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Chronic tendinopathy is a common musculoskeletal disorder that frequently affects athletes who train and compete at all levels. This Clinical Commentary presents a review of the etiology, incidence, and contributory factors related specifically to patellar tendinopathy. Examination and differential diagnosis considerations are provided, and an evidence-based, staged rehabilitation program is described.
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North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 166
ABSTRACT
Chronic tendinopathy is a common musculoskeletal disorder that frequently affects athletes who train and
compete at all levels. This Clinical Commentary presents a review of the etiology, incidence, and contribu-
tory factors related specifically to patellar tendinopathy. Examination and differential diagnosis consider-
ations are provided, and an evidence-based, staged rehabilitation program is described.
Key Words. Jumper’s Knee , patellar tendonitis
1
Hardin-Simmons University Physical Therapy Department,
Abilene, TX, USA
2
Texas Tech Health Science Center, Lubbock, TX, USA
NAJSPT
CLINICAL COMMENTARY
EVIDENCE–SUPPORTED REHABILITATION OF
PATELLAR TENDINOPATHY
Marsha Rutland , PT, ScD, OCS, COMT, CSCS
1
Dennis O’Connell , PT, PhD, FACSM, CSCS
1
Jean-Michel Brismée , PT, ScD, OCS, FAAOMPT
2
Phil Sizer , PT, PhD, OCS, FAAOMPT
2
Gail Apte , PT, ScD,COMT
2
Janelle O’Connell, PT, PhD, DPT, ATC, LAT, CEEAA
1
CORRESPONDENCE
Marsha Rutland, Hardin-Simmons
University, 2200 Hickory, Abilene, TX 79698
or mrutland@hsutx.edu
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 167
INTRODUCTION
Chronic tendinopathy is a common musculoskeletal
disorder affecting both recreational and elite ath-
letes potentially leading to disability lasting several
months. Overuse tendon injuries account for 7% of
the injuries seen in United States physician offices
1
and 40% of knee injuries in volleyball players.
2
Chronic patellar tendon conditions, also known as
patellar tendinosis or “jumper’s knee”, are numer-
ous in elite athletes who run and jump as in volley-
ball (44%) and basketball (32%).
3
Similar activity
occurs in soccer and dancers, who also participate in
repetitive kicking, jumping, and landing.
2 , 3
A higher
prevalence is noted in sports with high impact bal-
listic loading of the knee extensors.
3
This disorder is
a nemesis in weight lifters due to recurrent heavy
load squatting.
4
Patellar tendon overuse is also seen
in military recruits, accounting for 15% of all of their
soft tissue injuries
5
and up to 22% incidence in the
overall athletic population.
3
Microtrauma can occur when the patellar tendon is
subjected to extreme forces such as rapid accelera-
tion -deceleration, jumping, and landing.
2
The pos-
terior proximal patellar tendon is subjected to
greater tensile tendinous forces as compared to the
anterior region, especially with jumping activities
and deep squat exercises, with forces up to 17 times
body weight being placed on the patellar tendon in
Olympic weight lifters.
2 , 4 , 6 , 7
Patellar tendinopathy
occurs more frequently in those skeletally mature
adolescents or adults, ranging from ages 16-40
years.
8 10
There is disagreement as to whether the
incidence is more common in males than females,
although recent studies show equal occurrences in
both genders.
2 , 11 , 12
Acute tendinitis involves an active
inflammatory process, often occurring following an
injury, which if treated, properly heals in 3-6 wks.
13
In contrast, chronic patellar tendinopathy, also
referred to as patellar tendinosis, manifests itself
after 6 wks-3 months as degenerative changes occur
in the tendon
13 , 14
These changes include absence of
inflammatory cells in the tendon, a tendency toward
poor healing, and decreased quality and disorganiza-
tion of collagen fibers, both of which may lead to
decreased tensile strength.
13 , 14
Additionally, neovas-
cularization, the growth of new vasculature in areas
of poor blood supply, is common in chronic tendi-
nopathy and may contribute to pain perception.
13 , 15
While the relationship between pain perception and
neovascularization is not clearly understood, it is
believed that increased levels of the neurotransmit-
ter glutamate may play a role.
