Patellar tendinopathy

Irritation of the patellar tendon

Patellar tendinopathy

What is the patella tip syndrome and how does it develop?

The patella tip syndrome (jumper’s knee, patellar tendonitis) develops when the patellar tendon (patellar ligament) is irritated by unaccustomed or excessive tension forces. For example, in sports that involve intensive jumping (basketball, volleyball), activities that involve many stop-and-go movements (tennis, badminton) or quick changes in direction (football).

The patella tip syndrome is also widespread among runners, which is why it also called jumper's knee or runner's knee1. Thepain is felt around the tip of the kneecap.   

What is patellar tendinopathy and how does it start?

The following synonyms are used for patellar tendinopathy:

  • Patella tip syndrome
  • Runner's knee
  • Jumper's knee

Anatomy of the knee joint

The knee joint is one of the most used joints in the human body. The thigh bone (femur), the shinbone (tibia) and the kneecap (patella) form the bony elements of the joint.

The patellar tendon (patellar ligament) connects the lower end of the kneecap (patella) to the shinbone. Its main function is to transmit forces from the thigh to the lower leg, which is why it is exposed to permanent stress during sports.

Risk factors and causes

Anatomical factors

  • The elasticity of the tendons diminishes with increasing age
  • Malalignment of the knee
  • Foot deformities
  • Shortened tendons or muscles
  • Anatomical anomalies, for example bowlegs, knock knees or a movement disorder (dysmetria)
  • Congenital ligamentous weakness (lax ligaments)
  • A previous history of Osgood-Schlatter disease, a painful condition of the knee joint at the level of the shin bone.

External factors

  • Unsuitable footwear
  • Wrong sporting techniques
  • Excessively hard surfaces, for example asphalt
  • Excessively intensive training sessions
  • Unusual stress, for example. when learning a new sport or when training is started too enthusiastically and the knee is subjected to extreme forces.

Sports

  • Sports that involve intensive jumping– volleyball, basketball, some disciplines in light athletics such as long jump or high jump – which is how it got its name, jumper's knee
  • Jogging – which is why it is also called runner's knee1
  • Sports with rapid changes of direction – football, handball
  • Sports with abrupt stop-and-go movements – tennis, squash, badminton

The various degrees of severity of the patella tip syndrome

Doctors do not normally divide the patella tip syndrome into different stages. This four-part classification helps patients understand the clinical picture better.2

The various degrees of severity of the patellar tendinopathy

 

Initially, the pain is usually only felt after sports. In the further course, the patient develops "start-up" pain and feels pain during exercise, or even during everyday activities such as climbing stairs or after sitting for long periods. The persistent character of the symptoms is typical. It is often a chronic clinical picture that persists for many months or even years. Phases with relatively little pain are repeatedly followed by phases when pain develops again after exercise. Patellar tendinopathy can affect both knees, this occurs in 20 to 30% of patients. The following techniques are used for diagnostic investigation: ultrasound examination of the blood vessels, magnetic resonance imaging (MRI), X-rays.

How patellar tendinopathy is treated

Patellar tendinopathy is usually treated conservatively, i.e. without an operation. Surgical intervention is only needed if the patellar ligament actually ruptures. The following methods relieve pain and can stop progression of patellar tendinopathy.

Physiotherapy exercises

Special exercises strengthen the muscles and increase mobility. They can also boost the healing process when carried out regularly. A doctor can prescribe physiotherapy. Depending on the findings, ultrasound treatment, electrotherapy (TENS), transverse friction (a special form of massage of the affected muscle and tendon fibres), shockwave therapy or manual therapy may be advisable as add-ons.

Stretching

Regular stretching of the muscles over the front of the thigh reduces the tension that acts on the kneecap.

Supports

Special medical supports stabilise the knee joint. Knee supports with a strap system, such as medi's Genumedi PSS, are particularly suitable for a specific reduction of the peak pressure and tension forces that act on the patellar ligament.

Cooling

Mild cold treatments with cold packs relieve pain (refrigerator temperatures of about 7°).

Warmth

A heat pad, a hot water bottle or a massage with a warm towel roll (towel immersed in warm water) promote the circulation around the tendon insertion.

