What is the best course of treatment for a 30-year-old active duty male with a 3-week history of left knee pain following a fall onto the knee while rucking with weight, who has improved with ice and Motrin (ibuprofen) but still experiences mild pain and instability, particularly when walking down stairs?

Management of Suspected Patellar Tendinopathy in Active Duty Service Member

Continue conservative management with structured eccentric strengthening exercises as the primary treatment, combined with NSAIDs for pain control, activity modification, and consider patellar bracing for short-term symptom relief during duty activities. 1, 2

Clinical Presentation Analysis

Your patient's presentation is highly consistent with patellar tendinopathy:

• Pain with stair descent and weight-bearing is the hallmark symptom of patellar tendinopathy, as the patellar tendon experiences maximum loading during eccentric knee extension (descending stairs) 1
• Subjective instability/buckling likely represents quadriceps weakness and pain inhibition rather than true ligamentous instability, given negative special testing 2
• Pain reproduction with special testing despite negative findings suggests early-stage tendinopathy where structural damage is minimal but pain hypersensitivity is present 2
• Three-week duration with partial improvement indicates the condition is transitioning from acute inflammation to chronic tendinosis 1

Immediate Management Plan

Primary Treatment: Eccentric Strengthening Program

Initiate a structured eccentric exercise program immediately—this is the single most effective intervention for patellar tendinopathy with the strongest available evidence. 1, 2

• Exercise prescription specifics: Train quadriceps 2-3 days per week at 60-70% of one-repetition maximum for 8-12 repetitions across 2-4 sets, with at least 48 hours rest between sessions 2
• Critical execution detail: Focus on the eccentric (lowering) phase of exercises like decline squats or single-leg squats, as eccentric loading stimulates collagen production and guides normal alignment of newly formed collagen fibers 1, 2
• Rest intervals: Allow 2-3 minutes rest between sets to optimize strength gains 2
• Progression strategy: Gradually increase resistance and/or repetitions as strength improves, typically advancing every 1-2 weeks based on pain response 2

Pain Management

Use NSAIDs (oral or topical) for short-term pain relief to facilitate participation in eccentric exercises. 1

• Topical NSAIDs are preferred as they eliminate gastrointestinal hemorrhage risk while providing equivalent pain relief—apply to the anterior knee 3-4 times daily 1, 3
• If oral NSAIDs are chosen: Ibuprofen 400mg three times daily or naproxen sodium 220mg twice daily are effective for knee pain, with naproxen providing superior night pain relief 4
• Duration limitation: NSAIDs provide short-term pain relief but do not alter long-term outcomes—use for 7-14 days maximum during the initial treatment phase 1

Cryotherapy Protocol

Apply ice through a wet towel for repeated 10-minute periods, not continuous application. 1, 5

• Specific technique: Use melting iced water applied through a wet towel to achieve target temperature reduction of 10-15°C in the muscle 5
• Frequency: Repeat applications 3-4 times daily, allowing superficial skin temperature to return to normal between applications while deeper muscle temperature remains low 5
• Critical safety warning: Reflex activity and motor function are impaired for up to 30 minutes following ice treatment—avoid high-demand activities during this window 5

Activity Modification (Relative Rest)

Reduce repetitive loading activities that reproduce pain, but avoid complete immobilization. 1, 2

• Specific modifications for military duties: Temporarily reduce rucking distance/weight, avoid running downhill or descending stairs with heavy loads, and modify physical training to emphasize non-impact activities 1
• Critical pitfall to avoid: Complete immobilization causes muscular atrophy and deconditioning—maintain general fitness through swimming, cycling, or upper body training 1, 2

Adjunctive Interventions

Patellar Bracing

The brace you're providing is appropriate for short-term symptom relief during duty activities. 2

• Evidence basis: Medially directed patellar taping/bracing provides short-term relief when rehabilitation is hindered by elevated symptom severity and irritability 2
• Duration: Use during high-demand activities for 2-4 weeks while eccentric strengthening takes effect 2

Deep Transverse Friction Massage

Consider adding friction massage to reduce pain and potentially accelerate recovery. 1, 2

• Technique: Apply deep pressure perpendicular to the tendon fibers at the inferior pole of the patella for 5-10 minutes, 2-3 times weekly 1

Diagnostic Confirmation with Imaging

The weight-bearing knee radiographs you're obtaining today are appropriate to rule out fracture and assess for degenerative changes, but will not confirm tendinopathy. 1

• If radiographs are normal and symptoms persist beyond 4-6 weeks: Consider ultrasound (94% specificity for tendon thickening) or MRI (78% sensitivity, 86% specificity for chronic degenerative changes) 2
• Clinical diagnosis is sufficient to initiate treatment: Physical examination findings of pain at the inferior pole of the patella with resisted leg extension in full extension are diagnostic 1, 2

Expected Timeline and Follow-Up

Approximately 80% of patients recover completely within 3-6 months with appropriate conservative treatment. 2

• Reassess at 4 weeks: If no improvement in pain or function, intensify eccentric exercise program and consider adding corticosteroid iontophoresis (not injection) 1, 2
• Reassess at 3 months: If symptoms persist despite well-managed conservative treatment, consider advanced imaging and referral to sports medicine or orthopedics 2
• Surgery is reserved only for failure of 3-6 months of conservative treatment—never proceed to surgery without this adequate trial period 2

Critical Pitfalls to Avoid

• Never inject corticosteroids directly into the patellar tendon substance—this inhibits healing, reduces tensile strength, and predisposes to spontaneous rupture 2
• Do not prescribe opioids for this condition—they are not indicated for chronic tendinopathy and carry significant risks in the military population 1
• If multiple tendons become symptomatic, evaluate for underlying rheumatic disease (though unlikely in this isolated case) 2

Return to Full Duty Criteria

• Pain-free single-leg decline squat (places maximum load on patellar tendon) 1
• Quadriceps strength within 90% of contralateral side 2
• Ability to perform military-specific tasks (rucking, running, stair climbing) without pain or instability 2