Introduction
- Christopher C. Kaeding, MD
Epidemiology
Age
- •
16 to 35 years
Sex
- •
Occurs in both males and females, with a predilection for males
Sport
- •
Basketball
- •
Lacrosse
- •
Soccer
- •
Football
Position
- •
Positions requiring sudden start/stop and or jumping movements
Pathophysiology
Intrinsic Factors
- •
Enthesis is at risk for tendinosis.
- •
This junction of tendon/bone joins materials with different modulus of elasticity.
- •
This causes an area of stress concentration.
- •
Thus producing peak loads at the enthesis.
- •
These peak loads place enthesis at risk for overload pathological processes.
- •
Extrinsic Factors
- •
A high volume of high loading episodes without required periods of rest/recovery
- •
In positive adaptive environment, a tenocyte will produce growth factors such as TGF beta 1 and ILGF 1.
- •
This can result in increased tendon fiber size and number and thus greater tendon tensile strength.
- •
If loading surpasses threshold of a positive adaptive response, degenerative process can start.
- •
- •
Plyometric loading of tendon
- •
Tendons are viscoelastic and more stiff at higher loading rates.
- •
Thus plyometric exercise can result in significant higher tendon loads.
- •
Traumatic Factors
- •
Overuse injury that occurs from:
- •
High volume (frequency, duration + intensity) of explosive, plyometric type of quadriceps contractions
- •
Without required recovery period
- •
Puts enthesis at highest risk for tendinosis
- •
- •
Tenocyte de-differentiates into a more generic mesenchymal cell
- •
Loses spindle shape, becomes round
- •
- •
This cell produces catabolic signals that lead to tendon matrix degeneration.
- •
These include substance P, calcitonin related gene peptide, and matrix metalloproteases.
- •
Inflammation does not have a significant role during this process.
- •
Prostaglandin E, a marker for inflammation, is not found in tendinosis.
- •
- •
Early in the process there is a ingrowth of neovasculature and neurofilaments.
- •
Neurofilaments/substance P may be source of pain.
- •
No evidence for inflammation as source of pain.
- •
- •
Once established, tendinosis cell/function appears to be recalcitrant
- •
Understimulation theory
- •
Because of overloading there is a yet to be defined disruption of normal mechanotransduction by tenocyte.
- •
Unable to detect tensile loads, the tenocyte starts to function more and more like a tendinosis cell, which does not support normal tendon matrix.
- •
With lose of support of normal tenocyte and catabolic signals from the tendinosis cell, the matrix degenerates.
- •
Classic Pathological Findings
- •
Normal tendon ( Figure 29-1 )
- •
Tightly packed collagen fibers in longitudinal alignment
- •
Slight waving pattern
- •
Difficult to see spindle-shaped tenocytes
- •
No discernible ground substance
FIGURE 29-1
Normal tendon histology.
- •
- •
Tendinosis lesion ( Figure 29-2 )
- •
Disorganized /fragmented/widely spread collagen
- •
Mucoid ground substance
- •
Sparse spindle shaped tenocytes
- •
Hypercellularity
- •
Round plump cells
- •
Increased vascularity
- •
Increased nerve filaments
FIGURE 29-2
Tendinosis lesion histology.
- •
Clinical Presentation
History
- •
Typically insidious onset of symptoms
- •
Patient localizes pain to inferior pole of patella
- •
Pain is typically increased with loading of the patella tendon
- •
Clinical classification of severity
- •
Type 1: Sore after activity, but does not notice pain while playing
- •
Type 2: Pain with activity, but not enough to affect play
- •
Type 3: Pain impairs athlete’s ability to train and perform.
