What is the appropriate treatment algorithm for patellar tendinopathy (jumper's knee)?

Treatment Algorithm for Patellar Tendinopathy (Jumper's Knee)

Begin with eccentric strengthening exercises as the cornerstone of treatment, combined with activity modification and relative rest—this approach achieves full recovery in approximately 80% of patients within 3-6 months and should be attempted for at least 12 weeks before considering any surgical intervention. 1, 2, 3

First-Line Conservative Management (Months 0-3)

Eccentric Exercise Protocol (Gold Standard)

• Prescribe eccentric quadriceps training 2-3 times per week using 60-70% of one-repetition maximum, performing 8-12 repetitions for 2-4 sets with 2-3 minutes rest between sets 2
• Allow at least 48 hours between training sessions for the same muscle group to permit tissue remodeling 2
• Eccentric exercises stimulate collagen production and guide proper alignment of newly formed collagen fibers, directly addressing the underlying degenerative pathology 1
• Decline squats on a 25-degree board performed as a home exercise program (three sets of fifteen repetitions twice daily) have demonstrated efficacy in randomized controlled trials 3

Activity Modification and Load Management

• Implement relative rest by reducing—not eliminating—pain-provoking activities such as jumping, stair navigation, and prolonged sitting 1, 2
• Continue activities that do not worsen symptoms to prevent muscular atrophy and deconditioning 1
• Never prescribe complete immobilization, as this leads to muscle weakness and worse outcomes 2

Adjunctive Pain Management

• Apply ice through a wet towel for 10-minute periods after activity for short-term pain relief 1, 2
• Prescribe topical NSAIDs preferentially over oral formulations to eliminate gastrointestinal hemorrhage risk while providing equivalent short-term pain relief 1, 2
• Deep transverse friction massage may reduce pain when combined with eccentric training 4, 1
• Recognize that NSAIDs provide only temporary symptom relief without altering long-term outcomes or addressing the underlying degenerative process 1, 2

Second-Line Options for Persistent Symptoms (Months 3-6)

Corticosteroid Considerations

• Corticosteroid iontophoresis (non-invasive transcutaneous delivery) is effective for pain and function improvement 4
• Peritendinous corticosteroid injections may be considered as a safe adjuvant before surgery 5
• Never inject corticosteroids directly into the tendon substance, as this inhibits healing, diminishes tensile strength, and increases spontaneous rupture risk 2

Diagnostic Imaging When Diagnosis Unclear

• Ultrasonography is the preferred imaging modality with 94% specificity, showing tendon thickening, decreased echogenicity, and calcification 1
• MRI demonstrates 78% sensitivity and 86% specificity, useful for visualizing chronic degenerative changes and ruling out alternative diagnoses 1

Surgical Intervention (After 6 Months of Failed Conservative Treatment)

Indications for Surgery

• Reserve surgery exclusively for patients who fail 3-6 months of well-supervised conservative therapy including eccentric exercises, activity modification, and adjunctive treatments 6, 2, 3
• Patient continues experiencing significant pain affecting quality of life and cannot return to desired activity level 6

Surgical Techniques

• Open patellar tenotomy with wedge-shaped full-thickness excision of abnormal tissue followed by structured rehabilitation with gradual progression to eccentric training 3
• Arthroscopic surgery produces comparable outcomes to open surgery but results in faster recovery time 7
• Perform longitudinal tenotomies to release scarred and fibrotic areas 6, 2

Expected Surgical Outcomes

• In a randomized controlled trial, surgical treatment showed no advantage over eccentric training at 12 months, with both groups achieving similar VISA score improvements from 30 to 70 3
• Approximately 28% of surgical patients remain symptomatic at 12 months, similar to conservative treatment 3

Critical Pitfalls to Avoid

• Do not diagnose this as "tendinitis"—patellar tendinopathy represents chronic degenerative tendinosis, not acute inflammation, explaining why anti-inflammatory treatments provide only temporary relief 4, 2
• Avoid premature surgical referral—eccentric training must be attempted for a full 12 weeks before considering surgery 3
• Do not prescribe complete rest or immobilization, as the hypovascular nature of tendons near their insertion requires progressive loading for healing 2
• Evaluate for systemic rheumatic disease when multiple tendons are symptomatic bilaterally, as this pattern suggests systemic pathology rather than isolated mechanical overload 2