Physical Therapy in Sport 43 (2020) 58e64

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Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Original Research

Self-reported jumpers’ knee is common in elite basketball athletes e

But is it all patellar tendinopathy?
Madeline Hannington a, *, Sean Docking a, Jill Cook a, Suzi Edwards b, c, Ebonie Rio a
a
La Trobe Sport and Exercise Medicine Research Centre, College of Science, Health and Engineering, La Trobe University, Australia
b
School of Environmental and Life Sciences, University of Newcastle, Newcastle, Australia
c
Priority Research Centre for Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: To describe the prevalence and pain location of self-reported patellar tendinopathy and
Received 24 September 2019 patellar tendon abnormality in a male elite basketball population.
Received in revised form Design: Cross-sectional.
20 January 2020
Setting: Pre-season tournament.
Accepted 20 January 2020
Participants: Sixty male athletes from the Australian National Basketball League.
Main outcome measures: Self-reported patellar tendinopathy (PT) using the Oslo Sports Trauma Research
Keywords:
Centre Overuse Questionnaire (OSTRC). Pain location using pain mapping (dichotomised: focal/diffuse)
Patellar tendinopathy
Basketball
and severity during the single leg decline squat. Ultrasound tissue characterisation scans of both patellar
Pain mapping tendons.
Ultrasound Results: Thirteen participants (22.7%) self-reported PT. Only 3 who reported PT had localised inferior pole
pain. Thirty athletes reported pain during the decline squat, 15 described focal pain; 10 diffuse pain (5
missing data). Those with diffuse pain had greater years played [Md ¼ 21 (13e24), n ¼ 10 than focal pain
(Md ¼ 12 (7e26), n ¼ 15), p ¼ 0.042, r ¼ 0.3]. Bilateral tendon abnormality was found in 45% of athletes
and 15% had unilateral tendon abnormality.
Conclusion: Elite male basketball athletes self-reporting PT had heterogeneity in pain location. When
focal pain with loading was used as a primary definition of PT, ‘jumpers’ knee’ was not common in this
cohort. This study found that abnormality of the patellar tendon was common and did not correlate with
symptoms.
© 2020 Elsevier Ltd. All rights reserved.

1. Introduction The greatest barrier to capturing the impact of PT in sporting

Patellar tendinopathy (PT) is a common overuse injury in ath-
letes who jump and change direction in sports and is often called
‘jumpers’ knee’ (Ferretti, Ippolito, Mariani, & Puddu, 1983). Patellar
tendinopathy is the clinical presentation of pain and dysfunction
associated with activities that load the patellar tendon. Previous
research in sub-elite athletes has reported that volleyball and
basketball athletes have the highest prevalence of PT (14.4% and
11.8%, respectively), with the condition more common in male than
female athletes (Zwerver, Bredeweg, & van den Akker-Scheek,
2011).
* Corresponding author.
E-mail addresses: m.hannington@latrobe.edu.au (M. Hannington), s.docking@
latrobe.edu.au (S. Docking), j.cook@latrobe.edu.au (J. Cook), suzi.edwards@
newcastle.edu.au (S. Edwards), e.rio@latrobe.edu.au (E. Rio).
populations is the challenge with diagnosis. There is no single test
that diagnoses PT; pain during palpation, imaging abnormality,
outcome measures and pain during loading tests are all not specific
to PT (Cook, Khan, Kiss, Purdam, & Griffiths, 2001; Mendonca Lde
et al., 2016). Pain during palpation may not indicate clinical ten-
dinopathy as asymptomatic tendons can test positive during
palpation (Cook et al., 2001). Further, the patellar tendon has been
shown to be a highly sensitive area to pressure in patients with
knee osteoarthritis suggesting that palpation may not be specific to
patellar tendinopathy (Van Ginckel et al., 2016). This can lead to
false positives when using palpation alone to diagnose PT.
The use of imaging to diagnose PT also presents some limita-
tions. Tendon pathology on imaging is considered a risk factor for
symptom development (Comin et al., 2013; Malliaras, Cook,
Ptasznik, & Thomas, 2006) but not essential for clinical diagnosis
(Docking, Ooi, & Connell, 2015; Scott et al., 2013). In addition, it is