16
Overuse in athletes
who continue to push past pain may contribute to
the development of a chronic and problematic con-
dition taking 3-6 months to heal.
17
Many factors, both intrinsic and extrinsic, contribute
to patellar tendinopathy.
11 , 12
Intrinsic factors such as
strength imbalance,
1 , 12
postural alignment,
11 , 12
foot
structure,
11 , 12
reduced ankle dorsiflexion,
18
and lack
of muscle strength or flexibility
12
may play a role.
However the primary cause appears to relate to the
extrinsic factor of overuse. For example, an increased
physical load, repetition, intensity, frequency, and or
duration of greater than 10% per week in the training
schedule all contribute to this overuse syndrome.
19
Additionally fatigue, poor technique, and training
errors may play a role in this disorder.
20 , 21
Further
extrinsic etiologic considerations for injuries may
include improper training surfaces, insufficient foot-
wear or inappropriate equipment.
20
Progressing
physical loading, high intensity training, or repeti-
tive loading too fast may contribute to the develop-
ment of patellar tendinopathy.
20
This microtrauma
or “overuse” injury develops from repetitive mechan-
ical loading of the tendon through excessive jump-
ing and landing activity. Training duration within a
session or a season is the most common reason for
overuse.
21
Drastic changes in frequency and or inten-
sity of training may also lead to overuse training
errors.
19
A general rule of thumb for acceptable pro-
gression of training is a 10% increase in intensity,
duration, and frequency per week.
19
EVALUATION
The purpose of the evaluation is to differently diag-
nose between conditions affecting the patella. A com-
prehensive evaluation includes detailed examination
of both intrinsic and extrinsic factors. A detailed his-
tory of a patient’s workout schedule and duration of
symptoms is paramount to making a correct diagno-
sis. If symptoms have lasted longer than 6 weeks, ten-
dinopathy should be suspected. Evaluation of chronic
patellar tendinopathy should include the utilization
of Blazina’s knee scale
22
or Kennedy’s scale
23
( Table 1 )
which both assist the rehabilitation professional to
gauge the severity of the tendinopathy. Patients with
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 168
REHABILITATION
Stage 1: Initial Rehabilitation Controlled
Rest
Controlled rest is critical in the recovery of patellar
tendinopathy. During this phase of rehabilitation,
the athlete should refrain from sports activity or
abstain from the overuse abuse, and practice con-
trolled exercise without load.
11 , 27
During this phase,
patient education regarding activity is paramount. It
is critical to recovery to avoid jumping or deep squat-
ting ( Table 2 ) . Progressing to relatively pain free
activities, such as stationary cycling, performing
exercises on a Total Gym®, or working in an aquatic
environment can help maintain physical stamina,
and yet unload the tendon. Kennedy et al
23 , 28
sug-
gested subjects with pain in stage 1 tendinopathy
(pain only after activity) or stage 2 (pain during and
after activity) adapt their training schedule, whereas
subjects in stage 3 (pain during and after workouts
that affects performance) may need total rest from
aggravating activities. The athlete in stage 3 may
still exercise aerobically, but must avoid irritating
activities.
23 , 28
Visnes et al
29
reported that volleyball
players who continued to train and compete during
an eccentric rehabilitation exercise program showed
no benefit from rehabilitation exercises. Therefore,
Visnes et al
29
suggested that patients be removed
from sports participation while undergoing an
eccentric-only rehabilitation program, then resume
competitive sports training after 8 weeks, with a
gradual return to sporting activity over the next 4
weeks.
29 , 30
patellar knee pain may grade pain as general achi-
ness after activity (Blazina Stage 1) to pain during and
after activity which interferes with competition (Bla-
zina Stage 3). Total tendon disruption is present in
Blazina Stage 4.
22
Physical examination during all stages reveals ten-
derness to palpation and pain over the inferior pole
of the patella
24
and possibly in the body of the ten-
don.
24
Thickness of the tendon may be noted also in
all stages, but it is rare to see effusion. Pain in the
patellar tendon may be reproduced with resisted
knee extension.
24
Additional functional tests of
ascending or descending stairs, performing single leg
declining squats, jumping or hopping will most likely
reproduce patellar pain symptoms.
