Causes & Treatments For Knee Enthesopathy

Common Knee Enthesopathies

Knee enthesopathy is a disorder of the tendon or ligament as it attaches to the bone. Common enthesopathies occurring around the knee are at attachment sites on or around the patella bone, femur, tibia, and fibula.

Enthesopathies are usually the result of excessive stress or strain across the tendon and its attachment to the bone. Improper joint mechanics, muscle imbalance, or excessive activity can lead to the tissue damage. Multiple treatments are available to improve the tendon, ligament, or bone damage.

Systemic Enthesopathies

Some types of enthesopathies are related to inflammatory conditions such as Ankylosing Spondylitis or Rheumatoid Arthritis. Psoriatic arthritis can also cause enthesopathies around the knee. Enthesopathies that are the result of systemic conditions may require consistent medical and pharmacologic treatment to prevent future progression and deterioration of tendons and ligaments.

Tendon and Ligament Damage from Excessive Strain

The most common enthesopathies are the result of excessive stress and strain to the muscles, tendons, and ligaments that attach around the knee. In younger individuals, this is usually the result of sports, weight lifting, or running activities. In older individuals it can be the result of chronic, repetitive stress and strain to the tissues.

Conservative treatments for enthesopathies are very similar for both younger and older individuals. The exercises, physical therapy, massage therapy, and soft-tissue treatments vary depending on the specific tissue that is injured and the patient's overall goals.

tissue progression diagram

Enthesopathies can occur anywhere along the knee but are very common where the quadriceps muscle becomes a quadriceps tendon and attaches onto the patella bone. The patella tendon has an insertion along the superior or top of the patella bone. Enthesopathies can occur along the anterior surface where the patella tendon wraps around the bone, as well as also on the inferior or bottom of the patella bone. Patellar tendonitis is damage to the patella tendon as it attaches to the patella bone. Whereas patellar ligament strains are from the patella bone to its attachment site on the tibia.

quadriceps muscle anterior 3 labeled

Outside of the Knee

Iliotibial band syndrome is a very common tendon injury on the lateral aspect of the knee. The iliotibial tendon helps stabilize the knee and prevent excessive internal rotation or "wobbling" during walking. The rocking, or wobbling, is associated with knee muscle weakness, a lack of stability, and neuromuscular coordination. Iliotibial band friction syndrome is very common in runners and older patients with knee or hip weakness. It is also common in individuals with significant ankle, knee, hip, or back degenerative changes that cause limping.

Inside of the Knee

knee tendons medial labeled

On the inside or medial side of the knee we can see multiple types of enthesopathies at the pes anserine. The pes anserine is where three distinct tendons insert on the inside of the tibia below the knee: sartorius, gracilis, and semitendinosus muscles. These muscles help control the wobble or internal rotation of the knee during walking, running, and squatting motions. When these tendons are injured they become very tender to palpation. Many times people think they have internal knee damage or meniscus tears when really they are experiencing moderate to severe pes anserine enthesopathy.

On the back side of the knee, the popliteus, gastrocnemius, semimembranosus, and biceps femoris muscles cross the back of the knee to insert on the tibia and fibula. These strong and powerful muscles can develop micro tears and tissue damage anywhere across the muscles, tendons, or attachment points along the bone. Enthesopathy along the bone produces acute tenderness to palpation at the muscles insertion point. Patients often experience pain when flexing these muscles against resistance, squatting, or climbing stairs.

LCL and MCL Enthesopathies

The lateral collateral ligament (LCL) and medial collateral ligament (MCL) are another potential knee enthesopathy. These large stabilizing ligaments prevent excessive varus and valgus motions and prevent the knee from bending internally or externally. We often talk about damage to these ligaments with football or tackling-type injuries that bend the knee.

Knee Treatments for Enthesopathies

Cold Laser Knee Pain

Treatment for knee enthesopathies vary depending on the location and damage to adjacent tissues. Some patients respond better to massage therapy, Chiropractic, Physical Therapy, Graston Technique, Active Release Technique, Cold Laser, electric, heat, ice, stretching, or proprioceptive exercises.

The goals of treatment are always too decrease pain and inflammation in the injured tendons and ligaments. Goals of the next phase of treatment are to increase strength, endurance, and stability to the knee. A variety of exercises and activities can enhance these motions and movements preventing future injuries. Specific exercises depend on which muscles are weak and causing the chronic, repetitive stress injuries.

