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[ clinical commentary ]

PETER MALLIARAS, BPhysio (Hons), PhD1,2 • JILL COOK, PhD1,3 • CRAIG PURDAM, MSportsPhysio3-5
EBONIE RIO, BPhysio (Hons), MSportsPhysio, PhD1,3

Patellar Tendinopathy: Clinical Diagnosis,

Load Management, and Advice
for Challenging Case Presentations

nterior knee pain in athletes can be caused by a number for jumping, landing, cutting,
of anatomical structures. Patellar tendinopathy, one and pivoting when participating
source of anterior knee pain, is most commonly in these sports requires the
patellar tendon to repetitively
characterized by pain localized to the inferior pole of the store and release energy.2 Energy
patella and load-related pain that increases with the demand on storage and release (similar to
the knee extensors, notably in activities that store and release energy a spring) from the long tendons of the
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in the patellar tendon.33 Patellar tendinopathy is debilitating and lower limb are key features for high
performance while reducing the energy
can result in prolonged absence forced to retire from sport.52 cost of human movements.2,76 Repetition
and potentially retirement from sports Patellar tendinopathy is primarily of this spring-like activity over a single
participation. Cook et al16 found that more a condition of relatively young (15-30 exercise session,51 or with insufficient rest
than one third of athletes presenting for years old) athletes, especially men, who to enable remodeling between sessions,81
treatment for patellar tendinopathy were participate in sports such as basketball, can induce pathology and a change in the
unable to return to sport within 6 months, volleyball, athletic jump events, tennis, and tendon’s mechanical properties, which is
and it has been reported that 53% of football, which require repetitive loading a risk factor for developing symptoms.17,61
athletes with patellar tendinopathy were of the patellar tendon.57 The power needed Energy-storage load is defined in this
J Orthop Sports Phys Ther 2015.45:887-898.

article as high tendon load, because it is

TTSYNOPSIS: The hallmark features of patellar chain, as well as addressing key biomechanical associated with tendon injury.
tendinopathy are (1) pain localized to the inferior and other risk factors. Rehabilitation can be slow Although the relationship between
pole of the patella and (2) load-related pain that and sometimes frustrating. This review aims pain and tendon pathology is unclear,
increases with the demand on the knee extensors, to assist clinicians with key concepts related the presence of pathology appears to be
notably in activities that store and release energy to examination, diagnosis, and management
a risk factor for an individual becoming
in the patellar tendon. While imaging may assist of patellar tendinopathy. Difficult clinical
presentations (eg, highly irritable tendon,
symptomatic.17,61 Thus, it is important
in differential diagnosis, the diagnosis of patellar
tendinopathy remains clinical, as asymptomatic systemic comorbidities) as well as common for clinicians to have an appreciation
tendon pathology may exist in people who pitfalls, such as unrealistic rehabilitation time of tendon pathology. Briefly, tendon
have pain from other anterior knee sources. A frames and overreliance on passive treatments, pathology includes increases in tenocyte
thorough examination is required to diagnose are also discussed. J Orthop Sports Phys numbers and rounding, and in ground
patellar tendinopathy and contributing factors. Ther 2015;45(11):887-898. Epub 21 Sep 2015.
substance expression, causing swelling,
Management of patellar tendinopathy should focus doi:10.2519/jospt.2015.5987
matrix degradation, and neovascular
on progressively developing load tolerance of the TTKEY WORDS: anterior knee pain, eccentric
ingrowth.53,58 These changes have been
tendon, the musculoskeletal unit, and the kinetic exercises, knee, tendinitis
extensively reviewed elsewhere.1,19

Musculoskeletal Research Centre, La Trobe University, Bundoora, Australia. 2Centre for Sport and Exercise Medicine, Queen Mary, University of London, UK. 3Australian Centre
for Research Into Injury in Sport and Its Prevention, Federation University, Ballarat, Australia. 4Department of Physical Therapies, Australian Institute of Sport, Canberra,
Australia. 5Department of Physiotherapy, Faculty of Health, University of Canberra, Canberra, Australia. Dr Cook is supported by the Australian Centre for Research Into Injury
in Sport and Its Prevention, which is one of the International Research Centres for Prevention of Injury and Protection of Athlete Health supported by the International Olympic
Committee. Dr Cook is a National Health and Medical Research Council practitioner fellow (ID 1058493). Mr Purdam and Dr Rio are adjunct researchers at the Australian Centre
for Research Into Injury in Sport and Its Prevention. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct
financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Peter Malliaras, Musculoskeletal Research Centre, La Trobe University,
249 Auburn Road, Hawthorn 3122 Australia. E-mail: t Copyright ©2015 Journal of Orthopaedic & Sports Physical Therapy®