https://doi.org/10.1016/j.ptsp.2020.01.012
1466-853X/© 2020 Elsevier Ltd. All rights reserved.
 M. Hannington et al. / Physical Therapy in Sport 43 (2020) 58e64
well documented that asymptomatic imaging pathology has a high
prevalence in jumping athletes (Cook et al., 1998; Cook, Khan, Kiss,
& Griffiths, 2000; Docking et al., 2015).
Clinical tests can provoke different conditions of the anterior
knee. For example, the single leg decline squat (SLDS) is a test that
has demonstrated reliability as a patellar tendon pain provocation
test (Purdam, Cook, Hopper, & Khan, 2003). However, the SLDS
loads multiple structures in the anterior knee through different
ranges of knee joint motion and will provoke other knee joint
conditions including patellofemoral pain (Purdam et al., 2003).
Recording location and spread of knee pain during clinical tests
may provide more useful information to better describe and sub-
group the population with knee joint pain.
Pain mapping is a method for individuals to report precise
location of pain by using pictures or diagrams. Participants draw
their pain area on a body chart or select pre-determined options
(Boudreau, Badsberg, Christensen, & Egsgaard, 2016; Elson et al.,
2011). Previous research has used a selection of pre-determined
images to identify pain location in other musculoskeletal condi-
tions (Elson et al., 2011; Post & Fulkerson, 1994; Thompson et al.,
2009). Rio et al. (2018) found that patients self-reporting pain
maps were more repeatable than clinician reported pain maps,
recommending patient completion of pain maps following pain
provocation tests.
Capturing the prevalence of PT on a large scale (sporting injury
surveillance) presents further challenges. A combination of the
clinical tests recommended for diagnosis is often impractical. Patellar
tendinopathy can be long-standing, with many athletes continuing
to train and participate in sport while symptomatic. A previous study
in the National Basketball Association (NBA) reports only 0.8% of
missed games each year are attributed to patellar tendon injury
using a time-loss injury definition (Drakos, Domb, Starkey, Callahan,
& Allen, 2010). A time-loss injury definition (i.e. missed games) may
fail to capture the performance impact of overuse injuries, such as PT
(Clarsen, Ronsen, Myklebust, Florenes, & Bahr, 2014).
There has been limited research that describes the prevalence or
impact of non time-loss knee injuries in elite basketball athletes.
The Oslo Sports Trauma Research Centre is a validated overuse
injury questionnaire (OSTRC) that captures the impact of non time-
loss injuries (Clarsen, Myklebust, & Bahr, 2013). This questionnaire,
completed by the athlete, quantifies pain and impact of the injury
on their ability to train and perform.
As PT is an overuse injury, non-time loss measures such as the
OSTRC may be more appropriate to capture injury burden. Previous
research has used adapted versions of the OSTRC overuse ques-
tionnaire to identify the prevalence of PT in sporting populations
(Docking, Rio, Cook, Orchard, & Fortington, 2018; Owoeye, Wiley,
Walker, Palacios-Derflingher, & Emery, 2018). However, the
OSTRC was developed as a region-specific monitoring tool (e.g.
knee, back, shoulder), and the ability to be used for specific di-
agnoses (i.e. PT) has not been validated to date.
Therefore, the primary aim of this research was to describe the
prevalence and pain map presentations of self-reported PT in elite
basketball athletes. The secondary aims were to compare severity
between different outcome measures sub-grouped by pain location
and to examine the prevalence of patellar tendon abnormality us-
ing ultrasound imaging.
2. Methods
Participants currently playing in the National Basketball League
(the elite male basketball league in Australia) aged more than 17
years were included. Data were collected at the commencement of
the competitive season. Ethics was approved by a university ethics
committee and all players provided informed consent.
59
An online questionnaire was used to collect demographic player
data (date of birth, self-reported height [m] and body mass [kg]),
self-reported current or previous patellar tendinopathy and years
playing basketball (defined as “competitive with a referee”).
2.1. Questionnaires
Participants completed a modified OSTRC questionnaire to ask
about patellar tendon problems (Table 1). Questions were scored
using the methods described by (Clarsen et al 2014) and questions
were summed for a total OSTRC score. The total score possible
ranges between 0 and 100; 0 represents full participation without
pain or symptoms. Injury in this study was defined as a score >0 on
the OSTRC as outlined in Table 1.
Participants also completed the Victorian Institute of Sport e
Patellar tendon (VISA-P) questionnaire (Visentini et al., 1998) that
was used to assess pain severity and function, with a score of 100
representing no limitations.
2.2. Pain provocation testing
The single leg decline squat (SLDS) was used as a pain provo-
cation test for the anterior knee. Instructions were standardised for
all athletes. Participants stood on a 25 board with their back
against the wall and squatted on each leg to a range that provoked
pain, or to 90 knee flexion if they had no pain. Participants self-
reported a pain score on a numerical rating scale (NRS) from 0 to
10 when performing the SLDS, with 0 being no pain. Pain with
provocation testing was defined as a score >0 on the NRS during the
SLDS.
2.3. Pain location
If participants reported pain during SLDS, they were asked to
select one or multiple image/s that best represented where they
experienced knee pain during the SLDS. These images were based
on previous research into knee pain mapping (Thompson et al.,
2009) and piloted prior to use in this current study. The patella
was outlined on each image to orientate the participants to the
anatomy. If there was no picture or combination of pictures that
identified the athlete’s pain location, participants were instructed
to select ‘other’.
Pain map location was dichotomised a priori into focal or diffuse
pain groups for analysis. Focal pain was defined as pain no more
than two finger widths(~2e3 cm) in surface area (F, G, H: Fig. 1),
and diffuse pain was defined as pain greater than two fingers width.
The selection of more than one image when reporting pain was
classified as diffuse pain (A, B, C, D, E, I, or >1 image: Fig. 2).
2.4. Imaging
Ultrasound tissue characterisation (UTC) scans were performed
bilaterally to classify patellar tendon structure as normal or
abnormal. UTC scans were taken with participants lying supine,
with the knee bent to ~120 degrees of knee flexion. A 5e12Mhz
linear US Probe was used (SmartProbe 12L5, Terason 2000þ, Ter-
atech, Burlington, USA) on a customised UTC tracking unit (UTC
tracker, UTC Imaging, Stein, the Netherlands). The ultrasound probe
was placed perpendicular to the patellar tendon. The tracking unit
moves from proximal to distal along the patellar tendon and cap-
tures 600 transverse greyscale images at intervals of 0.2 mm. A
single experienced investigator completed all scans. A separate
investigator graded patellar tendon abnormality (PTA) on imaging
who was blinded to all clinical testing and questionnaire data and
had excellent reliability when compared with the single
60 M. Hannington et al. / Physical Therapy in Sport 43 (2020) 58e64

