New perspective on Physio, Health & Wellness

Knee Tendonitis: Have We Missed This? ft. Jaeger O’Meara

Knee Tendonitis: Have We Missed This? ft. Jaeger O’Meara
Through my clinical experience as a Physiotherapist it seems that we might be missing something with knee tendonitis. Could the back be at fault?

This is an article I’ve brought across and re-purposed from my days at Peninsula Physiotherapy. I still feel like this is very important and needs a reboot in 2019. Back in 2017, Jaeger O’Meara’s knee tendonitis and subsequent ruptured patella tendon was one of THE most talked about injuries in the AFL. As it stands Jaeger O’Meara’s knee is still a constant source of interest and provides great context to discuss what we may be missing with knee tendonitis.

Disclaimer

It’s worth noting from the outset that I have no inside information on Jaeger. I dearly wish I did, but I don’t. I have no professional links to the star, the Gold Coast Suns or the mighty Hawthorn Football Club. The details in this article are a mix of what I could take from years of extensive media coverage of Jaeger’s knee and my many years of Physiotherapy clinical experience. I have great respect for the way AFL medical teams go about their business, so to be very clear… no pot-shots here.

This is a light-hearted attempt to get my point out there and create some discussion, so please take it in the spirit it’s intended.

It’s also worth noting that I am a Hawthorn supporter and long-term member. Coincidentally I have also experienced similar knee issues as a junior footballer. So it’s fair to say I’m invested. If those who know me professionally think I’m a massive nerd about the human body, your head would explode if you even began to think about how much I love the AFL. But I digress…

 

Intro to Jaeger and Knee Tendonitis

As a Physio, I’m afforded the luxury of recognising and exploring patterns. Things that seem to pop up time and time again with the same problems. I’ll get in to the specifics of Jaeger’s issues a little later, but as an amuse-bouche (had to google that myself), I’m seeing a pattern I’m not sure many others are in terms of a potential cause for knee tendonitis.

NOTE: The term ‘tendonitis’ is a little old-school as ‘-itis’ suggests inflammation. Interestingly, most tendon dysfunction has a distinct lack inflammation, so don’t be surprised or confused if you hear the term ‘tendonopathy’ when describing knee tendonitis. It may be more correct but hasn’t gained as much traction yet with the wider public.

For the purposes of this article I hope to assume that everything reported in the media is indeed correct. If not, it probably doesn’t matter as even though this post is about Jaeger O’Meara, it’s not really about Jaeger. Having said that, I have (creepily) stalked his Instagram account for pics that highlight what I see far too often here at Peninsula Physiotherapy. I’ve also relied on a cameo from Victor Cruz, the NFL superstar who also succumbed to a patella tendon rupture a few years ago.

In short, I think we are missing something vital with the cause of knee tendonitis, and I hope to leverage Jaeger’s obvious misfortune in a positive way to garner some attention and help spread the word.

So with that out the way strap yourselves in and let’s get a little weird.

 

Jaeger’s (Complicated) History

As most Australians reading this may already appreciate, Jaeger’s a gun. He’s been earmarked for greatness even before being drafted by the Gold Coast Suns back in 2011. His first two years in the AFL seniors yielded 44 consecutive games – a rare feat for anyone let alone a debutante. This included the 2013 Rising Star Award for the best young player in the game.

On April 4th, 2015, during a preseason practice game in Cooparoo, Queensland, Jaeger ruptured his right Patella tendon when an opponent fell across his knee while attempting a kick. A rare injury amongst the elite.

Interestingly, it was revealed that Jaeger had required off-season surgery for severe bilateral knee tendonitis during the previous season. An issue that apparently prevented him from training much, if at all that year. At the time the Gold Coast medical staff were adamant that the rupture and recent surgery were unrelated. It was deemed a freakish accident.

The original aim was for a full 12 months out. However when on the cusp of a return to reserves football again, Jaeger was sent in for an Arthroscope.

It wasn’t until July, 2016 when Jaeger was able to play again. He played well in the reserves on limited minutes over the next few weeks, until succumbing to soreness in the knee again. It was his 3rd game back.

Unfortunately that was the end of Jaeger’s 2016 campaign.

A few months later he was poached by/reluctantly traded to Hawthorn – a team renowned for their elite medical team.

At this stage he had been out of senior football for two whole seasons. Again, another rarity in today’s game.

