Patella Tendinopathy

Rest, surgery or a combination - what cures patella tendon problems?

Dr Richard Steadman is the Colorado based knee specialist who successfully treated Alan Shearer and Ronaldo, when they were suffering from problems with their patella tendon. The American orthopaedic specialist has built a brilliant reputation by helping these high profile stars return from a condition that is notoriously difficult to treat.

Patella tendon problems are mostly due to repetitive overload and usually start as a minor discomfort, with the player able to continue to train and play matches. However, the pain does not often correlate with the amount of tissue damage, as the tissue damage has already started before the player feels any pain. Continuing to play makes the condition worse. This is due to the poor healing capacity of the patella tendon, owing to the tendon's poor blood supply. Injecting the area with corticosteroids only conceals the pain and adds to the degeneration of the tendon as it breaks down the collagen fibres that make up the tendon.

The collagen fibres that make up the patella tendon take 120 days to lay down and mature once the tendon has been damaged. Returning to sport before these collagen fibres have matured means that the tendon will lack its normal tensile strength and will be prone to re-injury. Returning to sport too early sets off a chronic cycle of tissue breakdown and partial recovery, which means that in most cases, unless the 120-day rest period is followed, the tendon will not fully recover.

Early diagnosis and rest are the key factors in the successful treatment of this condition, but this is not easy when football clubs have paid world record transfer fees for star names. The desire and enthusiasm of the player to play in matches further complicates the management of such a condition. Players may only get one chance to play in a World Cup Final or European Championship and this is what they have worked for all their lives. The current football calendar means there is very little time for the modern player to rest, since they usually play for 11 months of the year.

The club physiotherapists have the job of providing as many fit players as possible in order that the manager has a full squad from which to select on a week-to-week basis. But they also have an eye on the long term consequences of players continuing to perform with "minor" injuries. In the early stages of a patella tendon problem the player will almost certainly view the problem as minor and may not heed the advice of medical staff who advise him to rest. In many cases the player may not perceive the injury as a problem until it starts to affect his performance. This may manifest itself as an inability for the player to sprint or turn as fast as he usually does. Eventually the pain will prevent the player from continuing.

Enter Dr Richard Steadman, who is often asked his opinion at this stage by players who are desperate to get fit. In some cases surgery is required. The two most common operations are to remove a spur from the underside of the knee cap, which is thought to be causing irritation of the patella tendon; or a surgical removal of the scar tissue which has built up around the damaged tendon. Following either of these operations, the advice usually given is to undertake very gentle rehabilitation for 3 to 4 months before returning to sport. This means the magic 120-day rest period is provided for the patella tendon to repair itself, plus a little extra rehabilitation to allow the tendon to adapt to the demands of playing football.

This sensible advice has seen several top soccer stars return to play with their problems cured. But the question is, would the injury have healed with the long rest alone, and without surgery? Certainly the surgery may help to stimulate a healing response from within the tendon, and it may be necessary in order to stimulate a recovery. It is certainly much easier for the physiotherapist to tell the head coach that his star player has had surgery in the United States, and the surgeon has instructed the player not to train for 3 to 4 months, than it is for the physiotherapist to instruct the player to rest for 3 months, with no guarantee of an improvement in symptoms. Steadman's success rate with top players, and the uncertainty of conservative treatment of this condition, account for the transatlantic medical treatment of several top Premiership players.

Whether the player opts for a surgical approach or not, one thing is clear - the rehabilitation must be carefully gauged and progressive in nature. This is vital to allow the collagen fibres that make up the tendon to mature and gain the tensile strength that is required to play Premiership football. Overloading the maturing tendon can cause the problem to recur and adds to the pressure that the physiotherapy team are under when treating one of the team's (and the plc's!) prized assets. Alan Shearer, for one, appreciated the work undertaken by the physiotherapists at Newcastle United.

Patella Tendinopathy explained >