What Is It?
Complicated is what it is! So it used to be called tendonitis. But that implies inflammation of the tendon which is technically incorrect. Then the Physiotherapy world re-branded it tendonosis which means degeneration of the tendon. Which seems a little more accurate and has been in vogue for quite a while now.
To get full blown genuine problems with tendons you will see neovascularisation and collagen changes. For those that haven’t swallowed a medical dictionary that means that the body decides to lay down new blood vessels to deal with the pain which actually makes things less flexible and more painful – this is more commonly seen in Achilles tendon problems.
What leads to this is a reduction of normal collagen and an increase in type III collagen – translated this means less of the stuff that gives tendons strength and makes them springy. This all comes about initially from too much cell death (apotosis) which comes from the predisposing factors discussed below. Finally nerves that give sensation in this region come to the party and realise that something is awry and start letting you know by way of the medium of pain!
Who Does It Affect and Why?
It can affect anyone. From the elite athlete to the couch potato. As with most condition it is most likely to affect the elite athlete and the obese / inactive. But anyone in between can have the condition too.
Athlete wise it most likely affects people who specialise in explosive sports. For example Basketball, Long, High and especially triple jumpers. But anyone and everyone can have symptoms which mimic or indeed are issues related to the patella tendons.
Other predisposing factors are nutrition – as with all conditions – biomechanics – which we’ll come to later and genetic factors – for the really geeky out polymorphism with Tenascin C. For those of us who prefer to communicate in easy to understand English that means that communication between the cells goes a little off tangent and changes within the tendon are more likely.
Normally patella tendonitis is obvious as it is specific well localised pain at the bottom of the knee cap. Normally aggravated by jumping, periods of inactivity or intense training. It can however co-exist with other kind of knee problems and so the symptoms can be some what confused. The pain can be also the tendon at the top of the knee cap and also exist with whats called Patella Femoral Pain Syndrome which simply means around or behind the knee cap.
Why Doesn’t It Exist?
Ok so maybe it does exist. This is one of the conditions where there are physiological changes i.e. there are actual changes in the patella tendon. However, an increasing body of new research suggests that this is true of many conditions – yet in many cases the MRI image in no way reflects the symptoms.
This is backed up by a recent piece of research which came out of the NBA. From MRI scans it revealed that one-third of all professional basketball players in the NBA have signs on tendon degeneration. However, a very small proportion of those we found to be symptomatic.
This means that when we look at the amount of degeneration in the Patella Tendon this is in no way a reflection of the amount of pain that the owner of the tendon feels. You can have a significantly degraded tendon with no symptoms whatsoever. Equally you can have someone who has little or no changes within the Patella Tendon and describes agonising pain.
This is because we are human. We are a complete entity. Otherwise we’d have bits falling off. It essential when dealing with this or any other condition to fully understand which areas throughout the entire body are contributing to the individuals current pain experience.
Patella Tendonitis IS Over Diagnosed
Now I may have to concede that there are some true cases of Patella Tendonitis. The most high profile one being Rafael Nadal who seems to struggle with it at least once a season. Firstly I would question are his Physios truly changing the movement pattern that has caused the issue? Secondly, and in defence of his Physio team have you seen the size of his quads! That and the all action way in which he plays. Compare him to Roger Federer (who is rarely injured) and considered the relative pressure the tissues of their bodies are under.
The size of his and other peoples quadriceps are indicative of what we in the trade call quad dominance. That is to say that the quadricep muscles compensate for weaknesses elsewhere and do more work than they should putting more pressure on the Patella Tendon. Simply put all that needs to be done is to ensure that the muscles the quads can compensate for a working correctly (most obviously hip flexors – less obviously lats and obliques) and the quads become more efficient. Much better than hours of pointless exercises in the gym training the same movement pattern that got you injured in the first place.
This principle is not widely accepted. However, we find it hugely effective in our clinical practice for Patella Tendonitis and any knee complaint. Part of the reason can be summarised from one of Frank Netter’s classic anatomy drawings of the Femoral Nerve. Click here to launch in a new browser. As you can see the nerve has a terminus right over the patella tendon. It is normally factors affecting the nerve and the region itself that are the source of the pain. Even if there are changes within the tendon. The trick is to work out what those are… that’s what we get paid for!
As with any condition that’s been around in Physiotherapy for a long time I plead with Physiotherapists, Sports Therapists and clients alike to consider Patella Tendonitis as merely a label for pain in the region of the Patella Tendon. The real trick in getting it fixed is understanding the nuances of the individual with the condition and consider each case in complete isolation. Why does this person have this condition right now? And what can we, as therapists, do to help them get over it as quickly as possible? Rather than packing them off with a bunch of pointless exercises that more than likely won’t make any difference!
That’s my rant over for this week. It feel it was particularly ranty this week but that’s always the case when I get passionate about what I’m writing and feel there are many misconceptions that need correcting. If you’d like more information on any of the above or have a Patella Tendon or any other knee complaint you’d like some help with then give us a call on .