Patellar tendonitis or tendinopathy

Synonymous with patellar tendon tendinopathy

• Patellar tendinopathy
• Patellar tendinopathy
• Jumper's knee
• Jumper's knee
• Quadriceps tendinopathy

What is the difference between tendinitis and tendinopathy?

Tendinitis refers to inflammation of the tendon, while tendinopathy encompasses all tendon pain, with or without inflammation. Here's the good news: recent research shows that inflammation is not always present in tendon pain.

Imaging studies reveal that many painful tendons show degenerative rather than inflammatory changes.¹ The term tendinopathy is therefore more medically accurate.

In practice, this distinction makes little difference to you. Whether your tendon is inflamed or not, the physiotherapy treatment remains similar: progressive exercises, load management, and correction of contributing factors.

What is patellar tendinopathy?

Patellar tendinopathy is an irritation of the tendon that connects the kneecap to the tibia. This tendon transmits the force of the quadriceps to allow the knee to extend.

Anatomy of the patellar tendon

The patellar tendon is approximately 4 to 5 cm long. It attaches to the lower tip of the kneecap (inferior pole) and ends at the tibial tuberosity, the bump you can feel below the knee.

When the quadriceps muscle contracts, the force passes through the patellar tendon to extend the leg. This mechanism is essential for walking, running, jumping, and climbing stairs.

Patellar tendon vs quadriceps tendon

The quadriceps tendon is located just above the kneecap. It connects the quadriceps muscle to the kneecap. The patellar tendon is located below the kneecap and connects it to the tibia. Both can become irritated, but patellar tendinopathy (below the kneecap) is more common in athletes.

The treatment for both conditions is very similar. The term patellar tendinopathy is often used to refer to both.

Who is affected?

Patellar tendinopathy affects 14% of recreational athletes^.2 This percentage rises to 40-50% among high-level volleyball and basketball players.³ Sports that involve repeated jumping are most at risk, hence the nickname "jumper's knee."

What are the causes of patellar tendinopathy?

Patellar tendinopathy occurs when the tendon undergoes repetitive stress that exceeds its capacity to adapt. The main causes are training overload, biomechanical factors, and dosage errors.

Training overload

The most common cause is increasing activity too quickly. The tendon needs time to adapt to new demands. Progressing too aggressively does not allow it this time.

Classic examples:

• Resuming running after winter without progress
• Starting an intensive squat program
• Increase the frequency or intensity of your workouts
• Hiking in the mountains without preparation

Biomechanical factors

Certain factors increase stress on the patellar tendon:

• Weakness of the gluteal muscles
• Stiffness in the quadriceps or hamstrings
• Limited range of motion in ankle dorsiflexion
• Dynamic knee valgus (knee bending inward)

A study showed that athletes with patellar tendinopathy had an average reduction in ankle dorsiflexion of 5 degrees.⁴

Risky movements

The movements that put the tendon under maximum tension are:

• Jumping and landing (volleyball, basketball)
• Deep squats with weight
• Slots
• Going down hills or stairs
• Sprints and changes of direction

It's normal not to know what to do with your pain.

We were never taught this. Our newsletter helps you understand what your body is trying to tell you and how to respond.

To better understand my pain

What are the symptoms of patellar tendinopathy?

Patellar tendinopathy causes localized pain at the tip of the kneecap or just below it. The pain increases with activities that strain the tendon.

Typical location

The pain is located precisely:

• At the lower tip of the kneecap (lower pole)
• Just below the kneecap, on the tendon itself
• Sometimes above the kneecap (quadriceps tendon)

You can often reproduce the pain by pressing on this area.

Characteristic pain pattern

The typical pattern of patellar tendinopathy follows this progression:

Activities that increase pain

• Do a squat or a lunge
• Going up or down stairs
• Running, especially downhill
• Jump and land
• Sitting for a long time with your knee bent (movie theater sign)
• Getting up from a chair

How is patellar tendinopathy diagnosed?

The diagnosis is based on the history of symptoms and clinical examination. X-rays do not show tendinopathy. Ultrasound or MRI can visualize changes in the tendon, but are not always necessary.

Clinical evaluation

Your physical therapist will assess:

• The precise location of the pain
• Movements that reproduce your symptoms
• Quadriceps strength and flexibility
• Ankle mobility
• The biomechanics of the lower limb

Specific tests

Two tests are particularly useful:

Imaging

X-rays are normal in patellar tendinopathy. They can be useful in ruling out other causes of knee pain.

Ultrasound shows thickening of the tendon and changes in texture in established cases.⁵ MRI is generally not necessary unless the diagnosis is uncertain.

What are the risk factors?

The main risk factors are high training volume, jumping sports, muscle stiffness, and progression errors.

Modifiable factors

• Training volume too high or progression too rapid
• Stiffness in the quadriceps and hamstrings
• Weakness of the gluteal muscles
• Limited ankle dorsiflexion
• Inadequate jumping/landing technique
• Hard training surface

Non-modifiable factors

• Male gender (slightly higher risk)
• Age (peak between 15-30 years old)
• Large size and high weight in athletes
• History of patellar tendinopathy

When should you see a physical therapist, and how do they treat patellar tendinopathy?

Consult a physical therapist if the pain persists for more than 7 to 10 days despite relative rest, if it limits your sports or daily activities, or if you want a safe plan for returning to sports.

Signs that warrant a consultation

• Pain that does not improve after a week
• Pain that limits your daily activities
• Inability to play sports at your usual level
• Pain at rest or at night (less typical, to be investigated)
• Desire for a personalized rehabilitation program

Direct access

In Quebec, you can consult a physical therapist directly without a medical referral. If your condition requires further investigation, your physical therapist will refer you to the appropriate professional.