- •
Physical Examination
Abnormal Findings
- •
Tenderness of proximal patella tendon at the inferior pole of the patella
- •
May have some mild swelling or fullness in the area
- •
Pain on significant active quadriceps loading of tendon
Pertinent Normal Findings
- •
No effusion
- •
Ligaments stable
- •
No joint line tenderness
- •
Patella tracking is symmetrical
- •
Full range of motion
- •
No erythema or warmth to touch
Imaging
- •
Ultrasound will reveal an anechoic area
- •
MRI ( Figures 29-3 and 29-4 )
- •
Area most often involved is proximal, posterior tendon in mid/medial portion or tendon
- •
Tendon is thickened
- •
Increased signal within the thickened portion of tendon
FIGURE 29-3
Sagittal MRI image of normal patella tendon.
FIGURE 29-4
Sagittal MRI image of patella tendinosis.
- •
Differential Diagnosis
- •
Patella-femoral pain syndrome
- •
Pain is typically described in more generalized fashion about anterior knee
- •
There is no point tenderness at inferior pole of patella
- •
May not have history of high volume of ballistic quadriceps contractions
- •
- •
Patella-femoral chondrosis
- •
Likely to have patella-femoral crepitus
- •
May have mechanical symptoms of catching, clicking or locking
- •
Imaging (x-ray/MRI) likely to demonstrate chondral erosions
- •
Does not have point tenderness at inferior pole of patella
- •
- •
Osgood Schlatter’s disease
- •
Occurs during the adolescent growth spurt. Patella tendinosis is rare in this age group.
- •
Point of maximal tenderness is at the distal patella tendon insertion, as opposed to the proximal patella tendon origin in tendinosis.
- •
Typically has prominence and tenderness over tibial tubercle.
- •
Treatment
Nonoperative Management
- •
All of the following have been reported in the literature as treatment options for “chronic tendinitis” or tendinosis.
- •
Most have been reported to have 80% to 95% success rates.
- •
Very few, if any, have supportive high-quality controlled studies.
- •
Rest
- •
Diathermy
- •
Deep friction massage
- •
Extracorporal shock wave
- •
Electric stimulation
- •
Ultrasound
- •
Magnets
- •
Hyperbaric oxygen
- •
Free radical scavengers
- •
Sclerotherapy
- •
Platelet-rich plasma (PRP) injection
- •
Corticosteroids
- •
Needling
- •
Autologous blood injection
- •
Nitric oxide
- •
Eccentric exercise
- •
Prolotherapy
- •
Unloading devices
- •
Pulsed electromagnetic fields
- •
Acupuncture
- •
NSAIDs (nonsteroidal antiinflammatory drugs)
- •
DMSO (dimethylsulfoxide)
- •
Cold laser
- •
Radiofrequency ablation
- •
Matrix metalloproteinase inhibitors
- •
Stem cell injection
- •
- •
A summary of several of the more common non-operative treatments follows:
- •
Rest
- •
Has been shown to be effective in acute overuse situation
- •
Has not been shown to be effective in established tendinosis lesions
- •
- •
NSAIDs/corticosteroids
- •
May be of benefit in acute injury, if used for only a short period
- •
Have not been shown to be effective in resolving established tendinosis
- •
High or prolonged use may impair tendon healing
- •
- •
Nitric oxide
- •
Lab studies have shown some beneficial effects on tendon healing
- •
Clinical studies mixed
- •
Need further controlled trials and assessment of optimal dosing protocol
- •
- •
Extracorporeal shock wave therapy (ECSW)
- •
Conflicting evidence of clinical efficacy
- •
Need more controlled trials and evaluation of optimal treatment protocols
- •
- •
Platelet-rich plasma
- •
Basic science studies have demonstrated beneficial effects on tendon healing in lab
- •
Clinical studies mostly poorly controlled and mixed in results
- •
Strongest evidence of clinical efficacy is for lateral epicondylar lesions
- •
- •
Matrix metalloproteinase (MMP) inhibitors
- •
Work by inhibiting catabolic effects of matrix metalloproteases
- •
Some initial encouraging clinical results
- •
Need further studies on efficacy and optimal treatment protocols
- •
- •
Sclerotherapy
- •
Aims to sclerose blood vessels of tendinosis lesion, often using ultrasound guidance
- •
Some evidence of efficacy in producing pain relief
- •
May be related to ablation of neurofilaments accompanying blood vessels
- •
- •
Has not been shown to reverse tendinosis pathology
- •
- •
Eccentric exercises
- •
Strongest evidence of efficacy in treating tendinosis
- •
Best studied for Achilles lesions
- •
Continuing to establish optimal treatment protocols
- •
Guidelines for Choosing Among Nonoperative Treatments
- •
No good evidence that rest, corticosteroids, or NSAIDs are likely to provide lasting relief of an established patella tendinosis lesion.
