Jumper's Knee (Patellar Tendinitis): Physiotherapy Techniques For Rehabilitation

Jumper's Knee (Patellar Tendinitis): Physiotherapy Techniques For Rehabilitation

Jumper's Knee, also known as patellar tendinitis, is a chronic patellar tendon injury among athletes, characterized by inflammation or injury to the patellar tendon, which connects the kneecap (patella) to the shinbone (tibia). In sports like basketball and volleyball, its prevalence is very high.

Clinical Presentation of Jumper's Knee (Patellar Tendinitis)

Causes of Jumper's Knee (Patellar Tendinitis)

Diagnosis of Jumper's Knee (Patellar Tendinitis)

Patient History:

It includes gathering information about the patient's symptoms, activity level, and history of overuse or repetitive stress to the knee.

Physical Examination

• tenderness at the tendon insertion at the inferior pole of the patella
• patellar tendon is usually thickened
• atrophy of the quadriceps muscle, especially the Vastus Medialis
• reduced muscle-tendon function is noticed
• limited range of motion of several joints

Functional Tests

• Single-Leg Squat Test: Observe for pain and proper technique form during a single-leg squat.
• Decline Squat Test: Performing squats on a decline board to increase the load on the patellar tendon, which can elicit pain in case of jumper's knee.
• Hop Test: Have the patient perform single-leg hop to assess for pain and functional impairment.

Imaging Techniques

• Ultrasound - visualize changes in the patellar tendon, such as thickening or hypo-echoic areas (areas that appear darker on the ultrasound image, indicating potential tendon degeneration).
• Magnetic Resonance Imaging (MRI) - provides detailed images of the knee structures and can help identify changes in the patellar tendon and other associated structures.
• X-rays - used to rule out other potential causes of knee pain, such as fractures or osteoarthritis, rather than to diagnose jumper's knee directly.
• Doppler Ultrasound - increased vascularity is seen in tendinopathy and can help differentiate between tendinopathy and other types of tendon issues. The development of new blood vessels (neovascularization) within the tendon is a hallmark of chronic tendinopathy. Doppler ultrasound can identify these new blood vessels, which are not usually present in healthy tendons.

 

Differential Diagnosis of Jumper's Knee (Patellar Tendinitis)

• Fat Pad Impingement
• Plica Injuries
• Sinding-Larsen-Johansson Syndrome
• Patellofemoral Pain Syndrome (PFPS)
• Osgood-Schlatter Disease
• Quadriceps Tendinitis
• Chondromalacia Patella
• Meniscal Tear
• Infrapatellar Bursitis
• Iliotibial Band Syndrome
• Anterior Cruciate Ligament (ACL) Injury
• Medial Collateral Ligament (MCL) Injury
• Synovial Plica Syndrome
• Patellar Fracture
• Patellar Instability or Dislocation
• Osteochondritis Dissecans
• Referred Pain from Hip or Lumbar Spine Conditions

 

Physiotherapy Treatment of Jumper's Knee (Patellar Tendinitis)

Pain Management

Initially rest and activity modification is preferred but complete immobilization is not recommended as it lead to damage of muscle tendon unit. Tendon-Load is an important phenomenon. It is recommended to load the tendon very carefully, within pain free range, thereby enabling the athlete to perform. Further the physiotherapist can use following methods:

• Kinesio-taping
• Patellar Brace
• Cryotherapy
• Therapeutic Ultrasound 
• Transcutaneous Electrical Nerve Stimulation

Electromyostimulation

Electromyostimulation (EMS), also known as electrical muscle stimulation or neuromuscular electrical stimulation (NMES), is a technique that uses electrical impulses to elicit muscle contractions.

• help strengthen the quadriceps muscles
• allows for targeted stimulation of specific muscles, which can be particularly useful for isolating and strengthening weak muscle groups that contribute to knee pain - e.g. motor points of the vastus medialis, rectus femoris and vastus lateralis
• help re-educate muscles and improve neuromuscular coordination - e.g. to stimulate the exit of the femoral nerve

Strengthening Exercises

Based on clinical research strengthening exercises are given in following order that is isometric, eccentric and concentric exercises.

Isometric Exercises:

Start with isometric quadriceps exercises to reduce pain and maintain muscle strength without putting excessive strain on the tendon. 5 sessions of 20 repetitions is found beneficial in patients.

Eccentric Exercises:

Progress to eccentric exercises, which involve lengthening of the muscle tendon unit while it is under tension. These exercises are particularly effective for tendon rehabilitation. For example, during the single-leg decline squat the quadriceps muscle contracts while the patellar tendon-quadriceps unit elongates. These exercises stimulate regeneration in the tendon.

Clinically proven effective exercises regime include: (exercises given in ascending order)

• eccentric exercises, knee bend at 45°, 3 sessions of 15 repetitions, 3 times a week
• eccentric exercises, knee bend at 45°, 5 sessions of 15 repetitions, 3 times a week
• eccentric exercises, knee bend at 60°, 3 sessions of 20 repetitions, 3 times a week
• eccentric exercises, knee bend at 60°, 5 sessions of 20 repetitions, 3 times a week
• eccentric exercises, knee bend at 90°, 3 sessions of 20 repetitions, 3 times a week
• eccentric exercises, on an inclined plane of 25°, knee bend at 60°, 3 sessions of 20 repetitions, 3 times a week
• eccentric exercises, on a decline board of 25°, knee bend at 60°, 3 to 5 sessions of 20 repetitions, 3 times a week (without physical therapist supervision)
• eccentric exercises, on an inclined plane, knee bend at 90°, 5 sessions of 20 repetitions, 2 times a week (without physical therapist supervision) = warming-up

The intensity, duration and frequency of exercise is progressed as the condition of the patient improve.

Concentric Exercises:

Gradually incorporate concentric exercises (shortening the muscle under tension) as the patient's pain decreases and tendon tolerance improves.

Progressive Loading:

Implement a progressive loading program that gradually increases the intensity and frequency of exercises to strengthen the tendon and surrounding muscles.

Cycloergometer

A cycloergometer, or stationary bike, is often used in the management of jumper's knee (patellar tendinopathy) for several reasons:

• minimizes stress on the knee joints and tendons
• allows precise control over the resistance, enabling a gradual increase in load on the patellar tendon
• primarily engages the quadriceps muscles, which are important for stabilizing the knee and reducing strain on the patellar tendon
• repetitive motion of cycling can help improve the range of motion in the knee joint and promote flexibility in the surrounding muscles and tendons

 Proprioceptive Exercises

Incorporation of exercises that enhance proprioception (body awareness) and neuromuscular control, such as balance training and coordination drills is also beneficial.