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[ clinical commentary ]
The purpose of this commentary tendon pain as settling within 24 hours pathology.29 A systematic review ex-
was to combine available evidence and after energy-storage activities. Usually, amining landing strategies in 3 groups
expert opinion to guide clinicians in key the aggravation of symptoms manifests (controls, those with asymptomatic pa-
elements of examination, diagnosis, and as pain during loading activities, such as thology, and those with symptomatic
management of patellar tendinopathy, walking down stairs or when performing patellar tendinopathy) reported no dif-
including advice for difficult presentations. a decline squat. Pain level can be rated on ferences between the controls and those
an 11-point numeric rating scale, where 0 with symptomatic patellar tendinopa-
Examination of Patellar Tendinopathy is no pain and 10 is the worst pain imag- thy.89 However, the data from the meta-
The first clinical challenge is to establish inable. The Victorian Institute of Sport analysis only included 6 symptomatic
whether the tendon is the source of the Assessment-patella (VISA-P) question- athletes. The clinical experience of the
patient’s symptoms. Patellar tendinopa- naire is a validated pain and function present authors suggests that athletes
thy, as one of many potential diagnoses outcome measure that can also be used with patellar tendon pain tend to reduce
producing anterior knee pain, has spe- to assess severity of symptoms as well as the amount of knee flexion and appear
cific and defining hallmark clinical fea- to monitor outcomes.91 The VISA-P is a stiff in their landing. Regardless of the
tures32,55 that consist of (1) pain localized 100-point scale, with higher scores repre- individual strategy, it is optimal to try to
to the inferior pole of the patella11 and (2) senting better function and less pain. The distribute load through the entire kinet-
load-related pain that increases with the minimum clinically important difference ic chain, and the purpose of evaluating
demand on the knee extensors, notably in is a change of 13 points.47 In the authors’ function (including hopping and land-
activities that store and release energy in experience, as progress with patellar ing) is to identify deficits that need to be
the patellar tendon.57,77 Other signs and tendinopathy is slow and the VISA-P is addressed as part of rehabilitation.
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symptoms, such as pain with prolonged not sensitive to very small changes in the Patellar tendon imaging does not
sitting, squatting, and stairs, may be pres- condition, the VISA-P should be used at confirm patellar tendon pain, as pathol-
ent but are also features of patellofemoral intervals of 4 weeks or more. ogy observed via ultrasound imaging
pain (PFP) and potentially other patholo- A thorough examination of the entire may be present in asymptomatic indi-
gies. Tendon pain occurs instantly with lower extremity is necessary to identify viduals.61 Accordingly, serial imaging is
loading and usually ceases almost imme- relevant deficits at the hip, knee, and not recommended, as symptoms often
diately when the load is removed.75 Pain is ankle/foot region. Atrophy or reduced improve without corresponding changes
rarely experienced in a resting state.75 Pain strength in antigravity muscles, includ- in pathology on ultrasound imaging or
may improve with repeated loading (the ing the gluteus maximus,55 quadriceps,22 magnetic resonance imaging (MRI).27,60
“warm-up” phenomenon),55,75 but there is and calf,55 is often observed by the au- However, imaging can be helpful to in-
J Orthop Sports Phys Ther 2015.45:887-898.

often increased pain the day after energy- thors, and can be objectively assessed clude or exclude potential alternate di-
storage activities.75 Clinically, it is noted with clinical tests: repeated bridging or agnoses of anterior knee pain when the
that dose-dependent pain is a key feature, single-leg squat, resisted knee extension, clinical picture is unclear.14
and assessment should demonstrate that and repeated calf raises.46,55 Foot posture/
the pain increases as the magnitude or alignment,22,24 quadriceps and hamstring Differential Diagnosis
rate of application of the load on the ten- flexibility,95 as well as weight-bearing an- Aside from the inferior pole of the patella,
don increases.55 For example, pain should kle dorsiflexion range of motion4,62 have tendinopathy of the extensor mechanism
increase when progressing from a shallow been associated with patellar tendinopa- of the knee can occur at the quadriceps
to a deeper squat, and from a smaller to a thy and should also be assessed. tendon or distal insertion of the patellar
greater hop height. Deficits in energy-storage activi- tendon at the tibial tuberosity. These less
Assessing pain irritability is a funda- ties can be assessed clinically by ob- common clinical presentations also have
mental part of managing patellar tendi- serving jumping and hopping. There unique features. Quadriceps tendinopa-
nopathy and consists of determining the is evidence that a stiff-knee vertical thy is characterized by pain localized to
duration of symptom aggravation (dur- jump-landing strategy (reduced knee the quadriceps tendon32 and, in the au-
ing loading) following energy-storage flexion at peak vertical ground reaction thors’ experience, is often associated with
activities like a training session. Studies force) may be used by individuals with movements requiring deep knee flexion,
have suggested that up to 24 hours of a past history of patellar tendinopathy.9 such as those performed by volleyballers
pain provocation after energy-storage A stiff-knee strategy and then going and weight lifters.72 Distal patellar ten-
activities may be acceptable during re- into hip extension rather than flexion don pain, often seen in distance runners,
habilitation,54,83 so here we will define during a horizontal jump landing have is localized near the tibial tuberosity.32,78
“irritable” tendon pain as pain provoca- also been observed among participants The infrapatellar bursa is an intimate
tion of greater than 24 hours, and “stable” with asymptomatic patellar tendon part of the distal patellar tendon at-

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tachment,8 and irritation of the bursa as there are no clear sensitive and specific
often coexists with distal patellar tendi- clinical tests to help in the diagnosis.66,96
nopathy. Mid- or whole-tendon patellar Athletes with PFP often report aggra-
tendinopathy is generally the result of a vation of symptoms with activities that
direct blow42; however, careful differen- create low tendon load, such as walking,
tial diagnosis is required, as other struc- running, or cycling,13 which should result
tures, such as the bursae, fat pad, and in a high index of suspicion for a diagnosis
patellofemoral joint, can also be injured other than patellar tendinopathy. Reduc-
with this mechanism. Although these less tion of pain, when using patellofemoral
common clinical presentations have dif- taping, with provocative maneuvers, such
ferent features and management subtle- as performing a lunge or a squat, may as-
ties, the progressive-loading principles sist in confirmation of PFP.66 Patellofem-
described below equally apply (though oral joint mobility examination may also
the exercises may require modification). be helpful in the differential diagnosis.
Pain is typically more variable in na- In our clinical experience, patellar tendi-
ture and location when structures close nopathy and PFP rarely coexist, and the
to the patellar tendon, as opposed to the clinical assessment (not tendon imaging)
tendon itself, are the source of pain. The should guide management.
contribution of Hoffa’s fat pad to ante- Plica injuries79 and chondral surface
rior knee pain is poorly understood. But pathology may also produce anterior
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the fat pad is known to be active in cyto- knee pain. Palpation of the plica, a his-
kine production,87 to have vascular con- tory of snapping sensation, and MRI FIGURE 1. Single-leg decline squat performed with
nections to the patellar tendon,67 and to often assist in the diagnosis of a plica as an upright torso, to 90° of knee flexion or maximum
have fascial connections with the patel- being the source of pain. Pathology of angle allowed by pain.
lofemoral and tibiofemoral ligaments and the superior plica may be confused with
patellar tendon.15 Fat-pad injury may be quadriceps tendinopathy both clinically stresses applied to developing growth
associated with a tibiofemoral hyperex- and radiologically. Clinically, plica may plates may result in Osgood-Schlatter
tension incident,26 but insidious onset of be painful with activities requiring only syndrome at the tibial tuberosity (com-
fat pad–related pain is also common, of- shallow knee flexion (eg, walking), where- mon) or Sinding-Larsen-Johansson syn-
ten associated with repetitive end-range as pain from quadriceps tendinopathy is drome at the inferior pole of the patella
J Orthop Sports Phys Ther 2015.45:887-898.

