I have been researching into knee injuries generally following surgery on my knee for Patellar Teninopathy and have found some information which others may find of interest.
There is significant evidence now by respected researchers (Khan and Cook are the most famous), which suggests that most cases of Tendonitis are in fact Overuse tendinosis, and I have been pursuaded that this was in fact the case with my injury.
A classic symptom of both patellar tendonitis and tendinosis is pain near the lower end or inferior pole of the patella.
Patellar tendonitis is an inflammation of the tendon at the inferior pole of the patella. This, if rested, usually clears up within a few weeks.
Patellar tendinosis is nothing to do with inflammation, but in fact is where the Collagen fibres in the tendon, which give it its strength and run longitudinally, have broken down and their poercentage make up of the tendon has decreased. Instead of the collagen fibres being properly aligned, they are disoriented. The actually percentage of Collagen fibres is less than it was before.
It is therefore believed that this injury will not heal with just resting, because the Collagen fibres will not reproduce and realign unless the tendon is worked on by doing strengthening exercises (single leg squats and calf raises), which re-align them and instigate Collagen production.
Useful references can be found on www.findarticles.com, by looking up "patellar tendinopathy" and/or Khan or cook, although the links below are the best articles I could find.
http://www.physsportsmed.com/issues/2000/05_00/khan.htmand
http://www.physsportsmed.com/issues/2000/06_00/khan.htmOther places to research include the American Journal of Sports Medicine website where free abstracts can be obtained.
The recovery rate following open surgery (arthroscopic surgery recovery is slightly less)are not as good as I was lead to believe by my surgeon. He said 97% success, but the research says 80%, but this % relates to recovery being no more pain, not return to exercise. The figure for return to previous level of sport is 50%, which to be fair is pretty low. Recovery after surgery for those who do recover is 6 to 12 months - a very long time!
So persist with the physio, use surgery really as a last option.
Good luck all.
Comments
I seem to be partially at least on the mend (although I currently have a back injury which means I haven't been able to do anything for three weeks).
I suspect though that I will never return to my previous level of running but since I've now turned 40 I'm forgetting the past and will treat any running I do now as "new". Since I began my stuttering comeback in August I have found that running on a treadmill gives me far less trouble than running outside. At the moment I don't have a problem with this (as its bitterly cold outside)! I believe that if I can run three times a week then I can achieve my goals.
I have also now been taking Glucosamine and Chrondroitin (which are supposed to be good for joint connective tissues) since July and it seems to have really made a difference. This could be conincidence that I was getting better anyway.
Finally my doctor said that cycling was ok and over the last two years I have done a lot of cycling. The reason why he said this was ok is that my tendonitis stemmed from my having an unstable knee cap, therefore:
1. Cycling doesn't cause the knee cap to move around in the same way that running does; and
2. Part of the cause of instability is weakness in the stabilising muscles, all of which are strengthend by cycling.
I hope you continue to improve - don't give up hope!
you both seem to be well informed on this subject so i hope you can help.
i went to a physio about my knee and he said i had patellar tendonitis in my right knee, he did some ultrasound, didn't give me any strengthening exersises or stretches to do, and charged me £30.
i went to him 3 times before i got a bit sceptical and stopped going.
the problems still there and i'm going to see my doctor about it.
what i'm asking is, are there any specific tests i should make sure he performs to be certain it is patellar tendonitis? i do trust my doctors abilities but after the experience with this physio i want to know i'm in the right hands.
i've tried doing one legged squats but it hurts, it's not really painfull but i don't want to do more damage.
i used to cycle a lot and tried doing some time on an indoor trainer, my knee was ok when i was on the bike but hurt the day after.
i'm icing it twice a day for 20 mins a time, and i'm also doing the general leg stretches.
it started with e few twinges in my knee (right under the kneecap) a couple of months ago but really kicked in on one particular run on 25th of last month.
thanks
matt
Cycling may not strengthen the oblique fibres of vastus medialis which may result in an unequal pull on the patella and tracking problems - the reason being that the medial quads are more involved in final extension of the knee and unless your seat is quite high you don't really reach full extension cycling - and a lot of people do have their seat too low.
