About this client and how they’ve presented it.

I recently saw a 23-year-old male with increased right knee pain while playing basketball, volleyball, and doing his lower-limb strengthening exercises as prescribed by his physio. He described this pain as being vaguely near the inferior pole of the patella. 

During my subjective examination, I was able to learn that he had recently increased his level of sporting activity, returning to basketball and volleyball after several weeks off in lockdown. He complained of increased pain during standing, and a feeling of instability in the knee. The acute increase in jumping load, the pinpoint pain below the patella, and the ‘warm-up effect’ he described (pain eased slightly as he continued a painful activity) suggested to me that he was suffering from patellar tendinopathy. 

He also described some pain above the patella in the region of the VMO, which combined with the feeling of instability, indicated that he may have some issues in controlling knee extension.

As part of a clinical handover from his previous treating physio, I was informed that this patient’s glutes (hip abductors and external rotators) were weak, suggesting some issues with lumbopelvic stability may also be at play and may be contributing to his feeling of knee instability. I was also told that he had a meniscal tear in the same knee which he was currently rehabbing. 

During my objective examination, I found that this patient had some pain and a noticeable clunk during a McMurray’s test (adding weight to the my suspicion of a meniscal tear) – but this pain was not consistent with his other pain, and was likely an incidental finding. His pain slightly improved after doing 2×30” wall sits (isometrically loading the patellar tendon), which further strengthened my idea that this may be reactive patellar tendinopathy. During a decline squat assessment, he reported pain at the back of the knee during deep knee flexion, which is atypical for patellar tendinopathy, and may have indicated another source of knee pain (meniscal tear likely, baker’s cyst possible) that was present in addition to the patellar tendon pain.

Though this was a joint treatment where I was shadowing another therapist, I would have also liked to assess this patient’s ankle dorsiflexion ROM, to see if reduced dorsiflexion resulted in greater loads going through the knee joint during squatting and jumping movements.

What’s My Diagnosis of the condition?

Reactive patellar tendinopathy.

Pathophysiology background:

This patient’s sudden increase in patellar tendon load from the resumption of basketball & volleyball (sports requiring significant plyometric load through the patellar tendon during running and jumping) caused a short-term adaptive response within the tendon to lay down new collagen and adapt to its increased load demands. This adaptive response results in an increase in nociceptive signalling from the tendon under load (likely as a protective mechanism to prevent the tendon from further abusive loading until it has had time to adapt). This patient’s pain was likely a result of this increased nociception, which occurred during high tendon load tasks (jumping, etc).

Possible differential diagnosis

Meniscal tear (and subsequent knee instability)

Pathophysiology background:

A meniscal tear has the ability to change the loading of the tibiofemoral joint and cause increased loading to more neurally sensitive structures within the knee. Increased forces through the knee seen during jumping, etc, may cause acute changes in tibiofemoral loading which may cause increased nociception and thereby explain this patient’s knee pain during these activities.

Looking at Treatments

Treatment began with some soft tissue massage to the affected quadricep muscle. Though I am not certain as I did not have the chance to discuss this with my treating partner, I suspect this was to facilitate some relaxation of the musculotendinous complex of the patellar tendon, as well as to reduce this patient’s pain prior to exercise.

Most of this treatment session involved strengthening the affected lower limb in order to improve its (and its tendon’s) capacity to handle the load. We prescribed single leg squats in order to strengthen the affected quadricep muscles (while working some of the hip stabilisers which may have also been weak and affected this patient’s knee mechanics) in order to increase the patellar tendon’s tolerance to load directly. 

Though we could have added more quadricep-loading exercises, we chose to leave this session with only one, to see the pain response in the tendon the following day. We also chose to address the weak glutes and possible lack of lumbopelvic control with a clam exercise (glutes) and a Pallof press (core/lumbopelvic stability).

The Plan

As this tendinopathy was likely in the reactive stage, proper tendon rehab should assist this patient in regaining full pain-free function of the patellar tendon. 

We will need to first increase this patient’s lower limb strength and ability to tolerate slow loading prior to improving his ability to take high-load explosive exercise (being in the slow concentric/eccentric phase of the standard tendinopathy rehab continuum). I would expect this strengthening to take a minimum of 4-6 weeks (to allow for tissue healing and any hypertrophic effect of strength training), followed by another few weeks of a gradual return to explosive activity.

The load will need to be carefully monitored and managed during this time, and I would advise this patient to avoid acute spikes in load during this period (ease back into basketball/volleyball when this current lockdown ends, begin by playing no more than one half per game and be careful with jumping volume). Isometrics can still be utilised at any time in this process for pain relief, and we may need to address other biomechanical issues (lack of dorsiflexion, poor lumbopelvic control) in future sessions. Dorsiflexion range can be improved through therapist-led and patient-led talocrural mobilisations and soft-tissue work, and lumbopelvic control can be retrained concurrently with gradual quadriceps strengthening.