knee extension,26 as commonly per- provoked with activities requiring deep (rare),44 both potential causes of anterior
formed in some populations (eg, young knee flexion. On MRI, whereas quadri- knee pain. People of any age are also vul-
gymnasts). Infrapatellar fat-pad hyper- ceps tendinopathy may appear as diffuse nerable to systemic and sinister causes
trophy has been described in association thickening and increased signal of the of knee pain and other symptoms (eg,
with patellar tendinopathy.23 The main distal quadriceps tendon at its inser- tumor, infection), and these instances
differentiator from patellar tendinopa- tion,86 a clearly delineated lesion deep to of nonmechanical pain presentations
thy is the site of pain: fat-pad pain is not the quadriceps tendon raises a high index should be referred appropriately.13
localized to the inferior pole but is a more of suspicion for the superior plica involve-
diffuse pain located in the anterior infe- ment.43,79 The clinical presentation of Management of Patellar Tendinopathy
rior knee region. The pain is especially localized osteochondral lesions of the in- The most investigated intervention
felt during end-range extension or with ferior region of the patella or of the troch- for patellar tendinopathy is exercise,
digital pressure applied directly to the fat lea may sometimes closely mimic patellar especially eccentric exercise. 60 For
pad (Hoffa test).26,64 tendinopathy. Clinically, joint effusion is example, the decline squat program
The patellofemoral joint may also be generally an indicator of intra-articular involves performing 3 sets of 15 repetitions,
the cause of anterior knee pain among injury and does not occur with either pa- twice daily, of single-leg eccentric squats,
jumping athletes. Patellofemoral-related tellar or quadriceps tendinopathy. with an upright torso, while standing
pain is generally located diffusely around The age of the patient must also be on a decline board (FIGURE 1).50,71,97 The
the patella on pain mapping,68 compared considered in the differential diagnosis concentric phase of the squat is performed
with the typically localized inferior pole process. Both patellar tendinopathy and either using both lower extremities or the
of the patella in patellar tendinopathy. isolated fat-pad irritation are common unaffected side only. This program was
Patellofemoral pain has been suggested in adolescents.13 Adding to the challenge developed to concentrate load on the
to be primarily a diagnosis of exclusion, of diagnosis in this age group, excessive patellar tendon.71,98 However, eccentric

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[ clinical commentary ]
exercise for the treatment of patellar
tendinopathy may be too aggressive for Stage 1: Isometric Exercises
patients with a high level of irritability, A B
particularly during the sports season.34,93
Eccentric exercise, if used in isolation, as
is often described in the literature, also
fails to address specific impairments that
may exist throughout the kinetic chain,
such as calf weakness.
Despite the widespread clinical use
of eccentric exercise for the treatment of
patellar tendinopathy,35,92 there are lim-
ited high-quality data that demonstrate
positive clinical outcomes of this ap-
proach.60 Kongsgaard et al54 performed
a randomized clinical trial comparing Stage 2: Isotonic Exercises
heavy slow resistance (HSR) exercise B
and the decline squat program. The
HSR program consisted of concentric/
eccentric squats, hack squats, and leg
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presses, using both lower extremities. For

each exercise, 3 to 4 sets were performed,
progressing from an initial load based on
15 repetition maximum (15RM) to 6RM.
Pain and functional outcomes on the
VISA-P were similar at 6 months, but
patient satisfaction of those using the Stage 3: Energy-Storage Exercises
HSR program was significantly greater • Jumping (eg, 2-leg jumps, hops, forward hops, split jumps
(70%) than patient satisfaction of those • Acceleration (eg, sprinting from standing start over relevant distances)
using the decline squat program (22%). • Deceleration (eg, running and stopping suddenly on 2 limbs and then 1 limb)
J Orthop Sports Phys Ther 2015.45:887-898.

