What is the recommended management for patellar tendinosis and mild prepatellar bursitis?

Management of Patellar Tendinosis and Mild Prepatellar Bursitis

The recommended first-line treatment for patellar tendinosis and mild prepatellar bursitis is conservative management with eccentric strengthening exercises, relative rest, and ice application. 1, 2

Conservative Management Protocol

Immediate Interventions

• Relative rest: Avoid activities that exacerbate symptoms without complete immobilization
• Ice application: Apply for 10-minute periods to provide pain relief
• Pain management:
  • Acetaminophen (up to 4g/day) as first-line analgesic
  • NSAIDs at lowest effective dose for shortest duration if acetaminophen is inadequate
    • Options include meloxicam 15mg daily or celecoxib 200mg daily
    • Topical NSAIDs can be used for localized pain with fewer systemic side effects

Rehabilitation Program (Key Component)

• Eccentric strengthening exercises: Most effective treatment for patellar tendinosis 1, 2, 3
  • Begin with decline squats that place increased load on the patellar tendon
  • Progress gradually in intensity and volume
  • Continue for at least 12 weeks for optimal results
• Deep transverse friction massage: Recommended to reduce pain 1
• Range of motion exercises: Gentle exercises to prevent stiffness

Orthotic Support

• Consider knee orthosis/brace during activities
• May help correct biomechanical problems contributing to tendon overload 2

Monitoring and Progression

• Assess pain levels and function every 2-4 weeks
• Progress to sport-specific or activity-specific exercises as symptoms improve
• Expect gradual improvement over 3-6 months (approximately 80% of patients fully recover within this timeframe) 1, 2

When to Consider Advanced Interventions

If symptoms persist after 4-6 weeks of appropriate conservative management:

1. Corticosteroid treatments:

   • Corticosteroid iontophoresis can be effective for patellar tendinosis pain and function 1
   • Corticosteroid injections may provide short-term relief but should be used with caution 2

2. Other interventions with limited evidence:

   • Sclerosing injections 3, 4
   • Extracorporeal shock wave therapy 3

3. Surgical intervention:

   • Should only be considered after failure of a long-term (at least 6 months) appropriate conservative regimen 5, 6
   • For prepatellar bursitis specifically, endoscopic bursectomy may be considered if conservative treatment fails 7

Important Caveats

• Avoid the misconception that these conditions are primarily inflammatory ("tendinitis"); they are degenerative conditions ("tendinosis" or "tendinopathy") 1, 5
• Eccentric exercises stimulate collagen production and promote healing, making them more effective than anti-inflammatory approaches alone 2, 3
• Complete immobilization should be avoided as it can lead to muscle atrophy 2
• For athletes, especially those in jumping sports (basketball, volleyball) or sports requiring repetitive knee loading, a more gradual return to sport with continued eccentric training is essential 5

By following this structured approach with emphasis on eccentric strengthening exercises and appropriate pain management, most patients can expect significant improvement in symptoms and function within 3-6 months.