Patellar tendinopathy

At the time of writing (August 2012) there appears to be no universally accepted definition or typical clinical presentation that consistently indicates the presence of patellar tendinopathy. Broad suggestions exist (Brukner & Khan, 2011) but these are not evidence based and are at best consensus led. This likely reflects research findings that although histopathological changes may be present (collagen degeneration and neovascularisation), pain may or may not be present (Malliaras et al., 2010; Tol et al., 2012).

Although there is a considerable amount of research that demonstrates an absence of inflammation in such conditions the underlying pathophysiology of symptomatically painful tendons it is still very unclear why some tendons are painful and others are not. Current research suggests the presence of various neurotransmitters (glutamate etc.) within a particular tendon may be the most reliable indicator as to whether an individual tendon is clinically symptomatic (Schizas et al., 2012).

Therefore to summarise: tendon pain may occur in the absence of any obvious clinical (thickening, increased temperature etc.) or imaging findings, or there may be obvious clinical and imaging findings that are not clinically symptomatic (Khan et al., 2000).

Although some empirical studies suggest response to rehabilitation may take as little as 6 weeks (Roos et al., 2004), it generally appears response to treatment may typically take upward of 12 weeks (Purdam et al., 2004). This has led to recommendations that conservative management of tendinopathies should continue for a minimum of 3-6 months before more invasive approaches are adopted (Khan et al., 2000; Kountouris et al., 2007). In some instances rehabilitation may take up to a year in chronic cases (Alfredson & Cook, 2007).

However, sufficient time appears to be necessary in order allow symptomatic tendinopathies the necessary time to improve. As a compromise if there is no change in symptoms over 3-4 months, then referral on for further investigation may be prudent (Relwani et al., 2003) until further research is completed.

No specific testing protocol. See presentation and diagnosis.

• PEACE and LOVE
• Early rehab - address biomechanical and soft tissue dysfunction
• Minimum of 3 months - eccentric conditioning program
• Rehab > 3 months

Many strategies have been proposed across the literature concerning the management of patellar tendinopathies. Unfortunately there are common faults across the literature such as very small sample sizes, very low study power, inappropriate statistical testing, mistreatment of outlier and non-completion data, lack of placebo controlled trials, poor randomisation and blinding, an inability to determine true effect sizes of interventions, inconsistent measures etc.

Consequently results across studies cannot be pooled, direct comparisons cannot be made, the relative contribution of placebo and natural time course to the disease state, and conclusions concerning the clinical relevance of one intervention compared to another are effectively impossible. When considering clinical practice in particular, the limitations mentioned make it impossible to offer any definitive guidance concerning truly evidence-based management of tendinopathies at this time. This is echoed by Maffulli and Longo (2008).

Patient centred care

Treatment should take into account individual patient needs, preferences, expectations and functional status.  Clinical reasoning should inform treatment based on subjective and objective findings.  Good communication between therapist and patient is essential if a successful outcome is to be achieved.  Treatment options should be clearly explained so that patients can make informed decisions with regard to their care and management.

Evidence based strategies

Eccentric exercise

Of all the interventions that have been investigated so far in the management of patellar tendinopathy, it appears eccentric exercise is by far the most researched. Overall empirical evidence suggests eccentric exercise has a positive effect in cases of patellar tendinopathy (Purdam et al., 2004; Young et al., 2005; Visnes et al., 2007). However, important to note there is virtually no research concerning optimal treatment delivery.

Eccentric exercise can lead to improvement (Fhrom et al., 2006; Purdam et al.,2004 ; Young et al., 2005; Stasinopoulos et al., 2004; Stasinopoulos et al., 2012; Visnes et al., 2007).

Strong evidence for eccentric loading in patellar tendinopathy (Larsson et al., 2012).

No difference between surgery and eccentric exercise (Bahr et al., 2006).

Stretching

Stretching in addition to eccentric exercise was more effective than eccentric exercise alone (Stasinopoulos et al., 2012).

Non evidence based strategies

Biomechanical assessment and management: biomechanical assessment may be useful, no evidence was cited as to the importance of this (Khan et al., 1998).

Ultrasound

• No additional benefit on top of eccentric program (Stasinopoulos et al., 2004)
• No benefit of low intensity US compared to placebo (Warden et al., 2008)
• US likely has little role in the management of patellar tendinopathy (Larsson et al., 2012)

Acupuncture: little has been done evaluating the role of acupuncture in the management of patellar tendon pain.

Frictions: no additional benefit on top of eccentric program (Stasinopoulos et al., 2004).

Taping and bracing: little has been completed looking at the effects of taping etc. specifically looking at patellar tendinopathy.

Progressing as expected (up to 3 Rxs) before discharge or onward referral.

Refer to ortho, GP, other.

Escalation

Criteria to refer on:

It is important to stress there is no formal guidance concerning when it is appropriate to refer an individual on for further assessment or investigation (if there is no change in symptoms over 3-4 months then referral on for further investigation may be prudent (Relwani et al., 2003)).

