Article: Royce Lewis: Patellar Tendinopathy

[Heezy1323]

(Twins Daily Note: In a Jeff Johnson story in The Gazette from Cedar Rapids, Royce Lewis noted that he has been diagnosed with Patellar tendinitis and he has been playing with the injury for about a month. He did play in the Midwest League All Star game on Tuesday night, so it is considered a minor injury. Today, Heezy tells us all about patellar tendinitis.)

 

The Twins community recently received some concerning news about highly-regarded prospect Royce Lewis. Lewis left the Cedar Rapids Kernels Saturday game with what is being reported as ‘patellar tendinitis’, which has been causing him trouble off-and-on for about a month. But what is ‘patellar tendinitis’ exactly? And what might it mean for Royce going forward? Let’s discuss:Question 1: Where is the ‘patella tendon’?

 

The patella tendon is the tendon that goes from your kneecap (also called the patella) down to the upper part of your shin bone (tibia). It is the attachment of your quadriceps muscle group to your lower leg, and it is what allows people to extend the knee.

 

 

Question 2: What is ‘patellar tendinitis’?

 

Patella tendinitis is a term commonly used to refer to activity-related pain that occurs near the attachment of the patella tendon to the patella. The suffix ‘-itis’ is used to indicate inflammation. While the term is commonly used, in actuality a more appropriate term is ‘patella tendinopathy’, which refers to degenerative changes within the tendon in the absence of inflammation (which is more accurately the case in this diagnosis). This difference is important when considering treatment options.

 

Question 3: Royce is clearly a high-level athlete. Why did he get this problem?

 

Patellar tendinopathy is also commonly called ‘jumper’s knee’ since it occurs most frequently in athletes that do a lot of jumping. In some studies of professional volleyball and basketball players, the incidence of jumper’s knee has been shown to be more than 30%. It is much less common in non-jumping athletes, but still occurs in around 2-3% of soccer players. I was not able to find any information specifically discussing the incidence in baseball players.

 

It is unclear exactly why this problem occurs. It is most likely a combination of factors including BMI, flat feet, muscle imbalance in the quad/hamstrings, low flexibility, and intrinsic properties of the patellar tendon. There are likely other factors as well, including overuse.

 

The area involved is usually located directly at the bottom end of the patella/top part of the tendon. Symptoms usually come on gradually over time. Initially, the knee typically hurts only with activity. Over time, if the condition worsens, pain may begin to be present even at rest.

 

Question 4: How is patella tendinopathy diagnosed?

 

The diagnosis is usually fairly clear from the history and physical exam of the athlete. Xrays are usually normal, though in some cases calcifications of the tendon may be visible. An MRI is the standard test to identify the extent of the problem and also to rule out other problems inside the knee. The area of the tendon involved in the problem is typically fairly small- around the size of a couple tic-tacs.

 

Question 5: How is patella tendinopathy treated?

 

The most commonly prescribed treatment for patellar tendinopathy is rest from vigorous activity and specific physical therapy exercises (called eccentric exercises). These exercises are designed to strengthen the quad muscles, stretch the hamstrings and ultimately cause favorable adaptation of the knee. The time needed for symptoms to resolve can be highly variable, but often takes at least a few weeks.

 

When therapy isn’t effective, other treatments can be tried including various injections and ultrasound. At this time, there is no significant evidence that PRP (platelet rich plasma) injections are helpful for this condition, though I suspect it is being considered. There is, to my knowledge, no significant data on stem cell injections for this problem.

 

Question 6: Is surgery ever needed for patellar tendinopathy?

 

Rarely, yes. In most studies, around 10% of patients will fail to respond to appropriate conservative treatment. In these cases, surgery may be needed. There are two main options: open surgery and arthroscopic surgery. In either case, the procedure is similar- the area of affected tendon is excised and a small (a few millimeters) part of the patella bone is removed to stimulate healing. Therapy is begun soon after surgery. The success rate for return to sports is around 80% for both surgeries, with return after the arthroscopic version being quicker on average. Usually, 4-6 months is needed for full return to sports after surgery.

 

Question 7: Is Royce at increased risk of rupturing the patella tendon because of this problem?

 

No. Having patella tendinopathy does not appear to place anyone at increased risk of having a patella tendon rupture when compared to those without the problem.

 

Overall, I believe the most likely scenario to be that Lewis’ body is adjusting to playing professional baseball every day and he is having some minor issues as a result. I don’t expect this to be a substantial problem going forward, though the possibility that this requires surgery in the future does exist. Hopefully he will get through rehab quickly and be back on the field soon.

 

Click here to view the article

[Squirrel]

Thanks, heezy! Once again, educating the masses here at TD.

[bighat]

Thanks for the hot scoop. It's hard not to be concerned...but after reading your article it sounds like Royce might just need some rest, and we'll see how the therapy goes. Thanks again!

[jkcarew]

Thanks much, Heezy...related in language even I can understand.

 

The phrase I don't like in your post is "degenerative changes within the tendon".

While, it doesn't seem this is going to bother the 19 year-old Lewis much at all (he stole a base last night in the All-Star game)...without surgery, does this make it more likely that a 23-26 year-old Lewis starts to lose his speed 'prematurely'?

