Jumpers Knee (Patellar tendinopathy)

What is jumpers knee / patellar tendinopathy?

The patella tendon / ligament joins the kneecap (patella) to the shin bone or tibia. This tendon
is extremely strong and allows the quadriceps muscle group to straighten the leg. The
quadriceps actively straighten the knee in jumping to propel the individual off the ground as
well as functioning in stabilizing their landing.

As such this tendon comes under a large amount of stress especially in individuals who
actively put extra strain on the knee joint such as those who regularly perform sports that
involve direction changing and jumping movements. With repeated strain, micro-tears as well
as collagen degeneration may occur as a result in the tendon.

This is known as patellar tendinopathy or Jumpers Knee. It should be distinguished from

patella tendonitis (tendinitis) as this condition indicates an inflammation of the tendon whereas
tendinopathy is more about degeneration of the tendon.

What are the symptoms of jumpers knee?

 Pain at the bottom and front of the kneecap especially when pressing in or palpating
(see assessment).
 Aching and stiffness after exertion.
 Pain when you contract the quadriceps muscles.
 The affected tendon may appear larger than the unaffected side.
 May be associated with poor Vastus medialis obliquus (VMO) function
 Calf weakness may be present

Jumpers knee can be categorised into four grades of injury:

Grade 1: Pain only after training

Grade 2: Pain before and after training but pain eases once warmed-up

Grade 3: Pain during training which limits your performance

Grade 4: Pain during every day activities

Warning!! - This injury may seem like a niggling injury that is not that bad. Many athletes
continue to train and compete on it as it may not be a debilitating injury and recovers after a
short period of rest. However, neglect jumpers knee at your peril! If left to become chronic it
can be very difficult to treat and may require surgery.

What can the athlete can do about patella tendinopathy?

This depends on the extent or grade of the injury. A more severe injury may require longer
rest and may result in surgery.

 Rest from training

 In mild to moderate cases, adaptation of training to reduce impact and jumping
activities may be suitable.
 Apply cold therapy on a regular basis, especially after any form of exercise.
 Wear a knee support, or jumpers knee strap to reduce pain and ease the strain on the
tendon.
 See a sports injury specialist who can apply sports massage techniques to the tendon
and advise on a rehabilitation program.
 Eccentric strengthening is usually recommended.
 If the knee does not respond to conservative treatment, surgery may be required.

Treatment of jumpers knee

 Treatment of patellar tendinopathy is slow and may require a number of months of
rehabilitation in order to notice a decrease in aggravating symptoms. This may include
several months of rest.
 During rehabilitation the VISA questionnaire may be filled out to monitor the progress
of the tendinopathy.

Two modes of treatment may be advised - conservative treatment and surgical treatment:

Conservative (non-surgical) treatment

This is normally advocated initially after diagnosis of patellar tendinopathy. Care must be
taken so as to not overload the tendon. Treatment may involve:

 Quadriceps muscle strengthening program: in particular eccentric strengthening. These

exercises involve working the muscles as they are lengthening and are thought to
maximise tendinopathy recovery.
 Muscle strengthening of other weight bearing muscle groups, such as the calf muscles,
may decrease the loading on the patellar tendon.
 Ice packs to reduce pain and inflammation.
 Massage therapy - transverse (cross) friction techniques may be used.
 Aprotinin injections may help tendinopathies by restoring enzyme balance in the
tendon.

Surgical Treatment

This is normally advised as a last resort. Also, there is little convincing evidence to support
the use of surgery over conservative treatment for patellar tendinopathy. Surgery either
includes excision of the affected area of the tendon or a lateral release where small cuts are
made at the sides of the tendon which take the pressure off the middle third.

An intensive rehabilitative program is normally advised following surgery. In particular the

use of eccentric strengthening exercises may help stimulate healing.

A Sports Injury Specialist or Doctor may:

  Prescribe anti-inflammatory medication e.g. ibuprofen.
 Use ultrasound or laser treatment.
 Use cross friction massage techniques.
 Prescribe and supervise a full rehabilitation programme.
 A Surgeon can operate - see surgery for patella tendinopathy.

If the injury becomes chronic then surgery is an option. A lateral release of the patella tendon
is usually successful.

Similar or related knee injuries that are sometimes confused with this injury include
Patellofemoral pain.

