











































MANUSCRIPT TYPE


EVIDENCE TO PRACTICE REVIEW 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 2 – Issue 1 – February 2019 

 
 

Best Practices in Patellar Tendinopathy Management: An Evidence to 
Practice Review 
Christopher J Burcal, PhD, ATC*; Adam B Rosen PhD, ATC*; Tony Taylor, MS, ATC; and Mike Nicola, MS, 
ATC 
University of Nebraska at Omaha, Omaha, NE 
*These authors contributed equally to this work  

 
ABSTRACT 

Patellar tendinopathy (PT) is a degenerative condition that 
is common in sporting populations due to the loads placed 
on the tendon during dynamic activity. PT often occurs in 
overtraining situations; however, it may also occur in 
conjunction with and/or worsen through poor biomechanics, 
persistent inflammation, and altered movement patterns. 
Although sports medicine practitioners have evidence to 
support the prevalence of this injury, we do not have a 
strong base of evidence surrounding the contributing factors 
and pathophysiology that lead the pain and disability 
reported in patients with PT. The purpose of this evidence to 
practice review was to summarize a systematic review on 
interventions to treat PT. The authors aimed to include any 
randomized controlled trial that treated patients with PT 
and used the Victorian Institute of Sport Assessment Patellar 
Tendon Questionnaire (VISA-P) as an outcome measure. 
Seven different PT interventions were described and 
summarized by the authors in this review. On the 
conservative end of the treatment spectrum, eccentric 
loading programs and extracorporeal shockwave therapy 
were found to be effective at reducing pain. More invasive 
approaches often utilized after failed conservative 
treatment, such as platelet-rich plasma injections and 
arthroscopic tenotomy, were also deemed effective. 
Therapeutic ultrasound and sclerotherapy were found to be 
ineffective treatments, and corticosteroid injections are 
contraindicated in patients with PT. The review highlights 
that both conservative and invasive treatment approaches 
can reduce pain in patients with PT. However, there is still no 
consensus on the optimal treatment protocols for patients 
with PT due to the variability in in protocols. Thus, we 
recommend utilizing an individualized approach and 
appropriate clinical judgement to guide treatments derived 
from a thorough patient history and physical/biomechanical 
examination to identify interventions with the highest 
likelihood of resolving symptoms.  

Key Phrases 
Therapeutic devices, therapeutic exercise, rehabilitation 
 
Correspondence 
Dr. Christopher Burcal, 6001 Dodge Street, HK 207V, 
Omaha NE 68182. 
E-mail: cburcal@unomaha.edu  
Twitter: @c_burcal 
 
 

Full Citation 
Burcal CJ*, Rosen AB*, Taylor T, Nicola M. Best practices in 
patellar tendinopathy management: An evidence to practice 
review. Clin Pract Athl Train. 2019;2(1):4-10. 
https://doi.org/10.31622/2019/0001.2.  
 
Click Here for Supplemental Videos   
 
Submitted: February 14, 2019 Accepted: February 25, 2019 

 

ORIGINAL REFERENCE AND SUMMARY 

Everhart JS, Cole D, Sojka JH, Higgins JD, 
Magnussen RA, Schmitt LC, Flanigan DC. 
Treatment options for patellar tendinopathy: A 
systematic review. Arthroscopy. 2017;33(4):861-
872. 

SUMMARY 
 
CLINICAL PROBLEM AND QUESTION 
 

Patellar tendinopathy (PT) is a common, 

degenerative condition that affects up to 45% of 
collegiate and elite jumping athletes.1 Many 
athletes with PT suffer from long-term knee pain 
and movement impairments which frequently 
causes athletes to limit or discontinue sport 
participation.2,3  Several risk factors have been 
identified including an increased training load, 
decreased hamstring flexibility, an inferiorly-
placed patella, and reduced quadriceps 
strength.4,5 The majority of these risk factors are 
modifiable, suggesting there is a strong 
likelihood that patients can respond positively to 
therapeutic intervention.4,5 

