Knee pain is extremely common amongst athletes. At some point, almost every athlete, in every sport, complains of knee pain throughout his or her career.
Affecting elite and recreational athletes alike, knee pain can present in multiple ways, varying from structures deeper in the joint to more superficially.
One of the most common issues that can occur is patella tendinopathy. In this article, we will break down the condition’s pathology, sign, symptoms, and treatment.
To review, tendinopathy or commonly heard as tendinitis, are both terms used to describe pain and swelling of a tendon.
- Tendinopathy is the more updated term used to describe a non-rupture injury of a tendon that is caused by excessive mechanical loading.
- Tendinosis is usually used to describe a chronic issue of the tendon, an injury lasting for more at least 3 months.
Recent research and an improved understanding of the condition have resulted in a more specific language used to describe the pathology.
Tendon issues occur as a result of loading beyond their physiological capacity. This results in a cycle of injury, inflammation, and repair, which contributes towards the pain and swelling symptoms
This constant process results in the accumulation of poor quality repair tissue resulting in a deformation of the normal tissue integrity.
Think about a laceration or a cut that constantly fluctuates between healing and being reopened. Eventually, that tissue will look and feel, well, pretty “gnarly”. This is a huge contributor towards the slow resolution of the issue and inability to return to full activity quickly.
The more involved the tendon is, or the more damage that is done, the longer the rehab process.
Returning to activity with a poorly healed and deconditioned tendon can predispose individuals towards further issues throughout the kinetic chain
Compensation to the knee can contribute to ankle, hip and back issues.
Individuals with tendinopathy present with tendons that are thicker but with reduced tensile load capacity meaning for the same load, the tendon withstands higher strain compared to healthy tendons.
Even though it’s thicker, it is weaker. The disruption in tissue integrity may cause individuals to report the tendon feeling “stiff” which is an alteration in sensory and motor fibers.
With tendinopathy, there is basically a giant disorganization and “mess” of the structural components with certain areas of cell death being found
The image above demonstrates examples of tendon deformation in an Achilles tendon
Where is the patella tendon and what does it do?
The patella tendon attaches to bone from bone. It originates at the lower portion of the patella and inserts onto a boney prominence called the tibial tuberosity.
The areas of stiffness are the same between a bone-to-bone where the quadriceps tendon originates from four muscles and attaches to the top of the patella. This tendon connects two areas of different levels of stiffness, muscle to a bone instead of bone to bone.
Tendons have less stiffness closest to the muscle attachment. The varying integrity of a tendon allows for the transmission of force during an activity such as landing from a jump
Since the patella tendon is generally in a “stiffer position” being between two boney structures, its ability to be more compliant and essentially flexible to higher loads is less.
Anatomy of the knee
What causes patella tendinitis?
Patella tendinopathy presents as pain at the inferior pole of the patella, which is the lower portion of the kneecap. Pain is usually in response to high loads to the knee extensors such as the quadriceps.
Signs & Symptoms
Pain with prolonged sitting, squatting and stair engagement are common symptoms as well. Once the load is removed, the pain usually resolves.
Sometimes the pain may resolve with increased activity and loading known as the “warm-up phenomenon. This may give individuals the false sense that things are better but the pain usually occurs in greater levels the day after activity.
Quadriceps tendinopathy occurs above the patella at the superior pole basically where the quad attaches to the kneecap.
Patella and quad tendon issues are most commonly found with jumping athletes with studies revealing that up to 45% of elite athletes in all jumping sports experience symptoms at some point
The initial incident usually occurs with a high volume of eccentric loading to the knee such as landing from a jump in sports as basketball or volleyball.
Ultrasound imaging demonstrating the integrity of a healthy patella and quadriceps tendon
Area of pain highlighted in the above image
To review again, tendinopathies result from tendon overload with improper recovery. Studies have shown that greater loads result in a higher degree of pain usually during or immediately after activity.
Extrinsic factors contributing towards the condition are:
- Excessive volume
- The magnitude of loads
- Speed of loading
- Temperature and environment conditions
Intrinsic factors are:
- The individual’s biomechanics
- Muscle weakness
- Mobility issues
- Age and body weight
How to treat patella tendonitis
Physical therapists have used many modalities and applications over the years to treat tendinopathies but as described in previous articles discussing other forms of tendinopathy, corrective exercise is the best form of treatment.
Rehabilitation should focus on remodeling and repair rather than inflammation and aggravation
This is why it is important that the athlete or patient understands about activity modification.