[Darius]

I'm reading the words that indicate we shouldn't be alarmed. But, on the inside, I'm still thinking that this will totally derail his career in some way because that's just the kind of thing that happens around here.

[Heezy1323]

 

Thanks much, Heezy...related in language even I can understand.

 

The phrase I don't like in your post is "degenerative changes within the tendon".

While, it doesn't seem this is going to bother the 19 year-old Lewis much at all (he stole a base last night in the All-Star game)...without surgery, does this make it more likely that a 23-26 year-old Lewis starts to lose his speed 'prematurely'?

Thanks for the question. I wouldn't think so. Remember, this area is very small (around the size of a couple of peas), so we aren't talking about extensive involvement here. In this context, the term 'degenerative' refers more to the body's ability to rebuild this tissue in response to stress. When that balance is thrown out of whack by one or more factors, the tissue 'build-up' is unable to keep up with the tissue 'break-down' and the tissue starts to become 'degenerative'. Improving the balance of this equation can (and should) restore the tissue to a healthy condition. It may be something he needs to do maintenance exercises for going forward to prevent recurrence, but my hope would be that is the extent of it.

[brvama]

Heezy thanks so much for your medical seminar for "dummies." Does his age or growth physical growth have any impact?

[Heezy1323]

 

Heezy thanks so much for your medical seminar for "dummies." Does his age or growth physical growth have any impact?

I think his age only contributes to the extent that for the most part only young people are active enough to get this problem. By age 19, most males are done growing, though it's possible he isn't. If he isn't, that could be a factor. I think the most likely issue is relative overuse, given that he has likely played more baseball games this year  than he ever has previously. He likely just needs some time to figure out what it is going to take to keep his body in the best condition possible while playing professional sports. The answer to that is different for everyone, and often takes some experience to find the best methods for an individual. 

[glunn]

Great thread. My worry level has dropped by 90%. Now can we talk about the pain in my elbow? 

[Blake]

 

Thanks for the question. I wouldn't think so. Remember, this area is very small (around the size of a couple of peas), so we aren't talking about extensive involvement here. In this context, the term 'degenerative' refers more to the body's ability to rebuild this tissue in response to stress. When that balance is thrown out of whack by one or more factors, the tissue 'build-up' is unable to keep up with the tissue 'break-down' and the tissue starts to become 'degenerative'. Improving the balance of this equation can (and should) restore the tissue to a healthy condition. It may be something he needs to do maintenance exercises for going forward to prevent recurrence, but my hope would be that is the extent of it.

The tendon is being broken down faster than it can rebuild itself? Did I read that right?

 

Interesting. Thank you very much. 

[brvama]

Great thread. My worry level has dropped by 90%. Now can we talk about the pain in my elbow? 

And my shoulders?

 

Seriously, I really do enjoy your explanations of the various injuries these athletes suffer. Good job!

[Heezy1323]

 

The tendon is being broken down faster than it can rebuild itself? Did I read that right?

 

Interesting. Thank you very much. 

Yes, that's correct. Nearly all tissues in your body are constantly in a state of equilibrium between 'build-up' and 'break-down'. Sometimes, for various reasons, the balance can get tilted in favor of 'break-down', which is when trouble can occur. Usually some rest and rehab will restore the balance, but of course there can be times where that doesn't do the trick, and something else is required (i.e. surgery, PRP, stem cell treatments, etc.)

[Heezy1323]

 

Great thread. My worry level has dropped by 90%. Now can we talk about the pain in my elbow? 

Sure! I love talking elbows!

 

I actually saw two local teenagers this week that need Tommy John surgery. Not my favorite discussion to have, but unfortunately something I see too frequently. Pitching is awfully hard on the shoulder and elbow. To me, it's a wonder that anyone can actually make it to MLB and have a long pro career given the stresses of throwing (though I probably have a bias because I tend to see the injured throwers). We do appear to be in a wave of growing recognition of the problems of overuse and sport specialization, but these injuries can clearly still occur even under ideal conditions.

[glunn]

 

Sure! I love talking elbows!

 

I actually saw two local teenagers this week that need Tommy John surgery. Not my favorite discussion to have, but unfortunately something I see too frequently. Pitching is awfully hard on the shoulder and elbow. To me, it's a wonder that anyone can actually make it to MLB and have a long pro career given the stresses of throwing (though I probably have a bias because I tend to see the injured throwers). We do appear to be in a wave of growing recognition of the problems of overuse and sport specialization, but these injuries can clearly still occur even under ideal conditions.

You are a good person and a valuable asset to TD.

[Heezy1323]

 

You are a good person and a valuable asset to TD.

Thank you for the very kind words. I am fortunate to be able to do something I love. 

 

Probably the thing I enjoy most in clinic is when a patient tells me at the end of an appointment, "Thanks for explaining that to me doc, I understand it a lot better now." I'm hopeful that I can occasionally bring some of that to TD.

[Ncgo4]

Makes you understand just what rare specimens Roger Clements and Nolan Ryan really were.