Patellar Tendonitis Diagnosis, Exercises & Myth Busting

Patellar Tendonitis is often treated poorly. Why? Because people treat it, as if the tendon were inflamed. This means: rest and ice treatment. Let me guess: you’ve tried that approach, but the pain keeps coming back after you’re a little bit more active again?

Don’t worry! In this article I’ll cover everything you need to know: diagnosis, exercises and the common myths.

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Patellar Tendonitis – Diagnosis

Let’s start with the diagnosis, because you need to know if we’re really talking about a patellar tendonitis in your case or something else – otherwise your treatment probably won’t be very effective.

Most people rely on imaging, but this isn’t a good idea.

If you have a patellar tendon issue, you will see changes in imaging.

However, these changes are also common in people who have no symptoms (Docking et al. 2021). Imaging alone can’t diagnose the problem or guide the treatment (Docking & Cook 2018).

There are two main criteria that have to be met for a positive diagnosis.

  1. Pain in the patellar tendon (usually at the lower pole of the knee-cap)
  2. Pain has to be dose-dependent.

What do I mean by that?

For example, I’d expect your pain to be higher after jogging for 60 minutes compared to 30 minutes. Additionally, I’d also expect more pain from a countermovement jump than from a wall sit.

Patellar Tendonitis - Diagnosis

Before we get into the exercises, we have to briefly talk about inflammation.

This does not seem to be the main concern with a patellar tendonitis, which is why the term “Patellar Tendinopathy” is suggested in the scientific literature (Scott et al.).

Why the hell is this so important?

Because I need you to know, that your tendon is safe to be loaded again! And loading the tendon is actually super important if you want to get back into more intense activities like sports.

We want your tendon to be stronger than what you ask it to do or in other word: your capacity should be higher than the strain on the tendon.

Patellar Tendonitis - Capacity

And if you rest the entire time, the strength (aka capacity) of your tendon will decrease.

That’s also the reason why a lot of people have a pain flare-up after being more active again – because the capacity of their tendon has decreased so much due to rest and now the strain is too high.

Patellar Tendonitis - Capacity

Alright – let’s increase the capacity of your patellar tendon now with some exercises, shall we?

Exercises

We have two main goals with the exercises:

  1. Improve your tolerance to different loads.
  2. Restore the function of your patellar tendon and the rest of the lower body.

1. Isometric Training

Most protocols for tendinopathy start with isometric exercises. Why?

Because they can have a pain-relieving effect (Clifford et al. 2020) and are usually well tolerated since there’s no movement involved.

Here are a few examples of exercises you can do:

Patellar Tendonitis - Isometric Exercises
Patellar Tendonitis - Isometric Exercises

For the Single Leg Seated Knee Extension isometric, bend the knee between 90 and 60 degrees. You can also use a band.

3-5 sets per exercise with a hold time of 30-45 seconds work well here.

2. Heavy Slow Resistance Training

Tendons are more stressed by the speed of movement than by the load.

That’s why Heavy Slow Resistance Training is recommended in the earlier stages of tendinopathy rehab because due to the slow movement tempo we can safely use relatively heavy loads.

Here are some exercises you can gradually increase:

Patellar Tendonitis - Heavy Slow Resistance Exercises

For sets and repetitions, you can also do 3-5 sets per exercise with 6-15 repetitions.

It’s important to choose a slow movement pace.

For example, for a squat, you should lower yourself for 3 seconds, hold at the bottom for 1 second, and then rise back up for 3 seconds. You might want to use a metronome app if it helps.

The weight is secondary in this case, as shown in the recent study by Agergaard et al. (2022).

What matters more is that you stay consistent with your training and gradually increase the load.

3. Plyometric Training

This is super important. Rehab shouldn’t stop at stage 2 (at least not if you want to get back into faster sports like running, soccer, volleyball etc.).

In that case, your patellar tendon has to be able to work quickly. And this type of loading is what we train in the third stage by doing:

Patellar Tendonitis - Plyometric Exercises
Patellar Tendonitis - Plyometric Exercises

You can also do 3-5 sets per exercise with 6-15 repetitions. Since these exercises are very demanding on the tendon, I would recommend starting with fewer repetitions and sets and then working your way up.



4. Return to Sport

In this final stage, you need to perform your sport, which is why I can’t give you any exercises here.

Start slowly and work your way up over time.

Alright, we’ve talked about exercises now, but we’re not done yet.

You absolutely need to know about these 5 common myths about patellar tendinopathy that I’m about to tell you! Especially, myth number 5 is super important.

Myths

Myth 1: You Need to See Changes in the Structure of Your Tendon if You Want to Progress.

