T Nation

Chronic Tibial Tuberosity Pain (Still)


#21

I’ve had the same problem for the past few months, stemming from a volleyball game. Saw the athletic therapists at my university and was told i had a very tight vastus lateralis. Began with some deep tissue work, some PNF stretching and foam rolling along. I began with basic lunges and bodyweight squats, and have progressed to more difficult split squat variations and drop-jumps. Glad to say that over the last 5 weeks the pain had receeded greatly and that after a good warm up i can play a full volleyball game with minimal soreness in the morning. Also, wearing kneepads while playing i feel has helped by keeping the tendon warm the whole time.


#22

i have this same problem, i originally had the pain on my tendon i guess from putting too much stress on that leg when i was nursing my ankle on the other leg, Doc told me to rest for 3 weeks and take anti inflammatory, i did this and the pain was gone. but when i started playing soccer again the pain came back. i have had this pain for a year now. i hope i haven’t damaged myself permanently. by not resting.


#23

Hey Andy, I’d second the suggestion to looking into prolotherapy at the tibial tuberosity as well as dry needling and neural therapy of the quad and IT band. You mentioned you have done a fair bit of foam rolling already but perhaps some more aggressive trigger point work on your thigh may provide some relief.

I had a similar injury (bilaterally) that nagged me for sometime, lifting let alone getting out of bed the car as well as stairs were all quite painful. I finally got around to trying prolo and neural therapy and I never looked back.


#24

prolo is expensive. and the whole idea is to create an inflammatory response, which im sure you can do yourself by stressing your leg. plus you have to go back multiple times. i dont understand why an xray’s and MRI dont give any useful info in to treating this problem.


#25

I agree, it’s an expensive therapy. However, when you have struggled with something like this and burnt countless money and time on other things that have provided only some or no relief there comes a point where you have to ask what your health is worth to you. That helped push me along but I can’t say for Andy if this is where he is currently at. If he is making progress with other therapies there may be no need for prolo.


#26

My opinion is my current treatment is working. I am getting ART twice a week now (as I said before, from the Chicago Bears chiropractor, guy is really freaking good), and then some needling done on my VMO and adductor area so that I get a better contraction before my rehab exercises (Peterson step-ups, adductor/post med glute work, ankle eversion). I also do SMR on myself every day before my rehab movements.

While I think there is some definite tendinosis in my left patellar tendon, I think that is secondary to what was causing my pain directly on the bone of the tibial plateau area. There is a huge difference between the way my right VMO contracts (healthy knee), and the way my left VMO contracts (i.e. I can’t really feel it contracted at all, and thus inhibited). So my chiro diagnosed me as having patellar tendinitis at the tibial tuberosity, and the inflammation keeps coming back because when my shin feels better, I start squatting again but have the same dysfunction as before and thus, the pain comes back because of too much tension on the patellar tendon, for a number of reasons. He said my VMO is inhibited and my lateral quad/rectus femoris takes all the load, my adductors are weak and so is my glute med. He watches my squat every session and at the first visit he said my tibia was rotating a lot or something, and lately he says my left leg almost looks like the right leg when I squat so we are almost there.

Combine all this^ with the way I was squatting (knees over toes, Olympic style, with a heel elevation), and doing it nearly everyday… = my chronic inflammation pain.


#27

so you are basically strengthening all the muscles of your bad leg, so that when you start squatting again you don’t put too much pressure on the injured area???. you are also resting/ not running or anything while getting this treatment right? man i hope you get better, because if you do, then there hope for me lol.


#28

[quote]thepain wrote:
so you are basically strengthening all the muscles of your bad leg, so that when you start squatting again you don’t put too much pressure on the injured area???. you are also resting/ not running or anything while getting this treatment right? man i hope you get better, because if you do, then there hope for me lol. [/quote]
Pretty much. Since the beginning of treatment I have not done any leg work (besides hamstring/glute work), and no running. I do the rehab exercises nearly every day.


#29

Hey guy’s I have the exact same problem, I have a very excruciating pain in my right tibial tuberocity, I’ve never had OS, but I get similar symtoms.
I play racquetball, and my pain started playing my passion sport 2 years ago. I’m from Honduras and the doctors here have other priorities than observe my particular case, so everybody here just tell me to rest and retire from racquetball, I’m only 29 years old, and I’m not planning to stop doing what I love. But definitely the pain is bringing down my level, I can’t run without have this unberable pain, and it’s definitely not healthy.

