Patellar Tendinopathy

The cardinal symptom is well-localised pain at the inferior pole of the patella that patients point to with one finger. This precise localisation is the key differentiator from the diffuse peripatellar pain of PFP. Pain is load-dependent, provoked by jumping, landing, sprinting, cutting, squatting, and lunging. The warm-up phenomenon is typical: pain is worst at the start of activity, eases through the session, and returns the next morning. Stairs (particularly descending) provoke pain through eccentric loading. The cinema sign is not characteristic and points toward PFP, a commonly tested distinction. Patellar tendinopathy does not cause an effusion.

On examination, point tenderness at the inferior pole with the knee in full extension is the most sensitive finding. A single-leg decline squat on a 25-degree board is a useful provocation test. The Royal London Hospital test (tenderness at the inferior pole in extension that reduces in 90 degrees of flexion) is more specific but less sensitive and supports the diagnosis as part of a cluster. Always assess calf strength (heel-raise endurance), weight-bearing ankle dorsiflexion, quadriceps and hamstring flexibility, and landing mechanics. Acute extensor lag with a palpable gap below a high-riding patella indicates patellar tendon rupture and requires emergency surgical referral.

Patellar tendinopathy is a clinical diagnosis and imaging is not routinely required. Ultrasound is the practical first-line option when imaging is needed and demonstrates tendon thickening, hypoechoic areas, Doppler neovascularisation, and partial tears. MRI is useful for alternative pathology or surgical planning. Both modalities carry a critical caveat: changes are frequent in asymptomatic athletes, so treat the patient and not the scan. Plain radiographs are reserved for bony pathology including Sinding-Larsen-Johansson disease in adolescents. Bloods are not routinely required. The VISA-P questionnaire is a validated patellar tendinopathy-specific outcome measure for monitoring rehabilitation progress.

Management is primarily conservative, with progressive tendon-loading exercise the cornerstone. Education is fundamental: complete rest is not the answer because tendons need load to remodel via mechanotransduction. Recovery is measured in months. Pain during rehabilitation up to approximately 4 to 5 out of 10 is acceptable if it settles within 24 hours and is not worse the following morning. Address fear of rupture directly: appropriately loaded tendons do not rupture.

Load management identifies and modifies the precipitating training error, with graded reduction in jumping, landing, and sprinting frequency rather than complete withdrawal. Physiotherapy-led progressive tendon-loading rehabilitation, with heavy slow resistance well supported (high load, slow tempo, 3 to 3 seconds concentric and eccentric, 3 to 4 sets of 6 to 8 reps, three sessions per week), drives the strength gains.

Oral NSAIDs are useful in the reactive phase but offer less in the degenerative phase. Corticosteroid injection into or around the patellar tendon is generally not recommended because of tendon-weakening and rupture risk and is one of the clearest do-not-routinely-offer messages in tendinopathy. Adjuncts with limited or mixed evidence include extracorporeal shockwave therapy for recalcitrant cases, high-volume injection in specialist clinics, PRP, and blood flow restriction training as an emerging early-phase adjunct. Refer if symptoms persist despite 6 to 12 months of structured progressive loading, urgently for suspected patellar tendon rupture, and for adolescents with inferior pole pain (Sinding-Larsen-Johansson disease).

Recovery typically takes 3 to 12 months, and loading should be provocative but tolerable.

Phase 1 (pain-dominant, 0 to 4 weeks): load modification is the priority; reduce energy-storage activities. Isometric quadriceps loading is a reasonable starting point (e.g. single-leg extension holds at approximately 60 degrees of flexion) but must be progressed. Address calf strength and ankle dorsiflexion. BFR training may help.

Phase 2 (progressive loading, 4 to 12 weeks): the core phase. Heavy slow resistance using leg press, knee extension machine, hack squat, back squat, split squat, and single-leg decline squat. Three seconds concentric, three seconds eccentric, three to four sets of six to eight reps, three sessions per week. Load heavy enough that the last two reps are difficult. Continue calf, hip, and trunk strengthening.

Phase 3 (energy-storage reintroduction, 12 weeks plus): the phase most commonly rushed and most commonly responsible for relapse. Bilateral plyometrics first (pogo jumps), progressing to unilateral landing, drop jumps, cutting, and sport-specific jumping. Continue progressive loading throughout. Address running and landing mechanics.

Phase 4 (return to sport): criteria-based - pain-free or minimal-pain sport-specific activity, quadriceps strength 90% or more of the contralateral side, completion of the plyometric programme, and toleration of full training. Continue maintenance loading twice weekly long-term because the tendon remains vulnerable to load spikes. Common mistakes include stopping loading when pain resolves before the tendon has remodelled, rushing to plyometrics, relying on isometrics alone, and avoiding all pain during exercise.

• •Cook & Purdam (2009): The tendon continuum model frames pathology as reactive, dysrepair, and degenerative phases, guiding pathway-specific treatment choices.
• •Kongsgaard et al. (2009): Heavy slow resistance produced equivalent improvement to eccentric training with better patient adherence in patellar tendinopathy.
• •Rio et al. (BJSM, 2015): Isometric quadriceps loading produces immediate analgesia in patellar tendinopathy and is a useful early-phase tool, though it must be progressed.
• •VISA-P (Visentini et al., 1998): Validated patellar tendinopathy-specific outcome measure for monitoring rehabilitation progress.
• •BJSM tendinopathy management consensus: Progressive tendon-loading exercise is the evidence-based core treatment; corticosteroid injections into the tendon are rarely indicated.

• •Patellar tendinopathy presents with point tenderness at the inferior patellar pole and load-dependent pain. PFP produces diffuse peripatellar pain and is compression-dependent. The single most tested distinction in anterior knee pain.
• •The cinema sign points to PFP, not patellar tendinopathy. Patellar tendinopathy does not produce an effusion.
• •Diagnosis is clinical. Imaging changes are common in asymptomatic athletes; treat the patient, not the scan.
• •Corticosteroid injection into the patellar tendon is generally not recommended (tendon-weakening and rupture risk). One of the strongest do-not messages in tendinopathy.
• •Heavy slow resistance is well supported. Isometrics are an option early but must be progressed. Energy-storage reintroduction is the most commonly rushed phase.
• •In an adolescent with inferior pole tenderness, consider Sinding-Larsen-Johansson disease; Osgood-Schlatter sits at the distal end of the tendon (tibial tubercle).