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Jumper's Knee: From Pain to Performance with Manual Therapy and Functional Exercises


High Jump at a Basketball Game

Jumper's Knee, or Patellar Tendinopathy, is a common condition affecting athletes and active individuals, especially those engaged in sports that require repetitive jumping and rapid changes in direction, such as basketball and volleyball. This article presents a biomechanically-focused treatment approach centered on manual therapy techniques and functional exercise programs, with a special emphasis on Motion Specific Release (MSR).


This approach underscores the critical importance of early and accurate diagnosis, positioning manual therapy and targeted exercise as fundamental elements in the effective management and recovery of Patellar Tendinopathy. By addressing underlying biomechanical imbalances and promoting tissue flexibility, this method not only alleviates symptoms but also enhances overall athletic performance and reduces the risk of recurrence.


Article Index


Introduction


Examination & Diagnosis


Treatment


Exercise


Conclusion & References

 

Palpation of the Patellar Tendon

Jumper's Knee Anatomy and Biomechanics


The patellar tendon is a key structure connecting the patella to the tibial tuberosity, playing a vital role in the movement of the lower limb. It is composed of type I collagen fibers arranged in parallel, making it well-suited to handle tensile loads. However, repetitive or excessive mechanical stresses, particularly during jumping or rapid directional changes, can cause microtrauma and lead to tendinopathy.


Biomechanically, the patellar tendon transmits forces from the quadriceps muscles to the tibia, enabling knee extension. During jumping activities, the landing phase places high mechanical demands on the tendon through eccentric loading. If the tendon and muscles can't effectively absorb and distribute these forces, localized stress can cause cellular and structural changes, leading to a pathological state. This results in altered knee movements and, if not treated, can create a cycle of injury and re-injury.


 


Person Holding a Knee

Clinical Presentation


Understanding the clinical presentation of Patellar Tendinopathy is essential for both diagnosis and treatment planning. This section elaborates on the common signs and symptoms clinicians should be vigilant about during patient assessment.


Signs and Symptoms


Localized Anterior Knee Pain

  • One of the hallmark symptoms of Patellar Tendinopathy is localized anterior knee pain. Specifically, the discomfort tends to be concentrated just below the kneecap (patella).

  • Clinical Significance: Localized pain in the anterior knee region suggests an issue directly linked to the patellar tendon itself, distinguishing it from other knee-related pathologies such as osteoarthritis or meniscal injuries.


Pain Exacerbation During Tendon-Loading Activities


  • Patients often report a noticeable increase in pain levels during activities that load the patellar tendon. Activities commonly triggering this pain include squatting, lunging, and jumping.

  • Clinical Significance: The exacerbation of pain during these activities can indicate the severity of the tendinopathy and the extent of the tendon’s functional limitations. It serves as an essential parameter for healthcare providers to gauge the impact on a patient's mobility and lifestyle.


Presence of Crepitus

  • Crepitus refers to a crackling or grating sound or sensation, often palpable upon joint movement. In the context of Patellar Tendinopathy, this is most commonly observed in advanced or chronic cases.

  • Clinical Significance: The presence of crepitus could indicate fibrillar disruption within the tendon, a severe manifestation of the pathology. This symptom warrants further investigation, often through imaging modalities like ultrasound or MRI, to assess the extent of tissue degradation.


 

Diagnosis


A comprehensive diagnostic evaluation for Patellar Tendinopathy necessitates a multi-faceted approach that blends a detailed patient history with focused orthopedic tests. Here's are examples of orthopedic, neurological, and vascular examinations that we commonly perform on our patients:


Knee Examination

This video guide provides an in-depth look at orthopedic testing techniques tailored for knee examination. These tests are crucial for diagnosing conditions like Patellar Tendinopathy, or Jumper's Knee. Tune in to learn how these methods can accurately pinpoint the cause of knee pain and guide effective treatment strategies.


Lower Limb Neuro Examination

The lower limb neurological examination assesses the motor and sensory neurons supplying the lower limbs to detect any nervous system impairment. This examination is used both as a screening and investigative tool.