Table 1
Modified OSTRC questions for patellar tendinopathy.

Have you had any difficulties PARTICIPATING in normal training and competition due to patellar tendon problems during the past week?
Full participation without patellar tendon problems (0)
Full participation, but with patellar tendon problems (8)
Reduced participation due to patellar tendon problems (17)
Cannot participate at all due to patellar tendon problems (25)
To what extent have you REDUCED YOUR TRAINING VOLUME due to patellar tendon problems in the past week
No reduction (0)
To a minor extent (6)
To a moderate extent (13)
To a major extent (19)
Cannot participate at all (25)
To what extent have patellar tendon problems AFFECTED YOUR PERFORMANCE during the past week
No reduction (0)
To a minor extent (6)
To a moderate extent (13)
To a major extent (19)
Cannot participate at all (25)
To what extent have you experienced patellar tendon pain related to your sport during the past week
No pain (0)
Mild pain (8)
Moderate pain (17)
Severe pain (25)

Fig. 1. Focal pain map locations. Fig. 2. Diffuse pain map locations.

experienced investigator (ICC ¼ 0.98, 95% CI 0.662 to 0.998). Clas-
sification of PTA was defined a priori as the presence of a hypo-
echoic region on greyscale ultrasound image produced by the UTC.
2.5. Data analysis
For participants with unilateral pain, the painful side was
selected for inclusion. For participants reporting bilateral pain, the
side with higher NRS for pain on the SLDS was used, if equal
bilaterally, a coin toss was used to select the side included for data
analysis. Coin toss was also used for participants with no pain.
Inferential statistics were reported to compare outcome mea-
sures between those reporting symptoms (score >0 on NRS) and
those who did not. The Shapiro-Wilk test for normality was
completed using SPSS (SPSS version 25, IBM® SPSS®). Data were
identified as not normally distributed, therefore medians and
ranges were reported and Mann-Whitney U test were employed to
compare participant demographics between those with focal and
diffuse pain on the SLDS. Significance was set at p ¼ 0.05. Data
analyses were conducted using SPSS (SPSS version 25, IBM®
SPSS®).
 M. Hannington et al. / Physical Therapy in Sport 43 (2020) 58e64
3. Results
Six out of eight teams in the Australian National Basketball
League (NBL) participated. Therefore, 60 of possible 72 (83.3%) male
elite basketball athletes were included in the current study
(Table 2).
3.1. Self-reported patellar tendinopathy and tendon abnormality
Thirty-two participants (53%) self-reported a history of PT.
Thirteen participants (22.7%) self-reported current PT using the
OSTRC questionnaire. All 13 athletes who reported current PT had
also reported a history of PT. Sixty-two (62%) of athletes had
patellar tendon abnormality of one or both patellar tendons.
3.2. Pain mapping of self-reported patellar tendinopathy
Ten out of the 13 participants (77%) who self-reported PT on the
OSTRC also reported pain on the SLDS. Of these 10 participants, five
participants described ‘focal’ pain presentation, 3 of reported their
pain localised to the inferior pole of the patella, and five partici-
pants described their pain as ‘diffuse’ pain (1 had missing pain map
data). Two participants reporting PT symptoms on OSTRC did not
self-report any pain on the SLDS (Fig. 3).
3.3. Single leg decline squat and pain mapping
Thirty participants (50% of the cohort) reported pain on the
SLDS; ten (33%) reported diffuse knee pain, 15 (50%) reported focal
pain and five had missing pain map data. Of the 15 participants self-
reporting focal pain, 27% (n ¼ 8) reported localised inferior pole
pain (Table 3). Five participants who reported pain had missing
data for pain location. The three most common locations of pain
were localised pain at the inferior patella pole (pain map G) (n ¼ 8,
30%), localised pain at the superior patella pole (pain map F) (n ¼ 6,
20%), and diffuse pain over the patella (pain map A) (n ¼ 5,17%,
Table 3; Fig. 4).
3.4. Pain location and demographics
Participants with diffuse pain had been playing basketball for a
