1 · SNAPSHOT
Who: Jumping and sprinting sports — basketball, volleyball, netball, athletics, football. Any age, but the classic is a young athlete in a volume spike.
What: Load-related tendinopathy at the inferior pole of the patella.
How it behaves: Localised pain at the inferior pole. Aggs: jumping, landing, deceleration. Eases during activity but worsens afterward. Gradual onset with repetitive loading.
The one thing to take from this page:
It eases during and bites the morning after. That's the diagnosis, and it's also why they've been playing on it for six weeks — the warm-up makes it feel fine. Ask about the morning after, not the session.
This page has more evidence behind it than almost any other pattern
| What exists | Why that matters |
|---|---|
| A real multidisciplinary clinical practice guideline on anterior knee pain (Ophey et al. 2025) | An actual CPG, not a consensus statement |
| A Journal of Physiotherapy appraisal of it (Collins et al. 2026) | Someone has already done the critical appraisal for you |
| A 2025 Cochrane review of exercise (Lopes et al. 2025) | The strongest single source on this page. Read it |
| A UK Defence Rehabilitation consensus (Judd et al. 2026) | Conservative management, agreed |
So the honest position here isn't "we don't know." It's "go and read the Cochrane review."
2 · SE — THE SUBJECTIVE PATTERN (the 70%)
Five stages, in your course's order.
MAIN PROBLEM
"It's right on the bottom of my kneecap."
"It's sore for the first ten minutes then I forget about it."
"I can barely get down the stairs the next morning."
BODY CHART
- One finger, inferior pole. If they point above the patella, that's quadriceps tendinopathy
- If they wave a hand vaguely around the front, think patellofemoral pain.
- No swelling and no instability. If either is there, you're on a different page.
BEHAVIOUR — the warm-up paradox
| What they report | |
|---|---|
| Before activity | Stiff and sore, especially in the morning |
| Warm-up | It settles |
| During | Often fine — which is why they keep playing |
| After, and next morning | Worst. This is the diagnosis |
- Aggs: jumping, landing, deceleration, stairs down, decline running, prolonged sitting.
- Eases: warm-up, and then rest — but the rest brings the morning stiffness back.
- Severity: VAS 0–10 at best / at worst / right now.
- Irritability: resting symptoms + vigour of the provoking activity + time to settle. The 24-hour response is what you're actually measuring.
HISTORY
- What changed? Volume, surface, footwear, pre-season, a jump in jumping. Read further: risk factors [1][2].
- How long? Most have had it for months before they mention it.
- What have they already tried? Usually rest, and it came back.
- Both knees? Ask. Bilateral tendon structure change occurs in unilateral symptoms [3].
- Sport, position, and what they're training for.
SPECIAL / SCREENING QUESTIONS
- Any night pain, rest pain, fever, weight loss, or swelling?
- Any giving way, locking, or a traumatic onset?
- Adolescent? Then think apophysitis first — see the ranking.
Assessing this region? Download the Knee assessment template →
3 · HYPOTHESIS RANKING
| Competing pattern | The one discriminating feature |
|---|---|
| Patellofemoral pain | Diffuse, "around or behind" the kneecap, worse with prolonged sitting and stairs, reproduced on step-down with poor hip-knee control. Not one finger on the pole. |
| Quadriceps tendinopathy | Pain SUPERIOR to the patella, worse in deep flexion and resisted extension. |
| Sinding-Larsen-Johansson | Adolescent, inferior pole, growth spurt. Same site, different tissue — it's an apophysitis. |
| Osgood-Schlatter | Adolescent, tibial tuberosity, lump below the knee. |
| Fat pad irritation | Pain with hyperextension, tender either side of the tendon rather than on it. |
| Patellofemoral joint chondral change | Loaded flexion, crepitus, sometimes effusion. |
The one that decides the page in a teenager
Age. In a 12–16-year-old with inferior pole pain, apophysitis outranks tendinopathy — Sinding-Larsen-Johansson at the inferior pole, Osgood-Schlatter at the tuberosity. Both have their own pages, both are managed differently, and calling a growing athlete's apophysitis "jumper's knee" gets the load advice wrong.
And the ones that outrank everything
Septic arthritis, DVT, tumour. The red-flag pattern for this whole chapter. A hot, swollen knee, night pain that doesn't fit the load pattern, systemic symptoms, or calf pain and swelling — none of that is a tendon.
