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Chronic tendinopathy is a common musculoskeletal disorder that frequently affects athletes who train and compete at all levels. This Clinical Commentary presents a review of the etiology, incidence, and contributory factors related specifically to patellar tendinopathy. Examination and differential diagnosis considerations are provided, and an evidence-based, staged rehabilitation program is described.
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North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 166
Chronic tendinopathy is a common musculoskeletal disorder that frequently affects athletes who train and
compete at all levels. This Clinical Commentary presents a review of the etiology, incidence, and contribu-
tory factors related specifically to patellar tendinopathy. Examination and differential diagnosis consider-
ations are provided, and an evidence-based, staged rehabilitation program is described.
Key Words. Jumper’s Knee , patellar tendonitis
Hardin-Simmons University Physical Therapy Department,
Abilene, TX, USA
Texas Tech Health Science Center, Lubbock, TX, USA
Marsha Rutland , PT, ScD, OCS, COMT, CSCS
Dennis O’Connell , PT, PhD, FACSM, CSCS
Jean-Michel Brismée , PT, ScD, OCS, FAAOMPT
Phil Sizer , PT, PhD, OCS, FAAOMPT
Gail Apte , PT, ScD,COMT
Janelle O’Connell, PT, PhD, DPT, ATC, LAT, CEEAA
Marsha Rutland, Hardin-Simmons
University, 2200 Hickory, Abilene, TX 79698
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 167
Chronic tendinopathy is a common musculoskeletal
disorder affecting both recreational and elite ath-
letes potentially leading to disability lasting several
months. Overuse tendon injuries account for 7% of
the injuries seen in United States physician offices
and 40% of knee injuries in volleyball players.
Chronic patellar tendon conditions, also known as
patellar tendinosis or “jumper’s knee”, are numer-
ous in elite athletes who run and jump as in volley-
ball (44%) and basketball (32%).
Similar activity
occurs in soccer and dancers, who also participate in
repetitive kicking, jumping, and landing.
2 , 3
A higher
prevalence is noted in sports with high impact bal-
listic loading of the knee extensors.
This disorder is
a nemesis in weight lifters due to recurrent heavy
load squatting.
Patellar tendon overuse is also seen
in military recruits, accounting for 15% of all of their
soft tissue injuries
and up to 22% incidence in the
overall athletic population.
Microtrauma can occur when the patellar tendon is
subjected to extreme forces such as rapid accelera-
tion -deceleration, jumping, and landing.
The pos-
terior proximal patellar tendon is subjected to
greater tensile tendinous forces as compared to the
anterior region, especially with jumping activities
and deep squat exercises, with forces up to 17 times
body weight being placed on the patellar tendon in
Olympic weight lifters.
2 , 4 , 6 , 7
Patellar tendinopathy
occurs more frequently in those skeletally mature
adolescents or adults, ranging from ages 16-40
8 10
There is disagreement as to whether the
incidence is more common in males than females,
although recent studies show equal occurrences in
both genders.
2 , 11 , 12
Acute tendinitis involves an active
inflammatory process, often occurring following an
injury, which if treated, properly heals in 3-6 wks.
In contrast, chronic patellar tendinopathy, also
referred to as patellar tendinosis, manifests itself
after 6 wks-3 months as degenerative changes occur
in the tendon
13 , 14
These changes include absence of
inflammatory cells in the tendon, a tendency toward
poor healing, and decreased quality and disorganiza-
tion of collagen fibers, both of which may lead to
decreased tensile strength.
13 , 14
Additionally, neovas-
cularization, the growth of new vasculature in areas
of poor blood supply, is common in chronic tendi-
nopathy and may contribute to pain perception.
13 , 15
While the relationship between pain perception and
neovascularization is not clearly understood, it is
believed that increased levels of the neurotransmit-
ter glutamate may play a role.
Overuse in athletes
who continue to push past pain may contribute to
the development of a chronic and problematic con-
dition taking 3-6 months to heal.
Many factors, both intrinsic and extrinsic, contribute
to patellar tendinopathy.
11 , 12
Intrinsic factors such as
strength imbalance,
1 , 12
postural alignment,
11 , 12
11 , 12
reduced ankle dorsiflexion,
and lack
of muscle strength or flexibility
may play a role.
However the primary cause appears to relate to the
extrinsic factor of overuse. For example, an increased
physical load, repetition, intensity, frequency, and or
duration of greater than 10% per week in the training
schedule all contribute to this overuse syndrome.
Additionally fatigue, poor technique, and training
errors may play a role in this disorder.
20 , 21
extrinsic etiologic considerations for injuries may
include improper training surfaces, insufficient foot-
wear or inappropriate equipment.
physical loading, high intensity training, or repeti-
tive loading too fast may contribute to the develop-
ment of patellar tendinopathy.