During the rehab process, they aren’t asked to sit on the couch and wait it out. Many individuals will report that they stopped doing a certain activity, rested, it felt better and then resumed the activity.
They then find that the symptoms occur again with the resumption of the activity because they have not addressed the true underlying issue.
Research is still constantly investigating the best protocol for treating tendinopathies. Currently, it is known that with proper loading, it can be seen at a microscopic level that the tendon heals.
Disorganized fibers regress, collagen fibers become stronger, the tendon becomes less thickened and more resilient to loads.
Rehabilitation is focused on controlled and monitored loading to the tendon while focusing on correctly biomechanical deficits
Improving an individual’s squat form, lunge form, single-leg stability, and jumping mechanics are examples of appropriate loading.
The exercises are executed with forms of biofeedback such as ways to have the individual “feel” the movement correction. Improving motor control first before adding extra variables such as weights and resistance is important to establish a healthy baseline.
Running trails, hammering wall balls with thrusters and “pushing through” the pain ARE NOT appropriate methods of tendon loading during rehab.
The above image is common as it went viral once it was released. This image displays a very popular, top draft pick, NFL quarterback at the combine executing a vertical jump and landing.
Complete deficits instability can be seen here. This individual went on to tear his ACL twice in his career. Bonus points if you know who this is.
Provoking some pain is normal during rehab and may help the treating clinician understand where the most deficits reside biomechanically. Pain should not be extreme and should stay at a mild to moderate level during and after exercise regimens.
Eccentric loading has been shown to be a beneficial part of the rehab process but may be too aggressive for individuals with highly reactive and aggravated tendons
Starting with isometrics may be a better option to introduce loading and stress in a controlled form to the tendon with improved patient tolerance.
Decline board squats are common exercise used in the rehabilitation program for patella tendon issues
Isometric leg extensions and mini squat holds against resistance
Progressions to more advanced loading with isolated movements and functional movements
Focusing on stability in the hips and pelvis with targeted gluteal activation exercises has been shown to be very beneficial. (See my previous article on the importance of the gluteals)
Temptation and pressure from coaches or peers to return early to the demands of a sport or activity can be detrimental towards a full recovery. Return to activity is dictated by symptom response to activity, biomechanical stability, and movement efficiency.
The healing process is slow, with rehab programs sometimes taking up to 6 months in severe cases
The best course of action is once again, KNOWLEDGE. Gaining an understanding of these conditions so they can be addressed early while preventing progression towards a chronic stage is crucial.
Most conditions can be corrected quickly when addressed early enough as improving biomechanics and modifying activity can reduce the risk of excessive tissue damage.
Obstacle course racing is an example of a high-risk sport for this injury due to the nature of the sport’s demands. The variables of performance combined with the frequency of competition and training predisposition athletes towards injury.
Focusing time to work deficits in stability and mobility and establishing a strong base to progress from is the best way to prevent injury.
About the author
Michael St. George, PT, DPT (@icore_stgeorge on Instagram) is a physical therapist who works for Excel Physical Therapy and Fitness which is a private practice that is based around the greater Philadelphia region and suburbs. He is FMS, SFMA, Y Balance and Motor Control Test Certified with 8 years of experience in outpatient orthopedics and sports medicine. His training consists of experience working with physicians and surgeons from the Rothman Institute and therapists in his field specializing in various manual techniques and advanced treatment procedures.
- Scott, A., Backman, L., Speed, C. (2015) Tendionopathy: Update on Pathophysiology. Journal of Orthopaedic and Sports Physical Therapy. Vol 45 (11) 833-841
- Sprague, A., Epsley, S., Silbernagel, K. (2019) Distinguishing Quadriceps Tendinopathy and Patellar Tendinopathy: Semantics or Significant? Journal of Orthopaedic and Sports Physical Therapy. Vol 49 (9) 627-630
- Malliaras, P., Cook, J., Purdam, C., et al. (2015) Patellar Tendinopathy: Clinical Diagnosis, Load Management and Advice for Challenging Case Presentations. Journal of Orthopaedic and Sports Physical Therapy. Vol 45 (11) 887-889
- Will, R., Hoglund, L., Barton, C., et al. (2019) Patellofemoral Pain: Clinical Practice Guidelines Linked to the International Classification of Functioning, Disability and Health from the Academy of Orthopaedic Physical Therapy of the American Physical Therapy Association. Journal of Orthopaedic and Sports Physical Therapy. Vol 49 (9) CPG2-CPG95.