INJECTION THERAPY FOR PATELLA TENDINOPATHY

What is Patella tendinopathy (also known as Jumper’s  knee?)

Patella tendinopathy is a common overuse condition that causes discomfort and soreness in the front of the knee tendon. The quadriceps tendon connects your thigh muscles to the bone at the top of your shin (known as the tibia). Any activity that requires a big quadriceps muscular contraction, such as squatting, lunging, and especially impact movements like hopping, jumping, and sprinting, aggravates it. Pain is frequently better during activity and worse afterward.

The gold standard imaging modality for diagnosing patella tendinopathy and visualising if there is a tear is diagnostic ultrasonography. This is done at no extra charge during your initial appointment with Joint Injections.
 
Patella tendonopathy does not usually require complete rest. Stretching has also been proved to be ineffective in returning you to sport. The most effective treatment for patella tendinopathy is physiotherapy, which includes heavy slow resistance (HSR) training and activity moderation. Shockwave therapy combined with physiotherapy is another successful therapeutic option. If your discomfort persists after you’ve completed your physiotherapy and shockwave treatments, a high-volume saline injection may be an alternative.
 

What are the symptoms of Patella tendinopathy?

  • When you press the tendon at the front of your knee, just behind your knee cap, you will feel pain.
  • Impact activities such as running and jumping cause pain.
  • Pain that gets better with activity but gets worse afterward.
If this sounds like your issue, keep reading…
 

Other conditions that are associated with Patella tendinopathy

  • Meniscal (cartilage) tear
  • Knee osteoarthritis is a type of arthritis that affects the knee joint.
  • Pain in the patellofemoral (knee cap) joint
  • Bursitis of the prepatella
  • Tendonitis of the pes anserine
  • Inflammation of the fat pads

Patella tendinopathy vs Patellofemoral (kneecap) pain

Patella tendinopathy causes pain in the front of the knee at the lowest aspect of the patella (knee cap), which is painful when you press the tendon. When you push the knee, patellofemoral joint discomfort causes more diffuse (widespread) pain on the front of the knee with no evident painful regions. Pain from patella tendinopathy usually worsens after an exercise rather than during it. Pain in the patellofemoral knee joint is usually severe during activity and lessens afterward. Impact activities like sprinting and jumping, as well as going downstairs, aggravate both diseases.
 

What is Patella tendinopathy

Tendinopathy is thought to be responsible for a major fraction of all musculoskeletal disease that requires medical attention (Resteghini et al., 2016).

 Patella tendinopathy, sometimes known as jumper’s knee, is mostly a result of overuse. Through the action of the knee extensor mechanism, the patellar tendon is subjected to significant degrees of stress. It is a common place for discomfort and damage, particularly in the sporting community. According to studies, patella tendinopathy affects up to 14-16 percent of all athletes who participate in sports that require jumping, such as volleyball and basketball (Cong et al., 2016).
 
The patellar tendon can become inflamed and uncomfortable if it is subjected to repeated periods of high-intensity activity, such as leaping. Tendinitis is a condition in which a tendon becomes inflamed and painful. If the patellar tendon is repeatedly subjected to tendinitis, it is unable to fully recover, resulting in an incomplete, sub-optimal healing response. A pathologically weak and thickened tendon is the result of inadequate tendon repair. Tendinopathy is the medical term for a weak and thickened tendon. A pathologically weak tendon can result in significant pain and impairment, as well as tears in severe cases (Cong et al., 2016).
 

Anatomy of Patella tendon:

Between the bottom of your patella (kneecap) and the top of your tibia is the patella tendon (long bone of the shin). The patella tendon, which is positioned just above the patella, is a continuation of the quadriceps tendon. It connects to the quadriceps muscle, which is a big muscle in the front of your leg (see the below image).
 
The quadriceps muscles, quadriceps tendon, patella, and patellar tendon are all part of the knee extensor mechanism, which is responsible for extending (straightening) your knee when running and jumping.
 

Jumper’s knee is a type of tendonitis that affects three different parts of the knee extensor mechanism (Dan et al., 2018).