This microtrauma
or “overuse” injury develops from repetitive mechan-
ical loading of the tendon through excessive jump-
ing and landing activity. Training duration within a
session or a season is the most common reason for
Drastic changes in frequency and or inten-
sity of training may also lead to overuse training
A general rule of thumb for acceptable pro-
gression of training is a 10% increase in intensity,
duration, and frequency per week.
The purpose of the evaluation is to differently diag-
nose between conditions affecting the patella. A com-
prehensive evaluation includes detailed examination
of both intrinsic and extrinsic factors. A detailed his-
tory of a patient’s workout schedule and duration of
symptoms is paramount to making a correct diagno-
sis. If symptoms have lasted longer than 6 weeks, ten-
dinopathy should be suspected. Evaluation of chronic
patellar tendinopathy should include the utilization
of Blazina’s knee scale
or Kennedy’s scale
( Table 1 )
which both assist the rehabilitation professional to
gauge the severity of the tendinopathy. Patients with
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 168
Stage 1: Initial Rehabilitation Controlled
Controlled rest is critical in the recovery of patellar
tendinopathy. During this phase of rehabilitation,
the athlete should refrain from sports activity or
abstain from the overuse abuse, and practice con-
trolled exercise without load.
11 , 27
During this phase,
patient education regarding activity is paramount. It
is critical to recovery to avoid jumping or deep squat-
ting ( Table 2 ) . Progressing to relatively pain free
activities, such as stationary cycling, performing
exercises on a Total Gym®, or working in an aquatic
environment can help maintain physical stamina,
and yet unload the tendon. Kennedy et al
23 , 28
gested subjects with pain in stage 1 tendinopathy
(pain only after activity) or stage 2 (pain during and
after activity) adapt their training schedule, whereas
subjects in stage 3 (pain during and after workouts
that affects performance) may need total rest from
aggravating activities. The athlete in stage 3 may
still exercise aerobically, but must avoid irritating
23 , 28
Visnes et al
reported that volleyball
players who continued to train and compete during
an eccentric rehabilitation exercise program showed
no benefit from rehabilitation exercises. Therefore,
Visnes et al
suggested that patients be removed
from sports participation while undergoing an
eccentric-only rehabilitation program, then resume
competitive sports training after 8 weeks, with a
gradual return to sporting activity over the next 4
29 , 30
patellar knee pain may grade pain as general achi-
ness after activity (Blazina Stage 1) to pain during and
after activity which interferes with competition (Bla-
zina Stage 3). Total tendon disruption is present in
Blazina Stage 4.
Physical examination during all stages reveals ten-
derness to palpation and pain over the inferior pole
of the patella
and possibly in the body of the ten-
Thickness of the tendon may be noted also in
all stages, but it is rare to see effusion. Pain in the
patellar tendon may be reproduced with resisted
knee extension.
Additional functional tests of
ascending or descending stairs, performing single leg
declining squats, jumping or hopping will most likely
reproduce patellar pain symptoms.
Patients such as
weight lifters may complain of a “giving way” or a
perception that knee will “buckle” under load as well
as stiffness or achiness after activity.
they may complain of stiffness or achiness after
activity (Blazina stage 3 or Kennedy Stage 4).
The evaluation should include history, age and any
recent growth spurts, location of pain, and special
tests. The rehab professional should be able to dif-
ferentiate between patellar tendinopathy and addi-
tional diagnoses of 1) patellofemoral dysfunction
(more diffuse patellar pain),
2) Sinding-Larsen-
Johansson Syndrome(skeletally immature adoles-
cents with pain in the inferior pole of the patella),
and 3) Osgood Schlatter’s disease (skeletally imma-
ture adolescents with pain at the attachment of
patellar tendon at the tibial tubercle with possible
tibial tubercle enlargement).
Table 1. Scales to assist in evaluating patellar tendinopathy.
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 169
Table 2. Progression of rehabilitation exercises for patellar tendinopathy.
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 170
may contribute to tendon overload during jumping
and landing activities.
Lower extremity stretching
of 15, 30, 45, or 60 seconds or 2 minutes produces
significant gains in flexibility in healthy young or
middle age adults.
40 , 41
Static stretching of 30 seconds
at least three to four times per day is recommended
by various authors.
34 , 40 , 41
Soft tissue mobilization (STM) is used to reduce pain
and fibrotic limitations in tissue found in patellar
Deep transverse friction massage
for 5-10 minutes twice daily is recommended to help
promote normalized collagen alignment.
