Patellar Tendonitis – Jumper’s Knee Causes, Prevention & Rehabilitation

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Patella Etymology

Patella:” Is the diminutive of “patina.” And comes from Latin. Patella has two meanings, the first meaning generated the other by visual similarity.

  1. A small dish, plate, or pan;
  2. The central triangular sesamoid bone in the kneecap.

“-ar:” Is an English suffix used to indicate relation or vicinity.

Tendin“: The word comes from Middle French word “tendon.” It refers to the strong band of inelastic fibrous tissue that connects a certain muscle with its correspondent bony attachment.

“-itis:” Is both a Latin and Greek suffix meaning “pertaining to.” It’s used to denote a certain disease characterized by inflammation, often times caused by an infection.

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Wikimedia Commons | https://commons.wikimedia.org/wiki/File:Blausen_0597_KneeAnatomy_Side.png

What is Patellar Tendonitis – Jumper’s knee?

Patellar tendinitis, also known as the jumper’s knee, is an injury to the longitudinal tendon connecting the patella (kneecap) to the tibia (shinbone). It’s a very common overuse injury among athletes practicing sports that involve frequent and explosive jumping, sprinting, and running. The tendon works with the quadriceps (tight muscles) to extend the leg so you can jump, run, and kick.

Patellar tendinitis is caused by tiny tears in the tendon, also called micro tears or fractures. When the tendon is solicited in strenuous physical activities, it develops micro tears. If the micro tears are in large numbers it causes inflammation and can weaken the tendon to partial or complete immobility.

It is important to distinguish Patellar tendonitis from Patellofemoral pain syndrome which hurts along the top or the side of the kneecap and is usually sensitive to the touch. Patellofemoral pain syndrome requires a different treatment that may be contra productive in the case of patellar tendonitis. A correct diagnostic is very important for a fast healing without complications.

Such small tears in muscles or tendons are normal. It’s a natural physiological effect from strenuous activities, but in large numbers, it can develop a pathology such as Patellar tendinitis. Usually, inexperienced people who train or play sports have a less adapted body and will develop injuries more often than those who are more experienced. The microfractures are repaired by the body to improve the muscle or tendon for future activities. It follows the biological principle of continuous improvement and adaptation: what doesn’t kill you, makes you stronger.

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Wikimedia Commons | https://commons.wikimedia.org/wiki/File:Knee_diagram.svg

In the following piece, we’ll discuss how you can speed up the recovery time.

Patellar Tendonitis Symptoms

  • Pain in the anterior knee over the patella tendon;
  • Pain when jumping, landing, running, and sometimes when sitting on chairs for a prolonged time;
  • Localized tenderness over the patella tendon;
  • Stiff tendon especially in the morning;
  • Swelling/inflammation of the tendon.

Patellar tendonitis usually begins as a stiff feeling in the tendon, especially when descending stairs or when running downhill as the gravity force is greater on the tendon. The stiffness might go away once properly warmed up, but if let untreated, the symptoms worsen.

Pain is the first symptom patients accuse of. Usually in-between the kneecap and shinbone. Even in the case of a light injury, the pain usually worsens until regular daily activities such as walking or stair climbing are interfered with.

Partial or full lack of mobility is also commonly reported depending on the level of the injury which can greatly vary, from a low-intensity sprain to the complete rupture of the tendon.

Patellar-Tendonitis-Hurt-Knee
Wikimedia Commons | https://commons.wikimedia.org/wiki/File:Melicsohn_hurt.JPG

Medical pain classification of this injury comes in 4 stages:

  1. Tolerable pain post-activity, without the impairment of knee functionality;
  2. Pain during and after physical activity, with slight impairment of knee functionality because of the increasing discomfort when the knee is solicited;
  3. Almost intolerable pain for prolonged time during and after physical activity, with partial immobility;
  4. Intolerable pain because of fissures or tears that require surgical intervention.

Professional medical care is advised in case of worsening pain and/or swelling. If symptoms persist for more than a few days or if the lack of mobility affects daily activities you should seek medical attention. You should provide your doctor with all the possible information, so he can correctly assess your injury. It’s very important in the case of knee injuries, more precisely injuries regarding the patellar tendon because often times, diagnosis are erroneously put. It’s very important to get the correct diagnosis as an incorrect diagnosis can lead to further complication because of the different treatments.

