How Does an Expert Know It’s Patellar Tendinopathy?

Patellar tendinopathy can seem like a straightforward diagnosis. Pain at the front of the knee, tenderness around the patellar tendon and pain with jumping? It probably sounds like patellar tendinopathy.

But anterior knee pain can be messy. Patellofemoral pain can present similarly, the two conditions can coexist, and plenty of tests provoke pain around the front of the knee without necessarily telling you where that pain is coming from.

So, what does an expert actually look for? In her Practical, Dr Ebonie Rio demonstrates her in-clinic assessment of suspected patellar tendinopathy. This blog highlights some key things she looks for to rule in or out a diagnosis of patellar tendinopathy.

If you want to see exactly how an expert assesses patellar tendinopathy in the clinic, watch Ebonie’s full Practical HERE. With Practicals, you can be a fly on the wall and see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster. Learn more HERE.

#1 – Does the load fit?

We talk about “load” all the time, but not all load is the same. Understanding the different types of load a tendon experiences is really important, not only for your differential diagnosis, but also for guiding graded rehabilitation for that specific tendon.

Ebonie explains that there are four main types: tensile, compressive, combined tensile and compressive, and repetitive loading of the peritendon layers. Importantly, different types of load matter more for different tendons.

For the patellar tendon, fast tensile loading is particularly relevant. Think jumping, hopping, accelerating and other tasks where the tendon needs to rapidly transmit force.

This matters when we’re assessing someone with suspected patellar tendinopathy. A slow squat and a maximal hop place very different demands on the tendon, so we shouldn’t necessarily expect them to tell us the same thing.

Understanding what type of load you’re trying to reproduce can help you choose more useful assessment tasks and make sense of the patient’s response.

See Ebonie explain the types of load in this clip from her Practical:

#2 – Location++

Location is a big part of diagnosing patellar tendinopathy.

Someone with patellar tendinopathy will typically point quite specifically to the inferior pole of the patella during the subjective assessment, but it’s particularly important to identify where their symptoms are during the objective examination when the tendon is loaded.

The recently developed Tendinopathy Severity Assessment – Patellar (TENDINS-P) is a great way to progressively take a patient from lower patellar tendon load movements to higher-load tasks, while importantly asking two questions: Where is your pain? And how painful is it? Ebonie is looking for a dose-dependent increase in pain that stays focal to the inferior pole.

As tendon load increases, the pain might become more intense, but with patellar tendinopathy, its location shouldn’t start moving or spreading. That’s particularly important when using tests like the single-leg decline squat. It’s highly provocative, but not just for the patellar tendon, as it places a large load on the anterior knee as a whole.

See Ebonie demonstrate some of the progressively demanding tests in the TENDINS-P in this clip from her Practical:

If appropriate, depending on the patient’s response to the tests, she then progresses to the two highest-load tasks for the patellar tendon: 3 x vertical hops for height and, finally, 3 x forward hops for distance.

#3 – Does anything make her question her diagnosis?

Even when the load and location seem to fit, Ebonie looks for findings that might point elsewhere. Joint effusion, for example, suggests an intra-articular source, while a tendon that isn’t sore at all on palpation might make her question a diagnosis of patellar tendinopathy.

The tricky part is that findings in isolation aren’t always very specific. The single-leg decline squat can provoke both patellar tendinopathy and patellofemoral pain, and tenderness on palpation doesn’t necessarily confirm the tendon as the source of symptoms. In the Practical, Ebonie shows how she brings these findings together, including how she uses taping when she’s trying to tease out patellofemoral pain from patellar tendinopathy.

Wrapping up

As with many conditions, we all wish there was one single test to rule in patellar tendinopathy, but there’s not!

The next best approach includes looking for a consistent picture: the right type of load, pain that behaves as expected with increasing load, and a location that stays put, while checking for anything that doesn’t quite fit.

Want to see exactly how Dr Ebonie Rio does this in her assessment? Watch her full Practical here.