Diagnosis
Your doctor will diagnose your injury by inquiring about your history and by using a combination of manual examinations1 and imaging tests such as ultrasound or MRI.
MRIs and x-rays are also used for differential diagnosis, to rule out other knee injuries with similar symptoms.
However, in some cases patellar tendonitis is difficult to diagnose, because tendons can be painful with a normal ultrasound2, just like tendons that show pathological changes on ultrasound can still be pain-free3.
Treatments
A variety of treatments for patellar tendonitis are available.
Medication
Your doctor may prescribe pain relievers or non-steroidal anti-inflammatories (NSAIDs). NSAIDs can provide short-term pain relief4 and they are a viable option during the early stages of patellar tendonitis, but they actually slow down tendon repair once the injury has become chronic5.
Physical Therapy
Physical therapy with slow strengthening exercises such as eccentric squats6, leg presses7, or leg extensions8 have been shown to be very effective for providing long-term improvement.
Isometric holds, i.e. holding the weight in place instead of moving it, have also delivered promising results by reducing pain and muscular inhibition9.
Additionally, stretching exercises, like quad or hamstring stretches, can help prevent patellar tendonitis 10 and combined with strengthening drills they can produce superior treatment outcomes, compared to just doing strengthening alone11. However, in some cases stretching leads to a flare-up of pain, which is why caution is always advised.
Talk to your doctor before starting any exercise regimen.
Adjunct Treatments
The physical therapy exercises can be combined with adjunct treatments, but unfortunately there is no strong evidence that proves these treatments provide long-term benefits12.
Icing is a good option for pain management and to manage flare-ups, but it didn’t show any benefits in treating tendonitis13 and it will temporarily decrease tendon flexibility14.
Wearing a patellar tendon strap can lead to a short-term pain reduction in patients with patellar tendonitis15. It can also improve body awareness16, jumping mechanics17, and it may contribute to improved patellar tracking18. However, patellar tendon straps do not increase jumping performance19 and will not lead to long-term improvements.
Ultrasound therapy delivered inconsistent results as treatment for tendonitis20 and has failed to provide benefits in several studies21.
Iontophoresis can help drive a substance into body tissue by using an ionizing current22 and most commonly NSAIDs or corticosteroids are used for tendonitis. However, these treatments showed no improvement when compared to control groups23.
Invasive Procedures
Corticosteroid injections are inexpensive, easy to perform, and they carry a low risk of immediate complications24. They can lead to a short-term reduction of pain, but they also increase risk of suffering a relapse25. In one study on elbow tendonitis, 72% of patients treated with corticosteroid injections suffered a relapse26.
Unfortunately, over the long-term these injections will actually cause weaker tendons27 that are more prone to tearing28.
Platelet-rich plasma injections (PRP) are another popular treatment modality for patellar tendonitis. In this treatment centrifuged blood is injected into the injury site to speed up healing. Unfortunately there is little evidence to show an effect greater than placebo injections.29 However, PRP injections may be beneficial for recalcitrant cases of patellar tendonitis.
Prolotherapy and dry-needling are two other minimally invasive procedures for patellar tendonitis. Neither is supported by strong evidence30.
Surgery is a last resort treatment for refractory cases of patellar tendonitis31, when all non-surgical options have been exhausted and the patient fully understands the risks and benefits of the respective procedure32. It requires a longer rehab time of 6 to 12 months33, but the long-term results are promising34. For example, in one study surgery improved symptoms in 57% of patients35.
However, for non-recalcitrant cases of patellar tendonitis an exercise-based approach is a far superior option36 and performed correctly, it can produce outstanding results.
References
[2] S. de Jonge et al., “Relationship between neovascularization and clinical severity in Achilles tendinopathy in 556 paired measurements,” Scandinavian journal of medicine & science in sports 24, no. 5 (2014).
[3] Seán McAuliffe et al., “Can ultrasound imaging predict the development of Achilles and patellar tendinopathy? A systematic review and meta-analysis,” British journal of sports medicine 50, no. 24 (2016).
[4] Brett M. Andres and George A. C. Murrell, “Treatment of tendinopathy: what works, what does not, and what is on the horizon,” Clinical orthopaedics and related research 466, no. 7 (2008): 1542.
[5] J. L. Cook and C. R. Purdam, “Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy,” British journal of sports medicine 43, no. 6 (2009): 413.
