Dr Bowers’ Office Hours: Andrew Miller…Again

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Updated: August 23, 2017

On Monday, August 21 Andrew Miller was removed from a game against the Red Sox as all of Cleveland held their collective breath. Following the game, it was revealed that Miller had re-aggravated his patellar tendonitis; the southpaw was subsequently placed on the disabled list. The team indicated they are consulting with the Cleveland Cavaliers to determine the best course of management of the injury.   

 

My take. Andrew Miller’s first go around on the disabled list for his patellar tendonitis seemed to do the trick until a large drop off in the velocity of his fastball surfaced on Monday night. In terms of knee injuries, this is the best-case scenario for Miller as the team has not made any mention of damage to ligaments or cartilage in the knee. The team needs to take their time and get Miller ready to go for the postseason. Provided the team is not withholding any additional information regarding Miller’s knee, this injury is a very minor bump in the road. Patellar tendonitis is not a very common injury in baseball players with only two cases of the condition reported during the 2016 season (Heat Maps 2016 Injury Data). I anticipate the Indians will err on the side of caution in preparation for October. Expect a mid-September return from Miller, provided he doesn’t incur any setbacks. 

 

What is it? The patellar tendon is located immediately below the patella (kneecap); its purpose is to connect the patella to the tibia (shin bone) and assist the quad (thigh) muscle to straighten the knee. The suffix -itis refers to inflammation, so the term “tendonitis” indicates tendon inflammation. Patellar tendonitis is often times referred to as “jumper’s knee” and manifests itself as pain just below the kneecap, along the patellar tendon. The condition is most often seen in individuals who are subject to repetitive jumping such as basketball and volleyball players. Secondary to increased levels of pain, deficits in strength, range of motion and overall functional level can also be present. This condition is something that develops over time as a result of repetitive stress on the knee joint, patella and patellar tendon. Patellar tendonitis should not be confused with a condition called Osgood Schlatter’s disease, which results in similar knee pain during childhood.

 

How is it fixed? More often than not, conservative management of patellar tendonitis goes a long way. The key piece with any type of tendonitis is a temporary shutdown from the activity which aggravates the patient’s symptoms. 

If the individual continues to be subject to the aggravating activity which causes their symptoms/pain, then the body will have a difficult time progressing through the healing process. 

Physical therapy intervention for patellar tendonitis will incorporate a period of pain control early on via rest and ice among other things. A licensed rehabilitation professional will examine the patient’s strength and range of motion of their legs and identify any deficits which may be contributing to the problem. From here an effort to improve strength through the hips and quadriceps muscle will be made in order to provide better stability for the knee. 

The most important part of rehab for patellar tendonitis is something referred to as eccentric strengthening. The primary two types of muscle contraction utilized during exercise are concentric contractions and eccentric contractions.  Concentric contractions refer to the shortening of a muscle and its muscle fibers and eccentric contractions refer to the lengthening of a muscle and its muscle fibers. If we consider a bicep curl, for example, the concentric phase of the contraction occurs when an individual bends the elbow and dumbbell up towards the shoulder. Subsequently, the eccentric portion of the contraction occurs when the elbow extends and the individual lowers the dumbbell back down to the starting position. Concentric strengthening of the quadriceps muscle occurs with knee straightening and eccentric strengthening occurs with controlled knee bending with the foot on the ground. Eccentric strengthening assists in developing better control of a muscle and the joint it helps support. 

Once the individual is able to demonstrate pain free strength and range of motion of the leg/knee a progression to dynamic functional activities will be initiated. The individual will be allowed to continue to progress through rehab so long as they do not encounter any setbacks along the way. Return to baseball specific activities is the last phase of rehab and can begin once the player has cleared all previous physical therapy and functional goals.  

We will continue to monitor the status of Andrew Miller as he progresses through the rehab process and will provide the most up to date injury explanation and analysis as new information becomes available.

 

Brandon Bowers, PT, DPT, is a graduate of the University of Toledo, Doctor of Physical Therapy Program and currently practices in Columbus, Ohio. He is an avid Cleveland sports fan and has experience rehabbing athletes of all levels and from a variety of sports. Follow Brandon on Twitter for more Cleveland Indians injury insight and analysis: @blbowers12

 

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