Rehabilitation for Patellar Tendinitis (jumpers knee) and Patellofemoral Syndrome (chondromalacia patella)
The most common tendinitis about the knee is irritation of the patellar tendon. Commonly called “jumper’s knee”, patellar tendinitis is an inflammation of the tendon that attaches the patella (kneecap) to the tibia (shin bone). This condition is commonly seen in people who play basketball, volleyball, distance running, long-jumping, mountain climbing, figure skating, tennis or high impact aerobics. In many cases, you will notice a sudden onset of aching and pain in the area just below the kneecap after sports or recreational activities. You may notice pain when landing from a jump or when going up and down stairs. There is sometimes pain at rest, particularly after sitting with the knees bent for a period of time. Swelling in the area just below the kneecap is common, as well as a feeling of weakness at the knee when pain is felt.
The patellar tendon becomes inflamed and tender due to overuse. Overuse injuries of the patellar tendon occur when you repeat a particular activity (usually running, jumping or high-impact) until there is micro-failure of the tissue that makes up the substance of the tendon. Swelling, inflammation and pain follows. In the early (acute) stage of patellar tendinitis, the pain and inflammation subside with rest. There may be pain at the beginning of activity, but this pain often disappears after a period of warm-up and then re-appears after the completion of the activity. If you continue with your activity in the presence of pain, you initially can continue to exercise or perform at a normal level. However, if you continue to exercise and don’t rest, the pain will become more persistent and will be present before, during and after activity. At this stage, you can do permanent damage to the tendon if you continue your activity and it will take a long time to heal.
When the knee moves, the kneecap (patella) slides to remain in contact with the lower end of the thigh bone (trochlear groove of the femur). Normally, this motion has almost no friction: the friction between these two joint surfaces is approximately 20% the friction of ice sliding against ice. If the patella and /or femur joint surface (articular cartilage) becomes softened or irregular, the friction increases. Grinding or crepitus that can be heard or felt when the knee moves is the result. This condition in which there is patellofemoral crepitus is called chondromalacia patella or patellofemoral syndrome.
The force, or pressure, with which the patella pushes against the femur is 1.8 times body weight with each step when walking on a level surface. When climbing upstairs, the force is 3.5 times body weight and when going down stairs it is 5 times body weight. When running or landing from a jump the patellofemoral force can exceed 10 or 12 times body weight.
The symptoms of chondromalacia patella are usually pain in the front of the knee that is aggravated by going up and down stairs, sitting for long periods of time with the knees bent (such as in a movie) and when doing deep knee bends.
Pressure between the patella and femur is minimized when the knee is straight or only slightly bent. Exercises and activities that require deep knee bending, jumping and landing, pushing or pulling heavy loads and stopping and starting will place very high stresses on the patellofemoral joint and the patellar tendon.
Treatment has two objectives: to reduce the inflammation and to allow the tendon to heal. When the knee is painful and swollen, you must rest it. Avoid stair climbing and jumping sports. Keep your knee straight while sitting, and avoid squatting. Let pain be your guide. You are aggravating the condition if you continue activities while experiencing pain. Mild discomfort or ache is not a problem but definite pain is a cause for concern.
Ice your knee for 20 minutes, two or three times a day and after any sporting activities—apply a bag of crushed ice over a towel. This reduces swelling, inflammation and pain. Aspirin, Aleve or Advil sometimes helps to relieve pain and reduce inflammation. A physical therapist or Your doctor can recommend exercises to strengthen the muscles. Exercises can also be used to stretch and balance the thigh muscles.
In some cases, surgery may be indicated.
The best treatment for patellofemoral syndrome is to avoid activities that compress the patella against the femur with force. This means avoiding going up and down stairs and hills, deep knee bends, kneeling, step-aerobics and high impact aerobics. Do not wear high heeled shoes. Do not do exercises sitting on the edge of a table lifting leg weights (knee extension). An elastic knee support that has a central opening cut out for the kneecap sometimes helps. Applying ice packs for 20 minutes after exercising helps. Aspirin, Aleve or Advil sometimes helps.
Use your judgment. When your knees hurt, avoid sports that may aggravate your knee problems. Total rest may be required. When your knee is better after treatment, you should be able to enjoy many sports.
Sports that aggravate patellar tendinitis and chondromalacia patella: volleyball, basketball, soccer, distance running, racquetball, squash, football, weightlifting (squats).
Sports that may or may not cause symptoms: cycling (it is best to keep the seat high and avoid hills), baseball, hockey, skiing and tennis.
Sports that are easiest on the knees: Swimming (especially with a flutter kick), walking (avoid up and down hills), and cross-country skiing.
Do not do the following exercises:
leg extension machine
The following exercises are OK to do if they cause no pain, grinding or swelling:
straight-leg lifting exercises
stationary cycle (seat high, resistance low)
leg press (do not let the knees bend past 90 degrees)
hamstring curl machine
The following exercise program should be followed as instructed by the doctor or physical therapist. For the straight leg lift and short arc lift, ankle weights can be added to increase resistance and strength of the quadriceps. Generally, after 1 to 2 weeks, ankle weights can be added (starting at 1 pound) and increased by 1 pound per week until you build to 5 pounds. The exercises should be done daily until ankle weights are added. At this time, the straight-leg lift, short-arc lift and wall slides should be done every other day and the stretches should continue daily. When you have built up to 5 pounds on the straight-leg and short-arc lifts, continue the exercises 2 times per week for maintenance.
STRAIGHT LEG LIFT
Tighten the quadriceps muscle so that the knee is flat, straight and fully extended. Try to raise the entire operated limb up off of the floor or bed. If you are able to keep the knee straight raise the limb to about 45 degrees, pause one second and then lower slowly to the bed. Relax and repeat. If the knee bends when you attempt to lift the limb off of the bed, do not do this exercise. Keep trying to do the quadriceps setting exercise until you can lift the limb without letting the knee bend. Repeat 20 times.
SHORT ARC LIFT
With the knee bent over a rolled up towel or blanket, lift the foot so that the knee fully straightens. Hold the knee locked in extension for 5 seconds, then slowly lower. Repeat 20 times.
Stand upright with your back and buttocks touching a wall. Place the feet about 12 inches apart and about 6 inches from the wall. Slowly lower your hips by bending the knees and slide down the wall until the knees are flexed about 45 degrees (illustration). Pause five seconds and then slowly slide back up to the upright starting position. Doing this exercise too fast or too deep can aggravate your pain. Do not do this exercise if there is crunching or cracking at the kneecap or if it is painful. Do 3 sets of 10 to 15 repetitions.
Perform this stretch in the position illustrated at the right. Bend slowly forward at the hips, keeping the knee fully extended until you feel gentle stretch in the back of your thigh and knee. Hold the stretch for 15 to 20 seconds and repeat 3 to 5 times.
This stretch is performed in the position illustrated at the right. Lean gently backwards if bringing you heel toward the buttock. When a stretch is felt in the front of the thigh and knee, hold 15 to 20 seconds for 3 to 5 repetitions.
In the position illustrated, keep the heel flat on the floor and the knee fully extended. Lean forward at the hips with the arms supporting your weight. When you feel a gentle stretch in the back of your calf and knee, hold for 15 to 20 seconds, 3 to 5 repetitions.
LATERAL HIP AND THIGH STRETCH
Cross your left (right) leg over in front of the other. Lean to the left (right), bending at the waist and letting your right (left) hip jut out. When you feel a gentle stretch in the outside of hip, hold 15 to 20 seconds,3 to 5 repetitions.