Jumper's knee (patellar ligament enthesopathy) is one of the frequent overload injuries of the knee extension apparatus. The extension apparatus includes the quadriceps muscle of the thigh, the patella and the patella ligament which attaches to the tibial tuberosity. All structures are involved in actively extending the knee or inhibiting its bending when landing on a bent limb. Patellar ligament inflammation is a pain in the front of the knee that increases with or shortly after jumping and running training. Injury is most common among volleyball players, handball players, athletes and baseball players. Treatment depends on the degree of damage to the patella ligament and mainly consists in rehabilitation. When conservative treatment remains ineffective or there is severe damage or rupture of the ligament, surgery is required.
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How does patellar ligament inflammation occur?
A factor that increases the risk of ligament overload is practicing sports with a large component of jumping. The ligament microtrauma occurs during the landing phase, when the quadriceps muscle is simultaneously lengthened and contracted under heavy load. People with poor control of the eccentric work of the quadriceps, with a disorder of the joint axis (valgus, varus) and people with poor running technique are the most vulnerable to the development of the disease. Due to the high intensity and frequency of training, the healing processes do not keep up with the formation of further microdamages, as a result of which the structure of the patellar ligament is gradually degenerating.
Jumper's knee - symptoms
In the course of inflammation of the patellar ligament, there is pain at the front of the knee, the severity of which depends on the degree of damage. In sports, the most commonly used classification of the jumper's knee is based on the presence of pain during training:
Knee pain under the kneecap occurs only after the end of sports activities,
Pain appears already during the warm-up, then the pain during training slightly decreases (without limiting the player's capabilities), and then returns after its completion,
Strong pain is present throughout the sports activity, significantly reducing the athlete's efficiency,
Serious tearing or rupture of the patella ligament, taking up sports activities is impossible.
Jumper's knee symptoms also include swelling and tenderness at the site of the ligament attachment to the patella. Severe pain or significant damage to the patellar ligament make it impossible to continue training and may weaken the strength of the quadriceps muscle. It is possible to make a diagnosis on the basis of an interview and a medical examination. Performing an ultrasound of the knee may be helpful in assessing the extent of the patellar ligament damage.
Jumper's knee - conservative treatment
Grades I and II of the lesion can be successfully treated with rehabilitation. The treatment of the jumper's knee should be carried out under the supervision of an experienced physiotherapist, who has the possibility of direct consultation of the patient with the attending orthopedic physician. The aim of physiotherapy is, among others Healing of microdamages and stimulation of the reconstruction of the patellar ligament structure in order to provide it with adequate strength. Physiotherapy includes manual therapy, exercises to stretch and strengthen the thigh muscles, and physical therapy. A frequently used technique is deep transverse massage, which improves microcirculation, stimulates tissue metabolism and at the same time has an analgesic effect. A similar effect, but with greater force, is achieved thanks to the use of ESWT (Extracorporeal Shock Wave Therapy). Shockwave therapy uses the action of the sudden changes in pressure generated by the device. The pressure impulse is transmitted to the tissues through an applicator placed against the patella ligament. The therapy usually includes 3-6 treatments performed 1-2 times a week.
The performed exercises are designed to strengthen the quadriceps muscle of the thigh - they should mainly take into account the eccentric component, during which the working muscle is elongated and inhibits movement (e.g. when going down into a squat or deepening a lunge). An important principle is the gradual increase in the difficulty of exercises, thanks to which the kneecap ligament can be safely adapted to the increased load. An important goal of the therapy is also the correct activation of the muscles stabilizing the knee joint and keeping the kneecap in the correct position (mainly the medial part of the quadriceps muscle of the thigh - VMO, vastus medialis obliquus).
As part of conservative treatment, treatments in the field of regenerative medicine are also used. If you want to read more about how we treat it in our hospital, click here.
The administration of steroids to the patellar ligament is controversial. This position is justified by the possible weakening of the ligament structure after the administration of the steroid, which poses a higher risk of further ligament damage in the future.
Jumper's knee - surgical treatment
Patellar ligament repair procedures
The third degree of damage and the painful state of the ligament for many months that cannot be managed by conservative treatment are provided with surgery. The surgical procedure is performed openly or with a less invasive arthroscopic method. The open method requires making a few centimeters longitudinal incision at the front of the knee, while arthroscopy involves making 2-3 small holes (up to 4 mm) through which the surgeon inserts working tools. Less invasiveness and the minimal size of the scars left behind mean that convalescence after arthroscopy is faster. Anesthesia during the procedure consists in blocking the nerve supplying the lower limb or administering an anesthetic to the spinal canal in the lumbar region. The patient remains conscious for the duration of the procedure.
