What is patellar tendinopathy
The quadriceps is connected to the shinbone by a strong tendon, with the kneecap (patella) embedded within it. The part above the kneecap is called the quadriceps tendon, while the lower part is the patella tendon.
Patellar tendinopathy is an overuse injury that takes the form of an inflammation of the patella tendon. This typically occurs on one of the tendon’s bony insertion sites: either on the tip of the patella or on the tibial tuberosity, a bony bump on the shinbone. Problems with the patella tendon can almost always be traced to abnormal function of the quadriceps.
How can it occur?
Patellar tendinopathy in dancers is an overuse injury from intense ballet training, and especially relates to excessive jumping. Its underlying cause is dysfunction of the quadriceps, resulting in an abnormal mechanical load within the patella tendon. Muscle dysfunction can appear as muscle tightness (contraction) or weakness (inhibition). Typically, the outside muscles of the quadriceps muscle (vastus lateralis and rectus femoris) will be tight, whereas the vastus medialis muscle on the inside will be weak in an overuse situation. As a result, the patella will be pulled to the outside of the trochlear groove and the patellar tendon will be loaded asymmetrically. This can lead to local inflammation of the tendon especially on its bony insertion sites where flexibility of the tendon is low. In the long run, chronic inflammation may lead to tendon degeneration and even ruptures.
Muscle overuse often occurs when the body fails to compensate for existing muscle dysbalance. Muscle dysbalances are very common and naturally occur as the body adapts to specific training demands over time. As long as compensation is effective – or, in other words, as long as the dysbalance is well managed by the body – this need not cause any problems. However, with high training loads, insufficient rest or after a minor injury, the body may struggle to compensate, leading to muscle dysfunction in the various muscle groups involved in the compensation. This is why symptoms may simultaneously occur in different parts of the body in an overuse situation.
What are the typical symptoms of patellar tendinopathy?
Typical symptoms are pain below the kneecap or at the tibial tuberosity at the front of the shinbone. Swelling of soft tissues is frequent, especially around the tip of the patella. Pain usually occurs with excessive jumping or walking downhill, but may also occur after keeping the knee in a bend position for a longer time.
How can a patellar tendinopathy be diagnosed?
Your doctor will examine your knee and review your symptoms as well as your current training activities. He will especially check for pain in and around the patella tendon and put a focus on joint range of motion, leg alignment and knee stability. Correct diagnosis of this issue demands a thorough functional clinical examination, including specific tests to identify joint and muscle dysfunction. Finding out the exact causes of patellar subluxation is sometimes challenging and your doctor may ask a specialist in manual medicine for his opinion. X-rays may be ordered to find out about bony bumps or spurs (osteophytes) on the patella due to degenerative changes or anatomical abnormality. An ultrasound or MRI scan may help to reveal structural changes of the patellar tendon in chronic or very acute cases of patellar tendinopathy.
This side-view MRI of the knee shows a severely inflamed patella tendon. Fluids appear white in this picture. Inflamed soft tissue contains a higher amount of liquid. You can see that not only the tendon, but also the surrounding soft tissue is inflamed.
What are the treatment options?
If you have severe or constant knee pain, you should take a break from your ballet training immediately. Ignoring the pain can have serious consequences, as the situation will become increasingly complicated the longer you train with pain.
The RICE concept (rest, ice, compression and elevation) is an easy guideline that can be used to initially treat acute as well as overuse injuries. Please read my “First Aid” post to obtain some background information that you will need to adapt this concept successfully and learn about the use of painkillers.
In order to handle a given overuse situation successfully, its underlying causes – namely muscle dysfunction and muscle dysbalance – have to be addressed specifically in the rehabilitation process. Muscle dysfunction can appear as muscle tightness (contraction) or weakness (inhibition) and the muscles affected have to be treated accordingly in the rehabilitation process. Some muscles will have to be stretched whereas others will rather have to be strengthened. A well-suited training program including corrective exercises as well as a general strengthening and endurance routine is the most effective way to deal with most overuse situations.
Manual medicine and especially deep myofascial release treatment is recommended to address present joint and myofascial dysfunction. Restriction of the fascia plays a key role in all overuse issues and can be addressed effectively with manual medicine.
Ensure that you follow your specific training routine after the rehabilitation is finished. Myofascial rollers (Blackroll, Triggerpoint Roll, etc.) as well as Lacrosse balls and resistance bands are easy to use in the studio and will help you remain balanced in the long run.
Shock wave therapy as well as injections of autologous platelet rich plasma (PRP) are advanced (and relatively costly) treatments available to promote tendon healing. Your doctor or a sports medicine specialist will advise you if they are recommended in your case.
Do you have a problem with your patella tendon and want to have it sorted out? These are the next steps:
- See a doctor
Dancers seek help from various different kinds of therapists, many of whom may employ treatments that are outside of mainstream medicine. Before considering the use of such alternative medicine, you should see a doctor for an evaluation and diagnosis.
Finding a doctor who is familiar with the specific medical issues faced by dancers is often challenging and you may need to see several different specialists in order to get a full picture of your diagnosis. A good place to start is to ask your friends and fellow dancers for the names of their favorite doctors.
- Find a specialist in manual medicine
Doctors who specialize in manual medicine practice a whole-body approach. They will try to identify and specifically treat the underlying causes of your problem, rather than just the localized symptoms. This approach is important in addressing all aspects of the often very complex overuse problems that dancers experience. A specialist in manual medicine will perform a functional examination on every part of your body and will treat you according to these thorough findings.
To find a physician who specializes in this field, search for “Manual Medicine”, “Osteopathic Manipulative Medicine” or “Osteopathic Physician” on the internet.
- Start working on your problem
There is a lot that you can do to work on your problem after a proper diagnosis has been set. Ultimately, it often comes down to addressing the same fundamental issues. Here are some useful exercises that I recommend to my patients:
Please refer to your doctor to confirm that the exercises you choose to do are suited to your individual problem, and obtain supervision from a professional trainer to ensure that you are performing them correctly. A patellar strap may help to control pain while you exercise.
- Talk to your ballet master or dance teacher
Technical issues and faulty dance technique are important predisposing factors of overuse and injury in dancers. Amending dance techniques often plays a crucial role in the treatment and prevention of overuse and injury and you should not hesitate to address any issues, if necessary.