Patella tendon problems

I have been researching into knee injuries generally following surgery on my knee for Patellar Teninopathy and have found some information which others may find of interest.

There is significant evidence now by respected researchers (Khan and Cook are the most famous), which suggests that most cases of Tendonitis are in fact Overuse tendinosis, and I have been pursuaded that this was in fact the case with my injury.

A classic symptom of both patellar tendonitis and tendinosis is pain near the lower end or inferior pole of the patella.

Patellar tendonitis is an inflammation of the tendon at the inferior pole of the patella. This, if rested, usually clears up within a few weeks.

Patellar tendinosis is nothing to do with inflammation, but in fact is where the Collagen fibres in the tendon, which give it its strength and run longitudinally, have broken down and their poercentage make up of the tendon has decreased. Instead of the collagen fibres being properly aligned, they are disoriented. The actually percentage of Collagen fibres is less than it was before.

It is therefore believed that this injury will not heal with just resting, because the Collagen fibres will not reproduce and realign unless the tendon is worked on by doing strengthening exercises (single leg squats and calf raises), which re-align them and instigate Collagen production.

Useful references can be found on, by looking up "patellar tendinopathy" and/or Khan or cook, although the links below are the best articles I could find.


Other places to research include the American Journal of Sports Medicine website where free abstracts can be obtained.

The recovery rate following open surgery (arthroscopic surgery recovery is slightly less)are not as good as I was lead to believe by my surgeon. He said 97% success, but the research says 80%, but this % relates to recovery being no more pain, not return to exercise. The figure for return to previous level of sport is 50%, which to be fair is pretty low. Recovery after surgery for those who do recover is 6 to 12 months - a very long time!

So persist with the physio, use surgery really as a last option.

Good luck all.


  • I'm sorry to hear about the less than satisfactory rehab keef, reading your post I imagine that why, despite a long period of not running, my doctor my very reticent to recommend surgery.

    I seem to be partially at least on the mend (although I currently have a back injury which means I haven't been able to do anything for three weeks).

    I suspect though that I will never return to my previous level of running but since I've now turned 40 I'm forgetting the past and will treat any running I do now as "new". Since I began my stuttering comeback in August I have found that running on a treadmill gives me far less trouble than running outside. At the moment I don't have a problem with this (as its bitterly cold outside)! I believe that if I can run three times a week then I can achieve my goals.

    I have also now been taking Glucosamine and Chrondroitin (which are supposed to be good for joint connective tissues) since July and it seems to have really made a difference. This could be conincidence that I was getting better anyway.

    Finally my doctor said that cycling was ok and over the last two years I have done a lot of cycling. The reason why he said this was ok is that my tendonitis stemmed from my having an unstable knee cap, therefore:

    1. Cycling doesn't cause the knee cap to move around in the same way that running does; and

    2. Part of the cause of instability is weakness in the stabilising muscles, all of which are strengthend by cycling.

    I hope you continue to improve - don't give up hope!
  • hello all,
    you both seem to be well informed on this subject so i hope you can help.
    i went to a physio about my knee and he said i had patellar tendonitis in my right knee, he did some ultrasound, didn't give me any strengthening exersises or stretches to do, and charged me £30.
    i went to him 3 times before i got a bit sceptical and stopped going.
    the problems still there and i'm going to see my doctor about it.
    what i'm asking is, are there any specific tests i should make sure he performs to be certain it is patellar tendonitis? i do trust my doctors abilities but after the experience with this physio i want to know i'm in the right hands.
    i've tried doing one legged squats but it hurts, it's not really painfull but i don't want to do more damage.
    i used to cycle a lot and tried doing some time on an indoor trainer, my knee was ok when i was on the bike but hurt the day after.
    i'm icing it twice a day for 20 mins a time, and i'm also doing the general leg stretches.
    it started with e few twinges in my knee (right under the kneecap) a couple of months ago but really kicked in on one particular run on 25th of last month.
  • It also shows you that injections to counter inflammation can be counter productive - making holes in a damaged tendon can only do more damage to it and if it isn't inflamed in the first place it has no positive effects at all.