Medication

If necessary, patients may take an anti-inflammatory drug such as ibuprofen or diclofenac for a week or two. But always ask the doctor treating you first.

Ointments

Anti-inflammatory creams or ointments can be massaged into the affected site several times a day. This promotes recovery.

Insoles

Orthopaedic insoles (for example igli Allround Light) correct the body's posture and support the knee joint at every step.

Massages

Massages ease muscular tension and relieve pain. Experienced physiotherapists can relax the muscles with just a few massage strokes and increase the circulation.

Treatment should be adapted to each patient individually to suit his special needs and the exact clinical picture. Patients with postural problems are advised to consult an osteopath.

The "Patella tip syndrome" guide – download

All-in-one physiotherapy programme for patella tip syndrome

Besides the single-leg squats on a 25° decline board described above, further exercises can be done to stabilise the knee joint and strengthen the patellar ligament in the long term. medi has joined Dr Matthias Marquardt, sports doctor and active sportsman, to compile a training programme. It contains eleven exercises, including the single most important exercise described above, that can be done quickly and simply at home. In the videos, Dr Matthias Marquardt teams up with the professional triathlete and physiotherapist Laura Philipp to show how the exercises are done correctly – ideally three times a week.

Please ask your doctor first whether the exercises are suitable for you.

Coordination

Strengthening

Stretching

Coordination

Exercises on the stabilisation pad are perfect for developing balance and coordination skills. Do these barefoot. Thanks to the soft foam material, you sink into the mat a little and have to compensate for the resulting instability. This improves proprioceptive skills (proprioception = awareness of the body in space) and strengthens the deeper muscles.

Standing on one leg

Muscles involved: foot and hip muscles

Physiotherapy exercise standing on one leg

 

Equipment:

Stabilisation pad (alternatively: rolled-up towel, folded exercise mat)

Starting position:

  • Stand on one leg, barefoot and upright, on the stabilisation pad
  • Keep the knee of the leg you are standing on slightly bent
  • Lift the other leg up (one-leg stance) (Fig. 1)

Exercise:

  • You must now permanently compensate for the instability created by the soft surface of the stabilisation pad.
  • This automatically activates your foot and hip muscles.
  • Please make sure your trunk muscles are tensed and that you maintain an upright posture.
  • To do this, tense your abdominal muscles and make yourself as tall as possible.

Variations:

  • Make the exercise easier by doing it on a hard surface (without the stabilisation pad)
  • Make it more difficult by drawing figures of 8 (with the free leg) (Fig. 2)
  • Make it more difficult by lifting the free leg up to the hip (Fig. 3)
  • Make it more difficult by closing your eyes

Dosing:

  • Hold the exercise position for 30 seconds
  • Do three sets on each leg
  • Take a 15 second rest between each of the sets.

Jumping-jack

Muscles involved: foot and trunk muscles

Patella tendon syndrome jumping jack for coordination

 

Equipment:

Stabilisation pad (alternatively: rolled-up towel, folded exercise mat)

Starting position:

  • Stand on one leg, barefoot and upright, on the edge of the stabilisation pad
  • Keep the knee of the leg you are standing on slightly bent (Fig. 1)

Exercise:

  • Lift your free leg and both arms away from your body (Fig. 2)
  • Now slowly bring your arms and your free leg back towards your body (slow "jumping-jack movement")
  • You must thereby permanently compensate for the instability created by the soft surface of the stabilisation pad.
  • This automatically activates your foot and hip muscles
  • Please make sure your trunk muscles are tensed and that you maintain an upright posture
  • To do this, tense your abdominal muscles and make yourself as tall as possible

Variation:

  • Make the exercise easier by doing it on a hard surface (without the stabilisation pad)

Dosing:

  • Repeat the exercise 10 times
  • Do three sets on each leg
  • Take a 15 second rest between each of the sets

Mini knee bend

Muscles involved: foot and hip muscles

Mini knee bend physiotherapy exercise

 

Equipment:

Stabilisation pad (alternatively: rolled-up towel, folded exercise mat)

Starting position:

  • Stand on one leg, barefoot and upright, on the stabilisation pad.
  • Keep the knee of the leg you are standing on slightly bent.
  • Stretch out your arms and your free leg as an extension of your upper body and lean forward to an angle of about 20° (Fig. 1).