43 45
found that firm pressure during cross friction mas-
sage is more effective than light to moderate pres-
43 , 44
Use of a rigid instrument, such as a stainless
steel or hard plastic tool, may provide accelerated
early tissue level healing in ligamentous and tendi-
nous injuries ( Figure 1 ) .
45 , 46
Furthermore, STM applied
transversely to the line of collagen fibers while the
tissue is placed under tension may assist damaged
tissue to regain tensile strength and proper fiber ori-
entation in the early stages of healing.
Patients can
be educated to perform STM daily until tissue is nor-
malized and pain is absent with palpation.
Eccentric exercises play an important role in chronic
patellar tendinopathy rehabilitation. Performing
eccentric squats on a 25° decline board for 3 set of
15 repetitions twice daily is suggested.
2 , 22 , 23 , 25 , 36 , 37 , 47
Loading a tendon in a controlled environment
free from overuse with progressive stress improves
Rehabilitation incorporates three stages ranging
from limited partial weight bearing loaded exercise
to a sports specific return to play protocol. Since
overuse is a primary contributor to patellar tendi-
nopathy, it is important to avoid rapid progression in
frequency, intensity, and duration in rehabilitation
and functional progression.
Since most athletes
with patellar tendinopathy are treated non-opera-
it is imperative to understand rehabilitation
protocols and implement them wisely. Eccentric
exercise has been promoted as an important conser-
vative treatment choice for patellar tendinopa-
2 , 32 , 33 , 34 , 35 , 36
as well as for Achilles tendinopathy.
37 , 38
However, a variety of protocols have been imple-
mented for rehabilitation intervention.
2 , 25 , 32 37
example, the Alfredson protocol
of eccentric exer-
cise intensity to pain level up to 5/10 directly con-
trasts the early work of Stanish and Curwin
suggest that exercise only be performed without
pain. Because no standard rehabilitation protocol
has been established as it relates to pain symptoms
secondary to tendinopathy, the following protocol
has been developed by this author, involving a pain-
free intervention progressing from partial body
weight to full body weight positions.
Initial treatment for patellar tendinopathy includes
the following: absence from jumping, relative rest
(absence of abuse),
stretching of lower extremity
musculature, deep transverse friction massage of
the patellar tendon, eccentric quadriceps exercises,
strengthening of hip and knee musculature, utiliza-
tion of a patellar orthotic (if needed), and cryother-
apy. Since patellar tendinosis is a chronic, non-acute
condition, inflammation is absent. Thus, anti-inflam-
matory medications (NSAIDs) are seldom effective.
Additionally, the use of cortisone injections may
negatively affect tendon strength and may possibly
result in tendon rupture.
Prior to initiating exercise, a warm-up and stretching
period is recommended.
Cycling on a stationary
bicycle for 5-10 minutes with minimal resistance is
suggested as an active warm-up. Next, stretching
should be incorporated into the program before and
after the exercise routine in order to address any
flexibility imbalances ( Table 2 ) . Hip flexor, quadricep,
hamstring, and gastrocnemius and soleus tightness
Figure 1. Soft tissue mobilization. 1a: Deep friction with use
of device (longitudinally). 1b: Deep friction with use of device
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 171
tendon function.
A controlled tendon loading exer-
cise program can be initiated through utilization of a
Total Gym® ( Figure 2 ), Shuttle® ( Figure 3 ), or a pool.
Using a decline board, more specifically targets the
patellar tendon (25-30% higher patellar tendon
as compared to squats performed on flat
surfaces which more likely targets the quadriceps
muscle. This specificity of tendon training allows
the patient to progress faster than on a squat on flat
surface secondary to a better isolation of the knee
extensor mechanism. The patient performs partial
weight bearing eccentric squats in a pain-free range
of motion by placing a 25° decline board on a Total
Gym® ( Figure 2 ) or Shuttle® ( Figure 3 ). Progression
occurs as the angle of the Total Gym® or the resis-
tance on the Shuttle® is increased. Likewise, a simi-
lar approach can be used in the pool with a decline
board on the pool floor in shoulder deep water. Pro-
gression occurs from moving to waist deep water,
then shallower hip deep water.
A patient is ready to progress when they can easily
complete the 3 sets of 15 repetitions of eccentric
squats on a decline board pain-free. As one improves,
decline squats can increase in difficulty from
bilateral eccentric to unilateral eccentric, then to
concentric-eccentric contractions,
37 , 49
During the
concentric phase of the squatting motion, initially
one should use the unaffected leg to extend the knee,
then lower eccentrically bilaterally; progressing to
Figure 2. 2a: Patient initiates knee extension concentrically
by extending the unaffected extremity. 2b: Progression to
bilateral eccentric lowering with both lower extremities 2c:
Progression to full weight bearing on the affected extremity
eccentrically descends to at least a 60° angle.
