Patellar Tendinosis / Tendinopathy

[Skoorb]

I an ongoing effort to solve nagging knee pain, I'm starting this thread to illicit feedback from others who've successfully dealt with Patellar Tendinosis. In brief, this is a degredation of the patellar tendon without much or any inflammation. Generally, people consider it a tendinitis and try rest/NSAIDs, to little/no benefit. This condition is normally an overuse injury and even with vast periods of rest can resist recovery.

In my experience and what I've read on the net, this is probably not diagnoses often enough and many people, say runners, who present to their physician or physical therapist with this will be told they have tendinitis and given some kind of a stretching/strength program + drugs. Some may get better out of luck or having discontinued the aggrivating injury and others will not find resolution.

My tendinosis started while marathon training in 2005. I believe that a combination of hip/pelvic imbalance married with other factors like the wrong shoes (was given stability shoes at a well-reputed running store when I should have been in cushioning, as underpronation--not always overpronation--has been linked to a predisposition to patellar pain) is what caused this.

My pain is generally between 0-4, almost always 2 or less, but 0 only for very short periods. I can take months off activity and the knee continues to mildly ache, continues to be slightly stiffer than the good knee, and continues to click (what I presume is a build up of scar tissue). I can alternatively train for short distance triathlons and tolerate a decent bit of cycling and some mild running with only a modest increase in symptoms.

The best thing I've found, applied this year, was a lot of quad strengthening (one-legged step downs no deeper than 90 degrees). I also stretch a lot now and in the past 2.5 months came across the literature supporting eccentric, decline squats, so I'm trying to apply it now.

Given my low intensity of symptoms, all of the physicians I've seen are very carefree about it and don't think it's a big deal. I've had two mris, the first showing a possible meniscus tear but otherwise nothing (btw, no physician can illicit any meniscal symptoms; I consider it an aysmptomatic tear, like much of the population has). A year later another MRI found a possible minor tear, a patchy bone edema between a couple of condyles, and a possible patella tendon tear (bingo!). Xrays have always been flawless. I have had VMO wasting, which I mostly reversed this year with the diligent leg strengthening (4-5 times/week, 6 sets of the step downs or very careful lunges).

Nonetheless, I'm not a hypochondriac because if I start increasing running miles, pain is inevitable. I can sit at work and feel it throughout the day. It's actually at its worst if I stand--even for a short period of time (say 15 min).

Anyway, post if you've had success dealing with it, I'm spent :)

[Skoorb]

This is weird, but I'll post the first reply/question. I asked one of the moderators here, who I found able to become totally asymptomatic with his tendinosis 2.5 years ago about his results, and his advice was Anyway, what worked for me was 3 sets of 10-15 reps about 3/wk. The guidelines I give my patients and I use myself is that there should be no pain at the eccentric portion, but then a sharp pain in the tendon at the bottom when you begin your concentric portion. Research has shown that pushing through the pain improves outcomes vs avoiding pain. It has been my anecdotal experience with patients and personally that running or jumping during the treatment phase is very detrimental to recovery - for what that's worth.


to which I ask:

Interesting on the pain comments. Sometimes I will feel pain throughout the entire eccentric rep, but generally not. I can often get to the concentric transition pain free, but on the "bad" days, that exact moment is where I can count on pain, if I am expecting to have it.

That volume seems fairly low--have you had problems with people doing 6-7 times/week, or even twice/day as some of the studies have had?

--

Further, what are your results with patients; i.e. success rates? Are there certain red flags you've found that indicate a person is unlikely to succeed with the eccentric work or more likely based on his/her particular symptomology? My main concern for me has been what must be scar tissue causing the painless clicking in my knee. I would guess it cannot go away without surgical excision, which to date I've avoided.

[Jason Silvernail]

Hi Skoorb. I've had some luck with this both with myself and my patients.

I use the eccentric strengthening program and like it a lot. In fact, this is a rare useful application of HIT/Superslow training. (rimshot, nick!)

I've attached something that might be useful.

