Patella tendinopathy is one of the <a href="https://pubmed.ncbi.nlm.nih.gov/23015949/">more common injuries in the NBA.</a> Players need strategies to manage this problem during the season because cutting back on court volume and intensity isn&rsquo;t always an option.
In this series, I will discuss how I manage patella tendinopathy in-season.
When it comes to the patella tendon, I want to know the following:
<ol>
<li>How are forces being directed through the tendon?</li>
<li>Does the tendon have normal viscoelastic properties?</li>
</ol>
To answer the first question, we must know how the knee moves and examine the athletes center of gravity (COG).
We'll discuss viscoelastic properties in the next article.
<h2>Step 1: Restore Tibiofemoral Mechanics</h2>
The patella tendon (or ligament) forms a bone-to-bone connection between the patella and tibial tuberosity. It is tensioned when the knee flexes, such as when landing from a jump.&nbsp;
Therefore, when working with an athlete with patella tendon pain, checking knee range of motion is my first step. I will assess:
<ol>
<li>Supine Knee Flexion (~140 deg)</li>
<li>Tibial Rotation (~40-45 total rotation &mdash; internal and external)</li>
</ol>
The reason I look at both knee flexion and tibial rotation, is that the tibia internally rotation occurs during knee flexion (see the Knee chapter of&nbsp;<a href="https://www.amazon.com/Kinesiology-Musculoskeletal-System-Foundations-Rehabilitation/dp/0323287530/ref=sr_1_1?crid=22W73ZH19VBGJ&amp;keywords=kinesiology+of+the+musculoskeletal+system+neuman&amp;qid=1679054259&amp;sprefix=neuman+kin%2Caps%2C313&amp;sr=8-1">Kinesiology of Musculoskeletal System by Neumann</a>).
In weight bearing, the <a href="https://pubmed.ncbi.nlm.nih.gov/15598453/">majority of tibial IR occurs in shallower degrees of knee flexion.</a> Under normal conditions, this decreases the oblique orientation of the patella tendon as knee flexion increases. By 90 deg of knee bend, <a href="https://pubmed.ncbi.nlm.nih.gov/16624460/">the patella tendon will form approximately a right angle relative to the tibia plateau:</a>
<img src="https://s3.us-east-2.amazonaws.com/johndusel.com/production/images/pt-tibial-plateau-vs-knee-flexion-angle.png" alt="Graph showing the angle made by the patellar tendon and tibial plateau reaches 90 degrees when the knee is flexed 90 degrees" width="964" height="810">
I have found that a lot of athletes, will appear to have &ldquo;full knee flexion&rdquo; but lack the tibial rotation that is necessary for knee flexion to occur. &nbsp;In this case, the tibia will remain in relative external rotation in relation to the femur during knee flexion.
This can interfere with the normal twist of the patella tendon during knee flexion, overloading some areas of the tendon while simultaneously underloading others.
There are a few manual and non-manual techniques I will utilize to restore knee tibial internal rotation
<a href="https://www.youtube.com/watch?v=4T86TzqFBFY&amp;feature=youtu.be">Tibial Internal Rotation Mobilization</a>
From an exercise standpoint, I like to utilize isolate the movement and then integrate it into a movement that involves multiple joints.&nbsp;
<ol>
<li>
<a href="https://www.youtube.com/shorts/z9qeI1PcaOM">Supine Band Resisted Knee Flexion-Extension</a> Don&rsquo;t be fooled by this exercise. If you ever want to feel a VMO, this is it.
</li>
<li>
<a href="https://www.youtube.com/shorts/ihqx31zHBx0">Split Squat Isometric Hold</a>
</li>
</ol>
<h2>Step 2: Control Center of Gravity</h2>
After tibiofemoral mechanics are addressed, I will look at how the athlete manages their COG. This can be done with a simple movement such as a squat.
<img src="https://s3.us-east-2.amazonaws.com/johndusel.com/production/images/mceclip1.png" alt="Joint angle and moment difference with anterior and posterior weight shift" width="783" height="580">