Despite the frequency of PT, the pathological 
sequence and contributing factors to the reports 
of pain and disability are not universally agreed 

https://doi.org/10.31622/2019/0001.2
https://vimeo.com/320590928/e0231f5cc7


Best Practices in Patellar Tendinopathy Management: An Evidence to Practice Review 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 2 – Issue 1 – February 2019 
 

upon. Histopathological findings of patients 
suggest symptoms are not due to the 
inflammatory response and are rather due to 
degeneration of the tissue.6 Collagen fiber 
pattern disruption is often noticeable during 
sonographic examination in those with PT.7 
Although not an inflammatory response, the 
involved patellar tendon may show thickening 
and have a greater cross-sectional area upon 
inspection.8,9 This poor understanding of the 
pathological sequence leads to a decreased 
ability to develop and identify treatments that 
can effectively treat PT. Due to the lack of 
consensus of the causes and perpetuation of PT, 
intervention protocols vary widely. Therefore, the 
purpose of the reviewed study was to assess the 
effectiveness of interventions used to manage PT. 

SUMMARY OF LITERATURE  
 
The guiding systematic review’s authors 
conducted a systematic search of PubMed, 
Google Scholar, CINAHL, UptoDate, Cochrane 
Reviews, and SPORTDiscus to identify published 
clinical trials for the treatment of PT. Studies that 
were included in the systematic review had to 
meet the following inclusion criteria: (1) patients 
must have been diagnosed with chronic or acute 
PT, (2) used the Victorian Institute of Sports 
Assessment Patellar Tendinopathy Questionnaire 
(VISA-P) as an outcome, (3) have a clinical 
trial/therapeutic outcome design, (4) be 
reported in English, and (5) be an original 
research study published in a peer-reviewed 
journal.  

The search identified 691 potential articles that 
were screened for inclusion criteria, resulting in a 
total of 15 studies included in the systematic 
review and meta-analysis. Five studies 
investigated eccentric exercise training, 4 studies 
evaluated surgical intervention, 4 studies 
evaluated extracorporeal shockwave therapy, 2 
investigated platelet-rich plasma (PRP) injections, 
2 evaluated steroid injection therapy, 1 

evaluated therapeutic ultrasound, and 1 study 
investigated sclerotherapy.  

SUMMARY OF INTERVENTIONS  
 
Seven different treatment strategies were 
reported ranging from a more conservative 
approach of using eccentric therapeutic exercises 
to surgical intervention. Eccentric exercise 
protocols ranged from twice weekly to 7 days a 
week and from 5-weeks long to 12-weeks long. 
Exercises included eccentric strength training of 
the quadriceps and hamstrings, and single-limb 
squats on a 25° decline board. These were 
performed at a slow speed, approximate 30 
seconds count, at 15 repetitions for three sets. 
Surgery involved both open and arthroscopic 
patellar tenotomy, with a range of post-
operative rehabilitation protocols incorporating 
eccentric exercises. Extracorporeal shockwave 
therapy ranged from a single treatment session 
to 3 sessions in 3-day to 1-week intervals, with 
up to 1500 impulses of 0.18mJ/mm2. PRP 
injections were given in the most painful location, 
up to 2 treatments over a 2-week period. Up to 
two corticosteroid injections were investigated, 
and one protocol began eccentric rehabilitation 
exercises 3-4 days after receiving the steroid 
injection. Low-intensity pulsed ultrasound was 
applied for 20-minutes a day, 7-days a week 
for 12 weeks (2-ms burst of 1 MHz @ 100Hz). 
Sclerotherapy is a treatment that destroys 
microvessels that form during the 
pathophysiological sequela of PT; the 
investigation included in this SR used a single 
dose of a sclerosing agent guided by 
ultrasonography.  