greater number of years than those with focal pain. There were no
significant differences in height or symptom severity using the
VISA-P between pain focal and diffuse pain groups. Symptom
severity using the NRS during the SLDS was similar between
groups. There were similar prevalence rates of PTA found on im-
aging found between pain subgroups (Table 4).
4. Discussion
We found a high prevalence of self-reported PT using the OSTRC
questionnaire in a male elite basketball cohort. Although many
participants reported PT, there was heterogeneity in the pain
Table 2
Participant demographics.
Age (median, range) 25.0 (18e35)
Height (median, range) 198.0 (180e211)
Number of years of basketball playeda (median, range) 18 (1e26)
Trainings per week last month (median, range) 5.0 (3e10)
Games per week last month (median, range) 2.0 (1e8)
Patellar tendon abnormality (Unilateral) (n,%)b 9 (15%)
Patellar tendon abnormality (Bilateral) (n,%)b 27 (47%)
a
n ¼ 59 due to missing data (1 did not report).
b
n ¼ 58 Missing Data (2 UTC scans with image error).
61
Fig. 3. Pain location with PT symptoms as reported on OSTRC.
location using pain mapping during the SLDS with few athletes
localising their pain to the inferior pole. That is, there was disparity
between the high prevalence of self-reported PT and the low
prevalence of localised inferior pole pain during provocation
testing. Interestingly, the SLDS test was highly provocative causing
anterior knee pain in half the cohort.
The definition or inclusion criteria for PT is an interesting
consideration. If PT is diagnosed using self-report, we found a high
prevalence of PT within this cohort. Similarly, if PT is diagnosed
using pain on the SDLS, our prevalence was also reported to be high.
Further, if pathology of the patellar tendon on imaging is consid-
ered a key component for diagnosis, our prevalence in this cohort
supports previous literature (for example (Agel et al., 2007; Cook
et al., 2000; Zuckerman et al., 2016; Zwerver, Bredeweg, & van
den Akker-Scheek, 2011). However, when specifically asking par-
ticipants who self-reported PT about their pain location during a
pain provocation test, we revealed heterogeneity that warrants
further exploration. Localised inferior pole pain is frequently re-
ported as a key diagnostic sign for PT (de Vries, van der Worp,
Diercks, van den Akker-Scheek, & Zwerver, 2015; van der Worp,
van Ark, Zwerver, & van den Akker-Scheek, 2012) therefore, the
clinical and research implications are that adding a pain location
measure to a pain provocation test is critical.
Pain mapping may be a useful tool to examine variability of
anterior pain in clinical presentations. Previous research into knee
pain in other population groups has sub-grouped pain presentation
by location to assist in diagnosis and guide treatment (Elson et al.,
2011; Post & Fulkerson, 1994; Thompson et al., 2009). This research
highlighted that diffuse pain presentations have typically been
attributed to patellofemoral pain and tibiofemoral pain (Boudreau
et al., 2018), and are not reported to be a feature of PT. Recent
research examining patient reported pain mapping in patellofe-
moral pain has also found that diffuse and varied pain was common
(Boudreau et al., 2018; Matthews, Rathleff, Vicenzino, & Boudreau,
2018).
Allowing participants to self-select from multiple pain map
images during the SLDS allowed us to capture the variation in
clinical presentations within this cohort. Studies that simply report
the presence of tendon pain (yes/no), may fail to capture these
additional pain locations that may be assistive in diagnosis. This
highlights the potential importance of obtaining patient reported
pain location and the challenges with differentially identifying
contributors to pain (Matthews et al., 2018).
Self-reported PT prevalence using the OSTRC in this study
showed that PT was an injury burden but has some limitations.
Results from this study suggest that more than one fifth of a team
(three athletes per team of 12) are impacted by self-reported PT.
62 M. Hannington et al. / Physical Therapy in Sport 43 (2020) 58e64

