Patellar Tendinitis/ Patellar Tendinosis

[australia]

I am 40 and I have suffered with patellar tendinitis for 14 months.  An MRI confirmed the diagnosis of two orthopedic doctors, one of whom is a well-regarded orthopedic surgeon.  I have no other knee issues.  I have undergone physical therapy twice over this period at two different places with only modest success.  The docs emphatically said that I should not undergo surgery and that it should improve within 1-2 years.  However, I believe I am not improving much any more. 

I have little pain in the morning, but it progresses significantly by the afternoon.  In the afternoon, especially, the pain is particularly bad when sitting or standing in one place.  One of my pain symptoms is a burning-type pain.

A patellar strap can reduce the pain substantially.  However, when I wear the strap too much, I get acute IT-band pain.   

Over the past year, things I've tried that didn't help much included: six months of physical therapy, acupuncture, chiropractic, ibuprofen, shoe orthotics, new comfortable shoes, several months of glucosamine/chondroitin; knee-taping; regular leg & knee massages; a daily stretching & strengthening routine; and various creams & lotions.   

To deal with the pain, my doctors are now suggesting the following: 1) Taking Neurontin (gabapentin); 2) massaging the tendon with an electronic hand-held massager; 3) wearing a cho-pat dual-action knee strap to reduce IT-band-related side effects of a single strap; and 4) continuing physical therapy without any exercises that elicit tendon pain.

Does anyone have other suggestions to reduce pain?   

Thank you!

  

[Heather M.]

Arrrgghh!  I just wrote this response to you and then accidentally dragged the base of my palm across the top of my notebook's touchpad, which has the same effect as hitting the 'back' button in your web browser.  POOF!  There goes my post.  Sony's Vaio  is a grea, hight-speed, feather-light laptop, but the *%^[email protected]!$$*& touchpad is so sensitive that sometimes I want to throw the whole machine off the cliff in my backyard.

ANYWAY, I'm too tired to duplicate everything, so I'll cut to the chase and ask you to forgive the abrupt tone and lack of detail.  I have had patellar tendinosis for years, along with severe IT band syndrome--these two conditions are brutally painful and very tough to treat.  But in my case, both are secondary to another condition--arthrofibrosis.  So I was thinking that if your tendinosis is not responding to treatment (and it seems like you're doing all the right things), then maybe it's because there's an underlying condition that is perpetuating the tendinosis?  Have you had knee surgery in the past?  Any injury, like a blow to the knee or twisting injury or something like that?  What brought on the tendinosis? 

Has anyone ever mentioned arthrofibrosis or excess scar tissue in the joint to you?  This is a tricky little problem that can both cause things like ITBS & tendinosis, and yet also be *caused* by them!  Because the chronic inflammation of tendinosis, for example, can lead to the formation of excess scar tissue.  Or, if you already have the adhesions due to surgery (which is what happened in my case), you can then develop the tendinosis and/or ITBS due to the swelling, traction, changed mechanics, etc. that are symptoms of the scar tissue.

So anyway, it seems to me like finding the root cause would be crucial.  And while I know nothing about your current doctor, I know from personal experience how helpful it can be to see out an expert second opinion--or third, fourth, even fifth, if necessary.  Whatever it takes to get to the bottom of this.  Also, all PT's are not created equally, so make sure you are seeing a great one who has experience with soft tissue problems, arthrofibrosis, and treatment techniques like phonophoresis and myo-fascial release.

You may want to visit the soft tissue healing problems section for more ideas of what to do with the pain and rampant swelling that you have.  I'm fairly certain that most if not all of the posts on dealing with arthrofibrosis will be helpful and applicable to your case, because your goal is to reduce pain and chronic inflammation--same as with scar tissue.  So read the posts on the rehab and struggles of people dealing with arthrofibrosis from some PT ideas--the goal is to reduce inflammation and swelling/heat in the knee as much as humanly possible.  You have to break the cycle of inflammation to progress, so the idea of no pain, no gain has to be thrown right out the window.  There are lots of rehab tips in the soft tissue healing problem section, especially in the post-op journals you'll find there.

