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Physiotherapy Management of Patellar Tendinopathy in Tennis Players

  • Hio Teng Leong
  • Jill Cook
  • Sean Docking
  • Ebonie Rio
Chapter

Abstract

Patellar tendinopathy (often called jumper’s knee) is a common cause of knee pain in both recreational and elite tennis players. It can affect playing ability or even prevent a player from being on court. Management of patellar tendinopathy relies on understanding the pathophysiology of patellar tendinopathy; a detailed history and assessment of an individual with patellar tendinopathy to differentiate it from other potential diagnoses of anterior knee pain; recognizing the possible risk factors; and then prescribing appropriate treatment approaches and direction for the rehabilitation program of patellar tendinopathy.

References

  1. 1.
    Abrams GD, Renstrom PA, Safran MR. Epidemiology of musculoskeletal injury in the tennis player. Br J Sports Med. 2012;46:492–8.CrossRefGoogle Scholar
  2. 2.
    Hjelm N, Werner S, Renstrom P. Injury profile in junior tennis players: a prospective two year study. Knee Surg Sports Traumatol Arthrosc. 2010;18:845–50.CrossRefGoogle Scholar
  3. 3.
    Sell K, Hainline B, Yorio M, Kovacs M. Injury trend analysis from the US Open Tennis Championships between 1994 and 2009. Br J Sports Med. 2014;48:546–51.CrossRefGoogle Scholar
  4. 4.
    Simpson M, Rio E, Cook J. At what age do children and adolescents develop lower limb tendon pathology or tendinopathy? A systematic review and meta-analysis. Sports Med. 2016;46(4):545–57.CrossRefGoogle Scholar
  5. 5.
    Cook JL, Khan KM, Kiss ZS, Purdam CR, Griffiths L. Prospective imaging study of asymptomatic patellar tendinopathy in elite junior basketball players. J Ultrasound Med. 2000b;19:473–9.CrossRefGoogle Scholar
  6. 6.
    Visnes H, Bahr R. Training volume and body composition as risk factors for developing jumper’s knee among elite volleyball players. Scan J Med Sci Sports. 2013;23:607–13.Google Scholar
  7. 7.
    Zwerver J, Bredeweg SW, van der Akkler-Scheek I. Prevalence of jumper’s knee among nonelite athletes from different sports: a cross-sectional survey. Am J Sports Med. 2011;39(9):1984–8.CrossRefGoogle Scholar
  8. 8.
    Lian Ø, Refsnes P-E, Engebretsen L, Bahr R. Performance characteristics of volleyball players with patellar tendinopathy. Am J Sports Med. 2017;31(3):408–13.CrossRefGoogle Scholar
  9. 9.
    Ferretti A. Epidemiology of jumper’s knee. Sports Med. 1986;3:289–95.CrossRefGoogle Scholar
  10. 10.
    Maquirrianin J, Baglione R. Epidemiology of tennis injuries: an eight-year review of Davis Cup retirements. Eur J Sport Sci. 2016;16(2):266–70.CrossRefGoogle Scholar
  11. 11.
    Tiemessen IJ, Kuijer PP, Hulshof CT, Frings-Dresen MH. Risk factors for developing jumper’s knee in sport and occupation: a review. BMC Res Notes. 2009;8(2):127.CrossRefGoogle Scholar
  12. 12.
    Cook JL, Khan KM, Harcourt PR, Grant M, Young DA, Bonar SF. A cross sectional study of 100 athletes with jumper’s knee managed conservatively and surgically. The Victorian Institute of Sport Tendon Study Group. Br J Sportd Med. 1997;31:332–6.CrossRefGoogle Scholar
  13. 13.
    Kettunen JA, Kvist M, Alanen E, Jujala UM. Long-term prognosis for jumper’s knee in male athletes. A prospective follow-up study. Am J Sports Med. 2002;30(5):689–92.CrossRefGoogle Scholar
  14. 14.
    Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43:409–16.CrossRefGoogle Scholar
  15. 15.
    Corps AN, Robinson AH, Movin T, Costa ML, Hazleman BL, Riley GP. Increased expression of aggrecan and biglycan mRNA in Achilles tendinopathy. Rheumatology. 2006;45(3):291–4.CrossRefGoogle Scholar
  16. 16.
    Samiric T, Parkinson J, Ilic MZ, Cook J, Feller JA, Handley CJ. Changes in the composition of the extracellular matrix in patellar tendinopathy. Matrix Biol. 2009;28(4):230–6.CrossRefGoogle Scholar
  17. 17.
