Caring Medical - Where the world comes for ProlotherapyPatellar Tendinopathy | Jumper’s Knee

Danielle R. Steilen-Matias, MMS, PA-C | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Katherine L. Worsnick, MPAS, PA-C  | Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David Woznica, MD | Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois

In this article, we will examine research and clinical observations of various treatments for “Jumper’s Knee,” medically referred to as patellar tendinopathy, a degeneration process of the kneecap tendon. We will also look at the connection between patellar tendinopathy, knee ligament damage, and the knee instability it helps create that can to knee joint erosion and knee degenerative disease.

Understanding points: People will often come into the office with confusion because they have been diagnosed with patellar tendinosis or with patellar tendinitis. 

  • Patellar tendinitis is inflammation, pain, and swelling. Patellar tendinitis occurs, for instance, when a runner has knee pain after a run or someone in a sport that involves jumping suffers a more acute injury, especially a first-time acute injury. On examination, the patella tendon is very sore.
  • Patellar tendinosis is pain and weakness without inflammation. This is a chronic degenerative condition.  If this person/athlete gets cortisone shots in the patellar tendon or they take anti-inflammatories for a very long time the tendinitis (pain and degenerative knee disease symptoms with inflammation) becomes tendinosis  (pain and degenerative knee disease symptoms without inflammation).

First, treatments that have been shown to be ineffective and not work for Patellar Tendinopathy

An October 2017 study in the Clinical Journal of Sports Medicine from the Center for Sports Medicine at the University Medical Center Groningen in the Netherlands opens with this statement:

Currently, no treatments exist for patellar tendinopathy that guarantee quick and full recovery.(1) To prove this they tested some of the available treatments.

The researchers assessed which treatment option provided the best chance of clinical improvement.

These were the treatments they tested:

Participants were divided into 5 groups:

  • Extracorporeal shockwave therapy (ESWT) (A machine delivers acoustic pressure waves to the affected area) (31 participants),
  • ESWT plus eccentric training (Eccentric training is an exercise technique where the return to starting pose is done slowly. For instance, if you perform a knee lift, instead of letting your foot drop back down to the floor quickly, you slowly lower it to build muscle strength. (43 participants),
  • eccentric training (17 participants),
  • topical glyceryl trinitrate patch (Salonpas for instance) plus eccentric training (16 participants),
  • and placebo treatment (31 participants).

The results:

  • In comparison, clinical improvement was significantly higher in the eccentric training group and the ESWT plus eccentric training group compared to Extracorporeal shockwave therapy alone, topical glyceryl trinitrate patch, or placebo.
  • The higher training volume, a longer duration of symptoms, and older age negatively influence a treatment’s clinical outcome.

NO CLEAR BENEFIT to any of these treatments.

We do find that eccentric exercise training offered some degree of relief, however, the more exercise the less benefit (not what an athlete wants to hear), the longer the patient had the symptoms and the patients’ age also presented problems.

Take away points:

  • Extracorporeal shockwave therapy – the role remains unclear
  • Exercise the more important of the treatments, but not too much exercise
  • No comparison in this study was made to comprehensive Prolotherapy or Platelet Rich Plasma treatments which will be discussed below.

The research above continues the work from researchers at the University of Groningen. Earlier the University medical researchers investigated the impact patellar tendinopathy has on a patient’s sports and work performance. Their findings?

  • Reduced sports performance was reported by 55% of their study’s participants;
  • 16% reported reduced work ability and
  • 36% decreased work productivity, with 23% and 58%

The Dutch researchers concluded that the impact of Patellar Tendinopathy on sports and work performance is substantial and stresses the importance of developing preventive measures.(2) We will discuss our preventative and reparative options below.

The main problems with patellar tendinopathy – it is a degenerative disorder rather than an inflammatory disorder – should you have surgery?

If the doctor suggests your problem is due to patellar tendinopathy, you have a problem of the tendon that passes from the quadriceps muscle (the large muscle at the front of the thigh) over the kneecap (patella) to connect to the shinbone (tibia).

Patellar Tendinopathy causes

Researchers in Chile have published recommendations and guidelines for treatment in a paper from December 2016, here is what they say:

  • The main problem in patellar tendinopathy is tendinosis, which is a degenerative disorder rather than an inflammatory disorder; therefore, the other popular term for this disease, tendinitis, is not appropriate. Tendinosis – degeneration without inflammation (the body has given up trying to heal this injury), Tendinitis  – degeneration with inflammation (the body is trying to heal this injury). As we mentioned above.
  • The nonsurgical treatment of patellar tendinopathy is focused on eccentric exercises and often has good results.
  • Surgical treatment is indicated for cases that are non-responsive to nonsurgical treatment. Open or arthroscopic surgery can be performed; the two methods are comparable.(3)

As far as the surgical technique goes, doctors from the Department of Orthopedic Surgery and the Department of Physical Medicine and Rehabilitation, Mayo Clinic, Florida State University and the Florida State University College of Medicine, published their findings in the journal Orthopedics. They found open surgery and arthroscopic techniques achieved similar satisfactory results in 81% of patients, respectively. Average time to return to play was 5.6 months and 5 months, respectively.(4)

The unappealing aspects of Patellar Tendinopathy surgery – Average time to return to play was 5.6 months and 5 months. Second:  If the surgery fails, it is difficult to fix.

