by Maria I. Martos, Francey Royce & Barbara Harris

This article is from research pconducted by the authors and  will discuss patellar tendinitis resulting from playing volleyball in indoor hard courts. Volleyball requires the lower limbs to execute many movements—running, jumping, side to side, frontwards, backwards—all of which can result in numerous injuries. We’ve elected to identify a specific movement—jumping—and a resulting injury—patellar tendinitis, also know as “jumper’s knee.” We will also discuss modes of treatment and prevention for this injury.

Jumper’s knee is an irritation of the patellar tendon, or quadriceps tendon/ligament, of the knee. The knee is a hinge joint “roughly equivalent to a door hinge, but with a little ‘twist’ to lock it into full extension. Instead of a fixed axis, as with door hinge, it is a complicated movement consisting of gliding and rotation in such a fashion that the articulating surfaces are always changing. Hence, the axis is always changing. That can lead to trouble, particularly during unweighted exercises such as leg extension.”

Symptoms

  1. The tendon becomes inflamed due to repetitive knee extension activities such as jumping and running. A chronic inflammation develops in the tendon because the body does not have time to heal the tears in the soft tissue. Eccentric knee extension and intense repeated loading can cause a functional overload syndrome of the tendon just below the patella.

  2. Pain and tenderness is most commonly present at the tendon’s attachment to the inferior pole of the patella, but can also appear at the tendon’s attachment to the tibial tuberosity.

  3. Athletes usually feel a gradual increase in pain over a 2 to 3 week period when performing squatting or jumping activities.

  4. An athlete may complain of pain when running, walking up and down stairs, or standing after sitting for an extended period of time.

  5. They may also complain of catching or giving way of the knee or weakness of the quads.

Patellar tendinitis is seen in athletes participating in sports such as volleyball, basketball, the high jump and soccer. Volleyball players, especially those in the front row, do a lot of squatting, jumping and landing with eccentric knee extension. More common causative factors include how long and how hard the athlete trains and plays, and the playing surface. (As noted above, this text will focus exclusively on indoor hard court playing surfaces.) Less common factors involved in jumper’s knee are the flexibility of the athlete and h/her height and weight. Abnormal biomechanics may predispose or exacerbate an existing condition of jumper’s knee.

Below is a list of the primary muscles involved in eccentric knee extension.

Prime Movers

Origin

Insertion

Action

Function

Rectus Femoris Long head: anterior inferior iliac spineShort head: upper margin of acetabulum Patella and via patellar ligament to tibial tuberosity Extension of the knee Control bending backward, sitting down or rising, descending (controlled) ascending (shortening) stairs, and squatting
Vastus Lateralis Linea aspera on posterior femur, greater trochanter of femur Patella and via patellar ligament to tibial tuberosity Extension of knee and draws patella laterally See above
Vastus Medialis Linea aspera on posterior femur Patella and via patella ligament to tibial tuberosity Extension of knee and draws patella medially See above
Vastus Intermedius Anterior and lateral femoral shaft Patella and via patellar ligament to tibial tuberosity Extension of the knee See above

Synergists

Origin

Insertion

Action

Function

Tensor Fascia Latae Iliac crest (posterior to ASIS Iliotibial tract which continues to attach to the lateral condyle of the tibia Prevents collapse of extended knee in ambulation Assists hip flexion during swing and assists stabilization of pelvis during stance

Antagonists

Origin

Insertion

Action

Function

Biceps Femoris Long head: ischial tuberosityshort head: linea aspera Head of fibula Long head: extension of hipboth heads: flexion of knee and lateral rotation of flexed knee Keeps trunk erect during stance, decelerate forward moving limb during swing
Semitendinosus Ischial tuberosity Anterior proximal tibial shaft Extension of hip, flexion of knee, and medial rotation of flexed knee See above
Semimembranosus Ischial tuberosity Posterior medial tibial condyle Extension of hip, flexion of knee, medial rotation of flexed knee See above

Four Stages of Injury

Pain disappears after warm-up and reappears with fatigue  Stage 3:Pain during and after activity that impairs function

Patellar tendinitis has four stages of injury. They are as follows:
 Stage 1:

Pain after activity

No functional impairment

 Stage 2: Pain at beginning of activity
 Stage 3:

Athlete unable to participate

In sports at their previous level

Stage 4:

Complete tendon rupture

Injury Evaluation

To evaluate the stage of the injury, the following test can be conducted:

  1. Ask athlete to lie on unaffected side in sideline on treatment table.

  2. Passively flex athlete’s knee.

 

A positive sign for jumper’s knee will be if athlete feels pain at 120 degrees passive knee flexion or anytime during resisted knee extension. Remember to test the unaffected knee first in order to establish a baseline.

Commonly Prescribed Treatment

The commonly prescribed treatment for the above stages are as follows:

Stage 1 Increase warm-up before training. Use ice after activity. Take non steroidal anti inflammatory drugs (NSAID’s). Elastic knee support may be beneficial.
Stage 2 A hot pack or heating pad may be used to assist in the warm-up phase before activity. Also, cooling down, stretching and ice massage are indicated following activity. Rest and limitation of activities may be indicated.
Stage 3 Prolonged rest is the most important part of the treatment. Cessation of sports in conjunction with the treatment protocol outlined for stages 1 and 2 helps to diminish symptoms. Some patients with stage 3 may require surgery if there is tendon degeneration.
Stage 4 Requires surgery and extensive rehabilitation to regain motion and strength.

Preventative Measures: Strengthening

Preventative measures for patellar tendinitis include strengthening and stretching exercises. The following is an example of strengthening exercise:

Minisquats, done while holding on to a table or chair for support:

The athlete bends at the knee to about a 45 degree angle, pauses, and then returns to the standing position.

Rehabilitation progresses to no support and using only the involved leg. It should be noted that “eccentric quadriceps strengthening and a stretching program for the quadriceps, hamstrings, plantar flexors, hip flexors and extensors will assist in absorbing strain.”

Treatment for patellar tendinitis should include examination of the lower extremity for flexibility and tightness. The muscles that are most likely to develop tightness are the hamstrings, sartorius, gracilis, gastrocnemius, plantaris, and popliteus. The hamstrings in particular will be tight and should be addressed before working on the quadriceps. Quadriceps recovery is dependent upon releasing the tightness in the hamstrings.

Importance and Application to Massage Therapy

Sports massage therapy is important in the treatment of patellar tendinitis. It helps in the healing process by increasing circulation, decreasing tightness in adjacent muscles and increasing flexibility and strength.