I’m really excited I found this thread, in my country there aren’t too many physicians or Chiropractors, but I just found one, He seems good and I’m visiting him tomorrow, He sent me do some X ray’s to dismiss OS (although I’m certain I’m negative). I wear a knee strap and it helped at the begining, now I feel it’s doing nothing and I just wear it for Psicological boost ha! I have noticed that when I do stretch well, the pain is less intense. I have rested for 3 months, ice therapy, iboprufen, etc…

Please tell me how did you’re condition progressed? I want to take what your therapist did to you, and give it to mine!! Please tell me it works! I need to get to my level back up again!

Give us some updates!


#30

[quote]jrveroy wrote:
Hey guy’s I have the exact same problem, I have a very excruciating pain in my right tibial tuberocity, I’ve never had OS, but I get similar symtoms.
I play racquetball, and my pain started playing my passion sport 2 years ago. I’m from Honduras and the doctors here have other priorities than observe my particular case, so everybody here just tell me to rest and retire from racquetball, I’m only 29 years old, and I’m not planning to stop doing what I love. But definitely the pain is bringing down my level, I can’t run without have this unberable pain, and it’s definitely not healthy.

I’m really excited I found this thread, in my country there aren’t too many physicians or Chiropractors, but I just found one, He seems good and I’m visiting him tomorrow, He sent me do some X ray’s to dismiss OS (although I’m certain I’m negative). I wear a knee strap and it helped at the begining, now I feel it’s doing nothing and I just wear it for Psicological boost ha! I have noticed that when I do stretch well, the pain is less intense. I have rested for 3 months, ice therapy, iboprufen, etc…

Please tell me how did you’re condition progressed? I want to take what your therapist did to you, and give it to mine!! Please tell me it works! I need to get to my level back up again!

Give us some updates![/quote]
You still around for an update?


#31

Yes! Please!


#32

[quote]jrveroy wrote:
Yes! Please![/quote]
OK well I have one visit left in one week. At this point I have no pain on my tibial tuberosity, but some general tenderness at the inferior pole of my patella, which is probably some patellar tendinosis going on that can be remedied by eccentric single-leg squats on a decline board. This particular pain doesn’t bother me as it is not significant… the tibial tuberosity pain was the issue that would make me have to stop training immediately because it would only get worse, and hurt for days/even weeks.

Anyways, so I was in pain on the TT the first visit I saw the chiro, and the pain went away (as usual over the past two years) in about two weeks. The issue with me is that the pain will always come back… sometimes in the first workout of the week, sometimes much later. Two ortho docs have told me it is patellar tendonITIS, and I guess they were correct, even though this problem has been very chronic. Keep in mind that I have had an X-ray and MRI and both were unremarkable.

  1. This is what he does ART on to get rid of balled up/tightened muscles. If you have trigger points, strengthening certain muscles may be useless as inhibition may occur. He wants me to use a rumble roller/lacrosse ball on these muscles whenever I can as well.

Iliopsoas - he said mine were pretty good, but he does ART on it anyways
Rectus femoris and vastus lateralis
TFL
Adductors
Medial hamstring
Piriformis/other external rotators
Gastrocnemius

  1. He said these muscles of mine were weak, so he had me to rehab exercises for them:

Ab group (rectus abs, transverse abdominus) - he has me do core stabilization-type exercises
Gluteus medius/post glute med - hip abduction wall slides, side-lying clams
Gluteus maximus - glute bridge, single-leg glute bridge, bird dogs
VMO - peterson step-ups (my opinion is that you cannot preferentially recruit the VMO, I will explain in a bit)
Tibialis anterior - any dorsiflexion exercise… not a deal breaker, just something to add in
Plantar fascia - I basically try to strengthen my intrinsic foot muscles by gripping the floor

The main reason of why I was having this pain was two reasons: squat form and overuse. I was training too much without balancing the posterior chain, and I was also squatting in a way that has tremendous translitory force up and down the tibia. It was a typical Olympic high-bar squat, with elevated heels, and bending at the knees first and not engaging the glutes at ALL. I was doing this for years (also push presses, quad-focused deadlifts, jerks, and so on) and then my pain came on during a jerk, not surprising. So right now I am squatting with no elevated heel, pushing my hips back more, pushing the knees out to increase torque on the hip external rotators, and engaging/squeezing the glutes on the way up. I also have to keep my training sessions in check, and make sure I do daily stretches (2 minutes each) for the quads/rectus femoris, hips (couch stretch for both), calves, and hamstrings. Now stretching hamstrings is not really necessary for most. You would be better off focusing improving anterior pelvic tilt by strengthening the glute max and stretching the hips, which should decrease the tension on the hamstrings. Remember, the more you are tensed up through the quads, calves, and hamtsrings, the more tension there is on the patellar tendon.