The problem with surgery for the athlete are three-fold,

  • one the length of time to recovery is not appealing,
  • second, patellar tendinopathy is often a chronic problem.
  • Third, if the surgery fails, it is difficult to fix.

This is what a paper from the University of Salerno and the University of London suggested in the journal Sports Medicine and Arthroscopy Review.

  1. Many patients respond well to conservative treatment, but about 10% of them do not.
  2. In these cases, surgery is indicated.
  3. In a small percentage of patients, surgery is unsuccessful. This group of patients presents a major challenge, as options are limited.(5)

Non-surgical bio-treatments Prolotherapy and PRP Therapy

However, many doctors are confident suggesting the surgery because they feel the athlete has no other options.

Other doctors do feel there are options Here is what New York University doctors wrote in the Bulletin of the Hospital for Joint Diseases.

“Due to its common refractory response (non-responsive or difficult to treat) to conservative treatment, a variety of new treatments have emerged recently that include dry-needling, sclerosing injections (Prolotherapy), platelet-rich plasma therapy, arthroscopic surgical procedures, surgical resection of the inferior patellar pole (cutting away tendon tissue at the kneecap), extracorporeal shock wave treatment (as discussed in the other studies cited here), and hyperthermia thermotherapy (exposing the knee to high temperature) in addition to physical therapy.”(6)

Obviously, the list includes treatments that we offer at Caring Medical, Prolotherapy and Platelet Rich Plasma.

Non-surgical solutions to the problem of chronic and recurrent Patellar Tendinopathy

In Germany, doctors supported the New York University findings. Writing in the medical journal Der Unfallchirurg (English: The trauma surgeon), the German researchers suggested that treatment with platelet-rich plasma showed a significantly better outcome when used correctly. Additionally, treatments such as Extracorporeal shockwave therapy, operative treatment and sclerotherapy (Prolotherapy) have also shown positive effects. Treatment with corticosteroid injections and with oral non-steroidal anti-inflammatory drugs (NSAID) showed positive short-term effects.(7)

Prolotherapy can treat various knee disorders including problems of the tendons. Prolotherapy Injections of a dextrose solution directed at the weakened tendons and involved ligaments. This causes a mild, localized inflammatory response at the injured area which stimulates a string of healing events, which include an increase of blood supply, an influx of reparative cells, and the deposition of collagen cells. When the collagen matures, it will strengthen and tighten the damaged tendons and ligaments.

The most important finding is that PRP injections are statistically better than the control group (ESWT and dry needling) at longer term (6 months or more) follow-up suggesting that PRP is an effective and worthwhile treatment for Patellar Tendinopathy.

Doctors at the University of Pittsburgh writing in the Journal of Knee Surgery say athletes and doctors are turning to biomaterials, that is stem cells and blood platelets (PRP therapy). In fact, “They are becoming the mainstay of nonoperative therapy in the high-demand athletic population. The most well-studied agents include platelet-rich plasma (PRP) and stem cells-both of which have shown promise in the treatment of various conditions. Animal and clinical studies have demonstrated improved outcomes for patients with chronic patellar tendinopathy. “(8)

In a one-year study of patients who decided on non-surgical PRP treatments to get them back to their sport, European doctors found that all 20 patients in their study benefited from one injection of PRP coupled with a standardized eccentric rehabilitation (exercise). They concluded: “This study confirms that a local injection of PRP coupled with a program of eccentric rehabilitation for treating a chronic jumper’s knee, improves pain symptoms and the functionalities of the subjects’ knee up to 1 year after injection.”(9)

The most important finding in our meta-analysis is that PRP injections are statistically better than the control group (ESWT and dry needling) at longer term (6 months or more) follow-up suggesting that PRP is an effective and worthwhile treatment for Patellar Tendinopathy.

Doctors in the United Kingdom writing in the journal Knee surgery and related disease released their study in which they state: “The most important finding in our meta-analysis is that PRP injections are statistically better than the control group (ESWT and dry needling) at longer term (6 months or more) follow-up suggesting that PRP is an effective and worthwhile treatment for Patellar Tendinopathy.”(10)

March 2018: The American Journal of Sports Medicine: Multiple Injections of PRP may hold the answer

Doctors at The Rizzoli Orthopaedic Institute in Italy published their paper: Nonsurgical Treatments of Patellar Tendinopathy: Multiple Injections of Platelet-Rich Plasma Are a Suitable Option: A Systematic Review and Meta-analysis. It appeared in the March 2018 issue of the American Journal of Sports Medicine.

