In this weeks installment of our “injury of the week” series we’re going to be talking about patellar tendinitis. We’re going to keep the same format we’ve had all along. First we’re going to start off with a review of what the injury is and talk about if this is what you have have and when you need to worry/consult your doctor. From there we’re going to take you through the steps of the A-T-A self treatment system.
I have pain in the front of my knee! Is it patellar tendinitis??? (aka Jumpers Knee)
As a clinician, when I see a physician script come in that says patellar tendinitis, I always chuckle to myself. It is easily the most misdiagnosed soft tissue injury in the knee, both by patients who are self diagnosing on webMD and by doctors. The one thing that I can be sure of is that you have pain under or around the knee cap.
So how do you tell if what you have is tendinitis or PFS (patellofemoral syndrome)/chondromalacia? Let’s go to the anatomy. In the picture above, you can see the patella (knee cap). It actually sits in the tendon that attaches the quad muscles (there are four and they are the letters above the knee) to the tibia (lower leg bone). A true patellar tendinitis pertains to that small area from the knee cap to it’s insertion.
We’re talking #2 in the picture above, not #1 which is more of a lower quad issue.
We’re also not talking about a patellofemoral issue (like the picture above) where the knee cap is being pulled in different directions.
What causes it?
Patellar tendinitis is also known as jumpers knee for a reason. As the knee bends and the load increases on that tendon, it is susceptible to injury. The more often that tendon is loaded, the more at risk you are. To keep that tendon healthy and safe relies on normal flexibility in the thigh muscles, as well as, the strength to fully straighten that knee. Remember this picture?
To get into this position requires three things:
1) The mobility to straighten your knee all the way. That means flexible hamstrings and inner adductors.
This is what normal knee extension looks like. If you can’t get there, you can’t fully contract your quad muscles, which means they don’t ever fully relax. No relaxing means increased load on that tendon. Remember our saying: if you can’t move it, you can’t use it. This is key if you are plagued by knee pain.
2) Good mobility in your ankle and hip. Unfortunately the knee is stuck in the middle and it can get pretty beat up through no fault of it’s own. This means that you need to be able to extend your hip all the way.
It also means that you can fully dorsiflex your ankle.
So what do you really need to take away from all of that??
Patellar tendinitis is an injury that happens because of 1) mobility restrictions and 2) strength. You need to fix both components to get rid of it and keep it away for good.
My knee hurts. Now what?
First things first. Like we’ve said all along. This site is not designed to keep you from your doctor and healthcare team. It’s designed to teach you the things that you can do at home to help alleviate symptoms and prevent them from becoming a full blown injury. That being said, if you have any of the following, time to see your doctor. Visible swelling. Bruising around the knee cap. Buckling/giving out. Numbness/tingling anywhere in the leg. If you aren’t making any progress? See your doctor.
Be smart when self treating at home. If you aren’t getting better, get some help. I can’t tell you how many patients I get who wait weeks and even months before coming in for treatment. The longer you wait, the harder it is to get rid of. Here are some tips for finding the right health care professional:
- Find someone certified in soft tissue mobilization, whether it’s instrument assisted like Graston Technique or hands on like Active Release (ART). This is where you need to do your homework to see who’s near you. Follow the links to those sites to search their provider lists and read up on what each is all about. Graston works like a champ on tendons in particular and a cranky knee will always involve tight muscles pulling the knee out of whack.
- Not every PT and chiropractor are created equally. Some do very little soft tissue work and rely mostly on exercise and manipulations, others do not. We all specialize in our own little areas. Frustrating right? Nope! Most of us have websites to tell you what we are certified in. If we don’t? Pick up the phone and call us. There’s nothing worse than wasting 8 insurance visits not getting better only to switch places and have them fix it in two.
How to treat it.
Step 1- Traditional R.I.C.E. treatment:
When a new injury occurs, the first and most important goal is always to decrease pain and any swelling that may be present. In other words, we want to decrease inflammation. That means ice is mandatory. Absolutely no heat no matter how good it feels. Don’t short cut this stuff. It’s boring but it works, especially if your symptoms worsen as the day goes. It’s now easier than ever to smuggle an ice pack into the office fridge and wear compression gear under your dress clothes. Use that to your advantage when working to heal an injury!
Rest: This may sound obvious, but I’m going to say it anyway. An injured muscle/joint will require a decreased activity level to fully heal. The severity of the injury will determine if this is a full rest or more of an active recovery.