Figure 3. Unloaded squats can be performed on a Shuttle®.
If signifi cant pain with eccentric lowering, eccentric squats
can performed bilaterally.
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 172
single limb eccentrics using the affected leg. Addi-
tionally, speed should be addressed throughout
rehabilitation. Bilateral slow speed decline squats
are encouraged during the first week of rehabilita-
tion while faster speeds are encouraged during the
second week. Although pain reported by the patient
of up to level 5/10 on the Visual Analog Scale is com-
mon with some of the documented eccentric pro-
gressions of exercise,
37 , 49
other authors have found
exercising without induced pain to be beneficial to
34 , 50
This non-painful protocol may benefit
the non-athlete as well. Sayana et al
found only
56% of non-athletic subjects benefitted from full
weight bearing eccentric painful squat exercises.
Therefore, this pain-free protocol is recommended
by the author of this commentary for all individuals
with patellar tendinopathy.
Squatting depths are controversial among health
professionals and coaching instructors. Squatting
should be limited to no greater than 60-70° knee
51 , 52 , 53
due to the excessive forces on the patel-
lofemoral joint, patellar tendon, and the meniscus,
although some studies encourage full depth squats
to 90 degrees.
30 , 36
Other patellar tendinopathy proto-
36 , 53
had subjects performing squats slowly to
60° and 70° knee flexion respectively. Dillon et al
found significantly greater forces on the posterior
fascicles of the patellar tendon between 60-90° of
squatting. Squatting depths can be easily controlled
on a Total gym®, Shuttle®, or in the upright, full-
weightbearing position.
A proximal hip and thigh strengthening program
including “around the world” leg raises (straight leg
raises, sidelying hip abduction /hip adduction and
prone hip extension) with concentration on eccentric
lowering is important ( Figure 4 ) . Hip strengthening
exercise with a 2 second concentric leg lift, followed
by a 4 sec eccentric leg lowering is encouraged. Hip
strengthening exercises (with no weight initially)
combined with the decline eccentric squats should be
an essential element of injury and rehabilitation pro-
55 57
Education of the patient to perform exer-
cises at home is also key to full recovery.
Although ice has been shown to reduce inflammation
in acute conditions, varied results are found with the
use of ice in chronic conditions.
34 , 58
Ice massage for
Figure 4. “Around the World” leg raises. 4a. Straight leg
raise 4b. Hip Abduction side leg raise 4c. Hip adduction inside
leg raise 4d. Hip extension prone leg raise.
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 173
through a weighted belt, vest or bag, or by using a
backpack with weights. Once the subject can per-
form decline squats easily and without pain,
weights can be added in 5 kg increments, starting
with 10% of body weight.
Double leg jumping
squats on the Shuttle® or Total gym® may be initi-
ated at weeks 4-5 at a progressive resistance level
that does not produce patellar pain. The stretching
program as well as the “around the world” leg raise
routine using progressive ankle weights (1-2# per
week) should be continued. Additionally, deep-fric-
tion massage and ice following exercise should be
5 minutes or ice pack to the patellar tendon can be
applied for up to 10 minutes following the exercise
Knobloch et al
found intermittent cryo-
therapy of 3 sets of 10 minutes significantly decreased
local Achilles tendon mid-portion capillary blood flow
by 71%, thus promoting venous capillary outflow
in the tendon. Many common modalities, such as
60 , 61
and electrical stimula-
62 , 63
have not been found to be effective in treat-
ment of chronic tendinopathy. Extracorporeal shock
wave therapy (ESWT) for patellar tendinopathy
shows promise as a safe treatment based upon a lit-
erature review of seven studies, although no specific
treatment regime is recommended.
A systematic
review of low level laser treatment (LLLT) shows
potential effectiveness for treating tendinopathy when
recommended dosages are used.
Orthotics or taping may be beneficial for patellar
tendinosis. The Chopat® strap, or other varied patel-
lar tendon straps can help stabilize the tendon with
jumping activities, and may be used during rehabili-
tation. Although various authors
25 , 66 68
suggest use of
such orthotics, no randomized controlled trials have
been conducted examining their efficacy in patellar
tendinosis, and therefore evidence is lacking to the
effectiveness of a patellar strap. Further research
need to be conducted regarding the use of such
Stage 2: Progression
After pain symptoms decrease, progress the patient
to upright 25 decline eccentric squats (3 sets of 15
repetitions twice daily), utilizing the bilateral- uni-
lateral- eccentric-concentric progression as outlined
previously. The eccentric exercise program should
be progressed from partial-weight bearing to full
weight bearing ( Figure 5 ), then to weighted resistance
using a back pack or weighted vest ( Figure 6 ) . Speed
can be increased during the concentric-eccentric
phase, finally progressing to more ballistic type
activity (jump squats) to prepare for return to func-
tional activities. Once symptoms have subsided,
patients with tendinopathy should be encouraged to
continue eccentric strengthening exercise even after
their return to sport.
