Patella Tendonitis

[esw]

Hi Andrew (and other learned readers),

I have recently (the last 2/3 months) 'upped' my weight training for a team I am part of. It has been a prescribed 5 day program with heavy squats, heavy deadlifts, pistols, TGU's, weighted lunges etc... in the last few weeks running has been introduced and as a result of this extra load I have a form of tedonitis in my left knee above the kneecap (sore in the morning, takes a long time to warm up, squats hurt, stairs hurt).

A physio freind of mine has shown me some rehab movements (mostly eccentric phase leg extension stuff). I have had this before and generally adapted but it is paining more than normal now and starting to impact the quality of my training.

Do you have any recommendations for rehab/management of this 'injury'?

Cheers

[Paul in Hobart]

Quad trigger points?
"tendinitis" is not inflammation.
Too much volume /intensity will evoke trigger points. Get treated before microtrauma accumulates.
Cut out high shear stresses like pistols. With pain , you will reflexively develop faulty patterns = more injury
Good luck sorting this out. You should not get injured training in a controlled environment!

[esw]

Thanks Paul, please excuse the spelling mistakes.

[Paul in Hobart]

Was not picking you up on spelling, not for a moment! Just highlighting the general medical misuse of the term , which implies inflammation is the result or even the cause - I get to look at heaps of bits of joints from surgeons down the microscope - so I have formed by own view , supported by articles such as :
http://www.clinicalsportsmedicine.com/articles/common_tendinopathies.htm

"itis" implies inflammation - and all treatment is then skewed the wrong way.

Probably a bit hard to get people to use "tendinopathy" not "tendinitis". But over the decades I will try to change some ways of thinking!

[esw]

Interesting article, Paul. Thanks for the link. The upshot seems to be that although the various 'itis'' has been misconstrued that the traditional non-invasive treatments might be just as efficacious, though for different reasons.

I think, at this stage, as the article seems to suggest, I will focus on cryotherapy, strengthening through eccentric loading and of course rest from the pain inducing activities.

[VictorVondoomPhD]

Sure onto it tomorrow, paperwork day then.
Andrew
Prepare for success.

[VictorVondoomPhD]

Well, rather than specifically try to determine the pathology lets have a look at finding out why the pain has occurred. Shall we consider that your problem has been examined by a competent medical professional and we are now left with pain in the area you describe from the activities you describe.

I'd have a look at 2 areas initially. True core stability. Do you pass Vleeming's Test? Simply lie supine (on yer back)place your fingers on your ASIS points of your pelvis, then lift one leg approximately 30 degrees, feel whether your pelvis moves at all, try the other leg. Can you abdominally brace to correct the movement? If the pelvis moves, then when you are loading your true core is not stabilizing well enough.

Does your lumbar spine have reasonable Range of movement, how is your flexion?, especially how is your lumbar extension? Knee problems may relate to stiffness/fixation at approximately the L3 area, in extension do you hinge at all? is extension painfree? Running involves lumbar extension.

Obviously the glute hamstring connection needs investigation. In lying prone and lifting one leg into extension what fires first- Hamstrings or glutes? You will need someone to put their hand on your ass and hamstring. Some people get very lazy glutes, I expect almost co-contraction in this movement. A lag may indicate a propensity to internally rotate your femur in loading. Compare sides.

Look at a bridge test. Lie supine and bridge your hips up to a line between your shoulders and knees. Should be easy. OK then try it with one leg, you pelvis must not dip. This can be a weakness in glutes/ Lumbar spine/abs/hamstrings.

Yes, if you can load up. How do you go in the face the wall squat? How is your knee control? I mean really face the wall, 2cm at most from the wall.

I'm a bit hesitant to have a crack at eccentric leg extensions though, it is really a last resort. It will be a case of that which does not kill you makes you stronger. You will likely either get worse OR better. The science behind eccentrics is good, but there are no studies that give good loading reps/sets/weights that i have read that have been of any rational prescription, and trust me I read a lot. So an eccentric program is aimed at the pathology, but it does require an investigation of WHY did it begin in your program.

