Patellar Tendinopathy
1. Introduction
This condition commonly presents with anterior knee pain at the lower border of the kneecap (the inferior pole of the patella). Tendinopathy of the patellar tendon is also known as ‘jumpers knee’ due to its close association with the athletic population. For a long time, we called tendinopathies ‘tendinitis’ in a similar way to other tendon issues such as Achilles tendonitis, tennis elbow and golfers elbow. This was because we believed there was a lot of inflammation involved in the condition leading to treatments such as steroid injections and strong anti-inflammatory medication (such as Diclofenac or Naproxen). Over the past 15 years research has shown that there is not as much inflammation as we thought, and tendon degeneration seems to be a key element.
Treatments such as steroid injections are now not advised as they appear to cause much more harm than good in tendon issues. Our understanding of the best way to manage tendon problems is developing rapidly and it’s not unusual for patients to be working on outdated and less effective treatment approaches. We review the information on our website continually to ensure we are giving the best advice by integrating current research evidence with our clinical expertise.
Frequently Asked Questions
- This is a condition that involves microscopic damage to the tendon, typically due to overuse that causes pain when you bend the knee.
- In the general population, it affects less than 1% of people.
- It is much more common in younger, very active individuals. In this higher risk category, approximately 6% of patients with knee pain may present with patellar tendinopathy (1).
- No.
- With the right rehabilitation approach, tendinopathies generally recover well and are not linked to other serious pathology.
- Under 25-year-olds.
- Repetitive jumping sports such as basketball, volleyball.
- Males more commonly affected.
- Pain just below the kneecap with activity e.g. jumping, running, squatting.
- Pain with any pressure through the tendon e.g. touch, kneeling.
- Aching and stiffness after activity.
- Stiffness in the morning.
- Thickening of the tendon.
- Modifying your activity.
- Progressively loading the tendon as it recovers has been shown to be most effective.
- Advice by a qualified physiotherapist may be helpful in most cases.
- Initial recovery is usually within 2 to 3 months and full recovery is usually within 3 to 6 months.
- About 80% of people will fully recover within 12 months (2).
We recommend consulting a musculoskeletal physiotherapist to ensure exercises are best suited to your recovery. If you are carrying out an exercise regime without consulting a healthcare professional, you do so at your own risk.
2. Signs and Symptoms
Symptoms are localised to the inferior pole (bottom) of the patella and exacerbation of pain will come from activities that require repeated utilisation of the ‘spring action’ of the tendon. Squatting, prolonged sitting with the knees bent, and stairs, are common actions that are reported as aggravators.
Tendon pain is ‘dose–dependent’, which means the pain will be aggravated based on the amount of load and the volume it is subjected to (5). Essentially, if you load the tendon excessively by exposing it to higher tensile forces or by performing many repetitive movements in a relatively short period of time, the tendon cannot adapt quickly enough and may begin to break down, leading to pain and ultimately the risk of developing a tendinopathy. Gradually progressing load and training is the best way to avoid developing tendinopathies.
3. Causes
Symptoms usually develop alongside an increase in load or activity and therefore most prevalent in young sporty adults. The power needed for jumping, landing, cutting, and pivoting when participating in these sports requires the patellar tendon to repetitively store and release energy, placing considerable load through the tendon (7). Energy storage and release (like a spring) from the long tendons is vital to us as this can reduce the energy consumption through human movement. Repetition of this spring-like activity over a single exercise session, or with insufficient rest to enable repair & remodelling between sessions, can induce pathology and a change in the tendon’s mechanical properties, which is a risk factor for developing symptoms (7, 4).
4. Risk Factors
This is not an exhaustive list. These factors could increase the likelihood of someone developing patellar tendinopathy. It does not mean everyone with these risk factors will develop symptoms (4, 6).
- Under 25
- Gender – men are more prone than women
- Being overweight – increased load on the tendons
- Poor flexibility – tight quadriceps muscles
- Lack of variation in training
- Sudden rise in training intensity/volume with a lack of preparedness
- Poor strength – mainly in hip and knee muscles
- Training involving excessive hill running
- Poor balance between plyometric exercises (explosive jumping/bounding movements) and graded strengthening
5. Prevalence
In the general population, it affects less than 1% of people.
It is more common in young athletes (between the age of 15-30) who are heavily involved in sports such as basketball, volleyball, athletic jump events, tennis, and football. In this higher risk category, less than 6% of patients with knee pain may present with patellar tendinopathy.
6. Assessment & Diagnosis
A musculoskeletal physiotherapist can provide you with an accurate and timely diagnosis by obtaining a detailed history of your symptoms. A series of physical tests might be performed as part of your assessment to rule out other structures involved, get a greater understanding of your mobility and strength, and to help facilitate an accurate diagnosis.
Your physiotherapist will want to know how your condition is affecting your day-to-day so that your treatment can be tailored to your needs and will mean personalised goals can be established. Intermittent re-assessment will ascertain if you are making the best progress towards your goals and will allow adjustments to your treatment to be made. Imaging like magnetic resonance imaging (MRI) or ultrasound scans are usually not required to achieve a good working diagnosis, but in unusual presentations, they may be warranted.
7. Self-Management
As part of your treatment, your physiotherapist will help you understand the condition and what needs to be implemented to effectively manage your patellar tendinopathy. This will include activity modification strategies and useful treatments reducing discomfort.
A rehabilitation plan developed by an experienced physiotherapist plays a key role in the recovery of this condition. However, it is important to have a realistic expectation regarding the recovery time frame for a return to full capacity and sport.
8. Rehabilitation
Research is very clear that modifying the load (pressure) that goes through the tendon is the key element that stimulates the recovery of the tendon. Recovery can take some time as the speed of regeneration in a tendon is much slower than many structures in the body for example muscle can take weeks whereas tendons can take months to repair. Therefore, you should expect to work on tendon rehabilitation for several months to get solid and sustainable improvements.