    Docking SI, Daffy J, van Schie HT, Cook JL. Tendon structure changes after maximal exercise in the Thoroughbred horse: use of ultrasound tissue characterisation to detect in vivo tendon response. Vet J. 2012;194(3):338–42.CrossRefGoogle Scholar
  18. 18.
    Rosengarten SD, Cook JL, Bryant AL, Cordy JT, Daffy J, Docking SI. Australian football players’ Achilles tendons respond to game loads within 2 days: an ultrasound tissue characterisation (UTC) study. Br J Sports Med. 2015;49(3):183–7.CrossRefGoogle Scholar
  19. 19.
    Maffuli N, Ewen SW, Waterston SW, Reaper J, Barrass V. Tenocytes from ruptured and tendinopathic Achilles tendons produce greater quantities of type III collagen than tenocytes from normal Achilles tendons. An in vitro model of human tendon healing. Am J Sports Med. 2000;28(4):499–505.CrossRefGoogle Scholar
  20. 20.
    Danielson P, Alfredson HK, Forsgren S. Distribution of general (PGP 9.5) and sensory (substance P/CGRP) innervations in the human patellar tendon. Knee Surg Sports Traumatol Arthrosc. 2006;14:125–32.CrossRefGoogle Scholar
  21. 21.
    Kraushaar BS, Nirschl RP. Current concepts review - Tendinosis of the elbow (tennis elbow). Clinical features and findings of histological, Immunohistochemical, and Electron microscopy studies. J Bone Joint Surg Am. 1999;81(2):259–78.CrossRefGoogle Scholar
  22. 22.
    Lian Ø, Scott A, Engebretsen L, Bahr R, Duronio V, Khan K. Excessive apoptosis in patellar tendinopathy in athletes. Am J Sports Med. 2017;35(4):605–11.CrossRefGoogle Scholar
  23. 23.
    Docking SI, Cook J. Pathological tendons maintain sufficient aligned fibrillar structure on ultrasound tissue characterization (UTC). Scand J Med Sci Sports. 2016;26(6):675–83.CrossRefGoogle Scholar
  24. 24.
    Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? Br J Sports Med. 2016;0:1–7.Google Scholar
  25. 25.
    Rudavsky A, Cook J. Physiotherapy management of patellar tendinopathy (jumper’s knee). J Physiother. 2014;60(3):122–9.CrossRefGoogle Scholar
  26. 26.
    Kountouris A, Cook J. Rehabilitation of Achilles and patellar tendinopathies. Best Pract Res Clin Rheumatol. 2007;21(2):295–316.CrossRefGoogle Scholar
  27. 27.
    Malliaras P, Cook J, Purdam C, Rio E. Patella tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. J Orthop Sports Phys Ther. 2015;45(11):887–98.CrossRefGoogle Scholar
  28. 28.
    Cook JL, Khan KM, Kiss ZS, Griffiths L. Patellar tendinopathy in junior basketball players: a controlled clinical and ultrasonographic study of 268 patellar tendons in players aged 14-18 years. Scand J Med Sci Sports. 2000;10(4):216–20.CrossRefGoogle Scholar
  29. 29.
    Cook JL, Kiss ZS, Khan KM, Purdam CR, Wbster KE. Anthropometry, physical performance, and ultrasound patellar tendon abnormality in elite junior basketball players: a cross-sectional study. Br J Sports Med. 2004;38:206–9.CrossRefGoogle Scholar
  30. 30.
    Gaida JE, Alfredson H, Kiss ZS, Bass SL, Cook JL. Asymptomatic Achilles tendon pathology is associated with a central fat distribution in men and a peripheral fat distribution in women: a cross sectional study of 298 individuals. BMC Musculoskelet Disord. 2010;11:41.CrossRefGoogle Scholar
  31. 31.
    Gaida JE, Cook JL, Bass SL, Austen S, Kiss ZS. Are unilateral and bilateral patella tendinopathy distinguished by differences in anthropometry, body composition, or muscle strength in elite female basketball players? Br J Sports Med. 2004;38:581–5.CrossRefGoogle Scholar
  32. 32.
    Malliaras P, Cook JL, Kent PM. Anthropometric risk factors for patellar tendon injury among volleyball players. Br J Sports Med. 2007;41:259–63.CrossRefGoogle Scholar
  33. 33.
    Crossley KM, Thancanamootoo K, Metcalf BR, Cook JL, Purdam CR, Warden SJ. Clinical features of patellar tendinopathy and their implications for rehabilitation. J Orthop Res. 2007;25:1164–75.CrossRefGoogle Scholar
  34. 34.