I typically recommend 3-5/wk 3 sets of 10-15 reps, 5-10 second eccentric and 1-2 second concentric.
The guidelines I give my patients and I use myself is that there should be no pain at the eccentric portion, but then a sharp pain in the tendon at the bottom when you begin your concentric ascent. Research has shown that pushing through the pain improves outcomes vs avoiding pain. It has been my anecdotal experience with patients and personally that running or jumping during the treatment phase is very detrimental to recovery - for what that's worth.

[Bas]

I must say that your mentioning of "standing" as the most aggravating action, has me doubting that your patellar tendon tissue is actually still the culprit. In standing, the stress through the tendon is very low.....
Having no opportunity to personally check you out - it is safe to go with eccentrics. Done properly, they won't do harm.....

[Skoorb]

I must say that your mentioning of "standing" as the most aggravating action, has me doubting that your patellar tendon tissue is actually still the culprit. In standing, the stress through the tendon is very low.....
Having no opportunity to personally check you out - it is safe to go with eccentrics. Done properly, they won't do harm.....I suppose I should clarify, though I agree it's weird. The worst is if I run. I can inevitably get through a mile without pain, but depending on the day, at mile 2 or 3, and certainly by 4 or 5, I'll feel it (I've since stopped running; my only activity now is rehab and swimming). A couple of days ago I was on the roof and that requires balancing on the balls with knees very bent. It hurt for several hours after.

In the grand scheme "doing nothing", standing hurts it--like if I go shopping and I'm basically standing in place for a while, after some time I will definitely feel it, whereas if I spent that time instead doing a brisk walk, I'd probably have felt it no more, and very possibly less than with the standing alone.

Rest does help, like a few days after hard activity it feels better, but then the healing slows to the point where changes are only mildly noted from month to month. My longest period off so far is about 6 months with only doing a little bit in the knee and it will get mostly asymptomatic, but not perfect, and can be re-hurt quite quickly, so the inactive rest is certainly no solution.

Thanks for the posts!

[Bas]

I totally agree that inactive rest is not an answer to your type of problem. I have to admit that after I posted, I thought This: that maybe when you stand - without the white-noise effect of motion generated proprioceptive input to the brain and its paindampening effects - your brain may be simply more attentive to the knee input, thus "feeling" it more.

BTW, if you can run 1 mile without any aggravation, why not run 1 mile regularly? If that does not aggravate after a few times, run 100 yards extra the next day - do that for a few runs; if that is OK - run another 100 yards extra the next day .....you get my drift.

Just some further musings - many of the running patients I have had, had knee problems NOT originating in the knee itself. Feet, footwear, lumbar spine, work related inactivity, etc etc are just a few of the initiating aspects....
Personally - no running is fine with me - my knees have a lot of other things still to do in life....

[pht3k]

i would say check the recurrent branch of the peroneal nerve, and sup tibio-peroneal mobility.
a friend of mine would say try shockwave therapy

[Jason Silvernail]

Hi pht3k,
Why might those things help?

[pht3k]

the recurrent branch is going really near the patellar tendon. there might entrapment if there is extensor digitorum longus (http://en.wikipedia.org/wiki/Extensor_digitorum_longus) muscle tensions. thoses muscles tensions are sometimes secondary to superior tbio-fibular fixation. i saw (interpreted) this hypothesis more than once. manipulating this articulation might releive the symptoms. of course this is a differential diagnosis, not a cause of tendinosis.

[Diane]

I'd rule out inferior branch of the saphenous nerve (http://www.somasimple.com/forums/showthread.php?t=2814) myself.

[pht3k]

quote from diane's link: In most cases it crosses just below the joint line, passing over the patellar tendon at its insertion into the tibia.

i was used to think to the infra-patellar branch of the saphenous nerve with medial knee pain and around the mdeial articular interligne. i wasnt aware that the nerve endings might go as far as the patellar tendon.

thanks for the info. pretty useful for my practice.

[allenbr4]

Jason (et al),

Have you ever experimented with eccentric squat landings off of a box for patellar tendinosis? Or any method of the sort? I'm not aware of any literature on the subject.