Surgical treatment usually consists of arthroscopic "debridement" surgery, i.e. cleaning the area of the lower pole of the patella of pathological changes in the ligament and adhesions that may cause a painful conflict when bending and extending the knee. Sometimes it is necessary to remove part of the Hoffa's fatty body. Hoffy's body lies directly under the patella ligament and under the lower part of the patella itself, separating these structures from the femur. The structurally changed and thickened ligament of the patella can irritate Hoffa's body and contribute to the release of inflammation.
Less frequently, a longitudinal band of necrotically changed tissues is excised, while the adjacent bands are preserved. The longitudinal defect is completed by suturing the adjacent "healthier" ligament bundles "side to side", which allows the continuity of the ligament and enables a relatively quick return to sports activities.
Surgical reconstruction of the patellar ligament
Reconstructive procedures are performed in the case of complete rupture of the patellar ligament (4th degree of damage) and when the presence of extensive damage prevents effective repair procedures. The most common methods of reconstruction are a graft from the tendon of the semitendinus and slender muscles lying on the medial side of the knee. The surgeon places the grafts in the previously prepared bone tunnels on the patella and tibial tuberosity, and then stabilizes them with special anchors. The material for the transplant can also be a tendon taken from a deceased donor from a tissue bank, which allows you to avoid traumatization of your own hamstrings. Reconstructive procedures are performed openly.
Rehabilitation after jumper's knee surgery
Rehabilitation after surgery includes mobilization of postoperative scars, mobilization of the kneecap and a gradual increase in the range of motion of the knee. The rest of the steps are similar to those for the non-surgical rehabilitation of a jumper's knee. The progress of exercises to strengthen the quadriceps muscle of the thigh and a gradual return to normal activity after the surgery are determined individually for each patient in consultation with the physiotherapist and the attending physician. In most cases, it is possible to return to sports activities in the 6th month after the procedure. Particular attention should be paid to the management of patellar ligament reconstruction procedures, when rehabilitation cannot lead to stretching or destabilization of the graft. The recovery period after reconstructive procedures is longer, and its length depends on the technique used and the type of material used for the transplant.
Jumper's knee - relapse prevention
The treatment is considered complete when there is no pain during the activity, the intensity of which would allow the return to full training loads. The athlete can then continue training under the guidance of a trainer, increasing the volume and length of the training units. However, one should remember about the specific eccentric training of the quadriceps muscle, training of activating the muscles stabilizing the knee and the mobilization of the patella. It is also important to maintain appropriate recovery periods after exercise and to regularly use the services of a physiotherapist to control and strengthen the weaker links related to the functioning of the knee extension apparatus.
Source:Brockmeyer, Matthias et al. “Surgical Technique: Jumper’s Knee—Arthroscopic Treatment of Chronic Tendinosis of the Patellar Tendon.” Arthroscopy Techniques 5.6 (2016):e1419–e1424.
Frequently Asked Questions About Jumper's Knee:
The essence of the jumper's knee is the degeneration of the fibers of the patellar ligament that connects the kneecap to the tibia. The patella ligament tightens along with the quadriceps when the knee is extended and when landing on a bent leg. As a result of excessive overload accompanying jumping or running, microtrauma in his patellar ligaments and the release of pain ailments occur. Healing processes do not keep up with the formation of further microdamages, as a result of which the structure of the patellar ligament is gradually degenerating.
Jumper's knee is showing pain as well as possible swelling and palpation at the front of the knee under the kneecap. The ailments worsen during activities with a large component of running or jumping.
The main cause of the jumper's knee is excessive overloading of the joint and neglecting periods of recovery and rest. The risk of the disease is increased in people with weakened quadriceps muscle, imbalance of tension in the thigh muscles, disturbance of the knee axis (valgus, varus) or abnormal anatomical structure of the patellar femoral joint.
Minor injuries are subject to conservative treatment aimed at facilitating the healing process and then increasing the strength of the patellar ligament to loads. Rehabilitation includes transverse massage of the patellar ligament, shock wave therapy, and exercises to stretch and strengthen the quadriceps. Particular emphasis should be placed on exercises that improve the eccentric work of the quadriceps - that is, those that consist in inhibiting the knee deflection by the muscle (e.g. when going down into a squat or deepening a lunge).
When the patellar ligament damage is extensive, repair procedures are performed or ligament reconstruction procedures are performed.
