If you’ve ever tried to go up stairs the day after a long run and gotten a sudden intense pain in the front of your knee, you might know a little about what patellar tendinopathy feels like. Luckily, patellar tendinopathy is one of the easier flavors of knee pain to diagnose, and treatment can be simple in a lot of cases. In this post, we’ll define this nagging condition and its common characteristics, and lay out how to treat patellar tendinopathy.
Symptoms and Diagnosis of Patellar Tendinopathy
Patellar tendinopathy is characterized by pain near the inferior pole (bottom) of the knee cap that worsens with jumping, plyometrics, and sometimes running. Often, patellar tendinopathy symptoms will be worse when starting an activity, improve as you warm up, then worsen after doing the activity for an extended period.
Often, people with patellar tendinopathy will be able to go for a run, but then getting out of the car after the drive home or getting up from their desk at the end of the day of work is very painful and the symptoms may take a couple of days to fully resolve.
While patellar tendinopathy is typically easy to diagnose, there are a few knee injuries that can present similarly:
Patellofemoral pain syndrome (PFPS): pain directly over the knee cap, less likely to warm up, can hurt similarly with slow loading vs. fast, may also have pain with certain prolonged static positions.
Hoffa’s fat pad impingement: Pain with knee active or passive hyperextension, less clear reproduction of symptoms with tendon loading, pain not directly on the patellar tendon
How to Treat Patellar Tendinopathy: The Pyramid Approach
A pyramidal approach can be used to treat a variety of different conditions, including patellar tendinopathy. This approach just helps you prioritize all of the different things you can do.
At the base of the pyramid, you have the “must do’s.” If you don’t do these things, you probably won’t get all the way better.
The next level is the “should do’s.” These are things that will probably help you get better faster, and therefore you “should” do them.
The next level is the “could do’s.” These are the things that you “could” do to support your recovery, and if you have the access and resources to do them, you certainly should.
The final level is the “why nots.” These are the things that have mixed research behind them and might be expensive or time consuming for marginal gains. They probably won’t hurt you, but the juice might not be worth the squeeze.
Must Do
Progressive tendon loading is the cornerstone of treatment for ANY tendinopathy. Sort of like how a fire hose is the cornerstone of fighting fires.
Typically, this involves finding an entry point exercise where you can tolerate loading the tendon while keeping pain levels below 4/10 (some research says 5/10 but I’m more conservative).
Often, isometric exercises like wall sits or seated knee extension isometrics can be good starting points for someone who has low tolerance to tendon loading. Once exercises that involve movement (Isotonic) are introduced, the movement should be SLOW! Tendons respond best to moderate-heavy SLOW resistance. (1) This component is essential to the healing of the damaged tendon tissue.
Eventually, you can progress to plyometric exercises when pain levels are better controlled to start preparing for sports specific activities like running, jumping, or changing direction.
Should Do
If progressive tendon loading is like the "fire hose" of fighting fires, running gait retraining and foot/ankle deficit work are like moving flammable things away from the fire.
The purpose of these things are to prevent the fire from continuing, but doing them alone might not be enough to put it out completely. Done together with progressive loading, these strategies can speed up the recovery process considerably.
Think of the patellar tendon like a piece of tape. If you try to rip it by pulling both ends directly away from each other, it will be quite strong. But if you consistently only apply tension to one side of the tape, a rip may begin to form. Doing running gait retraining and foot/ankle deficit work help to ensure that you are not creating oblique or asymmetrical tension on the patellar tendon, causing it to break down.
Not sure if running gait analysis is worth it? Check out our other blog post where we answer that question.
BFRt or blood flow restriction training is a method of exercising with restricted blood flow to one or two extremities at a time that creates a high metabolic load but low mechanical load. What does that mean?
You can work at a low weight but high intensity.
This type of training has some excellent research behind it in terms of muscle hypertrophy and improving tendon stiffness. I am currently using BFR as part of my own patellar tendinopathy treatment and it is working wonders. Want to learn more? Check out our other blog post about BFR.
Could Do
If you have access to modalities like dry needling, shockwave, graston, cupping, or massage, they can certainly be helpful adjuncts.
The way that I approach these modalities with my patients dealing with tendinopathy is that they are the sprinkles on top of the cake. You have to make the cake first. I spend the first few sessions with new clients teaching them how to perform their progressive loading program and evaluating where we can make biomechanical adjustments to create better angles for the tendons to work with. We set the foundation first, then we start using modalities.
Why Not
Collagen supplementation likely has some benefit to treating patellar tendinopathy. (2) However, it can be expensive, and often not a good bang for your buck as long as you are fueling your body sufficiently. However, if you have the resources, then why not?
Final Notes on How To Treat Patellar Tendinopathy
Treating patellar tendinopathy is all about creating a well balanced strategy. Using a pyramid method to prioritize your treatments can be immensely helpful when there is so much information out there. Treatment of tendinopathy requires discipline and patience, and can be hard to do on your own.
In my professional experience, tendons take less time to feel better than they do to fully heal, and most people start to feel some symptom improvement within 4 weeks of starting treatment.
However, the research shows that even if everything goes perfectly, tendinopathies can take up to 12 weeks of consistent rehab to fully resolve! (3)
This means that you may feel better before you are better.
At Alterra, we specialize in helping runners resolve any and all of their injuries that limit their running ability or performance. If you're a local runner in Boston's Back Bay and are dealing with patellar tendinopathy, we'd love to help you eliminate it for good! Book a free discovery call to chat with a therapist today.
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Disclaimer: The information in our blog posts is not a substitute for professional medical advice. Consult a healthcare provider before making decisions related to your health. Use our content at your own risk.
Sources:
Khan KM, Scott A. Mechanotherapy: how physical therapists' prescription of exercise promotes tissue repair. Br J Sports Med. 2009;43(4):247-252. doi:10.1136/bjsm.2008.054239
Praet SFE, Purdam CR, Welvaert M, et al. Oral Supplementation of Specific Collagen Peptides Combined with Calf-Strengthening Exercises Enhances Function and Reduces Pain in Achilles Tendinopathy Patients. Nutrients. 2019;11(1):76. Published 2019 Jan 2. doi:10.3390/nu11010076
de Vos R, van der Vlist AC, Zwerver J, et alDutch multidisciplinary guideline on Achilles tendinopathyBritish Journal of Sports Medicine 2021;55:1125-1134.
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