patellar tendinopathy

Patellar Tendinopathy – Is Exercise Truly The Key?

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Patellar tendinopathy, a prevalent overuse injury, can often be effectively managed through carefully physiotherapy designed exercise programs. However, achieving success depends on the specific execution of these exercises and continuous feedback and monitoring to track progress and make adjustments. The key lies in identifying the stage of the tendon injury and, correspondingly, adjusting and fine-tuning the exercise parameters using the FITT principle.

Many individuals unintentionally perform exercises that resemble effective rehabilitation moves, but small adjustments—such as slower tempos or modified loads—can significantly improve results. A tailored, progressive, and holistic approach fosters long-term recovery while addressing the root causes of weakness. 

When combined with proper rest, attention to footwear, and consideration of both social and psychological factors, exercise becomes a powerful tool for healing and preventing recurrence, offering hope to those dealing with this persistent condition.

patellar tendinopathy

The Importance of Specificity for Patellar Tendinopathy

For patellar tendinopathy, specificity is the cornerstone of an effective and efficient rehabilitation process. By targeting the necessary areas with just the right amount of challenge, specificity not only optimizes outcomes but also minimizes setbacks, ensuring a smoother recovery journey. This process is guided by two essential factors.

1. Identifying the stage of tendon injury:

Understanding the stage of tendinopathy is critical to tailoring treatment effectively. Tendon injuries typically progress through three stages: reactive, dysrepair, and degenerative.

  • The reactive stage is the initial phase, often triggered by a sudden increase in activity intensity. Symptoms include muscle tightness, pain at rest, and discomfort usually more so in the mornings, lasting up to 6 weeks. 
  • The dysrepair stage follows, where pain arises earlier during activity, eases with warm-up, but re-emerges post-activity and takes longer to subside. This stage takes 6-12 weeks of modified exercise for it to settle. 
  • Finally, the degenerative stage is characterized by chronic pain. This is typically present in people who have tendinopathy lasting longer than 12 weeks, with perpetual overloading of the tendon.

2. Exercise parameters:

Rehabilitation success also hinges on optimizing the frequency, intensity, time, and type of exercises, also known as the FITT principle.

  • Frequency: Tendons adapt to consistent but spaced loading. Starting with 3 sessions per week and gradually increasing to 5 ensures sufficient stimulus without overloading.
  • Intensity: Effective exercises fall within specific thresholds. Pain levels on the Numeric Pain Rating Scale (NPRS) should not exceed 3 out of 10 during exercises, and the effort level should register between 4 and 6 on the Rate of Perceived Exertion (RPE) scale.
  • Time: Sessions typically last 15–30 minutes, with 1–2 minutes of rest between sets to balance recovery and performance.
  • Type: The selection of exercises plays a pivotal role in addressing the tendon’s needs and progression through recovery, with 3 main types.
    1. Isometric exercises involve contracting the muscle without movement, providing pain relief and promoting tendon remodeling. Some examples include wall sits or static leg presses.
    2. Isotonic exercises involve movement through the joint and are vital in rebuilding strength and restoring the tendon’s ability to withstand load. Particularly for eccentric exercises, which load muscles in a lengthening state, it is hypothesised that it  requires less oxygen consumption compared to concentric exercises, benefiting tendons and reducing pain while building tensile strength. Some exercises include leg extensions or body weighted squats, focusing on the slow lengthening phase.
    3. Functional exercises replicate the movements required for specific activities or sports, bridging the gap between rehabilitation and a return to normal function. For example, movements like lunges are specific to running and ensures the tendon can handle similar demands to the sport without reinjury.

The role of feedback and monitoring 

While specificity in rehabilitation provides a structured roadmap, the process is incomplete without effective feedback and monitoring to guide progress by fine-tuning the exercises. It is important to regularly assess the tendon’s response to exercises to ensure their rehabilitation remains both targeted and adaptable. Tools like the NPRS which measures pain levels on a scale of 0 to 10, and the RPE scale which measures effort levels on a scale of 0 to 10, allow patients to gauge the right about of pain and intensity during exercises.

For example, when performing a wall sit—a static, isometric exercise aimed at reducing pain and promoting tendon remodeling—monitoring pain to ensure it stays below 3 out of 10 on the NPRS is crucial. If pain goes beyond that, then a decrease in the duration of hold during the isometric exercise should be considered as it is an indication that it is too much load for the tendon at the current point in time.

Over time, as pain decreases to around 1-2 out of 10, progression to isotonic exercises, such as leg extensions, becomes appropriate. These exercises, which focus on controlled joint movement, help rebuild strength with a moderate intensity of 5-6 on the Rate of Perceived Effort (RPE) scale. 

Finally, functional exercises like lunges or stair climbing can be introduced to mimic sport- or activity-specific demands, preparing the tendon for real-world challenges. This progression not only reflects the tendon’s improving health but also fosters confidence in its ability to handle increasing loads. However, solely exercising may not be enough; progress also requires careful management of other activities to ensure that the tendon is not overloaded outside of rehab. Monitoring and modifying daily activities, just as with exercises, are essential next steps to support tendon recovery and prevent setbacks.

Adjusting The Load Of Your Current Activities

Introducing a tailored exercise program is crucial, but managing the loads of existing activities is equally important. Many people with patellar tendinopathy continue routines like running, jumping, or heavy lifting, often hindering recovery without realizing it. Gradual load reduction is the first step. Scaling back the intensity or volume of high-impact activities allows the tendon to heal without complete rest, which can lead to deconditioning. For instance, an example of adjusting intensity would be to replace plyometric drills with low-impact cardio, like cycling, helps maintain fitness without aggravating the injury. On the other hand, an example of reducing the volume would be to reduce your cycling from a 60 minute session, to a 30 minute session. Of course, the same principle applies here where using pain as a guide is also an effective strategy, as mentioned previously, to keep pain levels below 3 out of 10 during activities. Anything beyond that indicates that your current activity is putting excessive stress on the tendon and calls for adjustment, while anything within that indicates that the load parameters remain acceptable for healing. Modifying current activities prevents further damage and lays the foundation for a smoother and more sustainable rehab process.

Expanding Beyond Exercise

While exercise forms the foundation of recovery, its true effectiveness is unlocked when combined with proper rest, attention to footwear, and consideration of both social and psychological factors. Rest is essential to allow the tendon time to recover from loading sessions, ensuring the repair process remains on track. While rests between sets are important, the rest between exercise days are equally as important and can range from one to two days to ensure adequate recovery. Proper footwear, a simple yet powerful tool, helps optimize biomechanics. Supportive shoes or insoles can reduce strain on the patellar tendon by improving shock absorption and correcting foot alignment, thereby minimizing unnecessary stress during both rehab and daily activities. Workplace considerations are another critical yet often overlooked social factor. Many jobs involve repetitive movements, prolonged standing, or physically demanding tasks that can aggravate the patellar tendon. An example to combat this is to incorporate breaks to avoid overloading the tendon so as to prevent setbacks during recovery. On the psychological front, stress management plays a pivotal role in overcoming the mental challenges of recovery. Chronic conditions like patellar tendinopathy can lead to frustration, feelings of helplessness, or burnout, especially when progress feels slow. Incorporating mindfulness practices, such as meditation or deep-breathing exercises, can help individuals stay focused and positive. To tie these elements together, periodic check-ins with a physiotherapist or sports medicine specialist ensures optimized recovery and long-term success.

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