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Jumpers Knee Treatment

What you can do

Consult a sports injury expert

Apply ice packs/cold therapy

Wear a knee strap to relieve symptoms

Use a buoyancy aid for pool exercises

Patellar Tendinopathy is usually degenerative, and infrequently due to an inflammatory

response. Therefore, the use of anti-inflammatory medication (NSAIDs ) is not appropriate.
The action of the NSAIDs can actually be counter-productive, as these drugs inhibit the action
of naturally occurring chemicals that mediate a healing response, thus dulling the body's
ability to regenerate the damaged tissue. Ice Packs can be applied for periods of twenty
minutes every couple of hours (never apply ice directly to the skin as it can cause an ice
burn).

Early recognition by a doctor or Chartered Physiotherapist helps greatly, because the outcome
is better if treatment is initiated early. In minor cases of Patella Tendinopathy, a Patella
Tendon Strap can be effective in relieving symptoms by reducing the cross sectional area of
the tendon, the pressure applied by the Patella Tendon strap prevents maximal force being
transmitted through the tendon. This reduces the strain on the Patella Tendon and helps to
alleviate symptoms.

The key to fully recovering from Patellar Tendinopathy is in trying to elicit a healing response
without overloading the tendon. This may require rest from sporting activities for up to three
months. This is because the collagen tissue, which the body produces to repair the tissue
damage, takes three months to lay down and mature. This process may be assisted by
treatments that increase the temperature of the tendon, increasing the metabolic activity and
thus the healing process in the tendon.

As the tendon is healing, a Chartered Physiotherapist may gently mobilise the soft tissue by
providing gentle stress, to help the tendon to adapt and gain tensile strength. Running,
jumping and impact activities should be avoided as they can make the knee pain worse. Pool
running using a Buoyancy Aid and exercises in water are an excellent method of maintaining
cardiovascular fitness without aggravating the injury.

Research has suggested that recovery is optimised by using a programme that uses what is
called 'eccentric muscle work'. Eccentric muscle work refers to a muscle that is lengthening
while contracting - a contraction that occurs during movements such as landing and
decelerating. Maximal tension is generated in the muscle during the eccentric contraction and
this causes the tendon to adapt and get stronger.

Eccentric Strengthening Program

In persistent cases of Patella Tendinopathy, an injection of Aprotinin around the tendon helps
to prevent further tendon degeneration. Aprotinin is a protein which inhibits the enzyme
'Metalloprotease' that breaks down protein that makes up tendon tissue. This drug is useful as
it has been shown that in tendinopathies there is an imbalance between different types of
Metalloprotease, and Aprotinin addresses this imbalance. Also, Aprotinin does not have the
serious side effects of corticosteroids, and, if necessary, can be injected several times.

Another approach, which is currently being pioneered in Scandinavia, is based on the theory
that new blood vessels growing into the diseased tendon are the source of pain. The treatment,
which has shown very promising results from the initial studies, is to inject a 'Sclerosant' drug
into these blood vessels under the control of an ultrasound scanner which shows the blood
vessels. Sclerosant drugs destroy the new blood vessels and hence the proposed source of
pain. However, if there is tendon degeneration there may still be a mechanical weakness in the
tendon, so there is a lot of research yet to be done on this approach.

In severe cases of Patella Tendinopathy, which have failed to respond to six months of
supervised rehabilitation with a chartered physiotherapist, then surgery should be considered.
However, this is very much a last resort because the success of surgery, even with the best
surgeons, is not 100%.

Surgery involves removing degenerate tendon tissue and trying to restore a tendon to a good
level of tensile strength. This means that following surgery the tendon still doesn't have its
normal strength and careful rehabilitation is essential. The eccentric program under the
supervision of a chartered physiotherapist is indicated. As mentioned earlier, the slow rate of
collagen tissue production means that it takes three months to produce new healthy tendon
tissue and at least six months before a return to sporting activities can be resumed.

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Jumpers Knee Prevention

What you can do

Wear shock absorbing insoles

Training errors should be avoided. The intensity, duration and frequency of training should be
carefully monitored and gradually progressed, and sudden increases avoided. Muscle strength
and flexibility should be maintained through regular strengthening and stretching sessions.
The surface should be appropriate to the sport and it is important to wear the correct footwear.
Shock Absorbing Insoles can be helpful, as they reduce the stress on the Patella Tendon
during running.