Ice: while heat may feel better on stiff and sore muscles, ice only during the first 7 days following injury. This will help to decrease swelling, inflammation and pain. 10-15 minutes is sufficient and you can perform every hour as needed. Avoid direct ice to skin contact.
Compression: thanks to the recent explosion of compression sleeves, tights, shorts, etc, you have several options in this department. Ideally you want something that is snug without being uncomfortably tight (think recovery tights if you’ve ever worn them). You can also use a store brought ace wrap to accomplish this. Start the wrap below the injury using good tension on the bandage and move up above the injury. This will help keep swelling from moving down the leg.
Elevation: This is critical in the early days following acute injury where swelling may be present. In the case of an ankle injury for example, elevate the leg so that it is above chest level. This can be accomplished by laying down and propping for your foot up on the arm of the couch with pillows.
Step 2- Kinesiology taping:
There are two applications that you can use when healing up patellar tendinitis. Both essentially scoop up the lower part of the patella to keep it from irritating the lower tendon. Try both. One may feel better than the other.
1) Taping applications. Click here.
Step 3 – Getting mobility back
The second goal is going to be to loosen up the injured area. Below I have the treatment techniques set up in levels. As a rule, you must be able to complete #1 without pain to progress to the next level. Be smart! Healing a tendon injury isn’t about no pain, no gain. Don’t overdo it in an attempt to speed up your recovery.
1) R.I.C.E. + gentle stretching. There should be no pain with stretching.
2) Begin using the foam roller to work on the muscles first (in other words above the tendon). The tendon is what attaches the muscle to bone. The goal here is to start getting slack into the muscle without aggravating the injury itself. No tennis ball work or active/joint mobilizations. The order should be foam roll the muscle above the tendon -> stretch -> RICE.
3) Begin using the foam roller over the tendon to tolerance. The order should be foam roll the muscle above the tendon-> over the tendon -> stretch -> RICE.
4) Begin using the tennis ball for cross friction. Remember, you will want to work perpendicular to the the tendon (use the picture below; the tendon is green, you want to be working in the direction of the red line). Not sure on cross friction? Review here. Start with light pressure at one end of the tendon and work your way all the way down it. Repeat as needed (and as tolerated) with increased pressure. If it’s too painful- wait and try again the next day. The order should be foam roll the muscle above the tendon -> over the tendon-> cross friction -> stretch -> RICE.
5) As the tendon heals, we can really start to go after the muscles using the mobilization techniques. The order should be foam roll the muscle above the tendon -> over the tendon-> cross friction -> mobilizations -> stretch -> RICE.
How long do you need to R.I.C.E for??? Until it’s 100% gone.
Here’s what it looks like for patellar tendinitis. Use the guidelines above.
Step 4: Strengthening
We’ve broken the exercises down into three levels based on pain levels. This stuff should NOT hurt. If it does, go back a level or ease up on the resistance. Only progress as pain free.
What you’ll need: 1) ankle weights or 2) resistance band/tubing. Both are easy to find in any sporting good store these days or walmart/target.
Optional equipment: 1) a balance disc. Always good to add difficulty to your strength exercises. Affordable too at $20. 2) Suspension trainer. I’m a big believer in these because it takes up zero space in my house and is an easy/inexpensive way to add a dynamic component to my strength training. Prices range anywhere from $30-200. Click here to see some of the options out there.
Video’s for each level are here. Please note, in the PDF download (above) you will find details for reps and difficulty progression, as well as, benchmarks you should meet before progressing to the next level. The number one thing to remember is that these exercises should be pain free. If you’re getting discomfort, go back a level. You can’t force this injury to heal, but you certainly can make it worse if you over do it.
Hope that helps, and fire away with any questions in the comments section!
1) Capobianco, Dr. Steven and van den Dries, Greg. (2009). Power Taping, 2nd Edition, Rock Tape Inc, Los Gatos, CA.
2) Hammer, Warren. (2007). Functional Soft-Tissue Examination and Treatment by Manual Methods, 3rd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.
3) Hyde, Thomas and Gengenbach, Marianne. (2007). Conservative Management of Sports Injuries, 2nd edition. Jones and Bartlett Publishers, Inc, Sudbury, MA.
4) Kase, Kenzo, Wallis, Jim, and Kase, Tsuyoshi. (2003). Clinical Therapeutic Applications of the Kinesio Taping Method.
5) Michaud, Thomas C. (2011). Human Locomotion. Newton Biomechanics, Newton, MA.
6) Muscolino, Joseph. (2009). The Muscle and Bone Palpation Manual. Mosby, Inc, St. Louis, MO.