    Malliaras P, Cook JL, Kent P. Reduced ankle dorsiflexion range may increase the risk of patellar tendon injury among volleyball players. J Sci Med Sport. 2006;9:304–9.CrossRefGoogle Scholar
  35. 35.
    Kujala UM, Osterman K, Kvist M, Aalto T, Friberg O. Factors predisposing to patellar chondropathy and patellar apicitis in athletes. Int Orthop. 1986;10:195–200.CrossRefGoogle Scholar
  36. 36.
    Witvrouw E, Bellemans J, Lysens R, Danneels L, Cambier D. Intrinsic risk factors for the development of patellar tendinitis in an athletic population. Am J Sports Med. 2017;29(2):190–5.CrossRefGoogle Scholar
  37. 37.
    Lian O, Refsnes PE, Engebretsen L, Bahr R. Performance characteristics of volleyball players with patellar tendinopathy. Am J Sports Med. 2003;31:408–13.CrossRefGoogle Scholar
  38. 38.
    Culvenor AG, Cook JL, Warden SJ, Crossley KM. Infrapatellar fat pad size but not patellar alignment, is associated with patellar tendinopathy. Scand J Med Sci Sports. 2011;21:e405–11.CrossRefGoogle Scholar
  39. 39.
    Ranger TA, Wong AMY, Cook JL, Gaida JE. Is there an association between tendinopathy and diabetes mellitus? A systematic review with meta-analysis. Br J Sports Med. 2015;0:1–10.Google Scholar
  40. 40.
    Gaida JE, Ashe MC, Bass SL, Cook JL. Is adiposity an under-recognized risk factor for tendinopathy? A systematic review. Arthritis Rheum. 2009;61(6):840–9.CrossRefGoogle Scholar
  41. 41.
    Callewaert B, Malfait F, Loeys B, de Paepe A. Ehlers-Danlos syndromes and Marfan syndrome. Best Pract Res Clin Rheumatol. 2008;22:165–89.CrossRefGoogle Scholar
  42. 42.
    Lewis T, Cook J. Fluoroquinolones and tendinopathy: a guide for athletes and sports clinicians and a systematic review of the literature. J Athl Train. 2014;49(3):422–7.  https://doi.org/10.4085/1062-6050-49.2.09.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Crossley KM, Callaghan MJ, van Linschoten R. Patellofemoral pain. BMJ. 2015;451:h3939.CrossRefGoogle Scholar
  44. 44.
    Nunes GS, Stapait EL, Kirsten MH, et al. Clinical test for diagnosis of patellofemoral pain syndrome: systematic review with meta-analysis. Phys Ther Sport. 2013;14:54–9.CrossRefGoogle Scholar
  45. 45.
    Ng GYF, Cheng JMF. The effects of patellar taping on pain and neuromuscular performance in subjects with patellofemoral pain syndrome. Clin Rehabil. 2016;16(8):821–7.CrossRefGoogle Scholar
  46. 46.
    Eymard F, Chevalier X. Inflammation of the infrapatellar fat pad. Joint Bone Spine. 2016;83(4):389–93.CrossRefGoogle Scholar
  47. 47.
    Hardaker W, Whipple TL, Bassett FH. Diagnosis and treatment of the plica syndrome of the knee. J Bone Joint Surg Am. 1980;62(2):221–5.CrossRefGoogle Scholar
  48. 48.
    McConnell J. Running injuries: the infrapatellar fat pad and plica injuries. Phys Med Rehabil Clin N Am. 2016;27(1):79–89.CrossRefGoogle Scholar
  49. 49.
    McCarthy MA, Bollier MJ. Medial patella subluxation: diagnosis and treatment. Iowa Orthop J. 2015;35:26–33.PubMedPubMedCentralGoogle Scholar
  50. 50.
    Calmback WL, Hutchens M. Evaluation of patients presenting with knee pain: Part II. Differential diagnosis. Am Fam Physician. 2003;68(5):917–22.Google Scholar
  51. 51.
    Cook JL, Khan KM, Kiss ZS, Purdam CR, Griffiths L. Reproducibility and clinical utility of tendon palpation to detect patellar tendinopathy in young basketball players. Victorian Institute of Sport tendon study group. Br J Sports Med. 2001;35:65–9.CrossRefGoogle Scholar
  52. 52.
    Kongsgaard M, Aagaard P, Roikjaer S, Olsen D, Jensen M, Langberg H, Magnusson SP. Decline eccentric squats increases patellar tendon loading compared to standard eccentric squats. Clin bioech 2006;21:748-54. Clin Biomech (Bristol, Avon). 2006;21:748–54.CrossRefGoogle Scholar
  53. 53.
