Effective Treatment Techniques for Patellar Tendinopathy

Dr. Lindsey Hughey // #TechniqueThursday // www.ptonice.com 

In today's episode of the PT on ICE Daily Show, Extremity Management division leader Lindsey Hughey explains the rationale behind myofascial decompression or "cupping" for patellar tendinopathy and provides a technique demonstration.

Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog.

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EPISODE TRANSCRIPTION

LINDSEY HUGHEYPT on ICE Daily Show, waiting for YouTube and Instagram to catch up. So we are live on both. How's it going? I am joining you again this week on the PT on ICE Daily Show. Welcome. I'm Dr. Lindsey Hughey. I currently serve as one of the division leads at extremity management. And today I want to share with you a myofascial decompression technique for patellar tendinopathy. So today is either Technique Tuesday or Leadership Thursday. So we're bringing Technique Thursday to you all live. My model today is Daniel, my son. So what I want to unpack is a little bit about how do we know someone has patellar tendinopathy and who this might be appropriate for. with patellar tendinopathy, show you the technique, literally just demo it for you live, what you do, and then we'll chat also like how do you know the treatment worked. So we'll talk a little bit about our test retest options for patellar tendinopathy. And then we'll call it a morning technique Thursday, not Tuesday. Great to be with you all again. So first things first, someone with patellar tendinopathy is going to complain of a recent spike in load. Usually it's energy storage and release activities like jumping, sprinting. The other complaint, vice versa, they might have is that a dramatic de-load where they haven't, maybe it's their off season and then they stopped loading completely. this might flare up that patellar tendon. They will complain of pain with energy storage movements, and they'll specifically complain of pain right at the patellar tendon, where that inferior border of the patella sits to the tibial tubercle. When you palpate that as the clinician, that will be tender to palpation. Often when they extend their knees, so you're doing manual muscle testing of quadriceps, that will also cause their symptoms to blip. Having them do a one-legged squat on a slant board is another load test that will often bring on symptoms. The person with moderate to high irritability, patellar tendinopathy, often has coinciding hypertonicity throughout their quadriceps. So when you palpate, it's not just that patellar tendon that is bothering them. Like their quad also is kind of guarded around that knee joint. So myofascial decompression can be a great adjunct to treatment. If you've heard any podcasts that I've done on tendinopathy, you know, that load is our love language, or if you've been at our course, you know that. So ultimately, the teller tendinopathy is going to be healed by high tensile loading that involves loading the local tendon, the local muscle, quadriceps, the chain, and then off eventually gets into energy surge and release. So know this treatment technique that I'm about to show you is just an adjunct to care that creates a modulating window of opportunity to load that person better. So consider it's moderate to high irritability human. And so that's someone that like not just is their activity or sport starting to get interrupted. It's usually our basketball or volleyball players, but also like daily life is starting to get aggravated. They're not sleeping as well. Their performance has dropped. These folks need that treatment that kind of takes that edge off. So without further ado, you kind of understand who the person with teller tendinopathy is, who would be good to execute this treatment on. I want to show it to you. So I'm going to kind of move the camera around just a tiny bit. so that you can really see the quadriceps. So we're going to do one of two things. We'll make sure we've exposed the area. I want to not only get myofascial decompression to the quadriceps and hit each part, but I also want to decompress that patella and the patellar tendon. So to first decompress the patellar tendon and the patella, I'm going to use a silicone cup. So these silicone cups are awesome. The way we'll apply these is we're going to create negative pressure. So you really want to squish this in and then apply firm pressure down with your body, being mindful that this could be an irritating area. The way I would explain it to the patient is we're using this cup to just kind of offload that bone, that patella, and then offload the patellar tendon a bit. So I'm going to create that negative suction and compression. If you have very hairy patients, you're going to want to put some lubricant like a Biotone around that. Just a little bit will go a long way, but again, more hair endowed folks might need a little bit more. So we're going to go here. I'm going to create that negative pressure, I'm going to press down, and then if I've done a good job creating that suction, there'll actually be a little dip or dimple in the silicone cup. The cups I'm using today are from Chris DiPrato and his team. They are amazing cup therapy if you follow them on social media. I love their products. This comes in their kit, this silicone cup, and then their curved cups. These are actually their newest ones are what I'm going to use to hit the vastus lateralis, to hit vastus medialis, and then I really want to get after rectus femoris. I want to make sure I hit all three parts. You can't really get that intermedius without a needle. So we're going to hit those main more superficial areas. So we're going to hit that vastus lateralis first. And then I'm going to place that curved cup and then create suction with our gun. And there's various guns. This is a manual pump that you can use. There's ones with gauges and then electronic gauges. We want about 300 to 600 millimeters of mercury if you do have that pressure gauge that actually gives you a reading. So we'll hit vastus lateralis in two different spots. So one here and then one a little higher. I'll step away so you can see. Then we're going to want to go vastus medialis. So now I'm just on that inner part of the quadriceps. And then we want to hit that rectus femoris and I can hit here and then I can even do one more a little bit higher. I want to show you just there's, these are the newest curve cups. These are awesome as well. So I wanted to show you that. We'll go a little higher and we're really trying to hit that muscle belly here, not tendon. So then this is attached to patient. And I'm not just going to leave him sit here. So I promised him I wouldn't actually make him move. So I'm just going to talk through this. But I'd actually have him do some knee extension with those on. So mod to hired ability, we want to create an analgesic response. So we'll have them do some isometrics, shooting for that 45 second hold, trying to do five reps. So we'd start with just probably doing like a quad set where he'd like push his knee down and then maybe lift a little bit or combine it with a straight leg raise. That would be like level one. As soon as we can get him up and weight-bearing, I want to do like a wall sit or a Spanish squat with these on. So he's in this decompressed, he, they, she, whoever your patient is, decompressed state, and they're still loading. So it's not a static laying there thing or treatment. So once cups are applied, right, I do some kind of active treatment. I've named a few. Lowest level would be that knee extension with a lift and or just doing a nice quad set, then getting to a wall sit or a Spanish squat in a reduced range. We usually start about 60 degrees. And then we take the cups off, right? Reassess the soft tissue. Daniel's probably like, please take these cups off, mom. What we'll do is reassess the soft tissue, but not just the soft tissue. I want to see, is there less hypertonicity? I want to see, is the tendon, after I've palpated it, become a little less tender to palpation? In addition, I want to probably test a load test, like that slant board, if we had just tested that. And you may even see a change in motor response. So if you took your dynamometer, took a quadriceps reading, and then also got an NPRS, did this treatment, Then retested using your dynamometer, you often will see not only a change in pain, but you can even see motor uptick. So an increase in that strength measurement just because pain has now dampened. So this treatment doesn't take a long time, but can be super effective for our patients with that mod to high irritability where life is starting to get interrupted by their patellar pain.

SUMMARY Thank you for joining me this morning to learn one of my favorite techniques that I'll use for my folks with patellar tendinopathy. I hope you all have beautiful clinical Thursdays, whatever you do in the clinic, and will consider using this with your patient. If you want to learn more about research concerning patellar tendinopathy and how to load your folks well, join us on a weekend soon in extremity management. So we will be in not only North Dakota, but also in South Carolina, August 24th, 25th. So you have two opportunities coming up, and that'll be our last opportunity of the summer. So really jump in if you haven't yet. And if you want to learn a little bit about some myofascial decompression techniques, our colleague Chris DiPrato, we're a big fan of his courses. We also integrate that in our courses as well. So thanks again for joining me. Cheers. Happy Thursday, everyone.

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