4 · RED FLAGS — DON'T MISS THIS
This section is free, on every pattern, forever. Safety is never gated.
| Finding | What it suggests | What you do |
|---|---|---|
| Hot, red, swollen knee, painful with minimal movement | Septic arthritis | ED / same-day medical referral. Do not treat |
| Fever, malaise, systemic illness with knee pain | Infection | Urgent medical review |
| Calf pain or swelling | DVT | Urgent medical review |
| Night pain or rest pain that doesn't fit the load pattern | Tumour, infection | Urgent medical review and imaging |
| Unexplained weight loss, cancer history | Malignancy | Urgent medical review |
| A sudden pop with immediate loss of active extension | Patellar tendon rupture | URGENT orthopaedic review |
| Inability to straight-leg raise, high-riding patella | Tendon or quadriceps rupture | URGENT |
| True effusion, locking, or giving way | Intra-articular | Reassess — this isn't a tendon |
| Adolescent with inferior pole pain | Apophysitis, not tendinopathy | Different page, different load advice |
| Focal bony tenderness on the patella itself, after a training increase | Patellar stress fracture — a high-risk site | Offload and image. Don't load it as a tendon (McInnis & Ramey 2016) [21] |
| Child or adolescent with a traumatic effusion, instability, or an unexplained lump | Intra-articular injury or a lesion | Specialist referral (Khan & Gupte 2024) [22] |
The rule: tendinopathy behaves with load, and it behaves the same way every time. A knee that hurts at rest, at night, or without a load story is not a tendon until someone has said so.
Cross-links: Patellofemoral pain · Sinding-Larsen-Johansson syndrome · Osgood-Schlatter disease · Septic arthritis / DVT / tumour
5 · OE — THE OBJECTIVE (the 30%)
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Sign in or join free6 · MX — MANAGEMENT ESSENTIALS
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Sign in or join free7 · CLINICAL PEARLS + RETRIEVAL CHECK
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Twelve slides on this pattern: what you'll hear, what to examine, what to do. Free with an account.
Sign in or join freeGuideline anchor
No Australian guideline.
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But this is one of the best-anchored pages on CliniStudy — there is a real multidisciplinary clinical practice guideline on anterior knee pain covering patellofemoral pain and patellar tendinopathy (Ophey et al. 2025, PMID 39045713), appraised in Journal of Physiotherapy (Collins et al. 2026, PMID 41904080) — and a 2025 Cochrane review of exercise for patellar tendinopathy (Lopes et al. 2025, PMID 40421598). Add the UK Defence Rehabilitation consensus agreement for conservative management (Judd et al. 2026, PMID 39824541).
The guideline is Dutch, not Australian — read the J Physiother appraisal alongside it rather than importing it wholesale. The Cochrane review is the strongest single source here and it is a review of exercise, not a management guideline.
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Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.
Sign in or join freeSources · 20
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Every source on this page resolves and title-verifies against PubMed. Newest first.
- 2011van der Worp et al. (2011). Risk factors for patellar tendinopathy: a systematic review of the literature. British journal of sports medicine, 45(5), 446-52. https://doi.org/10.1136/bjsm.2011.084079
- 2018Sprague et al. (2018). Modifiable risk factors for patellar tendinopathy in athletes: a systematic review and meta-analysis. British journal of sports medicine, 52(24), 1575-1585. https://doi.org/10.1136/bjsports-2017-099000
- 2020Rabello et al. (2020). Bilateral changes in tendon structure of patients diagnosed with unilateral insertional or midportion achilles tendinopathy or patellar tendinopathy. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 28(5), 1631-1638. https://doi.org/10.1007/s00167-019-05495-2
- 2017Maffulli et al. (2017). The Royal London Hospital Test for the clinical diagnosis of patellar tendinopathy. Muscles, ligaments and tendons journal, 7(2), 315-322. https://doi.org/10.11138/mltj/2017.7.2.315
- 2025Deng et al. (2025). Do physical or imaging changes explain the effectiveness of progressive tendon loading exercises? A causal mediation analysis of athletes with patellar tendinopathy. Journal of science and medicine in sport, 28(6), 458-464. https://doi.org/10.1016/j.jsams.2024.12.006
