**7.3 Cryotherapy and physical modalities**

Cryotherapy helps in controlling initial tissue response to the injury. It is thought to act by decreasing the blood flow and metabolic rate, thereby decreasing the rate of inflammation. Electrical modalities that have been used in patellar tendinopathy include ESWT, ultrasound, heat, interferential therapy, magnetic fields, pulsed magnetic and electromagnetic fields, transcutaneous electrical nerve stimulation (TENS), and laser [10, 37, 38]. The true effects of the above mentioned modalities still remain unknown and further studies are required to support their use.

### **7.4 Remedial massage**

It tends to treat the tendon tissue by having an effect on the muscle stretch and direct effect on the tendon cells. Muscle belly massage is thought to increase the compliance of the muscle and decrease the load on the muscle. Deep friction massage is thought to activate the mesenchymal cells to stimulate the healing response. "Fibrolysis", a form of deep frictional massage originally developed in Finland, has been successful in Achilles tendinopathy. However a controlled study failed to provide any evidence of healing in patellar tendinopathy and further evidence is required to warrant its use [39].

### **7.5 Rehabilitation**

The key treatment nowadays to chronic tendinopathy is the stretching and strengthening programme of the whole muscle tendon unit. A staged program for tendinopathy corresponding to the stages of worsening severity of the condition [1] was outlined by Stanish et al. [40] outlined in **Table 1**.

Drop squat forms one of the key exercise for this condition in which patients are asked to sit to about 100–120° of knee flexion from a standing position and are advised to perform three sets consisting of 10 repetitions per session. It was observed that this regimen brought about complete relief in 30% of patients with reduction in the symptoms in further 64% of the patients [41]. Worsening symptoms were seen in the remaining 6% of patients. Cannell [42] observed that eccentric squats were better as compared to leg curl/extension exercises in treatment of the condition.


### **Table 1.**

*Program for patellar tendinopathy.*

### **7.6 NSAIDS**

Although the benefits of NSAIDs are dubious, they are the most common drug used for symptomatic relief [43]. Although the use of "anti-inflammatory" medication seems paradoxical for a condition that is essentially degenerative, it is believed NSAIDs might act via mechanisms different from their conventional anti-inflammatory actions [44]. In vitro studies in human cartilage have revealed a variable interaction of NSAIDs with glycosaminoglycans (GAGs) where some have been shown to stimulate and some to inhibit, its synthesis [45]. This mechanism also sheds light on its effect on the synthesis of extra-cellular matrix. In a double blinded placebo controlled study, the use of NSAIDs in tendinopathy, piroxicam did not benefit patients with Achilles tendinopathy however topical ketoprofen reached the target tissue in patients with patellar tendinopathy, but the clinical efficacy was not assessed [46].

### **7.7 Corticosteroids**

Corticosteroids are known for reducing the symptoms arising from the inflamed synovial structures. However the role of corticosteroids remains controversial in management of tendinopathy. According to Jozsa and Kannus [47] steroids are contraindicated in acute phase of tendinopathy and in the late chronic phase of tendinopathy when the tendon degeneration is advanced which may lead to tendon rupture. However it has proved beneficial when diluted with anesthetic for diagnostic reasons and to minimize adverse effects and in conditions where 1–6 week rest period combined with a programme of gradual strengthening is required before returning to activity.

### **7.8 Other medical treatments**

Aprotinin, an 85 amino acid 65 kDa basic polypeptide extracted from bovine lungs has shown to offer better pain relief than steroids at least in short term. However aprotinin which is a strong inhibitor MMP (matrix metalloproteinase) is less effective in insertional tendinopathy as compared to main body [48]. Another non-surgical treatment option includes use of sclerosing agent with chemical irritant (e.g. polidocanol) [8, 49, 50]. These targets the neovascularization and accompanying nerves. The use of platelet-rich plasma injection has been tried in tendinopathy and favorable outcome have been found [51–53]. However still there is no level 1 or level II studies about role of PRP in patellar tendinopathy. The glyceryl trinitrate (GTN) patch [54, 55], which delivers nitric oxide (NO) to pathological tendon which play role in tendon healing. But we still need level1or level II evidence to support it.

**63**

*Patellar Tendinopathy: "Jumper's Knee" DOI: http://dx.doi.org/10.5772/intechopen.84642*

procedure has not been elucidated.

Patellar tendon surgery is indicated in patients who have failed conservative management more than 6 weeks [56–58]. A variety of surgical procedures have been described such as resection of the tibial attachment of the patellar tendon with realignment, drilling of the inferior pole of the patella, macroscopic necrotic area excision [59], repair of macroscopic defects, longitudinal tenoplasty/tenotomy of the tendon [60] percutaneous longitudinal tenotomy, percutaneous needling [61] and arthroscopic assisted decompression [62, 63] of the tendon, possibly with excision of the inferior pole of the patella however the effectiveness of any single

Patellar tendinopathy is essentially a degenerative condition and the management should be based on the clinical assessment. Imaging appearances, although aids in the diagnosis but should not determine the treatment. Conservative treatment forms the mainstay of management, while surgery is indicated only after a dedicated period of appropriate conservative measures have been instituted, usually around 6–9 months. These include physical modalities such as local application of ice and graduated strengthening physiotherapy protocol such as functional exercises and eccentric strengthening; the latter are done only after the patient is pain free. Although there is a lack of level I evidence, eccentric training appears to be the most promising modality. Peritendinous corticosteroid or aprotinin infiltration may also be useful as an adjunct for the treatment of this condition. Although scientific consensus is lacking percutaneous needling appears to be the least invasive procedure, followed by percutaneous longitudinal tenotomy. Arthroscopic debridement has been proposed, but, although early results are encouraging, its efficacy is still

**7.9 Surgical treatment**

**8. Conclusions**

under scrutiny.

**Conflict of interest**

No conflict of interest.

**Acronyms and abbreviations**

BMI body mass index

NSAID nonsteroidal anti-inflammatory drug VEGF vascular endothelial growth factor MRI magnetic resonance imaging CT computed tomography GRE gradient echo sequence

ESWT extracorporeal shockwave therapy

MMP matrix metalloproteinase PRP platelet rich plasma GTN glyceryl tri-nitrate NO nitric oxide

TENS transcutaneous electrical nerve stimulation