Blackstar - have you read the articles i've mentioned above? If not then I suggest you have a good read and see whether you think Tendinosis applies to you. Like i've said above, most people get diagnosed with patellar tendonitis, when it is in fact tendinosis - so you need to find out straight away so you can start the correct strengthening exercises.
Having ultrasound treatment is goona do diddly squat if its not tendonitis - and even if it is, there's no research to back it up!
let me know how it's going once you've had a read through the articles. And in the mean time, I suggest you cut back on your running mileage - don't rest it completely though.
I'm not too sure about it causing degeneration although I believe there is a fair bit of research to show you are more likely to rupture your achiles after having a cortizone jab, this maybe because you don't notice the pain and carry on to overload.
Cotizone certainly inhibits collagen regrowth and production
Seeing as it's this that is usualy inflamed and not the tendon this would make more sense.
And it does weaken the tendon itself amoungst many other cotra's.
I can only relate to you my experience, but really the only cure is rest and lots of it. Cycling was fine for me as were other non-weight bearing activities e.g. swimming, rowing and to a degree skiing.
At the same time as resting you need to identify the cause otherwise as soon as you start running it will come back again. I would visit a podiatrist as well as a knee specialist (a physio will help with exercises to solve known problems but may not be an expert in identifying the problems)
So far I estimate I have spent close to €1,000 on doctors and treatments.
Been running about 8 months and all ok up til October. Not aware that overtraining was going to cause problems, I stepped up weekly mileage far to quickly for my first 1/2 marathon. Self diagnosed pateller tendonitis ( dont like docs) and it has taken about 6 weeks to clear. Total rest and elevation. Just started back running on a treadmill a couple of miles three times a week nd everythings gong ok. So it seems rest does the trick and starting again slowly. I'll certainly learn the lesson cos it was a killer 6 weeks out
It may be worth looking at your hip alignment as if you are out then there will be extra pull on your quads which leads to your patella.
There is another patella injury called chrondomalacia (spelling???) Patella which is roughening of the cartilage under the patella which causes pain on bending as the cartilage it rubbing and grinding.
Keep stretching all leg muscles when warm even when not running, usually after a bath or nice massage, hold the stretch for 30 seconds then push a bit more into stretch. Do this regularly as part of your every day routine and not just after a run!
Good luck everyone
finished reading those articles today, very interesting and informative, i'm still a little confused about certain areas but it is a lot to take in, i had to have a medical dictionary open in another window, well worth reading though.
still not too sure whether it's tendinitis or tendinosis but as the former is rare then i'd say it's most likely tendinosis,(hopefully not chronic).
at least have some ammo behind me when i see my doctor.
in the meantime i'm going to start up again with some light jogging and see how it goes.
i'm still sceptical about the physios where i live as i don't have much choice,(i live on a very small island, there isn't a lot of anything here).
martinh,
as i said i had some twinges in my knee before that particular run,so it didn't just suddenly appear.
the pain is on the front of the knee just below the kneecap, (toward the foot), and everything i have read points to it being patellar tendinosis.
i'm getting my running gait analysed in the uk in the new year so hopefully that will throw some light on the problem.
Just ensure knees don't travel past your toes when squatting.
You need to find out how to do a quad imbalnce test and then target whichever muscle needs attention.
If in doubt see a physio or sports therapist who know their stuff, there are a surprising number who don't.
I have tried a Patellar Strap and it didn't seem to make any difference.
I do both. I would say that cycling is the better activity for recovery as recovery from patella tendonitis is partially related to correct muscle imbalances, which cycling will do (there are other causes though so I would also check that you are biomechanically efficient with a podiatrist). However, i also enjoy rowing a lot as its a much better overall exercise.