The authors of a recent systematic • Cutting (eg, running and cutting 70°)
review determined that there was
limited evidence supporting the decline
squat program and moderate evidence
supporting the HSR program.60 Based Stage 4: Progressive Return to Sport
on the current evidence and their own • Sport-specific training (gradual training resumption)
clinical experience, the authors of this
commentary favor the use of an HSR- FIGURE 2. Progression of patellar tendinopathy rehabilitation. Stage 1: (A) isometric knee extension performed
between 30° and 60° of knee flexion, (B) Spanish squat at 70° to 90° of knee flexion. Stage 2: (A) isotonic knee
style program over the decline squat
extension, (B) leg press, (C) split squat. All exercises performed between 10° and 60° of knee flexion, progressing
program for the management of patellar to 90° as pain permits. Maintain the tibia perpendicular to the ground in the split squat, with the knee not going
tendinopathy. forward beyond the foot, so knee flexion is less than 90°, as indicated by the blue vertical line.
A 4-stage rehabilitation progression
for patellar tendinopathy is proposed, First, loading modification is used modification and eventual progressive
based on the available evidence and with the goal of reducing pain. This loading are based on careful pain moni-
the authors’ opinion. The focus is on involves initially reducing high-load toring. Some pain is acceptable during
developing load tolerance of the tendon energy-storage activities that may be and after exercise, but symptoms should
itself, the musculoskeletal unit, and aggravating the pain. Volume and fre- resolve reasonably quickly after exercise
the kinetic chain. Key rehabilitation quency (number of days per week they and should not progressively worsen
exercises in each stage are outlined are performed) of the highest-intensity over the course of the loading program,
(FIGURE 2). Progression criteria are activities, such as maximal jumping, may as monitored by the 24-hour response.54
individualized, based on pain, strength, need to be reduced in consultation with The authors measure pain response
and function (TABLE). both the athlete and coach. Both load using a pain-provocation test, such as

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greater knee flexion. Resistance should
Rehabilitation Stages be increased as quickly as tolerated and
and Progression Criteria the exercise should be performed on a
single leg if possible. An alternative is
Stage Indication to Initiate Dosage the Spanish squat6 (FIGURE 2), which is a
1. Isometric loading More than minimal pain during isotonic 5 repetitions of 45 seconds, 2 to 3 times double-leg squat performed at an angle
exercise* per day; progress to 70% maximal of approximately 70° to 90° of knee flex-
voluntary contraction as pain allows ion (a deeper angle is generally tolerated
2. Isotonic loading Minimal pain during isotonic exercise* 3 to 4 sets at a load of 15RM, progressing for a double-leg exercise) with the assis-
to a load of 6RM, every second day; tance of a rigid strap fixating the lower
fatiguing load
legs. This option can be useful, especially
3. Energy-storage loading A. Adequate strength† and consistent Progressively develop volume and then when there is limited or no access to gym
with other side intensity of relevant energy-storage
equipment (eg, the traveling athlete).
B. Load tolerance with initial-level energy- exercise to replicate demands of sport
storage exercise (ie, minimal pain
The exercise dosage depends on in-
during exercise and pain on load tests dividual factors, but evidence and clini-
returning to baseline within 24 h)* cal experience indicate 5 repetitions of a
4. Return to sport Load tolerance to energy-storage exercise Progressively add training drills, then 45-second hold, 2 to 3 times per day,18,74
progression that replicates demands competition, when tolerant to full with 2 minutes of rest between holds to
of training training allow recovery. A 70% maximal volun-
Abbreviation: RM, repetition maximum. tary contraction load, which has been
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*Minimal pain defined as 3/10 or less.

associated with reduced pain,74 can be

For example, around 150% body weight (4 × 8) for most jumping athletes.
estimated clinically on a knee-extension
machine by selecting the resistance that
the single-leg decline squat70 (FIGURE 1), pain in this article, but this should only can be held for 45 seconds. The key is
which is performed with an upright torso be used as a guide, and it is reiterated that to progress the load based on tolerance
to 90° of knee flexion or maximum angle in our opinion, greater emphasis should and, as discussed earlier, regular reas-
allowed by pain, as rated on a numeric be placed on the 24-hour pain response sessment of pain response with load
rating scale at maximum knee flexion an- to a predefined load test. tests. The authors have found that too
gle. The test is administered daily, at the Stage 1: Isometric Loading  Five repeti- little resistance (eg, isometric knee ex-
same time of day, throughout the entire tions of 45-second isometric mid-range tension as when performing quad sets
J Orthop Sports Phys Ther 2015.45:887-898.

rehabilitation process. As tendon pain is quadriceps exercise at 70% of maximal or the use of an elastic band to provide
intimately linked with load, the authors voluntary contraction have been shown an isometric resistance and holding at a
describe the response to the test as “load to reduce patellar tendon pain for 45 set deformation of the band) or progress-
tolerance.” If the pain score on the load minutes after exercise, a response asso- ing the load too quickly and beyond load
test (eg, 1 repetition of the single-leg de- ciated with a reduction in motor cortex tolerance are not effective. A good prog-
cline squat test at the same depth) has inhibition of the quadriceps, which is nostic sign for isometrics is an immedi-
returned to baseline within 24 hours of associated with patellar tendinopathy.74 ate reduction in pain with loading tests
the activity or rehabilitation session, the Isometric exercises are indicated to re- (eg, a single-leg decline squat test) after
load has been tolerated. If the pain is duce and manage tendon pain and ini- isometric exercise. It is important that
worse, load tolerance has been exceeded. tiate loading of the muscle-tendon unit there be no muscle fasciculation dur-
It is the authors’ opinion that pain assess- when pain limits the ability to perform ing the isometric exercises, as this may
ment based on a standard load test for isotonic exercises.18 Isometrics, using a be perceived to indicate that the load is
each individual is more important than knee extension machine (FIGURE 2), are too high. In stage 1, isometric exercises
a pain rating during exercise to deter- ideal for patellar tendinopathy, as they should be used in isolation (ie, without
mine the progression of loading through isolate the quadriceps. In our experi- isotonic loading). This stage may last
the course of the rehabilitation. Some ence, performing the isometric exercises a few weeks (sometimes longer) when
authors have suggested that a pain level in mid-range knee flexion (around 30°- managing individuals with a high level of
of up to 3 to 5 on a 0-to-10 numeric rat- 60° of flexion) is more comfortable, as pain irritability. Other exercises, such as
ing scale (0 is no pain and 10 is the worst people with patellar tendinopathy often heel raises, to address other strength or
pain imaginable) during exercise is ac- have pain when performing these with flexibility deficits throughout the lower
ceptable.54,83 A pain rating of 3/10 or less the knee near full extension (possibly due extremity can also be initiated during
is defined as acceptable and “minimal” to impingement of the fat pad) or with this initial phase.

