What is the initial management for patellar tendinopathy?

Initial Management for Patellar Tendinopathy

The initial management for patellar tendinopathy should focus on exercise therapy, particularly eccentric strengthening exercises, combined with NSAIDs for pain control and load reduction. 1, 2

Conservative Management Approach

First-Line Interventions

1. Exercise Therapy

   • Knee-targeted exercises with focus on quadriceps strengthening 1
   • Hip-and-knee-targeted exercise therapy (combines hip strengthening with quadriceps exercises) shows better efficacy than knee-targeted exercises alone 1
   • Eccentric exercises are considered the mainstay of physical therapy treatment 2

2. Pain Management

   • NSAIDs are strongly recommended as first-line treatment for tendon pain 1
     • Ibuprofen at 1.2g daily is the safest option
     • Can be increased to 2.4g daily if needed
     • Can be combined with paracetamol (up to 4g daily) for inadequate relief

3. Load Reduction

   • Relative rest and activity modification to reduce stress on the patellar tendon 3, 4
   • RICE protocol (Rest, Ice, Compression, Elevation) to manage pain and inflammation 1

4. Manual Therapy

   • Manual therapy of the lower quadrant is recommended 1
   • Massage can help with tissue healing 3

5. Orthotic Support

   • Prefabricated foot orthoses show primary efficacy compared to wait-and-see approach 1

Phased Rehabilitation Approach

The American Physical Therapy Association recommends a phased approach to rehabilitation 1:

Phase	Focus	Duration	Key Elements
Initial	Pain control and protected range of motion	0-4 weeks	RICE, NSAIDs, gentle stretching
Intermediate	Progressive strengthening exercises	4-8 weeks	Eccentric exercises, load progression
Advanced	Sport-specific or occupation-specific training	8-12 weeks	Return to activity preparation

Important Considerations

Understanding the Pathology

• Patellar tendinopathy is primarily a degenerative condition (tendinosis) rather than an inflammatory one (tendinitis) 3
• Treatment should address the underlying collagen breakdown rather than focusing solely on inflammation reduction 3

Common Pitfalls to Avoid

1. Overreliance on Corticosteroid Injections

   • Corticosteroid injections provide short-term pain relief but increase risk of tendon rupture 2
   • Should be limited to 2-3 injections with 4-6 weeks between injections 1

2. Premature Return to Full Activity

   • Return to full activity should only occur when the patient demonstrates:
     • Complete resolution of pain during and after activity
     • Full range of motion compared to uninjured side
     • Strength symmetry >90% compared to uninjured side
     • Successful completion of sport-specific functional tests 1

3. Ineffective Treatments

   • Extracorporeal shockwave therapy (ESWT) as a solitary treatment during competitive season shows no benefit over placebo for athletes with symptoms less than 12 months 5

When to Consider Surgical Intervention

Surgical consultation should be considered if:

• Pain persists despite 3-6 months of well-managed conservative treatment
• Functional limitations significantly impact quality of life
• Progressive joint degeneration is evident on follow-up imaging 1, 2

Surgical treatment has produced good to excellent outcomes in the majority of patients who fail nonoperative management 2.