Injury Library (8)
Many untreated sprained ankles heal incorrectly, leaving the athlete with a stiff or weakened ankle, which is at a higher risk of re-injury.
Anatomy of the Ankle Joint
The ankle's stability is provided by a number of ligaments, located on either side of the ankle joint, that are designed to protect the joint from excessive movement. On the inside of the ankle, the deltoid ligament, forms a dense strong supporting structure and consists of the tibionavicular, tibiocalcaneal and tibiotalar (anterior and posterior) ligaments. The lateral ligament complex (outside) consists of the weaker anterior talofibular, calcaneofibular and posterior talofibular ligaments.
|(Click images to view larger verson)|
What causes an ankle sprain?
An ankle sprain occurs when the ankle joint is taken beyond their normal range of movement and results in tearing of some of the above mentioned ligaments. Tearing is graded as:
- Grade 1: Mild: Involves a ligament stretch and no joint instability
- Grade 2: Moderate: Partial ligament tearing and some loss of joint stability
- Grade 3: Complete: Complete ligament rupture and abnormal joint motion and instability.
The most common mechanism of injury is when the foot lands awkwardly, resulting in the ankle joint suffering an inversion injury (i.e. the foot rolls inwards). This is often combined with a pointed foot, and results in the lateral structures becoming damaged. This is the most common type of ankle injury that occurs in sport, particularly those involving running, jumping and change of direction activities i.e. netball, basketball and all forms of football (soccer, rugby, Australian rules).
What are the symptoms?
- Pain and difficulty weight-bearing / walking
- Swelling, that may occur either quickly (less than 30 minutes) or later that day
- Restriction in ankle movement
- Giving way or a feeling of instability, particularly on un-even ground or when changing directions
- Recurrent clicking
What to do?
Rehabilitation is necessary to strengthen the ankle joint (and its associated structures) to withstand the strenuous demands required during activities of daily living and playing sport.
What can be done?
Physiotherapy management will involve a thorough physical and biomechanical assessment to assess the extent of your injury and proceed with any further investigations deemed necessary (i.e. x-ray if there is a concern of possible bone fracture). If the physiotherapist is satisfied that the injury only involves soft tissue structures, then treatment can commence immediately.
The rehabilitation program is based on an abundance of scientific research led by physiotherapists and is concentrated on immediate and correct management of the sprain during the acute inflammatory phase. This will assist in speeding up your recovery, while also allowing the repair phase of healing to proceed as soon as possible, to enable a successful recovery and return to sport. This program includes:
- RICE: this will prevent the ankle joint and its associated damaged structures becoming more sensitive and painful, and involves:
- Rest: by restricting loading on the ankle joint, it will minimise any further damage to your injured ankle. This may involve the use of crutches, braces and / or taping.
- Ice: regular application of ice will provide pain relief and minimize associated secondary soft tissue damage.
- Compression: minimise secondary damage and swelling to neighbouring soft tissues.
- Elevation: to assist in minimising ankle / foot swelling, by improving return blood flow to the heart.
- Massage: plays an important role with healing of the damaged ligaments by improving local blood flow and releasing adhesions between the collagen fibres that compose the ankle ligaments. This ensures they re-form appropriately, minimizing the development of any scar tissue in the ankle joint and / or ligamentous structures.
- Increase Strength: by a series of graduated exercises to the muscles of the lower leg, to improve the range of movement and the control of the ankle joint.
- Proprioceptive (Balance) Exercises: these will promote good foot positioning prior to landing and improve postural control. This is the most important part of the rehabilitation program, as it will significantly lower the risk of ankle re-injury.
- Stretching: poor gastrocnemius / soleus muscle flexibility can overload the ankle joint and associated foot structures. Hence, a regular stretching program to maximize their length is essential for correct ankle function.
- Correction of Pre-Disposing Factors: this ensures that the problem doesn't re-occur and can include:
- Education on correct training principles of duration, intensity and frequency, to ensure the ankle can progressively adapt to the demands placed upon it with training.
