Pathogenesis and Treatment of Patellar Tendinopathy

  • Ryohei Uchida
  • Norimasa Nakamura
  • Shuji HoribeEmail author


Patellar tendinopathy is one of the most common injuries caused by overuse. Generally, histological findings in tendinopathy indicate a degenerative process and loss of healing response. The symptoms of tendinopathy are pain and/or disability due to pain. Although many treatment methods are available for patellar tendinopathy, no consensus has been reached as to the proper use of these therapies because of the limited evidence from their application. Only eccentric exercise has strong evidence of effectiveness for patellar tendinopathy. Moderate evidence was found for heavy slow resistance training. Moreover, the evidence for sclerosing injections, shockwave therapy, and surgery is limited. The success rate of conventional conservative treatment of tendinopathy, including eccentric exercise, was >80%. For the remaining patients, invasive therapies such as arthroscopic and open surgeries are needed. The success rate of surgery for patellar tendinopathy was reported to be 60–90%. The mean period of return to sports after arthroscopic surgery was significantly shorter than that after open surgery, although the success and return-to-play rates were not significantly different between open and arthroscopic surgeries.


Hyaluronic Acid Patellar Tendon Eccentric Exercise Corticosteroid Injection Arthroscopic Surgery 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Abate M, Gravare Silbernagel K, Siljeholm C, Di Iorio A, De Amicis D, Salini V et al (2009) Pathogenesis of tendinopathies: inflammation or degeneration? Arthritis Res Ther 11(3):235CrossRefPubMedPubMedCentralGoogle Scholar
  2. Alfredson H, Ohberg L (2005 Mar) Neovascularisation in chronic painful patellar tendinosis—promising results after sclerosing neovessels outside the tendon challenge the need for surgery. Knee Surg Sports Traumatol Arthrosc 13(2):74–80CrossRefPubMedGoogle Scholar
  3. Basso O, Amis AA, Race A et al (2002) Patellar tendon fiber strains: their differential responses to quadriceps tension. Clin Orthop Relat Res 400:246–253CrossRefGoogle Scholar
  4. Blazina ME, Kerlan RK, Jobe FW, Carter VS, Carlson GJ (1973) Jumper’s knee. Orthop Clin N Am 4(3):665–678Google Scholar
  5. Boesen MI, Koenig MJ, Torp-Pedersen S, Bliddal H, Langberg H (2006) Tendinopathy and Doppler activity: the vascular response of the Achilles tendon to exercise. Scand J Med Sci Sports 16:463–469CrossRefPubMedGoogle Scholar
  6. Brockmeyer M, Diehl N, Schmitt C, Kohn DM, Lorbach O (2015) Results of surgical treatment of chronic patellar tendinosis (jumper’s knee): a systematic review of the literature. Arthroscopy 31(12):2424-9.e3CrossRefPubMedGoogle Scholar
  7. Cannell LJ, Taunton JE, Clement DB et al (2001) A randomised clinical trial of the efficacy of drop squats or leg extension/leg curl exercises to treat clinically diagnosed jumper’s knee in athletes: pilot study. Br J Sports Med 35:60–64CrossRefPubMedCentralGoogle Scholar
  8. Cook JL, Purdam CR (2009) Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy. Br J Sports Med 43(6):409–416CrossRefPubMedGoogle Scholar
  9. Dillon EM, Erasmus PJ, Müller JH et al (2008) Differential forces within the proximal patellar tendon as an explanation for the characteristic lesion of patellar tendinopathy: an in vivo descriptive experimental study. Am J Sports Med 36(11):2119–2127CrossRefPubMedGoogle Scholar
