Patellar Tendinopathy

Lower Limb

Overview

Patellar tendinopathy is a common overuse injury affecting the patellar tendon, characterized by pain at the inferior pole of the patella. It typically presents in individuals engaged in jumping or running activities and results from repetitive microtrauma exceeding the tendon's capacity to adapt. The condition exists on a spectrum from reactive tendinopathy to tendon degeneration with potential for chronicity if not appropriately managed.

Pathophysiology

Patellar tendinopathy develops through repetitive tensile loading that exceeds the tendon's adaptive capacity, leading to microtrauma, disrupted collagen organization, and neovascularization. Early stages involve reactive changes with swelling and inflammation, potentially progressing to degenerative changes with disorganized collagen, calcification, and intratendinous degeneration. The pathology is multifactorial, involving biomechanical dysfunction (excessive knee valgus, quadriceps dominance, poor hip control), training errors, reduced ankle dorsiflexion, and inadequate load management. Altered proprioception and motor control perpetuate the condition.

Typical Presentation

Site

Infrapatellar tendon, typically at the attachment to the inferior pole of the patella; may extend into mid-substance or superior insertion

Quality

Sharp, localized pain; aching; occasionally described as burning or throbbing, particularly after activity

Intensity

Variable; typically 3-7/10, may be 8-10/10 during acute exacerbations; characteristically worsens with activity and may improve briefly with warm-up ('warm-up pain')

Aggravating

Jumping, hopping, running, rapid changes of direction, ascending/descending stairs, squatting, prolonged sitting with knee flexed, rapid increase in training intensity or volume, tight hip flexors and quadriceps, activities with deceleration demands

Relieving

Rest, ice, gradual loading, adequate recovery, stretching, taping, activity modification, eccentric strengthening (after acute phase)

Associated

Anterior knee pain, mild swelling over patellar tendon insertion, tenderness on palpation, stiffness after periods of inactivity, reduced knee flexion ROM, weakness in hip abductors and external rotators, altered movement patterns (knee valgus on single-leg stance/squat), possible calf tightness

Orthopaedic Tests

Test descriptions are written with AI assistance from standard clinical texts. Where a test lists Sources, its description has been checked against them; those sources are independent and do not endorse OsteoKit. Accuracy figures and grades (A–D) appear only when checked against the published study; tests without one are marked “No accuracy study”.

Further reading: full test procedures are described in standard clinical examination texts, e.g. Magee & Manske, Orthopedic Physical Assessment (7th ed.), and Cook & Hegedus, Orthopedic Physical Examination Tests: An Evidence-Based Approach (2nd ed.).

No accuracy study

Single-Leg Decline Squat

Procedure

Patient stands on the affected leg on a board angled downwards at about 25°. Ask the patient to squat slowly on that leg to about 60° of knee flexion and rate the pain.

Positive Finding

Pain at the lower pole of the kneecap during the squat.

Interpretation

Loads the patellar tendon and is commonly used to rate pain and track progress. Pain in this position also occurs with patellofemoral pain, so pain location matters: at the lower pole of the kneecap for the tendon, around or behind the kneecap for the patellofemoral joint. The previously cited Hernandez-Sanchez work concerns the VISA-P severity scale, not the diagnostic accuracy of the decline squat; no validated sensitivity/specificity source was found.

Further reading

No accuracy study

Palpation of Patellar Tendon

Procedure

Patient supine, knee straight and relaxed. Palpate the tendon from the lower pole of the kneecap to the tibial tuberosity, pressing the upper pole of the kneecap down to tip the lower pole up.

Positive Finding

Tenderness at the lower pole of the kneecap that reproduces the familiar pain.

Interpretation

Tenderness here is common in jumping athletes without pain, so on its own it is not diagnostic. Pain with loading (decline squat, hops) that matches the history is more meaningful.

Sources

Not a diagnostic test

Quadriceps Length Test (Prone Knee Bend)

Procedure

Patient prone. Bend the knee, bringing the heel towards the buttock, and note the range and where the pull is felt.

Positive Finding

Reduced knee bend compared with the other side, or pain at the lower pole of the kneecap.

Interpretation

Measures quadriceps flexibility, which is often reduced in patellar tendinopathy and is a target for treatment. It does not stretch the tendon itself and is not a diagnostic test.