- •
Eccentric exercises have the strongest level of evidence of clinical efficacy.
- •
ECSW, nitric oxide, sclerotherapy, and PRP have encouraging evidence, but further studies are needed.
- •
MMP inhibitors and stem cells are early in the evaluation process.
Surgical Indications
- •
Surgery is indicated when
- •
There is a well-defined and well-established lesion.
- •
Pain is significantly impairing the desired activity level.
- •
Nonoperative measures have failed.
- •
The patient understands expected outcomes and risks.
- •
Aspects of History, Demographics, or Exam Findings That Affect Choice of Treatment
- •
Factors favoring operative treatment include
- •
Longstanding lesion
- •
High level of pain/disability
- •
Well-established and well-defined lesion on MRI
- •
Failure of nonoperative treatments
- •
- •
Factors favoring nonoperative treatment
- •
Recent onset
- •
Poorly delineated on MRI
- •
Lower levels of pain/disability
- •
Aspects of Clinical Decision Making When Surgery Is Indicated
- •
The patient decides to proceed with surgery after understanding risks and expected outcomes of surgical treatment.
- •
Decision regarding timing of surgery
- •
Patient expectations
- •
Schedule and priority of competitions and training regimens
- •
- •
Should an arthroscopy also be performed?
- •
Should excision of bone from the inferior patella be included in the procedure?
- •
Should a biological adjuvant treatment be added?
- •
Stem cells, platelet rich plasma, etc.?
- •
Evidence
Multiple Choice Questions
- QUESTION 1.
Tendinosis is a chronic overuse condition of tendon that is characterized by
- A.
chronic inflammation with high PGE levels.
- B.
decreased number and size of cells.
- C.
decreased vascularity and innervation.
- D.
increased number of abnormal cells.
- A.
- QUESTION 2.
The nonoperative treatment of tendinosis with the least amount of evidence of efficacy is
- A.
rest and NSAIDs.
- B.
sclerotherapy.
- C.
shockwave therapy.
- D.
eccentric exercises.
- A.
Answer Key
- QUESTION 1.
Correct answer: D (see Classic Pathological Findings )
- QUESTION 2.
Correct answer: A (see Nonoperative treatments )
Nonoperative Rehabilitation of Patellar Tendinopathy
- John DeWitt, PT, DPT, SCS, ATC
- Christopher C. Kaeding, MD
- •
Identify intrinsic and external risk factors for patellar tendinopathy.
- •
Evaluate efficacious nonoperative treatment interventions.
- •
Discuss appropriate return to sport criteria to prevent recurrence.
- •
Pain
- •
Progress eccentrics if less than 5/10 pain.
- •
Progress all other interventions if pain-free only.