Fig. 4. Pain map locations

Table 3 for capturing injuries based on anatomical location (Clarsen et al.,

Pain mapping locations with single leg decline squat.
Pain location Number
A 5
B 0
C 1
D 0
E 0
F 6
G 8
H 1
I 1
>1 LOCATION 3 assist with diagnosis for research purposes. Since the imple-
No Pain 30
Missing Data 5 validated a version of the OSTRC for use in diagnosis of PT (OSTRC-
This is higher than that reported in previous research (Agel et al.,
2007; Cook et al., 2000; Zuckerman et al., 2016; Zwerver et al.,
2011), and in an elite basketball population (Drakos et al., 2010).
Similar to our findings, research by Weiss, McGuigan, Besier, and
Whatman (2017) used the OSTRC to capture burden of knee
injury in a single professional men’s basketball team and found an
average weekly prevalence rate of 24%. The OSTRC was developed
2013); (ie knee, lower back, shoulder), however has not been
used extensively for specific pathology and diagnosis. Docking et al.
(2018) adapted the OSTRC to quantify tendon injuries in an elite
Australian Football population and found increased burden of
injury reported over the course of the season using the OSTRC
when compared with time-loss measures. However, as the OSTRC is
not diagnostic in nature, the prevalence of PT may be over-
reported.
Combining non time-loss measures with knee pain location may
mentation of this research, Owoeye et al. (2018) have adapted and
P). The OSTRC-P has added additional questions including location,
acuity and mechanism of injury. The OSTRC-P has been used to
examine the burden of PT in youth basketball athletes with a
positive predictive value of 95% (95% CI: 83%, 99%) when compared
to clinical diagnosis (Owoeye et al., 2018). The focal nature of PT and
validity of this adaption to the OSTRC suggests that knee pain
location may be a useful when measuring burden of PT in this
population group.
Focal and diffuse pain presentations had a similar scores in

Table 4
Differences between focal and diffuse pain groups on SLDS (n ¼ 55).