Patellar-Tendonitis-Hurt-Knee-Pain

Diagnosing Patellar Tendonitis

Here are some guidelines to help you get ready for your medical appointment:

List your symptoms in detail. Decide when the symptoms first started. Present your doctor with your medical background, including allergies, health problems, training regiments, diet, supplements, and lifestyle. Supply him with every information about yourself. Be honest, you’re covered by the patient-doctor confidentiality clause.

  • Organize your history
  • Anticipate what the doctor needs to know
  • Know your medications
  • Secure your medical records
  • Request a verbal summary
  • Prepare questions

 Causes of Patellar Tendonitis

Performing strenuous physical exercises after a long time of inactivity
Very often, people neglect the fact that their bodies become unaccustomed to physical activities. They get back on their usual training regiment after some time off which greatly increases chances of injury because the body became weaker, sort to say. Most physical adaptations cost  and resources which are regulated by the body based on necessity. If no stimuli are given for a longer period, then the body pulls the energy and resources out of that certain part of the body. Muscles and tendons both follow the same principle.

Warming up is extremely important and beneficiary. It prepares the body on all levels for vigorous physical activities. Tight muscles can lead to various injuries, and studies have show that knee injuries are greatly decreased after a comprehensive warm-up program. Do a 15 min dynamic warm-up before each training session. Static stretching should be performed only after the workout.

Other warm-up benefits include the release of adrenaline, increased heart rate and blood circulation, increased production of synovial fluid located between the joints to reduce friction, productions of enzymes activity, increased extensibility and elasticity of muscle fibres, Increased force and speed of contraction, more energy through breakdown of glycogen, Increase in speed of nerve impulse conduction, removal of lactic acid etc.

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Warmup: Dynamic Stretching for Injury Prevention
  • Improper diet

Diet is also an extremely important factor. As different food cause different physiological changes in your body, some of which can severely aggravate both your injury and overall health. Although the traditional narrative of the fitness industry advocates for large quantities of animal products, both dairy and meat, such foods are truly detrimental to one’s health, especially tissue wise. The acid nature of animal products has been found to cause osteoporosis, urinary calcium loss, heart and organ disease, and even cancer. A plant-based diet is strongly recommended, especially in the rehabilitation phase. Consider supplementing with vegetable-based protein powder and vitamins if you feel you can’t meet your usual macro and micro-nutrient needs, although is perfectly doable even on a strictly vegan diet.

Vitamin C helps in rebuilding collagen, so it’s an essential food for recovery, and in general. Berries, pineapple, citrus fruits, squash, green veggies, bell peppers, and such contain high amounts of Vitamin C, antioxidants that fight free radicals, and bromelain which is great fro treating inflammation.

High-potassium and magnesium foods such as coconut water, avocados, greens, and bananas are very important for muscle recovery, healthy circulation, and a good night’s sleep.

AVOID as much as possible alcohol, caffeine, cigarettes, too much sodium/salt, too much simple sugar, hydrogenated oils, and fried foods.

Alcohol increases inflammation and promotes bone loss. Caffeine takes a toll on your calcium levels. Salt and sodium further counteract potassium and other important nutrients. Too many simple sugars can affect your immune system, increases inflammation, and can make your weight gain, especially if you’re on time out, which can aggravate your Patellar tendonitis symptoms and recovery time. Also, avoid hydrogenated oils and fried foods as they promote inflammation and even cancer by releasing volatile aldehydes when fried, these molecules are free radicals and promote heart disease and even cancer.

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Avoid unhealthy Junk Foods
  • Age and medical condition

Aging and prior medical conditions can play a substantial factor in injuries, especially in overuse injuries. Having a bone or tissue condition should deter you from pursuing high-impact sports. Age is another important factor as it can make you more prone to injuries. Recognizing the impact aging has is very important. You should always keep track of this and modify your routine accordingly.

  • Improper form

Many injuries derive from improperly executed movements. Keep your form in check and ask professionals to observe and judge your sports techniques. High impact sports, weightlifting, and similar high-intensity physical activities can have life-threating consequences if performed improperly.

  • Improper training.

Every training regiment has to be thoroughly personalized. Everybody is different and the devilìs in the details. What might benefit someone may damage another one, so inform yourself before stating a certain training regiment or ask for professional help. Diet plays a huge factor, so make sure you’re eating more vegetables, fruits, nuts and seeds as opposed to dairy and meats.

Patellar-Tendonitis-proper-improper-training

  • Muscular imbalances

Certain sports can develop muscular imbalances, meaning that some muscles are much stronger than other muscle groups. Individual or team sports should be always accompanied by weight lifting or other types of physical exercises to balance the muscles out. The probability of an injury is greater in cases of muscular imbalances and can lead to other health and posture problems.