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[ clinical commentary ]
The patient response to heavy isomet- chine is useful to isolate the action of the ond.73 In comparison, during the landing
ric exercises during this stage may fur- quadriceps. The same HSR program dos- phase of a vertical jump, peak patellar
ther assist with confirming the diagnosis. age as used by Kongsgaard et al54 in their tendon forces have been estimated to be
While people with patellar tendinopathy clinical trial is recommended: 3 to 4 sets 5.17  0.86 body weight, with a loading
report decreased pain both during and at a resistance corresponding to 15RM, rate of 38.06  11.55 body weight per
immediately following knee extension progressing to 6RM, performed every second.49 Higher patellar tendon forces
isometric holds, individuals with other second day. It is important to progress are reported in the horizontal landing
sources of anterior knee pain (eg, patello- to heavier loading (ie, 6RM) as tolerated, phase of a stop land/jump sequence, with
femoral joint) may feel worse using heavy as heavy load is associated with tendon peak patellar tendon forces of 6.6  1.6
knee extension exercises (or the Spanish adaptation.12 body weight and loading rates up to 93
squat), potentially due to high patello- Stage 1 exercises should be continued  23 body weight per second.28 This pro-
femoral joint reaction forces.85 on the “off ” days to manage pain within vides an understanding that the major
Stage 2: Isotonic Loading  Loaded iso- the limits of muscle fatigue and soreness change through these activities is rate of
tonic exercise is initiated when it can be associated with the isotonic loading. Stage loading of the tendon, which should be
performed with minimal pain (3/10 or 2 exercises should be continued through- progressed gradually through relevant
less on a numeric pain-rating scale). A out rehabilitation and return to sport. energy-storage activities for the individ-
positive response to regular reassessment Stage 3: Energy-Storage Loading Re- ual athlete.
of pain with load tests continues to be introduction of energy-storage loads on Choice of exercise will depend on the
important. Isotonic load is important to the myotendinous unit is critical to in- demands of the individual sport. Thus,
restore muscle bulk and strength through crease load tolerance of the tendon and the selection and parameters of ener-
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functional ranges of movement. Based improve power as a progression to return gy-storage programs may vary greatly
on clinical experience, the HSR program to sport. Initiating this stage is based on among individuals who participate in
discussed earlier can be adapted to suit the following strength and pain criteria: different sports, as well as among posi-
the individual and maximize patient out- (1) good strength (eg, ability to perform tions in the same sport. Planning for this
comes. Initially, knee flexion during both 4 sets of 8 repetitions of single-leg press stage requires close consultation with the
non–weight-bearing and weight-bearing with around 150% body weight for most athlete and coach to appropriately deter-
exercises should be limited to between jumping athletes); and (2) good load tol- mine the training frequency, volume, and
10° and 60° of knee flexion or less, de- erance with initial energy-storage exer- intensity of the energy-storage exercise,
pending on pain, then progressed toward cises, defined as minimal pain (3/10 or and the type of exercise. Energy-storage
90° of flexion or further, as pain permits less on a numeric pain-rating scale) while exercise options may include jumping
J Orthop Sports Phys Ther 2015.45:887-898.

and based on the sport demands. The performing the exercises, and return to and landing, acceleration, deceleration,
authors have found that flexion beyond baseline pain (if there was an initial in- and cutting/change-of-direction activi-
90° and full knee extension can be pro- crease) during load tests, such as the ties, depending on the demands of the
vocative in the early stage of performing single-leg decline squat, within 24 hours. sport (FIGURE 2).
isotonic exercises; that is why due caution As with the other stages, individual- The start point of the energy-storage
is warranted initially. ization and clinical reasoning are neces- rehabilitation protocol depends on load
Exercises from the HSR program in- sary. In addition, progression should be tolerance and function during the initial
clude leg presses, squats, and hack squats. developed within the context of the loads energy-storage exercises. For example, a
However, a common pitfall is including the individual patient is required to at- jumping athlete may initially be able to
only double-leg, multijoint exercises (eg, tenuate for their sport and performance tolerate performing only 3 sets of 8 to 10
double-leg squats) that may not address level. The following examples, extrapo- low-intensity jumps and landings (eg,
quadriceps strength asymmetry if the lated from published data, may assist in jumps with limited jump height and/or
athlete spares (protects) the affected side. providing context to tendon loading and landing depth). The volume and inten-
The authors prefer exercises that can be force and rate changes with progression sity (depth and speed of the low-inten-
progressed easily to single-leg loading, in- to energy-storage exercise. A bilateral sity jumps and the split squat jumps)
cluding leg press, split squat, and seated leg press (which is not an energy-storage can then be progressed as tolerance
knee extension (leg extension machine) loading exercise) performed with a resis- increases and depending on individual
(FIGURE 2). Leg press and seated knee ex- tance equal to 3 times body weight (1.5 goals. Eventually, higher-intensity loads/
tension can be commenced initially and body weight for each lower extremity) exercises can be added in an attempt to
split squats added when technique and exerts a patellar tendon force equivalent simulate sport-specific training volume
capacity under load are adequate. As in to 5.2 body weight and a loading rate es- and intensity (eg, single-leg hops, for-
stage 1, the seated knee extension ma- timated at around 2 body weight per sec- ward hops, deeper split squat jumps,