No Pain (n ¼ 30) Focal Pain (n ¼ 15) Diffuse Pain (n ¼ 10) p

Age (median, range) 25 (18e35) 24 (21e31) 29(23e33) 0.015a

Height (median, range) 197 (185e211) 198 (180e211) 202 (194e211) 0.200
Years Played (median, range) 18 (1e25) 12 (7e26) 21 (13e24) 0.042b
VISA P (median, range) 89.7 (10.5) 74.7 (14.7) 77.7 (17.62) 0.637
NRS (median, range) 0 (0e0) 5 (1e7) 5 (1e9) e
OSTRC >0 2 5 5 e
Patellar tendon abnormality (Selected side) 14 9 8 e
Patellar tendon abnormality (Bilateral) 11 8 7 e
a
Age U ¼ 31.5, z ¼ 2.4, p ¼ 0.015, r ¼ 0.3.
b
Years played U ¼ 38.5, Z ¼ 2.03, p ¼ 0.042, r ¼ 0.3.
 M. Hannington et al. / Physical Therapy in Sport 43 (2020) 58e64
outcome measures such as the VISA-P and total OSTRC score, sug-
gesting these outcome measures may not be specific to PT. Though
the SLDS and VISA-P have often been used to identify, examine and
measure severity of patellar tendon symptoms (Mendonca Lde
et al., 2016; Purdam et al., 2003), it appears they may capture a
heterogenous group. There are two possible explanations; (1) PT
exhibits heterogeneity and pain spread, or (2) these tests have
identified multiple clinical presentations of different knee condi-
tions such as patellofemoral pain. Future studies should aim to
capture the heterogeneity of presentations and then determine if
this is important when intervening in players with anterior knee
pain.
With no gold standard for diagnosis of clinical presentations of
knee pain or the inclusion criteria for research, that is; asymp-
tomatic pathology is common, palpation may not be specific and
our pain provocation tests may aggravate a variety of conditions,
perhaps capturing features of pain such as spread will progress our
understanding of what is important to measure.
4.1. Strengths and limitations
This study asked athletes to self-report their history of PT and
examined non time-loss measures of PT in an elite basketball
cohort. Given athletes have been found to be reliable in reporting
pain location (Rio et al., 2018), capturing knee pain presentation
and severity during provocation testing enabled us to gather
athlete reported knee pain mapping in a cohort of people who
believed they had PT. The OSTRC questionnaire has not been used
or validated to examine the prevalence of specific injury and cannot
be used to measure prevalence of PT in isolation. Prevalence of PT
collected using the OSTRC can therefore only be classified as ‘self-
reported’ PT and this is a limitation. In addition, participants were
not asked to formally identify other sources of knee pain.
Further research is needed to examine symptom prevalence
over the course of the season, and should include and compare
athletes from other elite basketball leagues due to potential vari-
ability in demographics and overall workload. The addition of
outcome measures for other sources of knee pain would strengthen
understanding of the clinical presentations in this cohort and assist
in further isolating the true burden of PT in elite basketball athletes.
Despite a higher prevalence of PT being reported in male athletes in
the literature, future research should include elite female athletes
at this level to compare differences between genders.
5. Conclusion
Many elite male basketball athletes self-report PT. However,
when focal pain location during a load test was used as a primary
definition of PT, “jumpers’ knee” was not common in this cohort.
Athletes who self-report PT had heterogeneous pain locations.
Despite high prevalence of self-reported PT using the OSTRC and
SLDS methodology, we may need caution around PT diagnosis. The
SLDS is a pain provocation test that appears to aggravate many
anterior knee pain conditions. Other clinical presentations of
anterior knee pain may be more common than what has been
described in elite jumping athletes, including patellofemoral pain.
Understanding whether pain location is important in separating
responders and non-responders to interventions could help target
treatment and reduce the burden of knee pain in this population
group.
Conflicts of interest
None Declared.
63
Ethical approval
This study was approved by the La Trobe University Human
Ethics committee. All participants included in this study provided
informed consent.
Funding
This work was supported by a combined grant from the National
Basketball Association (NBA) and General Electric (GE) Healthcare.
Acknowledgments
A special thank you to all the physiotherapists from the teams
involved in this study. This research was associated with La Trobe
Sport and Exercise Medicine Research Centre which is part of the
Australian IOC centre of research excellence for the prevention of
injuries and promotion of health in athletes. Dr Ebonie Rio is sup-
ported by an NHMRC early career fellowship.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.ptsp.2020.01.012.
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