Method to manage patellar tendinopathy

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Method to manage patellar tendinopathy


Patellar tendinopathy is a painful overuse condition that is common in athletes, particularly those who engage in running and jumping. Symptoms include knee pain during activity, localised tenderness on palpation and reduced function. It is defined as pain from the insertion of the patellar tendon, to the inferior pole of the patella. Patellar tendinopathy is associated with structural changes within the tendon, such as disorganised collagen, increased water, vascularisation and cellularity. The preferred treatments to induce tendon adaptations include loading the patellar tendon.

Stage 1: Isometric Loading: five repetitions of 45-second isometric mid-range quadriceps exercise at 70% of maximal voluntary contraction have been shown to reduce patellar tendon pain for 45 minutes after exercise, a response associated with a reduction in motor cortex inhibition of the quadriceps, which is associated with patellar tendinopathy.74 Isometric exercises are indicated to reduce and manage tendon pain and initiate loading of the muscle-tendon unit when pain limits the ability to perform isotonic exercises

Stage 2: Isotonic Loading Loaded isotonic exercise is initiated when it can be performed with minimal pain (3/10 or less on a numeric pain-rating scale). A positive response to regular reassessment of pain with load tests continues

 to be important. Isotonic load is important to restore muscle bulk and strength through functional ranges of movement. Based on clinical experience, the HSR program discussed earlier can be adapted to suit the individual and maximize patient outcomes. Initially, knee flexion during both non-weight-bearing and weight-bearing exercises should be limited to between 10° and 60° of knee flexion or less, depending on pain, then progressed toward 90° of flexion or further, as pain permits and based on the sport demands

Stage 3: Energy-Storage Loading Reintroduction of energy-storage loads on the myotendinous unit is critical to increase load tolerance of the tendon and improve power as a progression to return to sport. Initiating this stage is based on the following strength and pain criteria: (1) good strength (eg, ability to perform 4 sets of 8 repetitions of single-leg press with around 150% body weight for most jumping athletes); and (2) good load tolerance with initial energy-storage exercises, defined as minimal pain (3/10 or less on a numeric pain-rating scale) while performing the exercises, and return to baseline pain (if there was an initial increase) during load tests, such as the single-leg decline squat, within 24 hours.

Stage 4: Return to Sport Progression back to sport-specific training can be commenced when the individual has completed energy-storage progressions that replicate the demands of his or her sport in regard to the volume and intensity of relevant energy-storage functions. At that time, stage 3 exercises are replaced by a graded return to training and eventually competition. In the early phases, training should match the volume and intensity of final progression of stage 3 energy-storage exercises, gradually replacing stage 3 activities with a volume and intensity similar to those of training drills to replicate the participation and fitness demands of the sport.

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