Patellar Tendon Pain Loading Strategies

[Taylor Blattenberger]

Hey everyone!

I was reflecting on a case I have been working on the past couple weeks and it challenged me to implement some of the skills AJ and I have been working on during mentorship time – more specifically utilizing test-retest in session to guide treatment. I found it took some odd turns and thought it would be a good topic to discuss.

Without getting too in depth with the case details, the patient was experiencing symptoms consistent with chronic (B) patellar tendinopathy including pain with heavily resisted knee extension, pain with palpation of the inferior pole of the patella, and pain with increased squatting activity.

It’s pretty clear that tendinopathies respond well to loading in some capacity. The one thing we can’t seem to agree on is the mode in which to load the system. Most recently I was reading this article that compared isometrics to isotonics for patellar tendinopathy. It raised a lot of questions and watching my patient respond to treatment helped me think through some things.

I’ll attach the article below. Have a read, see what sticks out to you, and let me know what you think. Feel free to link any other resources you’ve used to make clinical decisions about loading tendon pathologies!

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[Eric Magrum]

Attached is another editorial/article that I posted a few months ago; as our residents had similar discussions/decision making about 1 piece of new evidence the decision maker to make practice changes.

New and exciting doesn’t necessarily mean practice changing.

So just wanted to add this editorial to the discussion as we continue to be consumers of the evidence for clinical decision making.

Cheers – Thanks Taylor

Thoughts from everyone else?

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[helenrshep]

This always seems to be a point of disagreement among clinicians! I feel it has a lot to do with the patient’s irritability. I think the highly irritable patient responds better to isometrics, but I also think that has a lot to do with their perception – not asking them to go through a full range of motion “seems” tamer to them in my experience, and is consistent with the article’s point about fear of exercise. But a less irritable patient, or one that is familiar with exercise (like an athlete) may be just fine doing isotonics. Or maybe do both? I don’t think it necessarily has to be an either/or…

[helenrshep]

Apologies for the double post but I had more thoughts! – I also question the functionality of isometrics. You can do all the plantarflexion isometrics you want, but at the end of the day if you’re still walking then isn’t that technically an isotonic exercise in itself? And how much of a role does motor control play? Do you guys treat with isometrics or isotonics or both?

[Steven Lagasse]

Helen, I think considering the patient’s irritability is a good idea. Asking a patient to perform an exercise they find painful (i.e. an isotonic squat) may bring on fear, and perpetuate the problem. Modest interventions such as isometrics may be the better approach. Perhaps once their irritability has decrease we can then begin loading in a more functional way?

[awilson12]

I think the editorial Eric posted brings up some good points about the intention behind isometrics in this study. On a case by case basis there might be a time and place in the tendinopathy realm for isometrics- maybe based on irritability or dosed based on the RAMS (retrain, attain, maintain, or sustain) model and requirements for the patients goals versus for the intention of acute pain relief. I like that they point out that in situations of tendinopathy, the expectation of therapy shouldn’t be a “quick fix” and working into some pain may actually be necessary.

I have limited clinical experience with treating tendinopathies so I am always interested to hear what approach other therapists take based on the evidence out there and the patient they are dealing with. Personally I am not partial to one type of contraction over another. From an irritability standpoint I’m wondering if there is more utility in focusing on treating impairments away from the primary location of pain, along with education on activity modification, until more site specific treatment is tolerated. Thoughts?

[lacarroll]

I’m in the same boat as Anna with not having much experience treating patients with tendinopathies, and I feel like both of these pieces have some good points. Isometrics may have some analgesic effects early on, but eventually progressive strengthening is going to have to be worked into the plan of care to get back to previous level of function. Like everyone else has said, I think it all just has to tie back to the patient and their level of irritability and being able to find a happy balance between isometrics and progressive loading. I like Anna’s line of thought about treating up/down the chain away from the impairment while the tissue is more irritable. It seems like that way we can still make headway with treating some deficits and not just attacking one thing head on. Anyone have any good nuggets to share on that?

[Taylor Blattenberger]

I think everyone has made good points! I think one thing this article really misses is the clinical decision process. Maybe some people allocated in the isotonic group were more irritable and would have responded better to higher resistance isometrically than low load isotonics. No way to know this for sure, but definitely a difference between research application and clinical application.

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