Peripheral Vascular Examination

The peripheral vascular examination is a physical exam that evaluates the circulatory system outside of the heart and lungs. This exam is important in diagnosing and managing peripheral vascular diseases such as arterial occlusion, aneurysms, and venous insufficiency.



Specialized Orthopedic Tests for Patellar Tendinopathy:


  • Single-Leg Decline Squat: Instruct the patient to stand on a declined surface (10-25 degrees) with one leg. Ask them to perform a single-leg squat while observing for pain or instability. Pain during this test can indicate patellar tendinopathy.

  • Resisted Isometric Knee Extension: With the patient seated and knee flexed to 90 degrees, apply a resistive force against their lower leg as they try to extend their knee. Pain or weakness may indicate a compromised patellar tendon.

  • Functional Limitations Assessment: Evaluate the patient’s ability to complete tasks that load the patellar tendon, like squatting or jumping. Note any limitations in range of motion, strength, or performance.



MRI Machine

Imaging


Imaging modalities such as ultrasonography and MRI are pivotal for enhancing diagnostic accuracy and understanding the nuances of Patellar Tendinopathy. Each imaging method has distinct features that it brings to light:


  • Ultrasonography: This imaging technique primarily evaluates tendon morphology and echogenicity. In cases of Patellar Tendinopathy, you might observe hypoechoic regions representing areas of tissue degeneration or small tears. Additionally, it may reveal thickening of the patellar tendon.

  • MRI: An MRI is particularly useful for visualizing intrasubstance tears, as well as the severity of the condition. Within the scan, you would see changes in the signal intensity within the tendon substance, which may point to degeneration or tears. The severity can be gauged by the extent of these changes, including any involvement of surrounding structures.


By employing these imaging techniques judiciously, practitioners can achieve a more comprehensive understanding of Patellar Tendinopathy's clinical picture, thereby guiding the treatment strategy more effectively.


 

DDx Image

Differential Diagnosis


While the primary focus is on diagnosing Patellar Tendinopathy, it's essential to rule out other possible conditions that could manifest with similar symptoms. Here are some differential diagnoses along with brief explanations:


  • Quadriceps Tendinopathy: This condition involves pain and degenerative changes in the quadriceps tendon, often seen in athletes involved in jumping sports, similar to patellar tendinopathy.

  • Patellofemoral Pain Syndrome: Characterized by diffuse anterior knee pain originating from the patellofemoral joint, this condition is often aggravated by activities like squatting and climbing stairs.

  • Sinding-Larsen-Johansson Syndrome: A traction apophysitis at the inferior pole of the patella, commonly affecting adolescents and young athletes. It is similar to Osgood-Schlatter disease but occurs at a different site.


Distinguishing between these conditions and Patellar Tendinopathy often requires advanced imaging or metabolic profiling to achieve diagnostic accuracy.


 

Manual Therapy



In the subsequent videos, we demonstrate several effective Motion Specific Release procedures for addressing ligament injuries, including Patellar Tendinopathy of the knee. These procedures highlights the practical application of manual therapy procedures in promoting recovery and optimal function.


Knee Release Protocol - Motion Specific Release


In the accompanying video, Dr. Abelson demonstrates an effective knee release protocol using Motion Specific Release (MSR) procedures. These procedures address the localized area of pain and the broader kinetic chain, contributing to a more comprehensive treatment approach. It is essential to recognize that each instance of knee pain should be assessed and managed as a unique dysfunction tailored to the individual patient. In some cases, the treatment may focus on local structures, while in other instances, it may involve addressing a more extensive kinetic chain to achieve optimal results.


Increasing Knee Joint Mobility - 4 Point MSR Knee protocol


Effective Motion Specific Release knee mobility procedures are demonstrated in this video, which effectively addresses the body's entire kinetic chain. The femur, tibia, and patella, as well as a large number of muscles and ligaments, make up the complicated structure of the knee joint.


 

Treatment Frequency


The frequency of manual treatment is tailored to the severity of ligamentous injury. Mild injuries often require less intensive therapy, allowing for an early transition to self-managed care. Moderate injuries demand a more structured approach to navigate through healing phases and initiate rehabilitation. Severe, especially post-surgical injuries, necessitate intensive, prolonged therapy to ensure optimal recovery, manage scar tissue, and restore function while preventing secondary complications. Each injury grade thus dictates a distinct therapy approach and frequency, aligning with individualized therapeutic needs for optimal healing and functionality restoration.