The <span style="font-size: 12.0pt; font-family: 'Calibri',sans-serif; mso-ascii-theme-font: minor-latin; mso-fareast-font-family: Calibri; mso-fareast-theme-font: minor-latin; mso-hansi-theme-font: minor-latin; mso-bidi-font-family: 'Times New Roman'; mso-bidi-theme-font: minor-bidi; color: red; mso-ansi-language: EN-US; mso-fareast-language: EN-US; mso-bidi-language: AR-SA;">red line represents COG. The&nbsp;green dots are the axis of rotation for the hip and the knee. The&nbsp;<span style="color: #2e75b6; mso-themecolor: accent5; mso-themeshade: 191; mso-style-textfill-fill-color: #2E75B6; mso-style-textfill-fill-themecolor: accent5; mso-style-textfill-fill-alpha: 100.0%; mso-style-textfill-fill-colortransforms: lumm=75000;">blue lines represent external joint moments, drawn from the force vector to the center of rotation. An external moment or torque, is the product of the external force (in this case gravity) acting a distance from the center of rotation of a segment (see <a href="https://www.amazon.com/Kinesiology-Musculoskeletal-System-Foundations-Rehabilitation/dp/0323287530/ref=sr_1_1?crid=22W73ZH19VBGJ&amp;keywords=kinesiology+of+the+musculoskeletal+system+neuman&amp;qid=1679054259&amp;sprefix=neuman+kin%2Caps%2C313&amp;sr=8-1">Kinesiology of the Musculoskeletal System by Neumann</a>)
As you can see, shifting my weight forward increases knee torque (longer blue line), and shifting my weight towards my heels decreases knee torque (shorter blue line).
In NBA athletes, it is quite often to see a COG that is shifted forward. In a squat or a landing, this can be visually represented in a variety of ways.
One of the more common strategies is athletes flex their hips and turn the squat into more of a hinge. This redirects some of the ground reaction forces (GRF) away from the knee. It &ldquo;achieves&rdquo; the same outcome as shifting weight towards the heels.
<img src="https://s3.us-east-2.amazonaws.com/johndusel.com/production/images/mceclip2.png" alt="Hip dominant balance strategy" width="385" height="518">
This hip dominant pattern has been shown at higher speeds, as <a href="https://pubmed.ncbi.nlm.nih.gov/24577862/">athletes with patella tendinopathy will land in more hip flexion.</a>
However, the technical requirements constrain the athlete from always utilizing a hip flexed strategy. How many rebounds are you going to get looking at the ground?
<img src="https://s3.us-east-2.amazonaws.com/johndusel.com/production/images/mceclip3.png" alt="Three basketball athletes jumping for a ball at the net" width="393" height="552">
Image from <a href="https://en.wikipedia.org/wiki/Rebound_%28basketball%29#/media/File:InakiDeMiguel.jpg">Wikipedia</a>
A forward COG then forces the athlete into a knee bent position they cannot attain. Areas of the tendon that have been stress shielded are overloaded and problems ensue.
Increasing the capacity of the tendon itself to handle these loads is a necessary step, but <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4535734/">this can take time.</a> In-season in the NBA demand more rapid solutions.
Addressing COG can provide the athlete with an alternative movement strategy to decrease load going through the knee.
I typically seek out symptom-free exercises that teach the athlete to shift their COG posteriorly without significant compensation (trunk flexion as an example).
There are countless exercises that could be used here. The principle is to begin in more constrained and gravity-reduced positions. Load can be progressed from there. Here are three examples:
Exercise Sequence:
<ol>
<li style="text-align: left;"><a href="https://www.youtube.com/shorts/sDI11MACr5k">Wall Squat with Foam Roller</a></li>
<li style="text-align: left;"><a href="https://www.youtube.com/shorts/VkMP4guNuP0">Band Assisted Squat</a></li>
<li style="text-align: left;"><a href="https://www.youtube.com/shorts/TnlVR6mOSPA">Goblet Box Squat</a></li>
</ol>
As the athlete progresses, we increase velocity of the movement. These movements can be used as preparatory activities before the athlete is on the court. Here are two examples:
<ol>
<li><a href="https://www.youtube.com/shorts/6nW05hsD6T4?feature=share">Plate Squat Toe Drops</a></li>
<li><a href="https://www.youtube.com/shorts/UNtDu4xVT5Y">Band Resisted Squats&nbsp;</a></li>
</ol>
In part two of Managing In-Season Patella Tendinopathy, we'll examine strategies to aimed at improving patella tendon behavior.&nbsp;