My second suggestion would be to make sure you haven't developed any of the really frustrating complications that can slide in undetected when you're dealing with a chronic inflammatory condition like yours.  These can include conditions like the arthrofibrosis I already discussed; patella baja (where the patellar tendon gets wrapped in scar tissue from the constant trauma and actually shrinks/hardens, pulling the kneecap down and out of place and causing bone on bone grinding & eventual arthritis); calcification of the tendon (spots of bony or hard material in the damaged tendon--ouch!); focal scar tissue in places like the empty space behind the patellar tendon/under the kneecap (called the anterior interval) or over the insertion point of the IT band (very, very painful--been there, done that); bone spurs; tissue necrosis or areas of cell death in the most damaged parts of the tendon; and even a totally unrelated condition like a meniscal tear or area of damaged articular cartilage that can result from your altered gait and unconscious efforts to protect the joint, or even from changed mechanics over time as your body has compensated for the tendinosis.

But these suggestions like getting an expert second opinion, finding a fantastic PT, and looking for/eliminating secondary conditions and root causes.  Things you can do right now, tomorrow, to help with pain can include:  find a PT to do myo-fascial release (very specialized massage that can change your life after a few sessions--many PT's are trained, but you really need to find someone with a gift through word of mouth, internet research, calling training schools, etc.).  At PT, have the therapist do phonophoresis (ultrasound with cortisone cream) and/or iontophoresis to help instantly with pain and swelling.  Ask your OS about a short course of strong oral steroidal anti-inflammatories like the Medrol Dose Pack (aka Prednisone) to knock back inflammation and heat, and a longter term course of Cox-2 Inhibitors like Celebrex can be very helpful in knocking back the inflammation on a daily basis.  You may want to invest in a great cryo-cuff or 'ice machine' that gets more of the knee cold and keeps it that way for much longer (Breg has a great one--or if you can swing the $$, Game Ready has a top of the line machine that wraps around your whole leg and chills it to the bone), crutches and/or a cane to help take some pressure off the leg while you try to heal the tendon.  A couple of things that will not help with the inflammation, but will help calm the nerves in the area down (in addition to the Neurontin your OS is recommending) include Lidoderm patches and a home TENS/e-stim unit.  The Lidoderm especially can be incredibly helpful for irritated soft tissue like IT band and tendons--it is a moleskin like material that is impregnated with lidocaine.  You stick it directly on your skin and can wear it up to 12 hours out of each 24.  A TENS unit uses some electrodes placed over the skin to send out little pulses of electricity, which kind of 'trick' your nerves into stopping the constant transmission of pain messages.  And I think it might be a good idea to investigate a formal pain management program, which would likely incorporate many of the above items with a medical regimen including painkillers, trigger point injections, and other medications

These are some ideas of things that have worked for me.  But the most important thing was finding the root cause of my problem, and then finding the doctor witht he best credentials around for dealing with it.  I travel about 700 miles to see my surgeon (two day drive, as it's in the mountains) and have spent a total of about 12 weeks away from home receiving treatment at his clinic.  My new surgeon (I fired the old one after 5 procedures in 10 months left me worse off than ever) has done several operations, which included careful debriding of the patellar tendon, electro-cautery to remove the excess scar tissue, release of my IT band and a Z-plasty (kind of like a fasciotomy), which resulted in almost 8mm of additional 'length' or give in the tight tissues around the IT band that had been causing such traction and pain.  And the most important thing was the highly specialized physical therapy that was designed to keep the scar tissue from reforming in my knee, as it had so many times before. 

So finding an expert in treating patellar tendinosis would be my top recommendation to you, because he/she will likely suggest all the things I've written above.  Surgery is usually the last resort with patellar tendinosis, but it can help some people if it is done right and if the proper rehab regimen is followed.

Heather

PS Here's the link to the soft tissue healing problems section:  http://www.kneeguru.co.uk/KNEEtalk/index.php?board=9.0

[australia]

Heather --

You are clearly more knowledgeable about tendinosis than many docs and physical therapists!  I appreciate your reply.

