Treatment of Patellar Tendinopathy with Imaging-Confirmed Tendinosis
Begin with eccentric strengthening exercises as your primary treatment, combined with relative rest, ice therapy, and topical NSAIDs, while avoiding corticosteroid injections entirely. 1
First-Line Conservative Management (3-6 Months)
Eccentric Exercise Protocol
- Eccentric exercises are the cornerstone of treatment, as they stimulate collagen production and guide normal alignment of newly formed collagen fibers in the degenerative tendon tissue 2, 1
- This approach has strong evidence supporting its effectiveness for patellar tendinopathy specifically 3
- The presence of hypoechoic thickening and neovascularization on your patient's imaging confirms tendinosis (degenerative changes), not tendinitis, making eccentric loading the mechanobiologically appropriate intervention 4
Activity Modification
- Implement relative rest by reducing jumping, stairs, and prolonged sitting that provoke pain, while maintaining sufficient activity to prevent quadriceps atrophy 1
- Do not immobilize completely, as this causes muscle atrophy and joint stiffness 1
Pain Management
- Apply ice therapy for short-term pain relief and reduction of inflammation 1
- Use topical NSAID formulations (such as topical naproxen) rather than oral NSAIDs to eliminate gastrointestinal bleeding risk 1
- If oral NSAIDs are necessary, naproxen 500 mg twice daily can be used for acute tendonitis, but topical is preferred 5
Adjunctive Physical Therapy
- Deep transverse friction massage reduces pain and should be incorporated into the treatment plan 2, 1
- Corticosteroid iontophoresis (not injection) is effective for treating patellar tendinopathy pain and improving function 2, 1
Critical Pitfall to Avoid
Never inject corticosteroids into this tendon. 1 Corticosteroid injections do not improve long-term outcomes, may inhibit healing, reduce tissue tensile strength, and predispose to complete rupture—a catastrophic outcome in a 20-year-old athlete 1. The 1cm of centralized vascularity and hypoechoic changes indicate active tendinosis that requires mechanical loading stimulus, not anti-inflammatory suppression.
Timeline and Monitoring
- Continue conservative treatment for 3-6 months before considering more invasive interventions 1
- Most patients (approximately 80%) fully recover with appropriate conservative treatment within this timeframe 6
- Monitor for improvement in pain with stairs, decline squat test, and resisted leg extension 2
Surgical Consideration
Surgical treatment becomes indicated only if: 1
- Conservative treatment fails after a full 3-6 months of compliance
- OR the tear exceeds 50% of tendon thickness (your patient's 1cm centralized involvement likely does not meet this threshold)
Surgical technique involves excision of abnormal tendinous tissue and longitudinal tenotomies to release scarring and fibrosis 1. Arthroscopic approaches allow faster recovery than open surgery 4, 7.
Why This Approach for Your Patient
The imaging findings of 1cm hypoechoic thickening with neovascularization at the distal patella represent classic tendinosis changes 4. At age 20, this patient has excellent healing potential with mechanical loading through eccentric exercise, which directly addresses the pathophysiology of failed collagen remodeling 3, 8. The centralized nature and limited extent make this an ideal candidate for conservative management with high likelihood of success.