Patellar Tendonitis

Is the use of this popular summer footwear causing foot, ankle or even knee pain?

By Dr. Chad M. Pens

Now that summer is officially here, many of you will be wearing your sandals more frequently. When it comes to simplicity, style, and allowing the feet to be cool, the “flip flop” is usually a popular choice. Although flip flops may look good, they are not very good for your feet. There are a number of orthopedic overuse issues that can arise due to frequent use of this type of footwear. The problems flip flops present are the lack of support to the arches of the foot, they lack of proper cushioning, and they change the way people walk..

As we reach the middle of the winter sports season, where basketball, track, hockey and others are in full swing, complaints of pain in the front of the knee that is often aggravated by activity become more prevalent. So often these pains are attributed to "just tendonitis." To say that the pains in the front of the knee are tendonitis is possible, but to minimize the severity of such an injury is an injustice. Anterior knee pain originating from the patellar tendon is known as patellar tendonitis, or jumper's knee. Patellar tendonitis is an injury to the patellar tendon. The patellar tendon connects the quadriceps muscle group (thigh muscles) and the kneecap (patella) to the lower leg (tibia). This tendon is involved every time you attempt to straighten your legs including kicking a ball, running, jumping, or simply standing up or climbing stairs. The patellar tendon can become irritated or inflamed because of overuse. It can become a source of pain most commonly in athletes whose sports involve running and jumping, like basketball, football, track, soccer, volleyball, and several others. For this reason, it has also been termed "jumper's knee." However, patellar tendonitis can affect anyone, whether your daily activities involve frequent jumping or not.

What are the symptoms of patellar tendonitis?

Patellar tendonitis produces pain in the front of the knee (anterior knee pain) directly over the tendon itself. Painful activities that have been associated with patellar tendonitis are running, jumping, kneeling, squatting, and stairs. The tendon is often painful to the touch and becomes sore after prolonged periods of rest or sitting. There are occasionally complaints of clicking in the front of the knee with use. The pain from patellar tendonitis can var y depending on the stage of injury. In the early stage of tendinopathy, the pain will only present after exercise, typically when the activity is vigorous. The second stage is where the pain in the knee onsets with activity and can often worsen with continued activity. The third stage is where the knee pain is present at all times, at rest and with activity. X-ray tests are typically ordered to rule out any problems with the underlying bone structure. In chronic cases of patellar tendonitis, an MRI can be useful to identify areas of degeneration within the tendon.

What does the rehabilitation process entail?

Given that patellar tendonitis is an overuse injury, the first intervention is to create some form of relative rest. This can be accomplished by modifying the volume or intensity of the exercise work load. Then it is essential that the physical therapist identify any predisposing factors that might have led to the breakdown of the tendon. The most common deficiencies that lead to patellar tendonitis are inflexibility and/or weakness of the quadriceps muscle group. Weakness and inflexibility of the hamstrings, the calf or the glutes (buttock muscles) can also be contributing factors. The presence of flat feet can cause overpronation, which causes altered biomechanics at the knee with running or jumping activities. This may require corrective orthotics or simply an arch support, but a medical professional will determine which is appropriate for you.

Unfortunately, athletes often attempt to deal with tendonitis without appropriate treatment, when conservative treatment in the form of physical therapy has been found to be the most effective. When it comes to rehabilitation, the plan of care will be determined by the physical therapist based upon the detailed evaluation, addressing one's specific concerns, whether it is weakness, flexibility, orthotics, etc.

The use of physical therapy modalities, such as ultrasound or in some cases iontophoresis, can aid in the reduction of inflammation and reduction of pain. Electrical stimulation can be used to facilitate a targeted strengthening program while controlling for pain. The use of anti-inflammatory medications and ice is also quite useful for relieving discomfort and swelling. Be sure to talk to your physician before starting any medicine. The use of a brace known as a chopat strap can be quite useful to control discomfort during practice, games or even just during walking and climbing stairs. However, it is necessary that specific exercises are performed to address the reasons for the pain, because by ignoring the source of problem the pain will only get worse potentially leading to more damage to the tendon. When a conservative treatment program is successful and the individual has returned to pain free activities, it is important that a continued program of stretching and strengthening should be followed to avoid a reoccurrence of the problem.

Recent published literature has argued whether the patellar tendon is actually inflamed, which is the more conventional thought process, or has the tendon become degenerative. The degenerative nature of tendon injuries (tendonosis) influences the rehabilitation process. Rehabilitation approaches operating on the premise of tendonosis have shown to be very effective in allowing individuals to return to their prior level of function without pain. As a very last option, the presence of scar tissue or a large degenerative portion of the tendon may inhibit the success of a conservative rehabilitation program necessitating surgery to arthroscopically remove this area of the tendon.

This condition can often be confused with pain coming from the underside of the kneecap (patella) known as patellofemoral pain syndrome (PFPS) or chondromalacia patellae (CMP). Patellofemoral pain syndrome and CMP will have specific clinical findings that aide in its diagnosis. Therefore, it is essential that you consult with your physician or a physical therapist to determine what the source of your knee pain is, and more importantly to get you started on a rehabilitation plan of care to resolve the painful condition.