- Biomechanical factors such as over-pronation (flattening) of the feet can cause excessive demands on the joints and muscles of the lower leg. Wearing appropriate running shoes for your foot type will minimise these problems. An assessment by our sports podiatrist maybe appropriate to determine whether orthotics are required to assist with this stability.
- Surgery: can be a possibility with long-standing ankle instability caused by recurrent ankle sprains. If conservative physiotherapy rehabilitation fails, an appropriate referral to a foot orthopaedic surgeon for further investigations (Bone scans, CT, MRI) can assist in ongoing management and to determine whether surgery is appropriate.
Published by Balmain Sports Medicine
Nearly 60% of patients who present with hip pain are due to a condition called trochanteric bursitis. This form of bursitis is more common in women and the middle-aged or elderly, than in men or younger athletes.
Heat Illness & Exercise
In order to play and exercise safely in the hot summer months, it is important to understand how the body copes with exercise in the heat and the guidelines you can follow to exercise safely and optimize your performance.
What is Heat Illness?
Vigorous exercise in sport places some people at risk of heat illness. The risk of illness is obviously greater in hot humid weather because:
- During high intensity exercise in hot weather people may not be able to produce enough heat for adequate cooling
- High humidity may prevent adequate evaporation of sweat
- Heat illness is not a trifling matter- if untreated, it can lead to the rare but life threatening condition of heat stroke. This article will help you recognize and manage potentially dangerous situations that may arise during sport or physical activity, where exertion levels are out of the ordinary.
How do You Tell if Someone has Heat Illness?
Heat illness may occur in strenuous sports, but may also occur in prolonged moderately strenuous physical activity in hot weather. During training and competition exercisers should ‘listen to their bodies’. If they start to experience any of the following signs and symptoms they should stop exercising immediately:
- Light headedness / dizziness
- Obvious fatigue / weakness
- Muscle cramps
- Fast and / or weak pulse
- Cessation of sweating
- Ashen / pale / cool / moist skin
- Confusion / disorientation
- Altered consciousness
- Aggressive or irrational behaviour
- Obvious loss of skill / co-ordination / clumsiness
Types of Heat Illness
1. Muscle Cramps:
- Mildest form of heat illness
- Painful muscle cramps and / or spasms during or after intense exercise and sweating in high temperatures
2. Heat Exhaustion:
- The more common sports related heat illness
- Is the body's response to dehydration
- Participants who collapse after exercise, are likely suffering heat exhaustion, with low blood pressure (postural hypotension), but some may have heat stroke.
2. Heat Stroke:
- Is rare, but is a life-threatening condition
- Those who show signs of altered mental function, loss of consciousness or collapse during exercise are likely suffering heat stroke.
- Sports participants showing signs of confusion, loss of skill, loss of coordination or irrational behaviour should be stopped and removed from the field immediately.
Factors that Increase the Risk of Heat Illness include:
- High exercise intensity i.e. Exercising close to personal capacity
- Lack of fitness (due to insufficient training that includes some at competition intensity and duration)
- Previous history of heat illness or heat intolerance
- High air temperature
- High humidity
- Low air movement / no wind, following wind while performing exercise
- Solar radiation
- Heavy clothing and protective equipment i.e. padding
- Lack of acclimatisation (due to lack of recent training in warm and humid conditions)
- Dehydration (inadequate water intake before exercise and during activity longer than 60 minutes)
- Illness and medical conditions (current or recent infectious illness, chronic health disorders)
What Steps can be taken to Minimise the Risk of Heat Illness?
- Acquiring Adequate Fitness and Acclimatisation Excellent physical fitness markedly increases tolerance. Acclimatisation for sports activities requires at least 5 days of training in hot and humid conditions, progressing from moderate intensity and duration as acclimatisation develops.
- Adjusting training and Competition Intensity to Conditions This should be appropriate to current fitness and weather. In conditions of increased risk athletes should be provided with opportunities to rest for at least 10 minutes per hour. Rest breaks should be maximised by resting in shade, reducing clothing, drinking cool water or sports drinks and using fans to assist in evaporative cooling.