Many measures aim to change the structure of the patellar tendon, but remember, these so-called abnormalities are actually pretty normal.

A study by van Ark et al. from 2018 found that people with patellar tendon pathology saw an improvement in symptoms through an exercise program, even though the images showed no significant changes in tendon structure.

Myth 2: If Your Tendon Thickens, it’s a Bad Sign.

If your tendon looks or feels thickened, that’s actually a good sign. Docking et al. (2020) found that abnormal patellar tendons contain similar or even larger amounts of “normal” tendon structure (as a compensatory mechanism to maintain tissue balance).

Myth 3: If My Pain Is Alright During Exercise, I Chose the Right Training Load

That’s a very important myth that we need to bust.

What we see in tendons is a so-called “warm-up effect”. This means, that the tendon pain usually gets better if you move around a little bit. That’s also the reason why your pain during exercise usually gets better in time.

I want to you to monitor your pain according to the 24-hour-rule proposed by Silbernagel et al. in 2007. According to this rule, your pain should ideally be between 0-2 out of 10 during AND 24 hours after exercise.

Patellar Tendonitis - Pain Monitoring Model

If you hit a pain level of 3 to 5 that’s acceptable as well. But if your pain is above 5 then you’ve definitely done too much.

You can either check your pain during everyday activities (like walking down the stairs) or use a provocation test, such as a single-leg hop.

Myth 4: The Pain Level Should Be the Main Focus of the Treatment.

If your pain level is really high and stresses you out, then yes. This should be the main focus in the beginning.

But as soon as you’ve reached a tolerable level, this focus should switch, in my opinion.

It’s quite possible that your performance improves, but your pain level remains the same at first.

For example, if you can currently walk 1 km before feeling a pain level of 3/10, and in 3 months you can walk 3 km before reaching that pain level, that’s significant progress.

So, focus on your function in rehab and the activities you want to achieve, while still keeping track of your pain as I mentioned earlier.

Myth 5: You Need Other Treatment Options for Your Patellar Tendinopathy.

Alright, I’m going to quickly talk the other, most popular treatment options for patellar tendinopathy and tell you if they’re supported by scientific research or not:

Surgery: No advantage over strength training (Bahr et al. 2006).

Platelet-rich Plasma aka PRP: Not more effective than placebo treatment when combined with exercise (Scott et al. 2019).

Shockwave Therapy: Not more effective than a placebo or just doing exercises (Zwerver et al. 2011), (Thijs et al. 2017) , and (Lee et al. 2020).

Corticosteroid Injections: These actually have a poor long-term effect (Kongsgaard et al. 2009)! They actually damage the tendon tissue and cells (Dean et al. 2014)

Foam Rolling, Massage, Ice and other passive, conservative treatments: If it’s cheap and low-risk, feel free to try almost anything.

However, these should not be the main focus of your rehab and shouldn’t distract from the goal of gradually improving function.

These are, in my opinion at least, the 5 most common myths about patellar tendinopathy.

If you want to know what the 9 most common myths about pain are (which you should), then click here.



