Sporcularda Patellar Tendinopati için Güncel Tedavi Yaklaşımları

Öz

Patellar tendinopati (PT), özellikle sıçrama sporlarıyla uğraşan sporcuları etkileyen ağrılı bir kas-iskelet sistemi rahatsızlığıdır. PT semptomlarının yönetimi zordur ve spor ile fiziksel aktivite katılımını olumsuz etkiler. PT'nin iyileşme oranı tatmin edici değildir; iyileşme süresi uzundur ve nüks oranı yüksektir. Bu nedenle, sporcuların kısıtlanmış spor katılımını iyileştirmek amacıyla rehabilitasyon programlarının etkin bir şekilde yönetilmesi önemlidir. Bu derlemenin amacı, sporcularda PT’nin klinik tanısı, değerlendirilmesi ve yönetimine ilişkin mevcut kanıtları bir araya getirerek klinisyenlere rehberlik etmektir. Yüklenme, özellikle enerji depolayan tendonlar için olduğu gibi PT için de rehabilitasyonun en önemli parçasıdır. Rehabilitasyonda öncelik, ağrı veya yapısal iyileşmeden önce fonksiyonun yeniden kazandırılmasıdır. Egzersiz, tendonu fonksiyonuna uygun şekilde yüklemenin tek yolu olduğundan, PT için en yüksek kanıt düzeyine sahip birincil tedavi stratejisidir. Şok dalga tedavisi, spor bandajlaması ve kuru iğneleme gibi diğer yöntemler yardımcı tedavi olarak faydalı olabilir, ancak bu yöntemlere dair kanıtlar sınırlıdır. PT’ye sahip sporcular, diğer diz problemlerine sahip olanlara göre spora iki kat daha fazla devam etmektedir; ancak iyileşme süreçlerinden daha az memnundurlar. Uygun egzersizlerle yüklenme yönetimi, PT’li sporcuların kısıtlanmış spor katılımını iyileştirmek için en güçlü kanıt düzeyine sahip yaklaşımdır.

Anahtar Kelimeler

• sporcular
• egzersiz
• diz
• rehabiltiasyon
• tendinopati

Current Management Approaches for Patellar Tendinopathy in Athletes

Öz

Patellar tendinopathy (PT) is a painful musculoskeletal condition that particularly affects athletes participating in jumping sports. Symptoms of PT are difficult to manage, affect sports and physical activity participation. The recovery rate of PT is not satisfactory, with long recovery times and a high recurrence rate. Thus, it is important to manage rehabilitation programs to improve athletes’ compromised sports participation. The aim of this review is to combine and present available evidence to guide clinicians in key elements of clinical diagnosis, examination and management of PT in athletes. Loading is the most important part of rehabilitation, especially for energy storing tendons like PT. Function is the primary focus of rehabilitation, before pain or structural recovery. Exercise is the primary treatment strategy with the highest evidence level for PT as it is the only way to load the tendon in line with its function. Other modalities such as extracorporeal shockwave therapy, sports taping and dry needling may be beneficial as adjunct therapies, but evidence is limited. Athletes with PT play their sports twice as much as those with other knee problems, yet they are less satisfied with their recovery. Loading management with appropriate exercises is the best approach with a strong level of evidence for treating PT in athletes to improve athletes’ compromised sports participation.