SUMMARY OF OUTCOMES  
 
The authors of the guiding systematic review 
utilized the VISA-P to determine the efficacy of 
each PT intervention. The VISA-P is a patient-
reported outcome that assesses the symptoms, 
ability to complete functional tasks, and ability to 



Best Practices in Patellar Tendinopathy Management: An Evidence to Practice Review 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 2 – Issue 1 – February 2019 
 

complete sports.10 It can be scored within each 
domain, but composite scores range from 0 to 
100, with 0 representing maximal levels of 
perceived disability, and 100 representing no 
symptoms (i.e. healthy).10 A minimal clinically 
important difference of 13 from pre- to post-
testing has been established for the VISA-P.11 
With the ease of administration and grading, the 
VISA-P is a useful tool in determining treatment 
responses in patients with PT. 

FINDINGS AND CLINICAL IMPLICATIONS  

This systematic review assessed the evidence and 
elucidated intervention strategies that appear to 
be the most effective in patients with PT (Table 
1). In addition, athletes and recreationally active 
individuals often push through activities despite 
their condition, playing, and practicing through 
low to moderate pain and symptoms. These 
behaviors make it difficult for clinicians as they 
may have to choose between symptom 
management rather than promote tissue 
healing.12 Evidence also suggests that promoting 
tissue healing and managing symptoms are not 
mutually exclusive, as complete removal from 
sport may be contraindicated as loading is 
necessary to maintain healthy tendons.13 The key 
for clinicians is to manage and reduce training 

loads, which can be done by utilizing a pain-
monitoring model with visual analogue scales.14 In 
addition, poor patient compliance with eccentric 
protocols are often implicated in the lack of 
overall success due to their painful nature.15 

Heavy slow resistance training has become 
popular as an alternative method to traditional 
eccentric exercises to improve patient outcomes, 
as the treatment techniques is considered less 
painful while demonstrating improvements of 
histological factors associated with tendon 
healing.16 

Based on the findings of the systematic review, 
our own review of the evidence, and clinical 
expertise, we propose a framework for treating 
patients with PT (Figure 1). A thorough patient 
history and physical examination should be used 
to identify painful movements and any postural 
alignment issues/biomechanical insufficiencies 
which may need to be addressed during 
therapeutic rehabilitation. In both acute and 
chronic PT, the primary management strategy 
should consist of a two-pronged approach 
incorporating a loading program and 
therapeutic modalities. The loading program can 
aid in long-term pain relief, and should consist of 
eccentric and heavy slow resistance exercises 
(See supplemental videos).17 Heavy slow 

Table 1. Summary of Treatment Efficacy for Patients with Patellar Tendinopathy 
Intervention # of studies Effect size of Improvement in VISA-P Scores (95% CI) 
Eccentric Exercises 5 61% (53% to 69%) 
PRP Injections 2 55% (5% to 105%) 
Extracorporeal Shockwave 
Therapy 4 54% (22% to 87%) 

Steroid Injections 2 20% (-20% to 60%) 
Surgery 4 57% (52% to 62%) 
Low-dose Therapeutic 
Ultrasound 2 50% (42% to 58%) 

Moderate-dose Therapeutic 
Ultrasound 1 86% (82% to 90%) 

High-dose Therapeutic 
Ultrasound 1 27% (21% to 34%) 

Effect sizes reported reflect the magnitude of improvement on the VISA-P from pre-intervention scores. 
Thus, a pre-intervention score of 50 and a post-intervention score of 75 would represent a 50% 
improvement in the VISA-P. Based on this data, patellar tendinopathy patients treated with either eccentric 
exercises or surgery consistently display a positive response to their treatment. 

https://vimeo.com/320590928/e0231f5cc7


Best Practices in Patellar Tendinopathy Management: An Evidence to Practice Review 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 2 – Issue 1 – February 2019 
 

resistance exercises  consist of a concentric action 
over a longer period of time (about 30 
seconds),17 thus emphasizes both concentric and 
eccentric strength of agonist and antagonist 
muscle groups. The current systematic review also 
supports the use of extracorporeal shockwave 
therapy and PRP injections for pain reduction in 
patients with PT. Extracorporeal shockwave 
therapy has also shown efficacy in patients with 
medial tibial stress syndrome.18,19 However, it is 
an expensive treatment and not practical for all 
athletic trainers. Therefore, we recommend one 
considers both the time and financial investments 
implicated with using extracorporeal shockwave 
therapy when treating patients with PT. If pain 
and function fail to improve in your patient over 
a 6-month period, we suggest athletic trainers 
refer their athlete to a surgeon to discuss a 
patellar tenotomy. Surgery has been shown to 
be effective in the long-term at reducing pain in 
patients with PT. However, this is not the ideal 
approach for all athletes or patients with PT, thus 
we also suggest several adjunct therapies. 
Consistent evidence supports the use of isometric 
exercises for reducing pain in patients with PT.17 

