What is the treatment for patellar tendonitis?

Treatment of Patellar Tendonitis

Eccentric strengthening exercises are the cornerstone of treatment for patellar tendinopathy and should be initiated immediately as first-line therapy. 1

Initial Conservative Management (First 3-6 Months)

Primary Treatment: Eccentric Exercise Program

• Eccentric strengthening exercises are specifically recommended to reduce symptoms, increase strength, and promote tendon healing in patellar tendinopathy. 1
• These exercises can reverse degenerative changes in the tendon and should be performed consistently throughout rehabilitation. 2
• Heavy loaded isometric contractions provide immediate pain relief (lasting up to 45 minutes) and can be used for in-season athletes who need rapid symptom control. 3
• Progressive heavy loaded isotonic exercises also reduce pain at 4-week follow-up. 3

Relative Rest and Activity Modification

• Reduce repetitive loading activities that aggravate symptoms, but continue activities that don't worsen pain. 1, 2
• Avoid complete immobilization—this leads to muscle atrophy and deconditioning. 1, 2
• Tensile loading stimulates collagen production and guides normal alignment of newly formed collagen fibers. 1

Pain Management

• Cryotherapy through a wet towel for 10-minute periods provides effective acute pain relief by reducing tissue metabolism and blunting inflammatory response. 1, 2
• NSAIDs (oral or topical) for short-term pain relief, though they don't affect long-term outcomes. 2
• Topical NSAIDs are preferable due to fewer systemic side effects, particularly elimination of gastrointestinal hemorrhage risk. 2
• For acute tendonitis, naproxen 500 mg initially, followed by 500 mg every 12 hours or 250 mg every 6-8 hours (initial daily dose not exceeding 1250 mg, thereafter not exceeding 1000 mg). 4

Adjunctive Physical Therapy

• Deep transverse friction massage is recommended to reduce pain and may promote healing. 1, 2
• Stretching exercises are widely accepted as helpful and should be incorporated. 1

Secondary Treatment Options (If Initial Management Insufficient)

Corticosteroid Iontophoresis

• Corticosteroid iontophoresis is effective for treatment of patellar tendinopathy pain and function. 1
• This delivery method avoids direct tendon injection.

Corticosteroid Injections (Use With Extreme Caution)

• May provide faster short-term relief than oral NSAIDs in the acute phase, but do not improve long-term outcomes. 2, 5
• CRITICAL PITFALL: Never inject corticosteroids directly into the tendon substance—this inhibits healing, reduces tensile strength, and increases rupture risk. 2
• Corticosteroid injections increase the risk of tendon rupture. 5
• Avoid multiple injections as they may weaken tendon structure despite short-term symptom relief. 2

Extracorporeal Shock Wave Therapy

• Appears safe and effective for chronic tendinopathies, though costly. 2
• Can be considered for refractory cases. 5, 6

Emerging Therapies (Mixed Evidence)

• Platelet-rich plasma has demonstrated mixed results; evidence-based recommendations on its efficacy cannot be made. 5
• Glyceryl trinitrate and ultrasound-guided sclerosis are additional options with variable evidence. 5

Nutritional Support During Rehabilitation

• Vitamin C-enriched dietary gelatin supports tendon repair. 7
• Collagen peptides augment tendon hypertrophy during training. 7
• Maintain adequate protein intake (≥1.6 g/kg body mass) to prevent muscle loss and support tendon healing. 7
• Turmeric/curcumin provides anti-inflammatory and analgesic effects. 7

Surgical Management (Only After Failed Conservative Treatment)

• Surgery is justified only if pain persists despite 3-6 months of well-managed conservative treatment. 2, 5
• Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment, so surgery should be reserved for the minority who fail. 2
• Open or arthroscopic debridement with excision of abnormal tendinous tissue and longitudinal tenotomies to release areas of scarring and fibrosis. 2
• Arthroscopic surgery results in faster recovery time compared to open surgery, though both methods are comparable in outcomes. 8
• Surgical treatment produces good to excellent outcomes in the majority of refractory patients. 5

Critical Pitfalls to Avoid

• Do not inject corticosteroids directly into the tendon substance. 2
• Do not proceed to surgery without an adequate 3-6 month trial of conservative treatment. 2
• Avoid complete immobilization during rest periods. 1, 2
• If multiple tendons are symptomatic, evaluate for underlying rheumatic disease. 1, 2
• The term "tendinitis" is inappropriate—the main pathophysiology is tendinosis (degenerative disorder), not inflammation. 8