What is Jumper’s Knee?
‘Jumper’s Knee' or patellar tendinopathy is a type of knee pain that is experienced on the front of the knee. It is caused by an irritation of the patella tendon, the tendon just beneath your kneecap. Typically, this irritation in athletes occurs due to excessive or repetitive overload of the patellar tendon.
This is often a condition experienced by very active athletes, especially males, who participate in jumping sports such as volleyball, tennis, football, and basketball. Jumper’s knee is most prevalent in basketball whereby 32% of professional basketball players and 11-14% of amateur players experience this problem.
Pain in the patellar tendon is typically experienced during periods of load which usually ceases upon removal of the load. Signs and symptoms of patellar tendinopathy include:
pain localized to the inferior pole of the patella (pain just underneath the kneecap)
load-related pain increases with the demand on the knee extensors, notably in activities that store and release energy in the patellar tendon e.g. jumping, landing, etc.
pain with prolonged sitting, squatting, and stairs
no pain when resting
pain that improves with repetitive loading.
To be diagnosed, your physiotherapist will clinically assess the tendon’s integrity. Imaging does not confirm patellar tendon pain, as problems with the tendon may be present in asymptomatic individuals.
Let’s guide you through how we treat high ankle sprains using our Roadmap to Recovery:
Step 1. Pain Reduction
Step 2. Activation
Step 3. Movement
Step 4: Strengthening / Sports Performance
Pain Reduction
To manage and reduce symptoms, it is important to understand these four concepts:
Understanding tendinopathy
De-loading
Hands-on treatment
Movement strategies + gradual loading
Patellar tendinopathy arises from repetitive use of the tendon leading to inflammation, which may degrade a tendon’s integrity and thus cause weakness and pain. Exercise is the best medicine, not only for patellar tendinopathy but for many musculoskeletal issues.
Physiotherapy management first starts with de-loading the patellar tendon and activity modification. It is important that you reduce the amount of load to your tendon’s capacity. For most people, this might mean you need to lessen the frequency of loading activities such as jumping. For others, this might mean ceasing all loading activities.
During this phase, it is recommended to do isometric exercises for pain-relief. A great example is a wall-sit. There is very strong evidence that isometric exercises are superior to other types of exercise in pain-relief for tendinopathies. Furthermore, use of patellar strap and sports tape has been shown to have a short-term effect on pain. Hands-on treatment such as massage and ice will also be effective with pain-relief however will not increase your tendon’s capacity.
There is strong evidence around the risk factors that may pre-determine patellar tendinopathy such as:
gender (males > females)
weight and body mass index
training load (>12 hours/week)
decreased quadriceps flexibility
decreased hamstring flexibility
It is very important to address some of these risk factors in your later rehabilitation to learn how to prevent future re-injury. Once your knee experiences minimal pain during isometric exercise, it is important that you optimally train and condition your patellar tendon in other exercise types.
Activation
In the activation phase, we will begin to incorporate isotonic exercises which are exercises in which your muscles are contracting. During this phase, exercises should exceed no more than 3/10 pain. The more knee bending the more stress on the patella tendon, so work within your range of motion. When beginning this stage you will likely limit the knee bending to between 10 – 60 degrees of knee bending, proceed with caution here!
This stage is crucial to introduce higher amounts of load through not only the patellar tendon, but through the surrounding muscles to strengthen the leg musculature such as your quadriceps, hamstrings, glutes, etc. Some excellent exercises to implement are as below:
Spanish Squat: The band around your knees provides resistance to knee extension thus allowing for effective quadriceps activation. This is a great way of loading the patellar tendon while keeping knee flexion to a moderate amount. Avoid leaning your trunk forward. The more you lean into the band the easier it will be to keep your trunk upright.
Goblet Squat on Wedge: The wedge allows for the heels to be elevated and thus forces you to load your forefoot more which in turn loads your quadriceps and knees more effectively compared to a squat on a flat surface. This exercise is a great way of progressively loading the patellar tendon.
