Sunday, December 16, 2007

Treatments I tried for Patellar Tendinopathy

Physical Therapy -- Over three years I went to three different physical therapists. Altogether, I was in physical therapy for 2+ years. None of the therapists knew about the medical research on using eccentric exercise for patellar tendinopathy. The key benefit from physical therapy was learning the stretching exercises from the third physical therapist. I am convinced that the first physical therapist that I went to made my problem worse by having me ramp up way too quickly with certain (non-eccentric related) strengthening exercises. The second physical therapist I went to did not include any stretching into the program. Furthermore, that therapist had me do exercises that I believe should be contraindicated for early stages of patellar tendinitis -- jumping with heavy weights. Some of the modalities used in physical therapy for patellar tendinopathy such as ultrasound and electrical stimulation probably don't provide any real long-term benefits.
Unfortunately, many physical therapists are simply bad at what they do, and there are many stories of therapists injuring their clients.



Orthopedic surgeons -- Over the course of three years I consulted with three orthopedic surgeons, two of whom have been the chief physicians for college and professional sports teams. While they each gave me the same diagnosis, none could offer any solutions apart from physical therapy. I am grateful, however, that they refused to recommend cortisone or other steroid injections. This is because research has shown that such injections can weaken or rupture tendons. Furthermore, such injections may not provide any long-term benefit. I am also grateful that these surgeons did not recommend surgery. This is because surgical outcomes for patellar tendinopathy are often not that good. Surgery also requires recuperation time and physical therapy afterwards. Surgery can lead to complications. It is also irreversible. Unfortunately, none of these fine doctors mentioned eccentric exercise as a possible treatment.



Chiropractic techniques -- I went to two chiropractors for a period of time. The approach used by each was very different. I sometimes found short-term benefit (an hour or more of pain relief), but unfortunately no longer-term benefit. The approach of one was to use a butter-knife type instrument and apply a scraping-like motion across the tendon. The same chiropractor put me on a table and actively stretched my legs. I generally felt much better coming out of these sessions than when I went in. Unfortunately, the next day I was back to the same without any lasting improvement. I found less success with the second chiropractor I went to. This chiropractor's technique was to put intense finger-point pressure on muscles around the lower body and maintain that pressure for a period of time.



Massage of the tendon and surrounding muscles -- While this did not cure my patellar tendinosis, I believe that regular treatments may reduce the likelihood of problems in the first place and reduce the risk of re-injury.
Orthotics and shoes -- I have found some benefit to orthotics and certain shoes. However, I found this to be a bit of trial-and error in finding what was helpful. Furthermore, I found no benefit to customized orthotics versus standard orthotics that I bought in a store. In fact, I much preferred the feel of some off-the-shelf orthotics. Customized orthotics can cost substantially more than off-the-shelf orthotics (In 2008 a pair of custom-made orthotics cost around $400 versus off-the-shelf orthotics that cost as low as $18.) Orthotics may wear out and need to be replaced every year. I generally find sneakers to be much more comfortable (and less pain-provoking) than work shoes. Some types of sneakers are better than others. Some kinds of work shoes are much better than others, as well.



Patellar straps -- For me, these were an excellent way to deal with short-term pain. But, they only relieved short-term pain and did not provide a long-term solution. Unfortunately, I found that using these straps for many weeks on end led to other problems -- such as pain on the sides and back of the knee. While I recommend the straps when pain is bad, I would try not to use them everyday for weeks on end.
I ordered off the internet many variations of patellar straps and perhaps tried 5 to 10 different kinds. I found a few that I liked. Sometimes I preferred ones that applied more pressure to the tendon. These generally had a thick piece of rubber that curved around the tendon. Other times I preferred softer patellar straps without the rubber. I also found helpful "dual action" straps, which have one strap above the knee and one below.





Rest -- My view is that rest is good in the very early days and first few weeks of developing patellar tendinitis when there is inflammation. However, at some point, strengthening exercises, such as straight-leg leg lifts, should be added, to reduce the likelihood of muscle atrophy. I also believe that walking should be kept to a minimum in the early days of tendinitis. However, once tendinitis morphs into tendinosis after many months, rest won't serve any useful purpose and certainly won't cure longstanding tendinopathy.

Acupuncture -- I had too few sessions to likely make an informed opinion. However, I can say that a few sessions certainly did not work for me. Furthermore, while it may be possible for acupuncture to relieve some pain, it does not get at the root cause of the problem. It certainly won't cure the underlying pathology.


Ibuprofen and other anti-inflammation drugs -- Perhaps I had some very short term minor pain relief, but no long-term benefit. Taking too much of these or taking them for too many days can lead to significant negative medical complications, as well.



Ice -- During the early phases of acute tendinitis, ice can help reduce inflammation and pain. But, once the inflammation is gone and one is left with tendinosis, ice probably won't help except for providing a very short term benefit of pain relief. There likely won't be any long-term benefit. I believe that too much prolonged icing can lead to other problems, such as changes in skin and possible nerve damage. I used to ice religiously, but now I don't ice after doing my eccentric exercises. After experimenting with and without ice, I find no need for it.