- •
Phase I (weeks 0 to 2)
Protection
- •
No running or jumping
- •
Can do non-bounding exercise (elliptical, bike, swimming) if pain free to maintain cardiopulmonary endurance.
| PHASE I (weeks 0 to 2) | PHASE II (weeks 2 to 4) | PHASE III (weeks 4 to 8) | PHASE IV (weeks 8 to 12) |
|---|---|---|---|
|
|
|
|
Management of Pain and Swelling
- •
Ice massage
Techniques for Progressive Increase in Range of Motion
- •
Five-minute bike warmup
- •
Lumbosacral mobility (i.e., cat/camel exercise)
- •
Hip flexor and quadriceps flexibility (before and after activity)
- •
Assisted: Prone with opposite hip flexion to isolate soft tissue
- •
Self: Use belt or stand
- •
- •
Patellar tendon mobility (before activity)
- •
Instrument assisted soft tissue mobilization
- •
Cross-friction mobilization
- •
Neuromuscular Dynamic Stability Exercises
- •
Activation exercise
- •
Gluteal activation ( Figure 29-5 )
- •
Bilateral activation
- •
Reciprocal activation (frog leg-position)
FIGURE 29-5
Frog-leg gluteus activation.
- •
- •
Transversus abdominis
- •
Bilateral activation
- •
- •
Functional roll patterns ( Figure 29-6 )
FIGURE 29-6
A,B, Functional rolling to activate lumbosacral stabilizers.
- •
Posterior weight shifts against wall
- •
- •
Eccentrics (assist with concentric phase) ( Figure 29-7 )
- •
Squats on decline board, partial weight bearing (Shuttle, Total Gym)
- •
Progress from partial to full weight-bearing resistance able to complete if <5/10 pain
- •
Three sets × 15 repetitions (reps)
FIGURE 29-7
Partial weight-bearing decline eccentrics on Shuttle.
- •
- •
Stability exercise with correct mechanics (i.e., no pelvic drop, knee valgus, or excessive anterior weight)
- •
Strengthening
- •
Balance on stable surface
- •
Side lying abduction/clam shell series ( Figure 29-8 )
FIGURE 29-8
A–C, Clamshell series.
- •
Hip hike on single leg
- •
- •
Milestones for Progression to the Next Phase
- •
Appropriate gluteal maximus, transversus abdominis, and multifidi activation patterns. Tactile cueing, observation and external feedback devices can be used to ensure appropriate activation (i.e., no knee flexion with prone leg extension to assess appropriate gluteal activation).
- •
No compensatory movements with stability exercise (i.e., no pelvic drop, knee valgus or excessive anterior weight).
- •
Complete weight bearing eccentrics with less than 5/10 pain.
Phase II (weeks 2 to 4)
Protection
- •
Begin jogging, jumping on Shuttle.
- •
No full weight-bearing running
Management of Pain and Swelling
- •
Ice massage
Techniques for Progressive Increase in Range of Motion
- •
Lumbosacral mobility (i.e., cat/camel exercise)
- •
Hip flexor and quadriceps flexibility (before and after activity)
- •
Assisted: Prone with hip in flexion to isolate soft tissue
- •
Self: Progress to half-kneel with knee flexed ( Figure 29-9 )
FIGURE 29-9
Prone hip flexor stretching.
- •
- •
Patellar tendon mobility (before activity)
- •
Instrument-assisted soft tissue mobilization ( Figure 29-10 )
FIGURE 29-10
Instrument-assisted cross-friction mobilization.
- •
Cross-friction mobilization
- •
Neuromuscular Dynamic Stability Exercises
- •
Activation exercise
- •
Gluteal activation
- •
Progress to functional positions (i.e., tall kneel [ Figure 29-11 ] and half-kneel positions)
FIGURE 29-11
Tall kneel.
- •
Transverse abdominis/multifidi
- •
Add UE/LE movements with pelvic stability exercise. Use internal (isometric cueing) and external (dynamic stabilizer, electronic) feedback device.
- •
- •
Functional roll patterns (see Figure 29-6 )
- •
Eccentrics (assist with concentric phase)
- •
Squats on decline board—partial weight bearing less than 5/10 pain (Shuttle, Total Gym)
- •
Progress 50% to 75% resistance if less than 5/10 pain
- •
Three sets × 15 repetitions
- •
- •
Stability exercise (avoid pelvic drop, hip add, knee valgus, or excessive anterior weight)
- •
Posterior weight shifts (if needed) ( Figure 29-12 )
FIGURE 29-12
Posterior weight shifts.