PRP injections may also be used, either prior to 
beginning a loading program, or afterwards to 
accelerate recovery. Strapping may also be 
considered when managing patients with PT, as 
infrapatellar strapping has been shown to 
reduce pain and alter lower limb 
biomechanics.20,21 Ineffective approaches include 
both low- and high-dose therapeutic ultrasound, 
as well as sclerotherapy. Corticosterioid 
injections may sound like a logical treatment, 
however they are contraindicated for patients 
with PT and should not be used.  While this 
systematic review reports varied levels of 
efficacy of different treatments for reducing 
pain in patients with PT, they all used the VISA-P 
as an outcome. We strongly recommend clinicians 
continue to utilize such validated patient-
reported outcomes as a mean to track treatment 
success and aid in the clinical decision-making 
process. We also recommend incorporating 

quality improvement practices that utilizes 
patient-reported outcomes to address patients 
on an individual basis, in an effort to optimize 
your clinical management of patients with PT. 

CLINICAL BOTTOM LINE 
 
Several treatment protocols are available with 
varying success to manage patients with PT. 
Exercise protocols including isometric, eccentric, 
and heavy slow resistance exercises often report 
the best patient outcomes.  Extracorporeal 
shockwave therapy and PRP injections are also 
effective adjuvant interventions, and can be 
incorporated when a patient is not responding to 
an initial conservative treatment approach. 
Failed conservative treatments often lead to 
surgical interventions such as debridement to 
remove degenerative tissues to promote healing. 
Due to the wide variety of options, there is no 
consensus on the optimal treatments to improve 
outcomes in patients with PT. However, the 
literature shows that nearly all patients with PT 
can be treated effectively. Considerable 
evidence supports the use of conservative 
eccentric loading exercises, however, in lieu of a 
positive response to such conservative 
approaches, surgical intervention is effective at 
improving patient outcomes.  
 

REFERENCES 

1. Lian OB, Engebretsen L, Bahr R. Prevalence 
of jumper's knee among elite athletes from 
different sports: a cross-sectional study. Am J 
Sports Med. 2005;33(4):561-567. 
https://doi.org/10.1177/0363546504270
454.       

2. Khan KM, Maffulli N, Coleman BD, Cook JL, 
Taunton JE. Patellar tendinopathy: some 
aspects of basic science and clinical 
management. Br J Sports Med. 1998:346-
355. 
https://doi.org/10.1136/bjsm.32.4.346 

https://doi.org/10.1177/0363546504270454
https://doi.org/10.1177/0363546504270454
https://doi.org/10.1136/bjsm.32.4.346


Best Practices in Patellar Tendinopathy Management: An Evidence to Practice Review 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 2 – Issue 1 – February 2019 
 

3. Cook JL, Khan KM, Harcourt PR, Grant M, 
Young DA, Bonar SF. A cross sectional study 
of 100 athletes with jumper's knee managed 
conservatively and surgically. The Victorian 
Institute of Sport Tendon Study Group. Br J 
Sports Med. 1997;31(4):332-336. 
http://dx.doi.org/10.1136/bjsm.31.4.332.   

4. Morgan S, Van Vuuren ECJ, Coetzee FF. 
Causative factors and rehabilitation of 
patellar tendinopathy: A systematic review. 
S Afr J Physiother. 2016;72(1). 
https://dx.doi.org/10.4102%2Fsajp.v72i1.
338.   