25
Patients such as
weight lifters may complain of a “giving way” or a
perception that knee will “buckle” under load as well
as stiffness or achiness after activity.
22
Additionally,
they may complain of stiffness or achiness after
activity (Blazina stage 3 or Kennedy Stage 4).
The evaluation should include history, age and any
recent growth spurts, location of pain, and special
tests. The rehab professional should be able to dif-
ferentiate between patellar tendinopathy and addi-
tional diagnoses of 1) patellofemoral dysfunction
(more diffuse patellar pain),
12
2) Sinding-Larsen-
Johansson Syndrome(skeletally immature adoles-
cents with pain in the inferior pole of the patella),
26
and 3) Osgood Schlatter’s disease (skeletally imma-
ture adolescents with pain at the attachment of
patellar tendon at the tibial tubercle with possible
tibial tubercle enlargement).
10
Table 1. Scales to assist in evaluating patellar tendinopathy.
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 169
Table 2. Progression of rehabilitation exercises for patellar tendinopathy.
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 170
may contribute to tendon overload during jumping
and landing activities.
12
Lower extremity stretching
of 15, 30, 45, or 60 seconds or 2 minutes produces
significant gains in flexibility in healthy young or
middle age adults.
40 , 41
Static stretching of 30 seconds
at least three to four times per day is recommended
by various authors.
34 , 40 , 41
Soft tissue mobilization (STM) is used to reduce pain
and fibrotic limitations in tissue found in patellar
tendinopathies.
42
Deep transverse friction massage
for 5-10 minutes twice daily is recommended to help
promote normalized collagen alignment.
43 45
Hunter
found that firm pressure during cross friction mas-
sage is more effective than light to moderate pres-
sure.
43 , 44
Use of a rigid instrument, such as a stainless
steel or hard plastic tool, may provide accelerated
early tissue level healing in ligamentous and tendi-
nous injuries ( Figure 1 ) .
45 , 46
Furthermore, STM applied
transversely to the line of collagen fibers while the
tissue is placed under tension may assist damaged
tissue to regain tensile strength and proper fiber ori-
entation in the early stages of healing.
44
Patients can
be educated to perform STM daily until tissue is nor-
malized and pain is absent with palpation.
Eccentric exercises play an important role in chronic
patellar tendinopathy rehabilitation. Performing
eccentric squats on a 25° decline board for 3 set of
15 repetitions twice daily is suggested.
2 , 22 , 23 , 25 , 36 , 37 , 47
Loading a tendon in a controlled environment
free from overuse with progressive stress improves
Interventions
Rehabilitation incorporates three stages ranging
from limited partial weight bearing loaded exercise
to a sports specific return to play protocol. Since
overuse is a primary contributor to patellar tendi-
nopathy, it is important to avoid rapid progression in
frequency, intensity, and duration in rehabilitation
and functional progression.
19
Since most athletes
with patellar tendinopathy are treated non-opera-
tively,
31
it is imperative to understand rehabilitation
protocols and implement them wisely. Eccentric
exercise has been promoted as an important conser-
vative treatment choice for patellar tendinopa-
thy
2 , 32 , 33 , 34 , 35 , 36
as well as for Achilles tendinopathy.
37 , 38
However, a variety of protocols have been imple-
mented for rehabilitation intervention.
2 , 25 , 32 37
For
example, the Alfredson protocol
37
of eccentric exer-
cise intensity to pain level up to 5/10 directly con-
trasts the early work of Stanish and Curwin
34
who
suggest that exercise only be performed without
pain. Because no standard rehabilitation protocol
has been established as it relates to pain symptoms
secondary to tendinopathy, the following protocol
has been developed by this author, involving a pain-
free intervention progressing from partial body
weight to full body weight positions.
Initial treatment for patellar tendinopathy includes
the following: absence from jumping, relative rest
(absence of abuse),
27
stretching of lower extremity
musculature, deep transverse friction massage of
the patellar tendon, eccentric quadriceps exercises,
strengthening of hip and knee musculature, utiliza-
tion of a patellar orthotic (if needed), and cryother-
apy. Since patellar tendinosis is a chronic, non-acute
condition, inflammation is absent. Thus, anti-inflam-
matory medications (NSAIDs) are seldom effective.