- •
Lumbopelvic stability exercise
- •
Advance to unsupported double leg work (three sets 10 to 15 repetitions)
- •
Planks (two to three sets × 60 seconds)
- •
Chop/lift activities (three sets 10 to 15 repetitions)
- •
Strengthening
- •
Add unstable surface/foam to exercise
- •
- •
Bounding (avoid pelvic drop, knee valgus, or excessive anterior weight) ( Figure 29-13 )
- •
Jogging on Shuttle (1 to 2 minutes × 5 to 10 sets with no exacerbation of symptoms)
FIGURE 29-13
A,B, Bounding exercises.
- •
- •
Milestones for Progression to the Next Phase
- •
Appropriate gluteal maximus, transversus abdominis and multifidi activation patterns. Tactile cueing, observation, and external feedback devices can be used to ensure appropriate activation (i.e., no knee flexion with prone leg extension to assess appropriate gluteal activation).
- •
No compensatory movements with stability exercise (i.e., no pelvic drop, knee valgus, or excessive anterior weight)
- •
Complete weight-bearing eccentrics with less than 5/10 pain.
Phase III (weeks 4 to 8)
Protection
- •
Begin FBW jogging.
- •
May utilize nonbounding exercise 20 to 30 minutes if unable to complete jogging (bike, elliptical, swimming, etc.).
Management of Pain and Swelling
- •
Ice massage
Techniques for Progressive Increase in Range of Motion
- •
Dynamic warmup
- •
Inchworms, Spidermans, walking lunge (10 repetitions each) ( Figure 29-14 )
FIGURE 29-14
Dynamic warmups. A, Inchworm. B,C, Spiderman. D, Walking lunge.
- •
- •
Patellar tendon mobility (before activity if needed)
- •
Instrument assisted soft tissue mobilization
- •
Cross-friction mobilization
- •
Neuromuscular Dynamic Stability Exercises
- •
Activation exercise
- •
Progress functional roll patterns
- •
- •
Eccentrics (lowering phase only phase)
- •
Squats on decline board, FWB ( Figure 29-15 )
- •
Progress 5 to 10 lb/week if less than 5/10
FIGURE 29-15
Full weight-bearing squats on decline board.
- •
- •
Three sets × 15 repetitions
- •
Begin step downs ( Figure 29-16 )
- •
4” step at 4 weeks
- •
6” step at 6 weeks
- •
Three sets × 15 repetitions
FIGURE 29-16
Step downs.
- •
- •
- •
Stability exercise (Advance with good mechanics: no pelvic drop, hip add, knee valgus or excessive anterior weight)
- •
Lumbopelvic stability exercise
- •
Advance from double to single leg support if appropriate mechanics are maintained.
- •
- •
Strengthening
- •
Advance balance on unstable surface/add perturbations (three sets 10 to 15 repetitions)
- •
Single leg squat
- •
Add resistance, unstable surface (three sets 10 to 15 repetitions)
- •
- •
Split lunge with chop and lift (three sets 10 to 15 repetitions)
- •
Resisted band walking (three sets 10 to 15 repetitions)
- •
Step-up 12 onto ploy box (three sets 10 to 15 repetitions)
- •
- •
Bounding (appropriate landing mechanics)
- •
Begin double leg jumping on Shuttle or Total Gym
- •
Three sets × 15 repetitions
- •
- •
- •
Initiate walk/jog progression
- •
The Walk/Jog program ( Table 29-2 ) is to be performed in a step-by-step fashion. The program can be varied to meet individual situations. The patient should be progressing at a minimum of 1 day on, 1 day off basis with increased time off between bouts given on individual basis.