  10. Dragoo JL, Wasterlain AS, Braun HJ, Nead KT (2014) Platelet-rich plasma as a treatment for patellar tendinopathy: a double-blind, randomized controlled trial. Am J Sports Med 42(3):610–618CrossRefPubMedGoogle Scholar
  11. Ferretti A, Conteduca F, Camerucci E, Morelli F (2002) Patellar tendinosis: a follow-up study of surgical treatment. J Bone Joint Surg Am 84:2179–2185CrossRefPubMedGoogle Scholar
  12. Fredberg U, Bolvig L, Pfeiffer-Jensen M, Clemmensen D, Jakobsen BW, Stengaard-Pedersen K (2004) Ultrasonography as a tool for diagnosis, guidance of local steroid injection and together with pressure algometry monitoring of the treatment of athletes with chronic Jumper’s knee and Achilles tendinitis: a randomised, double-blind, placebo-controlled study. Scand J Rheumatol 33:94–101CrossRefPubMedGoogle Scholar
  13. Fredberg U, Stengaard-Pedersen K (2008) Chronic tendinopathy tissue pathology, pain mechanisms, and etiology with a special focus on inflammation. Scand J Med Sci Sports 18(1):3–15CrossRefPubMedGoogle Scholar
  14. Fritschy D, Wallensten R (1993) Surgical treatment of patellar tendinitis. Knee Surg Sports Traumatol Arthrosc 1:131–133CrossRefPubMedGoogle Scholar
  15. Graham HK, Holmes DF, Watson RB, Kadler KE (2000) Identification of collagen fibril fusion during vertebrate tendon morphogenesis. The process relies on unipolar fibrils and is regulated by collagen-proteoglycan interaction. J Mol Biol 295:891–902CrossRefPubMedGoogle Scholar
  16. Hansen P, Haraldsson BT, Aagaard P, Kovanen V, Avery NC, Qvortrup K, Larsen JO, Krogsgaard M, Kjaer M, Peter MS (1985/2010) Lower strength of the human posterior patellar tendon seems unrelated to mature collagen cross-linking and fibril morphology. J Appl Physiol 108(1):47–52CrossRefGoogle Scholar
  17. Hoksrud A, Ohberg L, Alfredson H, Bahr R (2006) Ultrasound-guided sclerosis of neovessels in painful chronic patellar tendinopathy: a randomized controlled trial. Am J Sports Med 34(11):1738–1746. Epub 2006 Jul 10. Erratum in: Am J Sports Med. 2011 Jul;39(7)Google Scholar
  18. Johnson DP, Wakeley CJ, Watt I (1996) Magnetic resonance imaging of patellar tendonitis. J Bone Joint Surg Br 78(3):452–457PubMedGoogle Scholar
  19. Jonsson P, Alfredson H (2005) Superior results with eccentric compared to concentric quadriceps training in patients with jumper’s knee: a prospective randomized study. Br J Sports Med 39:847–850CrossRefPubMedPubMedCentralGoogle Scholar
  20. Kelly JD IV. (2009) Arthroscopic excision of distal pole of patella for refractory patellar tendinitis. Orthopedics 32:504CrossRefPubMedGoogle Scholar
  21. Khan KM, Bonar F, Desmond PM, Cook JL, Young DA, Visentini PJ, Fehrmann MW, Kiss ZS, O’Brien PA et al (1996) Patellar tendinosis (jumper’s knee): findings at histopathologic examination, US, and MR imaging. Victorian Institute of Sport Tendon Study Group. Radiology 200(3):821–827CrossRefPubMedGoogle Scholar
  22. Khan KM, Cook JL, Maffulli N et al (2002) Time to abandon the “tendinitis” myth. BMJ 16:626–627CrossRefGoogle Scholar
  23. Khan KM, Maffulli N, Coleman BD, Cook JL, Taunton JE (1998) Patellar tendinopathy: some aspects of basic science and clinical management. Br J Sports Med 32(4):346–355CrossRefPubMedPubMedCentralGoogle Scholar
