What is the treatment for patella tendon injuries, such as tendinitis or minor tears?

Treatment of Patellar Tendon Injuries

Begin with a structured conservative management program centered on eccentric strengthening exercises combined with relative rest, ice therapy, and NSAIDs for 3-6 months before considering any invasive interventions. 1

Initial Conservative Management (First-Line Treatment)

Eccentric Exercise Program

• Eccentric strengthening is the cornerstone of treatment for patellar tendinopathy, with proven effectiveness in reducing symptoms, increasing strength, and promoting tendon healing 1, 2, 3
• Eccentric exercises stimulate collagen production and guide proper alignment of newly formed collagen fibers in the healing tendon 1
• Heavy-slow resistance (HSR) training that combines eccentric-concentric loading shows equivalent or superior evidence compared to isolated eccentric exercises, particularly for improving neuromuscular performance 4
• Continue this program for at least 3-6 months, as approximately 80% of patients fully recover with appropriate conservative treatment within this timeframe 5

Activity Modification and Relative Rest

• Reduce activities that involve repetitive loading of the patellar tendon, particularly jumping and navigating stairs 1
• Avoid complete immobilization, which leads to muscle atrophy and deconditioning 1
• Allow continuation of activities that do not worsen pain to maintain tensile loading necessary for collagen production 1

Cryotherapy

• Apply ice through a wet towel for 10-minute periods to provide short-term pain relief and reduce swelling 1, 5
• Ice therapy slows the release of blood and proteins from surrounding vasculature by reducing tissue metabolism 1

NSAIDs

• Topical NSAIDs are preferable to oral NSAIDs because they eliminate the increased risk of gastrointestinal hemorrhage while effectively relieving tendon pain 1, 5
• Oral NSAIDs can be used for acute pain relief but recognize that most chronic patellar tendinopathies involve degenerative changes (tendinosis) rather than inflammation 1, 3

Adjunctive Physical Therapy Modalities

• Deep transverse friction massage is recommended to reduce pain when combined with eccentric exercises 1, 6
• Stretching exercises are widely accepted and generally helpful for tendon rehabilitation 1, 5

Second-Line Conservative Treatments

Orthotics and Bracing

• Patellar tendon straps can help reinforce, unload, and protect the tendon during activity, though definitive evidence for effectiveness is limited 1
• These devices are safe and may help correct biomechanical problems 1

Corticosteroid Injections (Use with Caution)

• Corticosteroid injections should be used cautiously and only for short-term pain relief in the acute phase 1, 5
• They do not alter long-term outcomes and may inhibit healing, reduce tensile strength of the tissue, and predispose to spontaneous rupture 1, 5, 2
• Corticosteroid iontophoresis (non-injection delivery) is effective for patellar tendinopathy pain and function 1

Emerging Therapies

• Extracorporeal shock wave therapy (ESWT) appears safe and effective but requires further research to clarify optimal treatment strategies 1, 5, 2, 6
• Platelet-rich plasma (PRP) injections have demonstrated mixed results, and evidence-based recommendations on efficacy cannot be made 2, 6
• Therapeutic ultrasonography may decrease pain and increase collagen synthesis, though evidence for consistent benefit is weak 1, 5

Imaging and Diagnostic Considerations

When to Image

• Reserve imaging for cases where diagnosis remains unclear after thorough history and physical examination, for recalcitrant pain despite adequate conservative management, or for preoperative evaluation 1

Imaging Modalities

• Ultrasonography is highly specific (94%) but less sensitive (58%) for patellar tendinopathy, showing tendon thickening, decreased echogenicity, and calcification 1
• MRI has moderate sensitivity (78%) and specificity (86%), useful for showing chronic degenerative changes and detailed anatomic information 1
• Patellar tendon thickness >8.8 mm on axial MRI strongly correlates with the presence of a partial tear 7

Critical Pitfall for Partial Tears

• Patients with patellar tendon thickness >11.5 mm and/or partial tears >50% of tendon thickness on axial MRI are less likely to improve with nonoperative treatment and should be considered for earlier surgical referral 7
• Partial-thickness tears are located posterior or posteromedially in 91% of cases involving the proximal tendon 7

Surgical Management

Indications for Surgery

• Refer for surgical evaluation if pain persists despite 3-6 months of well-managed conservative treatment 1, 5, 2
• Surgery is particularly indicated for partial tears >50% of tendon thickness (median thickness >10 mm) 7

Surgical Techniques

• Both open and arthroscopic debridement of the patellar tendon are effective, with arthroscopic surgery resulting in faster recovery time 2, 3
• Surgical techniques include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis 5
• Surgery produces good to excellent outcomes in the majority of patients who fail nonoperative treatment 2, 3

Key Clinical Pearls

• Physical examination typically reveals well-localized tenderness at the inferior pole of the patella with the leg fully extended during resisted leg extension 1
• The decline squat test places increased load on the patellar tendon and often reproduces the patient's pain 1
• Technique modification to minimize repetitive stresses is essential for athletes and manual laborers 1, 5
• The term "tendinitis" is inappropriate for most chronic cases, as the main pathophysiology is tendinosis (degenerative disorder) rather than inflammation 3