Patellar tendinopathy
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What is patellar tendinopathy?
Patellar tendinopathy is a painful condition of the tendon located under the kneecap, caused by repetitive overload. It affects up to 45% of jumpers.1 The term "jumper's knee" accurately describes this condition, which is common among athletes who place intense strain on their knees.
The anatomy of the patellar tendon
Your patellar tendon is approximately 4 to 5 cm long. It connects the bottom of your kneecap (inferior pole) to your tibia (tibial tuberosity). This tendon transmits the force of your quadriceps to your leg, allowing you to jump, run, and climb stairs.
The tendon is composed of collagen fibers organized in parallel bundles. This structure allows it to withstand considerable forces. During a jump, your patellar tendon can withstand up to 8 times your body weight.
The most vulnerable point is where the tendon attaches to the kneecap. This is where pain most often occurs in patellar tendinopathy.
Tendinopathy vs. tendinitis: what's the difference?
| Appearance | Tendinitis | Tendinopathy |
|---|---|---|
| Meaning | Acute inflammation (ending in -itis) | Tendon disease (more specific) |
| Nature of the problem | Inflammatory | Degenerative |
| Effective treatment | Anti-inflammatory drugs | Strengthening exercises |
| Duration | Short term | May be chronic |
The term "tendinopathy" better reflects reality.2 Studies show that most chronic tendon problems are not inflammatory. This distinction is important: since the condition is generally not inflammatory, anti-inflammatory drugs are of limited use.
What are the causes of patellar tendinopathy?
Patellar tendinopathy results from repeated overload exceeding the tendon's ability to recover. Repetitive jumping, rapid increases in training, and certain biomechanical factors such as muscle stiffness contribute to this cumulative overload.
The tendon overload mechanism
Your tendon functions like a strong rope. Every time you jump or run, this rope is subjected to significant forces. Normally, your tendon repairs itself during rest.
The problem arises when demands exceed repair capacity. Collagen fibers become disorganized. Areas of degeneration gradually appear.2 It is this process of cumulative microtrauma that characterizes tendinopathy.
The main risk factors
| Category | Risk factors | Impact |
|---|---|---|
| High-risk sports | Volleyball, basketball, long jump/high jump | Prevalence up to 45% among elite volleyball players |
| Training errors | Rapid increase in volume, insufficient rest | Tendon doesn't have time to adapt |
| Surface area and equipment | Surface too hard, ill-fitting shoes | Insufficient shock absorption |
| Individual factors | Hamstring tightness, quadriceps weakness | Alter the biomechanics of the knee |
A volleyball player can make hundreds of jumps per week. Each jump creates a force equivalent to several times the body weight. Over time, these microtraumas accumulate if there is insufficient rest.
What are the symptoms of patellar tendinopathy?
The main symptom is pain located just below the kneecap, at the tendon. This pain occurs during or after jumping and running activities. Morning stiffness is common. The pain often decreases after warming up.
The typical presentation
The pain associated with patellar tendinopathy is characteristic. It is located precisely at the lower pole of the kneecap, where the tendon attaches. You can often point to it exactly.
At first, the pain only appears after activity. You finish your workout without any problems, then feel the pain a few hours later or the next morning. If the condition progresses, the pain appears during activity.
The 4 stages of progression
| Stadium | When pain occurs | Impact on business | Recommended approach |
|---|---|---|---|
| Stage 1 (mild) | After the activity only | No impact on performance | Modification of activities, prevention |
| Stage 2 (moderate) | At first, decreases with warm-up | Performance maintained | Active therapeutic exercises |
| Stage 3 (advanced) | During and after the activity | Reduced performance | Significant reduction in load |
| Stage 4 (severe) | Rest and daily activities | Unable to play sports | Intensive treatment, relative rest |
This classification helps determine the treatment approach and prognosis. Stages 1 and 2 generally respond better to conservative treatment.
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How is patellar tendinopathy diagnosed?
The diagnosis is based primarily on clinical examination: pain localized at the lower pole of the kneecap, tendon sensitivity on palpation, and reproduction of pain when squatting on one leg. Imaging is generally not necessary.
Clinical evaluation
Your physical therapist makes the diagnosis by combining several factors.
The history of your symptoms:- When did the pain start?
- What activities aggravate it?
- Have you increased your training volume recently?
- Palpation of the tendon (sensitivity to touch?)
- One-leg squat test on aninclined surface5
- Quadriceps strength assessment
- Thigh muscle flexibility tests
The most revealing test is the single leg decline squat. You stand on one leg on a surface inclined at 25 degrees and slowly lower yourself. This test puts significant strain on the tendon and often reproduces the characteristic pain.
The role of imaging
| Type of imaging | What it shows | When to use it |
|---|---|---|
| Ultrasound scan | Tendon thickening, areas of degeneration | Uncertain or chronic cases |
| MRI | Complete structural details | Exclude other problems, complex cases |
| No imaging | Not applicable | Most cases (clinical diagnosis sufficient) |
Be cautious with imaging results: several athletes have abnormal tendons on ultrasound without experiencing any pain. Imaging must therefore be interpreted in context with your symptoms. In most cases, no imaging is required.
How does physical therapy treat patellar tendinopathy?
The main treatment combines load management and progressive strengthening exercises. Isometric exercises provide rapid pain relief.4 Eccentric and slow heavy resistance exercises stimulate tendon remodeling over several weeks.
The principle of load management
The key to treatment is finding the right balance of activity. Too little exercise and the tendon weakens. Too much exercise and the irritation persists.