Taking a conservative approach during the off-season, Hawthorn made it very clear that Jaeger’s return to the elite level would not be rushed. Originally, his return was slated as 4-5 rounds into the 2017 season. Interestingly, Jaeger ended up playing every pre-season practice match and the first three games of the Premiership season before missing the next two for an unrelated knock to the same knee. He returned in round 6, only to be limited in his output and subsequently sent away to work on his fitness and conditioning indefinitely.

At the time of publishing (pre-round 13, 2017), Jaeger has still not returned. By all reports he’s on track to return soon but negative speculation remains rife. (Edit: as it turns out Jaeger did not return until round 22 and was able to play out the remaining two games of the season. He did however manage to play 21/24 games in the 2018 season.)

 

Knee Tendonitis (Tendinopathy)

Time to nerd out for a minute.

For those unaware, the patella tendon forms part of the structure that connects the Quadriceps to the top of the shin via the knee cap. It’s essential for straightening the knee.

Image showing the patella tendon and it's relation to the rest of the knee. To provide visual context for knee tendonitis
The patella tendon as it connects from the patella to the top of the shin.

Knee Tendonitis Risk Factors:

Clinically, knee tendonitis (also labelled Jumper’s Knee) is a loading issue.

As the label implies, sports/activities requiring repeated jumping, landing and running seem to claim a lot of patella tendons.

We blame abnormal increases in training load, frequency and intensity. We blame a surface that is too hard and often think of it as an overuse issue.

 

The Role of Poor Leg Mechanics?

We also recognise the importance of pre-existing poor biomechanics. Issues that, when exposed to altered training factors, may become exposed and eventually fail. We’re talking tight Quads, weak trunk and hip musculature etc.

This is where I’d love to play for a minute.

Despite the Medical industry’s sophistication, I feel we are missing one major thing with knee tendonitis. One factor that if recognised and successfully altered, has the potential to change the game completely. It may provide a strong platform for initial prevention, faster recovery and long-term prevention. This may be why Jaeger and many others are prone to a really frustrating knee issue.

 

What I’m Finding Clinically

After such a big build up I’ll cut straight to the chase.

Over the last few years it seems that every knee tendonitis I’ve seen as a Physiotherapist has associated stiffness in a very specific area of the lower back.

I’m noticing a lot of stiffness through the upper Lumbar and lower Thoracic spine around the T12-L3 segments.

Not necessarily any overt pain or discomfort, but specific stiffness. The kind best found by direct poking and prodding.

Interestingly, it’s often news to most patients that this section is stiff in the first place.

The super-nerds amongst us may recognise two things. These segments house both the Femoral Nerve (travels down the front of the hip to the Quads to supply this general area) as well as the body’s knee-related Dermatomes and Myotomes (sensory and muscular neural connections left over from our development from a fetus).

Image of a spine with a section of the thoracolumar spin circled. This often feels stiff in patients with knee tendonitis
The circled section often seems stiff with those suffering knee tendonitis

This spinal stiffness also seems to be accompanied by some increased neural tension through the Femoral Nerve, which makes sense.

My working theory is that this specific spinal stiffness “pulls the slack” from any associated neural and soft tissues. It essentially acts as a hand-brake to the knee. This may force a long-term shift in way the Patella tendon is loaded, therefore pre-empting the changes we see in knee tendonitis.

It sounds ridiculous to tell a patient that an asymptomatic back may contribute to their knee pain, but my clinical experience tells me otherwise.

By mobilising a patient’s spine in the above areas there is often some level of immediate change in their symptoms. It’s by no means a cure-all or a quick fix as clearly the tendon has to remodel itself through exercises and rehabilitation. But it’s a start.

Take the hand-brake off anything and things will eventually function better.

It’s important to note that I would not expect all stiff lower backs to end up with knee tendonitis. However, I am yet to see someone over the last half a decade with a tendinopathy who isn’t stiff/dysfunctional in this specific area.

Please read in to that as you will. I urge those treating these issues to at least humour me enough to go and have a look yourselves. Prove me wrong. Do all the testing you can to get a robust sense of your patient’s current situation. Smash the crap out of that spine, improve it’s function and then re-assess everything that’s important to you. Like me, I hope you find some surprising results.

 

What’s In A Picture?

To illustrate my point, I’ve momentarily turned Instagram stalker/groupie. Instagram has been a life saver in this regard.

I’m aware that trying to reinforce a theory through photos is a tough strategy. A picture only captures a moment in time and nothing more. That moment in no way guarantees a pattern, nor does it allow for too many inferences to be drawn. But it’s the best I can do without assessing these men in person. Despite this, I think these are very helpful.