- •
If painful, stop jogging. Once pain-free restart at the previous level to avoid re-aggravation.
- •
Phase IV (weeks 8 to 12)
Protection
- •
Only advance with jogging and sports specific-activity (speed and agility drills) if pain free.
- •
Eccentrics can be continued if less than 5/10 pain.
Management of Pain and Swelling
- •
Ice massage is needed
Techniques for Progressive Increase in Range of Motion
- •
Dynamic warmup
- •
Inch worms, Spidermans, walking lunge
- •
Ten repetitions each (see Figure 29-14 )
- •
- •
- •
Patellar tendon mobility (before activity if needed)
- •
Instrument assisted soft tissue mobilization
- •
Cross-friction mobilization
- •
Neuromuscular Dynamic Stability Exercises
- •
Activation exercise
- •
Progress functional roll patterns (see Figure 29-6 )
- •
- •
Eccentrics (lowering phase only phase)
- •
Squats on decline board, FWB
- •
Progress 5 to 10 lb/week if less than 5/10
- •
Three sets × 15 repetitions
- •
- •
Step downs
- •
8” step
- •
Three sets × 15 repetitions
- •
- •
- •
Stability exercise (i.e., no pelvic drop, hip add, knee valgus, or excessive anterior weight)
- •
Strengthening
- •
Step-up 24-inch plyo box—go onto toe
- •
Progress all LE strengthening exercise
- •
Bounding (ensure good mechanics with symmetrical landing and avoid jump/hop down off plyo boxes)
- •
Single leg jumping on Shuttle or Total Gym
- •
Three sets × 15 repetitions
- •
Begin double leg hop down on 4”
- •
Progress to 6” to 12” step as form improves
- •
Three sets × 15 repetitions
- •
Sports-specific drills (multidirectional, agility and speed activities such as dot and ladder drills) ( Figure 29-17 )
FIGURE 29-17
A–C, Sports-specific drills (dot and ladder drills).
- •
Progress walk/jog progression ( Table 29-1 )
Table 29-1
The Walk-Jog Program
Warm-up
Jog
Walk
Repetitions
Cool Down
Step I
5 min
1 min
3 min
5
5 min
Step II
5 min
1 min
2 min
7
5 min
Step III
5 min
2 min
1 min
7
5 min
Step IV
5 min
3 min
1 min
5
5 min
Step V
5 min
5 min
1 min
4
5 min
Step VI
5 min
20 min continuous
1
5 min
Step VII
5 min
Jog every other day reaching 30 min and increase pace
5 min
Adapted from OSU Sports Medicine walk/jog progression ( www.sportsmedicine.osu.edu ).
- •
- •
Milestones for Progression to Advanced Sport-Specific Training and Conditioning
- •
Demonstrate no greater than Blazina’s Phase I criteria.
- •
Hip flexor/quadriceps flexibility symmetry
- •
No compensatory movements with functional testing (i.e., no pelvic drop, hip add, knee valgus, or excessive anterior weight)
- •
Victorian Institute of Sport Assessment scale—Patellar tendinopathy (VISA-P) score of 60 or better
Criteria for Abandoning Nonoperative Treatment and Proceeding to Surgery or More Intensive Intervention
- •
Lack of progression or exacerbation with rehabilitation program
- •
Blazina Phase III greater than 3 to 4 months without change ( Table 29-2 )
Table 29-2
A Guide to Progression and Criteria to Modify Sport
Blazina’s Tendinopathy Stages
Kennedy’s Tendinopathy Stages
Phase I
No significant pain during athletic activity, but discomfort afterward
Pain after activity
Phase II
Pain before and after activity, but not enough during activity to alter their performance
Pain at the beginning and after activity
Phase III
Pain is severe enough that performance is affected and the athlete’s volume of activity has to be modified
Pain at the beginning, during, and after activity, but performance is no affected
Phase IV
Tendon rupture
Pain at the beginning, during, and after activity, and the performance is affected
For the purposes of these guidelines, Blazina’s classification is used.