  • Improper footwear.

It’s always advised running in minimalistic sneakers or barefoot running shoes. A lower-to-heel drop sneaker loads your patellar tendon less. A standard running shoe with an 8 to 12 mm heel-to-toe drop simulates a downhill where the gravity force is greater on the tendon.

It’s strongly advised that you transition to minimalistic or barefoot sneakers. Be aware, though, that the transition should be gradual because the load will be transferred to the ankle, forefoot, and Achilles tendon. You have to strengthen those parts first, in order to avoid injury.

It’s also possible that a shoe with a lower heel-to-toe drop may load your patellar tendon less, since running in a standard shoe with a 12mm heel-to-toe drop is similar to running on a downhill. If you want to experiment with lower drop shoes, be aware that the load that’s from your knee will be reallocated to your forefoot, ankle, and Achilles, so exercise caution.

  • Other external factors

Analise your environment and decide if there’s something that might affect you. Hard surfaces such as concrete pavements may contribute to injuries because of the reduce shock absorbance. Also, shoes of lower quality or shoes that have not been designed for certain sports may be an aggravating factor. Cold, humid, and windy environments are often overlooked by athletes.

  • Avoiding further complications

Never work your way through pain as it can lead to complications that can incapacitate you for a much longer time. A slight discomfort is acceptable, but never pain. If the tendon tissue has not been completely repaired, additional strain can lead to Tendinosis which in turn, will haunt you for life and can lead to other injuries such as the complete rupture of the tendon, in extreme cases.

osis“: Indicates a disease of chronic degeneration without inflammation.

Tendinosis, also known as chronic tendinitis, chronic tendinopathy, or chronic tendon injury refers to the damage at a cellular level as opposed to the physical tendon tissue. It’s caused by excessive repair cells produced by the body to repair the micro tears. Tendinosis causes degenerative changes in the collagenous matrix, hypervascularity, hypercellularity of the repair cells, and hypocellularity of the inflammatory cells.

Always let your body completely recuperate itself and proceed with caution afterward as the knee could still present vulnerabilities.

  • Avoid humidity, and excessive coldness or hotness

Proper thermal isolation of the affected area is very important as humidity in hot or cold environments can severely affect the knee or at least add to the overall pain by triggering the neuroreceptors in nerve endings. This is not to be treated lightly. If your environment is moist, hot, or cold then you’d better consider isolating the knee and keeping it nice and warm. Turn up the heat, wrap some long isolating sleeves, hot water bottle, do whatever it takes to minimize the risk of sabotaging yourself from the get-go.

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Wikimedia Commons | https://commons.wikimedia.org/wiki/File:Sweating_it_out_131027-M-DE426-044.jpg
  • Drink plenty of water

Keep hydrated with a minimum of 2L (68 fl oz) of water a day. That’s roughly 40 cups of water, keep the 8×8 rule to make it easier, and count them for a few days to see if you’re on point. You’ll also need plenty of electrolytes, monitor your levels, and consider buying the occasional electrolyte containing juice. Avoid sugar substitutes and consume in moderation.

There’s a direct link between humidity and dehydration in the body. High humidity levels thicken the blood, which increases pressure in the blood vessels, straining the heart, and slowing the healing process.

Also, humidity causes the already sensitive or inflamed tissues to expand, increasing pain and tearing. Furthermore, hot and humid environments cause excess sweating and loss of body fluid. The cartilage itself contains water and joints have water-needing cells for lubrication.

Ad-hoc medication and therapy for pain relief

RICE Treatment

What is RICE treatment

  • Immediate R.I.C.E. treatment.

Early stages of the injury may be treated using the R.I.C.E method, meaning rest, ice, compression, elevation.

  1. Rest means that you shouldn’t be performing physical activity until the injury is gone. A complete recovery, with physical therapy, requires 6 to 12 weeks.
  2. Ice should be applied as fast as possible to decrease inflammation. Put a bunch of ice cubes into a plastic bag and wrap it in a clean towel. Apply the pack onto your whole knee, and keep it there for 10-15 minutes.
  3. Compression helps with alleviating pain and further strain on the affected area. Adequate local compression can be achieved by using a tendon strap which is readily available at most drug and medical supply stores. The strap goes right under the patella. It compresses the affected area, redistributing the force load throughout the tendon. It’s a great rehabilitation device, reduces pay, and it’s quite cheap.
  4. Elevation helps with the inflammation and pain. By elevating your leg, you reduce the blood pressure in your veins. This is useful as it takes away the risk of blood spilling out of the plasma. When elevated, the blood flow clears the remaining edema fluid. Pain is greatly reduced with this method.