    Purdam C, Cook J, Hopper D, Khan K, VTS G. Discriminative ability of functional loading tests for adolescent jumper’s knee. Phys Ther Sport. 2003;4:3–9.CrossRefGoogle Scholar
  54. 54.
    Cook J, Khan K, Maffulli N, Purdam C. Overuse tendinosis, not tendinitis: applying the new approach to patellar tendinopathy. Phys Sportsmed. 2000a;28(6):31–46.CrossRefGoogle Scholar
  55. 55.
    Visentini PJ, Khan KM, Cook JL, Kiss ZS, Harcourt PR, Wark JD. The VISA score: an index of the severity of jumper’s knee (patellar tendinosis). J Sci Med Sport. 1998;1(1):22–8.CrossRefGoogle Scholar
  56. 56.
    Frohm A, Saartok T, Edman G, Renstrom P. Psychometric properties of a Swedish translation of the VISA-P outcome score for patellar tendinopathy. BMC Musculoskelet Disord. 2004;18(5):49.CrossRefGoogle Scholar
  57. 57.
    Wageck BB, de Noronha M, Lopes AD, da Cunha RA, Takahashi RH, Costa LO. Crosscultural adaptation and measurement properties of the Brazilian Portuguese version of the Victorian Institute of Sport Assessment-Patella (VISA-P) scale. J Orthop Sports Phys Ther. 2013;43:163–71.CrossRefGoogle Scholar
  58. 58.
    Hernandez-Sanchez S, Hidalgo MD, Gomez A. Cross-cultural adaptation of VISA-P score for patellar tendinopathy in Spanish population. J Orthop Sports Phys Ther. 2011;41:581–91.CrossRefGoogle Scholar
  59. 59.
    Macdermid JC, Silbernagel KG. Outcome evaluation in tendinopathy: foundations of assessment and a summary of selected measures. J Orthop Sports Phys Ther. 2015;45(11):950–64.CrossRefGoogle Scholar
  60. 60.
    Cook JL, Khan KM, Harcourt PR, Kiss ZS, Fehrmann MW, Griffiths L, Wark JD. Patellar tendon ultrasonography in asymptomatic active athletes reveals hypoechoic regions: a study of 320 tendons. Victorian Institute of Sport Tendon Study Group. Clin J Sport Med. 1998;8:73–7.CrossRefGoogle Scholar
  61. 61.
    Khan KM, Cook JL, Kiss ZS, et al. Patellar tendon ultrasonography and jumper’s knee in female basketball players: a longitudinal study. Clin J Sport Med. 1997;7:199–206.CrossRefGoogle Scholar
  62. 62.
    Warden SJ, Kiss ZS, Malara FA, Cook JL, Crossley KM. Comparative accuracy of magnetic resonance imaging and ultrasonography in confirming clinically diagnosed patellar tendinopathy. Am J Sports Med. 2007;35(3):427–36.CrossRefGoogle Scholar
  63. 63.
    Docking SI, Ooi CC, Connell D. Tendinopathy: is imaging telling us the entire story? J Orthop Sports Phys Ther. 2015;45(11):842–52.CrossRefGoogle Scholar
  64. 64.
    Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, Cook J. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015;49(19):1277–83.  https://doi.org/10.1136/bjsports-2014-094386.CrossRefPubMedGoogle Scholar
  65. 65.
    Basas Garcia A, Fernandez de las Penas C, Martin Urrialde JA. Tratamiento fisioterapico de la rodilla. Madrid, Spain: McGraw-Hill-Interamericana; 2003.Google Scholar
  66. 66.
    Cook JL, Purdam CR. The challenge of managing tendinopathy in competing athletes. Br J Sports Med. 2014;48:506–9.CrossRefGoogle Scholar
  67. 67.
    Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer M, Magnusson SP. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009;19(6):790–802.CrossRefGoogle Scholar
  68. 68.
    van Ark M, Cook JL, Docking SI, Zwerver J, Gaida JE, van den Akker-Scheek I, Rio E. Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-season? A randomised clinical trial. J Sci Med Sport. 2016;19(9):702–6.CrossRefGoogle Scholar
  69. 69.
    Cannell LJ. A randomised clinical trial of the efficacy of drop squats or leg extension/leg curl exercises to treat clinically diagnosed jumper’s knee in athletes: pilot study. Br J Sports Med. 2001;35(1):60–4.CrossRefGoogle Scholar
  70. 70.