With cycling i would try and not limit yourself to the gym - I find 20 minutes in the gym on a bike is very close to my boredom threshhold.
I'm hoping to go to the gym in the morning before work so maybe if I'm spinning along at a low-ish resistance I can just let my brain go back to sleep
I might take my real bike to the bike doctor next week to get it checked out for winter cycling. I live in the middle of a city and I'm not an experienced cycling so I must admit I'm not very confident in the dark on busy, wet roads...
After a cycling accident i developed patella tendonitis. Got it ultra sounded and mega pulsed for five or six sessions at the physio over a period of three weeks.
Got the knee dips exercise off the physio and went back to running a couple of miles once a week for two weeks and then back to running 2 miles 3 times a week for two weeks.
During that time my patella tendon has been fine. if anything my ex-poorly knee is a lot stronger than the knee that wasn't injured! that is until saturday when i noticed the same sort of niggling dull pain in the patella tendon once again. i'm really hoping it was just because it was a very cold day on saturday ... have been furiously doing knee dip exercises and will try and run again tomorrow.
Time to sign up to the gym and do some leg strengthening exercises to sort out any imbalances i reckon.
Good luck all of you with your pattella!
Knee pain - again
What exactly is “jumper’s knee” and why isn’t it called “weightlifter’s knee” or “hockey knee”? We open SIB this month with an authoritative and practical account of the pathology which usually gets diagnosed as “patellar tendinitis” but which is more likely in most cases to be “patellar tendinosis”.
Dr Rod Jaques, the new medical director of the English Institute of Sport, explains: “It is thought that the first symptoms of patellar pain correlate with fluid or oedema in the patellar tendon, often close to the lower pole of the patella. Very little inflammation if any occurs and studies show degenerative changes in the tendon rather than any clear inflammatory process. This syndrome of degenerative change in the patellar tendon is called ‘patellar tendinosis’.
Patellar tendinosis is an occupational hazard for anyone involved in sports that subject the lower patella area to direct loading, rapid deceleration or high traction forces – which covers the main jumping sports but also, for instance, weightlifting and hockey (played on Astroturf, the traction forces can be extreme).
Usually there will be distinct tenderness at a particular spot below the kneecap, and possibly thickening in more severe cases. There may also be swelling behind the kneecap and some quadriceps muscle wasting. Authoritative diagnosis is best done, Jaques says, with ultrasound rather than MRI or X-ray.
Patella tendinosis is another of those sporting injuries that we still don’t have definitive scientific explanations for. Jaques favours mechanical impingement of the back of the patellar tendon, but stresses that there may be other, indeed multiple causative factors. Things to look out for include:
*tight quadriceps
*weak quads relative to hamstrings
*very poor mobility of the lumbar spineJaques shares his preferred rehab technique with SIB readers, based on strict self-management of pain by clients, thorough assessment of hip mobility, and muscle strength and control from hip to leg, and a simple but powerful programme of eccentric exercises.
“The key to the rationale behind eccentric drills is that they are the best way of promoting tendon remodelling: the regrowth and reordering of collagen tissue in place of the fluid-filled degenerative tissue typical of tendinosis.”
For details of Rod Jaques’s rehab programme, read the new SIB.
For full details of Rod Jaques’s rehab programme, click here to read the new issue of Sports Injury Bulletin - we'll also give you a bundle of free reports to deal with the most common sports injuries
Yep, part of my joining the gym is to see how the treadmill goes. Perhaps after my patella recovered i got back into running too quickly and that's why it's complaining again.
Anyway, there was an interesting article in british runner about a runner taking up triathlon and being amazed at the injury free fitness level he achieved. So given i love cycling i thought i might go the way of triathlon.
In the same magazine they also had a little bit about patella tendon exercises and stretches. has anyone tried leg raises etc and strengthening the knee using weights?