Exercise:

  • Now do "mini knee bends" with the leg you are standing on (to about 30°) (Fig. 2).
  • You must thereby permanently compensate for the instability created by the soft surface of the stabilisation pad.
  • This automatically activates your foot and hip muscles.
  • Your arms, trunk and the lifted leg should form a straight line 
  • Please make sure your trunk muscles are tensed
  • Make sure the leg axis is straight
  • Avoid a knock knee position

Variation:

  • Make the exercise easier by doing it on a hard surface (without the stabilisation pad)

Dosing:

  • Repeat the exercise 10 times
  • Do three sets on each leg
  • Take a 15 second rest between each of the sets

Strengthening

A dynamic exercise consists of two different movement phases: the eccentric and the concentric phase.

During the concentric (take-off phase, positive-dynamic) phase, a resistance is overcome. In the case of single-leg squats, this would be the knee straightening movement, during which the body weight is pushed upwards. The muscle – in this case the thigh muscle – shortens. The origin and the insertion of the muscle move closer together during the movement. Concentric movements are also often called positive movements.

During the eccentric (relaxing, negative-dynamic) phase, the muscles give way to gravity. In the case of single-leg squats, this would be the knee bending movement, during which the body weight is slowed down (deceleration movement). The muscle – in this case the thigh muscle – is stretched. The origin and the insertion of the muscle move further apart. The muscles stretch under the load. Eccentric movements are also often called negative movements.

Doing eccentric exercises has proved to be particularly successful in the treatment of patella tip syndrome.

Single-leg knee exercises

Muscles involved: front of the thigh and patellar ligament

Physiotherapy exercise knee bending with one leg

 

Starting position:

  • Stand upright on one leg on a flat, firm surface
  • Keep the knee of the leg you are standing on slightly bent
  • Lift the other leg up (single-leg standing) (Fig. 1)

Exercise:

  • Now do knee bends with the leg you are standing on (up to about 60°)
  • Push your bottom backwards while you do this (Fig. 2)
  • Please make sure your trunk muscles are tensed
  • Do not push your knee ahead of your toes
  • Make sure the leg axis is straight
  • Avoid a knock knee position
  • Do the exercise slowly and under good control

Variations:

  • Make the exercise easier by holding on to something (e.g. a handrail, a therapy rod, broom handle)
  • Make the exercise more difficult by standing on a 25° decline board

Dosing:

  • Repeat the exercise 15 times
  • Do three sets on each leg
  • Take a 30 second rest between each of the sets

As soon as you are able to do this exercise correctly and safely on a flat surface, the single-leg knee bend can be intensified further by using a 25° decline board. For example, you will find a 25° decline board in the carton for the Genumedi PSS knee support from medi.

Single-leg knee bend with decline board

Muscles involved: front of the thigh and patellar ligament

Physiotherapy exercise single-leg knee bend with decline board

 

Equipment:

25° decline board (enclosed in the carton for the Genumedi PSS knee support from medi)

Starting position:

  • Stand upright on one leg on the 25° decline board
  • Keep the knee of the leg you are standing on slightly bent
  • Lift the other leg up (single-leg standing) (Fig. 1)

Exercise:

Now do knee bends with the leg you are standing on (to about 60°) (Fig. 2)

  • Please make sure your trunk muscles are tensed
  • Do not push your knee ahead of your toes
  • Make sure the leg axis is straight
  • Avoid a knock knee position
  • Do the exercise slowly and under good control

Variation:

  • Make the exercise easier by standing on a flat, firm surface
  • Make the exercise easier by holding on to something (e.g. a handrail, a therapy rod, broom handle)
  • Make the exercise more difficult by adding extra weight (e.g. a rucksack with weights)

Dosing:

  • Repeat the exercise15 times
  • Do three sets on each leg
  • Take a 30 second rest between each of the sets

Lunge

Muscles involved: hamstrings and bottom

Physiotherapy exercise lunge

 

Starting position:

  • Stand upright with your feet hip-width apart
  • Do a long backward lunge, so that the heel of the back leg is off the floor
  • Stay upright and keep your back straight (Fig. 1)

Exercise:

  • Keep your back straight, lower the back knee towards the floor and push the front knee forwards (Fig. 2)
  • Now raise your body again a little
  • Then lower the back knee towards the floor again and push the front knee forwards
  • To reinforce the eccentric training, you may push the point of the knee in front of your toes
  • Do the exercise slowly and under good control

Variation:

  • Make the exercise more difficult by standing on a 25° decline board

Dosing:

  • Repeat the exercise 15 times
  • Do three sets on each leg
  • Take a 30 second rest between each of the sets

As soon as you are able to do this exercise correctly and safely on a flat surface, the lunge can be intensified further by using a 25° decline board. For example, you will find a 25° decline board in the carton for the Genumedi PSS knee support from medi.

Lunge with decline board

Muscles involved: hamstrings and bottom

Physiotherapy exercise lunge with decline board

 

Equipment:

25° decline board (enclosed in the carton for the Genumedi PSS knee support from medi)

Starting position:

  • Stand upright with your feet hip-width apart on a 25° decline board
  • Do a long backward lunge with the other leg, so that the heel of the back leg is off the floor
  • Stay upright and keep your back straight (Fig. 1)

Exercise:

  • Keep your back straight, lower the back knee towards the floor and push the front knee forwards (Fig. 2)
  • Now raise your body again a little
  • Then lower the back knee towards the floor again and push the front knee forwards
  • To reinforce the eccentric training, you may push the point of the knee in front of your toes
  • Do the exercise slowly and under good control

Variation:

  • Make the exercise easier by standing on a flat, firm surface

Dosierung:

  • Repeat the exercise 15 times
  • Do three sets on each leg
  • Take a 30 second rest between each of the sets

Bridging

Muscles involved: hamstrings and bottom

patella tip syndrome physiotherapy exercise bridging

 

Equipment:

Exercise mat (alternatively: a towel)

Starting position:

  • Lie on your back
  • Place both heels on the floor (Fig. 1)

Exercise:

  • Now push your pelvis towards the ceiling
  • Tense your buttocks and pull your tummy button towards your spine (Fig. 2)
  • Now let your pelvis sink back down slowly
  • Then lift your pelvis back up again slowly
  • Please make sure you maintain the right distance between your ankles and your bottom
  • When you have raised your pelvis, your knee bend angle should be 90°

Variation:

  • Make the exercise more difficult by performing it on one leg (hold the free leg in the air with the hip and knee bent)

Dosing:

  • Repeat the exercise 10 times
  • Do three sets (single-leg variant: three sets per leg)
  • Take a 30 second rest between each of the sets

Calf raise

Muscles involved: calf muscles

patella tip syndrome physiotherapy exercise calf raise

 

Equipment / where to exercise:

A stair tread (optionally with a handrail at the side)

Starting position:

  • Stand with the balls of both feet on the edge of a step (e.g. stair tread)
  • Bend your knees slightly

Exercise:

  • Raise yourself up on tiptoe (Fig. 1)
  • Now lower your heels until you feel slight tension in your calves (Fig. 2)
  • Now raise yourself back up on tiptoe
  • Do the exercise on non-slip stairs and wear shoes
  • Hold onto a handrail tightly for more stability

Dosing:

  • Repeat the exercise 10 times
  • Do three sets
  • Take a 30 second rest between each of the sets

Stretching & fascia training

Stretching and fascia training can ease the tension on the painful patellar ligament. Fasciae are connective tissue structures that surround and stabilise the muscles. A fascia roller stimulates the circulation to the tissues to improve tissue tone.

Iliopsoas muscle

Muscle involved: iliopsoas muscle

patella tip syndrome physiotherapy exercise iliopsoas muscle

 

Equipment:

Exercise mat (alternatively: a towel)

Starting position:

  • Stand in a long lunge position
  • Rest your back knee on the floor ("dubbing" position)
  • Stay upright and keep your back straight (Fig. 1)

Exercise:

Press your hips forwards with your hands until you sense a feeling of tension in the groin (Fig. 2)

  • Please be sure not to push the point of the knee in front of your toes
  • If you find the pressure on your kneecap uncomfortable, you can use a softer surface.