Your physical therapist will help you identify your optimal load zone. This is the level of activity that stimulates tendon adaptation without further irritating it.
In concrete terms, this means:
- Temporarily reduce or eliminate aggravating activities (jumping, sprinting)
- Maintain moderate physical activity (cycling, swimming, walking)
- Gradually introduce therapeutic exercises
Types of therapeutic exercises
| Type of exercise | Description | Profits | When to use it |
|---|---|---|---|
| Isometric | Contraction without movement (e.g., wall squat for 45 seconds) | Fast pain relief4 | Acute phase, competitive season |
| Eccentrics | Slow controlled descent (board at 25°) | Stimulates tendon adaptation | Strengthening phase |
| HSR (Heavy Slow Resistance) | Heavy loads, slow movements | Structural changes inthe tendon3 | Remodeling phase |
What doesn't work
Certain approaches are not recommended:
- Prolonged complete rest: Weakens the tendon without rehabilitating it.
- Aggressive stretching: May further irritate the tendon
- Long-term anti-inflammatory drugs: Tendinopathy is not inflammatory.
- Cortisone injections: Risk of weakening the tendon
Treatment progress
| Phase | Typical duration | Objective | Exercises |
|---|---|---|---|
| Phase 1 | Weeks 1-2 | Reduce pain | Isometric exercises, modification of activities |
| Phase 2 | Weeks 3-8 | Strengthen the tendon | Progressive eccentrics or HSRs |
| Phase 3 | Weeks 9-12+ | Return to sports activities | Explosive exercises, progressive jumps |
| Phase 4 | Weeks 12-24+ | Return to full sports activity | Sport-specific training |
What is the recovery time?
Full recovery usually takes 3 to 6 months with proper treatment. Chronic cases may require 6 to 12 months. Continuing to play through the pain significantly prolongs the healing time. Patience is essential as the tendon slowly remodels itself.
Prognostic factors
| Postman | Good prognosis | Poor prognosis |
|---|---|---|
| Duration of symptoms | Less than 3 months | More than 6 months |
| Stadium | Stage 1 (pain after activity) | Stages 3-4 |
| Adherence to treatment | Good compliance with exercises | Non-compliance |
| Behavior | Temporary change in activities | Keep playing despite the pain |
Studies show an average duration of symptoms ranging from 32 to 76 months in elite athletes who continue to play. These figures often reflect poorly managed cases. With appropriate and early treatment, the results are much better.
Returning to sport
| Criterion | Description |
|---|---|
| Pain | No pain during or after therapeutic exercises |
| Strength | Quadriceps strength equal to or greater than the healthy side |
| Tolerance | Ability to perform low-intensity jumps |
| Function | Pain-free single-leg squat |
- Light jogging (2-3 weeks)
- Moderate intensity running (2-3 weeks)
- Jumping on two legs (2-3 weeks)
- Jumping on one leg (2-3 weeks)
- Sport-specific training (progressive)
When should you see a specialist?
Consult a specialist if there is no improvement after 3 months of regular physical therapy, if the pain limits your daily activities, or if you suspect a tear. Shockwave therapy and PRP are options for refractory cases.
Warning signs
Consult quickly if you have:
- Sudden, severe pain after an explosive movement
- Inability to put weight on the leg
- Significant swelling or bruising (blue)
- Popping or tearing sensation
These signs could indicate a partial or complete tear of the tendon, which requires urgent evaluation.
Advanced treatment options
| Treatment | Description | Indications | Effectiveness |
|---|---|---|---|
| Shock waves | Sound waves stimulating healing | Chronic refractory cases | Promising results |
| PRP | Injection of the patient's own concentrated blood | Cases that do not respond to exercises | Mixed evidence |
| Surgery | Excision of degenerated tissue | Failure of 6-12 months of conservative treatment | ~85% return to sports |
Surgery is rarely necessary. It is reserved for cases that do not respond to 6-12 months of conservative treatment that has been followed correctly.
Frequently Asked Questions
Can patellar tendinopathy be completely cured?
Yes, in most cases. With proper treatment and patience, most people recover completely and can resume their sporting activities. Persistent cases are often linked to inadequate load management or resuming activity too quickly.
Can I continue playing sports with this condition?
It depends on the severity. At stage 1 (pain only after activity), you can often continue with modifications. At more advanced stages, a period of relative rest is usually necessary.
Do knee pads or straps help?
Patellar straps can provide temporary relief by altering the distribution of forces on the tendon. They can be useful during the return to sport phase, but are not a substitute for underlying treatment.
Are anti-inflammatory drugs useful?
Anti-inflammatory drugs can temporarily relieve pain, but they do not address the underlying problem. Therapeutic exercise remains the primary treatment.
How can recurrence be prevented?
Prevention is based on maintaining a strengthening program, gradually increasing loads (never more than 10% per week), warming up properly before explosive activities, and listening to the first signs of overload.
Key points: Patellar tendinopathy is a common condition among jumpers, but it usually responds well to conservative treatment. The key to success is proper load management and progressive strengthening exercises. Be patient: your tendon needs time to remodel.References
- Lian OB, Engebretsen L, Bahr R. Prevalence of jumper's knee among elite athletes from different sports. Am J Sports Med. 2005;33(4):561-567.
- Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med. 2009;43(6):409-416.
- Kongsgaard M, et al. Corticosteroid injections, eccentric decline squat training, and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports. 2009;19(6):790-802.
- Rio E, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015;49(19):1277-1283.
- Malliaras P, et al. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. J Orthop Sports Phys Ther. 2015;45(11):887-898.
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