Literature

  • Agergaard, A. S., Svensson, R. B., Malmgaard-Clausen, N. M., Couppé, C., Hjortshoej, M. H., Doessing, S., Kjaer, M., & Magnusson, S. P. (2021). Clinical Outcomes, Structure, and Function Improve With Both Heavy and Moderate Loads in the Treatment of Patellar Tendinopathy: A Randomized Clinical Trial. The American journal of sports medicine49(4), 982–993. https://doi.org/10.1177/0363546520988741 
  • Clifford, C., Challoumas, D., Paul, L., Syme, G., & Millar, N. L. (2020). Effectiveness of isometric exercise in the management of tendinopathy: a systematic review and meta-analysis of randomised trials. BMJ open sport & exercise medicine6(1), e000760. https://doi.org/10.1136/bmjsem-2020-000760
  • Bahr, R., Fossan, B., Løken, S., & Engebretsen, L. (2006). Surgical treatment compared with eccentric training for patellar tendinopathy (Jumper’s Knee). A randomized, controlled trial. The Journal of bone and joint surgery. American volume88(8), 1689–1698. https://doi.org/10.2106/JBJS.E.01181
  • Clifford, C., Challoumas, D., Paul, L., Syme, G., & Millar, N. L. (2020). Effectiveness of isometric exercise in the management of tendinopathy: a systematic review and meta-analysis of randomised trials. BMJ open sport & exercise medicine6(1), e000760. https://doi.org/10.1136/bmjsem-2020-000760
  • Dean, B. J., Lostis, E., Oakley, T., Rombach, I., Morrey, M. E., & Carr, A. J. (2014). The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon. Seminars in arthritis and rheumatism43(4), 570–576. https://doi.org/10.1016/j.semarthrit.2013.08.006
  • Docking, S. I., & Cook, J. (2018). Imaging and its role in tendinopathy: current evidence and the need for guidelines. Current Radiology Reports6, 1-3.
  • Docking, S. I., Girdwood, M. A., Cook, J., Fortington, L. V., & Rio, E. (2020). Reduced Levels of Aligned Fibrillar Structure Are Not Associated With Achilles and Patellar Tendon Symptoms. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine30(6), 550–555. https://doi.org/10.1097/JSM.0000000000000644 
  • Docking, S. I., Rio, E., Girdwood, M. A., Hannington, M. C., Cook, J. L., & Culvenor, A. G. (2021). Physical Activity and Investigation With Magnetic Resonance Imaging Partly Explain Variability in the Prevalence of Patellar Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals. The Journal of orthopaedic and sports physical therapy51(5), 216–231. https://doi.org/10.2519/jospt.2021.10054
  • Kongsgaard, M., Kovanen, V., Aagaard, P., Doessing, S., Hansen, P., Laursen, A. H., Kaldau, N. C., Kjaer, M., & Magnusson, S. P. (2009). Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scandinavian journal of medicine & science in sports19(6), 790–802. https://doi.org/10.1111/j.1600-0838.2009.00949.x
  • Lee, W. C., Ng, G. Y., Zhang, Z. J., Malliaras, P., Masci, L., & Fu, S. N. (2020). Changes on Tendon Stiffness and Clinical Outcomes in Athletes Are Associated With Patellar Tendinopathy After Eccentric Exercise. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine30(1), 25–32. https://doi.org/10.1097/JSM.0000000000000562
  • Scott, A., Squier, K., Alfredson, H., Bahr, R., Cook, J. L., Coombes, B., de Vos, R. J., Fu, S. N., Grimaldi, A., Lewis, J. S., Maffulli, N., Magnusson, S. P., Malliaras, P., Mc Auliffe, S., Oei, E. H. G., Purdam, C. R., Rees, J. D., Rio, E. K., Gravare Silbernagel, K., Speed, C., … Zwerver, J. (2020). ICON 2019: International Scientific Tendinopathy Symposium Consensus: Clinical Terminology. British journal of sports medicine54(5), 260–262. https://doi.org/10.1136/bjsports-2019-100885
  • Scott, A., LaPrade, R. F., Harmon, K. G., Filardo, G., Kon, E., Della Villa, S., Bahr, R., Moksnes, H., Torgalsen, T., Lee, J., Dragoo, J. L., & Engebretsen, L. (2019). Platelet-Rich Plasma for Patellar Tendinopathy: A Randomized Controlled Trial of Leukocyte-Rich PRP or Leukocyte-Poor PRP Versus Saline. The American journal of sports medicine47(7), 1654–1661. https://doi.org/10.1177/0363546519837954
  • Silbernagel, K. G., Thomeé, R., Eriksson, B. I., & Karlsson, J. (2007). Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. The American journal of sports medicine35(6), 897–906. https://doi.org/10.1177/0363546506298279
  • Thijs, K. M., Zwerver, J., Backx, F. J., Steeneken, V., Rayer, S., Groenenboom, P., & Moen, M. H. (2017). Effectiveness of Shockwave Treatment Combined With Eccentric Training for Patellar Tendinopathy: A Double-Blinded Randomized Study. Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine27(2), 89–96. https://doi.org/10.1097/JSM.0000000000000332
  • Van Ark, M., Rio, E., Cook, J., van den Akker-Scheek, I., Gaida, J. E., Zwerver, J., & Docking, S. (2018). Clinical Improvements Are Not Explained by Changes in Tendon Structure on Ultrasound Tissue Characterization After an Exercise Program for Patellar Tendinopathy. American journal of physical medicine & rehabilitation97(10), 708–714. https://doi.org/10.1097/PHM.0000000000000951
  • Zwerver, J., Hartgens, F., Verhagen, E., van der Worp, H., van den Akker-Scheek, I., & Diercks, R. L. (2011). No effect of extracorporeal shockwave therapy on patellar tendinopathy in jumping athletes during the competitive season: a randomized clinical trial. The American journal of sports medicine39(6), 1191–1199. https://doi.org/10.1177/036354651039549
Gino Lazzaro

Gino Lazzaro

Gino has a Master's degree in sports physiotherapy. His primary focus is helping athletes who have been in pain for more than 3 months get back to their sport. If that's what you want to achieve, then you can apply here.

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