It’s greatly advised that you also immobilize the affected leg with orthopedic devices. Severe cases may require specially designed braces which can be easily improvised or bought. Immobilize and seek medical attention.

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Wikimedia Commons | https://commons.wikimedia.org/wiki/File:Knee_Brace_Mississauga.jpg

Patellar Tendonitis Treatment

  • Non-steroidal anti-inflammatory pills

Ibuprofen or naproxen sodium are the most common and effective active substances in over-the-counter drugs. Make sure you eat something before taking them as they present a small risk of gastrointestinal bleeding. Always carefully read the drug’s package insert. When in doubt, ask your doctor!

  • Physical therapy

Physical therapy should be performed gradually after the symptoms are gone and after complete mobility is restored. Keep in mind that the tendon is weaker after a full recovery, so be careful to pace yourself from the beginning. Don’t just jump on a training regiment your body can’t handle. Start with body weight and let muscle memory do its job. Warm up before and cool down after with some light stretching and foam rolling. The latter two increase short and long term flexibility, increases blood flow, reduces muscle spasm, lengthens the muscle-tendon unit, and slightly aids in athletic performances. An adequate training regiment will be provided at the bottom of this guide.

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Wikimedia Commons | https://commons.wikimedia.org/wiki/File:Skeen.Monahan.png
  • Analgesics

Analgesics come in both pills and gels. For example, paracetamol (known in North America as acetaminophen or simply APAP) is an efficient over-the-counter drug for pain and inflammation. Topical gels may be a better alternative to pills as they act on the specific location without passing through the digestive system. Don’t over use, read the package insert.

  • Iontophoresis

This non-invasive therapy involves spreading a corticosteroid medicine on the skin and then utilizing an electric device that delivers a low electrical charge to push the medicine through the skin. Talk to your doctor about it. The therapy is unlikely to be covered by insurance.

  • Extra-corporeal shock wave therapy

This alternative therapy consists in selectively breaking down tissue with sound waves to stimulate the repair cells. Although it’s not a common therapy, studies have shown it to aid in recovery and reduce chronic pain. The therapy is unlikely to be covered by insurance.

Avoid painkillers as much as possible!

Surgical and other invasive procedures.

If conservative treatments aren’t working, further investigation is needed through X-rays, ultrasound, or magnetic resonance imaging (MRI). If the problem requires a more serious intervention, then the patient may be subjected to one or more of the following.

  • Corticosteroid injection

It refers to needle injection guided by ultrasound. The injection is usually made into the sheath around the patellar tendon. This technique should be always be administrated by a licensed doctor as it’s a sensible intervention that can lead to irreversible damage if done improperly. Studies have found that the use of cortisone injections may negatively affect tendon strength and may possibly result in tendon rupture, so it may not bee the best solution for you. Ask your doctor so he can evaluate your knee by X-rays, ultrasounds, and MRIs.

  • Platelet-rich plasma injection

Another innovative invasive procedure is an injection Platelet-rich plasma, also called thrombocytes which seek to heal tendon damage and promote the formation of new tissue. The doctor will first take a blood sample from you, then, the sample is centrifugated to separate the blood from the platelet-rich plasma which will be injected directly into the tendon. The poor blood supply of tendons means a reduced repair capacity. Such injections seek to compensate this. The entire procedure takes about 15 minutes and presents little pain, no local anesthesia is needed. Such injections are usually not covered by insurance.

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  • Growth Hormone Treatment

Consider asking your doctor about a GH treatment. Studies have shown increased collagen production, repair of damaged tissue, production of new tissue at a faster rate, reduced inflammation, and restored muscle mass.On the other hand, up to 30% of users experience side effects that include fluid retention, carpal tunnel syndrome (pressure on the nerve in the wrist causing hand pain and numbness), joint and muscle pain, and high blood sugar levels. Overdosing is not dangerous but shouldn’t be treated lightly as it can lead to the permanent thickening of extremities. If used accordingly, GH can slice the recovery time in half.

  • TB-500

TB-500 is a synthetic peptide molecule consisting of a fraction of the protein thymosin beta-4 which consists of 43 amino acids and is encoded by the gene TMSB4X. The protein is present in almost all human and animal cells. It’s produced in higher concentration wherever tissue has been damaged and contains potent anti-inflammatory agents.

