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Journal of
PHYSIOTHERAPY
journal homepage: www.elsevier.com/locate/jphys
K E Y W O R D S
Patellar tendinopathy
jumpers knee
tendinopathy
treatment
physiotherapy
Introduction
Prevalence
http://dx.doi.org/10.1016/j.jphys.2014.06.022
1836-9553/ 2014 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/3.0/).
[(Figure_1)TD$IG]
123
Extrinsic factors
the continuum model of tendinopathy has the most overt clinical
correlation.7 The continuum model places tendon pathology in
three somewhat interchangeable stages: reactive tendinopathy,
tendon dysrepair and degenerative tendinopathy (Figure 1). Many
patellar tendons have a combination of pathology state (reactive
on degenerative pathology). A degenerative patellar tendon with a
circumscribed degenerative area is thought to have insufcient
structure to bear load resulting in overload in the normal area of
the tendon, leading to a reactive tendinopathy in this area.
The capacity for tendon pathology to move forward and back
along the continuum was demonstrated in the patellar tendons of
Table 1
Risk and associated factors for patellar tendinopathy.
Study
Visnes16
Cook25
Malliaras26
Cook4
Cook20
Witvrouw19
Witvrouw19
Malliaras26
Edwards22
Lian63
Culvenor27
Gaida15
Jannsen64
Factor
Risk factor or
associated factor
Patellar tendinopathy
or tendon pathology
Comment
Gender
Both
Both
Waist circumference
Imaging abnormality
Hamstring length
Hamstring length
Quadriceps length
Dorsiexion
Altered landing strategies
Jumping ability
Fat pad size
Loading
Associated
Risk
Associated
Risk
Risk
Associated
Associated
Both
Associated
Associated
Pathology
Tendinopathy
Pathology
Tendinopathy
Tendinopathy
Pathology
Pathology
Tendinopathy
Tendinopathy
Tendinopathy
124
[(Figure_2)TD$IG]
125
soft at the ankle and hip. The quality of movement can be assessed
with various single-leg hop tests and specic change of direction
tasks. Record pain (VAS) and function at take off and landing,33 and
note if more load induces more pain. If possible, measurement of
angles and individual joint moments through video/biomechanical
analysis can help with more elite athletes. Hop tests for height and
distance can also be used to assess kinetic chain quality, as well as
providing an objective means of monitoring progress.
Muscle strength, assessed through clinical and functional
measures (repeated calf raise and decline squats), is useful to
assess the level of unloading in the essential muscles. Dorsiexion
range of movement is a critical assessment, as the ankle and calf
absorb much of the landing energy.34 Stiff talocrural joint
dorsiexion,26 general foot stiffness and/or hallux rigidus all
contribute to increased load on the musculotendinous complexes
of the leg.
Imaging
[(Figure_3)TD$IG]
Figure 3. Ultrasonic tissue characterisation: (A) normal patellar tendon appearance, (B) mild patellar tendon disorganisation and (C) severe patellar tendon disorganisation.
Note: green colour represents good tendon structure; blue, red and black represent increasing structural disruption.
(Images supplied by SI Docking).
[(Figure_4)TD$IG]
126
Figure 4. UTC pictures of a degenerative patellar tendon structure (A) progressing to a reactive on degenerative patellar tendon structure (B).
Note the increase in blue pixilation in what was previously normal (green) tendon structure.
(Images supplied by SI Docking)
Table 2
Suggested rehabilitation progression for patellar tendinopathy.
Phase of rehabilitation
Aim of treatment
Pain management
Reduce pain
Strength progression
Improve strength
Functional strengthening
Increase power
Energy-storage/
stretch-shorten cycle
Maintenance
Intervention
Isometric exercises in mid-range as tolerated.
Reduce loading and activity modication
Heavy slow resistance as tolerated (isotonic)
Progressive resistance exercise program,
functional tasks, address movement patterns,
kinetic chain and endurance training as required
Increase speed of muscle contraction, lower the
number of repetitions
Plyometric exercises, graded gradually
Drills specic to sport including endurance training
Education, continue strength training and manage
loading as tolerated
Example exercises
Sustained holds on leg extension; 45 s,
4 repetitions, 2 times/day.
Leg extension/press, 4 sets of 6-8 repetitions,
3-5 times/wk
Walk lunge with body weight or extra weight,
stair walking
Split squats, faster stairs, skipping exercises
Jumping, deceleration and change of direction tasks
Sports specic drills at set intensity and duration
Continue leg extension strength or Spanish squat
exercise while training and playing
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128
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