According to Dan et al. (2018), the following tendon diseases (seen below) are related with Jumper’s knee:

  • The quadriceps tendon joins to the highest portion of the patella, causing insertional quadriceps tendinopathy. In 25 percent of all cases of jumper’s knee, insertional quadriceps tendinopathy has been recorded.
  • Proximal patella tendinopathy (also known as inferior pole tendinopathy) — the patella tendon originates at the ‘inferior pole’ on the bottom of the patella. According to studies, proximal patella tendinopathy is responsible for 65 percent of all jumper’s knee pain. At Joint Injection’s, we notice this as the most typical cause.
  • Distal patella tendinopathy (also known as tibial tubercle tendinopathy) — the patellar tendon inserts in the tibial tubercle, a tiny bony protrusion at the top of the tibia that accounts for about 10% of all jumper’s knee cases.

The rest of this article focuses on the most common condition of the three; proximal patella tendinopathy

The following are some of the most common risk factors for tendonopathy:

  • Running, squatting, climbing, and jumping are examples of sports that require repetitive, high-intensity knee extension.
  • Tendinopathy is most typically encountered in people in their forties and fifties.
    Patella tendinopathy is more frequent in men than in women.
  • Muscle weakness or tightness can cause muscular imbalances. The biomechanics around the knee can be altered, resulting in patella tendon overload and tendinopathy.
  • Inadequate sport preparation — if your tendon has not been properly prepared for the increasing demands of sport, it may be vulnerable to injury.
  • Tendonopathy can be avoided with sport-specific strength training and an effective warm-up.
  • Starting a new sport and raising the frequency or intensity of your exercise too rapidly are examples of sudden changes in activity levels.
  • Increased weight (high body mass index (BMI)), high cholesterol, diabetes, and other metabolic disorders have all been linked to tendonopathy.

How do we know if you’ve patella tendinopathy?

Symptoms of tendon overload often appear gradually, without damage, and can require months of repetitive overloading before becoming serious.

Patella tendinopathy can cause the following symptoms:

  • Just below the knee cap, there is a pain.
  • Increased amounts of exercise, such as walking, running, or jumping, exacerbate the pain.
  • Pain is frequently exacerbated by physical exercise.
  • Pain after waking up from a long period of rest, such as when getting up from your desk or getting out of bed in the morning.
  • Having difficulty navigating stairwells and inclines.
  • Stiffness in the morning — your knee may feel stiff in the morning. The stiffness usually goes away after an hour.

How is patella tendinopathy diagnosed?

It’s critical to have a precise diagnosis of jumper’s knee. It enables your doctor to choose the most effective treatment plan for you. Your clinician will make a diagnosis after doing a thorough clinical examination and a diagnostic ultrasound scan.

The following items are frequently included in clinical evaluations:

  • An in-depth clinical interview — your physician will ask you a series of questions to assist create a hypothesis about why you are experiencing pain. Questions will be asked about why your pain began, how long you’ve had it, what aggravates your symptoms, and what relieves your symptoms. A complete medical history will be recorded as well. This is to rule out any medical illnesses that could be causing your pain, such as rheumatoid arthritis-related systemic inflammation.
  • Physical examination — Your clinician will examine your knee using a battery of tests that include joint range of motion, muscle flexibility and strength, and palpation of various structures around the knee. Your physician may also ask you to complete a series of simple functional exercises, such as single-leg balance, single-leg squatting, lunging, and jumping. They may examine your walking and running patterns as well.

A patella tendonopathy can usually be diagnosed based on a clinical examination. A clinical examination, on the other hand, is limited in terms of providing more information on the tendon structure and surrounding tissues. This is especially critical if your symptoms aren’t improving.

Ultrasound imaging of the musculoskeletal system for diagnostic purposes

On your first visit, a diagnostic ultrasound scan is performed to obtain further information. The following questions will be answered by a scan:

1. What is the severity of the tendonopathy?
2. Is a tear in the tendon present?
3. Is the bursa that surrounds it inflamed?
4. Is there any fat pad inflammation?
5. Is it possible that additional structures, such as the meniscus, are involved? (cartilage in the knee)

Tendon anatomy and inflammation linked with tendinopathy can be assessed with a diagnostic ultrasound scan. The gold standard imaging tool for examining tendon anatomy and disease is ultrasound (Dan et al., 2018). It provides a better view of the tendon’s interior structure than an MRI scan.

