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THE INJURY
The patella tendon is located just below the knee cap (patella) and is approximately two finger breadths wide. The tendon is where the quadriceps muscles at the front of the thigh converge and attach to the shin bone.
The function of the patella tendon is to transfer the force of the quadriceps muscles which, when they contract, results in the extension (straightening) of the knee. The quadriceps muscles are involved in most activities during sport, including running and kicking the ball, but the most stress is put through the patella tendon during jumping and, just as important, during landing. During jumping a player develops an explosive spring by forceful contraction of the quads muscles which straighten the knees. Together with the calf muscles, the quads push the athlete up into the air. As the athlete thenlands it is the quads that help to control the landing by allowing a small amount of knee bending to take place.
If this type of activity is practiced too much the strain on the patella tendon becomes too great and there is microscopic damage to the tissue that makes up the tendon. At first this damage may be too small to cause the player any problems. But, if the player continues to over do jumping activities, the damage will get progressiveley worse.
At times the problem may flare up and, if the reaction is inflammatory, the condition is classified as Patella Tendonitis. However, as we get older the healing response of our body is diminished and damaged tissue may not completely heal. When it affects tendon tissue this degeneration is known as tendonosis. The breakdown of the tendon is characterised by focal areas of degeneration and a proliferation of weak, immature scar tissue. The result is that the tendon loses it's tensile strength and is prone to rupture.
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SIGNS AND SYMPTOMS
Typical signs include a 'creaking' or 'grating' sound at the front of the knee, pain on sitting for long periods, pain on resisting knee straightening and pain when touching just below the knee cap; this may be exasperated by activity.
As the condition gets worse the pain becomes present all the time. This is a sign of severe tissue damage and it would be very unwise to continue to participate in sports. At this stage the tendon is so weak it is liable to rupture completely. A ruptured patella tendon is a catastrophic injury that requires surgery and a six to twelve month period of rehabilitation.
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TREATMENT
Because Patella Tendonosis is not an inflammatory condition, anti-inflammatory treatments, such as ice packs and NSAID medication, are not appropriate. In fact, NSAIDs may be counter productive as they inhibit natural chemicals that can promote a healing response.
The key to treatment of tendon degeneration is three months rest from sporting activities to allow regeneration to take place. Research has shown that the collagen scar tissue that the body lays down to heal damaged tendon, takes three months to mature to the point where it can cope with increased loads. Treatment by a Chartered Physiotherapist to promote this healing response may include heat treatments or friction massage. Once the pain has settled and enough time has been given to allow the scar tissue to mature, more active rehabilitation can be initiated.
Supervised rehabilitation with a chartered physiotherapist can help to reduce the chances of a recurrence of symptoms. This will take the form of stretching and strengthening of the quadriceps (thigh) muscles. The physiotherapist will prescribe specific exercises where the load and speed of loading are carefully controlled. The key to this rehabilitation is gradually progressing the load and this is achieved by doing what is called 'eccentric' quadriceps work.
Eccentric muscle work refers to a muscle which is lengthening while contracting - a contraction that occurs during movements such as landing and decelerating. Maximal tension is generated in the muscle during the eccentric contraction and this causes the tendon to adapt and get stronger. These are then gradually increased to the point where the tendon is under the same load as during sport. During the rehabilitation period the tendon adapts and gets stronger.
An eccentric strengthening programme forms the basis of the rehabilitation exercises detailed for this injury, and can also help with injury prevention.
Surgery is an option for severe patella tendonosis. If required, the surgeon removes the damaged tissue and reunites the healthy tissue. Sometimes a small piece of bone is removed from the bottom of the patella tendon as this is believed to cause irrritation of the tendon. The surgical intervention produces a healing response and the tendon regenerates to form healthy tissue. Again, the scar tissue should be given three months to mature before more active rehabilitation is undertaken.