I would check out these websites:

http://www.dynamicchiropractic.com/mpacms/dc/article.php?id=52178


#33

Now, I said I don’t think you can preferentially recruit the VMO over the VL above, and that I would explain why in the above post. First, this is still a debate right now among researchers… some like to prescribe exercises that are supposed to focus on the VMO (Peterson step-ups, TKE’s, etc), while others think it is pointless. There was actually a systematic review of EMG studies on if the VMO can be recruited preferentially over the VL ( http://www.ncbi.nlm.nih.gov/pubmed/19212898 ), and they stated: “These reported principally that altering lower limb joint orientation or the addition of a co-contraction does not preferentially enhance VMO activity over VL”.

My opinion is… with someone who has patellar tendon or tibial tuberosity pain, we can assume they are just straight-up over-tensed through the quads/rectus femoris, no? Why then would we want to focus on a knee extension exercise to make them even more balled up, and enforce a ‘knees-first’ squat pattern? I think it would be a better idea to focus strengthening dormant muscles and doing SMR on trigger points and just let the VMO fall into place… from the second link I posted above:

“The gluteus maximus (GM) is primarily responsible for eccentric deceleration of hip flexion, internal rotation and adduction. Weakness or inhibition of the GM increases sacral rotation and stresses the tibiofemoral joint, leading to patellar tendonitis. This alters the length-tense relationship of several muscles. The gluteus medius is weakened, taking away its ability to perform hip abduction. The TFL and iliotibial band begin to compensate, and this overactivity inhibits the vastus medialis oblique (VMO), increasing femoral flexion, internal rotation and adduction. This increases stress to the tibiofemoral joint and the patellofemoral joint.”


#34

Oh and Jrveroy… if you are hurting right now (training through the pain in hopes something magical will happen from one visit with a doctor) you need to stop hurting. Rest your knee, and do rehab, and see what your doctor says. I believe tibial tubercle pain (if one doesn’t have Osgood or a stress fracture) is basically considered patellar tendonitis.


#35

I’m glad I found this thread. I’m having the same issues on and off for about 8 months now. I’ve done some ART and it seemed to be getting better but had to stop because the office was so far away.

You mentioned you have a new chiropractor doing ART and he works with some sports teams. Would you mind sharing who you normally see?

Thanks!


#36

[quote]hiccup wrote:
I’m glad I found this thread. I’m having the same issues on and off for about 8 months now. I’ve done some ART and it seemed to be getting better but had to stop because the office was so far away.

You mentioned you have a new chiropractor doing ART and he works with some sports teams. Would you mind sharing who you normally see?

Thanks! [/quote]
Dr. Josh Akin in Chicago. Chiropractor for the CHI Bears and Cubs.


#37

Great. Thank you.

How are you feeling? Everything still going well?


#38

[quote]hiccup wrote:
Great. Thank you.

How are you feeling? Everything still going well? [/quote]
Yep. Still a little pain on the patellar tendon right under the inferior pole of the patella, but that is not worrisome to me… probably some tendinosis. The pain on the tibial tuberosity has been gone for awhile, so it’s just a matter now of not doing too much too soon, keeping up the rehab exercises (foot intrinsic muscles, ankle eversion, big toe exercise, glute med/max, VMO), and making sure I am squatting correctly (which I wasn’t, he totally changed my squat technique).

This week he wants me to start squatting with weight (work up to 135 lbs), and doing 1/2 mile runs 2x a week.


#39

Thanks Andy! I’ll take your advice. I’m very happy I found this, now I have something to work with my dr.

Take care, and I hope ypu guys get better too.

Junior.


#40

Well, I thought things were going well, but the pain came back two days ago during an overhead squat. So mark that off the list of ‘things that didn’t work’ for me.

In the meantime I am doing ice massage to get the inflammation down, and going to do some stretching of the quads later today.

Kind of out of ideas. My only options at this point are 1) go back to one of my physios who was treating it as patellar tendinopathy (eccentric decline squat protocol, etc), 2) prolotherapy, or 3) surgery, although this seems unlikely because I have no idea what kind of surgery this would be and whether it would even be effective or not.