Seems to be much more functional than a 10 second eccentric squat. Of course, that doesn't mean it'd work.

Thoughts?

[Mary C]

speaking of chronic knees, Skoorb said

as underpronation--not always overpronation--has been linked to a predisposition to patellar pain) is what caused this.


Try positioning on a wobble board, using perfectionism (in bare feet.) Feet apart and parallel as in skiing, relaxed toes, ankle mortise directly over calcaneum, nice long arch, knees slightly bent. Then make it interesting.....

Juggling, etc.

Then learn to do all this standing on 1 foot on the wobble board.

The aim is to train the person to maintain a good position throughout all the movements of the legs while balancing.

[ginger]

Skoorb, The most likely answer to your persistant pain problem is somatic referred pain arising from irritation to the nerve root at or near L3. This is a common condition and one of the most misdiagnosed in MSK medicine. The pain and dysfunction will continue untill or unless the facet joint at L3 is returned to a non protected fully mobile state. The 'chicken' may oir may not be related to the incident with running you mentioned , but is likely to relate to the ongoing effects of poor sacro iliac function. SIJ function is commonly lost in those who overpronate and have poor antipronation control. Wearing "correct" shoes or even orthotics will not correct dysfunction at this pair of powerful pelvic joints however , it requires manual treatments and is easily achieved in the right hands. Spinal Protective behaviour is the ubiquitous element in spinal pain, dysfunction and referred events. The way forward may not be easy for you however as the likelihood of finding someone who is familiar with Continuous Mobilisation is not good. Nevertheless you will find relief permanently from this problem ( and quite quickly too , one treatment is the standard for immediate and lasting improvmenets in my own experience ) if you can find a therapist to mobilise L3 on the side of your painfull knee. For a full explanation of Continuous Mobilisation go to rehabedge and look up CM in the manual therapy archives.
Don't bother with any more medical treatments , the path in that direction is strewn with failures who have given up hope.
All the best

[Jason Silvernail]

Brian-
Tendonosis has been linked to jumping and explosive contractions such as plyo/jumping, and it has been my overwhelming anecdotal experience that jumping is the "last" thing a patient like this can tolerate. Given some of the latest data on pushing through the pain being beneficial, I'd be interested to see it studied.

Do you have a physiological mechanism in mind for why that would be better than a slow eccentric for purposes of remodeling the tendon?

[marcelk]

Skoorb,

Has that tendinosis been diagnosed by echo or any other method?
Or was it just a diagnosis from ....?

[TC_PT]

Skoorb,

I've had good clinical outcomes with patellar tendonosis using a combination of eccentric quad. strengthening and aggressive soft tissue work (I use ASTYM). The soft tissue work should be aggressive enough cause an acute inflammatory response and a "redo" for remodeling the tissue in question. A program of stretching four times daily aids in proper remodeling.

Based on clinical experience the soft tissue work significantly speeds the process.

[neil]

With regards your exercise prescription of eccentric work 5-6 days per week. It is worth bearing in mind that you are aiming to increase collagen depostition in the tendon by delivering an intense stimulus (i.e. eccentric loading). Due to the intensity of eccentric contraction you need to allow time to recover and let the body repond to to the stimulus by laying down more collagen. I do not think eccentric work on consecutive days would allow for this recovery. Therefore a day or so between eccentric sessions would give you a better response.

Neil

[marcelk]

Skoorb,

I've had good clinical outcomes with patellar tendonosis using a combination of eccentric quad. strengthening and aggressive soft tissue work (I use ASTYM). The soft tissue work should be aggressive enough cause an acute inflammatory response and a "redo" for remodeling the tissue in question. A program of stretching four times daily aids in proper remodeling.

Based on clinical experience the soft tissue work significantly speeds the process.

How do you define significance based on clinical experience?

You say that your soft tissue work should be aggressive enough to cause an acute inflammatory response.
Where do you think that response takes place in the tendon or skin?

Any data to back this up?