As previously mentioned, resistance weight may
be added to the single squat eccentrics, either
Figure 5. Decline squats. 5a. Ascending to upright can be
performed with the majority of weight on the unaffected leg.
5b.Upon descent, full weight is placed on the affected extrem-
ity as the patient eccentrically lowered to at least a 60° angle.
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 174
Avoidance of sports activity during the first 8 weeks
is crucial for continued healing. Those who have
continued to train and compete in sports activities
during treatment progression have demonstrated
little change in prognosis.
Stage 3: Sports Specifi c:
Return to Play
In this phase, the athlete should continue the above
routine, adding more weight in 5 kg increments with
the weighted eccentric decline squats. Progression
to a drop squat, involving rapidly eccentrically drop-
ping into a stationary squat position, should include
3 sets of 20 reps with incremental weight as above.
Three sets of 15 repetitions daily of eccentric step
downs off of 4, 6 and 8 height steps performed
with minimal to no discomfort are appropriate as
well ( Figure 7 ) .
Jumping activities can then be
added to this routine. Progression of double leg
jumping squats (involving concentric and eccentric
jumping in a squat position repetitively) on the
Shuttle® or Total gym® to a single leg jump should be
initiated before beginning standing jumps. Follow-
ing pain-free movement off of the 6-8 step down,
progress to drop jumps.
34 , 69
Progression includes
drop jumping off small step (4), progressing to 6
and 8 steps when 3 sets of 20 repetitions daily are
maintained. At 4 weeks, slow pain-free jogging on
flat ground, as well as resisted cycling or water jog-
ging can be added.
Figure 6. To progress patient, add weighted backpack.
Figure 7. Step Downs. 7a. Step down off 4 step. 7b. Step down off 8 step.
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 175
position at a dosage of 3 sets of 15 repetitions twice
daily for 12 weeks. Progressive jumping activities
are added midway through the program. Other con-
siderations may include slow progression back to
sporting events after 2-3 months, assuming the ten-
don site is pain-free in all activities.
A variety of rehabilitation techniques are necessary
to assist an individual in returning to recreational
activities following patellar tendinopathy. A combi-
nation of active rest, education, eccentric exercise,
progressing the training regime by 10% weekly, and
modifying activity have all been found to be effec-
tive in tendinopathy treatment.
19 , 70
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29 , 30 , 36 , 53
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... Malliaras et al. [29] contend that the treatment of PT should focus on progressively developing load tolerance of the tendon with exercise and that other modalities are only beneficial as an adjunct to exercise therapy. Rutland et al. [63] agreed and stated that active rest, activity modification, and eccentric exercise are cornerstones of PT management. ...
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Patellar tendinopathy is a common injury characterized by progressive activity-related anterior knee pain. It is highly prevalent in sports which involve jumping and changing direction. The aim of this paper is to review recent high-quality evidence regarding the effectiveness of physical therapy in the treatment of patellar tendinopathy. Randomized controlled trials (n = 22) researching the effects of exercise therapy, physical agents, and soft tissue techniques were included. The results show that exercise therapy is the most effective. While eccentric exercise is commonly used, very promising progressive tendon-loading exercise therapy programs are recently emerging. Extracorporeal shock wave therapy, dry needling, and orthoses are no more effective than eccentric exercises or placebo groups. Isometric and isotonic exercise, patellar strap, sports tape, and kinesiotaping have a short-term effect on functional improvement and pain reduction, while progressive tendon-loading exercise, dry needling, platelet-rich plasma, and extracorporeal shock wave therapy have long-term effects.
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Background: Jumper’s knee is a degenerative condition among athletes, and it has been treated with conventional physical therapy (CPT). Ultrasound guided dry needling (USG-DN) is a relatively new technique to explore clinical outcomes in patients with tendinopathy. Methods: This parallel group, single-blinded randomized controlled trial was carried out involving 94 athletes with clinically diagnosed jumper’s knee, divided into an intervention group (USG-DN + CPT, n = 47) and a control group (CPT, n = 47). Participants received a 4-week programme; the intervention group received ultrasound guided patellar tendon dry needling (DN) in conjunction with CPT. The control group received only CPT. The visual analog scale (VAS), Victorian institute of sports assessment-Patellar tendinopathy (VISA-P) questionnaire, Lysholm scale, Knee injury and osteoarthritis outcome score (KOOS) and ultrasonographic features of patellar tendinopathy were evaluated at baseline,1 week, 2 weeks, and 4 weeks. The data were analyzed through SPSS-26. Results: The study found statistically significant differences (P < 0.05) regarding VAS, Lysholm, VISA-P, and KOOS scales at baseline, 1st, 2nd, and 4th week post-intervention. Within-group differences also showed statistically significant results after the intervention. There were significant results observed in ultrasonographic outcomes between both groups at 1 month post-intervention (all P < 0.05). Conclusion: The results of the current study suggest, ultrasound guided DN of patellar tendon in combination with CPT reduced pain, improved function, and showed a tendency to decrease tendon thickness in patients with patellar tendinopathy. Clinical Trial Registration Number: (IRCT20210409050913N1). Dated: 17.04.2021.
