What is the conservative treatment for patellar tendinopathy (PTTD)?

Conservative Treatment for Patellar Tendinopathy (PTTD)

The mainstay of conservative treatment for patellar tendinopathy is exercise therapy, particularly eccentric strengthening exercises, combined with load management and pain control measures. 1

First-Line Treatment Approach

Pain Management

• NSAIDs are strongly recommended as first-line medication for tendon pain management 1
  • Ibuprofen 1.2g daily is the safest option
  • Can be increased to 2.4g daily if needed
  • May be combined with paracetamol (up to 4g daily) for inadequate relief
• RICE protocol in acute phases 1
  • Rest (relative)
  • Ice
  • Compression
  • Elevation

Exercise Therapy

• Hip-and-knee-targeted exercise therapy is more effective than knee-targeted exercises alone 1
• Eccentric training is the cornerstone of rehabilitation 2, 3
• Progressive loading program following a phased approach: 1
  1. Initial phase (0-4 weeks): Pain control and protected range of motion
  2. Intermediate phase (4-8 weeks): Progressive strengthening exercises
  3. Advanced phase (8-12 weeks): Sport-specific or occupation-specific training

Adjunctive Treatments

• Manual therapy of the lower quadrant 1
• Prefabricated foot orthoses 1
• Immediate functional treatment rather than immobilization 1
  • Pain-free walking as soon as tolerated
  • Pool-based exercises
  • Low-load strengthening exercises starting with seated calf raises
  • Progress to bilateral standing heel raises as tolerated

Treatment Considerations

Pathophysiological Basis

It's important to understand that patellar tendinopathy is primarily a degenerative condition (tendinosis) rather than an inflammatory condition (tendinitis) 4. This explains why treatment should focus on promoting tissue healing and remodeling through controlled loading rather than solely addressing inflammation.

When to Consider Advanced Interventions

Consider surgical consultation if: 1

• 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

Return to Activity Criteria

Return to full activity is permitted when the patient demonstrates: 1

• 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
• Ability to perform repeated single-leg hopping without pain

Common Pitfalls and Caveats

1. Overemphasis on anti-inflammatory treatments: Since the condition is primarily degenerative rather than inflammatory, treatments focusing solely on inflammation control may be insufficient 4

2. Corticosteroid injections: While they provide short-term pain relief, they increase the risk of tendon rupture and should be used cautiously 2

3. Inadequate load management: Failing to appropriately modify activities during rehabilitation can lead to persistent symptoms 3

4. Premature return to full activity: Returning before meeting all criteria increases risk of recurrence 1

5. Neglecting hip strengthening: Focusing only on knee exercises is less effective than combined hip-and-knee approaches 1

By following this structured approach to conservative management of patellar tendinopathy, most patients can expect significant improvement without requiring surgical intervention 2, 5.