Jumper's Knees - "Cures"

[coolcolj]

2 posts that may help
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Having seen and treated a lot of Jumpers Knee`s over the years (mainly Basketball-Players) I can only say this: forget everything you think you know about it. There`s only one treatment that works: and that`s an eccentric strengthening program for the patellar tendon (or ligament if you like).

Other treatments may provide short term relief-but every one of those fails in the long run because they didn`t address the underlying cause of the problem.

In your case the increase in training load probably put more stress on the tendon than it could handle. Since tendons have zones with very poor nutrition (low blood supply) the tendon gets damaged and is not able to repair the damage fast enough till the next training session comes along. This micro-damage leads to altered muscle recruitment patterns throughout the whole leg-adding further unfamiliar stress to the tendon.

The tissue that is being built up to repair the damaged tendon has less tensile strength than the original tendon. It`s scar tissue. To adequately remodel this tissue a proper loading strategy is necessary.

The altered recruitment patterns themselves are another problem that has to be adressed; because what good is a new and improved tendon if the muscles still pull at the wrong time with the wrong force and start the cycle all over again?

This is the good news: since our brains use two different pathways for controlling concentric and eccentric contractions this issue is solved all by itself. The eccentric training program takes care of both at the same time. One could say that eccentric training has a higher motor-learning effect than concentric training.

The program follows the same frame as that by Alfredson used so effectively for Achilles tendinitis: 3 sets of 15 repetitions of eccentric loading of the patellar tendon for 3 months. The downside is that the pain in most cases is gone within 2 weeks-so people stop doing the exercise till it flames up again.

It`s 3 months-daily training or nothing at all! Shorter times don`t work because of the special nature of tendon tissue-it takes ages for it to be remodelled.

How to do it? Well-only one affected knee would`ve been easier-but here`s how to do it with two:

kneel down-your body is above your knees; slowly let the body "fall" (sink) backwards with all the movement occuring in the knee joint. When the body is as far back as it can go without you falling backwards bring your body forward again to the starting position-BUT WITHOUT!!!! using your legs, i.e. you have to pull yourself forward with your hands (tie a rope to a doorknob or something like that). The quadriceps muscle has to do eccentric work only!!

That`s how I would start the training. After a few days I would increase the tendon loading by decelerating the backwards movement with one leg only. After a few weeks one could use additional weigths to further increase the load.

Under no circumstance "stretch" the tendon passively-that ruins it completely. Unfortunately there are still some people out there who do that.

As I said before: this program should show results within two weeks maximum. That`s the best way to see if it really adresses the problem you have.

Matthias Weinberger Physical Therapist Regensburg, Germany

 

[coolcolj]

Jan Baggerud Larsen wrote:
>I was wondering what your experience is with "jumpers knee". I've just been diagnosed with jumpers knee (tendonosis) in both knees. I'm a competitive powerlifter and I've had knee problems during the past two years. I've been squatting for almost 20 years (I'm 34 now) and never had a problem with my knees in the past. The problems started when I did an aggressive training protocol and tripled my squat volume. <

You sure it didn't start when you achieved those dramatic flights down the stairs on the Swiss ball?

Playing the edge of training paradigms is certainly one way to enter into the "you don't really know your limits until you exceed them" experience. One can't be a high level competitor without that kind of effort, but by using it one discovers that sometimes the price of exceeding those limits can become a real nag or worse. Micro-trauma builds to macro imperceptibly until lo and behold, there's schmutz in the tissues. Whether we call it tendinosis due to the fact that it is now chronic, or adhesions in the infra-patellar tendon (or ligament, as Dr. Mel seemed to prefer), IMO, you gotta now get the schmutz out, if that tissue is going to return to its ability to sustain high performance as you want it to.

>I've done pretty much everything I could think of: Stretching, ice, rest, MSM, glucosamine, vitamin C, fish oils, flax oil, lots of different NSAIDs (naproxen, ibuprofen, celebrex, brexidol). I've been reading up on tendonosis, so I know why the NSAIDs didn't work, if my problem in fact is tendonosis. <

All good aspects of preventive care and recovery, but as you discovered, not so effective at getting the adhesions cleared out once you have exceeded your recovery abilities or sustained a good old fashioned training glitch and adhered the connective tissue. Tis important, IMO, to keep up the stuff that helps connective tissue recover while you address it more directly, ie proper hydration, adequate protein intake and frequency, fish oil, msm, glucosamine, anti-oxidants, well designed training paradigm in the rehab mode now for the specific injured part. As you have frustratingly discovered, just laying low and eating well, once you're adhered ain't enuf usually to get it outa there.