Anatomy of the Knee Joint

knee model patella labeled

The large femur sits atop of the tibia, much like two pillars stacked on top of each other. The smaller fibula bone is on the outside of the tibia in the lower leg. The fibula provides some weight bearing but not near as much as the tibia. At the end of the femur are two large condyles with rounded edges that allow for the rocking or hinging motion associated with knee movement.

In between the femur and the tibia are fibrocartilage shock absorbers or meniscus. Several large stabilizing ligaments on the inside and outside of the knee prevent excessive forward and backwards movements. These stabilizing ligaments include the Anterior Cruciate Ligament (ACL) and Posterior Cruciate Ligament (PCL), and the previously mentioned LCL and MCL.

The patella bone sits in front of the femur and slides in a groove. The backside of the patella is covered with hyaline cartilage along with the front side of the groove on the femur, which minimizes the friction as the patella slides. The patella is a large sesamoid bone which means it is surrounded in muscle or tendon. Sesamoid bones act as a pulley system to change the direction of forces, in this case from the quadriceps muscle to the tibia.

The knee is a complex joint that is surrounded by a ligament joint capsule and lined with a synovial membrane that produces synovial fluid which helps lubricate the knee. The lubrication reduces friction and damage to the internal components of the knee. Bursa are fluid-filled sacs that help reduce friction as muscles and tendons glide across the bursa.

Home Treatments

At home the first step is always PRICE: Protect, rest, ice, compress, and elevate. Reduce the stress and strain to the knee. Over the counter nonsteroidal anti inflammatory drugs (NSAIDs) as recommended by your doctor can help reduce pain and inflammation. Ice helps block the knee pain and reduce inflammation.

Medical Treatments

NSAIDs are often prescribed for the initial acute injury stages. In severe cases that involve multiple joint regions, muscle relaxers or oral steroids can be given. Trigger point injections, botox, or steroid injections can be treatment options, as well. Pain management is not usually required unless stronger medications or joint injections are involved in treatment.

MRI and X-rays will not usually be ordered to evaluate mild to moderate muscle, tendon, and ligament injuries. Severe cases may utilize advanced imaging to rule out bone fractures, edema, nerve entrapments, tendon or muscle ruptures. Nerve conduction velocity (NCV) testing may be utilized in cases that also involve muscle, sensory, or reflex loss.

Conservative Treatments

GT therapy

Therapeutic treatments for addressing soft tissue injuries involve massage therapy, manual therapy, trigger point therapy, Graston Technique, or Active Release Technique. These treatments increase blood flow, decrease muscle spasms, enhance flexibility, speed healing, and promote proper tissue repair.

When these treatments are incorporated into a treatment plan, patients heal faster and are less likely to have long-term pain or soft tissue fibrosis or scar tissue in the injured muscle. These soft tissue treatments are incorporated with therapeutic exercises and flexibility programs.

Video: Scar Tissue Treatment with Graston Technique

Improve Movements to Eliminate Knee Pain

The lower extremity works as a comprehensive unit performing many of the repetitive tasks at home, work, and recreational sports. Injuries to one area of the musculature often indicate that additional damage has been incurred by other muscles.

Many therapeutic exercises can help restore proper strength and endurance to the leg muscles. Isometric exercises are often the initial treatment exercises, followed by single plane rubber band exercises for the hip, knee, and ankle: flexion, extension, adduction, abduction, circumduction, inversion, and eversion. Dynamic exercises involving stability foam, rubber discs, exercise ball, and BOSU balls can be performed on the floor. The more unstable of the surface, the more effort and stabilization is required of all the lower extremity muscles.

Vibration plates enhance neuromuscular learning throughout the ankle, knee, foot, hip, and back muscles. Additional strength exercises can be found on the hip, knee, and foot strengthening pages. More information for injuries and treatments for knee pain and foot pain.

Our Chandler Chiropractic & Physical Therapy clinic treats patients with a variety of muscle, tendon, joint, and ligament injuries. The clinic provides treatment for runners, tri-athletes, and weekend warriors in addition to common headache, neck, and back patients traditionally seen in Chiropractic, Physical Therapy, Massage Therapy clinics. We work with all ages and abilities of the residents in Phoenix, Tempe, Gilbert, Mesa, and Chandler AZ.