Knee taping -- This provided some short-term pain benefit, but it certainly wasn't a long-term solution. Having to reapply tape every few days and ripping the tape off was not a real long-term solution. Furthermore, walking up and down stairs wasn't very possible at times because of the position of the tape.
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Topical knee creams -- I tried a variety of balms, creams and lotions. While those with camphor and menthol provided very short-term pain relief, others with aspirin derivatives provided no short-term help. However, none of these potions provided any long-term benefits. Plus, some of them have strong odors that can permeate an office environment. Also, avoid compounds with capsaicin (sometimes used for arthritis and other ailments), which will temporarily worsen your pain by making your knee feel like it is on fire.

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Glucosamine & chondroitin pills -- I took these for three months and saw no change in my pain level.
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Eccentric exercise -- This is the only thing that has worked to substantially reduce my knee pain on a longer-term basis. But, such exercise must be done properly with the right protocols, otherwise it can lead to a relapse of symptoms. Eccentric exercise is one of the few treatments that I know about that might actually help reverse or improve the underlying tendon pathology.



19 comments:

Anonymous said...

Thanks for your story. I'll try it out and let you know. I'm currently suffering from patellar tendinosis for almost a year now.

Matthew said...

Thank you for this blog. I've been dealing with anterior knee pain for over two years. It was on and off for many years, but the miles required to ramp up to a marathon threw me over the edge and what I think now was tendonitis has changed into tendonopathy. I have had MRIs and multiple doctors visits with no clear diagnosis. Over time, following the same obssessive and money/effort-be-damned approach you're obviously embracing, I've come to similar conclusions you have.

I'm only about two months into the eccentric work, which I do 1-2 times/day on a decline board, per studies/recommendations I've read on this. Overall, my knee is doing fairly well but sometimes it feels like it did a few months back and I wonder if it's for naught, but this is a long time thing and I still believe that short of surgery (which has inconsistent results), eccentric is the key hope at this time.

You are also quite correct on the rest thing. When the knee is bad, rest fixes most of the pain, but the small pains I get even after months off and the mild tightness (used to be severe but went down this year after a large amount of stretching and quad strengthening) and knee click never fully go away. The literature I've read (which was contrary to the ~1 month recovery I've heard from various highly-praised doctors/PTs) indicates that 4-6 months or longer is reasonable for recovery of this and that's if one's following the proper program.

Another approach one must take is to avoid recurrence. In my case a hip imbalance and/or leg length discrepancy put me in this mess to begin with, so to that end I've been hammering away with yoga and other stretching.

The funny thing about excercise is that it generally bothers my knee but from time to time a very hard workout (either a fast run or bike ride) will at times leave me, the next day, in substantially less pain/tightness than normal. That said, these days I'm doing only the rehab and swimming. I do nothing to my knee besides the "prescribed" program.

Thanks again for the blog. I've bookmarked it. There is not nearly enough info on our particular condition. It is glossed over or not diagnosed properly for many people.

Anonymous said...

Hi
I am a physio and regularly treat people with patella tendinopathy/osis. I was browsing the internet on this subject and came across your blog and have since recommended it to several of my patients. It is useful for them to read info that is not overly medical and from someone who has obviously been there and done that. It can sometimes be difficult to get patients to buy into the idea of eccentric rehab as it can take a while to get results, so I found your blog site very helpful in this respect.Thanks!

Anonymous said...

thanks for sharing.i think sharing helps the mental aspects of the problem.

Abdul Shohid said...

Hi mate, thanks for sharing your story.

I believe I have tendinosis wrist extensor tendons (tennis elbow but with pain near the wrist)from a few months overuse of the computer and playing video games. Ive had it for a year and a half now and its really destroyed all semblenses of a normal life, just brusting my teeth is painful.

My physiotherapist has suggested eccentric exercises but thought my own experiences and now reading your blog I believe Ive been doing too many reps and sets. I will now use far less force and aim to do the exercises without the accompaning burn on my tendon afterwards.

But dealing with this injury I believe early deep tissue massage along the attached muscle can in many cases reduce the severity of tendinosis and may even stop tendinosis all together.

I keep you updated on how I get along.

Fingers crossed

KickingWorld.com said...

great site and very accurate information. I go to a physical therapist now and the eccentric work is really helpful for patellar tendinitis. I also coach kickers and punters and this workout is especially useful for soccer-style kickers and soccer players. Check out my site at www.kickingworld.com

Anonymous said...

Thank you for this blogg! It is a topic of great interest to me after having suffered from tendonitis for 1½ year.

I have tried just about anything there is to try, but must admit that I haven't given eccentric training a serious shot. I have tried the exercises, but every time progressed to rapidly.

I'll try and follow your program and share my experience.

The latest posts I can see from you are from the beginning of the year. Have anything changed with regards to your tendonitis - further progress or still some pain?