    Cycling may not strengthen the oblique fibres of vastus medialis which may result in an unequal pull on the patella and tracking problems - the reason being that the medial quads are more involved in final extension of the knee and unless your seat is quite high you don't really reach full extension cycling - and a lot of people do have their seat too low.
  • I'm just back from the physio because of knee pain under my Patella. I received very good value for my £35. It seems the main cause of my problem is an imbalance with my muscle build up. The muscles on the outside of my thigh (can't remember the proper names) are far stronger than the inner ones. This means the Patella pulls up to the outside rarther than tracking straight up. I,ve now got my knees taped up and have a course of exercises for my inner thigh muscles. This muscle imbaslance seems to be a very common cause of knee trouble and can easily be helped with specific exercises.
  • Popsider, contrary to popular belief they do not inject the tendon itself, as this would cause degeneration. they simply inject the liquid intot the space surrounding the tendon and then tendon absorbs it.

    Blackstar - have you read the articles i've mentioned above? If not then I suggest you have a good read and see whether you think Tendinosis applies to you. Like i've said above, most people get diagnosed with patellar tendonitis, when it is in fact tendinosis - so you need to find out straight away so you can start the correct strengthening exercises.

    Having ultrasound treatment is goona do diddly squat if its not tendonitis - and even if it is, there's no research to back it up!

    let me know how it's going once you've had a read through the articles. And in the mean time, I suggest you cut back on your running mileage - don't rest it completely though.
  • This happens alot with achiles "tendonitis" as well, people stop running because they don't want to agrevate the injury when realy they should be doing a fair bit of gentle ecentric work to re-align the newly forming colagen fibres.
  • Ultra sound is particulary dangerous on tendons and ligamnets as they are a-vascular and if the ultra sound is not carried out in a very mild mannor it can fry the tendon or ligamanet.
  • Keef - they inject it inside the tendon sheath don't they - bit too close to the tendon for comfort ! Still some evidence that it causes degeneration if you do it too often - which suggests to me that maybe doing it once causes a little bit of degeneration - maybe I'm too cautious.
  • Youv'e got to be a good shot to get it in the sheath and not the tendon, as you say, too close for comfort.
    I'm not too sure about it causing degeneration although I believe there is a fair bit of research to show you are more likely to rupture your achiles after having a cortizone jab, this maybe because you don't notice the pain and carry on to overload.

    Cotizone certainly inhibits collagen regrowth and production
  • No they don't Popsider, and the only evidence for degenerative effect is that from when it was injected directly into the tendon in the 80's (particularly of footballers). with modern techniques there is no apparent risk of degeneration no matter how many injections you have.
  • Well they certainly did - I must have been speaking to an old school doctor - I still wouldn't take the chance.
  • No PS you're right on both counts. It's in the old days that cortisone was injected directly into the tendon. Nowadays it is seen as last resort before surgery and is injected into the tendon sheath.
    Seeing as it's this that is usualy inflamed and not the tendon this would make more sense.
    And it does weaken the tendon itself amoungst many other cotra's.
  • Blackstar - patellar tendonitis (from my understanding) is a repetitive injury and therefore if it came on suddenly at the end of a run then that may suggest a more traumatic injury. If the injury is trauma caused then the prognosis would be completely different. When you say the pain is "under" the knee cap do you mean "under" as in below or "under" as at the bottom of the knee tap (i.e. in the direction of the foot)? This is where the tendon lies.

    I can only relate to you my experience, but really the only cure is rest and lots of it. Cycling was fine for me as were other non-weight bearing activities e.g. swimming, rowing and to a degree skiing.

    At the same time as resting you need to identify the cause otherwise as soon as you start running it will come back again. I would visit a podiatrist as well as a knee specialist (a physio will help with exercises to solve known problems but may not be an expert in identifying the problems)

    So far I estimate I have spent close to €1,000 on doctors and treatments.
  • My comments for all they're worth

    Been running about 8 months and all ok up til October. Not aware that overtraining was going to cause problems, I stepped up weekly mileage far to quickly for my first 1/2 marathon. Self diagnosed pateller tendonitis ( dont like docs) and it has taken about 6 weeks to clear. Total rest and elevation. Just started back running on a treadmill a couple of miles three times a week nd everythings gong ok. So it seems rest does the trick and starting again slowly. I'll certainly learn the lesson cos it was a killer 6 weeks out
  • The tendon that works with your patella is from your quads and as previously mentioned has alot to do with tracking and weak quads.

