With sports starting to slowly start back up, and young athletes’ eagerness to get back into the gym and work on their skill, we saw a dramatic rise in the number of overuse injuries in our office. Overuse injuries are already common due to the lack of proper load management, plus with the perfect storm of the coronavirus shutdown, athletes have gone from 0 to 100 in a matter of weeks. With proper treatment and early exercise prescription, prevention of long term pain can be achieved. However, a delay in fixing the issue can cause a long nagging injury that never fully goes away. This is especially true in the cases of tendinopathies/tendinitis, and today’s focus will be on the main tendon of the knee.
If you have recently aggravated the area right below your kneecap after a recent increase in activities such as sprinting, jumping, or rapid change of direction. Then you may have aggravated an area called your patellar tendon.
It works in conjunction with your quad to extend your knee and has an enormous amount of capacity for storing energy, and for the release of that energy during explosive movements. However, if it is overworked and becomes damaged it may turn into a condition called patellar tendinopathy. Also known as Jumper’s knee due to the nature of the injury. It is one the most common knee complaints we see with the majority of our young athletes and occurs from excess dynamic loads on the lower extremity such as a basketball player ramping up his time on an older basketball court too quickly after a long offseason. The patellar tendon is not prepared for this rapid increase in explosive movements and thus becomes damaged and weakened. Although sports like basketball and volleyball are the most susceptible to these types of injuries at rates of 32% and 45% respectively due to the hard surface and repeated jumping needed for their sport, other activities may lead to it as well. If you have pinpoint pain just below the knee cap after a recent increase in running, jumping, or working out, then these exercises will be crucial for your recovery.
Why Do Tendinopathies Last for So Long?
The tricky part about treating patellar tendinopathy is that the tendon has a very poor blood supply. So once you damage this tendon, the damaged portion does not fully heal and will be weaker than the rest of the tendon. So the first tip to fixing your jumper’s knee is to not fully rest once you have the knee pain. Taking a break from the activity that initially aggravated the knee may be necessary, but complete inactivity does more harm than good. This damaged tendon will never fully heal from rest alone due to the lack of blood supply and since you can’t fix the weakened part, you have to strengthen the healthy portion. We can accomplish this by loading the tendon in such a way to activate as many fibroblasts as possible to lay down new healthy tendon, without aggravating it further.
The patellar tendon is active during any four of the possible contractions of the quadriceps muscles. We will break these contraction types down from least to the greatest load placed on the tendon:
1. Isometric – Quads are contracted but there is no movement being involved.
2. Eccentric – Quads are being contracted while the muscle is being lengthened.
3. Concentric – Quads are being contracted while the muscle is being shortened.
4. Dynamic – Similar to concentric, but a more explosive movement that causes rapid shortening of the quad (ex. Jumping).
To promote the highest number of fibroblasts while limiting the total amount of strain on the patellar tendon, these exercises will be from the first two categories: isometric and eccentric. A key note on all of these exercises is that there may be slight discomfort over the tendon, which is normal, but as a general rule limit this discomfort to a 1-2 on 10 point pain scale. This concept is reiterated by the International Journal of Sports Physical Therapy, “eccentric exercise should be painful to perform, and when a patient reaches the point that the exercise is no longer painful; the load should be increased to the point that it becomes painful again.” So for the exercises listed below, if they become too easy that there is no longer any discomfort, this means that the resistance needs to be increased. However, if there is an increase in pain 24 hours after the exercises, there was an overload of the tendon and the exercises should be scaled down. So for the next four weeks perform these three exercises every other day and you should begin to notice a drastic decrease in your knee pain. As always, consult with your healthcare professional about whether or not these exercises are right for you. If you have any questions or would like assistance in the treatment of your patellar tendinopathy, please schedule a visit to our office.
The Wall Squat
1. The Wall Squat – 3 Sets of 30-second holds.
Although this may be a throwback exercise that coaches have been known to torture their athletes with, it truly is essential for the treatment of your patellar tendinopathy. It is an isometric exercise that will leave your quads on fire with minimal tendon strain.
Increase resistance: Place a plate on your knees or hold dumbbells in your hands.
Tip: The Long Squat is the preferred method of the two shown since it has the feet farther from the wall which causes less compressive force on the tendon.
Single Leg Decline Squat
1. Single Leg Decline Squat – 3 Sets of 10 Single Leg Squats
This exercise may be difficult if you do not have the slanted board needed to perform, but will provide huge benefits if you can make it work. The focus should be on the controlled descent of the squat which is the eccentric phase of the muscle.
Increase Resistance: Hold dumbbells or increase reps.
Tip: Only perform half a squat to limit the stress placed on the tendon. Make sure the knee goes straight forward during the squat and don’t allow for it cave in towards the opposite knee.
Spanish Squat
1. Spanish Squat – 2 Sets of 20 Second Holds, and 1 set of 8 Squats.
All you need to perform this exercise is a heavy resistance band. Attach it to a secured area such as a weight rack and place the band behind the knees while you perform either an isometric hold or an active squat. You should be able to lean back into almost the same position as the wall squat with the knees behind the toes, back straight, and in a 90-degree squat position.
Increase Resistance: Use a heavier band to pull knees forward or increase the time in the squat position.
Tip: Focus on pushing hips back to avoid knees going over the toes during the squat. When performing the active squat, try to push the band back with your knees by squeezing your quad at the top of the squat position.
References:
Reinking MF. CURRENT CONCEPTS IN THE TREATMENT OF PATELLAR TENDINOPATHY. Int J Sports Phys Ther. 2016;11(6):854-866.
Escamilla RF, Zheng N, Macleod TD, Edwards WB, Imamura R, Hreljac A, Fleisig GS, Wilk KE, Moorman CT 3rd, Andrews JR. PATELLOFEMORAL JOINT FORCE AND STRESS DURING THE WALL SQUAT AND ONE-LEG SQUAT. Med Sci Sports Exerc. 2009 Apr;41(4):879-88.
Needham R.A, Walley C, Bodden J, Walker P, Carter R.A BIOMECHANICAL INVESTIGATION OF A SPANISH SQUAT: THE EFFECT OF TRUNK INCLINATION ON QUADRICEPS ACTIVATION. Center for BiomechaniCs and Rehabilition Technologies. Staffordshire University.
Van Der Worp H, Van Ark M, Roerink S, Pepping GJ, Van Den Akker-Scheek I, Zwerver J. RISK FACTORS FOR PATELLAR TENDINOPATHY: A SYSTEMATIC REVIEW OF THE LETERATURE. Br J Sports Med. 2011 Apr;45(5):446-52.
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