If you also experience pain in other areas of the knee, such as behind the knee or on the sides, mention this during your assessment.

How physical therapy treats patellar tendinopathy

Physiotherapy treatment is based on progressive strengthening exercises, training load management, and correction of contributing factors. This is the first-line treatment recommended by research^.

Comprehensive assessment

Your physical therapist will assess:

• Your sports and training history
• The mobility of your ankle, knee, and hip
• Strength of the quadriceps, glutes, and calves
• Your squat and jump technique is so relevant.
• Biomechanical factors contributing to the problem

Progressive exercise program

Strengthening exercises are the cornerstone of treatment. The typical protocol progresses in four phases:

Isometric contractions (holding a position without moving) can reduce pain quickly.⁷ For example, hold a partial squat for 45 seconds.

Slow, controlled movements throughout the entire range of motion: squats, leg presses, knee extensions.

Gradual increase in weight and intensity.

Jumps, landings, and power exercises to prepare for returning to sports.

Load management

Complete rest is generally not recommended. A load management approach allows you to remain active while allowing the tendon to heal:

• Reduce training volume by 30-50%
• Temporarily avoid movements that are very painful
• Maintain tolerated activities (swimming, cycling, walking)
• Gradually reintroduce problematic activities

Complementary techniques

Based on your assessment, your physical therapist may also use:

• Manual therapy to improve mobility
• Taping to support the tendon
• Dry needling to release tension points
• Advice on equipment and technique

What exercises can I do at home?

Quadriceps strengthening exercises are essential. Progression should be guided by pain: a slight increase is acceptable during exercise, but it should not persist afterward.

Isometric exercises (initial phase)

• Sitting with your leg stretched out
• Contract your quadriceps by pushing your knee toward the floor.
• Hold for 45 seconds, 5 repetitions
• Can relieve pain immediately

• With your back against the wall, slide down to a 60-70 degree bend.
• Hold for 45 seconds, 4-5 repetitions
• Adjust the angle to find a comfortable position.

Strengthening exercises (intermediate phase)

• 2-3 inch elevated heels (book, board)
• Lower yourself slowly over 3 seconds.
• Wind up for 3 seconds
• 3 sets of 15 repetitions

• Light to moderate load
• Slow and controlled movement
• 3 sets of 15 repetitions

• On a 4-6 inch step
• Slowly lower yourself onto the affected leg.
• 3 sets of 10 repetitions per leg

Additional stretches

• Stand up, grab your foot behind you
• Keep your knees together
• Hold for 30-45 seconds.

• Sitting with leg stretched out in front
• Lean forward while keeping your back straight.
• Hold for 30-45 seconds.

Can you treat patellar tendonitis yourself?

Self-treatment can relieve mild patellar tendonitis (ice, rest, light stretching). However, without appropriate load progression, you risk aggravating the tendinopathy. Without an accurate diagnosis, you risk maintaining compensations or doing counterproductive exercises that delay healing.

The physical therapist guides the progression of load to optimize tendon healing. An assessment identifies the exact cause, eliminates red flags, and creates a progressive treatment plan. Exercises are tailored to your specific condition, not generic.

Our approach: professional assessment + supervised home exercise program = better long-term results.

Are you unsure whether to self-treat or seek medical advice? Free 15-minute consultation to discuss your situation.

How long does recovery take and how can recurrence be prevented?

Recovery from patellar tendinopathy usually takes 3 to 6 months with an appropriate rehabilitation program. Mild cases may improve within a few weeks, while chronic cases may take longer.

Factors that influence healing

• Early consultation
• Adherence to the exercise program
• Proper load management
• Correction of contributing factors

• Delay before consulting (chronification)
• Continue with very painful activities
• Not doing the exercises regularly
• Returning to sports too quickly

Back to sports

The return to sport is gradual, guided by objective criteria:

• Symmetrical quadriceps strength (less than 10% difference)
• Ability to jump without pain
• Ability to perform specific athletic movements
• Confidence in the knee

Returning too quickly increases the risk of recurrence. Patience pays off.

How to prevent recurrence

Prevention involves maintaining a strengthening program, gradually increasing your training, and paying attention to your body's signals.

• Continue strengthening exercises 2-3 times per week.
• Follow the 10% weekly increase rule.
• Warm up properly before intense activities.
• Vary your activities to avoid repetitive stress
• Maintain good flexibility in your quadriceps and hamstrings.

Reduce the intensity if you notice:

• Pain that gradually increases over several days
• Morning stiffness lasting more than 30 minutes
• Pain that persists for more than 24 hours after exercise
• Decrease in performance

If the pain persists despite these adjustments, consult your doctor. It is better to act early than to wait for the problem to worsen.

If you are a runner, the prevention principles are similar to those for tibial periostitis or Achilles tendinopathy: gradual progression and regular strengthening.

References

• Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Medicine. 1999;27(6):393-408.

• Lian OB, Engebretsen L, Bahr R. Prevalence of jumper's knee among elite athletes from different sports: a cross-sectional study. Am J Sports Med. 2005;33(4):561-567.

• Ferretti A, Puddu G, Mariani PP, Neri M. The natural history of jumper's knee. Patellar or quadriceps tendonitis. Int Orthop. 1985;8(4):239-242.

• Backman LJ, Danielson P. Patellar tendinopathy—clinical diagnosis, load management, and advice for challenging case presentations. J Orthop Sports Phys Ther. 2011;41(11):832-839.

• Warden SJ, Brukner P. Patellar tendinopathy. Clin Sports Med. 2003;22(4):743-759.

• Malliaras P, Cook J, Purdam C, Rio E. Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. J Orthop Sports Phys Ther. 2015;45(11):887-898.

• Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015;49(19):1277-1283.