Anahtar Kelimeler

• athletes
• exercise
• knee
• rehabilitation
• tendinopathy

Kaynakça

1. Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: Summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42(2):311–9.
2. Järvinen TAH, Kannus P, Maffulli N, Khan KM. Achilles tendon disorders: Etiology and epidemiology. Foot Ankle Clin. 2005;10(2):255–66. DOI: 10.1016/j.fcl.2005.01.013
3. Lian OB, Engebretsen L, Bahr R. Prevalence of jumper’s knee among elite athletes from different sports: a cross-sectional study. Am J Sports Med. 2005 Apr;33(4):561–7. DOI: 10.1177/0363546504270454
4. Zwerver J, Bredeweg SW, Van Den Akker-Scheek I. Prevalence of jumper’s knee among nonelite athletes from different sports: A cross-sectional survey. Am J Sports Med. 2011;39(9):1984–8. DOI: 10.1177/0363546511413370
5. Nutarelli S, Lodi CMT da, Cook JL, Deabate L, Filardo G. Epidemiology of patellar tendinopathy in athletes and the general population: A systematic review and meta-analysis. Orthop J Sport Med. 2023;11(6):1–11. DOI: 10.1177/23259671231173659
6. Khan KM, Maffulli N, Coleman BD, Cook JL, Taunton JE. Patellar tendinopathy: some aspects of basic science and clinical management. Br J Sports Med. 1998;32(4):346–55. DOI: 10.1136/bjsm.32.4.346
7. Cook JL, Khan KM, Kiss ZS, Purdam CR, Griffiths L, Study VIST. Reproducibility and clinical utility of tendon palpation to detect patellar tendinopathy in young basketball players. Br J Sports Med. 2001;35(1):65–9.
8. Hoksrud A, Ohberg L, Alfredson H, Bahr R. Color Doppler ultrasound findings in patellar tendinopathy (jumper’s knee). Am J Sports Med. 2008 Sep;36(9):1813–20. DOI: 10.1177/036354650831989