>I got some suggestions from my physio/orthopaed(sp) and I've been reading up on tendonosis on www.tendinosis.org so I've got some ideas what I should do and not do. I realize these injuries can take months or even years to heal. <

I work as a sports massage therapist with several of the powerlifters at the LA Lifting Club, some Olympic Weightlifters and other types of athletes to help keep the schmutz cleared out of muscles and their connective tissue components, as well as using various massage methods as one part of their active recovery schemes. Here's a verbal rendition of part of an 'in the trenches' method we've used on several such occurrences to good effect. If you'd like to give it a try and report back to this group on the results, 'twould be a good test of the paradigm that I think is a very effective working model of how to speed up the healing and clear out this kind of glitch. I've personally used variations of it for tennis and golfer's elbows, rotator cuff tendinitis/osis, carpal tunnel if it is sourced in the tendons and not some structural anomaly, Achilles tendintis/osis, jumpers knee, groin pulls, psoas tendons if not a bursa problem, adhesions in spinal erectors or quadratus lumborum, IT band adhesions, biceps, triceps tendons, medial and collateral ligaments and the ligaments surrounding the lateral maleolus in an ankle sprain. This combo of specifically applied DTF, ice massage, ice packs and exercises can be very effective, but it is not a fluffy style of massage. This is a combination of one type of clinical deep tissue massage, topical modalities and a specifically designed training protocol. Optimally it should be done in the off season of training when the training paradigm can be amended to a rehab foundational GPP period. If close to the event, we improvise with care not to work too deeply on tissues that are now being trained close to the 90+ percentiles of their capacities. Much trickier business, with careful attention to details.

Hope I can do this verbally, rather than with fingers. I'm gonna hand you some of my assumptions, knowingly so, without taking the time to source the belief systems. Since the proof is in the pudding, you can tell me, us, if this method works better than what you've been doing so far. Since it's a pretty straight forward mechanical technique, the only thing you'll lose if it doesn't work is a bit of time trying it, and suffer a certain degree of personally applied discomfort. From some of your hilarious antics cited on this list, that won't be a first for you, will it?

Often with jumper's knee the adhesions occur at the lateral or medial edges of the infra or supra patellar tendons, where it is thinner and not as strong as in the thicker central portion. Palpate all along the lower edge of the patella and find the most painful spots. Do this by placing one hand just above the patella and tiddly wink it on the upper edge so the lower edge lifts up into space a bit. With that flipped up position held by one hand, rub up against the lower edge of the patella, now exposed more efficiently to your touch. You are not rubbing in the direction downward toward the tibia/fibula, but rather right up against the lower edge of the patella, like rubbing across the striated edge of a dime, in this case a silver dollar. Once you have identified all the very painful spots, you will continue to rub across them, moving to and fro, side to side across the site of the lesions, with the skin and the underlying tissue moving as one. I suggest you look along the upper edge of the patella too, tiddly winking it in the other direction to find all the pertinent spots, incase there are spots up there as well, that are in a lower level of trouble. Treat them all at once, prodromes and screamers.

Since it is hard to inflict pain on oneself, and DTF (deep transverse friction) is intrinsically a bit fierce to be effective, I often suggest that folks who are attempting self treatment use an ice cube with part of it wrapped in a paper towel to handle, as a tool to do the actual cross fiber friction. Dixie cup of water frozen, then the lip peeled back with a paper towel wrapped around its base for additional insulation works great too. You can hold the ice for a few seconds on the spot to numb it a bit, then go after it. I usually do the work in sets of 15, since athletes are used to suffering thru reps of various kinds of discomfort. Make the first treatment a minute duration in each spot you find. Perhaps there will only be one spot the width of your ice cube to work on. Great! 4 sets of 15 and you're done for the first treatment. If, however there is a spot on the lateral side and medial side or the lesion is wider than the ice cube then you will have to endure 4x15 in each location for your first treatment. Follow the DTF session with an ice pack for 15 minutes. Ice it 5 more times that day and the next, 15 min on the ice pack, 90 min between icings. You can take anti-inflammatories as you choose to good effect, since this treatment is designed to intentionally inflame the tissues as one part of how it stimulates healing. If you are a hard core kinda guy and want to hit it with some DMSO after the ice pack, go after it. Cut it with something soothing that is ok to absorb into the tissues along with the DMSO, cause it is too harsh full strength on the skin, IMO, even the 70 percent stuff.