Anonymous said...

i've had severe knee pain (in both knees) for 15 years, only recently diagnosed as patella tendonitis. Is it too late to treat?

Sigfús Víkþörðson said...

This is in response to your question about whether it is too late to treat patellar tendinitis that you've had for 15 years. No, it's not too late. You may be a very good candidate for the eccentric exercise protocol. The protocol is meant for people who have chronic patellar tendinitis. Try it and let us know whether it helps you.

Patch said...

Great post. Your story basically summarizes my last 10 years struggling with chronic patellar tendonitis. I have tried everything you have and am looking forward to utilizing some of the eccentric exercises to help prevent me from re-aggravating my tendons as I slowly increase my activity. Thanks for the post, and encouragement...

Anonymous said...

Thanks for your story. I had surgery on my knee for patellar tendinitis and you have no idea how much I wish I would have seen this site before surgery. It's been 7 months now and my patellar pain recently came back. I also have general stiffness and pain in the entire knee from the surgery. My doctor said nothing to me about the different stages of tendinitis. Looking back I was probably between stage 2 and 3. If you are considering surgery make SURE you have done everything possible to increase flexibility and strength in the quad, hamstring and calf before opting for surgery. Don't make the same mistake I did.

Sigfús Víkþörðson said...

Thank you very much for your comment. Your experience with surgery provides invaluable information to others. I hope your pain and stiffness go away soon. Unfortunately, it is likely to take some time.

TSA Taekwondo said...

Hi,
Thanks for your story, some great tips for this condition.
I have had patella tendinopathy for about 1 year now and it was eventually diagnosed by my Osteopath. My condition does seem quite mild in comparison to others listed.

Read my story at:

http://patellatendinopathy.blogspot.com/

The Osteopath says that it will be Sep 2009 when I am fully recovered so I will keep checking in and watching the videos. I will be mentioning the eccentric exercises but I think mine is too mild and it is too soon in my treatment which is why my Osteopath has not mentioned it. I will be asking him if they are appropriate for recovery and for reducing the risk of re-injury.

Gubert said...

Weakness in either the calves, the glutes or the hamstrings is also a possibility you have to consider. I have found strengthening of the calves to be particularly helpful. Strengthening the muscles around the knee might mean that you place less stress on the patellar tendon. Other than that I do think that the eccentric exercise protocol makes the tendon stronger.

luke13sam said...

Again thank for this blog, i have been suffering from tendonitus/tendonosis for the past 2 years, the first signs of inflamation of the tendon was from playing basketball several times of the day every day of the week, and i have just been diagnosed with tendonosis as there is little inflamation over the tendon but a very tender spot over the top half, i felt icing 3 times a day helped with the burning/aching of the tendon however did not help the underliying problem. I have recently started an ecentric programme of 13 reps in sets of 3's 3 times a day and for once its starting to feel abit better although as others have said it can randomly feel like it used to again, thanks for the blog this is a real nightmare and its a subject thats realy not discussed/studied enough
Luke

Anonymous said...

Hey .. good information here.

I have been to physio after physio over the years and have found none of them to be overly accurate with tendinosis.

Eccentric exercises are definitley the best form of treatment, well, thats what I've found.

My problem is impatience, so I do eccentric exercises for a week and then try and blast a football game on the weekend .. not advised.

Had the problem for over 5 years, both knees. Had Osgood Sclatters as a teen also.

THIS is 100% the best exercise to cure the issue, plus having the right mindset and believing you're going to improve. Get rid of all negativity and you'll find your healing will be quicker.

I've tried everything, just like the author, but made a 45 degree board which has helped me no end.

Cheers,
Lloyd
God Bless.

Sigfús Víkþörðson said...

I received a question about whether vigorous "cross-friction" massage of the patellar tendon may be helpful. And, perhaps in combination with eccentric exercise.

Personally, I found no benefit from such massage, unfortunately. Others may have better luck. I would also focus on one kind of therapy at a time. Fine-tuning the eccentric protocol for each person is complicated enough without adding in another variable. Additional therapies done at the same time may be counterproductive, rather than additive.

Anonymous said...

I just have a short poem for you. It goes like this:
I love you ,I love you, I love you, I love you, I love you, I love you, I love you, I love you, I love you, I love you, I love you.
You and your website have saved my military career and my knees thank you so much.

groovyoldlady said...

I almost cried reading this. I am training for a 3 day 180 mile bike ride. 2 years ago severe pain below mu left knee took me out of the ride 12 miles into my second day. I had no idea what I had done, only that it was not bone or muscle pain. Last year I skipped the ride and volunteered for the event instead. This year I started training again. The one day I rode 50 miles the pain was back. Now it nags at me if I go over 30 miles.

I am SO THRILLED that it has a name! And a treatment!

I'll have to go short term for now with lots of massage and a knee strap and very careful riding techniques on a limited training schedule. But I am looking forward to nailing this thing for good now.

Thanks for giving me hope!