Patellar tendinopathy is a load-related disorder of the patellar tendon, most often causing localized pain at the inferior pole of the patella. The diagnosis is primarily clinical: the pain should be localized to the tendon and reproduced by activities that load the knee extensor system, such as jumping, running, squatting or deceleration. Anterior knee pain, however, is not automatically patellar tendinopathy. Patellofemoral pain, fat-pad irritation, quadriceps-tendon pathology and intra-articular knee conditions can create similar symptoms. At Novo Soft Tissue in the Denver Tech Center, we begin by determining which structure is actually producing the pain, then select progressive tendon loading, shockwave therapy or another pathway based on the diagnosis and the tendon's current load tolerance.
What Is Patellar Tendinopathy?
Patellar tendinopathy is primarily a clinical diagnosis characterized by localized patellar-tendon pain that increases as knee-extensor demand increases. Its two hallmark features are pain localized to the inferior pole of the patella, and load-related pain that rises with demand on the knee extensors, especially in activities that store and release energy in the tendon, such as jumping, landing and changing direction. It is common in jumping sports, but it also occurs in runners and active adults.
The older terms “tendinitis” and “tendinosis” are still used. Tendinopathy is preferred because persistent tendon pain is mainly about reduced load tolerance rather than ongoing inflammation.
Not Every Case of Anterior Knee Pain Is Patellar Tendinopathy
- Patellar tendinopathy: focal pain at or near the inferior pole of the patella, load-related, worse with jumping, acceleration, deceleration and deep knee-extensor loading. Pressing on the tendon may reproduce the familiar pain.
- Patellofemoral pain: more often felt around or behind the kneecap with squatting, stairs, running or prolonged sitting, with a broader peripatellar distribution that is not sharply localized to the tendon.
- Infrapatellar fat pad (Hoffa) irritation: anterior knee pain beside the patellar tendon, sometimes provoked by full extension or compression, with tenderness around the fat pad.
- Quadriceps tendon pain: pain above the kneecap rather than below it. See quadriceps and rectus femoris pain.
- Intra-articular, meniscal or osteoarthritic pain: joint-line pain, swelling, catching or locking, mechanical symptoms, or an age and history that point to the joint. See knee pain and osteoarthritis.
Patellofemoral pain is also primarily a clinical pattern rather than a single-test diagnosis. Pain distribution, aggravating activities and the overall examination are more useful than relying on one provocative test. No single test settles which source is responsible, and the two most common patterns can coexist. The differences are explained in patellar tendinopathy vs. patellofemoral pain.
What We Examine
- Exactly where the pain is, and what provokes it: jumping, running, squatting, stairs, sitting or deceleration
- How the tendon responds to graded loading, from a partial squat to single-leg and decline tasks where tolerated
- Tenderness at the inferior pole, along the tendon, at the fat pad, around the kneecap and at the joint line
- Quadriceps, hip and calf strength, and single-leg control
- Swelling, catching, locking or giving way that point inside the joint
- Training load, sport demands, recent changes and previous treatment
Provocation is most useful when combined with exact symptom location and the pattern of increasing mechanical demand.
Does Patellar Tendinopathy Need an MRI or Ultrasound?
Usually not to make the initial diagnosis. Ultrasound or MRI becomes more useful when the diagnosis is uncertain, symptoms are atypical, a partial tear is suspected, or the patient is not progressing as expected.
Structural tendon abnormalities can exist without symptoms, so imaging must be interpreted clinically. In a study of elite athletes, 14% of patellar tendons in athletes who had never had anterior knee pain showed hypoechoic regions on ultrasound. Ultrasound abnormalities increase the likelihood of future symptoms, but abnormal structure is not equivalent to current pain. Imaging must be interpreted alongside the history and examination.
Knee Pain That Needs Urgent Assessment
Patellar tendinopathy is not the same as an acute partial tear or a complete patellar tendon rupture. A sudden pop, being unable to actively straighten the knee, a palpable gap in the tendon, a kneecap that sits higher than usual or any other concern about the knee’s extensor mechanism after an injury needs urgent imaging and an orthopedic pathway, not routine tendinopathy care.
