Member Case Study: Acute and Chronic Patellar Tendonosis

author : AMSSM

comments : 1

My symptoms have been present off and on for almost two years. Is this a surgical problem, or should I just keep managing it for as long as I can?

Member question from Run4Life

I have had a nagging problem with acute and chronic patellar tendonosis. My symptoms have been present off and on for almost two years. During that time I have taken two three-month periods off running to try and heal. Each time off I have felt much better and my symptoms went away. Unfortunately, when I have returned to running, my knee pain returned. I have seen two orthopedic surgeons and been through therapy. I have increased my stretching and am now really working on strengthening my legs with the hope of overcoming some of the problems I have had. I routinely ice my knee after workouts. I also tried to modify my running form from a traditional heel strike to more of a mid foot landing with a little bit of success.

Currently, I can run one or two times a week conservatively and manage my symptoms OK. Biking doesn’t seem to exacerbate anything. I am looking towards training for a half-Iron distance race, and consequently will need to increase my running. I was wondering if you had any suggestions for addressing this problem in a more definitive manner. Is this a surgical problem, or should I just keep managing it for as long as I can?

Answer by Chad Asplund, M.D.

Member AMSSM

Introduction
Recurrent anterior knee pain can be frustrating, and may be caused by a variety of factors. Patellar tendonitis initially is caused by swelling in the patellar tendon and later thought to be from degenerative changes to the tendon (tendonosis); it is generally not due to inflammation. Given the chronic nature, your pain is likely due to patello-femoral joint dysfunction and not from an active inflammatory process.

Case
Since your pain returns primarily when you resume run training, it would be a good idea to have a foot type and gait analysis done by a sports medicine provider. If you have flat feet or if you overpronate, you are placing additional stress on your patella and may benefit from shoes that control excess foot motion (stability or motion control shoes), or from arch support insoles to limit excess pronation. Although you are not having pain with bicycling, incorrect position on the bike may also be contributing.

I would recommend having your bicycle fit analyzed. Typical culprits causing anterior knee pain in bicyclists are those who have the saddle too low, crank arms that are too long or improper alignment at the shoe-cleat-pedal interface (typically internal rotation of the cleats). Finally, as triathlon also includes swimming, excess breast stroke or too many kick drills place undue stress on the anterior knee and should be minimized during your rehabilitation period.

Treatment
As this injury has no inflammatory component, it is illogical to use non-steroidal anti-inflammatory medication. Likewise, there is no proven benefit from anti-inflammatory modalities (such as ultrasound therapy). You may get some pain relief from the use of a tendon unloader brace (i.e. Chopat Strap). This, is not the definitive treatment, but may serve as a bridge while you work to increase your quadriceps strength and correct your biomechanics. You may also do deep water running while rehabilitating your knee.

Rehabilitation
The most important rehabilitation exercises for anterior knee pain are quad strengthening exercises, especially eccentric strengthening (exercises which strengthen the muscle while it lengthens). There has been a lot of published work on the benefit of eccentric exercises and in my practice I have seen significant benefits to the athletes I treat. The key to the rationale behind eccentric drills is that they are the best way of promoting tendon remodeling: the regrowth and reordering of collagen tissue in place of the edematous (fluid filled) degenerative tissue typical of tendinosis.

The eccentric exercise of choice for patellar tendonosis are decline squats.

Table 1: Decline squat progressions

The movement down must be done slowly (to a count of three) and the return can be done quickly (to a count of one). When away from home, the slope can be replaced by the edge of a curb or step so that opportunities can be taken whenever possible to do the drills.

The number of repetitions is determined by the amount of discomfort felt in the patellar tendon. I advise athletes to stop a sequence of repetitions when they start to feel pain in the patellar tendon. The rationale for this is to stimulate the patellar tendon eccentrically to a fixed (symptomatic) level each day, but without such effort to produce pain and further damage. I suggest to athletes that they can do these repetitions as often as possible every day and many achieve the repetitions two to four times a day.

Good luck and good running!

Chad Asplund, M.D.
Eisenhower Army Medical Center, Fort Gordon, GA

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date: January 16, 2008