Winter season is upon us, recreational and competitive athletes alike. For some of us that means the long anticipated basketball season is finally here (break out your favorite college or NBA gear), and that leads us to the topic of this week's blog.
Patella tendonopathy is one of the most common causes of anterior knee pain in an active person of all ages and all levels of ability. It is seen more frequently in athletes participating in sports that involve a lot of jumping and running, such as basketball, volleyball, soccer and track (hence the term "jumper's knee").
In one study of high level basketball players, approximately 1/3 had some patella tendonopathy. Not surprisingly, the risk of developing patellar tendon problems does appear to increase with increasing training intensity, frequency and duration. Poor flexibility, and specifically tight quadriceps and hamstrings, may also contribute to an athlete developing patellar tendonopathy. It does appear to affect males and female athletes equally.
To provide some technical context, the term patellar tendonopathy encompasses the spectrum of patella tendon problems, ranging from tendonitis to tendonosis to a frank rupture or tear of the tendon.
Tendonosis is more commonly seen than tendonitis.
The actual root cause of tendonosis causing pain and dysfunction is not entirely clear—it may be due to poor blood supply (ischemic) or may be due to abnormal pain mechanisms (neuropathic) within the abnormal tendonotic tendon. Regardless, once structural changes occur at the tissue level and the athlete is experiencing pain and dysfunction, the patellar tendon problem may be more challenging to treat successfully.
A good history and physical exam is essential to making the appropriate diagnosis. There are other causes of anterior knee pain in an active person. Imaging is not usually necessary to make the diagnosis of patellar tendonopathy, though it can be helpful in determining the extent of the condition or to exclude other causes. MRI or ultrasound are the most helpful imaging modalities in differentiating between tendonitis and tendonosis, or if concerned about a tendon tear.
The treatment goals are to maximize comfort and to restore and maximize function. A key part of the management—and one supported by the medical literature, is good physical therapy, and specifically eccentric strengthening exercises. Anti–inflammatory medications are often used as an adjunct, as is counter force brace (jumper's knee strap) that helps to reduce tension on the insertion of the proximal tendon. Surgery for patellar tendonopathy is rarely, if ever, required and entails excision or debridement of the abnormal tendon tissue. There are two newer treatments with promising initial results in the medical literature: topical nitroglycerin to the affected tendon (increases blood flow and stimulates cellular activity), and injection of platelet rich plasma into the abnormal tendon (promotes healing with factors derived from the patient's own blood.)
As with other overuse injuries in the active person, a common sense approach can be useful in the busy athlete of all ages. If there is no trauma history, ice applied topically, acetaminophen (Tylenol), and relative rest or activity modification (avoiding aggravating exercises) are usually good first line self-management approaches. Redness, swelling, bruising, numbness or weakness, or inability to flex and extend the knee may be signs to get medical attention sooner.
For the cases that do come to medical attention, patellar tendonopathy can be a challenging condition, and our goal in sports medicine is to help the athlete return to their sport or desired activity with appropriate intervention and management.