Dosing:

  • Hold the stretch position for 20 seconds
  • Do three sets on each side
  • Take a 30 second rest between each of the sets.

Front of the thigh

Muscles involved: front of the thigh

patella tip syndrome physiotherapy exercise thigh stretching

 

Equipment:

Exercise mat (alternatively: a towel)

Starting position:

  • Lie on your side on the floor
  • Bend both the knee and the hip of the lower leg to an angle of 90° (Fig. 1)

Exercise:

Now pull the upper leg backwards by grasping your ankle joint until you feel the stretch down the front of the thigh (Fig. 2)

  • Please make sure you keep your thigh parallel to the floor.
  • Always tense your abdominal muscles and avoid a hollow back.

Dosing:

  • Hold the stretch position for 20 seconds
  • Do three sets on each side
  • Take a 30 second rest between each of the sets.

Thigh rolling

Muscles involved: muscles over the front of the thigh

patella tip syndrome physiotherapy exercise thigh rolling

 

Equipment:

Fascia roller (e.g. from Blackroll®) Optional: exercise mat

Starting position:

  • Lie on your front
  • Place the massage roller under the muscles over the front of your thigh
  • Lean on your forearms (Fig. 1)

Exercise:

  • Roll backwards and forwards over the roller slowly along the full length of the front of your thigh, i.e. from your knee to the hip.
  • You will feel the pressure point treatment in the muscles over the front of your thigh (Fig. 2).
  • Keep your trunk straight and relax the muscles over the front of the thigh – as far as possible.
  • The exercise may be slightly painful at first, but the pain should never be more than you can easily tolerate.

Dosing:

  • Roll backwards and forwards 10 times
  • Do three sets (single-leg variant: three sets per leg)
  • Take a 30 second rest between each of the sets.

Calf rolling

Muscles involved: calf muscles

patella tip syndrome physiotherapy exercise calf rolling

 

Equipment:

  • Fascia roller (e.g. from Blackroll®)
  • Optional: exercise mat

Starting position:

  • Sit on the floor
  • Place one foot on the floor and lay the calf of the other leg on the fascia roller
  • Lean back on your hands (Fig. 1)

Exercise:

  • Lift your bottom a little off the floor.
  • Now slowly roll the whole length of your calf, forwards and backwards, i.e. from the Achilles tendon to the hollow of the knee.
  • You will now feel the pressure point treatment in your calf muscles.
  • Your trunk muscles will help move your body (Fig. 2).
  • Point your toes downwards, so that your calf muscles are relaxed.
  • The exercise may be slightly painful at first, but the pain should never be more than you can easily tolerate.

Variation:

  • Make the exercise more difficult by rolling both legs
  • Make the exercise more difficult by crossing your legs

Dosing:

  • Roll backwards and forwards 10 times
  • Do three sets (single-leg variant: three sets per leg)
  • Take a 30 second rest between each of the sets.

Supports from medi

Genumedi PSS knee support from medi

Genumedi PSS

medi has developed the knee support Genumedi PSS for conservative therapy of patellar tendinopathy. It combines the tried-and-tested properties of a support with the additional benefit of a patellar support strap: the support safely and reliably guides and stabilises the knee joint and relieves tension on the insertions of the patellar ligament.

Click here for more information about medi's Genumedi PSS knee support.

Click here for an overview of all topics covering diagnosis and treatment

Sources

1 The term "runner's knee" is often also used as a synonym for the iliotibial band syndrome (ITBS) or iliotibial tract friction syndrome. ITBS is considered the most common cause of pain over the outside of the knee. It occurs predominantly in long distance runners. The iliotibial tract is a fibrous band. It runs from the anterior superior iliac spine on the front of the pelvis over the hip joint and the knee joint to the outer border of the tibia. Due to the constant flexion and extension of the knee joint when running, the tract rubs against the epicondyle of the thigh – like a rope over the edge of a rock – and this irritates the fibrous band and thus leads to ITBS.

2 Roels et al., 1978

3 Eccentric training means loading a muscle or a tendon by slowing down a weight or a resistance.

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