Grade 1 Tear (Mild):

  • Initial: 2 times per week

  • Duration: 1-2 weeks, transitioning to home exercises and self-management

  • Approximate Total Appointments: A total of 3 to 6 appointments, encompassing 2 to 4 initial treatment sessions followed by 1 or 2 follow-up appointments, depending on patient response.


Grade 2 Tear (Moderate):

  • Initial: Weekly to bi-weekly visits

  • Duration: 2-4 weeks, then tapering off as symptoms improve and home exercises progress

  • Approximate Total Appointments: 3 to 8 appointments, comprising weekly to bi-weekly visits over a span of 2-4 weeks, followed by 1 or 2 follow-up appointments, depending on patient response.


Grade 3 Tear (Severe - Requires Surgery):


In severe cases, post-operative rehabilitation begins with managing pain and swelling, and immobilizing the ankle. Early rehabilitation introduces weight-bearing and basic exercises. Intermediate rehabilitation advances strengthening and normalizes walking. Late rehabilitation intensifies strength training and introduces sport-specific exercises. Finally, a gradual return to full activities commences.


 


Woman Performing Leg Exercises

Functional Exercise Programs


Functional exercise programs are a cornerstone in the rehabilitation of Patellar Tendinopathy. Designed to promote functionality, strengthen the tendon, and improve mobility, these targeted regimes form an essential part of any comprehensive treatment plan.


A successful rehabilitation journey in the management of Patellar Tendinopathy is contingent upon a phased, evidence-based approach. Knowing when to transition from one phase of exercise to another is crucial for optimized recovery and reducing the risk of re-injury.


Transition Guidelines


1. Isometric, Concentric and Eccentric Training


The transition from isometric exercises to concentric and eccentric training should be guided by significant pain reduction and increased tendon stability. The goal of isometric training is primarily pain modulation, making it a preliminary phase in rehabilitation.


Indicators for Transition

  • Pain levels reduced to 3 or below on a 10-point visual analog scale (VAS)

  • Ability to complete all isometric exercises without sharp pain

  • Clinical evaluation showing improved tendon stability


Start integrating concentric and eccentric exercises only after satisfying these indicators. Consult your healthcare provider for a customized assessment.



2. Concentric, Eccentric to Plyometric Training


The move to plyometric exercises is the final leap in a graduated exercise regimen for patellar tendinopathy. This stage is designed to reintroduce dynamic and impact-based activities into the daily routine safely.


Indicators for Transition

  • Sustained ability to perform concentric and eccentric exercises with proper form and without pain

  • Strength measures (e.g., via dynamometry) returning to near pre-injury levels

  • Functional tests, such as single-leg hops or squats, performed without pain or instability


Plyometric training should only commence after successfully satisfying the aforementioned criteria and with clearance from a qualified healthcare provider.

Now that you have the general concepts lets discuss some the actual exercises that we often prescribe to our patients.


 

Specific Exercises


Woman Performing Wall Squat

Isometric Exercises: Pain Modulation Phase


Isometric exercises are particularly effective for initial pain modulation. By applying tension without actual movement, they allow for muscle engagement without stressing the affected tendon. This can be a crucial first step in the rehabilitation process.


Static Quadriceps Hold
  • Instructions: Sit on the floor with your legs extended. Tighten your quadriceps while pressing the back of your knee into the floor.

  • Sets & Repetitions: 4 sets of 10-second holds.


Isometric Wall-Sit
  • Instructions: Stand with your back against a wall. Slide down into a squat position and hold.

  • Sets & Repetitions: 3 sets of 20-30 second holds.



Woman Performing Deep Squat

Concentric and Eccentric Training: Active Strengthening Phase


Once pain modulation is achieved through isometric exercises, the next phase involves concentric and eccentric training. Concentric movements strengthen the muscle while shortening it, and eccentric movements do so while lengthening it. This phase aims for a more dynamic strengthening of the muscle-tendon unit.


