What is the management of knee patellar tendinosis?

Management of Patellar Tendinosis

Eccentric strengthening exercises should be the cornerstone of patellar tendinosis treatment, combined with activity modification and NSAIDs as needed for pain control. 1

First-Line Treatment Approach

Initial Phase (0-4 weeks)

• Eccentric exercises on a 25° decline board - Perform 1-2 times daily as the primary intervention 1, 2
• Activity modification - Reduce activities that load the damaged tendon 1
• Pain management:
  • Acetaminophen (up to 4g/day) as first-line analgesic 1
  • NSAIDs at lowest effective dose for shortest duration if acetaminophen is inadequate 1
  • Consider topical NSAIDs to minimize gastrointestinal side effects 1

Progressive Phase (4-12 weeks)

• Increase intensity of eccentric exercises - Gradually progress loading protocols to build tendon tolerance 1
• Add deep transverse friction massage to reduce pain in the affected area 1
• Supervised exercise program - Active physical therapy is more effective than passive modalities 1, 3
• Consider corticosteroid iontophoresis if pain persists despite exercise adherence 1

Advanced Treatment Options for Refractory Cases (>12 weeks)

For cases not responding to first-line treatment after 8-12 weeks:

• Extracorporeal shock wave therapy (ESWT) - May provide benefit though evidence shows mixed results 1, 4
• Ultrasound-guided intrasheath anesthetic injections may be considered 1
• Therapeutic ultrasound - May decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1
• Surgical intervention - Consider if symptoms persist despite 3-6 months of well-managed conservative treatment 1
  • Typically includes excision of abnormal tendon tissue and longitudinal tenotomies 1
  • Arthroscopic shaving with real-time ultrasound guidance may be superior to sclerosing injections 2

Treatment Considerations and Cautions

• Avoid peri-tendon corticosteroid injections - Can increase risk of tendon rupture 1
• Steroid injections are inferior to exercise interventions and are not recommended 2
• Experimental treatments with limited evidence:
  • Injections of autologous blood, platelet-rich plasma, and hyperosmolar dextrose 2
  • Low-intensity pulsed ultrasound appears ineffective 4
• Braces can reinforce and protect tendons during activity, though limited data supports their effectiveness 1
• Regular reassessment every 4-6 weeks to adjust treatment plan 1

Evidence Quality and Considerations

The strongest evidence supports eccentric training as the primary treatment for patellar tendinopathy 1, 2, 5, 4. A 2022 systematic review confirmed that load monitoring and therapeutic exercise are effective in rehabilitating patellar tendinopathy with positive short and medium-term results 3.

While multiple treatment options exist, most studies have methodological limitations including small sample sizes, short follow-up periods, and potential bias 5, 4. The Cochrane review (2025) found that strengthening exercises may make little or no difference to function compared to no treatment, and the evidence comparing exercise to surgery or injections remains of low certainty 5.

Most research has been conducted in athletic populations (predominantly male), potentially limiting generalizability to the broader population 5, 6. Treatment should be adjusted based on symptom duration, severity, and patient activity level.