9. Scott A, Squier K, Alfredson H, Bahr R, Cook JL, Coombes B, et al. ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical terminology. Br J Sports Med. 2020;54(5):260–2. DOI: 10.1136/bjsports-2019-100885
10. Tayfur A, Şendil A, Sezik AÇ, Kaux J-F, Sancho I, Le Sant G, et al. Self-reported bio-psycho-social factors partially distinguish patellar tendinopathy from other knee problems and explain patellar tendinopathy severity in jumping athletes: A case-control study. Phys Ther Sport. 2023;61:57–65. DOI: 10.1016/j.ptsp.2023.02.009
11. Tayfur A, Tayfur B. The Knee. In: Kaya Utlu D, editor. Functional Exercise Anatomy and Physiology for Physiotherapists. Springer; 2023. p. 291–314. DOI: 10.1007/978-3-031-27184-7_14
12. Khan KM, Cook JL, Kannus P, Maffulli N, Bonar SF. Time to abandon the “tendinitis” myth: painful, overuse tendon conditions have a non-inflammatory pathology. Br Med J. 2002;324(7338):626–7. DOI: 10.1136/bmj.324.7338.626
13. Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med. 1999 Jun;27(6):393–408. DOI: 10.2165/00007256-199927060-00004
14. Puddu G, Ippolito E, Postacchini F. A classification of Achilles tendon disease. Am J Sports Med. 1976;4(4):145–50.
15. Backman C, Boquist L, Fridén J, Lorentzon R, Toolanen G. Chronic achilles paratenonitis with tendinosis: An experimental model in the rabbit. J Orthop Res. 1990;8(4):541–7.
16. Kirkendall DT, Garrett WE. Function and biomechanics of tendons. Scand J Med Sci Sports. 2007;7(2):62–6. DOI: 10.1111/j.1600-0838.1997.tb00120.x
17. Thorpe CT, Godinho MSC, Riley GP, Birch HL, Clegg PD, Screen HRC. The interfascicular matrix enables fascicle sliding and recovery in tendon, and behaves more elastically in energy storing tendons. J Mech Behav Biomed Mater. 2015;52:85–94. DOI: 10.1016/j.jmbbm.2015.04.009
18. Finni T. Structural and functional features of human muscle-tendon unit. Scand J Med Sci Sports. 2006;16(3):147–58. DOI: 10.1111/j.1600-0838.2005.00494.x
19. Earp JE, Newton RU, Cormie P, Blazevich AJ. Faster movement speed results in greater tendon strain during the loaded squat exercise. Front Physiol. 2016;7:366. DOI: 10.3389/fphys.2016.00366
20. Tayfur A, Salles JI, Miller SC, Screen H, Morrissey D. Patellar tendinopathy outcome predictors in jumping athletes: feasibility of measures for a cohort study. Phys Ther Sport. 2020;44:75–84. DOI: 10.1016/j.ptsp.2020.05.004
21. Janssen I, Steele JR, Munro BJ, Brown NAT. Predicting the patellar tendon force generated when landing from a jump. Med Sci Sports Exerc. 2013;45(5):927–34. DOI: 10.1249/mss.0b013e31827f0314
22. Decker M, Torry M, Wyland D, Sterett W, Steadman J. Gender differences in lower extremity kinematics, kinetics and energy absorption during landing. Clin Biomech. 2003;18(7):662–9. DOI: 10.1016/S0268-0033(03)00090-1
23. Devita P, Skelly WA. Effect of landing stiffness on joint kinetics and energetics in the lower extremity. Med Sci Sports Exerc. 1992;24(1):108–15.
24. van der Worp H, van Ark M, Roerink S, Pepping G-J, Van Den Akker-Scheek I, Zwerver J. Risk factors for patellar tendinopathy: a systematic review of the literature. Br J Sports Med. 2011;45(5):446–52.
25. Van Der Worp H, Van Der Does HT., Brink MS, Zwerver J, Hijmans JM. Prospective study of the relation between landing biomechanics and jumper’s knee. Int J Sports Med. 2016;37(3):245–50. DOI: 10.1055/s-0035-1555858
26. Sprague AL, Smith AH, Knox P, Pohlig RT, Silbernagel KG. Modifiable risk factors for patellar tendinopathy in athletes: a systematic review and meta-analysis. Br J Sport Med [Internet]. 2018 [cited 2020 Apr 10];52:1575–85. DOI: 10.1136/bjsports-2017-099000
27. Besier TF, Lloyd DG, Cochrane JL, Ackland TR. External loading of the knee joint during running and cutting maneuvers. Med Sci Sports Exerc. 2001;33(7):1168–75. DOI: 10.1097/00005768-200107000-00014
28. Bahr R, Reeser JC. Injuries among world-class professional beach volleyball players: The Federation Internationale de Volleyball beach volleyball injury study. Am J Sports Med. 2003;31(1):119–25. DOI: 10.1177/03635465030310010401
29. Edwards S, Steele JR, Cook JL, Purdam CR, McGhee DE, Munro BJ. Characterizing patellar tendon loading during the landing phases of a stop-jump task. Scand J Med Sci Sport. 2012 Feb;22(1):2–11. DOI: 10.1111/j.1600-0838.2010.01119.x