Next day train the quads using a full ROM but with very light loads. The idea this day is to move the tissues through a full ROM while they recover from the ungluing that the DTF is reputedly achieving. We want full contractions, but not enough of a load to re-injure the still fragile tendons. Could be leg extensions with light weights, body weight only step ups or split squats, whatever suits your fancy in the way less than 50 percent of max range. More ice, right after training, and several more times that day. Stretching is not a protocol to use at this stage in the rehab paradigm. Just light full ROM action. Next day train the quads under heavier loads, but not exceeding 65 percent of max. Could be leg press, squats, lunges, again you choose, but choose something that you can control, keeping the knees in good positions over the feet. Ice after training and 3 more times that day. Next day train some other body part, give the legs a rest. Do another DTF treatment, but if it is already improved (decreased pain upon palpation) as we think it will be, work on each spot for a little longer. Up to 2 minutes per spot. Maybe you want to do 4 sets of 30 or 8 sets of 15, whatever suits your pain tolerance. Follow with ice, anti- inflammatories and repeat training protocols for next 2 days as before, increasing the loads cautiously within reason on the 2nd day as it improves. It usually takes 3-6 sequences of these combinations of DTF, ice, ROM only the next day, med percentile training the following day (2 days after DTF treatment) to clear the schmutz all the way out of the tissues. Depends on how long it's been hanging out in there, getting thick and hard like chewing gum on the bedpost, how big the trauma is, how well you recover, how well you choose the exercises and how well you manage not to reinjure it while proceeding to bring it back. After you finish your ice cube DTF treatments you can bring the training loads up to full loads in a well designed plan for increasing intensity. Unless you re-injure it, I have found that the schmutz stays out of tissues once eradicated in this way.

Although Dr. Mel was firmly opposed to the value of static evaluations of ROM ala Kendall McCreary, personally, I do find that it might be useful to do a little look see to try to determine if there is a huge discrepancy in the static length of the quads compared to hamstrings and calves, in this case. I know I might be opening a bed of worms in this discussion group with this suggestion, but IMO, there could be some adhered connective tissue in the quad bellies themselves causing them to tug tighter on that distal attachment that might have been a prodrome to your original injury. The calves also might behave as if functionally shorter than they ought to be to keep the loads more evenly distributed in your squats, for example.

If your heel doesn't come anywhere near your tush in prone position as you pull back on your ankle, but you can lay supine and raise the leg to 90 degrees at the hip joint, why not spend a bit of time after training stretching the quads a bit, actively or statically as you choose, to get them a bit longer. Or find someone with good soft tissue palpation skills to work thru the bellies of the short muscles for you, soften them up a bit. I offer this suggestion, just in case that might be an underlying consideration regarding how the original jumper's knee occurred, rather than simply you exceeding your optimum recovery volume loads. If there's no ROM beyond 90 degrees dorsiflexion in the ankle joint, work on getting more length in that a bit too while you're working out in a foundational phase. What's the minus in checking for possible weak links or restrictions in your chain of strength and attending to them? Time is what it costs as far as I can tell. Might be worth the investment.

If you decide to try this method, please let us know how well it works for you. I hope it helps. It certainly has for a number of athletes in my care. This is admittedly an anecdotal offering. I am not a researcher nor am I concerned with scientifically studying which part of this paradigm is the most effective component. It's one set of combined methods that has worked well for me with many athletic folks who have come to my office bringing old training glitches that have malingered and adversely affected optimum performance. It also works for new injuries if located in musculo-tendinous or tendinous tissue. Muscle bellies need to be dealt with differently if the injury is fresh, as I currently understand them. Just one girl's experience. No books to sell nor seminars to pitch.

Best regards and good luck,

Dianna Linden Santa Monica, CA, USA

 

[AlbinoAssassin]

I would have to go with stop jumping as my way to stop jumper's knee. I had it back in the day. I grew about 10 inches in a year, yes it kicked my ass. It just went away though, don't really know why.

 

[Tagio]

Great info. I may start doing that exercise daily to keep the knees from flaring up.

I've had minor pain in my knees at times in the past, but it usually goes away completely if I keep impacts and squatting to a minimum for a few days. Actually strengthening the tendons would be great though.

 

[b fold the truth]

Thanks my friend...

B True

 

[endpoint]

last athlete i asked said (no shit)......just inject more growth hormone into the patella region alternating sites once in a while.

 

[collegiateLifter]

good read. The first article reminded me of a newsletter I got by Charles Staley a while back, prescribing eccentrics to treat tendonitis.

That said, in th case of there being massive amounts of scar tissue near the joint, I would recomend trying ART to anyone.