Case Study Patellar tendonopathy
A 42 year old male cyclist, director of a PR company, participating in triathlons since the age of 19, presented with a two weeks history of significant anterior knee pain related to pedalling and other knee extension activities. Three months earlier, during a wet training session, he fell onto the knee. After a five day break from training, he resumed his training schedule in preparation for a forthcoming event. During training, the pain developed early in the session, decreased well into the training schedule and then returned towards the end. It was initially relieved by rest. As a result, he stopped cycling and running altogether but continued with swimming training sessions. The history, clinical findings and Diagnostic Ultrasound confirmed the diagnosis of patellar tendonosis. He was treated with relative tendon unloading, eccentric drills and two guided injections of autologous blood into the tendon. After making some adjustments to the bike, he returned to competing eight weeks after starting treatment.
Tendinosis results from irritation of the tendon occurring with overuse and repetitive motion injury. It is most likely caused by excess angular traction on the tendon. Frequently, cyclists develop overuse conditions in the early season due to a rapid increase in distance. There are three areas of bike fit that could predispose to patellar tendonosis: the crank arms (too long), the cleats (improperly aligned), and the saddle (too far forward).
Relative tendon unloading is critical for treatment success and may be accomplished by correcting anatomic, functional, or equipment related errors. The key to the rationale behind eccentric drills is that they are the best way of promoting tendon remodeling. A loss of eccentric control of the patellar tendon may lead to increased strain through the tendon and damage. It is crucial to assess the level of hip mobility (tight extensors), pelvic control, and quadriceps stretch. Controlled lunging and step-down tests may give an indication of the eccentric control on the tendon. Weak quadriceps muscles in comparison with hamstring strength and control would increase the shear forces on the patellar tendon. Lower back problems (stiffness at the L3-L4 level) could also affect neural firing to the quadriceps and might increase shear forces through the tendon.
In most ski areas, snowboarders seeking the adrenaline rush account for about 25% of all users. Injury comes with the territory. The good news however is that given that the average boarder does about 12 days per season, an individual snowboarder is likely to injure some area of the body on average once every 19 years!!
The typical profile of an injured boarder is a young male from a non-skiing background who has had no professional instruction. Snowboarding has a completely different pattern of injury to skiing – upper limb injuries predominate, followed by head injuries and lower limb (mainly ankle) injuries. The risk varies with experience – the highest risk group being beginner snowboarders (especially those on their very first day). The risk becomes lower for those with between 4 and 8 weeks experience but then climbs again amongst experienced boarders with riskier and faster boarding.
The commonest upper limb injury is to the wrist and those with the highest risk are teenage snowboarders (95,000 snowboard wrist fractures world-wide per season). One simple technique that may protect your upper limb in the event of a fall is to learn to fall correctly. Highly recommended, is the purchase of wrist protection – either as a standalone pair of wrist guards or as an integrated glove/guard system. There is now overwhelming evidence to support their effectiveness in reducing the incidence of wrist injuries.
Whether you like two sticks or one, the things are strapped to your legs. Bones can only handle so much. Lower limb injuries affect the thigh bone, shin bones, the knee, and the ankle. Trees and another person are the commonest things to collide with. Collisions with trees in particular can be associated with some serious trauma and kissing a tree at 25mph+ is definitely to be avoided! Most of these direct impact injuries to the lower leg affect the lead (front) leg and they can range from a simple bruise up to a nasty fracture. Ankle injury as a snowboarder is related to the kind of boot (hard or soft shell) worn. Soft boots are favoured by beginners as they allow some degree of ankle movement which helps the rider to manoeuvre the board. Unfortunately they do not offer the ankle as much in the way of protection. Ankle injuries are particularly common after jumping when a combination of compression and inversion (the ankle turning in) forces are experienced. This may lead to an ankle sprain or to a more serious condition called snowboarder’s ankle, a type of fracture. Unfortunately it may not show on a normal x-ray and may need more advanced imaging. So, if you suffered an ankle injury and still have severe pain or cannot weight bear on the ankle after 1 week (maximum), you need to seek medical attention and mention this injury! If left untreated, it can lead to the early development of arthritis and long term disability.
Knee injuries are less common and less serious in snowboarders. A fair percentage of the knee injuries we see occur on drag lifts. Why? Well, the lead leg is still attached to the board whereas the trailing leg is not. If the board moves awkwardly (as it can do on a lift), any twisting force is applied to the knee joint. Similarly, snowboarders should be aware of the risks of demounting from a chairlift with one foot out of the binding. If the snowboard edge catches, this can suddenly and quite violently twist the knee of the attached leg.
Powder is soft, but trees aren’t too forgiving. The majority of those with head injuries wear no head protection. There seems little doubt that wearing a helmet makes sense. They are, however, still viewed as un-cool and not trendy. But what’s cool about brain damage?! If you are buying a helmet, try and get one that meets one of the US standards (Snell RS 98 or ASTM 2040) or the European standard EN1077).
Spinal injuries are relatively rare but devastating and are the result of a jump that has gone wrong with the boarder landing in an awkward position on the neck/back or on someone or something else.
If you plan to go off piste, consider the risks the mountain can present (eg avalanches). Check the wording of your insurance policy carefully (what d’ya mean, “what insurance policy….”??!!!) as many exclude off-piste activities and require you to be with a professional guide or instructor for cover to be valid.
And finally, drink plenty (I don’t mean alcohol), stay warm, and don’t forget the sunglasses and sunscreen lotion. So stay safe on the slopes and enjoy!