Adapted from Rutland.
- •
Unable to change from Kennedy’s Phase IV criteria (see Table 29-1 )
Tips and Guidelines for Transitioning to Performance Enhancement
- •
Athletes need to be reminded on appropriate warm-up and corrective mobility techniques before sports-specific training to help correct and prevent compensatory movement patterns.
- •
Sports-specific training can be progressed only if pain is felt after activity; however, no symptoms should be noted before or during activity.
Performance Enhancement and Beyond Rehabilitation: Training/Trainer and Optimization of Athletic Performance
- •
It is important to recognize intrinsic and extrinsic risk factors of patellar tendinopathy to prevent re-injury.
- •
The following should be considered when designing a performance enhancement program:
- •
Intrinsic factors
- •
Thigh weakness
- •
Thigh hypomobility
- •
Ankle DF hypomobility
- •
Higher waist to hip ratio
- •
- •
Extrinsic factors
- •
Sex (male)
- •
Competition level (elite)
- •
Sport (volleyball and basketball)
- •
Hard surface
- •
Lifting weights
- •
Higher jumping performance
- •
- •
Specific Criteria for Return to Sports Participation: Tests and Measurements
- •
Demonstrate no greater than Blazina’s Phase I criteria.
- •
Less than 10% side to side difference with isokinetic quadriceps strength
- •
Less than 10% side to side difference with functional testing (single leg, triple, crossover hopping)
- •
Restore symmetrical hip flexor/quadriceps and ankle DF joint mobility and muscle-tendon flexibility
- •
No compensatory movements with functional testing (hopping, FMS, single leg squat, etc.)
- •
VISA-P score of 70 or greater
Evidence
Multiple Choice Questions
- QUESTION 1.
Which extrinsic risk factor is a potential contributor to patellar tendinopathy?
- A.
Female gender
- B.
Ankle dorsiflexion hypomobility
- C.
Sport (volleyball and basketball)
- D.
Quadriceps weakness
- A.
- QUESTION 2.
Which bonding exercise should be avoided to limit deleterious stress through the patellar tendon?
- A.
Hop/jump done from elevated surface
- B.
Agility drills
- C.
Broad jumping
- D.
Hop/jump ups onto elevated surface
- A.
- QUESTION 3.
What pain response recommendations should be used when performing eccentric exercise to treat patellar tendinopathy?
- A.
Pain-free only
- B.
Less than 3/10
- C.
Less than 5/10
- D.
Greater than 7/10
- A.
- QUESTION 4.
Which criteria should be used before returning to sport?
- A.
10% limb symmetry index with hop testing
- B.
25% quadriceps difference with isokinetic strength testing
- C.
Moderate compensation with functional movements
- D.
Less than 5/10 with sports-specific tasks
- A.
- QUESTION 5.
Which exercise provides the most stress to facilitate soft tissue healing for a patient suffering patellar tendinopathy?
- A.
Single leg squat on a flat surface
- B.
Single leg squat on an incline surface
- C.
Single leg squat on decline surface
- D.
Single leg squat on an unstable surface
- A.
Answer Key
- QUESTION 1.
Correct answer: C (see Guiding Principles of Nonoperative Rehabilitation box)
- QUESTION 2.
Correct answer: D (see Phase IV )
- QUESTION 3.
Correct answer: C (see Phase I )
- QUESTION 4.
Correct answer: A (see Phase IV ).
- QUESTION 5.
Correct answer: C (see Phase I )
Related posts:
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Lateral Collateral Ligament and Posterolateral Ligament Injuries
Superior Labral Pathology (SLAP/Long Head Biceps)
Leg Pain in the Athlete: Stress Fractures, Medial Tibial Stress Syndrome, and External Compartment Syndromes
Ulnar Collateral Ligament Injuries
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