Further reading

Performance measure

Vertical Jump or Single-Leg Hop Test

Procedure

Ask the patient to perform a few vertical jumps, then single-leg hops, and rate any pain.

Positive Finding

Pain at the lower pole of the kneecap during or just after jumping.

Interpretation

Reproduces the load that typically provokes patellar tendinopathy. Useful for grading irritability and for guiding return to sport. Pain location separates it from patellofemoral pain. Figures previously shown were not traceable to a validated diagnostic-accuracy study.

Sources

No accuracy study

Isometric Mid-Range Quadriceps Contraction

Procedure

Patient seated, knee bent to about 60°. Ask the patient to push the leg straight against resistance and hold for up to 45 seconds, rating pain before and after.

Positive Finding

Pain at the lower pole of the kneecap during the hold, or a change in pain afterwards.

Interpretation

Used to find a tolerable loading level and to monitor the tendon. It is part of management rather than a diagnostic test.

Further reading

No accuracy study

Single-Leg Rotation in Flexion

Procedure

Patient stands on the affected leg with the knee slightly bent and rotates the body in and out a few times, with support for balance.

Positive Finding

Pain at the lower pole of the kneecap during the movement.

Interpretation

Not a recognised test for patellar tendinopathy; the Thessaly test is a meniscal test. Pain at the joint line rather than the tendon should prompt a meniscal assessment. The Thessaly test is a meniscal test; a "patellar-load" modification is not a validated entity and has no diagnostic-accuracy data.

Further reading

⚠ Red Flags

  • •Signs of acute rupture (sudden inability to extend knee, palpable defect, severe swelling)
  • •Systemic inflammatory symptoms (fever, weight loss, widespread joint pain)
  • •Signs of infection (increasing warmth, redness, systemic malaise)
  • •Severe unremitting pain unresponsive to conservative management over 12 weeks
  • •Neurological symptoms (pins and needles, numbness, referred pain down leg)
  • •History of malignancy or corticosteroid use increasing rupture risk

⚡ Yellow Flags

  • •Excessive pain catastrophizing or fear-avoidance behaviors
  • •Overtraining or obsessive exercise patterns suggesting addictive behavior
  • •Poor self-efficacy regarding recovery
  • •Significant psychological distress or depression
  • •Unrealistic expectations about recovery timeline
  • •Occupational stress or dissatisfaction contributing to symptom maintenance
  • •Poor sleep quality impacting healing and pain modulation
  • •Perfectionistic personality traits driving excessive training loads

Osteopathic Techniques

Progressive tendon loading is the usual base of care, although even the exercise trials are small and uncertain. Soft tissue techniques added to exercise helped in some trials.

Region

Patellar tendon and infrapatellar region

Technique

Soft tissue, knee and quadriceps
Grade C
Limited evidence: indirect or low-quality support only
Soft tissue techniques added to exercise helped pain and function in half the trials. Trials are small and the techniques mixed.

Rationale

Hands-on work, including friction massage, to the patellar tendon, given alongside loading exercise.

How it's done & evidence

How it's done

Hands-on kneading, stroking and sustained pressure to the quadriceps, the patellar and quadriceps tendons, the iliotibial band near the knee and the tissues around the joint. Transverse friction massage across a tendon is one form. In trials it was given alongside exercise.

Evidence in Patellar Tendinopathy

Ragone 2024 (6 trials, n=309): soft tissue techniques (including transverse friction massage, dry needling and stretching) added to exercise improved results over exercise alone in half the studies.

Region

Quadriceps (rectus femoris)

Technique

Muscle energy, hip and thigh musclesNo trials found

Rationale

Low-force, patient-powered stretch for tight hip and thigh muscles.

How it's done, cautions & evidence

How it's done

The muscle (for example the hamstrings, adductors or rectus femoris) is taken to its barrier. The patient pushes gently, at about 10–20% effort, against resistance for 5–10 seconds, relaxes for 3–5 seconds, and the new barrier is taken up.

Cautions

Not used with an acute fracture, a joint infection or a bone malignancy; take care with severe osteoporosis or after surgery that limits muscle contraction. Use the least force needed: too much can tear a muscle or pull off a tendon, especially in older patients.

