinesiophobia) should be used to assess patient outcomes from treatment for patellar tendinopathy [27].

References:

  1. Scott, A., et al., Icon 2019: international scientific tendinopathy symposium consensus: clinical terminology.British journal of sports medicine, 2020. 54(5): p. 260-262.
  2. Peers, K.H. and R.J. Lysens, Patellar tendinopathy in athletes: current diagnostic and therapeutic recommendations. Sports medicine, 2005. 35: p. 71-87.
  3. Cook, J. and C.R. Purdam, Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British journal of sports medicine, 2009. 43(6): p. 409-416.
  4. Cook, J., et al., Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? British journal of sports medicine, 2016. 50(19): p. 1187-1191.
  5. Cook, J.L. and H.R. Screen, Tendon pathology: have we missed the first step in the development of pathology?Journal of Applied Physiology, 2018. 125(4): p. 1349-1350.
  6. Nutarelli, S., et al., Epidemiology of patellar tendinopathy in athletes and the general population: a systematic review and meta-analysis. Orthopaedic Journal of Sports Medicine, 2023. 11(6): p. 23259671231173659.
  7. Coombes, B.K., M.D. Mendis, and J.A. Hides, Evaluation of patellar tendinopathy using the single leg decline squat test: Is pain location important? Physical Therapy in Sport, 2020. 46: p. 254-259.
  8. Hannington, M., et al., Self-reported jumpers’ knee is common in elite basketball athletes–but is it all patellar tendinopathy? Physical Therapy in Sport, 2020. 43: p. 58-64.
  9. Sahota, B., et al., Association between knee pain location and abnormal imaging or arthroscopic findings: a systematic review. Annals of Physical and Rehabilitation Medicine, 2022. 65(4): p. 101638.
  10. Millar, N.L., et al., Tendinopathy. Nature reviews Disease primers, 2021. 7(1): p. 1.
  11. Smith, A.M. and E.K. Milliner, Injured athletes and the risk of suicide. Journal of athletic training, 1994. 29(4): p. 337.
  12. Leddy, M.H., M.J. Lambert, and B.M. Ogles, Psychological consequences of athletic injury among high-level competitors. Research quarterly for exercise and sport, 1994. 65(4): p. 347-354.
  13. Windt, J., et al., Does player unavailability affect football teams’ match physical outputs? A two-season study of the UEFA champions league. Journal of Science and Medicine in Sport, 2018. 21(5): p. 525-532.
  14. Calleja-González, J., et al., A commentary of factors related to player availability and its influence on performance in elite team sports. Frontiers in Sports and Active living, 2023. 4: p. 1077934.
  15. Saithna, A., et al., Eccentric Exercise Protocols for Patella Tendinopathy: Should we Really be Withdrawing Athletes from Sport? A Systematic Review. The open orthopaedics journal, 2012. 6: p. 553.
  16. Sprague, A.L., et al., Pain-guided activity modification during treatment for patellar tendinopathy: a feasibility and pilot randomized clinical trial. Pilot and feasibility studies, 2021. 7: p. 1-17.
  17. Jeon, H., et al., Clinical measures and their contribution to dysfunction in individuals with patellar tendinopathy.Journal of sport rehabilitation, 2019. 28(2): p. 165-170.
  18. Crossley, K.M., et al., Clinical features of patellar tendinopathy and their implications for rehabilitation. Journal of orthopaedic research, 2007. 25(9): p. 1164-1175.
  19. Tayfur, A., et al., Are landing patterns in jumping athletes associated with patellar tendinopathy? A systematic review with evidence gap map and meta-analysis. Sports Medicine, 2022: p. 1-15.
  20. Kongsgaard, M., et al., Fibril morphology and tendon mechanical properties in patellar tendinopathy: effects of heavy slow resistance training. The American journal of sports medicine, 2010. 38(4): p. 749-756.
  21. Agergaard, A.-S., et al., Clinical outcomes, structure, and function improve with both heavy and moderate loads in the treatment of patellar tendinopathy: a randomized clinical trial. The American journal of sports medicine, 2021. 49(4): p. 982-993.
  22. Breda, S.J., et al., Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. British journal of sports medicine, 2021. 55(9): p. 501-509.
  23. Núñez-Martínez, P. and D. Hernández-Guillen, Management of patellar tendinopathy through monitoring, load control, and therapeutic exercise: a systematic review. Journal of Sport Rehabilitation, 2021. 31(3): p. 337-350.
  24. Andriolo, L., et al., Nonsurgical treatments of patellar tendinopathy: multiple injections of platelet-rich plasma are a suitable option: a systematic review and meta-analysis. The American journal of sports medicine, 2019. 47(4): p. 1001-1018.
  25. Dan, M., et al., Surgery for patellar tendinopathy (jumper’s knee). Cochrane Database of Systematic Reviews, 2019(9).
  26. Cognetti, D.J., et al., Surgical management of patellar tendinopathy results in improved outcomes and high rates of return to sport: a systematic review. The Journal of Knee Surgery, 2023. 36(11): p. 1171-1190.
  27. Vicenzino, B., et al., ICON 2019—International Scientific Tendinopathy Symposium Consensus: There are nine core health-related domains for tendinopathy (CORE DOMAINS): Delphi study of healthcare professionals and patients. British journal of sports medicine, 2020. 54(8): p. 444-451.

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