Patellar Tendinopathy: The Basketballers Guide
Knee pain is the third most common type of basketball injuries according to research from the NBA and NATA. There are many potential diagnoses for knee pain but one common issue for ballers is patellar tendinopathy.
I was prompted to write this blog as I came across a study from Breda et al (2020) that was funded by the NBA and recently published in the British Journal of Sports Medicine. I thought it would make a nice addition to the ‘Basketballers Guide to Injury’ series as well as taking a look into the new research.
What is Patellar Tendinopathy
Patellar tendinopathy, also known as jumpers knee, is a source of anterior (front) knee pain. The pain is sited in the tendon below the kneecap. Pain is usually aggravated by loading and increasing the demand on the muscles that extend (straighten) the knee. This is more notable if increasing powerful movements such as jumping, hence the name jumpers knee.
Patellar tendinopathy is more common in younger male athletes; 15 to 30 years old. Unsurprisingly, it is more common in those sports that require repetitive loading of the patellar tendon such as running and jumping, i.e. basketball.
The cause of patellar tendinopathy is not fully understood. Although, as with other tendon issues, it is common for it to start around a sudden increase in demand and the tendon has been unable to adapt to the level of the strain it is under.
Symptoms
There are two defining clinical features of patellar tendinopathies:
1. Pain localised at the base of the patella.
2. Pain that increases loading on the knee extensor muscles; jumping and running.
Interestingly, for some individuals, the pain can get better while exercising and then find it increases after resting. Another common symptom is tenderness over the patellar tendon, meaning kneeling can be painful. Some individuals may also find that knee becomes stiff in the morning, this usually eases with movement.
Risk Factors
There are a number of risk factors for patellar tendinopathy and it is not always a simple case of too much exercise:
- Age
- Gender: it is more common in men
- Weight: individuals who are overweight are more at risk
- Reduced flexibility of the quadriceps and poor mobility of the knee
- Inadequate conditioning of quadriceps
- Poor conditioning of hip and ankle
For some people, training errors can increase risk:
- Excessive plyometrics
- Poor programming and overloading of weight-training
- Too much hill running
- Sudden increases in running distances
- Poor variation in exercise
- Poor recovery strategies
Minimising Risk for Patella Tendinopathies
A sudden increase in activity is often the main cause, so taking your time to grade up activity is best. If you are thinking of building up weight training to compliment your game, start steady and gradually build. Get support with building a routine or plan.
Disturbed sleep, anxiety and depression can all be associated with increases in pain. Making sure you improve sleep and manage your mental health can minimise the risk of pain and flare-ups.
It is also worth noting that endocrinometabolic diseases (obesity, diabetes mellitus, hypertension, increased serum lipids, hyperuricemia) have been linked with other tendinopathies i.e. Achilles tendinopathy. There could be an argument that this applies to all tendons although not backed currently by research. Nutrition could have a part to play in recovery.
Unfortunately, for those veteran ballers again (and maybe some of the younger ones), carrying excess weight around the midriff could also be a risk factor. Managing and maintaining a healthy weight is important when it comes to tendinopathies.
The following tips can help you minimise the risk of patellar tendinopathy or recurring problems:
- Conditioning so the ankle can tolerate running, jumping and landing
- Hip and core conditioning is key to helping with running, jumping and landing mechanics.
- Practice stability training, including balance exercises.
Supports and taping can be utilised, but not in replacement of the above.
Treatment
The first thing I would always recommend doing when it comes to managing any pain problem is addressing any current risk factors. What is currently going on life that will be a barrier to recovery? Without addressing activity cycles, stressors and lifestyle factors, you may just keep banging your head against a wall when it comes to treatment and rehab.
Modify not rest
Tendinopathies do not generally improve with rest, yet many medical professionals advise rest. There is a bit of a false economy with rest as it may help symptoms settle but many get frustrated that symptoms increase again when returning to activity. Rest doesn’t help because it doesn’t increase the tolerance of the tendon to load. Initially, modifying activity is best and being wary of activity cycles you have fallen into.
Exercise is one of the most evidenced-based treatments there is for tendinopathies. Progressive loading of the muscles/tendon is required for patellar tendinopathy to improve. Interestingly, this is what the recent study looked at; so more about that in a moment. Gradually building up the load can help develop tolerance to the required loads for daily and sporting activity. Exercise often needs to be individualised, so speak to your therapist about this or drop us a message.
If you do need to take complete rest from basketball, I would recommend that you keep training the rest of your body. Don’t forget, ball handling and shooting practice can still be done. You may also find that swimming, cycling or aqua jogging can help keep your fitness up whilst off-loading the tendon. Other cross-training ideas:
- Pilates
- Yoga
- Circuits
- Weight-training
- Rowing
- Cross-trainer (other gym equipment)
Patella tendon strap?
I generally advise against using taping and straps. Especially, as they allow individuals to become passive in the management of the issue. If they enable you to continue to be active without making the issue worse then use one. As always, straps and supports are not to be used as a replacement for addressing other risk factors.
Ice?