I’ve laid out four random pics I’ve taken from Instagram and Google Images. Without too much prompting, can anyone see something consistently sneaky happening to the mid/low sections of their spine?

Hopefully you can. It’s what I see everyday with my Patella Tendinopathy patients.

In each of these pictures, there seems to be a very definable “hinge” in their spine. As a rule, the spine is designed to be relatively straight, this is considered a neutral shape. If bending forward, the spine should ideally flex with a global bend, one without any specific sharper angles involved. Clinically, these hinges tend to be a beacon for stiffness as a sign of improper spinal loading.

If these pictures truly reflect what’s happening with their respective lower backs, Jaeger and Victor’s spinal function may have directly set them up to fail. Maybe not to the degree of a rupture, but most certainly when talking performance and function.

Not every patient seems to present with an obvious hinge like Jaeger and Victor but they are stiff in the same areas nonetheless.

 

The Role of Poor Posture

With this in mind it’s important to briefly discuss a potential link to bad postures and positions.

Clinically, the stiffness relating to these issues seems directly linked to poor spinal habits. So much so that if you were to watch someone with knee tendonitis sit in an unsupported position, I’d bet you’ll see their back hinge through the relevant areas. That local dysfunction has to come from somewhere.

With any conversation about posture and back dysfunction it’s important to recognise a lack of good quality research in this area. There’s disagreement in the medical fraternity about poor posture’s role in back pain, but clinically there are tangible links to explore.

As an interesting aside, I also have the exact same weak point in my spine. One that hinges just below my Thoracic spine. I had horrible postural habits as a kid and unknowingly asked my spine to bend poorly for at least a decade. I can speak to the toll it’s taken on my spine.

Where To Now?

A shift in awareness.

My industry has put a lot of time into understanding local tendon dysfunction and I honestly think this discovery also warrants strong consideration.

It’s important to note that treating spinal dysfunction alone will clearly not resolve long-term tendon dysfunction. It’s clear these days that the make up of a tendon changes in order for it to become problematic. But by improving our spinal function we could potentially:

  • solve one of if not the original causes of our tendon dysfunction
  • speed up recovery
  • decrease the risk of re-occurrence

If you have an open mind I strongly believe it’s worth looking in to.

 

Conclusion

Despite our in-depth knowledge and understanding of knee tendonitis I think we might be missing a spinal link. And why wouldn’t we? Spinal joint stiffness and dysfunction is often asymptomatic to most people. But it’s there. Or at least that’s what I am consistently finding here with my work as a Physiotherapist. In my experience we need to resolve this at some point. Conventional rehab is still vital, but can we hasten the whole process by treating the lower back as well?

From my experience, almost no injury is bad luck – or at least we give luck far too much credit. Any musculoskeletal problem happens for a reason. It’s just that the reason may not always be instantly obvious if you aren’t looking for it. Accidents clearly do happen – Jaeger can’t help someone falling across his knee as he attempted to kick the footy. But the state of our tissue and its underlying mechanics could be the difference between a year on the sidelines, a few weeks out or potentially nothing at all.

Which patella tendon is more likely to rupture if significantly challenged? One immersed in normal mechanics or dysfunctional ones?

Could the state of Jaeger’s back have been the defining feature that led to his knee tendonitis? Could it have left him vulnerable to a subsequent rupture?

I’d love to get my hands on the young man and see for myself.

So with all of this in mind I hope to draw the attention of the wider public and those in my field to this phenomenon. I hope to arm those suffering from knee tendonitis (tendinopathy) with the same perspective that I have come to learn. Take a step back and check this out for yourself – don’t just take my word for it. Speak to your relevant health professional and get them to check your back out. Hell, grab a foam roller and go hunting yourself. It’s safe, free and may be a missing piece to your rehab puzzle. It’s hard to argue with results.

I hope that I can raise a little interest towards something that I have never seen mentioned in regards to this before. I also hope that those with the ability to research and solidify this idea at least consider its merit. Selfishly I hope this promotes the kind of deeper exploration I really enjoy as a Physiotherapist.

Finally, of most importance, I hope this assists Jaeger and the Hawks in some small way. My ego isn’t anywhere near big enough to assume it will, but as a long suffering Hawks supporter (come at me) it’s worth putting this out there for that reason alone. GO HAWKS.

What are your thoughts on this? Let me know in the comments or on our forum!

Alternatively please consider sharing this article around. I’d greatly appreciate it!



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