The clinicians at Joint Injections are all highly skilled physiotherapists and musculoskeletal sonographers. During your initial evaluation, you will be given a formal diagnosis based on a mix of clinical examination and diagnostic imaging, and the doctor will be able to prescribe the best treatment for your illness.

How do we treat patella tendinopathy?

Patella tendonopathy is notoriously difficult to rehabilitate, so it’s critical to start treatment as soon as possible (Cong et al., 2016). Jumper’s knee rehabilitation necessitates the use of a specialist physiotherapist who can use any of the following techniques:

  • Advice on how to modify your activities to allow the patellar tendon to rest and heal properly.
  • Exercises to strengthen the hips and knees. Heavy slow resistance (HSR) workouts have been demonstrated to help with patellar tendinopathy in studies (Kongsgaard et al, 2009).
  • Biomechanical re-education — this could include learning how to squat, run, or jump properly.
  • Your clinician may use soft tissue manipulation techniques or acupuncture to help alleviate any pain that is making your rehabilitation exercises difficult to complete.
  • During sports, advice on taping or wearing a patellar tendon support.
  • According to research, a three-month rehabilitation programme for patella tendonopathy should be completed before contemplating further treatment options such as injections or shockwave therapy.

What if PT isn’t effective?
Physiotherapy will always remain the cornerstone of your treatment, however there are other choices available to help you progress if needed:

Extracorpeal shockwave Therapy 
Shockwave therapy uses a succession of high-intensity sound waves to provide a regulated dose of microtrauma to the patella tendon. Shockwave has been demonstrated in studies to enhance the natural healing mechanism of tendons, so commencing a new healing phase. These pulses desensitise local nerve terminals surrounding the injured tendon, resulting in pain relief and symptom decrease.

Recent research suggests that 3-5 shockwave treatment sessions combined with a progressive loading exercise programme for the treatment of all lower limb tendinopathies result in positive results (Zwerver et al, 2010).

Injection Therapy 
If your pain has persisted for more than three months and physiotherapy hasn’t helped, you may be a candidate for injectable treatment. Injection therapy has long been utilised in musculoskeletal medicine to alleviate pain and inflammation, allowing you to recover your condition more efficiently.

It’s especially useful in the following situations:

  • Your pain is preventing you from sleeping or waking you up during the night.
  • Your pain is making it difficult for you to carry out normal daily tasks or participate in sports or leisure activities.
  • Your pain is making it difficult for you to complete your rehabilitation routines.
  • Your pain is growing worse, or you’ve reached a stalemate in your development.
  • You’ve been on a three-month rehabilitation programme with little or no results.

Patella tendonopathy can be treated by stripping procedure.

1. High-volume injection guided by ultrasound

The internal structure of the patellar tendon is weakened when it becomes tendinopathic. The process of neovascularisation is triggered by tendonopathic alteration. The formation of new blood vessels within and around the tendon is known as neovascularisation. The nerves that accompany these new capillaries are quite tiny. Some of the discomfort associated with patella tendinopathy is thought to be caused by these tiny nerves.

To eliminate these little arteries and nerves and relieve pain, an ultrasound-guided high-volume injection employs a combination of saline (sterile water) and a local anaesthetic. This method has been used for over a decade and has some evidence to back it up (Barker-Davies et al, 2017). A tiny amount of corticosteroid (also known as steroid) may be administered to the injection on rare occasions. Steroid is a powerful anti-inflammatory that should only be used in the most irritated and inflamed situations.

Recent study has raised questions about the use of steroid injections to treat patellar tendonitis. This is because there is a tiny danger of tendon rupture after the procedure, hence corticosteroid injection should be used sparingly (Resteghini et al., 2016). Following your assessment and ultrasound scan, the use of steroid in your unique instance will be considered.

Ultrasound guiding is vital for ensuring injection precision and limiting any potential side effects. Patients who experience less procedural pain tolerate ultrasound-guided injections better. All injection techniques at Joint Injection’s are done using ultrasound guidance to guarantee you get the most benefit with the least amount of discomfort.

Joint Injection’s experts are dual-trained, highly specialised physiotherapists and musculoskeletal sonographers with extensive experience diagnosing all knee disorders. We provide a ‘one-stop’ clinic, which means you’ll get an examination, a diagnostic ultrasound, and, if necessary, an ultrasound-guided injection.