  24. Kongsgaard M, Qvortrup K, Larsen J et al (2010) Fibril morphology and tendon mechanical properties in patellar tendinopathy: effects of heavy slow resistance training. Am J Sports Med 38(4):749–756CrossRefPubMedGoogle Scholar
  25. Kongsgaard M, Reitelseder S, Pedersen TG et al (2007) Region specific patellar tendon hypertrophy in humans following resistance training. Acta Physiol 191(2):111–121CrossRefGoogle Scholar
  26. Kumai T, Muneta T, Tsuchiya A, Shiraishi M, Ishizaki Y, Sugimoto K, Samoto N, Isomoto S, Tanaka Y, Takakura Y (2014) The short-term effect after a single injection of high-molecular-weight hyaluronic acid in patients with enthesopathies (lateral epicondylitis, patellar tendinopathy, insertional Achilles tendinopathy, and plantar fasciitis): a preliminary study. J Orthop Sci 19(4):603–611CrossRefPubMedGoogle Scholar
  27. Larsson ME, Käll I, Nilsson-Helander K (2012) Treatment of patellar tendinopathy—a systematic review of randomized controlled trials. Knee Surg Sports Traumatol Arthrosc 20(8):1632–1646CrossRefPubMedGoogle Scholar
  28. Lavagnino M, Arnoczky SP, Elvin N, Dodds J (2008 Nov) Patellar tendon strain is increased at the site of the jumper’s knee lesion during knee flexion and tendon loading: results and cadaveric testing of a computational model. Am J Sports Med 36(11):2110–2118CrossRefPubMedGoogle Scholar
  29. Leal C, Ramon S, Furia J, Fernandez A, Romero L, Hernandez-Sierra L (2015) Current concepts of shockwave therapy in chronic patellar tendinopathy. Int J Surg 24(Pt B):160–164CrossRefPubMedGoogle Scholar
  30. Liddle AD, Rodríguez-Merchán EC (2015) Platelet-rich plasma in the treatment of patellar tendinopathy: a systematic review. Am J Sports Med 43(10):2583–2590CrossRefPubMedGoogle Scholar
  31. Lind B, Ohberg L, Alson H (2006) Sclerosing polidocanol injections in mid-portion Achilles tendinosis: remaining good clinical results and decreased tendon thickness at 2-year follow-up. Knee Surg Sports Traumatol Arthrosc 14:1327–1332CrossRefPubMedGoogle Scholar
  32. Maffulli N, Longo UG (2008) How do eccentric exercises work in tendinopathy? Rheumatology 47:1444–1445CrossRefPubMedGoogle Scholar
  33. Maffulli N, Longo UG, Denaro V (2010) Novel approaches for the management of tendinopathy. J Bone Joint Surg Am 92(15):2604–2613PubMedGoogle Scholar
  34. Maffulli N, Oliva F, Maffulli G, King JB, Del Buono A (2014) Surgery for unilateral and bilateral patellar tendinopathy: a seven year comparative study. Int Orthop 38(8):1717–1722CrossRefPubMedPubMedCentralGoogle Scholar
  35. Maffulli N, Sharma P, Luscombe KL (2004) Achilles tendinopathy: aetiology and management. J R Soc Med 97:472–476CrossRefPubMedPubMedCentralGoogle Scholar
  36. Malliaras P, Barton CJ, Reeves ND et al (2013) Achilles and patellar tendinopathy loading programmes: a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med 43(4):267–286CrossRefPubMedGoogle Scholar
  37. McLauchlan GJ, Handoll HH (2001) Interventions for treating acute and chronic Achilles tendinitis. Cochrane Database Syst Rev (2):CD000232Google Scholar
  38. Muneta T, Koga H, Ju YJ, Mochizuki T, Sekiya I (2012) Hyaluronan injection therapy for athletic patients with patellar tendinopathy. J Orthop Sci 17:425–431CrossRefPubMedGoogle Scholar
  39. Ogon P, Maier D, Jaeger A, Suedkamp NP (2006) Arthroscopic patellar release for the treatment of chronic patellar tendinopathy. Arthroscopy 22:462.e1–462.e5CrossRefGoogle Scholar
