1. Patellar Tendinopathy

2. Normal Anatomy Distal pole of patella Superior facet tibial tuberosity

3. Normal Anatomy Collagen – Parallel – Crimped – Tensile strength Ground Substance – Proteoglycans (PG) – Glycosaminoglycan (GAG) tail – Hydrophillic – Compressive strength

4. Mechanism of Injury Tendon is over or under loaded Results in some tissue degradation Repair is attempted Insufficient time or load Tendon degeneration Cook and Purdam, 2008

5. Mechanism of Injury Magnusson et al, 2008

6. Pathophysiology Increased tenocyte activity Increase ground substance Collagen deterioration Neovascularisation Nerve sprouting

7. Pathophysiology Reactive – Inflammatory markers – Minimal tissue degradation – ?Reversible structural change Degenerative – Disorganised tendon – Decrease Type 1 collagen – Increase Type 3 collagen Maffuli et al, 2000

8. Pathophysiology Cook et al, 2001

9. Pathophysiology Cortical changes may be present “All or nothing” response to loading Neural compromise Radiculopathy

10. Pathophysiology Transcranial Magnetic Stimulation

11. Pathophysiology ReactiveDegenerative SymptomsIrritableStable HistoryRecent load changeStable load AgeYoungOlder USReactive (acute) Degenerative (acute on chronic) Degenerative likely PathologyReversibleIrreversible PrinciplesSettle tenocytesStimulate tenocytes

12. Associated Pathologies Inferior pole – PFPS – Fat pad – Sinding-Larsen-Johnansson Disease Tibial Tuberosity – Osgood-Schlatter’s Disease – Infrapatellar bursa – Pes anserinus

13. Subjective Usually atraumatic Local pain Night pains ?History of lower limb injury Reported change in loading Lag between load and symptoms Some initial pain, reduces and returns after exercise

14. Objective Observation – Spine alignment – Tendon thickening – Muscle bulk ROM – Full ROM Strength – Kinetic chain Malliaras and Cook, 2011

15. Objective Neural – Femoral nerve Palpation – Local tenderness – Pinpoint location

16. Objective Movement Patterns – Single leg stance – Squat and single leg squat Biomechanics – Femoral torsion – Tibial torsion

17. Special Tests Standing Active Quads Sign – Palpate in standing – Locate point tenderness – Unilateral stand – 30 degrees knee flex – Decrease symptoms on palpation Passive Ext-Flex Sign – Palpate in supine – Leg in extension – Locate Point tenderness – Passive 90 degrees knee flex – Decrease symptoms on palpation London Hospital Test

18. Further Investigation US Scan MRI Hypo-echoic more likely pain Should always be a clinical diagnosis! Malliaras et al, 2010

19. Management Reduce pain Increase load tolerance Improve function Time ?Improve structure

20. Conservative - Management Load Modification Reactive – Address load – Correct biomechanics Degenerative – Correct biomechanics – Loading strategies – Isometric – Conc/Ecc

21. Conservative Isometric – 4-5 reps 3-4 per day – 40-60 sec hold – High load – Little or no pain Mechanotransduction Minimal movement Tendon Loading – No matrix stimulation

22. Conservative Eccentric – Leg extension – Leg press – Split Squat – Squat S&C Sport specific

23. Conservative - Management Adjuncts – Acupuncture – Deep transverse frictions – Joint mobilisations – Shockwave – Soft tissue massage – Taping and strapping

24. Surgical - Management Injections – High Volume – Steroid – PRP Debridement Shockwave

25. References Birch HL. (2007). Tendon matrix composition and turnover in relation to functional requirements. Int J Exp Path. 88; 241-248 Cook JL, Khan KM, Purdam CR. (2001). Conservative treatment of patellar tendinopathy. Physical Therapy in Sport. 2; 54-65 Cook JL, Purdam CR. (2008). Is tendon pathology and continuum? A pathology model to explain the clinical presentation of load- induced tendinopathy. Br J Sports Med. 43; 409-416 Maffuli N, Ewen S, Waterston S, Reaper J, Barrass V. (2000). Tenocytes from ruptured and tendinopathic achilles tendons produce greater quantities of type III collagen than tenocytes from normal achilles tendon. Am J Sports Med. 28; 499-505

26. References Magnusson SP Langburg H, Kjaer M. (2010).The pathogenesis of tendinopathy: balancing the response to loading. Nat Rev Rheumatol. 6; 262–268 Malliaras P, Purdam C, Maffuli N, Cook J. (2010). Temporal sequence of greyscale ultrasound changes and their relationship with neurovascularity and pain in the patellar tendon. Br J Sports Med. 44; 944-947 Malliaras P, Cook J. (2011). Changes in anteroposterior patellar tendon diameter support a continuum of pathological changes. Br J Sports Med. 45; 1048-1051 Warden SJ. (2003). Patellar tendinopathy. Clinical Sports Medicine. 22; 743-759