This chapter starts with a brief description on the pathophysiological process after spinal cord injury and peripheral nerve injury and then focuses on the bio‐fabricated products that aid neural regeneration in central and peripheral nervous systems. Discussion on the mechanism of these products is also included. In the peripheral nervous system, the neural regeneration scaffolds improve the functional recovery after injury by rebalancing the microenvironment: (i) the overactive immune responses, (ii) the inefficient metabolic processes, (iii) the insufficient microcirculatory support, and (iv) the loss of bioelectrical signal conduction. In the central nervous system, the neural regeneration scaffolds (nanoparticles, electrospun fibers, and self‐assembled peptides) are reviewed, and the mechanism can be generally divided into three aspects: (i) to alleviate the inflammatory stress, (ii) to overcome the inhibitory effects, and (iii) to promote axonal regeneration. Finally, this chapter discusses the clinical application and evaluation of the neural regeneration scaffolds.
Tendons connect muscles to bones and transmit forces to maintain position and produce locomotion. Chronic and acute tendon injuries are very common and result in considerable pain and disability and incapacitating people in their daily life. The available therapies in clinical practice are of limited and disputed clinical effectiveness because of the lack of understanding of tendon biology and cellular and molecular mechanism of tendon injuries. Human and animal models have been studied for tendon repair following injury. These studies have highlighted the physical modalities, mechanical loading and mobilization, specific cytokines, and growth factors that involved in tenogenesis during developmental and repair processes, tissue engineering, and adhesion prevention. Understanding the association between various managements and biological parameters involved in tendon development, homeostasis, and repair is crucial for treatment optimization for chronic and acute tendon injuries.
Patellar tendinopathy (PT) is a common nontraumatic orthopaedic disorder of the knee suffered by many service members. Understanding the make-up of usual care for PT at the system level can better frame current clinical gaps and areas that need improvement. Exercise therapy is recommended as a core treatment for PT, but it is unclear how often it is used as a part of usual care for PT within the Military Health System (MHS). The purpose of the study was to identify interventions used in the management of PT and the timing of these interventions. A secondary purpose was to determine if exercise therapy use was associated with reduced recurrence of knee pain. In total, 4,719 individuals aged 17 to 50 years in the MHS diagnosed with PT between 2010 and 2011 were included. Pharmacological and nonpharmacological interventions, visits to specialty providers, and imaging services were captured. Descriptive statistics were used to report the findings. Interventions were further categorized as being part of initial care (within the first 7 days), the initial episode of care (within the first 60 days), or the 2-year time period after diagnosis. Linear regression assessed the relationship between the number of exercise therapy visits in the initial episode of care and recurrences of knee pain. In total, 50.6% of this cohort had no more than one medical visit total for PT. Exercise therapy (18.2%) and nonsteroidal anti-inflammatory drugs (4.3%) were the two most used interventions in the initial episode of care. Radiographs were ordered for 23.1% of the cohort in the initial episode of care. The number of exercise therapy visits a patient received during the initial episode of care was not associated with recurrences of knee pain. Half of the individuals received no further care beyond an initial visit for the diagnosis of PT. Exercise therapy was the most common intervention used during the initial episode of care, but exercise therapy did not influence the recurrence of knee pain.
Aim: Determining the effectiveness of the developed comprehensive physical rehabilitation program for athletes with chronic patellar tendinopathy. Materials and Methods: Participants were randomly divided into the main and control groups consisting of 11 people each. The complex rehabilitation program in the main group combined laser therapy and different types of therapeutic exercises, in the control group the laser therapy was excluded. The effectiveness of the intervention was evaluated by the intensity of pain in the patella (Visual Analog Scale) and the functional ability of the knee (VISA-P scale). Results: At the end of the intervention, a significant reduction in pain was observed in both groups. The average scores on the VAS scale were reduced to 2.0 points in the main group and to 3.5 in the control one. The share of patients, whose pain was eased, was 27.27 per cent in the main group, in the control group such people were not detected. After two months of intervention according to the results of the VISA-P scale in both study groups, there was an improvement in the functional capacity of the knee joint. Thus, the average number of points increased by 30.5 points in the main group, and by 12.0 in the control one. Conclusions: The use of high-frequency laser therapy in a comprehensive program of physical rehabilitation of patients with patellar tendinopathy shows better results for reducing pain and improving the functioning of the knee joint than without it. We believe that high-frequency laser therapy can be used as an important adjunct to various types of therapeutic exercises in the comprehensive rehabilitation of patients with patellar tendinopathy.