How Treatment Is Selected
Load management. The goal is usually not complete unloading. It is to reduce excessive irritation while progressively rebuilding the tendon’s ability to accept load, which often means temporarily modifying the most provocative tasks rather than stopping all activity.
Progressive tendon loading. Progressive loading remains the foundation of patellar-tendinopathy rehabilitation. Depending on stage and irritability, it may include isometric holds, heavy slow resistance, eccentric or decline work, then jumping, landing and sport-specific loading. Rehabilitation should progress tendon demand rather than treating every exercise as equivalent.
Radial shockwave is a potential adjunct for persistent cases, used alongside loading rather than in place of it.
Focused shockwave is an alternative way to deliver ESWT in selected cases. Current evidence does not establish that either focused or radial treatment is universally superior.
Manual treatment may address contributing soft-tissue restriction in the quadriceps, hip or surrounding tissue where it is clinically relevant. It is not a way to remodel the patellar tendon.
Imaging or referral comes first when the diagnosis is unclear, a partial tear or acute traumatic injury is suspected, there is substantial weakness, persistent swelling or locking, progress stalls, or another pathology is suspected.
Corticosteroid injection is not a routine part of patellar-tendon care. Peritendinous corticosteroid may provide short-term symptom relief in some tendon disorders, but repeated or intratendinous glucocorticoid exposure is generally approached cautiously because of tendon biology and recurrence concerns.
You do not need to decide which treatment you need before your visit. All four tools are compared on the services page, and shockwave at Novo is explained on shockwave therapy in Denver.
What Research Says
- Diagnosis: a 2015 clinical commentary in the Journal of Orthopaedic & Sports Physical Therapy identified the two hallmark features as pain localized to the inferior pole of the patella and load-related pain that increases with knee-extensor demand, and noted that the diagnosis remains clinical (Malliaras, 2015).
- Imaging: hypoechoic tendon changes appeared in 14% of tendons in elite athletes with no history of anterior knee pain (Cook, 1998). A 2025 meta-analysis found abnormal ultrasound raised the risk of later patellar tendon pain about sixfold (risk ratio 6.07), but only 27.2% of abnormal tendons went on to become painful (Cushman, 2025).
- Loading: a systematic review of 12 trials found that load monitoring and therapeutic exercise improved pain, function and strength (Núñez-Martínez, 2022). A 2026 review of 40 reports concluded that structured tendon loading remains central, without one loading prescription being universally superior (Bruna-Mejias, 2026).
- Shockwave: the newest patellar-specific evidence is encouraging. A 2026 systematic review and meta-analysis of 13 studies found that ESWT reduced average pain scores from 5.24 to 2.71 and improved VISA tendon-function scores from 54.65 to 74.86. Control groups improved less on both measures. The authors concluded that focused and radial ESWT represent viable noninvasive treatment options for patients who have not responded adequately to conservative care (Friedman, 2026). Protocols varied substantially across studies, however, and shockwave should still be paired with an appropriate progressive loading strategy.
- Why response is not universal: a sham-controlled trial of 62 competitive jumping athletes who kept training and competing found no added benefit from ESWT used on its own (Zwerver, 2011), and a 2021 network meta-analysis found little short-term difference between ESWT and sham when both groups performed eccentric loading (Challoumas, 2021).
This is why Novo treats shockwave as an adjunct selected after the diagnosis and loading problem are established—not as a replacement for rehabilitation.
Read the full patellar tendinopathy shockwave evidence review → · Patellar tendinopathy vs. patellofemoral pain →
Sources: Malliaras et al., J Orthop Sports Phys Ther 2015 · Cook et al., Clin J Sport Med 1998 · Cushman et al., Clin J Sport Med 2025 · Núñez-Martínez & Hernández-Guillen, J Sport Rehabil 2022 · Bruna-Mejias et al., J Funct Morphol Kinesiol 2026 · Friedman et al., Arch Rehabil Res Clin Transl 2026 · Zwerver et al., Am J Sports Med 2011 · Challoumas et al., BMJ Open Sport Exerc Med 2021
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