Cheers

[TC_PT]

How do you define significance based on clinical experience?

You say that your soft tissue work should be aggressive enough to cause an acute inflammatory response.
Where do you think that response takes place in the tendon or skin?

Any data to back this up?

Cheers
Hi Marcel,

my post is in response to Skoorb, who's asking for help with a problem on which he/she is "spent". I'm offering my best advice (proven or otherwise) based on what has worked best for me over 17 years.

I probably wouldn't define significant. Merriam-Webster lists one definition as: probably caused by something other than mere chance. Seriously though, I'd estimate the speed of symptom reduction/relief moves from months to weeks. No, regretably no data.

I think the inflammatory response takes place in both the skin and tendon as well as associated muscle.

Here is some research from the ASTYM website.http://www.performancedynamics.com/upload/pdf/ASTYM%20Article%20Summaries.pdf



Marcel, what advice would you offer Skoorb?

[Diane]

Hi TC_PT,
I think the inflammatory response takes place in both the skin and tendon as well as associated muscle.
More likely (seems to me) it would be localized axon reflex in the skin. Which is there to protect all that which lies beneath, lest we forget.
If the muscle were attached to the underside of the skin itself, like it is, a few places in the body (face, front of neck, tensor fascia lata), then I would agree with you, but around the knee it isn't. Also the fascia thickens distally, making it even less likely that any fingers or implement would actually get all the way in to irritate muscle or tendon.

[allenbr4]

Jason,

Thanks for your response. I stated that I thought eccentric landings seemed more functional, or specific, to the act of running.

Just thinking about heel strike and the quick eccentric contraction during walking or running, as opposed to the slow eccentric contraction that you describe for the exercises.

Point taken about tolerance in severe cases.

Brian

[Jason Silvernail]

Brian-
I'd agree that they're closer to running but there's some question of whether or not that can resolve the pain and create the remodeling we're looking for. Another way to think of it - the patient is there because those things hurt, if they were helpful wouldn't the condition resolve itself?

Having said that I recall a guy years and years ago who used drop squats ( the fast eccentric you're talking about) with sandbags for patellar tendonopathy and reported good results - darned if I can remember his name though.
Sounds like a good comparison study to see regarding speed of contraction, though...

[John W]

Skoorb,

Given the chronicity of your problem, I wouldn't rule out trying some of the newer injection procedures. There is some pretty solid preliminary evidence that injection with certain protease inhibitors in both Achilles and patellar tendinopathies can be effective. Go to pubmed and enter "injection and patellar tendinosis" in the search box for some recent studies.

One of the issues seems to be the problem of neovascularization that occurs in tendinopathies. Where there are blood vessels there are C-fibers that can contribute to nociception, thus fueling the pain experience. There are also sympathetics perhaps contributing to some persistent mal-adaptive neurosignature through the the HPA.

You need to weigh the risk of harm, of course, with your level of exasperation and feelings of futility. There's likely more than one way to skin this cat (no pun intended, Diane:D). No doubt, though, that the nervous tissue is the tissue of greatest import. Keep that in mind (no pun intended, again:embarasse).

[Jon Newman]

John I agree. If you're trying to jump start or restart inflammation in a specific tissue it makes intuitive sense to me to be as specific as possible. Bluntly creating inflammation in a generalized area in hopes that your target tissue is at least one of the tissues that become inflammed doesn't appeal to me.

Am I being overly cautious?

[Jon Newman]

Never mind. I was thinking of some sort of pro-inflammatory agent.

[John W]

Jon,
I think you're talking about prolotherapy with the use of a pro-inflammatory agent, which is commonly a dextrose solution. Those studies will come up with those search terms as well.

[Jon Newman]

Here's an example of someone that had a sclerosing type injection therapy. Also, it serves as an example (not necessarily a typical or modifiable via PT type) of "safe but sore."