30. Van Der Worp H, De Poel HJ, Diercks RL, Van Den Akker-Scheek I, Zwerver J. Jumper’s knee or lander’s knee? A systematic review of the relation between jump biomechanics and patellar tendinopathy. Int J Sports Med. 2014;35(8):714–22. DOI: 10.1055/s-0033-1358674
31. Tayfur A, Haque A, Salles JI, Malliaras P, Screen H, Morrissey D. Are Landing Patterns in Jumping Athletes Associated with Patellar Tendinopathy? A Systematic Review with Evidence Gap Map and Meta-analysis. Sports Med. 2022 Jan;52(1):123-137. DOI: 10.1007/s40279-021-01550-6
32. Lui PPY, Maffulli N, Rolf C, Smith RKW. What are the validated animal models for tendinopathy? Scand J Med Sci Sports. 2011;21(1):3–17. DOI: 10.1111/j.1600-0838.2010.01164.x
33. Breda SJ, Oei EHG, Zwerver J, Visser E, Waarsing E, Krestin GP, et al. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. Br J Sports Med. 2021 May;55(9):501–9. DOI: 10.1136/bjsports-2020-103403
34. Kettunen JA, Kvist M, Alanen E, Kujala UM. Long-term prognosis for jumper’s knee in male athletes: A prospective follow-up study. Am J Sports Med. 2002;30(5):689–92. DOI: 10.1177/03635465020300051001
35. Cook JL, Khan KM, Harcourt PR, Grant M, Young DA, Bonar SF. A cross sectional study of 100 athletes with jumper’s knee managed conservatively and surgically. Br J Sports Med. 1997;31(4):332–6.
36. Tayfur A, Gülle H, Delen M, Zenner D, Miller SC, Screen H, Morrissey D. Prognostic Factors for Recovery from Patellar Tendinopathy in Jumping Athletes: An International Prospective Cohort Study. Sports Med Open. 2025 Nov 21;11(1):143. doi: 10.1186/s40798-025-00940-8. PMID: 41269475; PMCID: PMC12638584.
37. Hägglund M, Zwerver J, Ekstrand J. Epidemiology of patellar tendinopathy in elite male soccer players. Am J Sports Med. 2011;39(9):1906–11. DOI: 10.1177/0363546511408877
38. Morton S, Williams S, Valle X, Diaz-Cueli D, Malliaras P, Morrissey D. Patellar tendinopathy and potential risk factors: An international database of cases and controls. Clin J Sport Med. 2017;27(5):468–74. DOI: 10.1097/JSM.0000000000000397
39. Rio EK, Mc Auliffe S, Kuipers I, Girdwood M, Alfredson H, Bahr R, et al. ICON PART-T 2019-International Scientific Tendinopathy Symposium Consensus: recommended standards for reporting participant characteristics in tendinopathy research (PART-T). Br J Sports Med. 2020 Jun;54(11):627–30. DOI: 10.1136/bjsports-2019-100957
40. Rudavsky A, Cook J. Physiotherapy management of patellar tendinopathy (jumper’s knee). J Physiother. 2014;60(3):122–9. DOI: 10.1016/j.jphys.2014.06.022
41. Brukner P. Brukner & Khan’s clinical sports medicine. North Ryde: McGraw-Hill; 2012.
42. Figueroa D, Figueroa F, Calvo R. Patellar tendinopathy: diagnosis and treatment. J Am Acad Orthop Surg. 2016;24(12):e184–92. DOI: 10.5435/JAAOS-D-15-00703
43. Cantu RC. Patellar tendinopathy in athletes: Current diagnostic and therapeutic recommendations. Sport Med. 2006;35:71–87. DOI: 10.2165/00007256-200535010-00006
44. Coombes BK, Mendis MD, Hides JA. Evaluation of patellar tendinopathy using the single leg decline squat test: Is pain location important? Phys Ther Sport. 2020 Nov;46:254–9. DOI: 10.1016/j.ptsp.2020.10.002
45. Malliaras P, Cook J, Purdam C, Rio E. Patellar tendinopathy: Clinical diagnosis, load management, and advice for challenging case presentations. J Orthop Sports Phys Ther. 2015;45(11):887–98. DOI: 10.2519/jospt.2015.5987
46. Vicenzino B, De Vos RJ, Alfredson H, Bahr R, Cook JL, Coombes BK, et al. ICON 2019 - International Scientific Tendinopathy Symposium Consensus: There are nine core health-related domains for tendinopathy (CORE DOMAINS): Delphi study of healthcare professionals and patients. Br J Sports Med. 2020;54(8):444–51. DOI: 10.1136/bjsports-2019-100894
47. Krause DA, Cloud BA, Forster LA, Schrank JA, Hollman JH. Measurement of ankle dorsiflexion: a comparison of active and passive techniques in multiple positions. J Sport Rehabil. 2011;20(3):333–44. DOI: 10.1123/jsr.20.3.333
48. McAuliffe S, McCreesh K, Culloty F, Purtill H, O’Sullivan K. Can ultrasound imaging predict the development of Achilles and patellar tendinopathy? A systematic review and meta-analysis. Br J Sports Med. 2016;50(24):1516–23. DOI: 10.1136/bjsports-2016-096288
49. Sprague AL, Couppé C, Pohlig RT, Cortes DC, Silbernagel KG. Relationships between tendon structure and clinical impairments in patients with patellar tendinopathy. J Orthop Res. 2022 Oct;40(10):2320–9. DOI: 10.1002/jor.25262