I'd also have a look at your foot mechanics, you will need a fine podiatrist to see if you are having problems due to foot structural or loading issues.

Start with this and report back, i'll see what we can find then.
Andrew

[esw]

Thanks for the fulsome response, Andrew.

I'll go through the tests you noted and get back to you.

[esw]

Well, rather than specifically try to determine the pathology lets have a look at finding out why the pain has occurred. Shall we consider that your problem has been examined by a competent medical professional and we are now left with pain in the area you describe from the activities you describe.

I'd have a look at 2 areas initially. True core stability. Do you pass Vleeming's Test? Simply lie supine (on yer back)place your fingers on your ASIS points of your pelvis, then lift one leg approximately 30 degrees, feel whether your pelvis moves at all, try the other leg. Can you abdominally brace to correct the movement? If the pelvis moves, then when you are loading your true core is not stabilizing well enough.

In doing this i felt only my leg contracting and lifting, however, i am not %100 sure that I was pressing the right spot.


Does your lumbar spine have reasonable Range of movement, how is your flexion?, especially how is your lumbar extension? Knee problems may relate to stiffness/fixation at approximately the L3 area, in extension do you hinge at all? is extension painfree? Running involves lumbar extension.

Interesting you wrote that Andrew because on Sunday night I strained a disc in my lower back...in about the region you suggest. Been very very painful the last few days. On the mend however. Increasingly i think the sore knees and sore shins and now lower back are all related. I presume you already knew this ;-)


Obviously the glute hamstring connection needs investigation. In lying prone and lifting one leg into extension what fires first- Hamstrings or glutes? You will need someone to put their hand on your ass and hamstring. Some people get very lazy glutes, I expect almost co-contraction in this movement. A lag may indicate a propensity to internally rotate your femur in loading. Compare sides.

Hamstring activates first and with much more 'ferocity' for want of a better word than the glute. Both sides.


Look at a bridge test. Lie supine and bridge your hips up to a line between your shoulders and knees. Should be easy. OK then try it with one leg, you pelvis must not dip. This can be a weakness in glutes/ Lumbar spine/abs/hamstrings.

2 legs - no dip, one leg - only a very slight dip.


Yes, if you can load up. How do you go in the face the wall squat? How is your knee control? I mean really face the wall, 2cm at most from the wall.

To my untrained eye it appears that my knee's turn out a little bit on a deep face the wall squat.


I'm a bit hesitant to have a crack at eccentric leg extensions though, it is really a last resort. It will be a case of that which does not kill you makes you stronger. You will likely either get worse OR better. The science behind eccentrics is good, but there are no studies that give good loading reps/sets/weights that i have read that have been of any rational prescription, and trust me I read a lot. So an eccentric program is aimed at the pathology, but it does require an investigation of WHY did it begin in your program.

I'd also have a look at your foot mechanics, you will need a fine podiatrist to see if you are having problems due to foot structural or loading issues.

Start with this and report back, i'll see what we can find then.
Andrew

I have not been to the podiatrist but my left arch is flatter than my right, enough that it is noticeable to the naked eye.

Thanks for your help Andrew and Paul.

esw

[VictorVondoomPhD]

i'll be onto this next week. Damn busy week, booked 8-6 today tomorrow and monday. gotta judge ifbb pro show saturday. so likely tuesday.
stay big
andrew

[VictorVondoomPhD]

So definately time to get onto those glutes. The best thing is to buy those yellow powerbands. I do a series of glute exercises with them. Such as lying in a bridge position and having the band above the knees (you need to tie the band in half first, then use only one half), then as you push against the band as you bridge.
Also simply lie in this position (pre-bridge position) and push out against the band, you will feel both glutes. Must get those glutes to fire early.
Always keep the abs tight!

Low back wise, aim for strength now.
Lying face down and lifting both legs at once and holding for 60 seconds is useful, should be no pain. Endurance strength time.

You must have painless, excellent lumbar extension as well.
]
Catch you further!

Andrew

[esw]

Thanks Andrew, let me clarify that by bridge you mean back to the floor and hips up (shoulders on the deck?).