_Patellar Tendinopathy / "Jumper's Knee"_
Summary
Overload tendinopathy of the patellar tendon (typically at the inferior pole). Reactive/degenerative, largely non-inflammatory. Managed by symptom modulation plus progressive tendon loading.
Pathology. Patellar tendinopathy is an overload condition of the patellar tendon, typically at the inferior pole, common in jumping and change-of-direction athletes. The tendon shows reactive/degenerative matrix change (not classic inflammation — hence "tendinopathy"). The guiding principle is progressive load management: passive modalities modulate symptoms and prepare tissue, while loading (isometric → eccentric → heavy-slow resistance) drives recovery.
Clinical presentation (signs & symptoms)
Localised anterior knee pain at inferior pole of patella, dose-dependent with activity; stiffness after rest; pain on jumping/landing and descending; may "warm up" then worsen afterwards; usually no swelling, no instability.
Assessment (Examination & Assessment)
Subjective
Load-related anterior knee pain localised to the inferior pole of the patella; worse with jumping/landing, descending stairs, decline squats and after prolonged sitting ("movie sign"). History of jumping / change-of-direction sport. Pain scale.
Objective
Observation (quad bulk, VMO, alignment); palpation of inferior pole of patella & proximal tendon (localised tenderness); single-leg decline squat 25° (key test — reproduces pain); resisted knee extension; knee ROM; assess glute strength & ankle dorsiflexion; VISA-P for baseline.
Differentiate from
Patellofemoral pain, quadriceps tendinopathy, fat pad (Hoffa's) syndrome.
Key special tests
| Test | What a positive result indicates | |---|---| | Single-leg decline squat at 25° | loads the patellar tendon and reproduces inferior-pole pain (primary test) | | Palpation of the inferior pole of the patella | localised tendon tenderness | | Resisted knee extension | pain on quadriceps/tendon load | | VISA-P questionnaire | baseline severity and between-session monitoring |
Red flags & when to refer
- Acute patellar or quadriceps tendon rupture (sudden pop, extensor lag, palpable gap)
- Suspected fracture
- True locking or giving-way suggesting intra-articular pathology
Contraindications & precautions
- Dry needling: consent & hygiene; avoid over infection, over neurovascular structures, needle phobia; caution with anticoagulants; avoid joint/acute inflammation.
- Ultrasound: avoid over growth plates (children), malignancy, implants/pacemaker area, DVT, altered sensation; adjust parameters acutely.
- General: rule out acute tendon rupture and red flags before treating.
Treatment protocol
Session structure & time scales
- Pre-assessment + prep (10 min): consultation, key tests, VISA-P.
- Soft tissue — quads/ITB/gastrocnemius (10–15 min).
- Patellar mobilisations (5 min).
- Dry needling — quadriceps trigger points (8–10 min).
- Electrotherapy — US and/or NMES for quads (8–10 min).
- In-clinic isometric loading + taping (5–8 min).
- Reassessment + home programme (5 min).
Modalities & rationale
| Modality / technique | Rationale (why it is used for this pathology) | |---|---| | Advanced massage (quads, ITB, gastroc) | reduces tone and addresses kinetic-chain contributors → lowers tendon load. | | Patellar mobilisations (Maitland) | accessory glides for pain modulation and mobility (Banks, 2013). | | Dry needling (VL, rectus femoris) | reduces myofascial pain (Sharkey, 2017). Check contraindications. | | Electrotherapy | US may influence repair (evidence debated; Watson, 2008); NMES aids quads activation to support loading. | | Isometric loading (Spanish squat / knee-ext holds) | acute analgesia + introduces load — the central active component. | | Sports taping (infrapatellar strap) | symptomatic relief via offloading. |
Loading & exercise progression
Isometric (analgesia) → isotonic heavy-slow resistance → energy-storage/plyometric → return to sport. Monitor: pain ≤ acceptable level and settling within 24 h; track VISA-P.
Home care / self-management
Progressive home loading (isometric for pain → eccentric/HSR as tolerated), sport load management (reduce jumping/impact temporarily), education on dose-dependent pain, pain scale as guide.
Outcome measures & re-assessment
- Pain scale (NPRS 0–10) pre and post.
- Repeat single-leg decline squat; compare pain/movement quality.
- Repeat inferior-pole palpation + knee ROM.
- VISA-P as between-session progress measure.
Anatomy reference
| Structure | Origin | Insertion | Action | |---|---|---|---| | Rectus femoris | AIIS | patella → tibial tuberosity (via quads & patellar tendon) | knee extension + hip flexion | | Vastus lateralis | greater trochanter & lateral lip linea aspera | patella → tibial tuberosity | knee extension | | Vastus medialis (VMO) | intertrochanteric line & medial lip linea aspera | patella | knee extension + patellar tracking | | Vastus intermedius | anterolateral femoral shaft | patella → tibial tuberosity | knee extension | | Patellar tendon | apex of patella | tibial tuberosity | — |
Clinical reasoning (Q&A for the system)
_These question–answer pairs encode the expected clinical reasoning for this condition. Use them to justify decisions and to check generated plans._
Q: What signs and symptoms would make you suspect patellar tendinopathy? A: Load-related anterior knee pain localised to the inferior pole of the patella, worse with jumping/landing, decline and prolonged sitting; dose-dependent; usually no swelling.
Q: Which test isolates the patellar tendon, and what does a positive result show? A: The single-leg decline squat at 25° — it loads the patellar tendon and reproduces the inferior-pole pain; combined with localised palpation of the inferior pole.
Q: Justify your choice of isometric loading and dry needling for this injury. A: Isometrics give acute analgesia and let load be introduced safely — loading is the driver because the tendon needs graduated mechanical stimulus to remodel. Dry needling eases quadriceps trigger points and pain-related inhibition, supporting that loading.
Q: Give the origin, insertion and action of rectus femoris and why it's relevant here. A: O: AIIS; I: patella → tibial tuberosity via the quadriceps and patellar tendon; A: knee extension and hip flexion. It crosses both joints, so hip position influences patellar-tendon load.
Q: What would you progress to after the four/seven treatments? A: Progress isometric → heavy-slow resistance → plyometric/energy-storage loading, monitor with VISA-P, manage sport load, and stage return to jumping.
References
- Banks, K. (2013) _Maitland's Peripheral Manipulation Management._ Elsevier.
- Banks, K. (2013) _Maitland's Vertebral Manipulation Management._ Elsevier.
- Sharkey, J. (2017) _The Concise Book of Dry Needling._ Lotus Publishing.
- Watson, T. (2008) _Electrotherapy: Evidence Based Practice._ Elsevier.
- Clarkson, H. M. (2013) _Musculoskeletal Assessment._ 3rd edn. Lippincott.
- TODO: add a condition-specific loading-protocol reference (from module notes), Harvard format.