It’s distinct from other repair factors such as growth hormone, IGF-1 etc. because it supports endothelial and keratinocyte migration. It has a very low molecular weight and doesn’t bind to the extracellular matrix. Because of this TB-500 travels very easily in the body, meaning it can be injected anywhere.

TB-500 regulates Actin, the cell-building protein. Studies have shown large repairing benefits after a heart attack by reactivating cardiac progenitor cells to restore damaged heart tissue.

  • Surgery

Surgery is needed in the rarest of cases if other treatments fail, it’s the last resource. Knee surgeries present small incisions with fairly little scarring.

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Hip Strength

There are two main test that you can perform on the spot to determine if you need to strengthen your hip muscles to prevent future injuries, especially Patellar tendonitis. There are two components you’re going to test:

  1. The overall hip strength
  2. The coordination of your hip stabilizing muscles

 

Hip Strengthening Exercises

Lay yourself flat on the ground, slowly lift your midsection using your legs. When in the bridge position, slowly lift up to the ceiling one leg. Place the leg back, and do the same thing with the other one. Observe the stability of your pelvis, it should NOT tilt on either side. The final position, with a leg up, your pelvis is supported by your hip abductor and external rotator muscles. The pelvis should barely move when lifting up a leg. A slight tilt or “dip” on the unsupported side means you should work on your hip strength. An external observer is advised.

  • Single Leg Squats 

Simply do 5 or 10 single-leg squats. Keep your torso upright and the knee about even to your toes. Observe your knee while performing the squats. Is it pointing straight forward, or is it inward rotated/buckled? It should NOT:

  1. The knee shouldn’t collapse inward over the ankle (aka. „Valgus”);
  2. The knee and torso shouldn’t shake, tremble, or wobble;
  3. The heel shouldn’t rise off the ground;
  4. Pain should be absent;
  5. The torso shouldn’t rotate outwards over the knee.

The knee should be very easy to control. If you find it hard to control the movement of your knee, you might have some problems with fiber activation.

If upon performing these tests you find you may be lacking in hip strength or coordination, then you’ll have to strengthen your muscles and address lack of muscular flexibility.

 

Eccentric Squats

The eccentric squat is the staple exercise for treating Patellar tendonitis. This squat variation will strengthen the hamstrings, glutes, and quad muscles, the main muscles associated with the condition. Let your injury heal completely before rehabilitation.

You’ll need to stand on a 25-degree inclined surface to perform these exercises. Don’t further risk your health by exercising on unsafe platforms. Choose a sturdy, fixed platform which can withstand your weight without a problem. It’s preferred that you buy a special platform online or from specialized sports shops.

  1. Place a foot on the board;
  2. Extend your hands to keep balance;
  3. Commence lowering yourself. Try to control the motion as much as possible, improve your mind-body connection by “feeling” every fiber twitch on the way down. Keep your back straight and never use momentum. The final position should be ass-to-grass.
  4. Try to explode on your way up.
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Wikimedia Commons | https://commons.wikimedia.org/wiki/File:Parallel_Squat_Form.jpeg

Start with a double leg squat if you have difficulties and proceed to single-leg squats. Do squats with both your leg forward as well as backward. The first one better targets your quadriceps and the latter better targets your glutes and hamstrings. Don’t go to failure. Stop if discomfort becomes pain.

What else can you do for Jumper’s Knee

Treatment

In addition to the eccentric decline squat, you should also train the strength of your other adjacent muscles: hamstrings, quadriceps, abductors, adductors, glutes, and calves.

  • Isometric exercises are advised if the healing is not yet complete.

They consist in repetitions in which the joint angle and muscle length do not change during contraction. Such exercises are recommended even if the patient has a completely immobilized leg as to avoid muscular atrophy. If the patient has sufficient mobility and reduced pain, compound and plyometric exercises can be added to the training program. Keep in mind that high-impact exercises should be avoided in the recuperation phase. Consider other alternatives such as swimming, shadow boxing, cycling etc.

  • Incorporate compound exercises if healing is complete

For the compound exercises, weight should be increased gradually and protective measures should be in place as to not further strain the knee. Squats on a 25-degree inclined surface, wearing a knee strap, and so on.

Bands are also useful because they allow a large array of exercises within a small space, and are relatively cheap. An exercise ball can prove pretty useful for the same reasons.