Below are three rehabilitation plans created by our specialist physiotherapists targeted at resolving patella tendinopathies. Although a one-to-one assessment would be best placed to target the exercise level most accurately to your needs the below rehab plans will give you a good idea of what to do.
9. Patellar Tendinopathy
Rehabilitation Plans
Our team of expert musculoskeletal physiotherapist have created rehabilitation plans to enable people to manage their condition. If you have any questions or concerns about a condition, we recommend you book an consultation with one of our clinicians.
What Is the Pain Scale?
The pain scale or what some physios would call the Visual Analogue Scale (VAS), is a scale that is used to try and understand the level of pain that someone is in. The scale is intended as something that you would rate yourself on a scale of 0-10 with 0 = no pain, 10 = worst pain imaginable. You can learn more about what is pain and the pain scale here.
This plan is focusing on maintaining range in the knee joint, loading the tendon in a supported way and maintaining the quadriceps (thigh muscle) power and stability. We suggested carrying this out once a day over for 2-6 weeks as pain allows. Pain should not exceed 4/10 on your perceived pain scale whilst completing this exercise programme.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This is the next set up in the plan. More focus is given to progressive loading of the tendon and strengthening the quadriceps muscles which power the kneecap and tendon. This plan is likely to give some pain which is expected and nothing to worry about (3). Pain level should be manageable around 5/10 on a pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
This plan is more challenging and is target at progressive loading of the tendon and supporting structures. This plan is likely to give some pain which is expected and nothing to worry about (3). Pain level should be manageable around 5/10 on a pain scale.
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 910
10. Return to Sport / Normal life
For patients wanting to achieve a high level of function or return to sport, we would encourage a consultation with a physiotherapist as you will likely require further progression beyond the advanced rehabilitation stage. Before returning to sport a rehabilitation program should incorporate plyometric based exercises this might include things like bounding, cutting, and sprinting exercises (5, 7).
As part of a comprehensive treatment approach, your musculoskeletal physiotherapist may also use a variety of other pain relieving treatments to support symptom relief and recovery. Whilst recovering you might benefit from a further assessment to ensure you are making progress and establish the appropriate progression of treatment. Ongoing support and advice will allow you to self-manage and prevent future re-occurrence.
11. Other Treatment Options
Podiatry referral to address gross biomechanical alignment issues may be helpful in the short term. Although there is a lack of evidence of any long-term value for tendon issues.
Injections of steroid (cortisone injections) are not recommended for tendon issues as research shows they are likely to provide little or no long-term benefit and have been linked to tendon damage and even rupture in some cases
Surgery – this could be the last option if the patient has exhausted all other pathways. Surgery has poor outcome when done in less active patients and is now carried out in very few cases.
References
- Cassel H. Baur A. Hirschmüller A. Carlsohn K. Fröhlich F. Mayer. (Sep 2014). Prevalence of Achilles and patellar tendinopathy and their association to intratendinous changes in adolescent athletes.https://doi.org/10.1111/sms.12318
- Wilson, JJ; Best TM. (Sep 2005). “Common overuse tendon problems: A review and recommendations for treatment” (PDF). American Family Physician. 72 (5): 811–8. PMID 16156339.
- Silbernagel, K. G., Thomeé, R., Eriksson, B. I., Karlsson, J. (2007). Sahlgrenska akademin, Institute of Clinical Sciences, . . . Sahlgrenska Academy.Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with achilles tendinopathy: A randomized controlled study. The American Journal of Sports Medicine, 35(6), 897-906. doi:10.1177/0363546506298279
- Cook, J. L. & Purdam, C. R. (2009). Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. British journal of sports medicine, 43(6), 409-416.
- Kountouris, A. & Cook, J. (2007). Rehabilitation of Achilles and patellar tendinopathies. Best practice & research clinical rheumatology, 21(2), 295-316.
- Lin, T. W., Cardenas, L. & Soslowsky, L. J. (2004). Biomechanics of tendon injury and repair. Journal of biomechanics, 37(6), 865-877.
- Malliaras, P., Cook, J., Purdam, C. & Rio, E. (2015). Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. Journal of orthopaedic & sports physical therapy, 45(11), 887-898.
Other Conditions in
Knees
Patellofemoral Pain Syndrome (PFPS)
Knee pain around the kneecap usually worse in static positions, squatting or kneeling.
Osgood-Schlatter Disease
Pain in an area just below the knee on the shin bone, often with a lump.
Meniscus Injury
Structural knee injury, triggered either by a tear or through wear and tear.
Knee Replacement Surgery
Replacement of the knee hinge joint, typically as a result of severe osteoarthritis or trauma.
Knee Osteoarthritis
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Iliotibial Band Syndrome
Presents as pain on the outside of the knee, normally occurring because of overload due to prolonged or repeated bouts of exercise.
Femoral Nerve Radiculopathy
This is where the nerve that supplies the front of the leg is irritated and causes pain/numbess.
Fat Pad Impingement
A rare condition affecting the adipose (fat) tissue that sits under the kneecap (patella) between the joint spaces of the knee.
Degenerative Meniscus
Seen to be normal as we age, but in some situations can result in knee aches, pain or joint swelling.
Bowed Knees
A condition in which the legs are bowed outwards leaving a greater space in between your knees.
Benign Joint Hypermobility Syndrome
Common age related changes to the structure of the knee joint which may be associated with pain, stiffness and loss of function.
Baker’s Cyst
Swelling in the popliteal space (space behind the knee) that causes a visible lump.
Anterior Cruciate Ligament (ACL) Injury
Injury to a major stability ligmant in the knee, normally occuring following a significant twisting injury.