Treatment of Quadriceps Tendon Tenderness Over the Patella
Begin with 3-6 months of conservative therapy consisting of relative rest, ice therapy, eccentric strengthening exercises, and NSAIDs, as approximately 80% of patients will fully recover with this approach. 1
Understanding the Pathology
- Most quadriceps tendon pain represents degenerative tendinopathy ("tendinosus") rather than acute inflammation, despite the presence of tenderness. 1
- The condition involves degeneration of normally arranged collagen fiber structure at the bone-tendon junction, not primarily an inflammatory process. 2
First-Line Conservative Management (0-6 Months)
Relative Rest
- Allow continuation of activities that do not worsen pain while avoiding those that exacerbate symptoms. 1
- Complete immobilization must be avoided as it causes muscular atrophy and deconditioning. 1
- Tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers. 1
Cryotherapy
- Apply ice through a wet towel for 10-minute periods repeatedly to reduce tissue metabolism, slow release of blood and proteins from surrounding vasculature, and provide short-term pain relief. 1
- This is the most effective cryotherapy technique based on systematic review. 2
Eccentric Strengthening Exercises
- Eccentric exercises are the critical cornerstone of treatment as they stimulate collagen production and guide normal alignment of newly formed collagen fibers. 1
- Evidence is strongest for patellar and Achilles tendinosis, with proven effectiveness in reversing degenerative changes. 2
NSAIDs
- Topical NSAIDs are preferred over oral NSAIDs as they effectively relieve tendon pain while eliminating the increased risk of gastrointestinal hemorrhage. 1
- NSAIDs provide short-term pain relief but do not alter long-term outcomes. 2
- Important caveat: Animal studies demonstrate that most NSAIDs (except ibuprofen) may have detrimental effects on healing strength at the bone-tendon junction by decreasing collagen content. 3
- Use NSAIDs judiciously for the shortest duration necessary, prioritizing topical formulations when possible. 1, 4
Second-Line Interventions (If First-Line Fails)
Bracing
- Braces can reinforce, unload, and protect tendons during activity and are safe despite limited data supporting definitive conclusions regarding effectiveness. 1
Corticosteroid Injections
- Use with extreme caution and only for acute phase pain relief. 1
- May be more effective than oral NSAIDs for acute phase relief but do not alter long-term outcomes. 2
- Never inject directly into the tendon substance as this may inhibit healing, reduce tensile strength, and predispose to spontaneous rupture. 1
- Peritendinous injections should also be used cautiously as they may inhibit healing. 2
Extracorporeal Shock Wave Therapy (ESWT)
- Appears safe and effective but requires further research to clarify optimal treatment strategies. 1
- Represents a noninvasive option for chronic cases. 2
Surgical Management
- Reserve surgery for patients who have failed 3-6 months of well-managed conservative treatment. 1
- Surgical techniques typically include excision of abnormal tendon tissue and longitudinal tenotomies to release areas of scarring and fibrosis. 5
- Surgery is effective in carefully selected patients, producing good to excellent outcomes in the majority of refractory cases. 2, 6
Critical Pitfalls to Avoid
- Do not completely immobilize as this leads to muscular atrophy and deconditioning. 1
- Do not inject corticosteroids directly into tendon substance as this increases rupture risk. 1
- Do not mislabel as inflammatory "tendonitis" when it is actually degenerative tendinopathy, as this may lead to inappropriate treatment focus. 1
- Do not abandon conservative management prematurely as most patients (80%) recover within 3-6 months with appropriate treatment. 1
- Use NSAIDs cautiously given evidence of potential negative effects on tendon healing, particularly at the bone-tendon junction. 3