A Full Court Press: Overcoming In-Season Patella Tendinopathy

Denver and Utah <a href="https://insider.espn.com/nba/insider/story/_/id/9014283/nba-analyzing-real-home-court-advantage-utah-jazz-denver-nuggets">consistently</a> <a href="https://practicallypredictable.com/2018/01/23/nba-teams-different-amounts-home-court-advantage/">rank</a> among the best homecourt advantages in the NBA. There has even been research suggesting the&nbsp;<a href="https://harvardsportsanalysis.wordpress.com/2011/05/18/does-altitude-affect-free-throw-percentage/">road teams shoot a lower free throw percentage at altitude</a>. Talking to NBA athletes about playing on the road at altitude, they often describe feeling out of breath, especially the first few minutes they are on the court. Less total oxygen available at altitude leads to&nbsp;hypoxia &mdash; lower levels of oxygen in the blood.
In this post I will discuss:
<ol>
<li>The impact of altitude on basketball performance</li>
<li>In-game strategies I have used to help NBA athletes perform at altitude</li>
</ol>
It is common practice in the NBA to have a hard session, immediately upon arrival with the thought of &ldquo;getting used to the altitude.&rdquo; However, <a href="https://pubmed.ncbi.nlm.nih.gov/23751901/">research has shown it can take up to 6 days to acclimatize in Denver</a>. The density of the NBA schedule doesn&rsquo;t allow this to happen, as teams will fly in most often within 24 hours of the game.&nbsp;
<h2>Two Strategies for Game Day Performance</h2>
This past season, we played Utah and Denver on back-to-back games. We landed in Denver at 2am. This left approximately 17 hours until tip off. &nbsp;Given the constraints, our staff utilized a two-step process to maximize performance.&nbsp;
<h3>Step 1: Coach our athletes' breathing</h3>
Ventilation allows for the exchange of O2 and CO2, we are driven to keep O2 levels high for survival. Hypoxia corresponds to a linear decrease in VO2 max (see p. 541 of <a href="https://www.amazon.com/Exercise-Physiology-Human-Bioenergetics-Applications/dp/0072556420">Exercise Physiology by Brooks, Fahey, and Baldwin</a>). Efficiency drops and athletes are operating at a higher percentage of their maximum workload. Hypoxia causes athletes to hyperventilate, this increases O2 consumption and decreases CO2 levels.
To realize the impact of hyperventilation, we must look at the connection between O2 and hemoglobin. Hemoglobin is the transporter molecule that is bound to oxygen. The Oxyhemoglobin dissociation curve (ODC) describes how blood carries and releases oxygen via its relationship with hemoglobin.
As a result of the drop in CO2, Hyperventilation shifts the ODC curve to the left.
<img src="https://s3.us-east-2.amazonaws.com/johndusel.com/production/images/Oxygen_Dissociation_Curve.png" alt="Oxygen Dissociation Curve" width="556" height="418">
Hyperventilation is a double-edged sword; It does increase oxygen levels; however, it increases how tightly hemoglobin binds to oxygen (Brooks, Fahey &amp; Baldwin, 2019). This left shift in the graph means it takes a lower concentration of oxygen for hemoglobin to liberate O2 in the tissues.
Restoring the O2 / CO2 &nbsp;relationship by decreasing hyperventilation is paramount. &nbsp;We aimed to educate our athletes on controlling their breathing rate and depth. <a href="https://pubmed.ncbi.nlm.nih.gov/23152851/">Slow, deep breathing (6 breath cycles per min for 5 min) at altitude has been shown to significantly increase blood oxygen, without the negative secondary consequences of hyperventilation.</a>
An easy to learn breathing technique is square or box breathing.
<img src="https://s3.us-east-2.amazonaws.com/johndusel.com/production/images/Screen_Shot_2023-03-27_at_10.36.28_PM.png" alt="Box breathing" width="663" height="509">
Source: <a href="https://www.bsu.edu/-/media/www/departmentalcontent/counseling-practicum-clinic/pdfs-new-website/square-breathing.pdf?sc_lang=en&amp;hash=C93DFFEF567518288125A59798B2C3A3325CAECD" target="_blank" rel="noopener">bsu.edu</a>
If you want to look more into breathing strategies to improve athletic performance, I recommend looking into <a href="https://oxygenadvantage.com/science/holding-your-breath-benefits/">Oxygen Advantage</a>.
<h3>Step 2: Use of supplemental oxygen</h3>
There is conflicting research regarding the benefit of supplemental oxygen for athletic performance at altitude. <a href="https://doi.org/10.1371/journal.pone.0140616">Some research supports using it</a>, while <a href="https://link.springer.com/article/10.1007/s40279-022-01803-y">others question its impact</a>. Ultimately, our staff choose to use it in-game for recovery periods.
I can&rsquo;t stress enough, that you MUST get step #1 down first. The key with supplemental oxygen at altitude is to first control ventilation. If you don&rsquo;t and you inhale a ton of oxygen all at once, you might get the opposite impact of what you want (remember the ODC curve)?
The breathing sequence we taught to our athletes on the pregame and on the bench was:
<ul>
<li>3 cycles of box breathing</li>
<li>1 inhalation with supplemental oxygen</li>
<li>3 cycles of box breathing</li>
<li>Repeat two times</li>
</ul>
This roughly equates to 6 min of controlled breathing.
Products like <a href="https://www.boostoxygen.com/">Boost Oxygen</a>, now make supplemental oxygen that is in small canisters and relatively inexpensive.
<h2>Summary</h2>
<ul>
<li>Altitude leads to hyperventilation which impacts the ratio of O2 to CO2 in our bodies</li>
<li>First control your breathing rate</li>
<li>There may be some value to supplemental oxygen (IF breathing slowed FIRST)</li>
</ul>

Buffering the Mile High Advantage: A two-step process to improve in-game NBA performance at altitude

John is the thinking man's athletic trainer and coach. His ability to combine a deep academic understanding of human movement, pathology and performance with the practical needs of athletes and their teams make him a rare bird in the pro sport space. I was lucky and grateful to have him on my team for as many years as I did.

John Dusel

Latest Posts

A Full Court Press: Overcoming In-Season Patella Tendinopathy

Buffering the Mile High Advantage: A two-step process to improve in-game NBA performance at altitude