Understanding Patellar Tendinopathy
The quadriceps muscle is the long, thick muscle on the front of your thigh. It originates on the front of the hip and travels down the front of the thigh. As it passes over the kneecap it becomes the patellar tendon, which attaches into the top of the tibia (about an inch below the kneecap). The quadriceps is a very important knee muscle, which acts to extend and stabilize the knee. If the quadriceps becomes strained or overloaded it can cause the patellar tendon to pull too hard on its attachment site, leading to pain just below the knee cap.
In our experience, almost every case of patellar tendinopathy is related to a biomechanical problem in the lower extremity that is creating excessive strain on the patellar tendon. When this is the case these issues must be addressed to fully resolve the patellar tendon problem (see discussion below).
Signs and Symptoms of Patellar Tendinopathy
- Gradual onset of pain and/or tightness on the front of the knee, just below the kneecap
- there may be swelling below the kneecap
- Stiffness or tightness on the front of the knee
- Focal pain just below the knee cap with walking, running, squatting, and going up or downstairs
- In the early stages, pain symptoms usually improve with warm-up or exercise
- In later stages, pain may worsen and be present during activity.
What Causes Patellar Tendinopathy?
Patellar Tendinopathy is an example of a repetitive strain injury. Unlike a traumatic injury which is caused abruptly following a trauma or accident, repetitive strain injuries (referred to as an RSI for short) are associated with very small amounts of tissue stress and damage that, if not addressed, can accumulate slowly over time and lead to pain.
Here’s how this works….
As the quadricep/patellar tendon is stressed and over-used it can lead to small scale damage in the muscle iteslf and/or the patellar tendon. This damage is referred to as ‘micro-trauma. Although only small this damage still needs to be repaired. The body does this by forming new tissue in and around the injured tissue. This new tissue, often referred to as scar tissue or soft tissue adhesions, is very sticky and acts to ‘glue’ the damaged tissues back together. For an analogy, think of a big rubber band with a pinprick in it. This pin-prick does not affect the rubber band much, but we still want to repair it so we put a little dab of glue over the area.
If the overload at the quadricep/patellar tendon continues (this is almost always associated with biomechanical problems at the hip or foot, see below) there will be ongoing micro-trauma and subsequent repair of this micro-trauma. Overtime, this scar tissue will build up and will start to interfere with the normal strength and flexibility of the quadricep and patellar tendon. Going back to our analogy, think of this as more and more pinpricks in that rubber band, followed by a big build-up of glue around the area. This will, in turn, make the rubber band stiffer and weaker. As scar tissue builds-up in the quadricep/patellar tendon, it will compromise the strength and flexibility of the tissue. At this point, pain will develop, usually just below the kneecap.
Why the hip and foot are important with Patellar Tendinopathy
It is important to realize that many cases of patellar tendinopathy are actually caused by a problem at the hip or foot. If the muscles around these segments are not working properly it will force the quadriceps to contract harder than normal during activities such as walking, running, climbing stairs, or with exercises at the gym. With this scenario, the quadricep is essentially forced to compensate for these problematic muscles. (“Do you want to know if your knee pain is linked to a problem at your hip or pelvis? Try squat test or 1 leg squat test… click each test to find out more). If these issues are not resolved the knee pain will not fully resolve, and will likely come back in the future.
Treatment – Resolving Patellar Tendinopathy
The proper treatment of patellar tendinopathy must not only address pain and tissue damage at the quadricep/patellar tendon itself, but MUST correct the biomechanical problems at the hip or foot.
For treatment to be effective we have found that there are certain steps that must be followed, and these steps must be performed in the right order if we are to expect the right results. Here is our approach when treating patellar tendinopathy in our clinic….
Step 1 – Resolve scar tissue adhesions and facilitate healing
Perhaps the most critical step is to treat the scar tissue adhesions. These adhesions are a sign that the quadricep/patellar tendon (or other surrounding muscles) are not healthy, and unhealthy tissue will not respond as well to traditional stretches and exercises – think of trying to stretch out that rubber band caked with glue. Resolving scar tissue adhesions is a critical step in resolving patellar tendinopathy, but it is often a missed or underappreciated step as many practitioners do not have the clinical skills to address this problem.
Scar tissue adhesions do not resolve with stretching or traditional massage or soft tissue methods, but instead must be treated with specialized techniques. One of the most effective methods is to use a technique known as Active Release Techniques (ART). For those who are unfamiliar with this treatment method, ART is a new and highly successful hands-on treatment method that was specifically designed to identify and address scar tissue adhesions that are interfering with the normal movement of the body.
During an ART treatment, the practitioner will first shorten the muscle, tendon, ligament, or joint capsule and then apply a very specific tension with their hands as they stretch and lengthen the tissues. As the tissue lengthens the practitioner is able to assess the texture and tension of the tissue to determine if the tissue is healthy or contains scar tissue that needs further treatment. When scar tissue adhesions are felt the amount and direction of tension can be modified to treat the problematic area. There are ART protocols to treat specific muscles and tendons, as well as a restriction in the sciatic nerve.
Step 2 – Correct strength and flexibility
Simply treating the scar tissue adhesions will make the damaged tissue healthier, and will often result in a significant reduction in pain. In fact, it is not uncommon to see a significant improvement in just a few visits. However, although addressing the scar tissue makes the muscles healthier, they may still be somewhat tight or weak. When this is the case-specific stretches or exercises can be incorporated into a home exercise/rehabilitation routine to help support in-office care. Initially, the focus is on correcting local muscle deficiencies (i.e., at the knee, hip, or foot).
Step 3 – Re-Train Functional Movement Patterns
The final stage with treatment is to ensure proper alignment and movement coordination of the foot, knee, hip, and trunk with functional movement patterns. This ensures movement of the hip, knee, and foot are coordinated and working together as a unit. This is what is required during real-life activities such as running, walking, cycling, and climbing stairs (the key functional movement patterns with respect to patellar tendinopathy include the squat, 1 leg squat, and lunge).
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