39
Additionally, the use of cortisone injections may
negatively affect tendon strength and may possibly
result in tendon rupture.
16
Prior to initiating exercise, a warm-up and stretching
period is recommended.
38
Cycling on a stationary
bicycle for 5-10 minutes with minimal resistance is
suggested as an active warm-up. Next, stretching
should be incorporated into the program before and
after the exercise routine in order to address any
flexibility imbalances ( Table 2 ) . Hip flexor, quadricep,
hamstring, and gastrocnemius and soleus tightness
Figure 1. Soft tissue mobilization. 1a: Deep friction with use
of device (longitudinally). 1b: Deep friction with use of device
(cross-friction).
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 171
tendon function.
31
A controlled tendon loading exer-
cise program can be initiated through utilization of a
Total Gym® ( Figure 2 ), Shuttle® ( Figure 3 ), or a pool.
Using a decline board, more specifically targets the
patellar tendon (25-30% higher patellar tendon
forces)
35
as compared to squats performed on flat
surfaces which more likely targets the quadriceps
muscle. This specificity of tendon training allows
the patient to progress faster than on a squat on flat
surface secondary to a better isolation of the knee
extensor mechanism. The patient performs partial
weight bearing eccentric squats in a pain-free range
of motion by placing a 25° decline board on a Total
Gym® ( Figure 2 ) or Shuttle® ( Figure 3 ). Progression
occurs as the angle of the Total Gym® or the resis-
tance on the Shuttle® is increased. Likewise, a simi-
lar approach can be used in the pool with a decline
board on the pool floor in shoulder deep water. Pro-
gression occurs from moving to waist deep water,
then shallower hip deep water.
A patient is ready to progress when they can easily
complete the 3 sets of 15 repetitions of eccentric
squats on a decline board pain-free. As one improves,
decline squats can increase in difficulty from
bilateral eccentric to unilateral eccentric, then to
concentric-eccentric contractions,
37 , 49
During the
concentric phase of the squatting motion, initially
one should use the unaffected leg to extend the knee,
then lower eccentrically bilaterally; progressing to
Figure 2. 2a: Patient initiates knee extension concentrically
by extending the unaffected extremity. 2b: Progression to
bilateral eccentric lowering with both lower extremities 2c:
Progression to full weight bearing on the affected extremity
eccentrically descends to at least a 60° angle.
Figure 3. Unloaded squats can be performed on a Shuttle®.
If signifi cant pain with eccentric lowering, eccentric squats
can performed bilaterally.
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 172
single limb eccentrics using the affected leg. Addi-
tionally, speed should be addressed throughout
rehabilitation. Bilateral slow speed decline squats
are encouraged during the first week of rehabilita-
tion while faster speeds are encouraged during the
second week. Although pain reported by the patient
of up to level 5/10 on the Visual Analog Scale is com-
mon with some of the documented eccentric pro-
gressions of exercise,
37 , 49
other authors have found
exercising without induced pain to be beneficial to
healing.
34 , 50
This non-painful protocol may benefit
the non-athlete as well. Sayana et al
50
found only
56% of non-athletic subjects benefitted from full
weight bearing eccentric painful squat exercises.
Therefore, this pain-free protocol is recommended
by the author of this commentary for all individuals
with patellar tendinopathy.
Squatting depths are controversial among health
professionals and coaching instructors. Squatting
should be limited to no greater than 60-70° knee
flexion
51 , 52 , 53
due to the excessive forces on the patel-
lofemoral joint, patellar tendon, and the meniscus,
although some studies encourage full depth squats
to 90 degrees.
30 , 36
Other patellar tendinopathy proto-
cols
36 , 53
had subjects performing squats slowly to
60° and 70° knee flexion respectively. Dillon et al
52
found significantly greater forces on the posterior
fascicles of the patellar tendon between 60-90° of
squatting. Squatting depths can be easily controlled
on a Total gym®, Shuttle®, or in the upright, full-
weightbearing position.