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and sport-specific jumps such as volley- load response test the day after a stage 3 days, as with the stage 3 exercises, but
ball block and spike jumps). This process training session indicates that load toler- this can vary depending on symptom
can take several weeks to months for ance has been exceeded (irritable pain) response and demands of individual
some athletes (eg, for volleyball players and loading should be adjusted accord- sports/teams. Our recommendation
to build up to the 300 landings typically ingly (eg, regress to the previous level of would be no more than 3 high-intensity
performed in a single training session).5 training, or further, to restore load tol- training or competition sessions that
For athletes who do not require signifi- erance on load tests again). In some in- involve energy-storage exercises within a
cant volumes of jumping and landing stances, pain may increase for days after week in the recovering tendon, which in
in their sport (sprinters, rugby players), an energy-storage progression that was elite sport is maintained as a principle for
a similar progression targeting accel- not gradual enough. Therefore, it may be the first year of return.
eration, deceleration, and/or cutting/ necessary to regress to solely isometrics
change-of-direction maneuvers may be for several days until pain is settled. Stage Maintenance Exercise
emphasized (FIGURE 2). Clearly, many 3 exercises can then be reintroduced with As a maintenance program once athletes
athletes (basketball players, for example) modification of the progression that was have returned to sport, stage 2 strength-
may require a combination of jumping/ considered to be provocative. The authors ening exercises are performed at least
landing and acceleration, deceleration, have found that performing isometric twice per week, preferably using loaded
and cutting abilities. loading (stage 1, low tendon load) and and single-leg exercises (eg, split squats,
Accurate quantification of load is im- then isotonic loading (stage 2, medium seated knee extension, leg press). Stage 1
portant at this stage. In jumping sports, tendon load) on subsequent days pro- isometric exercises can be continued and
the number and intensity of jumps and vides a 3-day, high-low-medium load performed intermittently (eg, prior to or
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all other energy-storage activities should cycle (with 1 rest day per week) that is after training) for their immediate effect
be considered to ensure that loads are generally well tolerated. Some athletes on pain. Athletes should also continue
progressively applied to meet the ulti- feel worse the day after a rest day, requir- addressing other relevant flexibility and
mate demands of the sport. For example, ing a program that loads the tendon every strength deficits identified throughout
a high jumper may progress through day, most likely with isometric exercises. the lower extremity, such as gluteal or
double- to single-limb small vertical Stage 4: Return to Sport Progression calf-strengthening exercises.
jumps and hops, to horizontal bounding back to sport-specific training can be
(eg, 4-6 times, 8-12 contacts), 2-legged commenced when the individual has Common Management Pitfalls
hurdle jumps up to 1 m high (eg, 3 times, completed energy-storage progressions Rehabilitation of patellar tendinopathy
8 contacts), scissor jumps over the bar that replicate the demands of his or can be a slow and frustrating process,
J Orthop Sports Phys Ther 2015.45:887-898.

from 5-step run-up (8-10 contacts), then her sport in regard to the volume and both for the athlete and clinician. There
flop jump from 5-step run-up (8-10 con- intensity of relevant energy-storage are multiple potential management pit-
tacts), and finally to a full run-up flop functions. At that time, stage 3 exercises falls in the rehabilitation stages outlined,
jump (8-10 contacts). In essence, the are replaced by a graded return to training including failure to gain control of pain,
volume (ie, number of contacts or jumps) and eventually competition. In the early normalize muscle capacity, effectively
is progressed before the intensity ( jump phases, training should match the volume progress energy-storage exercises, and
height and speed) for each exercise to and intensity of final progression of stage effectively progress return-to-sport train-
approach the optimal training intensity 3 energy-storage exercises, gradually ing volume and intensity. More specific
and energy-storage exercise demands of replacing stage 3 activities with a volume pitfalls will be outlined in this section,
the sport. and intensity similar to those of training including unrealistic rehabilitation time
The introduction of energy-storage drills to replicate the participation and frames, inaccurate beliefs and expecta-
exercises is often the most provocative fitness demands of the sport. Return tions about pain, failure to identify cen-
stage, so loading is performed every third to sport is recommenced when full tral sensitization, overreliance on passive
day initially, based on a 72-hour collagen training is tolerated without symptom treatments, not addressing isolated
response to high tendon loading, as de- provocation (24-hour response on load muscle deficits, failure to address kinet-
scribed by Langberg et al.56 Progressions test, such as the single-leg decline squat) ic-chain deficits, and not adequately ad-
are guided by pain experienced in the and any existing power deficits have been dressing biomechanics.
decline squat 24 hours after exercise, as resolved. The authors often use the triple Unrealistic Rehabilitation Time
described earlier. Stage 1 isometric loads hop test for distance45 or maximal vertical Frames  The temptation or pressure
can be used in combination to manage hop height for that purpose. to shorten rehabilitation time is un-
stable pain following energy-storage ex- Ideally, sports loads (competition and derstandable given athletes’ eagerness
ercise; however, increased pain in the training) should be performed every 3 to return to sport and the demands of