• Moderate – severe persistent pain not controlled by appropriate medication
• Significant sleep disturbance
• Significantly reduced walking distance? tried / uses walking aid
• Significantly interfering with ADLs, job, hobbies
• Patient agreeable to surgical opinion
• Persisting pain/symptoms despite conservative management

Alfredson H, Cook J. A treatment algorithm for managing Achilles tendinopathy: new treatment options. Br J Sports Med 2007 Apr;41(4):211-216. Click here for full text (link correct as at 20.8.15)

Brukner P, Khan K. Clinical sports medicine. 3rd ed. ed. Australia: McGraw-Hill; 2007

Khan KM, Cook JL, Maffulli N, Kannus P. Where is the pain coming from in tendinopathy? It may be biochemical, not only structural, in origin. Br J Sports Med 2000 Apr;34(2):81-83. Click here for full text (link correct as at 20.8.15)

Kountouris A, Cook J. Rehabilitation of Achilles and patellar tendinopathies. Best Pract Res Clin Rheumatol 2007 Apr;21(2):295-316. Click here for full text (link correct as at 20.8.15)

Malliaras P, Purdam C, Maffulli N, Cook J. Temporal sequence of greyscale ultrasound changes and their relationship with neovascularity and pain in the patellar tendon. Br J Sports Med 2010 Oct;44(13):944-947. Click here for full text (link correct as at 20.8.15).

Roos EM, Engstrom M, Lagerquist A, Soderberg B. Clinical improvement after 6 weeks of eccentric exercise in patients with mid-portion Achilles tendinopathy -- a randomized trial with 1-year follow-up. Scand J Med Sci Sports 2004 Oct;14(5):286-295. Click here for full text (link correct as at 20.8.15)

Tol, J. L., Spiezia, F., & Maffulli, N. (2012). Neovascularization in achilles tendinopathy: Have we been chasing a red herring? Knee Surgery, Sports Traumatology, Arthroscopy, 20(10), 1891-4. Click here for full text (link correct as at 20.8.15)

Schizas N, Weiss R, Lian O, Frihagen F, Bahr R, Ackermann PW. Glutamate receptors in tendinopathic patients. J Orthop Res 2012 Sep;30(9):1447-1452. Click here for full text (link correct as at 20.8.15)

LUNDBERG, M. and MESSNER, K., 1996. Long-term prognosis of isolated partial medial collateral ligament ruptures. A ten-year clinical and radiographic evaluation of a prospectively observed group of patients. The American Journal of Sports Medicine, 24(2), pp. 160-163.

BAHR, R., FOSSAN, B., LOKEN, S. and ENGEBRETSEN, L., 2006. Surgical treatment compared with eccentric training for patellar tendinopathy (Jumper's Knee). A randomized, controlled trial. The Journal of bone and joint surgery. American volume, 88(8), pp. 1689-1698. Link here (link correct as at 21/8/15)

DIMITRIOS, S., PANTELIS, M. and KALLIOPI, S., 2012. Comparing the effects of eccentric training with eccentric training and static stretching exercises in the treatment of patellar tendinopathy. A controlled clinical trial. Clinical rehabilitation, 26(5), pp. 423-430. Link here (link correct as at 21/8/15)

FROHM, A., SAARTOK, T., HALVORSEN, K. and RENSTRÃM, P., 2007. Eccentric treatment for patellar tendinopathy: a prospective randomised short-term pilot study of two rehabilitation protocols. British journal of sports medicine, 41(7), pp. e1-e6. Link here (link correct as at 21/8/15)

KHAN, K.M., MAFFULLI, N., COLEMAN, B.D., COOK, J.L. and TAUNTON, J.E., 1998. Patellar tendinopathy: some aspects of basic science and clinical management. British journal of sports medicine, 32(4), pp. 346-355. Link here (link correct as at 21/8/15)

LARSSON, M.E., KALL, I. and NILSSON-HELANDER, K., 2012. Treatment of patellar tendinopathy--a systematic review of randomized controlled trials. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 20(8), pp. 1632-1646. Link here (link correct as at 21/8/15)

MIYAMOTO, R.G., BOSCO, J.A. and SHERMAN, O.H., 2009. Treatment of medial collateral ligament injuries. The Journal of the American Academy of Orthopaedic Surgeons, 17(3), pp. 152-161. Link here (link correct as at 21/8/15)

PURDAM, C.R., JONSSON, P., ALFREDSON, H., LORENTZON, R., COOK, J.L. and KHAN, K.M., 2004. A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy. British journal of sports medicine, 38(4), pp. 395-397. Link here (link correct as at 21/8/15)

RELWANI, J., FACTOR, D., KHAN, F. and DUTTA, A., 2003. Giant cell tumour of the patellar tendon sheath--an unusual cause of anterior knee pain: a case report. The Knee, 10(2), pp. 145-148. Link here (link correct as at 21/8/15)

STASINOPOULOS, D. and STASINOPOULOS, I., 2004. Comparison of effects of exercise programme, pulsed ultrasound and transverse friction in the treatment of chronic patellar tendinopathy. Clinical rehabilitation, 18(4), pp. 347-352. Link here (correct as at 21/8/15)

VISNES, H. and BAHR, R., 2007. The evolution of eccentric training as treatment for patellar tendinopathy (jumper's knee): a critical review of exercise programmes. British journal of sports medicine, 41(4), pp. 217-223. Link here (link correct as at 21/8/15)

WARDEN, S.J., METCALF, B.R., KISS, Z.S., COOK, J.L., PURDAM, C.R., BENNELL, K.L. and CROSSLEY, K.M., 2008. Low-intensity pulsed ultrasound for chronic patellar tendinopathy: a randomized, double-blind, placebo-controlled trial. Rheumatology (Oxford, England), 47(4), pp. 467-471. Link here (link correct as at 21/8/15)

WOO, S.L., VOGRIN, T.M. and ABRAMOWITCH, S.D., 2000. Healing and repair of ligament injuries in the knee. The Journal of the American Academy of Orthopaedic Surgeons, 8(6), pp. 364-372. Link here (link correct as at 21/8/15)

YOUNG, M.A., COOK, J.L., PURDAM, C.R., KISS, Z.S. and ALFREDSON, H., 2005. Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. British journal of sports medicine, 39(2), pp. 102-105. Link here (link correct as at 21/8/15)