Seated Knee Flexion: This exercise does not directly load the patellar tendon, however, it activates the hamstrings (the muscles that counteract the quadriceps). Appropriate hamstring activation ensures even load distribution through the front and back thigh muscles when later using these muscle groups for larger movements (as opposed to the quadriceps and patellar tendon doing all the work).
Videos of these exercises:
Movement
Now that we’ve accustomed your patellar tendon to progressively greater loads, let’s challenge it even more with larger movements! In the movement phase, we want to start to address the musculoskeletal risk factors of developing Jumper’s knee. Thus, movement exercises will be targeted towards quadriceps and hamstrings strength as well as flexibility. Studies have shown that for the hamstrings, eccentric (loaded lengthening) is an extremely effective way of increasing muscle length and flexibility. This principle will be applied in this stage. The following 3 exercises are definitely ones to include in your rehab:
B-Stance RDL: This hamstring and glutes exercise is perfect to increase strength and increase flexibility. During this exercise, it is important to emphasise the slow descent. The perfect ratio is 3 seconds down, 1 second up. It is important you stop within your active range of motion, meaning that you stop descending as soon as your lower back starts to round.
Split Squats: This exercise is a great movement for the leg musculature to work in conjunction with one another. To increase eccentric quadriceps range, have a heel wedge under your front foot in order to attain greater knee flexion and thus greater load through the patellar tendon and quadriceps.
Single Leg Jump With Pause: This exercise will begin to address what once was an aggravating activity. It is crucial to begin to teach the patellar tendon how to accept higher amounts of tensile loading when doing powerful movements like jumping. Ensure that your hip, knee, and ankle are stacked on top of one another in a straight line to optimise shock absorption during this exercise.
Videos of these exercises:
Strengthening/ Sports Performance
Return to sport is recommended when full training is tolerated without symptom provocation. An important thing is to also make sure there are no remaining power deficits. Power can be measured by testing a triple hop test for distance or a maximal vertical hop height. At Breathe, we utilize VALD technology to attain accurate measures regarding your power generation, limb asymmetries, etc. to provide you with the best chances of returning to sport.
‘Prehab’ is crucial when it comes to most injuries, and the Jumper’s knee is no different. You must prepare your body for all the jumping, cutting, and pivoting that basketball requires. Rehab for a jumper’s knee can be slow and frustrating, make sure to progress through each of these phases. It is highly recommended to go see a physiotherapist to get a tailored return to sport protocol to ensure you get back onto the court with minimal problems. It is important to be patient and motivated, good luck!
References
Aicale, R., Oliviero, A., & Maffulli, N. (2020). Management of Achilles and patellar tendinopathy: what we know, what we can do. Journal of Foot and Ankle Research, 13(59), 1-10. https://doi.org/10.1186/s13047-020-00418-8
Malliaras, P., Cook, J., Ptasznik, R., & Thomas, S. (2006). Prospective study of change in patellar tendon abnormality on imaging and pain over a volleyball season. British journal of sports medicine, 40(3), 272–274. https://doi.org/10.1136/bjsm.2005.023846
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, 45(11), 887-898.
Reinking, M. F. (2016). CURRENT CONCEPTS IN THE TREATMENT OF PATELLAR TENDINOPATHY. International journal of sports physical therapy, 11(6), 854-866.
van Rijn, D., van den Akker-Scheek, I., Steunebrink, M., Diercks, R. L., Zwerver, J., & van der Worp, H. (2019). Comparison of the Effect of 5 Different Treatment Options for Managing Patellar Tendinopathy: A Secondary Analysis. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine, 29(3), 181-187. https://doi.org/10.1097/JSM.0000000000000520
Vetter, S., Schleichardt, A., Köhler, H.-P., & Witt, M. (2022). The Effects of Eccentric Strength Training on Flexibility and Strength in Healthy Samples and Laboratory Settings: A Systematic Review. Frontiers in physiology, 13, 1-3. https://doi.org/10.3389/fphys.2022.873370