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[ clinical commentary ]
competing in elite sport. In the authors’ necessarily equal to harm, and some pain timal, given that passive strategies have
experience, progression of rehabilita- during rehabilitation is acceptable. It is not been shown to normalize tendon ma-
tion is related to symptom response to important to educate patients regarding trix or muscle tissue or to address other
load (load tolerance) and neuromuscular the concept of load tolerance as defined deficits throughout the lower extremity.39
function, both of which also determine in this article, so that they are eventually The use of passive interventions may lead
capacity to return to play. Progression able to self-manage based on symptom to reliance on the therapist to deliver
can be slow, sometimes taking 6 months response to load. a cure, which is misleading. Friction
or longer. Bahr and Bahr5 investigated Failure to Identify Central Sensiti- massage has been shown to be less
long-term outcome after eccentric train- zation  There is evidence of sensory effective than exercise as a stand-alone
ing to manage patellar tendinopathy and motor changes in lateral elbow intervention.84 While there is limited
and determined that only 46% (6/13) tendinopathy that suggests central evidence that shockwave may offer a
of athletes had returned to full training sensitization, including secondary benefit equivalent to that of exercise,36,94
and were pain free at 12 months. In the hyperalgesia and reduced reaction the exercise programs utilized in these
authors’ experience, poor baseline neuro- times.10,20,31 There is a paucity of comparative studies were either poorly
muscular function, muscle atrophy, pain literature on this issue, with only 1 study described or not best practice. There is no
irritability, as well as multiple prior in- demonstrating reduced mechanical pain high-quality evidence (from randomized
tratendinous interventions (eg, platelet- threshold in individuals with patellar trials) to support the stand-alone use of
rich plasma or other injections) appear tendinopathy.90 Despite the lack of other passive interventions to effectively
to be associated with longer rehabilita- supporting literature, the authors have manage patellar tendinopathy.39
tion times. It is important to educate pa- occasionally encountered typical central In the authors’ experience, multiple
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tients and other stakeholders (parents, sensitization features in patients with tendon injections can lead to poorer
coaches) about realistic time frames. All patellar tendinopathy, often associated long-term outcomes, perhaps secondary
stakeholders should be involved in set- with multiple failed injections and/ to protracted unloading of the tendon
ting short- and long-term goals, based or surgery. Careful pain mapping may and lower extremity. Kongsgaard et
on strength and functional targets (eg, a identify diffuse sensitivity to manual al54 reported that steroid injection
leg-press strength of 8RM on the affected palpation and more diffuse rather than used in isolation was associated with a
side and equal performance on the triple localized pain on tendon loading. These poorer outcome at 6 months compared
hop for distance are commonly used in individuals often have a long history with exercise. It must be emphasized
elite athletes by the present authors), as of pain that is not aggravated by the that there are few high-quality studies
these serve to motivate athletes, monitor typical jumping, change-of-direction, on injection therapies to date,88 and
J Orthop Sports Phys Ther 2015.45:887-898.

progress, and provide objective measures and other energy-storage loads that are injections are often offered when
for progression. a clear feature of patellar tendinopathy, rehabilitation has been inadequate.80 The
Inaccurate Beliefs and Expecta- suggesting that their pain is no longer key strategy for avoiding multiple passive
tions About Pain Beliefs about pain related to a tendinopathic process. Our interventions is setting realistic goals
and pathology may influence the experience is that these patients are less based on a sound understanding of the
development and management of likely to respond to an isolated tendon condition and its rehabilitation. Despite
unresponsive symptoms.7,65 Some athletes rehabilitation approach. potential pitfalls and limited evidence,
may have been told that “tears” and Overreliance on Passive Treat- judicious use of passive interventions
“degeneration” have caused permanent ments  Common passive or adjunct may still be occasionally indicated, but
tendon “weakening,” increasing the risk interventions include manual therapy, only as an adjunct to exercise, especially
of rupture. Patellar tendon rupture (in such as transverse frictions, electrotherapy in difficult presentations that will be
the absence of systemic disease) in sport (eg, ultrasound), shockwave therapy, and discussed below.
is rare.59 Some athletes may develop injections (sclerosing, steroid, platelet- Not Addressing Isolated Muscle Defi-
fear-avoidance behavior, which has rich plasma). Given that exercise is the cits  Rio et al74 found that patellar
been associated with poorer functional most evidence-based intervention,39 the tendinopathy was associated with
outcomes in individuals with lower-limb authors recommend against using only substantial motor cortex inhibition
tendinopathy.82 Education about pain and passive interventions in the management of the quadriceps, which may explain
realistic time frames for rehabilitation of patellar tendinopathy. 35 While persistent muscle atrophy with long-
are important. This includes education there may be useful adjuncts for pain standing patellar tendinopathy. Altered
regarding the potential link between management to enable rehabilitation neuromuscular output is likely to be
psychosocial factors and pain. Athletes progression, using passive interventions a response to pain, but may persist
need to be aware that pain is not as a substitute for exercise is less than op- even after symptoms have resolved.48

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Compound (bilateral and involving other Landing retraining can be progressed even in the young, active population.63
muscle groups) rehabilitation exercises, from double- to single-leg landings. Although uncommon, symptomatic
such as double-leg squatting, lunging, and Importantly, changes to jump-landing patellar tendinopathy may be associated
gym-based exercise such as the leg press, mechanics should not be attempted prior with metabolic, autoimmune, or
may not adequately address quadriceps to adequate rehabilitation (ie, meeting connective tissue disease (eg, diabetes,
atrophy if compensatory strategies spare criteria to progress to stage 3 energy- psoriatic arthritis).1 Symptoms are often
the very muscle group targeted. A clinical storage exercise). Pain and weakness are bilateral, and a high level of irritability
indicator of compensatory strategy commonly the cause of changes in landing may be present. Clinicians should per-
is fatigue in the gluteals rather than strategies and should be addressed first. form adequate screening to rule out
quadriceps during compound exercises systemic comorbidities as contributing
such as the leg press. Seated knee Difficult Patient Presentations factors to patellar tendinopathy, par-
extension, using moderate resistance, This section is based on the authors’ ex- ticularly when it is difficult to attribute
is an ideal exercise option because it perience and provides management guid- significant load history to the onset of
can specifically load the quadriceps3 ance for difficult presentations, including pain. The principles of management
and, when performed isometrically, has athletes with highly irritable tendons, for tendinopathy in the presence of a
demonstrated reversibility of quadriceps athletes with systemic comorbidities, in- systemic driver are as described for the
inhibition immediately following the season athletes, deconditioned athletes, irritable tendon, but may require a refer-
exercise bout.74 and young jumping athletes. ral for proper medical management.
Failure to Address Kinetic-Chain Highly Irritable Tendons A highly In-season Athletes In-season athletes
Deficits  In rehabilitation, there is a irritable tendon is defined as the clinical with patellar tendinopathy can be difficult
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temptation to focus on the injured site, in situation in which pain is significantly to manage,18 primarily because energy-
this case the patellar tendon. Addressing and sometimes dramatically increased storage loading may be difficult to modify
other potentially contributing factors for several days or weeks after even subtle sufficiently to allow symptoms to settle. A
present throughout the lower extremity progressions of energy-storage load. The key requirement is to address underlying
is essential for successful resumption patellar tendon that is highly irritable muscle strength deficiencies within the
of sporting activity. As discussed in the may require the use of bilateral loading overall sports training environment
assessment section, lack of hamstring exercises early in the rehabilitation while persistent symptoms continue to
and quadriceps flexibility,95 as well as process; however, progression to single- restrict training and competition. There
restricted ankle dorsiflexion4,62 range leg isometric loading with resistance is evidence that using the decline squat
of motion and decreased calf and hip should remain a short-term aim, guided program during the season, among
J Orthop Sports Phys Ther 2015.45:887-898.

