Putting it together with a case study.
Mr R, 25 year old of good general health, no previous or current significant leg injuries.
Starts playing club rugby for the first time in 4 years. Hasn't been very active till preseason. Training twice a week plus one game. 6 weeks into the season presents with pain in the front of the knee. Pain has been worsening over last 6 weeks following a big preseason camp. Notices it most with warm up and after games/training. Ice and pool sessions help. Initially only lasted the day of game/training, now sore everyday and terrible in the morning, walking downstairs sucks and feels weak.
Can still play as it is fine when it is warmed up.
What presents here is relatively typical. This is how physio's look at this history:
- significant change in activity level
- peak load moment leading to first pain presentation (training camp)
- 6 week progression of symptoms relating to continued loading
- no significant rest/de-load
- pain at tendon
On testing there was tenderness at the tendon, some mild swelling, quads inactivity, poor tolerance to load and explosive movements.
Diagnosed as patella tendinopathy
Due to the time-frame of symptoms and history, we established it was a reactive tendon (reactive pain and inflammation) with probable significant tissue changes (time-frame and persistent pain).
In this case the clinical diagnosis was straight forward. The tricky bit was the management. The player could still play, and the team was approaching playoffs, other players were injured etc. Therefore a lot of external and internal pressure to keep playing. We had to invest a lot of time in not just establishing the appropriate physical rehabilitation (more on this shortly) BUT more so we had to focus on the education. To make progress we needed to work with the player, we all needed to be on the same page. The coach was involved in this conversation and a plan for limited game time and training load was put in place. The goal became for management through the season and recovery in the off season.
So, what did the physical plan look like:
- Gym loading was adjusted so that there was a focus on simple tolerable load through the legs. A focus on symptomatic guidance rather than load was implemented.
- Stretching, rolling and recovery processes rose in priority
- Training was adjusted - fitness work was adjusted to manage running loads
- The coach was encouraged to start the player as that was when he was most primed
Through this program, we were able to manage the player through the season. In the off season we were able to get back to basics; we focused on mechanics and stability in the first phase, before introducing a progressive loading program starting with isometric loads in comfortable range, working into high rep slow paced isotonic loading, then small set heavy slow resistance, and finally introduced more powerful movements. This process took 8 months and he was able to return to pain-free play midway through the next season.
As you can see; despite a simple diagnosis, a thorough long term management plan is required for resolution. Load management is key for physical management, but like any injury education and understanding from all parties is essential for a good outcome.