Patella Tendinopathy

Where is patella tendinopathy painful? (Body Chart)


What are the classical features of patella tendinopathy?

Age: Younger population (18-35)

Gender: Males have a higher prevalence compared to females

– Sport: increased prevalence in sports with high tendon load (plyometric) including basketball, volleyball, netball, high jump, soccer, football

Where is patella tendinopathy painful?

– Anterior aspect of the knee

– Will report symptoms at the inferior pole of the patella and always superior to the tibial tuberosity

– Pain will always stay local, if diffuse consider a differential diagnosis

Characteristics of symptoms for patella tendinopathy

– Very localised

– Stiffness type pain

– Dull aching normal especially in AM or after provocative activity

– Will settle with rest but can take up to 24 hours

Typical activity capability/restriction for clients with patella tendinopathy

– Progressive with restriction with activities that require high spring loads of the lower limb

– Limitations in running, jumping, hopping, change of direction and acceleration

– Inhibit or reduced performance in sport

Behaviour of symptoms for patella tendinopathy

Agg: jumping, change of direction, decelerating, decline (stairs/walking) running, sitting with knees bent, crossing legs kneeling

Ease: sit with legs out straight or laying down, rest, NSAIDs,

24 hours: AM stiffness <30min and pain, warm-up effect phenomena with cool down effect

Typical history of a client with patella tendinopathy

– Associated with physically active individuals

– Acute increase in loading // commonly increased sport participation or training, always check for multiple sports due to patient demographic

– Typical ‘tendon signs’ (AM stiffness, warm-up phenomenon, cool down effect)

– Onset with energy-storing loads

– Can be insidious or acute with presentation

– Check for history of tendon issues

Pathobiological mechanisms behind patella tendinopathy

– Nociceptive with acute presentation (more commonly a reactive presentation)

– The more degenerative the presentation the increased likelihood of nociplastic pain mechanisms

– Also be mindful of the presence of nociplastic if long term rehabilitation

Proposed pathology underlying patella tendinopathy

Thought to be an imbalance between the capacity of the tendon and the load that is being placed through it. An example of this is the Cook and Purdham paradigm.

Reactive Tendinopathy

– sudden increase in relative load

– leads to high levels of pain and functional decline

– commonly younger individuals

Degenerative Tendinopathy

– sustained period of poor tendon health leading to structural changes in the tendon

– has mechanical changes with reduced stiffness and strength

– can be both symptomatic and asymptomatic

Reactive on degenerative is the most common

Physical impairments & associated structure/tissue sources (ie P/E findings)


– Tenderness on palpation of the PT // especially at the inferior pole

– quads sensitivity and/or wastage

– Knee extension contraction // painful but not always, should be worse when lengthened due to increased compressive forces

– Thickened patellar tendon

– may have some local swelling, no joint swelling


– glutes sensitivity to palpation

– femoral nerve sensitivity

– Increased prevalence of reduced strength in other lower limb muscles (calves, quads, glutes)

– tightness in anterior and lateral hip compartments


– Tip: therapist should sequentially increase tendon load with functional activities (ie DL squat, SL squat, jumping, hopping, plyos)

– Isometric loading test

– decline squat test

Typical contributing factors to patella tendinopathy

– Maladaptive biomechanics

– Weight


– Waist to hip ratio

– Leg length differential

– reduced quads length

– Reduced arch height

– Reduced hamstring length

– Reduced quads strength

– Poor vertical jump performance

Relevant precautions/ contraindications to P/E and treatment

– Severity and irritability

– Consider history and type of tendon (reactive vs degenerative) when considering how aggressive to be with testing

– ie if degenerative want to be cautious of spikes in loaded activities especially in relation to baseline (chance of rupture)

– Absolute rest is contraindicated

Relevant diagnostic imaging for patella tendinopathy

Ultrasound: is adequate to make diagnosis // more cost-effective

MRI: gold standard

Doppler: can be used to assess vascular changes

– Note that both have low sensitivity but high specificity so consider in the context of your patient

– 50% of asymptomatic plays in high patella tendon loading sports have abnormalities on imaging

Typical prognosis for patella tendinopathy

– The earlier treatment is started the more positive the prognosis

– 3-18 months according to evidence

– is estimated on the level of dysfunction of the individual and also the demand on the athlete’s sport

– 1/3 of athletes did not return to their sport within 6 months

– 53% of athletes retired from their sport secondary to the pathology

Management/treatment selection for patella tendinopathy

High-level evidence:

Relative load reduction:

– can be done in numerous ways (training, gametime, or adjustment of high peak force activities)

– attempt to optimise energy storage of tendon in this process

Isometric exercises (Spanish squat or wall squat)

– evidence to suggest helpful with pain reduction and improves motor drive (5 x 45″ holds with 2 min in between @ 70% MVC)


– Place high emphasis on calf and glutes as both have a key role in attenuating forces whilst landing

– Quads used to prevent unloading weakness and atrophy (not associated with reduced pain or increased performance)

Energy storage

– emphasis on later stage rehab

– try to make it as sport-specific as possible

– introduce gradually and ensure ample rest period


– evidence shows exercising with pain isn’t contraindicated however apply to the patient circumstance

– NSAIDs is shown to have a positive effect on reactive patellar tendinopathies

Low-level evidence


– study showed slight pain reduction // no preferred direction as placebo tape same effect as inferiorly directed tape

Manual therapy

– friction historically a popular treatment // no evidence to support and can cause irritation to the area

– some logic in the soft tissue work of local muscle groups however no evidence to support the benefit

Differential diagnosis for patella tendinopathy

– Infrapatellar bursitis // compression and inflammatory signs

– PFPS // PFJ assessment, compression with wind up

– Fat Pad // palpation and Hoffa’s test

– Referred from hip // clear hip tests

– Referral from Lx // neurological and lumbar spine assessment


– avulsion of the patella tendon

– Tib plateau fracture

– Stress fracture of the patella

– Osteochondritis Desiccans

Subjective exam special questions

– Cancer

– patella instability (dislocations)


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Everhart, J.S., Cole, D., Sojka, J.H., Higgins, J.D., Magnussen, R.A., Schmitt, L.C. and Flanigan, D.C., 2017. Treatment options for patellar tendinopathy: a systematic review. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33(4), pp.861-872.

​​Larsson, M.E., Käll, I. and Nilsson-Helander, K., 2012. Treatment of patellar tendinopathy—a systematic review of randomized controlled trials. Knee surgery, sports traumatology, arthroscopy, 20(8), pp.1632-1646.

Malliaras, P., Cook, J., Purdam, C. and Rio, E., 2015. Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. journal of orthopaedic & sports physical therapy, 45(11), pp.887-898.

Van der Worp, H., van Ark, M., Roerink, S., Pepping, G.J., van den Akker-Scheek, I. and Zwerver, J., 2011. Risk factors for patellar tendinopathy: a systematic review of the literature. British journal of sports medicine, 45(5), pp.446-452.