- 2025Lopes et al. (2025). Exercise for patellar tendinopathy. The Cochrane database of systematic reviews, 5(5), CD013078. https://doi.org/10.1002/14651858.CD013078.pub2
- 2025Ophey et al. (2025). Dutch multidisciplinary guideline on anterior knee pain: Patellofemoral pain and patellar tendinopathy. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA, 33(2), 457-469. https://doi.org/10.1002/ksa.12367
- 2026Collins (2026). Appraisal of Clinical Practice Guideline: Dutch multidisciplinary guideline on anterior knee pain: Patellofemoral pain and patellar tendinopathy. Journal of physiotherapy, 72(2), 152. https://doi.org/10.1016/j.jphys.2026.01.007
- 2026Judd et al. (2026). UK Defence Rehabilitation consensus agreement for the conservative management of Achilles and patellar tendinopathy: a modified Delphi approach. BMJ military health, 172(2), 172-177. https://doi.org/10.1136/military-2024-002893
- 2015Rio et al. (2015). Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. British journal of sports medicine, 49(19), 1277-83. https://doi.org/10.1136/bjsports-2014-094386
- 2018Lim & Wong (2018). Effects of isometric, eccentric, or heavy slow resistance exercises on pain and function in individuals with patellar tendinopathy: A systematic review. Physiotherapy research international : the journal for researchers and clinicians in physical therapy, 23(4), e1721. https://doi.org/10.1002/pri.1721
- 2021Challoumas et al. (2021). Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies. BMJ open sport & exercise medicine, 7(4), e001110. https://doi.org/10.1136/bmjsem-2021-001110
- 2013Malliaras et al. (2013). Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports medicine (Auckland, N.Z.), 43(4), 267-86. https://doi.org/10.1007/s40279-013-0019-z
- 2020Vander Doelen & Jelley (2020). Non-surgical treatment of patellar tendinopathy: A systematic review of randomized controlled trials. Journal of science and medicine in sport, 23(2), 118-124. https://doi.org/10.1016/j.jsams.2019.09.008
- 2021Breda et al. (2021). Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. British journal of sports medicine, 55(9), 501-509. https://doi.org/10.1136/bjsports-2020-103403
- 2025Deng et al. (2025). Long-term Prognosis of Athletes With Patellar Tendinopathy Receiving Physical Therapy: Patient-Reported Outcomes at 5-Year Follow-up. The American journal of sports medicine, 53(7), 1568-1576. https://doi.org/10.1177/03635465251336466
- 2015Malliaras et al. (2015). Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. The Journal of orthopaedic and sports physical therapy, 45(11), 887-98. https://doi.org/10.2519/jospt.2015.5987
- 2020Hannington et al. (2020). Self-reported jumpers' knee is common in elite basketball athletes - But is it all patellar tendinopathy?. Physical therapy in sport : official journal of the Association of Chartered Physiotherapists in Sports Medicine, 43, 58-64. https://doi.org/10.1016/j.ptsp.2020.01.012
- 2022Rosen et al. (2022). Clinical Management of Patellar Tendinopathy. Journal of athletic training, 57(7), 621-631. https://doi.org/10.4085/1062-6050-0049.21
- 2023Nutarelli et al. (2023). Epidemiology of Patellar Tendinopathy in Athletes and the General Population: A Systematic Review and Meta-analysis. Orthopaedic journal of sports medicine, 11(6), 23259671231173659. https://doi.org/10.1177/23259671231173659
Mapped to this pattern
Generic measures that also apply
- Borg RPE
Borg Rating of Perceived Exertion Scale (6-20)
perceived exertion · 1 items · 1 min
- GROC
Global Rating of Change Scale
perceived change since baseline · 1 items · 1 min
- NPRS
Numeric Pain Rating Scale
pain intensity · 1 items · 1 min
- PGIC
Patient Global Impression of Change
perceived change since baseline · 1 items · 1 min
- PSFS
Patient-Specific Functional Scale
patient-generated function · 3 items · 2 min
- SANE
Single Assessment Numeric Evaluation
patient-rated function as a percentage of normal · 1 items · 1 min
- VAS
Visual Analogue Scale
pain intensity · 1 items · 1 min
- Borg CR10
Borg Category Ratio 10 Scale
perceived exertion or symptom intensity, ratio scale · 1 items · 1 min
- GAS
Goal Attainment Scaling
individualised goal achievement · 10 min
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