A proximal hip and thigh strengthening program
including “around the world” leg raises (straight leg
raises, sidelying hip abduction /hip adduction and
prone hip extension) with concentration on eccentric
lowering is important ( Figure 4 ) . Hip strengthening
exercise with a 2 second concentric leg lift, followed
by a 4 sec eccentric leg lowering is encouraged. Hip
strengthening exercises (with no weight initially)
combined with the decline eccentric squats should be
an essential element of injury and rehabilitation pro-
grams.
55 57
Education of the patient to perform exer-
cises at home is also key to full recovery.
Although ice has been shown to reduce inflammation
in acute conditions, varied results are found with the
use of ice in chronic conditions.
34 , 58
Ice massage for
Figure 4. “Around the World” leg raises. 4a. Straight leg
raise 4b. Hip Abduction side leg raise 4c. Hip adduction inside
leg raise 4d. Hip extension prone leg raise.
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 173
through a weighted belt, vest or bag, or by using a
backpack with weights. Once the subject can per-
form decline squats easily and without pain,
weights can be added in 5 kg increments, starting
with 10% of body weight.
29
,
53
Double leg jumping
squats on the Shuttle® or Total gym® may be initi-
ated at weeks 4-5 at a progressive resistance level
that does not produce patellar pain. The stretching
program as well as the “around the world” leg raise
routine using progressive ankle weights (1-2# per
week) should be continued. Additionally, deep-fric-
tion massage and ice following exercise should be
5 minutes or ice pack to the patellar tendon can be
applied for up to 10 minutes following the exercise
program.
34
Knobloch et al
58
found intermittent cryo-
therapy of 3 sets of 10 minutes significantly decreased
local Achilles tendon mid-portion capillary blood flow
by 71%, thus promoting venous capillary outflow
in the tendon. Many common modalities, such as
iontophoresis,
59
ultrasound,
60 , 61
and electrical stimula-
tion
62 , 63
have not been found to be effective in treat-
ment of chronic tendinopathy. Extracorporeal shock
wave therapy (ESWT) for patellar tendinopathy
shows promise as a safe treatment based upon a lit-
erature review of seven studies, although no specific
treatment regime is recommended.
64
A systematic
review of low level laser treatment (LLLT) shows
potential effectiveness for treating tendinopathy when
recommended dosages are used.
65
Orthotics or taping may be beneficial for patellar
tendinosis. The Chopat® strap, or other varied patel-
lar tendon straps can help stabilize the tendon with
jumping activities, and may be used during rehabili-
tation. Although various authors
25 , 66 68
suggest use of
such orthotics, no randomized controlled trials have
been conducted examining their efficacy in patellar
tendinosis, and therefore evidence is lacking to the
effectiveness of a patellar strap. Further research
need to be conducted regarding the use of such
devices.
Stage 2: Progression
After pain symptoms decrease, progress the patient
to upright 25 decline eccentric squats (3 sets of 15
repetitions twice daily), utilizing the bilateral- uni-
lateral- eccentric-concentric progression as outlined
previously. The eccentric exercise program should
be progressed from partial-weight bearing to full
weight bearing ( Figure 5 ), then to weighted resistance
using a back pack or weighted vest ( Figure 6 ) . Speed
can be increased during the concentric-eccentric
phase, finally progressing to more ballistic type
activity (jump squats) to prepare for return to func-
tional activities. Once symptoms have subsided,
patients with tendinopathy should be encouraged to
continue eccentric strengthening exercise even after
their return to sport.
As previously mentioned, resistance weight may
be added to the single squat eccentrics, either
Figure 5. Decline squats. 5a. Ascending to upright can be
performed with the majority of weight on the unaffected leg.
5b.Upon descent, full weight is placed on the affected extrem-
ity as the patient eccentrically lowered to at least a 60° angle.
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 174
Avoidance of sports activity during the first 8 weeks
is crucial for continued healing. Those who have
continued to train and compete in sports activities
during treatment progression have demonstrated
little change in prognosis.
29
Stage 3: Sports Specifi c:
Return to Play
In this phase, the athlete should continue the above
routine, adding more weight in 5 kg increments with
the weighted eccentric decline squats. Progression
to a drop squat, involving rapidly eccentrically drop-
ping into a stationary squat position, should include
3 sets of 20 reps with incremental weight as above.