5. Morton S, Williams S, Valle X, Diaz-Cueli D, 
Malliaras P, Morrissey D. Patellar 
tendinopathy and potential risk factors: an 
international database of cases and controls. 
Clin J Sport Med. 2017;27(5):468-474. 
https://doi.org/10.1097/JSM.0000000000
000397.    

6. Khan KM, Cook JL, Kannus P, Maffulli N, 
Bonar SF. Time to abandon the "tendinitis" 
myth. BMJ (Clin res ed). 
2002;324(7338):626-627. 
https://doi.org/10.1136/bmj.324.7338.62
6.   

7. Peace KAL, Lee JC, Healy J. Imaging the 
infrapatellar tendon in the elite athlete. Clin 
Radiol. 2006;61(7):570-578. 
https://doi.org/10.1016/j.crad.2006.02.00
5.   

8. Helland C, Bojsen-Moller J, Raastad T, et al. 
Mechanical properties of the patellar tendon 
in elite volleyball players with and without 
patellar tendinopathy. Br J Sports Med. 
2013;47(13):862-868. 
https://doi.org/10.1136/bjsports-2013-
092275.    

9. Pfirrmann CW, Jost B, Pirkl C, Aitzetmuller G, 
Lajtai G. Quadriceps tendinosis and patellar 
tendinosis in professional beach volleyball 
players: sonographic findings in correlation 
with clinical symptoms. Eur Radiol. 
2008;18(8):1703-1709. 

https://doi.org/10.1007/s00330-008-
0926-9.   

10. Visentini PJ, Khan KM, Cook JL, Kiss ZS, 
Harcourt PR, Wark JD. The VISA score: an 
index of severity of symptoms in patients 
with jumper's knee (patellar tendinosis). 
Victorian Institute of Sport Tendon Study 
Group. J Sci Med Sport. 1998;1(1):22-28. 
https://doi.org/10.1016/S1440-
2440(98)80005-4.   

11. Hernandez-Sanchez S, Hidalgo MD, Gomez 
A. Responsiveness of the VISA-P scale for 
patellar tendinopathy in athletes. Br J Sports 
Med. 2014;48(6):453-457. 
https://doi.org/10.1136/bjsports-2012-
091163.   

12. Rudavsky A, Cook J. Physiotherapy 
management of patellar tendinopathy 
(jumper's knee). J Physiother. 
2014;60(3):122-129. 
https://doi.org/10.1016/j.jphys.2014.06.0
22.   

13. Saithna A, Gogna R, Baraza N, Modi C, 
Spencer S. Suppl 3: Eccentric Exercise 
Protocols for Patella Tendinopathy: Should 
we Really be Withdrawing Athletes from 
Sport? A Systematic Review. Open Orthop J. 
2012;6:553. 
https://dx.doi.org/10.2174%2F18743250
01206010553.   

14. Silbernagel KG, Thomeé R, Eriksson BI, 
Karlsson J. Continued sports activity, using a 
pain-monitoring model, during rehabilitation 
in patients with Achilles tendinopathy: a 
randomized controlled study. Am J Sports 
Med. 2007;35(6):897-906. 
https://doi.org/10.1177/0363546506298
279.   

15. Lorenzen J, Krämer R, Vogt P, Knobloch K. 
Systematic review about eccentric training in 
chronic patella tendinopathy. Sportverletz 
Sportschaden. 2010;24(4):198-203. 
https://doi.org/10.1055/s-0029-1245818.   