Authors Gisslen K (http://ovidsp.tx.ovid.com/spa/ovidweb.cgi?&S=OKOPFPFEPDDDFFLBNCHLJBPJFOJDAA00&Search+Link=%22Gisslen+K%22.au.). Ohberg L (http://ovidsp.tx.ovid.com/spa/ovidweb.cgi?&S=OKOPFPFEPDDDFFLBNCHLJBPJFOJDAA00&Search+Link=%22Ohberg+L%22.au.). Alfredson H (http://ovidsp.tx.ovid.com/spa/ovidweb.cgi?&S=OKOPFPFEPDDDFFLBNCHLJBPJFOJDAA00&Search+Link=%22Alfredson+H%22.au.).

Title Is the chronic painful tendinosis tendon a strong tendon?: a case study involving an Olympic weightlifter with chronic painful Jumper's knee.

Source Knee Surgery, Sports Traumatology, Arthroscopy. 14(9):897-902, 2006 Sep.

Abstract

The chronic painful tendinosis tendon is generally considered a degenerated and weak tendon. However, this has not been scientifically verified, and is to be considered a hypothesis. We present here a case study involving a high-level Olympic weightlifter with chronic painful patellar tendinosis who started heavy-weight training very early after successful treatment with sclerosing injections. A 25-year-old super heavy-weight (+105 kg) Olympic weightlifter with 9 months duration of severe pain (prohibiting full training) in the proximal patellar tendon, where ultrasound and Doppler showed a widened tendon with structural changes and neovascularisation, was given one treatment with ultrasound and Doppler-guided injections of the sclerosing agent polidocanol. The injections targeted the neovessels posterior to the tendon. The patient was pain-free after the treatment, and already after 2-weeks he started with heavy-weight training (240 kg in deep squats) to try to qualify for the Olympics. Additional very heavy training on training camps, most often without having any discomfort or pain in the patellar tendon, resulted in Swedish records and ninth place at the European Championships 17 weeks after the treatment. Despite beating the national records, he did not qualify for the Olympics. Ultrasound and Doppler follow-ups have shown only a few remaining neovessels, and little structural tendon changes. This case questions previous theories about the weak tendinosis tendon, and stresses the importance of studies evaluating tendon strength.

[TC_PT]

Hi TC_PT,

More likely (seems to me) it would be localized axon reflex in the skin. Which is there to protect all that which lies beneath, lest we forget.
If the muscle were attached to the underside of the skin itself, like it is, a few places in the body (face, front of neck, tensor fascia lata), then I would agree with you, but around the knee it isn't. Also the fascia thickens distally, making it even less likely that any fingers or implement would actually get all the way in to irritate muscle or tendon.

Hello Diane,

Did you take a look at the histological studies provided in the link I posted? Seems to me those studies contradict your doubt about the soft tissue work's ability to stimulate beyond skin deep.

Anecdotally I'd add that observation of the hematoma/bruising following ASTYM treatments is different than the skin's response which has more an abrasion-like presentation.

[Diane]

Yes, I have.
I gather there are mechanotransductive channels in tenocytes (http://ajpcell.physiology.org/cgi/content/abstract/00053.2006v1), fine, but I what I object to in principle is the inherent implication, provided on the site itself, that therefore every pain known to humankind is now treatable by ASTM (http://www.performancedynamics.com/patients/), which will of course benefit ASTM more than it will the patients. Really. Probably only a few of whom have pain that is directly attributable to tenocytes that went the wrong way in life and now have to squished with tools to straighten out their ion channels. ;)

[allenbr4]

Jason,

In regards to your eccentric protocol, would you treat osgood-schlatters, or an insertional patellar tendinosis, the same as you would tendinosis more proximal along the tendon?

Thanks!

[Jason Silvernail]

Hi Brian.
Good question - answer is - sort of.
I don't have a good track record with O-S as I recall, I think that rest is the main ingredient. If I do treat it, I will use very light eccentrics along with some other things.
In regards to insertional tendonosis - the patellar insertion is usually where people have most of their pain. Its been my anecdotal experience that when it is insertional there and not midsubstance that these folks are often labelled with Patellofemoral pain and failed to improve with care for that, but do well with eccentrics.