- Timing of Games or Activity Avoid the hottest part of the day between 11am and 3pm. Early morning or night games are recommended.
- Clothing You should allow for easy evaporation from the skin. Key factors include light coloured, light weight, loose fitting items that provide protection from the sun. Wear well-vented broad brim hats and water soluble sunscreen for sun protection. Caps do not provide adequate sun protection.
- Modifying Warm-Up In hot conditions reduce duration and intensity of warm-up, to minimise increase in body heat and temperature before competition.
- Drinking (Hydration) Substantial amounts of water are lost through sweating when exercising vigorously in the heat. To minimise dehydration, drink about 500ml of water in the 2 hours before exercising. During exercise lasting 60 minutes or longer, 500-750ml of cool water / sports drink per hour, are sufficient for most sports. Water intake exceeding sweat loss, in events lasting several hours, can lead to the harmful condition of hyponatremia (low blood sodium).
- Heat Waves, Unusually Hot Weather and Travelling Extra caution needs to be taken in these conditions. Athletes that lack acclimatisation are at increased risk of heart illness if they exercise in the hot weather, at their cool climate intensity.
- Other Medical Considerations
- If you have recently experienced a high temperature, infection, diarrhoea or vomiting, you should NOT take part in strenuous exercise.
- People who suffer from a variety of medical conditions, who are taking medication or who are pregnant may experience difficulties exercising in the heat i.e. asthma, diabetes, heart conditions, overweight and obesity.
Treating Heat Illness
If an athlete is exhibiting signs of heat illness take the following action:
- Remove the athlete from the field of play
- Lay the person down in a cool place
- Raise legs and pelvis to improve blood pressure
- Remove excess clothing
- Cool by wetting skin liberally and use of vigorous fanning (for evaporative cooling)
- Apply ice packs to groin, armpits and neck
- Give cool water if conscious
Athletes Suffering from Heat Exhaustion usually recover rapidly with this assistance. If the athlete remains seriously ill, confused, vomiting or shows signs of altered consciousness, call the ambulance immediately and seek medical help, as they are likely to be suffering from heat stroke.
Ambient Temperature and Exercise
Below is a table that will give you an easily understood guide to exercise on hot, dry days.
|Ambient Temperature (°C)||Relative Humidity||Risk of Thermal Injury||Possible Modifying Action for Vigorous Sustained Activity|
|15 - 20||-||Low||Heat illness can occur in distance running|
|21 - 25||Less than 60%||Low||Moderate Increased vigilance|
|26 - 30||Less than 50%||Moderate||Moderate early pre-season training intensity. Reduce intensity & duration of play / training. Take more breaks.|
|31 - 35||Less than 30%||High - Very High||Limit duration to < 60 min per Session.|
|36 and above||Less than 25%||Extreme||Consider postponement to a cooler time of the day or cancellation|
Treating for Heat Stroke
- Continue cooling. If available, cool in a shallow canvas / plastic bath of iced water (5-10 minutes)
- If necessary, cooling should continue during transport to hospital.
For more information the Bureau of Meteorology provides detailed information about daily temperature conditions in Australia (http://www.bom.gov.au/). Information on sport safety can be attained by going to http://www.sma.org.au/ and clicking on the hot weather icon.
Published by Balmain Sports Medicine
Headaches & How Physiotherapy Can Help
Headaches affect almost two thirds of the population. There is significant clinical evidence and research to confirm that many headaches arise from stiffness in the joints of the upper neck.
Anatomy of the Cervical Spine (Neck)
The cervical spine is made up of 7 vertebrae in the spine, stacked on top of each other, starting just below the skull and ending at the base of the neck. The cervical spine has a lordotic curve (a backward “C”-shape), with its inherent structure providing a large degree of movement in all directions. Successive vertebra are ‘linked together’ via a pair of facet joints, one on each side of the neck, with an intervertebral disc in between each vertebra. The atlas (first cervical vertebra - C1) sits on top of the axis (second cervical vertebra - C2), with their unique arrangement and its associated ligaments, provide the neck with its high degree of rotation.
