Knee Pain - How to Deal With Tendonitis

Anterior knee pain is very common (pain in the front of your knee, above or below your kneecap), especially with activities such as bending, squatting, stairs or running. One major cause of this is tendonitis. There are two main tendons that get strained in your knee most commonly: the patella tendon and the quadriceps tendon.

The quadriceps muscle is the large muscle in the front of your thigh which attaches to your knee cap ("patella") via the quadriceps tendon. Your knee cap must move up and down in its groove in order for your knee to bend and straighten. Your quadriceps "tendon" comes from the quadriceps muscle in your upper thigh, and then wraps down over the knee cap. The quadriceps tendon is then referred to as the "patella tendon" as it attaches below the knee cap to your tibia, (your lower leg bone).

Quadriceps and patellar tendonitis usually occur from repetitive stresses on the tendons from repetitive bending and straightening your knee such as squatting, stairs, running, jumping or quick starts and stops. The forces going through your knee are approximately 2-3x your body weight just with walking, and up to 5x your body weight when you are running. This is a lot of stress through your joint. Muscle imbalances, as well as poor alignment within your knee joint or your lower leg or ankle can also lead to uneven forces on the tendon, which can overstress the tendon even with low impact activities. You do not have to be running or an athlete to get tendonitis. Tendonitis is also common for people who have had knee surgery in the past and moved too quickly back into activity without fully regaining the strength in their quadriceps, or fully balancing all of the muscles in their leg.

Just like in any tendonitis, if the stresses going through your tendon are too much, then you can get tissue breakdown and microtears in the tendon, which can lead to inflammation and pain and even partial tearing of the tendon. Chronic tendonitis can also lead to degeneration of the tendon and scarring within the tendon or tendon sheath, which is considered tendonosis.

Pain with quadriceps or patella tendonitis is typically right around the tendon, at your lower thigh, either right above your knee cap or below your knee cap, respectively. The tendon is typically tender to touch or massage and usually will hurt when you bend and straighten your knee. It can be swollen if severe enough and can also get stiff after sitting for a long time, or when you first wake up in the morning.

The biggest thing with any tendonitis to remember is that it is inflammation in the tendon, so rest is important. You do not want to continue to increase that inflammation; you need to let the tendon fibers heal. You can also take anti-inflammatory medication over the counter, such as Ibuprofen. If you see an orthopedic doctor you will probably be given a prescription anti-inflammatory medication, such as Celebrex or a Medrol Pack (Prednisone) which should help. The best thing you can do at home for it besides rest is icing. Better than even an ice pack, is an ice massage to the tendon, if you can tolerate it. Fill a small paper cup/ Dixie cup with water and freeze it, then you can massage the ice over that area for 1-2 minutes, or whatever you can tolerate.

Also important is gentle stretching. For your quadriceps, the best way to stretch is on your stomach so that your hip is straight. Place a rolled up towel or pillow under your lower thigh to slightly lift your leg off the surface and gently pull your ankle towards your buttock. You can stretch yourself, or if that is too difficult to do without twisting your back or your hip, then have someone gently stretch your knee for you. Just make sure they are doing it very gently and not pushing through pain. Hold the stretch for 10-15 seconds and repeat 5 times.

If it has moved from acute tendonitis to more of a tendonosis, then it is not as much inflammation that is the primary problem but that degeneration and scarring of the tendon has occurred. If so, doing massage right at the tendon would be helpful to break up the adhesions. If it's really tender to massage, you might want to do the ice massage first to numb it a little, and then massage, and then do another ice massage after. You want to be massaging back and forth over the tendon fibers, because adhesions can build up within the tendon and the tendon's sheath. Also continue with the gentle stretching.

If it does not get better I would suggest seeing your orthopedic doctor because he or she will most likely send you to physical therapy which can be very beneficial. The physical therapist, after evaluating you will most likely do the cross friction massage and the stretching for you, and they also can do modalities to help bring down the inflammation and break up the scar tissue or adhesions, such as ultrasound, electrical stimulation and iontophoresis.

You may have seen people wearing a knee strap on their knee for tendonitis. These can be helpful for patellar tendonitis. The knee straps or bands are worn beneath your kneecap, putting pressure on your patella tendon. This can sometimes help to decrease the stress through the patella tendon where it attaches to the bone. If you do have anterior knee pain from patella tendonitis (so the pain is below your knee cap, versus above the knee at the quadriceps tendon as discussed earlier) then a knee strap may help reduce your pain and the stress on your tendon with activities. However, be aware that the strap will not take the place of the other treatment suggestions discussed above. The strap is also typically only helpful for patellar tendonitis, and is not used for quadriceps tendonitis.

As the inflammation and pain go down you really want to be careful how you progress back into exercising and high level activities. Over stressing the tendon can cause microtearing and tissue breakdown, which leads to the inflammatory response and can lead to partial tendon tearing. It's a vicious circle that you need to break, so if you start going back to working out, running or high level activities too early, especially doing repetitive knee flexion/extension exercises which stress the quad tendon, such as squatting, repetitive stairs, running or the knee extension machine, it can definitely exacerbate things. If you are working with a physical therapist they should help guide you back into your activities safely.