[6] P. Jonsson, “Superior results with eccentric compared to concentric quadriceps training in patients with jumper’s knee: a prospective randomised study,” British journal of sports medicine 39, no. 11 (2005); C. R. Purdam, “A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy,” British journal of sports medicine 38, no. 4 (2004); Craig R. Purdam et al., “Discriminative ability of functional loading tests for adolescent jumper’s knee,” Physical Therapy in Sport 4, no. 1 (2003); M. A. Young, “Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players,” British journal of sports medicine 39, no. 2 (2005).
[7] Peter Malliaras, Lower Limb Tendinopathy Course (London, 31.10.2016), p. 12; Peter Malliaras et al., “Achilles and patellar tendinopathy loading programmes: A systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness,” Sports medicine (Auckland, N.Z.) 43, no. 4 (2013).
[8] L. J. Cannell, “A randomised clinical trial of the efficacy of drop squats or leg extension/leg curl exercises to treat clinically diagnosed jumper’s knee in athletes: pilot study,” British journal of sports medicine 35, no. 1 (2001).
[9] Ebonie Rio et al., “Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy,” British journal of sports medicine 49, no. 19 (2015): 1281.
[10] Maria E. H. Larsson, Ingela Käll, and Katarina Nilsson-Helander, “Treatment of patellar tendinopathy—a systematic review of randomized controlled trials,” Knee Surgery, Sports Traumatology, Arthroscopy 20, no. 8 (2012): 1643.
[11] Stasinopoulos Dimitrios, Manias Pantelis, and Stasinopoulou Kalliopi, “Comparing the effects of eccentric training with eccentric training and static stretching exercises in the treatment of patellar tendinopathy. A controlled clinical trial,” Clinical rehabilitation 26, no. 5 (2012).
[12] Peter Malliaras, Lower Limb Tendinopathy Course (London, 31.10.2016), pp. O5.
[13] P. Manias and D. Stasinopoulos, “A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy,” British journal of sports medicine 40, no. 1 (2006).
[14] Ibid.
[15] A. de Vries et al., “Effect of patellar strap and sports tape on pain in patellar tendinopathy: A randomized controlled trial,” Scandinavian journal of medicine & science in sports 26, no. 10 (2016).
[16] de Vries, Astrid J et al., “Effect of a patellar strap on the joint position sense of the symptomatic knee in athletes with patellar tendinopathy,” Journal of science and medicine in sport (2017).
[17] Adam B. Rosen, Jupil Ko, and Cathleen N. Brown, “Single-limb landing biomechanics are altered and patellar tendinopathy related pain is reduced with acute infrapatellar strap application,” The Knee 24, no. 4 (2017).
[18] Adam B. Rosen et al., “Patellar tendon straps decrease pre-landing quadriceps activation in males with patellar tendinopathy,” Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine 24 (2017).
[19] Gali Dar and Einat Mei-Dan, “Immediate effect of infrapatellar strap on pain and jump height in patellar tendinopathy among young athletes,” Prosthetics and Orthotics International 43, no. 1 (2018).
[20] Brett M. Andres and George A. C. Murrell, “Treatment of tendinopathy: what works, what does not, and what is on the horizon,” Clinical orthopaedics and related research 466, no. 7 (2008): 1542.
[21] Rachel Chester et al., “Eccentric calf muscle training compared with therapeutic ultrasound for chronic Achilles tendon pain–a pilot study,” Manual therapy 13, no. 6 (2008); S. J. Warden et al., “Low-intensity pulsed ultrasound for chronic patellar tendinopathy: a randomized, double-blind, placebo-controlled trial,” Rheumatology (Oxford, England) 47, no. 4 (2008); Maria E. H. Larsson, Ingela Käll, and Katarina Nilsson-Helander, “Treatment of patellar tendinopathy—a systematic review of randomized controlled trials,” Knee Surgery, Sports Traumatology, Arthroscopy 20, no. 8 (2012): 1645.
[22] Mark F. Reinking, “CURRENT CONCEPTS IN THE TREATMENT OF PATELLAR TENDINOPATHY,” International journal of sports physical therapy 11, no. 6 (2016).
[23] Brett M. Andres and George A. C. Murrell, “Treatment of tendinopathy: what works, what does not, and what is on the horizon,” Clinical orthopaedics and related research 466, no. 7 (2008): 1542.
[24] Angelo de Carli et al., “Calcific tendinitis of the shoulder,” Joints 2, no. 3 (2014): 133.
[25] U. Fredberg et al., “Ultrasonography as a tool for diagnosis, guidance of local steroid injection and, together with pressure algometry, monitoring of the treatment of athletes with chronic jumper’s knee and Achilles tendinitis: a randomized, double-blind, placebo-controlled study,” Scandinavian journal of rheumatology 33, no. 2 (2004).