What causes a Cervicogenic Headache?
The joints most commonly causing headaches are the upper facet joints (the joints formed by ‘side links’ between the vertebra), that under normal circumstances should glide freely to allow neck movements. If the joint, surrounding ligaments or muscles are injured, the joints can become stiff and the associated spinal nerves become irritated, acting as a trigger for referred pain into the head and behind the eyes. Misdiagnosis is common.
What Are The Symptoms?
If you have any of the following symptoms, it could suggest the headache has originated in the neck, and can therefore be relieved by physiotherapy treatment:
- history of trauma to the neck (i.e. acute: whiplash, chronic: repetitive work / sporting activity)
- often appears as a slow, insidious onset
- described as a constant, steady, dull ache,
- maybe present for days / weeks / months
- stiffness and restricted movement of the neck
- the headache seems to radiate from the back to the front of the head and often appears worse on one side.
- headache is brought on by certain neck movements or sustained postures eg. sleeping face down with the head turned to one side.
- headache appears to ease when pressure is applied to the neck or the base of the skull.
- often involves light-headedness and nausea
What To Do?
Physiotherapy management will involve a thorough clinical history related to the headache qualities and a physical assessment of the movements of the neck. This will usually provide sufficient information for a diagnosis, however if the physiotherapist isn’t satisfied that the injury is ‘mechanical’ in nature (i.e. abnormalities in the cervical joints, fascia and neural structures), then the individual needs to be referred to a sports physician / neurosurgeon for further investigations (i.e. neurological testing, CT scans) and the exclusion of more sinister causes of headaches.
What Can Be Done?
The individual with upper neck stiffness will usually respond very well to physiotherapy. Treatment is based on scientific research led by physiotherapists and is concentrated on immediate correction of the neck stiffness and any precipitating factors that may be present. This treatment program includes:
- Massage: will assist in resolving the multiple trigger points (small hypersensitive areas within a muscle) located within the short muscles at the base of the skull. These trigger points cause dysfunction in a muscle, reducing muscle length and strength and may also refer pain into the either shoulder or the head (front and / or back). Massage will help relax and remove trigger points to improve neck muscle function.
- Joint Mobilisations: are passive movement techniques applied to the vertebral joints of the cervical spine. Joint mobilisations aim to restore full pain-free range of motion in each of the cervical joints. To help prevent the recurrence of your headaches you will be shown exercises for your neck so you can maintain your ‘new’ mobility and movement.
- Stretching: poor cervical extensor muscle flexibility can ‘overload’ the upper cervical joints and associated structures. Hence, a regular stretching program to maximize their length is essential for correct neck function.
- Strength: Research performed by physiotherapists has found that ongoing neck problems may be due to weakness in the supporting and postural muscles. Loss of postural control can lead to the neck poking forward and a rounding of the shoulders ie, slouch. This combination overloads the neck joints and other soft tissue structures, which over time, summates to cause pain and dysfunction. Specific strength trainiing will aim to reverse weakness in the correct areas.
- Ergonomic Assessment of Workstation: the layout and design of your workstation (desk height, chair height, computer screen, desk space) can significantly increase the postural load on your bodies joints and muscles throughout a long work day; as such, this may lead to developing neck pain and headaches.
- Stress: is often a large precipitating factor associated with cervicogenic headaches. As such, these need to be identified and addressed as part of the rehabilitation program, as it will significantly lower the occurrence of the headaches.
Published by Balmain Sports Medicine
Low back pain (LBP) is an extremely common symptom in the general population, with up to 80% of people suffering from various levels of discomfort and limitation in their daily lives.
LBP is a mystery, even to the experts, with it often not caused by trauma, such as lifting a heavy couch or a bruising tackle in a contact sport. It is often due to an ‘insidious onset’, such as bending forward to put your shoes on or picking up a pen awkwardly from the floor.