The research for ice is poor. However, if you find it useful, generally there is no harm is using during acute stages. If you are going to use ice, please take care and do not apply directly to the skin or for too long. Ice burns can be caused so regularly check your skin when using. Do not use an ice pack where you have numbness, decreased sensation or poor circulation.
Anti-inflammatories?
Inflammation might not be as big a factor as previously thought. Therefore, anti-inflammatories are not helpful for many. They may be helpful in the early acute stage but might not be best to take in the longer term.
Scan required?
Changes on MRI scan do not equal the amount of pain or pain someone experiences. Some people can have severe pain and no changes in their imaging whilst others may have a lot of changes and no pain. In addition, the severity of the changes seen on a scan does not mean you can’t get better or have a poorer outcome.
Even if your pain and symptoms are persisting, MRI scan and other diagnostic tests may not be helpful. Even when someone improves their symptoms and function, the changes on a scan can remain. Therefore it is best to target treatment towards improving pain and building function.
Injections, massage, ultrasound and passive treatments?
These treatments are often adjuncts to load management and exercise and evidence is limited to them speeding up recovery. Most tendinopathies are self-limiting; you can throw all the treatments at it (even exercise) and it still might only get better by itself.
For some individuals, these passive treatments do help to calm down symptoms but do not be disheartened if they don’t. If they do, remember they are there to help you calm it down so you can gradually build load. Try not to fall into the trap that if the pain is better you can rush back to exercise/load.
Strengthening/rehab
Now, historically, eccentric only exercise protocols have been the most relied on for treating tendinopathies. Some individuals will find that this approach works for them. For others, this left them wanting. More recently there have been approaches such as heavy slow resistance exercise. Again, this works for some and not for others. Now we have this new study looking at progressive loading. But, before I discuss the study…I promise I will get to it in a second. When it comes to strengthening, don’t forget the other muscle groups of the hips and ankle.
New patellar tendinopathy research
Finally, we get to the new study. The Breda et al (2020) study looked at comparing the traditional eccentric only exercise method versus a 4 stage progressive tendon loading exercise (PTLE) method. They split 72 athletes into two groups. The athletes, on average, had a history of 2 years of pain and had already failed other conservative treatments.
In addition to either eccentric or PTLE, the athletes were also given education on load management and the condition itself. Further to this, they also were given exercises to address risk factors at the ankle and hip i.e. mobility exercises, hip and calf strengthening. This could actually be a limitation of the study as it is unclear exactly what improvements were made from which elements. However, this is what happens when you attend a therapist, they will often look at and address multiple factors. Dependant on which way you look at it, it is either a limitation or a study that is similar to the real world of rehab?
Results of the study
The PTLE group came out on top in the study. They had a better improvement in the main outcome measure used, the VISA-P. They also had a higher return to sport rate (at 24 weeks) than the eccentric only group, 43% compared to 27%. Finally, the PTLE group had more satisfaction from their management.
It is worth noting, that the adherence rate was low, around 40%. This could be due to the fact that the programme was comprehensive and that can be challenging for individuals to keep up, especially over 24 weeks. There was also a lot of individual variation, meaning that as with a lot of other approaches, it may be better suited to some than others.
The 4 stages of PTLE
This strategy may be a good way for those of you have a diagnosis of patellar tendinopathy. I would recommend discussing this with your trainer or therapist. The stages were:
Stage 1
Isometric Exercises – these are static exercises and so the muscles do not change length. Meaning there is tension through the muscle but no change in length. Static single leg press and seated knee extension are the examples used.
Stage 2
Isotonic Exercises – these are dynamic exercises. Meaning there is a consistent weight/load/tension whilst moving your muscles throughout its range of movement. This is similar to the heavy slow resistance exercises and could include: leg press, lunge/split squats, single-leg dip/squat.
It would be important to progress the resistance and build up the load. As load build this may also result in a reduction in repetitions, this is where support from a therapist or strength and conditioning coach could come in useful. In addition to progressing load, starting with a smaller range of movement and gradually progressing to larger movements can help with pain management.
Stage 3
Energy Storage Exercises – these are plyometric exercises and the aim is to improve power. Box jumps, hopping, bounding and running drills are all great energy storage exercises. For the research, they used jump squats, box jumps and cutting drills.
Stage 4
Sport Specific Exercises – in the study, they slowly graded athletes back to their training sessions allowing 2-3 days recovery between sessions. For basketball, this could include change of direction work, footwork for jumps stops and layups and basketball handling drills.
Interestingly, it was only in stage 4 where they reduced the frequency of the exercises from stage 1 and 2.
Takeaways from the Study
As mentioned, there were good results from the study so I would consider using this approach. It adds weight to the way I usually manage patellar tendinopathies, although I would tailor the progression specifically to the individual I am working with. Therefore, If you are thinking of taking this approach, consider getting a programme tailored to your specific needs.
The other key takeaway is the time it to for the athletes to return to sport, 24 weeks. This is a reminder that tendon issues take time to recover, regardless of treatment approach. Unfortunately, there are no quick fixes. Slow and progressive rehab often is best despite the frustrations that may bring.
Remember, these resources should not replace diagnosis and management from a medical professional. Always check before you follow the guidance.
