Patella tendinopathy

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Case
A 26-year-old recreational player presented after a 12-month history of localised anterior knee pain. This came on insidiously and has remained painful during and after football (and any other running-based activity). The pain is not associated with any swelling, mechanical symptoms or instability.

On examination there is localised tenderness about the proximal patellar tendon and pain with a single leg hop. There were no other findings of note.

Findings
An x-ray series of the knee is normal. The MR sequences show that there is distortion and irregularity of the deep aspect of the proximal patellar tendon with partly linear, high fluid signal intensity suggestive of a moderate grade partial thickness insertional tear measuring 10 mm CC by 8 mm W by 6 mm AP. There is also some associated subchondral bone oedema/reactive signal intensity change in the inferior pole of patella without fracture or bony avulsion injury identified. The remainder of the patellar tendon and extensor mechanism is intact.

Discussion
This player had symptoms and signs that were highly suggestive of patellar tendinopathy. The MRI was ordered, rather than an ultrasound, to look for other potential causes of pain that might have better explained his refractory symptoms. A diagnosis of patellar tendinopathy was made. The player had received a range of treatments prior to this assessment. These had included a period of relative rest, an eccentric strengthening programme, a PRP injection and a trial of extra-corporeal shockwave therapy. These had not made a meaningful difference. After a discussion about the different treatment options he elected to try a Heavy Slow Resistance (HSR) strength programme.

There are a range of treatments that can be used to treat patellar tendinopathy. Arguable the most widely prescribed regime involves eccentric squatting exercises on a decline board. Other regimes involve the use of isometric strengthening exercises or, as outlined in this week’s FastFact a progressive tendon loading programme. This player was treated with an HSR programme. This was because he had not responded to the more traditional eccentric programme, he felt very frustrated with these exercises and because he enjoyed training in a gym-based environment.

HSR training involves exposing a painful tendon to high loads. The protocol that is documented in the literature, and was used by this player, is very prescriptive and simple to follow. It involves training three times per week, performing squats, hack squats and leg press. The player is asked to start with a relatively low load but to then progressively increase the load (and decrease the number of repetitions) over a three month treatment period. Each work out involves four sets in each exercises with a 2–3‐min rest between sets. The repetitions/loads are: 15 repetition maximum (RM) week 1, 12RM weeks 2–3, 10RM weeks 4–5, 8RM weeks 6–8 and 6RM weeks 9–12. Each repetitions involves three seconds completing each of the eccentric and concentric phases (six second total). As with most tendon loading regimes, pain during exercises is acceptable but pain and discomfort should not increase following training.

The HSR regime exposes the tendon to high load, but with a relatively low number of total repetitions. It is thought that this increased ‘time under tension’ may promote tendon adaptation by creating changes in muscle fibril morphology, the creation of new fibrils and ultimately tendon healing.

Important notice
FIFA does not bear any responsibility for the accuracy and completeness of any information provided in the “Radiology Review” features and cannot be held liable with regard to the information provided or any acts or omissions occurring on the basis of this information.

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John McKellar
07 May 2021 12:42

Nice article, factual and to the point.
Thank you for sharing this 👍

Yousef Salim Karnoub
08 May 2021 0:58

Commonly seen in practice
Thank you

Hussein Ali kahdim alzuabidi
09 May 2021 10:02

What Laboratory investigations to be done

Phumi Skosana
20 May 2021 12:25

Briliant case, really enjoyed the elaboration on the heavy slow resistance program. I’m happy to apply this in practise