Patellofemoral disorders are common causes of knee pain that result in frequent visitations to musculoskeletal care clinics. Patellar tendinopathy, patellar instability and patellar maltracking, and pain are some of the most common pathologies resulting in patellofemoral dysfunction. For each of these diagnoses, there are unique orthoses and braces available, some of which are uniquely designed to address the pathology involved. While the spectrum of patellofemoral disorders is wide ranging and can often be challenging to treat, bracing frequently plays a large role in the overall treatment algorithm. In this article, we summarized the current literature and treatment recommendations related to the most common types of patellar braces. We performed a thorough review of randomized controlled trials and up to date literature to reach well-informed conclusions on current best practice regarding the uses of patellar braces for patellofemoral disorders.
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Cheerleading is a highly popular youth sport in the United States and has been increasingly recognized in recent years for its athleticism and competitive nature. The sport has changed dramatically since its inception. When the sport of cheerleading was first developed, its primary purpose was to entertain crowds and support other athletes. Today, cheerleaders are competitive athletes themselves. Cheerleaders, most of whom are in the pediatric age group, and their parents commonly approach orthopaedic surgeons and sports medicine physicians with questions regarding the risks associated with participation in the sport. Appropriate clinical guidance is especially important for athletes returning to the sport after an injury. However, unlike other popular sports (eg, football, basketball, and volleyball), the intricacies of cheerleading are not well-known to those outside the sport, including many health care providers. Previous studies have reported on the epidemiological patterns of injuries associated with cheerleading and how such aesthetic sports affect the body, finding that fractures and concussions are prevalent and that catastrophic injuries are more common than in most other sports. Here, we provide an evidence-based discussion of 10 pertinent topics regarding cheerleading and its risks to the musculoskeletal system. The purpose of this review is to provide a comprehensive resource for orthopaedic surgeons and sports medicine physicians who care for these athletes.
Overuse injuries result from cumulative trauma or many repetitive minor insults and can lead to loss of playing time, physiologic exhaustion, and pain. Overuse injuries typically present with a gradual onset of pain, masking the true severity of the injury. Female athletes have an increased risk of overuse injuries compared with male athletes. It is important to identify and properly manage these types of injuries in order to allow athletes to return to sport safely. This chapter provides an overview of the various types of overuse injuries affecting female athletes.
Anterior knee pain is a common problem in daily practice and is associated with a high morbidity and rate of chronification. The legislature created a basis for the use of digital health applications with the “Digitale-Versorgung-Gesetz” (Digital Healthcare Act). In cooperation with Deutsche Kniegesellschaft (German Knee Society), a mobile application as an advertisement-free medical product class 1 based on the current evidence is created for continuous 12-week exercise therapy for the indications patellofemoral pain syndrome, patellar dislocation and patella tendinopathy. The digital library provides additional information about disease pattern, coping with pain and behavioral strategies. A multicenter randomized controlled study to examine the medical benefits has started.
Conference Paper
Musculo tendinous injuries are frequent pathologies in sport medicine. Rest and classical treatments are, very often, not enough to succeed a good healing and return to sport activities. The aim of this prospective study is to demonstrate the interest of eccentric isokinetic exercise in the treatment of sub acute injuries of the calcanean tendon and of the thigh muscles. Complementary with classical kinesitherapy treatment, isokinetic work allowed a complete healing and return to anterior sport activities, without any recurrent injuries for a majority of the patients. We suggest in conclusion a specific protocol to care these pathologies using an isokinetic dynamometer in eccentric mode.
