Patella Tendinopathy is a complex and often frustratingly long rehabilitation to return to sport or pain free daily living. The following blog is a part 2 of a previous blog discussing what patella tendinopathy is and how we manage this condition. This blog will discuss the first 2 stages of rehabilitation.
Stage 1: Isometric Exercises
Performed Daily: Five repetitions of 45 second isometric mid-range quadriceps exercise at 70% of maximal voluntary contraction.
Seated Knee Extension Isometric Hold
Isometric exercises are indicated to reduce and manage tendon pain and initiate loading of the muscle-tendon unit when pain limits the ability to perform isotonic exercises.
The seated knee extension machine is ideal in patella tendon rehabilitation as it isolates the quadriceps. Isometric loading performed in mid-range (30-60 deg) flexion provide the least amount of discomfort. The resistance should be increased as quickly as tolerated and performed on the single leg if possible/appropriate.
Holding the knee extension at 30-60 deg extension. Perform 5 repetitions of a 45 second hold 2-3 times per day, with 2-minute rest break between holds to allow for recovery.
If you do not have access to a seated knee extension machine, then the Spanish Squat is an excellent alternative.
To perform the Spanish Squat you will need either a rigid belt, or a thick/heavy resistance band fixated to a sturdy surface at knee height. Place the band behind your knees, with your knees wide, lean backwards and perform a double leg squat with 70-90 degrees knee flexion. Things to monitor include; knees not translating over the toes, the shin should remain perpendicular to the ankle and your torso should remain upright. This position should be held for 45 seconds, there should be no pain in the patellar tendon.
5 repetitions of a 45 second hold, 2-3 times per day, with 2 minute rest break between holds to allow for recovery.
Stage 2: Isotonic Exercises
Performed Every Second Day; Progressing from 15RM (rep max) for 3-4 sets, to 6RM for 3-4 sets
Loaded isotonic exercise is initiated when it can be performed with minimal pain (3/10). Isotonic load is important to restore muscle bulk and strength through functional ranges of movement. Isotonic exercise involves shortening of muscles as it contracts against a constant load. Examples of isotonic exercises are lunging, leg press, seated knee extension.
The research supports the progression to heavy loading in this stage, as heavier loads have shown to be associated with tendon adaptation and remodelling.
Current literature supports 3-4 sets at a resistance corresponding to 15RM, progressing to 6RM, performed every second day. It is important to progress to heavier loading (ie. 6RM) as tolerated, as heavy load is associated with tendon adaptation.
Leg press and seated knee extension can be commenced initially and split squats added when technique and capacity under load are adequate. As in stage 1, the seated knee extension machine is useful to isolate the action of the quadriceps.
Stage 1 exercises should be continued on the “off” days to manage pain within the limits of muscle fatigue and soreness associated with the isotonic loading. Stage 2 exercises should be continued throughout rehabilitation.
If you are experiencing any anterior knee pain, or tendon pain anywhere throughout the body you will benefit greatly from a physio assessment from one of the team at Bend + Mend, to provide you with an individualised rehabilitation program.
Reference: Malliaras, P., Cook, J., Purdam, C., & Rio, E. (2015). Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. Journal of Orthopaedic & Sports Physical Therapy, (0), 1-33.