Evidence in Patellar Tendinopathy

Searched 24 Oct 2026: no trials of quadriceps muscle energy technique in patellar tendinopathy.

Region

Gluteal and hip rotator muscles

Technique

Soft tissue, lumbar and glutealNo trials found

Rationale

Eases tension in the hip and thigh muscles that help control knee alignment.

How it's done, cautions & evidence

How it's done

Hands-on soft-tissue work (kneading, stretching and sustained pressure) to the lumbar paraspinals, quadratus lumborum and gluteal muscles, usually prone or side-lying.

Cautions

Only minor side effects have been reported in trials.

Evidence in Patellar Tendinopathy

Searched 24 Oct 2026: no trials of gluteal soft tissue technique in patellar tendinopathy.

Sources

Region

Tibiofemoral and patellofemoral joints

Technique

Articulation, knee (tibiofemoral and patellofemoral)No trials found

Rationale

Gentle, rhythmic glides of the knee and kneecap within their range to ease pain and stiffness.

How it's done, cautions & evidence

How it's done

Passive, low-velocity glides of the knee within its range, with no thrust: distraction and front-to-back glides of the tibia on the femur, and glides of the kneecap in each direction, usually 2–3 oscillations a second for 1–2 minutes. A Mulligan variant holds a sustained glide of the tibia while the patient actively bends and straightens the knee.

Cautions

In knee osteoarthritis trials, no serious adverse events were reported with manual therapy.

Evidence in Patellar Tendinopathy

Searched 24 Oct 2026: no trials of knee mobilisation in patellar tendinopathy.

Region

Gastrocnemius and soleus

Technique

Muscle energy, calf (gastrocnemius and soleus)No trials found

Rationale

Low-force, patient-powered stretch for a tight calf.

How it's done, cautions & evidence

How it's done

The calf is taken to its barrier by dorsiflexing the ankle. The patient pushes the foot gently down, at about 10–20% effort, against resistance for 5–10 seconds, relaxes for 3–5 seconds, and the new barrier is taken up.

Cautions

Not used with an acute fracture, a joint infection or a bone malignancy; take care with severe osteoporosis or after surgery that limits muscle contraction. Use the least force needed: too much can tear a muscle or pull off a tendon, especially in older patients.

Evidence in Patellar Tendinopathy

Searched 24 Oct 2026: no trials of calf muscle energy technique in patellar tendinopathy.

Rehabilitation Exercises

Supine Knee Flexion with Hip Support

Range of MotionBeginner

Quadriceps Self-Stretch (Standing or Lying)

StretchingBeginner

Gastrocnemius and Soleus Calf Stretch (Wall-Supported)

StretchingBeginner

Figure-4 Hip Flexor and Piriformis Stretch

StretchingBeginner

Supine Gluteal Bridge (Bilateral)

StrengtheningBeginner

Side-Lying Hip Abduction

StrengtheningBeginner

Supine Quadriceps Isometric (VMO Emphasis)

StrengtheningBeginner

Eccentric Single-Leg Decline Squat (Progressive)

StrengtheningIntermediate

Single-Leg Hip Bridge (Gluteal Focus)

StrengtheningIntermediate

Single-Leg Stance with Hip Alignment Focus

PosturalIntermediate

Lateral Step-Down with Controlled Knee Valgus Prevention

BalanceIntermediate

Graded Return to Running Protocol (Walk-Jog Intervals)

CardiovascularAdvanced

Referral Criteria

  • •Suspected patellar tendon rupture (inability to extend knee, palpable defect, severe acute swelling)
  • •Signs of systemic inflammatory or infectious conditions
  • •Severe pain unresponsive to conservative management after 12 weeks
  • •Significant functional limitation affecting activities of daily living or work
  • •Chronic patellar tendinopathy with consideration for advanced imaging or injection-based interventions
  • •Comorbid pathology identified (meniscal lesion, cartilage damage, patellofemoral osteoarthritis)
  • •Neurological symptoms or progressive neurological deficit
  • •Severe psychological distress, depression, or anxiety interfering with rehabilitation compliance
  • •Need for specialist sports medicine assessment or consideration of surgical intervention
  • •Patient not progressing despite adherence to conservative management over 8-12 weeks