In managing back injuries, the physiotherapist will perform a thorough assessment to exclude obvious diagnoses, such as fractures and the more serious (rare) conditions such as malignancy or osteoporosis. Following this, it is often not possible to make a precise diagnosis. However physiotherapy management involves an identification and correction of any abnormalities in movement patterns, as well as strengthening the muscles around the spine, to minimize the risk of back pain returning.
The more common clinical causes of low back pain include Non-Specific Low Back Pain (NSLBP), Intervertebral Disc Degeneration / Sciatica and Lumbar Stress Fractures (and its associated conditions).
1. Non-specific Low Back Pain (NSLBP)
Low back pain can be caused by structures being too tight (hypo-mobility) or too loose (hyper-mobility). The pain producing structures in the lumbar spine include the vertebra, the facet joints (links two vertebra together in your spinal column), intervertebral disc, ligaments, nerves and their protective coverings, muscles and their attachments.
With our activities of daily living (whether this is by being inactive or participating in sport) these structures may become overloaded and fatigued over time. This ‘wear and tear’ cause’s micro-trauma within the facet joint or intervertebral disc, causing it to ‘lock’, preventing the joint from moving smoothly throughout its normal range. This can result in pain, movement dysfunction and degeneration.
2. Intervertebral Disc Degeneration / Sciatica
The intervertebral discs are composed of a soft, inner nucleus pulposus surrounded by a tough fibrous outer ring, the annulus fibrosus. With trauma and / or ageing, the annulus fibrosus can weaken and thin (disc degeneration or herniation), particularly with the repetitive combination of bending forwards while rotating the trunk i.e. lifting. This may result in the disc bulging outwards and exerting pressure on one or more of the closely associated spinal nerves. This disc degeneration process is often incorrectly termed as the ‘disc slipping out and in’, and it’s important to realise that this does not occur. In some serious cases, the disc may leak some fluid into the spine from the internal nucleus pulposus, known as a disc prolapse.
Compression of a spinal nerve by a disc fragment causes radiculopathy, which may include weakness of muscles controlled by that spinal nerve, pain in the distribution of the nerve root, or sensory changes such as numbness, tingling, or hypersensitivity in the same area. Back pain is often experienced in conjunction with these symptoms. Sciatica is a term used to describe pain which occurs in the distribution of the sciatic nerve, a major nerve in the leg made up of several spinal nerves from the lower spinal cord.
3. Lumbar Stress Fractures
LBP may also be caused by spondylolysis, or a stress fracture of the pars interarticularis, a region of the vertebra. This is often seen in sports involving repeated back extension and rotation, such as gymnastics, cricket fast bowling or tennis. While it was thought to be congenital, it is probably an acquired overuse injury. The fracture usually occurs on the opposite side to the one performing the task i.e. a left sided fracture occurs in a right handed tennis player.
Spondylolisthesis, which is defined as a slippage of one vertebral body forwards in relation to the one below, can also cause LBP. This usually occurs where the lumbar and sacral spines meet at the bottom of the back. This slippage may be caused by stress fractures of the pars regions (as above), degenerative changes in the spine, congenital defects of the spine, or trauma. The result is pain caused by spinal nerve compression, with symptoms similar to those seen in spinal canal stenosis, or irritation of nerve endings at the joints, which results in back pain. It is most commonly seen in children between the ages of 9 and 14 years of age.
4. Spinal Canal Stenosis
Another commonly encountered cause of LBP is spinal canal stenosis. It is a condition that is rare in young and middle-aged athlete’s, but may be seen occasionally in older athletes. The condition is caused by arthritic degeneration of the spine, resulting in the vertebra, facet joints, and ligaments which surround the spinal nerves of the spinal cord to become enlarged. In this manner, these structures may compress one or several spinal nerves, causing LBP, leg pain, and leg numbness while walking. These symptoms maybe relieved by rest.
In the management of most cases of LBP, investigations are not required. However, there are certain clinical indications that require further investigations. This may include:
- X-ray: to exclude fractures and to ‘screen’ those patients whose LBP is not responding to treatment.