extensor function, may be associated by load-tolerance assessment, particularly jumping athletes, does not improve
with patellar tendinopathy, and the 24-hour response to load. Selected symptoms,93 and may actually increase
addressing these deficits should be part adjunct interventions, which may include the risk of developing pain among
of its comprehensive rehabilitation.55 A nonsteroidal anti-inflammatory drugs athletes with asymptomatic pathology
truly comprehensive approach should or corticosteroids (taken orally or with of the tendon as seen on imaging.34
also consider deficits of the trunk a peritendinous injection)18 in difficult The authors have found that isometric
musculature as well as the contralateral cases, can be very useful in reducing exercises (eg, seated knee extension,
lower extremity. symptoms to allow load progression Spanish squat holds) are most effective
Not Adequately Addressing Biomechan- within a controlled rehabilitation at managing pain and can be performed
ics  Athletes with patellar tendinopathy program. The authors have observed several times daily, as described under
may require progressive jump-land that intratendinous injections, such as stage 1 of the rehabilitation process. This
retraining. The strategies of landing with platelet-rich plasma, administered to the should be coupled with load management
a stiff knee9,29,89 and moving into hip highly irritable tendon are more likely to by reducing or removing training drills
extension rather than hip flexion (in a have a negative effect, potentially due in that involve high-intensity energy storage
horizontal jump)29 have been associated part to the needle passing through richly (eg, landing or change of direction),
with higher patellar tendon injury. innervated peritendon.92 and intrinsic unloading through better
Landing kinematics can be retrained, Systemic Comorbidities  The etiology of distribution of energy absorption
focusing on soft landings on the forefoot- patellar tendinopathy is multifactorial, across the joints of the lower extremity
midfoot region, with greater ankle, knee, including both load-related and systemic (kinetic chain). Anti-inflammatories, the
and hip range of motion,69 to reduce drivers.37,38,40,41,63 Systemic pathological tendon polypill,30 corticosteroid (oral or
the magnitude of peak vertical ground drivers associated with tendinopathy injectable),54 and high-volume injection21
reaction forces and peak loading rates.25 include increased central adiposity, may again have an adjunct role, for

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[ clinical commentary ]
example, in the short time leading up to CONCLUSION 2004;50:3306-3313.
a tournament or toward the end of the art.20566

season. As discussed above, multiple atellar tendinopathy can 9. Bisseling RW, Hof AL, Bredeweg SW, Zwerver
J, Mulder T. Relationship between landing
interventions at the expense of carefully frequently be difficult to manage.
strategy and patellar tendinopathy in volleyball.
planned and executed rehabilitation This review highlights key clinical Br J Sports Med. 2007;41:e8. http://dx.doi.
are not recommended, and preference aspects in diagnosis, examination, and org/10.1136/bjsm.2006.032565
should be given to the least provocative management. The cornerstone of patellar 10. Bisset LM, Coppieters MW, Vicenzino B. Sen-
sorimotor deficits remain despite resolution
and least invasive options. tendon management and rehabilitation
of symptoms using conservative treatment in
Deconditioned Athletes The authors remains a highly specific and thorough patients with tennis elbow: a randomized con-
have found that athletes who return to approach to progressive loading of the trolled trial. Arch Phys Med Rehabil. 2009;90:1-
training and playing after a period of lower extremity (kinetic chain), muscle- 8.
11. Blazina ME, Kerlan RK, Jobe FW, Carter VS, Carl-
inactivity are susceptible to developing tendon unit, and tendon itself. In this
son GJ. Jumper’s knee. Orthop Clin North Am.
the symptoms of patellar tendinopathy, commentary, we propose a 4-stage re- 1973;4:665-678.
particularly athletes with a past history habilitation program based on available 12. Bohm S, Mersmann F, Arampatzis A. Human
of patellar tendinopathy. This may occur evidence and expert opinion that can as- tendon adaptation in response to mechanical
loading: a systematic review and meta-analysis
from both brief and longer periods of sist the clinician in guiding athletes back
of exercise intervention studies on healthy
inactivity due to other minor or more to sport effectively. These stages can be adults. Sports Med-Open. 2015;1:7. http://dx.doi.
severe injuries, as well as scheduled modified for difficult presentations to op- org/10.1186/s40798-015-0009-9
holidays and the off-season. The primary timize management outcomes. t 13. Brukner P, Khan K. Clinical Sports Medicine. Rev
3rd ed. Sydney, Australia: McGraw-Hill; 2010.
concern is the resulting deconditioning of
14. Calmbach WL, Hutchens M. Evaluation of patients
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