69
Three sets of 15 repetitions daily of eccentric step
downs off of 4, 6 and 8 height steps performed
with minimal to no discomfort are appropriate as
well ( Figure 7 ) .
54
Jumping activities can then be
added to this routine. Progression of double leg
jumping squats (involving concentric and eccentric
jumping in a squat position repetitively) on the
Shuttle® or Total gym® to a single leg jump should be
initiated before beginning standing jumps. Follow-
ing pain-free movement off of the 6-8 step down,
progress to drop jumps.
34 , 69
Progression includes
drop jumping off small step (4), progressing to 6
and 8 steps when 3 sets of 20 repetitions daily are
maintained. At 4 weeks, slow pain-free jogging on
flat ground, as well as resisted cycling or water jog-
ging can be added.
30
Figure 6. To progress patient, add weighted backpack.
Figure 7. Step Downs. 7a. Step down off 4 step. 7b. Step down off 8 step.
North American Journal of Sports Physical Therapy | Volume 5, Number 3 | September 2010 | Page 175
position at a dosage of 3 sets of 15 repetitions twice
daily for 12 weeks. Progressive jumping activities
are added midway through the program. Other con-
siderations may include slow progression back to
sporting events after 2-3 months, assuming the ten-
don site is pain-free in all activities.
A variety of rehabilitation techniques are necessary
to assist an individual in returning to recreational
activities following patellar tendinopathy. A combi-
nation of active rest, education, eccentric exercise,
progressing the training regime by 10% weekly, and
modifying activity have all been found to be effec-
tive in tendinopathy treatment.
19 , 70
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29 , 30 , 36 , 53
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... Malliaras et al. [29] contend that the treatment of PT should focus on progressively developing load tolerance of the tendon with exercise and that other modalities are only beneficial as an adjunct to exercise therapy. Rutland et al. [63] agreed and stated that active rest, activity modification, and eccentric exercise are cornerstones of PT management. ...
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“Jumper's knee” (patellar or quadriceps tendinitis) appears to be increasing in incidence in both athletic and recreational activities. The clinical and therapeutic aspects of this phenomenon are described. Much more information needs to be elicited before the symptom complex and its treatment can be formally defined.
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Objective. To investigate the reliability and validity of five squat-based loading tests that are clinically appropriate for jumper's knee. The loading tests were step up, double leg squat, double leg squat on a 25-degree decline (decline squat), single leg decline squat, and decline hop. Design. Cross-sectional controlled cohort. Subjects without knee pain comprised controls, those with extensor tendon pain comprised the jumper's knee group. Setting. Institutional athlete study group in Australia Participants. Fifty-six elite adolescent basketball players participated in this study, thirteen comprised the jumper's knee group, fifteen athletes formed a control group. Intervention. Each subject performed each loading test for baseline and reliability data on the first testing day. Subjects then performed three days of intensive (6 h daily) basketball training, after which each loading test was reexamined. Main outcome measures. Eleven point interval scale for pain. Results. The tests that best detected a change in pain due to intensive workload were the single leg decline squat and single leg decline hop. This study found that decline tests have better discriminative ability than the standard squat to detect change in jumper's knee pain due to intensive training. The typical error for these tests ranged from 0.3 to 0.5, however, caution should be exercised in the interpretation of these reliability figures due to relatively low scores. Conclusions. The single leg decline squat is recommended in the physical assessment of adolescent jumper's knee. The decline squat was selected as the best clinical test over the decline hop because it was easier to standardise performance. Yes Yes
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Patellar tendinopathy causes substantial morbidity in both professional and recreational athletes. The condition is most common in athletes of jumping sports such as basketball and volleyball, but it also occurs in soccer, track, and tennis athletes. The disorder arises most often from collagen breakdown rather than inflammation, a tendinosis rather than a tendinitis. Physicians must address the degenerative pathology underlying patellar tendinopathy because regimens that seek to minimize (nonexistent) inflammation would appear illogical. Suggestions for applying the 'tendinosis paradigm' to patellar tendinopathy management include conservative measures such as load reduction, strengthening exercises, and massage. Surgery should be considered only after a long-term and appropriate conservative regimen has failed.