Quadriceps Tendinopathy Rehabilitation Protocol

Pathophysiology

Quadriceps tendinopathy, commonly known as "jumper's knee" although it can occur in non-athletes, involves pain and dysfunction in the quadriceps tendon at or near its insertion point on the superior pole of the patella. The pathophysiology typically involves repetitive tensile loading exceeding the tendon's capacity to adapt, leading to micro-tears and a failed healing response. This response results in tendon thickening, neovascularization, and altered collagen fiber organization, contributing to pain and decreased functional capacity. Overuse, especially during activities involving jumping, landing, and rapid changes in direction, is a major contributing factor. Other factors include poor biomechanics, muscle imbalances (quadriceps dominance over hamstrings), insufficient warm-up, and inadequate flexibility. Chronic cases can lead to significant disability and even partial or complete tendon ruptures if left unaddressed. Understanding the load management principle is crucial for successful rehabilitation, balancing exercise and rest to allow for tendon healing and adaptation.

Common Special Tests

• Palpation: Pain upon palpation of the quadriceps tendon, especially at its insertion on the patella.
• Single Leg Decline Squat: Reproduction of pain during a single leg squat performed on a decline board (approximately 25 degrees).
• Royal London Hospital Test: Palpation of the inferior pole of the patella and quadriceps tendon during a quadriceps contraction. A positive test involves decreased pain with patellar taping (inferior glide) or manual resistance reduction.
• Modified Thomas Test: Assesses quadriceps and hip flexor flexibility, which can contribute to quadriceps tendinopathy.

Phase I: Protection (Week 1-2)

Goals: Pain reduction, inflammation control, protect the healing tendon, minimize further tissue damage, and maintain general fitness.

• Activity Modification: Avoid activities that provoke pain, such as jumping, running, and deep squats. Modify or eliminate aggravating activities to reduce tendon load.
• Pain Management:
  • Relative Rest: Decrease activity level to allow the tendon to heal.
  • Ice: Apply ice packs for 15-20 minutes, 2-3 times per day.
  • Medications: Over-the-counter pain relievers (e.g., ibuprofen, naproxen) or topical creams (e.g., diclofenac) as prescribed by a physician.
• Isometric Exercises:
  • Quadriceps Sets: Tighten the quadriceps muscle without movement, holding for 5-10 seconds, repeating 10-15 times, 2-3 times per day. Perform at multiple knee angles (e.g., 90 degrees, 45 degrees).
  • Straight Leg Raises (SLR): With knee extended, lift leg 6-12 inches off the ground, hold 5-10 seconds, 10-15 repetitions, 2-3 times per day. Focus on maintaining a straight knee without locking.
• Range of Motion (ROM) Exercises:
  • Heel Slides: Lie on your back and slide your heel towards your buttocks, bending your knee as far as comfortable. 10-15 repetitions, 2-3 times per day.
  • Gentle Stretching: Hamstring stretches (e.g., towel stretch), calf stretches (gastrocnemius and soleus), and gentle quadriceps stretches (e.g., lying prone, pulling heel towards buttocks). Hold each stretch for 30 seconds, repeating 2-3 times.
• Patellar Mobilization: Gentle patellar glides in all directions (superior, inferior, medial, lateral) to maintain joint mobility and reduce stiffness.

Phase II: Loading (Week 3-6)

Goals: Gradually increase tendon loading, improve strength and endurance, normalize movement patterns, and reduce pain with functional activities.

• Progressive Resistance Training: Focus on controlled movements and proper technique. Increase weight/resistance gradually, monitoring pain levels.
  • Wall Squats (Partial): Begin with shallow squats, gradually increasing depth as tolerated. 3 sets of 10-15 repetitions.
  • Leg Press: Start with light weight and focus on controlled movements. Avoid full knee extension at the top of the exercise. 3 sets of 10-15 repetitions.
  • Hamstring Curls: Prone or seated hamstring curls to address any muscle imbalances. 3 sets of 10-15 repetitions.
  • Calf Raises: Standing or seated calf raises to improve lower extremity strength and stability. 3 sets of 15-20 repetitions.
• Eccentric Exercises: Introduce eccentric exercises gradually, as they are highly effective for tendon remodeling but can also be more painful initially.
  • Decline Board Eccentric Squats: Start with bodyweight and progress to adding weight (e.g., dumbbells). Focus on slow, controlled descent. 3 sets of 8-12 repetitions. Monitor for pain and adjust accordingly.
  • Nordic Hamstring Exercise: Performed with a partner assisting with slow, controlled lowering. This is also an eccentric exercise.
• Proprioception Exercises:
  • Single Leg Stance: Progress from eyes open to eyes closed, and on stable to unstable surfaces (e.g., foam pad, balance board). Hold for 30-60 seconds, repeating 2-3 times.
  • Balance Board Activities: Gentle rocking and tilting on a balance board to improve balance and coordination.
• Continue Stretching: Maintain flexibility gained in Phase I.

Phase III: Return to Function (Week 7-12+)

Goals: Restore full functional capacity, return to sport or desired activity level, and prevent recurrence.

• Progressive Plyometrics: Introduce plyometric exercises gradually, starting with low-impact activities and progressing to higher-impact exercises.
  • Double Leg Jumps: Progress from jumping in place to jumping forward and backward.
  • Single Leg Hops: Progress from hopping in place to hopping forward and backward.
  • Box Jumps: Start with low box heights and gradually increase the height as tolerated.
• Sport-Specific Training: Focus on exercises that mimic the movements and demands of the individual's sport or activity.
  • Agility Drills: Cone drills, shuttle runs, and other agility exercises to improve speed, agility, and coordination.
  • Running Program: Gradual return to running, starting with short distances and gradually increasing distance and intensity.
  • Sport-Specific Drills: Drills that mimic the movements and demands of the individual's sport or activity.
• Strength Maintenance: Continue strength training exercises to maintain strength and prevent recurrence.
• Monitor Pain: Closely monitor pain levels and adjust training accordingly.
• Functional Testing: Complete functional tests (e.g., single leg hop test, triple hop test, timed hop test) to objectively assess readiness for return to sport/activity.

Important Considerations: This protocol is a general guideline and should be modified based on the individual's specific needs and progress. Close communication between the patient, physical therapist, and physician is essential for optimal outcomes. Pain should always be the guiding factor in determining the progression of exercises. A gradual, progressive approach is crucial to prevent re-injury and ensure successful rehabilitation.