    It may be worth looking at your hip alignment as if you are out then there will be extra pull on your quads which leads to your patella.

    There is another patella injury called chrondomalacia (spelling???) Patella which is roughening of the cartilage under the patella which causes pain on bending as the cartilage it rubbing and grinding.

    Keep stretching all leg muscles when warm even when not running, usually after a bath or nice massage, hold the stretch for 30 seconds then push a bit more into stretch. Do this regularly as part of your every day routine and not just after a run!

    Good luck everyone
  • keef,
    finished reading those articles today, very interesting and informative, i'm still a little confused about certain areas but it is a lot to take in, i had to have a medical dictionary open in another window, well worth reading though.

    still not too sure whether it's tendinitis or tendinosis but as the former is rare then i'd say it's most likely tendinosis,(hopefully not chronic).

    at least have some ammo behind me when i see my doctor.

    in the meantime i'm going to start up again with some light jogging and see how it goes.

    i'm still sceptical about the physios where i live as i don't have much choice,(i live on a very small island, there isn't a lot of anything here).

    as i said i had some twinges in my knee before that particular run,so it didn't just suddenly appear.

    the pain is on the front of the knee just below the kneecap, (toward the foot), and everything i have read points to it being patellar tendinosis.

    i'm getting my running gait analysed in the uk in the new year so hopefully that will throw some light on the problem.
  • WTIDWTID ✭✭✭
    I have had knee pain. Sorry don't know what type or technical name but have found when i strengthen my legs i.e weighted squatting helps.
    Just ensure knees don't travel past your toes when squatting.
  • Anyone tried a patella tendon strap?
  • Following my eight weeks out, my treadmill running is going great (touch wood). My left sided muscles have always been significantly under strength and is noticeably leaner. I would be interested to know the best leg strengthening exercises to do as I'm convinced the weaker muscles (quads) contributed to the knee injury.
  • Carefull with quad strengthening. The quads are made up of 4 (shock!) muscles which all do something slightly different. A common (not nesseccaryly your problem) knee pain complaint is brought about by an imbalance with the quad group and often it is the oblique fibres of the vastus medialis.
    You need to find out how to do a quad imbalnce test and then target whichever muscle needs attention.
    If in doubt see a physio or sports therapist who know their stuff, there are a surprising number who don't.
  • If you are a runner then most doctors will recommend cycling as a good "balancing" exercise.

    I have tried a Patellar Strap and it didn't seem to make any difference.
  • With cycling, you have to make sure that your leg is fully extended or the oblique fibres of vastus medialis don't come into play. So raise that sadddle.

  • My GP seems to think I have patella tendonitis and suggested both cycling and rowing as replacement activities. Anyone got any experience of rowing for rehabilitation?
  • Oh hello again mooncalf!

    I do both. I would say that cycling is the better activity for recovery as recovery from patella tendonitis is partially related to correct muscle imbalances, which cycling will do (there are other causes though so I would also check that you are biomechanically efficient with a podiatrist). However, i also enjoy rowing a lot as its a much better overall exercise.

    With cycling i would try and not limit yourself to the gym - I find 20 minutes in the gym on a bike is very close to my boredom threshhold.
  • I was hoping I could listen to the radio or possibly even read a magazine on an exercise bike to make the time pass a bit more quickly. Thankfully the gym I'm going to doesn't have MTV!

    I'm hoping to go to the gym in the morning before work so maybe if I'm spinning along at a low-ish resistance I can just let my brain go back to sleep :)

    I might take my real bike to the bike doctor next week to get it checked out for winter cycling. I live in the middle of a city and I'm not an experienced cycling so I must admit I'm not very confident in the dark on busy, wet roads...
  • Just to add some anecdotal evidence - I've been on the rower for a week and a half and my p.t. has made significant progress. This may very well be a co-incidence, but it kind-of feels like it backs up what's been said here about working it (but NOT running on it) being a factor in repair.
  • very interesting. just signing onto the thread .......... i'll read the articles over the next few days.