- CT scan: is commonly performed in patients suspected of nerve root compression, spinal cord stenosis or facet joint pathology.
- MRI: is used to investigate the structural status of the intervertebral disc i.e. degeneration (‘bulging’) or a tear in the outer annular wall.
Symptoms of LBP May Include:
- Pain in the back and occasionally in the legs
- Difficulty in moving i.e. can’t straighten up or uncomfortable sitting
- Muscle spasms in the back
- Referred pain and / or altered sensation into the groin, thigh, leg or foot
- Sleep can be disturbed with pain on rolling over
- Slumped positions such as that in a car seat or on the couch at home, cause pain
- Pain sometimes on coughing and sneezing
- Pain on weight bearing
What can Physiotherapists Do To Help?
The physiotherapy management varies depending on the specific back diagnosis of the individual athlete, but will possibly include:
- Massage of the muscles to relieve pain, muscle spasm and promote healing.
- Gentle joint mobilization techniques to relieve the spinal segment and ‘free it’ to move without pain, throughout its full range.
- Strapping techniques in the acute stages to protect the vulnerable joints.
- Commence a progressive muscle strengthening program to improve both your core stability and general back strength, so as to protect your intervertebral disc, their associated ligaments and joints, from ‘general wear and tear’. The major muscle groups that work in synergy to protect the back and the spine are: (1) the multifidus, a deep back muscle and (2) the transversus abdominis, which joins the back bone with the rib cage. Recent scientific evidence has shown in a variety of different populations with LBP, whether you are an athlete or not, that these deep back muscles, in particular the multifidus, have shrunk in size and strength.
- Maximise your muscle flexibility, in particular your hamstrings, buttock and hip muscles.
- Improve your physical fitness and advise you on ongoing activity as maintenance.
- Provide postural education on reducing the load on the joints and muscles, so as to minimize the recurrence of back pain. This includes modifying your daily work tasks, sporting and personal activities.
Published by Balmain Sports Medicine
Good shoulder function is essential for many popular sports, particularly repetitive sporting movements, such as racquet (i.e. tennis serve, golf swing) or ball sports (i.e. throwing in baseball / cricket).
Aching at the front of the knee is one of the most common presenting symptoms in athletes. It is typical in children and more common in girls than boys.
The two most common causes of anterior knee pain are
- Patello-Femoral Syndrome
- Patellar Tendinopathy
Diagnosing these conditions can often be difficult as they often have similar symptoms, and can even present together. The patello-femoral joint is formed by the knee cap (patella) sitting on the front of the thigh bone (femur).
As the knee bends, the patella moves in a groove found at the end of the femur. The patella is a floating bone. Therefore, the patella’s position and function depend intimately on the structures that attach to the patella. This is important to remember when we discuss treatment and management.
Patellofemoral Pain What is it?
Patello-femoral pain occurs when the under surface of the patella (knee cap) is pain sensitive, due to damage and irritation to any of the pain sensitive structures between the patella and femur. This can be caused by incorrect tracking, or movement of the patella, as the knee bends and straightens. The patella rubs against the femur, instead of gliding correctly in the groove.
What causes it?
Remember the patella is a floating bone. Therefore, structures that are too tight will pull the patella into the wrong position. Usually the tightness occurs in the lateral thigh structures (tensor fascia latae, gluteals, quadriceps, hamstrings, calf) and a loss of muscular control (and strength) of the inner quadriceps muscle, the vastus medialis oblique (VMO). Typically, the ‘tug-of-war’ between the outside and inside structures is won by the outside, pulling the patella laterally. Eventually, too much incorrect rubbing leads to inflammation, pain, swelling and dysfunction (ie difficulty walking down stairs and hills). What are the symptoms?
- Pain that gradually worsens with activity i.e. running
- Pain going up or down stairs
- Pain with squatting
- Pain with prolonged sitting (movie-goers knee)
- Pain deep in the front of the knee
- Giving way or a feeling of instability
- Recurrent clicking What can be done? A thorough physical and biomechanical assessment, including functional testing to reproduce the patient's pain and locate the nature of the symptoms is required.
