Case of the day

So today was a patella tendinopathy day.  Two patients out of my 5 morning clinic patients had this problem.  And one is now pain free.  Fantastic.

So how did we manage that!?

Well I'd like to think that it's all to do with my amazing treatment but in fact I never laid a hand on him.  No, I'm afraid I have to put most of the praise on the patient on this occasion.  He listened, he took advice, he followed his rehab programme, he came for his treatments....and he is better.  I wish I was able to do the same myself! 

So, what is patella tendinopathy?  Well, the patella tendon is the tendon that runs from the bottom of the kneecap and connects it to the top of your shin-bone (tibia).  In some ways it could be called a ligament because in fact it actually connects bone to bone but this is just human semantics.  We do like to divide things up into separate muscles and tracts and fascias and give them all different names, when in fact the human body isn't a machine, made up of lots of separate parts that can be individually identified, sorted, injured, fixed...  We are a biological organism and in my mind, although we have organs that undertake specific tasks in the body, they are all very intricately linked and the human musculoskeletal system has to be one of the most co-ordinated systems of all.  There aren't just individual muscles performing individual jobs.  Our tissues work together to make our bones move - muscles, tendons, ligaments, fascia, nerves....all playing their part to carry out a co-ordinated movement.

Anyway, tendon or ligament - it can become overloaded - much like the achilles or the plantar fascia.  And it's often due to weak hamstrings, poor pelvic and glute control combined with an 'overload' situation.  And as will all this kind of soft tissue, the healing doesn't tend to go very well, with degenerative change, new vessel ingrowth with new nerve ingrowth, pain, fatty infiltration on the back of the tendon.....

We treated this guy with exercise therapy - an eccentric loading programme for the patella tendon, plus glute/hamstring/calf strength work and on top of this we offered Extracorporeal shock wave therapy (ESWT) where a kind of pistol is used to deliver shockwaves to the soft tissue which is thought to disrupt the fibres - particularly the new (and unwanted) vessels and nerves.  5 treatments over 5 weeks (each one lasting no more than 5 mins to deliver the shocks), together with the exercise programme and avoidance of aggravating activity have worked.

There is still room for a steroid injection (possible large volume - which might serve to strip just a bit of the fat off the back of the tendon) if things don't all go well.  But steroid is a good pain killer - for a limited time only - and so the exercise therapy has to be the most important thing here.

I'm pleased.  It's not every day (unfortunately) that you see a patient who is pain free again.  Unfortunately too many of my patients end up being referred to a surgeon for an operation.  So, in those where surgery is not required, it is nice to get to the point where the patient can return to their running.

I'm not back running yet.  And I am trying very hard to listen to my own advice.  I'll let you know how I get on...