    After a cycling accident i developed patella tendonitis. Got it ultra sounded and mega pulsed for five or six sessions at the physio over a period of three weeks.

    Got the knee dips exercise off the physio and went back to running a couple of miles once a week for two weeks and then back to running 2 miles 3 times a week for two weeks.

    During that time my patella tendon has been fine. if anything my ex-poorly knee is a lot stronger than the knee that wasn't injured! that is until saturday when i noticed the same sort of niggling dull pain in the patella tendon once again. i'm really hoping it was just because it was a very cold day on saturday ... have been furiously doing knee dip exercises and will try and run again tomorrow.

    Time to sign up to the gym and do some leg strengthening exercises to sort out any imbalances i reckon.

    Good luck all of you with your pattella!
  • Just got this email from peak performance ... worth reading the link i'm sure ... will check it out at lunchtime. Off to see the physio again tomorrow. Have bought a patella strap as well to give it a go ... only £10 so if it's no use then it's not a great loss when compared to physio fees. Pretty much decided to just run once a week during the winter and to concentrate on weights, cycling and swimming instead.

    Knee pain - again

    What exactly is “jumper’s knee” and why isn’t it called “weightlifter’s knee” or “hockey knee”? We open SIB this month with an authoritative and practical account of the pathology which usually gets diagnosed as “patellar tendinitis” but which is more likely in most cases to be “patellar tendinosis”.

    Dr Rod Jaques, the new medical director of the English Institute of Sport, explains: “It is thought that the first symptoms of patellar pain correlate with fluid or oedema in the patellar tendon, often close to the lower pole of the patella. Very little inflammation if any occurs and studies show degenerative changes in the tendon rather than any clear inflammatory process. This syndrome of degenerative change in the patellar tendon is called ‘patellar tendinosis’.

    Patellar tendinosis is an occupational hazard for anyone involved in sports that subject the lower patella area to direct loading, rapid deceleration or high traction forces – which covers the main jumping sports but also, for instance, weightlifting and hockey (played on Astroturf, the traction forces can be extreme).

    Usually there will be distinct tenderness at a particular spot below the kneecap, and possibly thickening in more severe cases. There may also be swelling behind the kneecap and some quadriceps muscle wasting. Authoritative diagnosis is best done, Jaques says, with ultrasound rather than MRI or X-ray.

    Patella tendinosis is another of those sporting injuries that we still don’t have definitive scientific explanations for. Jaques favours mechanical impingement of the back of the patellar tendon, but stresses that there may be other, indeed multiple causative factors. Things to look out for include:

    *tight quadriceps
    *weak quads relative to hamstrings
    *very poor mobility of the lumbar spineJaques shares his preferred rehab technique with SIB readers, based on strict self-management of pain by clients, thorough assessment of hip mobility, and muscle strength and control from hip to leg, and a simple but powerful programme of eccentric exercises.

    “The key to the rationale behind eccentric drills is that they are the best way of promoting tendon remodelling: the regrowth and reordering of collagen tissue in place of the fluid-filled degenerative tissue typical of tendinosis.”
    For details of Rod Jaques’s rehab programme, read the new SIB.

    For full details of Rod Jaques’s rehab programme, click here to read the new issue of Sports Injury Bulletin - we'll also give you a bundle of free reports to deal with the most common sports injuries

  • New runner - if it helps, I have found that running on a treadmill causes far less aggravation than running on roads - or at least it did until I injured my back!
  • Hope the back recovers :)

    Yep, part of my joining the gym is to see how the treadmill goes. Perhaps after my patella recovered i got back into running too quickly and that's why it's complaining again.

    Anyway, there was an interesting article in british runner about a runner taking up triathlon and being amazed at the injury free fitness level he achieved. So given i love cycling i thought i might go the way of triathlon.

    In the same magazine they also had a little bit about patella tendon exercises and stretches. has anyone tried leg raises etc and strengthening the knee using weights?
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