Physiotherapy management is based on scientific research led by physiotherapists. Treatment concentrates on improving the control of the patella, leading to a successful recovery and return to sport.
This will include:
- Relative Rest: inflammation must settle for motor control to improve • Minimise inflammation: regular application of ice will provide pain relief. Anti-inflammatories prescribed from your doctor may also assist at this time.
- Taping: of the patella to correct abnormal patellar position, will minimize pain and facilitate the contraction of the VMO / quadriceps muscle.
- Massage: plays an important role in allowing the lateral structures to stretch by ironing out any tight knots.
- Foam Roller and Self Trigger Point Management: self massage at home will help improve the effects of stretching and restore muscle function and alleviate tightness
- Increase Strength: of the VMO, to improve the control of the patella, and pelvic stabilisers (i.e. gluteal muscles of the buttock), to minimise the load on the patellofemoral joint.
- Correction of Pre-Disposing Factors: this ensures that the problem doesn't re-occur and can include advice on training principles (overload and recovery) and biomechanical issues such as lower limb mechanics including foot posture and function:
Patella Tendinopathy In the past this injury was labelled ‘patella tendonitis'.
Tendonitis suggests inflammation of the patella tendon, however recent clinical research has more accurately termed it ‘patella tendinopathy'. Histochemical examination indicates that there are few if any inflammatory chemicals in the patella tendon when it has pain and dysfunction. Hence the name change to tendinopathy. What is it? Patella tendinopathy, or ‘Jumper's knee', refers to a painful overuse injury of the patella tendon, which connects the kneecap (patella) to the shin (tibia). This occurs as a result of degeneration (either acute or chronic) and a 'weakening' within the patella tendon itself, without the presence of inflammation. Many cases of patella tendinopathy also co-exist with patellofemoral syndrome.
What causes it?
It is caused by excessive loads on the patella tendon, particularly if there are insufficient rest periods. It is most commonly seen in athletes that engage in running and jumping type sports, such as netball or basketball. What are the symptoms? • pain is well localised (from a dull ache to severe and sharp) at the front of the knee
- anterior knee pain is usually of a gradual onset
- jumping and landing activities will increase the pain • the bottom of the patella will be tender to touch
- pain will occur with squats and stairs, particularly descending • below the patella can be swollen, or ‘puffy', but this is rare
- unlikely to be episodes of giving way or instability What can be done? Rehabilitation is a lengthy process and the athlete may take from 3 - 6 months to return to sport. This may include:
- Rest / Ice: Reducing your activity levels and regular periods of applying ice is essential to prevent the patella tendon becoming more sensitive and painful.
- Taping: of the patellofemoral joint should be used if it is contributing to the symptoms. Taping the patella tendon itself can also assist in reducing the load on the tendon.
- Massage: is performed on the patella tendon to improve local blood flow and release adhesions between the collagen fibres that compose the patella tendon. Often other thigh structures (quadriceps, iliotibial bands) will also need to have any trigger points resolved.
- Stretching: poor hamstring and quadriceps muscle flexibility can overload the patella tendon. Hence, a regular stretching program, particularly in ‘growing' children, is essential.
- Increase Strength: a quadriceps strengthening program is needed to increase the tensile strength of the patella tendon. This involves a graduated series of exercises, that start slowly, and then progress by increasing the speed and weight involved during exercise.
- Correction of Pre-Disposing Factors: as already outlined in ‘patellofemoral pain' above, these changes ensure that the problem doesn't re-occur in the future.
- Surgery: if conservative management fails, then surgery can be a possibility with long-standing patella tendinopathy. Further investigations (ultrasound, MRI) can assist in determining whether surgery is required. The rehabilitation process is slow and lengthy, following the principles outlined above. A return to sport is approximately 6 - 12 months, with only 60-75% of patients returning to their previous levels of sport.
Published by Balmain Sports Medicine