Bilateral Squats
  • Instructions: Start in a standing position. Perform a squat by lowering your hips back and down while keeping your chest lifted.

  • Concentric Phase: Rise back up to standing position.

  • Eccentric Phase: Lower yourself back down slowly, taking twice the time as rising up.

  • Sets & Repetitions: 4 sets of 8-12 reps.


Leg Press Machine

  • Instructions: Sit in the leg press machine. Place your feet hip-width apart on the platform.

  • Concentric Phase: Extend your legs to push the weight up.

  • Eccentric Phase: Lower the weight back down in a slow and controlled manner.

  • Sets & Repetitions: 3 sets of 10-15 reps.



Box Jump Exercise

Plyometric Training: Advanced Training Phase


Plyometric exercises introduce controlled impact forces to further challenge the tendon and supporting musculature. Designed for those in the advanced stages of rehabilitation, these exercises aim to restore the tendon's ability to handle dynamic, high-impact activities safely.


Box Jumps
  • Instructions: Stand in front of a box or a sturdy platform. Jump up onto the box, landing softly with knees slightly bent.

  • Sets & Repetitions: 3 sets of 8 reps.


Depth Jumps
  • Instructions: Stand on a platform. Step off, then immediately jump vertically as high as you can.

  • Sets & Repetitions**: 3 sets of 6 reps.


By incorporating a three-phase approach that includes isometric exercises, concentric and eccentric training, and plyometric activities, practitioners can offer a holistic and scientifically-grounded regimen for managing Patellar Tendinopathy.



 

Beach Volleyball

Conclusion


In conclusion, Jumper's Knee, or Patellar Tendinopathy, poses a significant challenge for athletes and active individuals involved in repetitive jumping and rapid directional changes. This article has presented a comprehensive, biomechanically-focused treatment approach centered on manual therapy techniques and functional exercise programs.


Early and accurate diagnosis is paramount in effectively managing Patellar Tendinopathy. By addressing underlying biomechanical imbalances and promoting tissue flexibility, this method not only alleviates symptoms but also enhances overall athletic performance and reduces the risk of recurrence. Through a phased exercise regimen and targeted manual therapy, patients can achieve optimal recovery and return to their activities stronger and more resilient. This integrated approach underscores the importance of personalized care and the role of advanced therapeutic techniques in overcoming this prevalent condition.


 

References


  1. Cook, J. L., & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British Journal of Sports Medicine, 43(6), 409-416.

  2. Lian, Ø., Engebretsen, L., & Bahr, R. (2005). Prevalence of jumper's knee among elite athletes from different sports: A cross-sectional study. The American Journal of Sports Medicine, 33(4), 561-567.

  3. Visnes, H., & Bahr, R. (2007). The evolution of eccentric training as treatment for patellar tendinopathy (jumper's knee): a critical review of exercise programmes. British Journal of Sports Medicine, 41(4), 217-223.

  4. Kongsgaard, M., Kovanen, V., & Aagaard, P. (2009). Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scandinavian Journal of Medicine & Science in Sports, 19(6), 790-802.

  5. Malliaras, P., Cook, J. L., Purdam, C. R., & Rio, E. (2015). Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. The Journal of Orthopaedic and Sports Physical Therapy, 45(11), 887-898.

  6. Scott, A., & Backman, L. J. (2018). Platelet-rich plasma for managing pain and inflammation in osteoarthritis. Nature Reviews Rheumatology, 14(12), 721-730. (Focuses on biologics and their application to tendinopathies).

  7. Rio, E., Kidgell, D., Purdam, C., Gaida, J., Moseley, G. L., Pearce, A. J., & Cook, J. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British Journal of Sports Medicine, 49(19), 1277-1283.



 

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DR. BRIAN ABELSON DC. - The Author


Photo of Dr. Brian Abelson

Dr. Abelson is dedicated to using evidence-based practices to improve musculoskeletal health. At Kinetic Health in Calgary, Alberta, he combines the latest research with a compassionate, patient-focused approach. As the creator of the Motion Specific Release (MSR) Treatment Systems, he aims to educate and share techniques to benefit the broader healthcare community. His work continually emphasizes patient-centered care and advancing treatment methods.



 


MSR Instructor Mike Burton Smiling

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