The root cause of my tendinitis/tendinosis, as I will explain, is why one needs to be extremely careful to find an outstanding physical therapist.  I believe I currently have one of the better ones, after going to three in the past 1-2 years. 

The cause of my tendinitis/tendinosis is, unfortunately, from physical therapy I did last year after developing IT-band problems from too much bicycling.  In April, 2004 I began picking up bicycling after a winter of doing little training.  I put in too much mileage too soon and developed IT-band syndrome.  This was diagnosed by two docs.  I stopped bicycling and went to physical therapy and things got worse over the next 2-3 months.  While the IT-band issues went away, I developed tendinitis during the course of physical therapy.  I believe that I slowly developed tendinitis over this time, and that certain exercises that were good for IT problems were NOT good for tendinitis.  The physical therapist thought I only had IT-problems, and didn't realize I was developing tendinitis.  In July, 2004 my doctors said my IT-problems were improved, but that I developed tendinitis during the course of physical therapy.  My docs said the tendinitis could take 8-18 months to resolve.

I am fortunate that I don't have any visible swelling or a "hot knee."  I haven't had either of these symptoms in 9-12 months.  I just have pain, most significantly in the afternoon.

I will re-read your note carefully and look into your suggestions!

Thank you.

   

[s_]

I believe I am having a similar issue with tendinosis, have either of you had any positive updates you could share (granted these posts are from almost ten years ago    )?

Thanks,
S

[Fred Wilkins]

Hi Australia,

I suffered what i thought was patellar tendonosis for about a year or so and i'm only 22!  I had a few MRI's and not much came up.  Eventually they found out it was Deep Infrapatellar Bursitis which is basically an inflamed fluid sack which helps lubricate the joint.  It gives pretty much the same symptoms as jumperes knee (patellar tendonosis) so maybe rule out that its not that.

Anyway, long story short, i was going to have this thing called "shockwave therapy" to help my tendonosis before we found it it wasnt!  It basically kick starts the inflammation and turns it back to the acute phase thus starting the healing again.  Have a look into this.  I'm assuming you're from Australia so i'm sure this therapy is around.  It's F#!£ing expensive, about £1,500 for three sessions but it has a success rate of about 70% i was told.  But you cant put a price on getting better hey!  So perhaps look into that and give that a go.

Second thing is, smash out eccentric exercises.  You can buy, or make, a 25 degree decline board where you do eccentric exercises.  The surgeon who suffered from this injury himself told me to do 3 sets of 20 reps, twice daily.  you should feel some discomfort but thats normal and what you want.

Like i said, it turns out i dont have this injury after all, but i thought i had it for about a year, despite studying physiotherapy so i should have realised what i had, but there we go.  So i know exactly where you are coming from.  look into shockwave therapy. Note- its not electronic shockwaves, its mechanical shockwaves.

Knowledge is power, so research as much as you can and best of luck with this.  Please let me know how you get on.  I'm sorry if this post is written pretty badly, extremely tired but thought i'd try and help you since i know how you're feeling!

Fred

[Hasan89]

I had patellar tendonitis for almost 2 years. People usually suffer from this injury for a long duration of time because they don't tackle or treat the pain early on. Instead they let it progress until it's at a stage were your body's bio-mechanics adapt and almost accept the dis-functionality at your knee's. Once it gets to this point it is a long road from there, which is why this injury can take months or years to heal. The longer you have suffered from patellar tendonitis, the longer your recovery and rehabilitation will need to take.

You cannot force or rush anything with this injury. Your patellar tendon is constantly inflamed and in pain for a reason. You must (with the help of a physio therapist) find the route to your problem, what is not working properly in your body?

[Sara10]

Hi all,

Still have tendinosis, both knees, worse in my left.   Overall, there's last 2.5 years, I've been able to walk more and do more.  But pain is still roughly same.   I don't know anymore.   I keep failing eccentrics I think.   I get motivated, do them well for 3 weeks and then I stop because of an increase in pain.    Really thinking about prp injections.   Would like to hear anyone's thoughts on it.   I'll talk to my ortho is two weeks about it and getting another MRI on both knees,   P.s,   Last two kris show normal.  But let's see if this thing thickens