    Kongsgaard M, Qvortrup K, Larsen J, Aagaard P, Doessing S, Hansen P, Kjaer M, Peter Magnusson S. Fibril morphology and tendon mechanical properties in patellar tendinopathy. Am J Sports Med. 2017;38(4):749–56.CrossRefGoogle Scholar
  71. 71.
    Rio E, van Ark M, Docking S, Moseley GL, Kidgell D, Gaida JE, et al. Isometric contractions are more analgesic than isotonic contractions for patellar tendon pain: an in-season randomized clinical trial. Clin J Sport Med. 2016.  https://doi.org/10.1097/jsm.0000000000000364.CrossRefGoogle Scholar
  72. 72.
    van Ark M, Cook JL, Docking SI, Zwerver J, Gaida JE, van den Akker-Scheek I, Rio E. Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-season? A randomised clinical trial. J Sci Med Sport. 2016;19(9):702–6.  https://doi.org/10.1016/j.jsams.2015.11.006.CrossRefPubMedGoogle Scholar
  73. 73.
    Mani-Babu S, Morrissey D, Waugh C, Screen H, Barton C. The effectiveness of extracorporeal shock wave therapy in lower limb tendinopathy. Am J Sports Med. 2015;43(3):752–61.CrossRefGoogle Scholar
  74. 74.
    van Leeuwen MT, Zwerver J, van den Akker-Scheek I. Extracorporeal shockwave therapy for patellar tendinopathy: a review of the literature. Br J Sports Med. 2009;43(3):163–8.CrossRefGoogle Scholar
  75. 75.
    Fredberg U. Local corticosteroid injection in sport: review of literature and guidelines for treatment. Scand J Med Sci Sports 1997;7:131–39.CrossRefGoogle Scholar
  76. 76.
    van Ark M, Zwerver J, van den Akker-Scheek I. Injection treatments for patellar tendinopathy. Br J Sports Med. 2011;45(13):1068–76.CrossRefGoogle Scholar
  77. 77.
    Fredberg U, Bolvig L, Pfeiffer-Jensen M, et al. Ultrasonography as a tool for diagnosis, guidance of local steroid injection and, together with pressure algometry, monitoring of the treatment of athletes with chronic jumper’s knee and Achilles tendinitis: a randomized, double-blind, placebo-controlled study. Scand J Rheumatol. 2004;33(2):94–101.CrossRefGoogle Scholar
  78. 78.
    Dragoo JL, Wasterlain AS, Braun HJ, Nead KT. Platelet-rich plasma as a treatment for patellar tendinopathy. A double-blind, randomized controlled trail. Am J Sports Med. 2014;42(3):610–8.CrossRefGoogle Scholar
  79. 79.
    Liddle AD, Rodriguez-Merchan EC. Plasma-rich plasma in the treatment of patellar tendinopathy: a systematic review. Am J Sports Med. 2015;42(10):2583–90.CrossRefGoogle Scholar
  80. 80.
    Kaux J-F, Bruyete O, Croisier J-L, Forthomme B, Le Goff C, Crielaard JM. One-year follow-up of platelet-rick plasma infiltration to treat chronic proximal patellar tendinopathies. Acta Orthop Belg. 2015;81(2):251–6.PubMedGoogle Scholar
  81. 81.
    Chen S-K, Lu C-C, Chou P-H, Guo L-Y, Wu W-L. Patellar tendon ruptures in weight lifters after local steroid injections. Arch Orthop Trauma Surg. 2009;129(3):369–72.CrossRefGoogle Scholar
  82. 82.
    Lavagnino M, Arnoczky SP, Dodds J, Elvin N. Infrapatellar straps decrease patellar tendon strain at the site of the jumper’s knee lesion: a computational analysis based on radiographic measurements. Sports Health. 2011;3(3):296–302.CrossRefGoogle Scholar
  83. 83.
    de Vries A, Zwerver J, Diercks R, Tak I, van Berkel S, van Cingel R, et al. Effect of patellar strap and sports tape on pain in patellar tendinopathy: a randomized controlled trial. Scand J Med Sci Sports. 2016;26(10):1217–24.  https://doi.org/10.1111/sms.12556.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Hio Teng Leong
    • 1
  • Jill Cook
    • 2
  • Sean Docking
    • 2
  • Ebonie Rio
    • 2
  1. 1.Department of Orthopaedics and Traumatology, Prince of Wales HospitalThe Chinese University of Hong KongShatinHong Kong
  2. 2.La Trobe Sport and Exercise Medicine Research CentreLa Trobe UniversityMelbourneAustralia

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