[26] L. Bisset et al., “Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial,” BMJ 333, no. 7575 (2006).
[27] M. Kongsgaard et al., “Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy,” Scandinavian journal of medicine & science in sports 19, no. 6 (2009); Brooke K. Coombes et al., “Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial,” JAMA 309, no. 5 (2013).
[28] Jianying Zhang, Camille Keenan, and James H.-C. Wang, “The effects of dexamethasone on human patellar tendon stem cells: implications for dexamethasone treatment of tendon injury,” Journal of orthopaedic research : official publication of the Orthopaedic Research Society 31, no. 1 (2013); Ronald Hugate et al., “The effects of intratendinous and retrocalcaneal intrabursal injections of corticosteroid on the biomechanical properties of rabbit Achilles tendons,” The Journal of bone and joint surgery. American volume 86-A, no. 4 (2004).
[29] Micheal P. Hall, James P. Ward, and Dennis A. Cardone, “Platelet Rich Placebo?: Evidence for Platelet Rich Plasma in the Treatment of Tendinopathy and Augmentation of Tendon Repair,” Bulletin of the Hospital for Joint Diseases 71 (2013): 57; Nasir Hussain, Herman Johal, and Mohit Bhandari, “An evidence-based evaluation on the use of platelet rich plasma in orthopedics – a review of the literature,” SICOT-J 3, no. 1 (2017); Peter Malliaras et al., “Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations,” The Journal of orthopaedic and sports physical therapy 45, no. 11 (2015): 894; de Vos, Robert J et al., “Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial,” JAMA 303, no. 2 (2010); Robert-Jan de Vos, Johann Windt, and Adam Weir, “Strong evidence against platelet-rich plasma injections for chronic lateral epicondylar tendinopathy: a systematic review,” British journal of sports medicine 48, no. 12 (2014); Franciele Dietrich et al., “Effect of platelet-rich plasma on rat Achilles tendon healing is related to microbiota,” Acta Orthopaedica 88, no. 4 (2017).
[30] Lane M. Sanderson and Alan Bryant, “Effectiveness and safety of prolotherapy injections for management of lower limb tendinopathy and fasciopathy: a systematic review,” Journal of foot and ankle research 8, no. 1 (2015); O. Morath et al., “The effect of sclerotherapy and prolotherapy on chronic painful Achilles tendinopathy-a systematic review including meta-analysis,” Scandinavian journal of medicine & science in sports 28, no. 1 (2018); Ulrike H. Mitchell et al., “The Construction of Sham Dry Needles and Their Validity,” Evidence-Based Complementary and Alternative Medicine 2018, no. 5 (2018); Patrick C. Wheeler et al., “A Comparison of Two Different High-Volume Image-Guided Injection Procedures for Patients With Chronic Noninsertional Achilles Tendinopathy: A Pragmatic Retrospective Cohort Study,” The Journal of Foot and Ankle Surgery 55, no. 5 (2016); F. A. Chaudhry, “Effectiveness of dry needling and high-volume image-guided injection in the management of chronic mid-portion Achilles tendinopathy in adult population: a literature review,” European Journal of Orthopaedic Surgery & Traumatology 27, no. 4 (2017): 446.
[31] Antonio Pascarella et al., “Arthroscopic management of chronic patellar tendinopathy,” The American journal of sports medicine 39, no. 9 (2011).
[32] F. A. Chaudhry, “Effectiveness of dry needling and high-volume image-guided injection in the management of chronic mid-portion Achilles tendinopathy in adult population: a literature review,” European Journal of Orthopaedic Surgery & Traumatology 27, no. 4 (2017): 447.
[33] N. Maffulli et al., “Surgical management of tendinopathy of the main body of the patellar tendon in athletes,” Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 9, no. 2 (1999); Peter Malliaras, Lower Limb Tendinopathy Course (London, 31.10.2016).
[34] N. Maffulli et al., “Surgical management of tendinopathy of the main body of the patellar tendon in athletes,” Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine 9, no. 2 (1999).
[35] Joshua S. Everhart et al., “Treatment Options for Patellar Tendinopathy: A Systematic Review,” Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association 33, no. 4 (2017).
[36] Carla van Usen and Barbara Pumberger, “Effectiveness of Eccentric Exercises in the Management of Chronic Achilles Tendinosis,” The Internet Journal of Allied Health Sciences and Practice 5, no. 2 (2007): 8, http://ijahsp.nova.edu/articles/vol5num2/van_Usen.pdf.
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