16. Malliaras P, Barton CJ, Reeves ND, 
Langberg H. Achilles and patellar 

http://dx.doi.org/10.1136/bjsm.31.4.332
https://dx.doi.org/10.4102%2Fsajp.v72i1.338
https://dx.doi.org/10.4102%2Fsajp.v72i1.338
https://doi.org/10.1097/JSM.0000000000000397
https://doi.org/10.1097/JSM.0000000000000397
https://doi.org/10.1136/bmj.324.7338.626
https://doi.org/10.1136/bmj.324.7338.626
https://doi.org/10.1016/j.crad.2006.02.005
https://doi.org/10.1016/j.crad.2006.02.005
https://doi.org/10.1136/bjsports-2013-092275
https://doi.org/10.1136/bjsports-2013-092275
https://doi.org/10.1007/s00330-008-0926-9
https://doi.org/10.1007/s00330-008-0926-9
https://doi.org/10.1016/S1440-2440(98)80005-4
https://doi.org/10.1016/S1440-2440(98)80005-4
https://doi.org/10.1136/bjsports-2012-091163
https://doi.org/10.1136/bjsports-2012-091163
https://doi.org/10.1016/j.jphys.2014.06.022
https://doi.org/10.1016/j.jphys.2014.06.022
https://dx.doi.org/10.2174%2F1874325001206010553
https://dx.doi.org/10.2174%2F1874325001206010553
https://doi.org/10.1177/0363546506298279
https://doi.org/10.1177/0363546506298279
https://doi.org/10.1055/s-0029-1245818


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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 2 – Issue 1 – February 2019 
 

tendinopathy loading programmes. Sports 
Med. 2013;43(4):267-286. 
https://doi.org/10.1007/s40279-013-
0019-z.   

17. Lim HY, Wong SH. Effects of isometric, 
eccentric, or heavy slow resistance exercises 
on pain and function in individuals with 
patellar tendinopathy: A systematic review. 
Physiother Res Int. 2018;23(4):e1721. 
https://doi.org/10.1002/pri.1721.   

18. Moen M, Rayer S, Schipper M, et al. 
Shockwave treatment for medial tibial stress 
syndrome in athletes; a prospective 
controlled study. Br J Sports Med. 
2012;46(4):253-257. 
https://doi.org/10.1136/bjsm.2010.08199
2.   

19. Newman P, Waddington G, Adams R. 
Shockwave treatment for medial tibial stress 

syndrome: a randomized double blind sham-
controlled pilot trial. J Sci Med Sport. 
2017;20(3):220-224. 
https://doi.org/10.1016/j.jsams.2016.07.0
06.   

20. De Vries A, Zwerver J, Diercks R, et al. Effect 
of patellar strap and sports tape on pain in 
patellar tendinopathy: A randomized 
controlled trial. Scand J Med Sci. 
2016;26(10):1217-1224. 
https://doi.org/10.1111/sms.12556.   

21. Rosen AB, Ko J, Brown CN. Single-limb 
landing biomechanics are altered and 
patellar tendinopathy related pain is 
reduced with acute infrapatellar strap 
application. Knee. 2017;24(4):761-767. 
https://doi.org/10.1016/j.knee.2017.03.00
3.  

  

https://doi.org/10.1007/s40279-013-0019-z
https://doi.org/10.1007/s40279-013-0019-z
https://doi.org/10.1002/pri.1721
https://doi.org/10.1136/bjsm.2010.081992
https://doi.org/10.1136/bjsm.2010.081992
https://doi.org/10.1016/j.jsams.2016.07.006
https://doi.org/10.1016/j.jsams.2016.07.006
https://doi.org/10.1111/sms.12556
https://doi.org/10.1016/j.knee.2017.03.003
https://doi.org/10.1016/j.knee.2017.03.003


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Figure 1. Overview of effective therapies and recommended course of treatment. 

 

 
Loading programs 

Isometric Exercises 

Eccentric Exercises 

Heavy Slow Resistance 
Exercises 

Therapeutic Modalities  

 Extracorporeal Shockwave 
Therapy 

Platelet Rich Plasma 
Injections  

Initial Conservative Management 

Secondary Management  

After 6 months of conservative  

treatment failure 

Surgical Intervention 

Open Tenotomy 

Arthroscopic Tenotomy  

Adjunct/Adjuvant 
Therapies 

Shockwave therapy 

Platelet Rich Plasma  

Patellar Tendon Strapping 

Contraindicated Therapies 

Corticosteroid Injections 

Ineffective Therapies 

Low and High Dose 
Therapeutic Ultrasound 

Sclerotherapy 