What they were looking for was the evidence on nonoperative options to treat chronic patellar tendinopathy: Three treatments came to the forefront as the most studied: They are mentioned in the research above:

  1. eccentric exercise,
  2. extracorporeal shockwave therapy (ESWT),
  3. and platelet-rich plasma (PRP).
    1. Single and multiple PRP injections were evaluated separately.

CONCLUSION:
“Eccentric exercises may seem the strategy of choice in the short-term, but multiple PRP injections may offer more satisfactory results at long-term follow-up and can be therefore considered a suitable option for the treatment of patellar tendinopathy.”(11)

A quick work on Patellar Tendinopathy and ligament weakness

  • Chronic patella pain and tendinosis are rooted in knee instability. Upon examination, we find patients who have patellar tendinitis may have laxity in the anterior cruciate ligament (ACL), medial collateral ligament (MCL) or a posterolateral ligament injury.
  • The ligaments are the primary stabilizers of the knee. If the knee is unstable, the patellar tendon will be under strain and weaken.

To address this, a series of injections are placed at the tender and weakened areas of the patella tendon and knee ligaments. These injections contain a proliferant to stimulate the body to repair and heal by inducing a mild inflammatory reaction. The body heals by inflammation, and Prolotherapy stimulates this healing. As the ligaments tighten and the patella tendon heals, the knee structures function normally rather than moving out of place. When the knee functions normally, the pain goes away.

Prolotherapy Specialists Patellar Tendinopathy

If you have questions about Patellar Tendinopathy treatment options, get help and information from Caring Medical

1 van Rijn D, van den Akker-Scheek I, Steunebrink M, Diercks RL, Zwerver J, van der Worp H. Comparison of the Effect of 5 Different Treatment Options for Managing Patellar Tendinopathy: A Secondary Analysis. Clin J Sport Med. 2017 Oct 10 [Google Scholar]

2 De Vries AJ, Koolhaas W, Zwerver J, Diercks RL, Nieuwenhuis K, Van Der Worp H, Brouwer S, Van Den Akker-Scheek I. The impact of patellar tendinopathy on sports and work performance in active athletes. Research in Sports Medicine. 2017 Apr 9:1-3. [Google Scholar]

Figueroa D, Figueroa F, Calvo R. Patellar Tendinopathy: Diagnosis and Treatment. J Am Acad Orthop Surg. 2016 Dec;24(12):e184-e192. [Google Scholar]

Stuhlman CR, Stowers K, Stowers L, Smith J. Current Concepts and the Role of Surgery in the Treatment of Jumper’s Knee. Orthopedics. Nov 1 2016;39(6):e1028-e1035. doi: 10.3928/01477447-20160714-06. [Google Scholar]

5 Maffulli N, Giai Via A, Oliva F. Revision Surgery for Failed Patellar Tendinopathy Exploration. Sports Med Arthrosc. 2017 Mar;25(1):36-40. [Google Scholar]

6 Christian RA, Rossy WH, Sherman OH. Patellar tendinopathy – recent developments toward treatment. Bull Hosp Jt Dis (2013). 2014;72(3):217-24. [Google Scholar]

7 Horstmann H, Clausen JD, Krettek C, Weber-Spickschen TS. Evidence-based therapy for tendinopathy of the knee joint : Which forms of therapy are scientifically proven? Unfallchirurg. 2017 Mar;120(3):199-204.  [Google Scholar]

8 Kopka M, Bradley JP. The Use of Biologic Agents in Athletes with Knee Injuries. J Knee Surg. 2016 Jul;29(5):379-86. doi: 10.1055/s-0036-1584194. Epub 2016 May 20. [Google Scholar]

Kaux JF, Bruyere O, Croisier JL, Forthomme B, Le Goff C, Crielaard JM. One-year follow-up of platelet-rich plasma infiltration to treat chronic proximal patellar tendinopathies. Acta Orthop Belg. 2015 Jun;81(2):251-6. [Google Scholar]

10 Dupley L, Charalambous CP. Platelet-Rich Plasma Injections as a Treatment for Refractory Patellar Tendinosis: A Meta-Analysis of Randomised Trials. Knee surgery & related research. 2017 Sep;29(3):165. [Google Scholar]

11 Andriolo L, Altamura SA, Reale D, Candrian C, Zaffagnini S, Filardo G. Nonsurgical Treatments of Patellar Tendinopathy: Multiple Injections of Platelet-Rich Plasma Are a Suitable Option: A Systematic Review and Meta-analysis. The American journal of sports medicine. 2018 Mar 1:0363546518759674. [Google Scholar]

 

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