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If you are a practitioner of some type of physical activity, surely you have ever suffered, or have heard someone complain about the pain caused by their Patellar Tendonitis. Tendinopathies are an increasingly frequent problem among the population, mainly due to the increased participation of the population in sports activities. Within this group, one of the most common injuries is Patellar Tendinitis, also known as “Jumper’s Knee”, as Doctor Blazina named it in 1973. Patellar tendinopathy is characterized by pain that can appear in the lower pole of the patella (1), in the superior pole of the patella (2) or in the tibial tuberosity (3), being the most frequent, representing 65% of the total, the tendinopathy that causes pain in the insertion of the inferior pole of the ball joint.
Tendinitis or tendinosis?
Tendons are the elements responsible for transmitting the energy generated in the muscles to the bones, thus generating joint movement, with minimal energy loss. To do this, tendons have characteristics such as great tensile strength, very good elasticity and an optimal capacity to withstand stretching forces. As you can see in the image, the tendons can undergo deformations of up to 4% or 5% of their length without problems, but when the tendon undergoes repeated mechanical loads above this elastic limit, cumulative micro-injuries are generated that, over time , Weaken the tendon structures, and affect the architecture of the tendon, making it softer, depleting its collagen fibers and showing signs of degeneration and sometimes micro-ruptures. All without the presence of inflammatory cells.
As a consequence, we cannot say that patellar tendinopathy is tendinitis (which would be an inflammatory process), but rather Tendinosis, first described by Puddu in 1976 as “Degenerative tendon disease, without clinical signs of inflammation and with cellular changes that alter the properties of this fabric. ” This degeneration causes pain that is due not to inflammation, but to the presence of microlesions, the accumulation of substances such as glutamate or substance P, and hypervascularization.
In the following image you can see the difference between a normal tendon and a tendon that suffers from tendinosis, and you will understand why this degenerative process hurts so much. On the left you can see a healthy tendon and on the right a tendon with signs of degeneration typical of tendinosis.
- Pain in the lower pole of the patella, upper pole of the patella, or tibial tuberosity
- Partial functional inability to exert effort with that leg
- Sometimes loss of muscle mass in quadriceps and twins
STAGES ACCORDING TO THE SERIOUSNESS OF THE INJURY
- Stage 1: Pain only after activity, without functional alteration
- Stage 2: Pain during and after activity, although you will still be able to exercise normally
- Stage 3: Prolonged and increasing pain during and after activity. Your performance is affected by pain.
- Stage 4: Total rupture of the tendon. Requires surgery
After knowing what Tendinitis is, which you actually now know is Tendinosis, the most important part comes. What to do to get rid of it?
There are various strategies proposed for the treatment of tendinosis, but the most important is patience, since you should know that the tendon has a very slow metabolic activity, a low supply of oxygen (13% of muscle supply) and a low vascularity, what is added that the appearance of the symptoms occurs when the damage has already occurred. For all this, unfortunately, the repair process of a tendon affected by tendinosis tends to take longer than desired.
STRATEGIES TO TREAT ROTULIAN TENDINOSIS
- Therapies with very limited scientific evidence regarding their validity
The evidence at this point is very limited and there are no conclusive studies on the efficacy of these techniques, however, these are the possible effects of these therapies:
Ultrasound: Can improve collagen synthesis and tendon strength under repair
Cyriax: deep cross massage. Used to release adhesions and increase blood flow to the affected area. Without clear scientific evidence to support it.
Nitric Oxide Patches: Could stimulate tendon regeneration and decrease pain
Injections of polidocanol, lidocaine, epinephrine … It seems that there are promising results, but the evidence is not yet sufficient
2. Therapies that work. CRYOTHERAPY, RELATIVE REST AND THERAPEUTIC EXERCISE
You should use it after exercising, and it helps control pain. Never put ice directly on the skin, as this could cause serious burns. 20 minutes of application after exercise seems like a sufficient strategy
While the pain lasts, you should avoid those activities that cause pain or decrease their intensity. It has been proven that reducing activity to zero delays the time of incorporation into activity, since this activity causes muscle atrophy and loss of fitness. In summary, while the treatment lasts, stay as active as you can, avoiding activities that cause pain.
Therapeutic exercise is based on Wolf’s Law and Mechanotransduction. “Human tissue responds to mechanical load with an increase in circulatory and metabolic activity and with an increase in extracellular matrix synthesis.”
Therefore, the key will be to know what type of exercise in particular promotes tendon tissue repair. Since Curwin and Stanish discussed it in 1984, countless authors have found that ECCENTRIC EXERCISE accelerates repair and is associated with normalization of tendon structure.
Let’s see how you can structure the recovery of your patellar tendon
During this phase you should keep relative rest and avoid those activities that produce pain, trying to carry out painless complementary activities of low intensity and long duration, to avoid muscle atrophy.
These are some exercises that will help you. You must do them every day, at the rate of 4 sets of 15 repetitions of each. It is normal that at first you experience a little pain doing them. Supplement these activities with stretches for, especially, the quadriceps, psoas, hamstrings, glutes, calves, and solos.
- Inclined plane eccentric press: You must perform the positive part (push the weight) with both legs and the negative part (bring the weight to the starting position) slowly with the leg. Start using a very light weight, to gradually increase the weight, always based on the non-appearance of pain. Ideally, the best results are achieved with a 25 degree inclined plane placed on the platform.
- Isometric strengthening exercises
You can go to this phase when the exercises in Phase 1 do not cause you any pain. In this phase you will see that you can gradually increase the intensity of your workouts, but always, for the moment, avoiding those situations that cause pain.
You should continue doing rehabilitation exercises every day. Same series and repetitions.
Squat on an inclined plane. Using the 25 degree inclined plane. At first go up with two legs and go down with the injured leg, then, always depending on the pain, you can perform the exercise only with the injured leg, and finally you can add additional weight such as weightlifting discs or a simple backpack. When you can do this exercise without pain, you should gradually increase the speed of execution
- Continue with isometric strengthening exercises, but adding extra resistance with elastic bands or ankle weights. You should also continue the stretching exercises.
This is the phase of readjustment to the activity. Little by little you will be able to return to the workouts you did before getting injured. As the last phase of therapeutic exercise you should include what is called “Eccentric – explosive training”.
You can tackle this last part of the exercises using a raised surface as a base, from which you should let yourself fall and “cushion” the fall as gently as possible. 4 sets of 8 repetitions each day are a good guideline to start.
Add a series every 3 or 4 days, little by little increasing the height of the fall, dare at the end of the process to fall only on your injured leg, which you can already baptize as ex-injured leg.
Continue with the isometric strengthening and stretching and you will see that little by little you will be able to do any activity that you propose without pain. This phase is suitable for introducing explosive gestures such as sprints, multi-jumps, changes of direction …
If everything goes normally, in this process that should have taken between 4 and 6 weeks, you will have said goodbye to what you called patellar tendinitis, or, to be rigorous, to your patellar tendinosis.