50. Sancho I, Morrissey D, Willy R, Tayfur A, Lascurain-Aguirrebeña I, Barton C, et al. Recreational runners with Achilles tendinopathy have clinically detectable impairments: A case-control study. Phys Ther Sport. 2022;55:241–7. DOI: 10.1016/j.ptsp.2022.05.002
51. Sancho I, Willy RW, Morrissey D, Malliaras P, Lascurain-Aguirrebeña I. Achilles tendon forces and pain during common rehabilitation exercises in male runners with Achilles tendinopathy. A laboratory study. Phys Ther Sport. 2023;60:26–33. DOI: 10.1016/j.ptsp.2023.01.002
52. Docking S, Rosengarten S, Daffy J, Cook J. Treat the donut, not the hole: The pathological Achilles and patellar tendon has sufficient amounts normal tendon structure. J Sci Med Sport. 2014;18:e2. DOI: 10.1016/j.jsams.2014.11.015
53. Escriche-Escuder A, Casaña J, Cuesta-Vargas AI. Load progression criteria in exercise programmes in lower limb tendinopathy: a systematic review. BMJ Open. 2020 Nov;10(11):e041433. DOI: 10.1136/bmjopen-2020-041433
54. Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007;35(6):897–906. DOI: 10.1177/0363546506298279
55. Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015 Oct;49(19):1277–83. DOI: 10.1136/bjsports-2014-094386
56. Lim HY, Wong SH. Effects of isometric, eccentric, or heavy slow resistance exercises on pain and function in individuals with patellar tendinopathy: A systematic review. Physiother Res Int. 2018;23(4):e1721. DOI: 10.1002/pri.1721
57. Challoumas D, Pedret C, Biddle M, Ng NYB, Kirwan P, Cooper B, et al. Management of patellar tendinopathy: A systematic review and network meta-analysis of randomised studies. BMJ Open Sport Exerc Med. 2021;7(4):e001110.
58. Gaida JE, Cook J. Treatment options for patellar tendinopathy: critical review. Curr Sports Med Rep. 2011;10(5):255–70. DOI: 10.1249/JSR.0b013e31822d4016
59. Visnes H, Hoksrud A, Cook J, Bahr R. No effect of eccentric training on jumper’s knee in volleyball players during the competitive season: a randomized clinical trial. Clin J Sport Med. 2005;15(4):227–34. DOI: 10.1097/01.jsm.0000168073.82121.20
60. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med. 2013 Apr;43(4):267–86. DOI: 10.1007/s40279-013-0019-z
61. Silva RS, Song K, Hullfish TJ, Sprague A, Silbernagel K, Baxter J. Patellar tendon load progression during rehabilitation exercises: Implications for the treatment of patellar tendon injuries. Med Sci Sport Exerc. 2023;56(3):545. DOI: 10.1249/MSS.0000000000003323
62. Burton I. Interventions for prevention and in-season management of patellar tendinopathy in athletes: A scoping review. Phys Ther Sport. 2022;55:80–9. DOI: 10.1016/j.ptsp.2022.03.002
63. Vander Doelen T, Jelley W. Non-surgical treatment of patellar tendinopathy: A systematic review of randomized controlled trials. J Sci Med Sport. 2020 Feb;23(2):118–24. DOI: 10.1016/j.jsams.2019.09.008
64. Larsson M, Käll I, Surgery KN-H-K, Sports U, 2012 U. Treatment of patellar tendinopathy—a systematic review of randomized controlled trials. Knee surgery, Sport Traumatol Arthrosc. 2012;20(8):1632–46. DOI: 10.1007/s00167-011-1825-1
65. Mendonça LDM, Leite HR, Zwerver J, Henschke N, Branco G, Oliveira VC. How strong is the evidence that conservative treatment reduces pain and improves function in individuals with patellar tendinopathy? A systematic review of randomised controlled trials including GRADE recommendations. Br J Sports Med. 2020;54(2):87–93. DOI: 10.1136/bjsports-2018-099747
66. Everhart JS, Cole D, Sojka JH, Higgins JD, Magnussen RA, Schmitt LC, et al. Treatment options for patellar tendinopathy: a systematic review. Arthroscopy. 2017;33(4):861–72. DOI: 10.1016/j.arthro.2016.11.007
67. Andriolo L, Altamura SA, Reale D, Candrian C, Zaffagnini S, Filardo G. Nonsurgical treatments of patellar tendinopathy: Multiple injections of platelet-rich plasma are a suitable option: A systematic review and meta-analysis. Am J Sports Med. 2019;47(4):1001–18. DOI: 10.1177/0363546518759674
68. Chen PC, Wu KT, Chou WY, Huang YC, Wang LY, Yang TH, et al. Comparative effectiveness of different nonsurgical treatments for patellar tendinopathy: A systematic review and network meta-analysis. Arthroscopy. 2019;35(11):3117–31. DOI: 10.1016/j.arthro.2019.06.017