Background Eccentric training has been demonstrated to decrease pain in patients with Achilles tendinopathy. Whether an Achilles wrap in addition to eccentric training changes parameters of tendon microcirculation in insertional and midportion tendinopathy is not known. Study Design Randomized clinical trial; Level of evidence, 2. Methods One hundred twelve subjects were recruited. A laser Doppler system assessed capillary blood flow, tissue oxygen saturation, and postcapillary venous filling pressure. Group A performed daily eccentric training for 12 weeks with additional daily Achilles wrap (AirHeel™, 54 tendons of 54 patients), while group B performed the same eccentric training only (64 tendons of 59 patients). Results Ninety-one patients (81%) completed the 12-week training period. Tendon oxygen saturation increased significantly in group A at the insertion (70% ± 11% to 75% ± 7%, P = .001) and distal midportion (68% ± 12% to 73% ± 9%, P = .006); this increase was greater than that in group B (69% ± 11% vs 68% ± 15%, P = .041 vs A). Postcapillary venous filling pressures were significantly reduced in group A at 5 of 8 positions at 2 and 8 mm tendon depths (up to 26%, P = .003), while only in 3 of 8 positions in group B (up to 20%, P = .001). Pain on the visual analog scale was 5.1 ± 2.1 vs 3.2 ± 2.7 (A,–37.3%, P = .0001) and 5.5 ± 2.1 vs 3.6 ± 2.4 (B, P = .0001,–34.6%) (P = .486 for A vs B). Conclusion Tendon oxygen saturation was increased, and capillary venous clearance facilitated using an Achilles wrap in addition to a daily 12-week eccentric training program. Achilles wrap and eccentric training increased subjective assessment of Achilles tendinopathy, while pain level reduction remained the same in both groups.
This article presents an assessment and treatment procedure for work with soft tissue injuries. It focuses on aims of treatment following soft tissue injury; the healing process; and formulation of an assessment and treatment concept. A case study is included. The conclusion is that more research is needed into the effect of mobilisation on soft tissue injury.
Patellar tendinopathy disrupts athletic careers in several sports and is resistant to many forms of conservative treatment. Outcome after conservative treatment has been minimally investigated, and the effect of these treatments on the pathology of overuse tendinopathy are not well understood. The clinical assessment of patellar tendinopathy appears straightforward, but evidence suggests that the importance of imaging and palpation in diagnosis and ongoing assessment may be overestimated. There is a lack of clinically relevant research on which to base treatment. However, the principles of management for patellar tendinopathy derived from clinical experience include load modification, musculotendinous rehabilitation, and intervention to improve the shock absorbing capacity of the limb. The role of electrophysical agents, massage, and stretching in the treatment of patellar tendinopathy are also discussed. The progression of treatment is based on clinical grounds due to a lack of reliable subjective and objective tools to assess recovery. The failure of some conservative programs could be due to either athlete compliance or practitioner expertise. The management of patellar tendinopathy is complex, and if the physiotherapist addresses all the principles of treatment, the chance of success could be increased.<br /
“Jumper's knee” (patellar or quadriceps tendinitis) appears to be increasing in incidence in both athletic and recreational activities. The clinical and therapeutic aspects of this phenomenon are described. Much more information needs to be elicited before the symptom complex and its treatment can be formally defined.
Objective. To investigate the reliability and validity of five squat-based loading tests that are clinically appropriate for jumper's knee. The loading tests were step up, double leg squat, double leg squat on a 25-degree decline (decline squat), single leg decline squat, and decline hop. Design. Cross-sectional controlled cohort. Subjects without knee pain comprised controls, those with extensor tendon pain comprised the jumper's knee group. Setting. Institutional athlete study group in Australia Participants. Fifty-six elite adolescent basketball players participated in this study, thirteen comprised the jumper's knee group, fifteen athletes formed a control group. Intervention. Each subject performed each loading test for baseline and reliability data on the first testing day. Subjects then performed three days of intensive (6 h daily) basketball training, after which each loading test was reexamined. Main outcome measures. Eleven point interval scale for pain. Results. The tests that best detected a change in pain due to intensive workload were the single leg decline squat and single leg decline hop. This study found that decline tests have better discriminative ability than the standard squat to detect change in jumper's knee pain due to intensive training. The typical error for these tests ranged from 0.3 to 0.5, however, caution should be exercised in the interpretation of these reliability figures due to relatively low scores. Conclusions. The single leg decline squat is recommended in the physical assessment of adolescent jumper's knee. The decline squat was selected as the best clinical test over the decline hop because it was easier to standardise performance. Yes Yes
Patellar tendinopathy causes substantial morbidity in both professional and recreational athletes. The condition is most common in athletes of jumping sports such as basketball and volleyball, but it also occurs in soccer, track, and tennis athletes. The disorder arises most often from collagen breakdown rather than inflammation, a tendinosis rather than a tendinitis. Physicians must address the degenerative pathology underlying patellar tendinopathy because regimens that seek to minimize (nonexistent) inflammation would appear illogical. Suggestions for applying the 'tendinosis paradigm' to patellar tendinopathy management include conservative measures such as load reduction, strengthening exercises, and massage. Surgery should be considered only after a long-term and appropriate conservative regimen has failed.