  40. Ohberg L, Alfredson H (2002) Ultrasound guided sclerosis of neovessels in painful chronic Achilles tendinosis: pilot study of a new treatment. Br J Sports Med 36:173–175CrossRefPubMedPubMedCentralGoogle Scholar
  41. Pascarella A, Alam M, Pascarella F, Latte C, Di Salvatore MG, Maffulli N (2011) Arthroscopic management of chronic patellar tendinopathy. Am J Sports Med 39(9):1975–1983CrossRefPubMedGoogle Scholar
  42. Pearson SJ, Hussain SR (2014) Region-specific tendon properties and patellar tendinopathy: a wider understanding. Sports Med 44(8):1101–1112CrossRefPubMedGoogle Scholar
  43. Peers KH, Lysens RJ, Brys P, Bellemans J (2003) Cross-sectional outcome analysis of athletes with chronic patellar tendinopathy treated surgically and by extracorporeal shock wave therapy. Clin J Sport Med 13:79–83CrossRefPubMedGoogle Scholar
  44. Rees JD, Stride M, Scott A (2014 Nov) Tendons—time to revisit inflammation. Br J Sports Med 48(21):1553–1557. doi: 10.1136/bjsports-2012-091957. Epub 2013 Mar 9. Review
  45. Romeo AA, Larson RV (1999) Arthroscopic treatment of infrapatellar tendonitis. Arthroscopy 15:341–345CrossRefPubMedGoogle Scholar
  46. Sharma P, Maffulli N (2006) Biology of tendon injury: healing, modeling and remodeling. J Musculoskelet Neuronal Interact 6(2):181–190PubMedGoogle Scholar
  47. Smillie IS (1962) Injuries of the knee joint, 3rd edn. Livingstone, Edinburgh, pp 264–267Google Scholar
  48. Stasinopoulos D, Stasinopoulos I (2004) Comparison of effects of exercise programme, pulsed ultrasound and transverse friction in the treatment of chronic patellar tendinopathy. Clin Rehabil 18:347–352CrossRefPubMedGoogle Scholar
  49. Taunton KM, Taunton JE, Khan KM (2003) Treatment of patellar tendinopathy with extracorporeal shock wave therapy. B C Med J 45:500–507Google Scholar
  50. Toumi H, Higashiyama I, Suzuki D, Kumai T, Bydder G, McGonagle D, Emery P, Fairclough J, Benjamin M (2006) Regional variations in human patellar trabecular architecture and the structure of the proximal patellar tendon enthesis. J Anat 208(1):47–57CrossRefPubMedPubMedCentralGoogle Scholar
  51. Verheyden F, Geens G, Nelen G (1997) Jumper’s knee: Results of surgical treatment. Acta Orthop Belg 63:102–105PubMedGoogle Scholar
  52. Vetrano M, Castorina A, Vulpiani MC, Baldini R, Pavan A (2013) Ferretti A Platelet-rich plasma versus focused shock waves in the treatment of jumper’s knee in athletes. Am J Sports Med 41(4):795–803CrossRefPubMedGoogle Scholar
  53. Wasielewski NJ, Kotsko KM (2007) Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis? A systematic review. J Athl Train 42:409–421PubMedPubMedCentralGoogle Scholar
  54. Zwerver J, Dekker F, Pepping GJ (2010) Patient guided piezo-electric extracorporeal shockwave therapy as treatment for chronic severe patellar tendinopathy: a pilot study. J Back Musculoskelet Rehabil 23:111–115CrossRefPubMedGoogle Scholar

Copyright information

© ISAKOS 2017

Authors and Affiliations

  • Ryohei Uchida
    • 1
  • Norimasa Nakamura
    • 2
  • Shuji Horibe
    • 3
    Email author
  1. 1.Department of Orthopaedic Sports MedicineSeifu HospitalOsakaJapan
  2. 2.Institute for Medical Science in SportsOsaka Health Science UniversityOsakaJapan
  3. 3.Faculty of Comprehensive RehabilitationOsaka Prefecture UniversityOsakaJapan

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