Patellar-Tendonitis-elastic-band

While performing the exercises, you should focus on the so-called mind-muscle connection. Also, exercises like squats, for example, should be performed with one leg, without additional stabilization, as to train your coordination and muscle fiber activation by keeping balance. There are a ton of exercises which focus solely on balance, such exercises can prove incredibly helpful in avoiding future tendon injuries.

  • Learn to always warm up & cool down to reduce chances of injury

Warming up and cooling down can also prove very beneficiary in overall athletic performance and avoiding injuries. Acquire a foam roll or improvise one from a sturdy cylindrical piece like a PVC tube, for example, and perform self-myofascial release after each training session, and even on off days. Tightness in either of the adjacent muscle to the knee can put further pressure on the tendon, so addressing inflexibility issues is a must.

Conclusion

All in all, this common injury is fairly easy to treat if you follow all the guide’s recommendations. It’s very important to not further complicate the injury upon the installation of symptoms. Carefully read the guide, put your current training regiment on hold, and speak with your doctor. Present him with the solutions in this guide and let him assess your medical condition in order to develop the perfect rehabilitation plan for you. Keep in mind that everybody is different, and although most of this guide is universally designed, you should seek the opinion of an official medical practitioner – better if it’s your family doctor as he may be better aware of your medical history. Play safe, play smart!

 

Sources Used While Conducting Our Research

Sources

  1. Mayo Clinic Staff, Overuse injury: How to prevent training injuries,
  2. Frank B. Kelly, MD, Platelet-Rich Plasma (PRP),
  3. Rick Wilkerson, DO, Patellar Tendon Tear,
  4. Garrett Scott Hyman, MD, MPH, Jumper's Knee,
  5. eOrthopod, A Patient’s Guide to Patellar Tendonitis,
  6. Marsha Rutland | Dennis O'Connell | Jean-Michel Brismée | Phil Sizer | Gail Apte | Janelle O'Connell, Evidence–Supported Rehabilitation of Patellar Tendinopathy,
  7. Brett M. Andres, MD | George A. C. Murrell, MD, Treatment of Tendinopathy: What Works, What Does Not, and What is on the Horizon,
  8. Mayo Clinic Staff, Diseases and Conditions: Patellar tendinitis,
  9. Garrett Scott Hyman, MD, MPH, Jumper's Knee Treatment & Management,
  10. Sports Injury Clinic, Jumpers Knee Exersises,
  11. Sports Injury Clinic, Knee Exercises & Knee Rehabilitation,
  12. The Sports Injury Doctor, Patellar tendinitis: why patellar tendinitis is usually the wrong diagnosis for patellar tendon pain, and how to banish patellar tendon pain,
  13. C R Purdam | P Jonsson | H Alfredson | R Lorentzon | J L Cook | K M Khan, A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy,
  14. J L Cook | K M Khan, What is the most appropriate treatment for patellar tendinopathy?,
  15. Joel W. Beam, MEd, ATC | Philip R. Lozman, MD, ATC | John W. Uribe, MD, Surgical Treatment of Chronic Patellar Tendinitis in a Collegiate Football Player,
  16. Elizaveta Kona | Giuseppe Filardoa | Marco Delcoglianoa | Mirco Lo Prestia | Alessandro Russoa | Alice Bondia | Alessandro Di Martinoa | Annarita Cenacchib | Pier Maria Fornasarib | Maurilio Marcaccia, Platelet-rich plasma: New clinical application: A pilot study for treatment of jumper's knee,
  17. Letha Y. Griffin, MD, Treating tendinopathy with PRP,
  18. Dr. Mark W. Galland, What is PRP: Platelet-Rich Plasma therapy,
  19. Robert P Heaney | Donald K Layman, Amount and type of protein influences bone health,
  20. ESWT, ESWT: Extracorporeal Shock Wave Therapy,
  21. Jacob P. Meyer | Kieran E. McAvoy | Jack Jiang, Rehydration Capacities and Rates for Various Porcine Tissues after Dehydration,
  22. Simon Doessing | Katja M Heinemeier | Lars Holm | Abigail L Mackey | Peter Schjerling | Michael Rennie | Kenneth Smith | Søren Reitelseder | Anne-Marie Kappelgaard | Michael Højby Rasmussen | Allan Flyvbjerg | Michael Kjaer, Growth hormone stimulates the collagen synthesis in human tendon and skeletal muscle without affecting myofibrillar protein synthesis,
  23. Harvard Medical School, Growth hormone, athletic performance, and aging,