Archives of Orthopaedic and Trauma Surgery (2023) 143:6695–6705

https://doi.org/10.1007/s00402-023-04998-5

ARTHROSCOPY AND SPORTS MEDICINE

Patellar tendinopathy: an overview of prevalence, risk factors,

screening, diagnosis, treatment and prevention
Andreas Theodorou1 · Georgios Komnos1 · Michael Hantes1

Received: 22 November 2022 / Accepted: 18 July 2023 / Published online: 4 August 2023
© The Author(s) 2023

Abstract
Patellar tendinopathy (PT), or jumper’s knee, is an overuse injury that occurs in professional, as well as recreational, ath-
letes. This condition is a noncontact injury, typically characterized by gradually increasing pain in the patellar tendon. It is
prevalent in participants of several sports, but it occurs mostly in jumping sports. The diagnosis of PT is primarily clinical;
however, imaging techniques can be useful as well. Risk factors differ between sexes, playing conditions, the kind of sport,
playing level and personal characteristics. Screening is an essential tool to assess PT. This condition affects athletic perfor-
mance and often persists for years. The use of preventative methods is imperative because of the persistence of this condition,
especially in elite athletes who sometimes end their career after long and failed treatments. There are a wide variety of treat-
ment and rehabilitation options available, the majority of which are non-operative, such as eccentric exercises, cryotherapy,
platelet-rich plasma (PRP) injections, and anti-inflammatory strategies. If conservative treatment fails, surgery is the next
most preferable step. Even though there are many surgical treatment methods, there is no clear evidence on what is the most
effective approach to address PT. Taking this into consideration, as well as the extent of this clinical entity, novel therapeutic
techniques, as well as screening and prevention methods, are expected to emerge in the near future.

Keywords Patellar tendon · Jumper’s knee · Patellar tendinopathy

Introduction For PT, several evidence-based nonsurgical and surgical

treatment options and diagnostic pathways are presented in
Patellar tendinopathy (PT), despite its frequency and clinical the literature [1, 8–10].
importance, remains a real challenge for every sports phy- The aim of this literature review is to characterize typical
sician, mostly because of its persistence [1, 2]. According symptoms, provide an overview of available risk factors,
to a prospective study involving elite athletes competing in diagnostic techniques, screening, treatment and prevention
football (soccer), long-distance running, volleyball, orien- options.
teering, basketball and ice-hockey, more than 50% of the
athletes with PT were forced to retire from active sport [3].
High prevalence rates of PT are especially present in jump- Methods
ing athletes [4, 5].
Inflammation of the tendon could occur when there is The electronic database PubMed was searched in March
overuse during athletic activities, although this can be return 2021. Considering the developed promoted by scientific
to normal when the load is adjusted. However, when high progress in imaging, non-operative treatment and surgical
load persists, the injury can become chronic [6, 7]. techniques, the search was conducted from January 2001 to
March 2021. The following key words were used alone and
in combination: “patellar tendinopathy”, “jumper’s knee”,
“prevalence”, “risk factors”, “screening”, “diagnosis”,
* Andreas Theodorou “treatment” and “prevention”.
[email protected] All retrieved article (n = 747) abstracts were screened for
this review, and all the irrelevant papers were filtered out.
1
Faculty of Medicine, University of Thessaly, 41500 Larissa, Furthermore, reference lists from the selected studies and
Greece

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6696 Archives of Orthopaedic and Trauma Surgery (2023) 143:6695–6705

review articles (n = 84) were assessed for eligibility, and arti- field athletes (6.9%), and then field hockey (5.1%), korfball
cles published before 2001 (n = 14) were added. During the (4.8%), and soccer (2.5%) players [5].
final processing of the manuscript, another 4 articles were Zwerver et al. identified that participation in sports is
identified as relevant to our review and were added. a risk factor for PT [5]. Furthermore, it could be assumed
that the number of training hours is an additional risk factor
for developing PT, because the elite athletes who trained
Results for more than 12 h per week developed PT more frequently
in comparison with non-elite athletes who practiced 4 to
Prevalence and risk factors 5 h weekly, as has been reported by some studies [5, 12].
Similarly, Sprague et al. demonstrated that increased sports
There are many causes and possible risk factors described participation was a risk factor for PT [13].
in the literature that could lead to PT [11]. There are also Being more youthful and taller could be additional risk
controversial reports on some of the described risk factors. factors, according to Zwerver et al. [5]. However, these find-
According to Lian et al. the prevalence rates of PT in pro- ings were not confirmed in some other studies [14–17].
fessional volleyball and basketball players are 45% and 32%, In an online survey which included 2224 subjects, the
respectively, whereas the overall prevalence in elite players identified risk factors found for PT included playing at the
from nine different sports is 14.2% [4]. Van der Worp et al. national level, male gender and playing volleyball (in com-
reported that the prevalence of PT in their study popula- parison to basketball) [11]. This difference between vol-
tion, which included volleyball and basketball athletes, was leyball and basketball players could be explained by the
18.6%, with 12.3% of the subjects diagnosed with unilateral fact that professional volleyball players jump higher than
PT and 6.3% with bilateral PT [11]. Zwerver et al. stud- professional basketball players, as measured in a drop jump
ied a population of 891 male and female non-elite athletes task [17]. Specifically, volleyball players, such as outside
who played in seven popular sports; they concluded that the hitters and middle blockers hitters, had an increased risk
overall prevalence of PT was 8.5% (Table 1). The highest when compared with setters [11]. As for the basketball play-
prevalence was in volleyball players (14.4%), followed by ers, no risk factors related to playing style were found [11].
handball (13.3%) and basketball (11.8%) players, track and The personal monitoring of athletes according to individual

Table 1  Prevalence and risk factors of PT

Authors Prevalence Risk Factors

Lian et al. [4] Volleyball 45% Male gender

Basketball 32% High weight
Overall prevalence in these sports: 14.2% Tall height
Increased number of weight and jump training
Increased number of sport-specific training in basketball
Zwerver et al. [5] The overall prevalence of PT is 8.5% Male gender
Volleyball: 14.4% Participating in sports
Handball: 13.3% Increased number of training hours
Basketball: 11.8% Playing surface
Track and field: 6.9% Young age
Field hockey: 5.1% Higher BMI
Korf-ball: 4.8% Tall height
Soccer: 2.5%
de Vries et al. [8] Overall prevalence in study’s population (Volley- Male gender
ball and basketball): 13% Heavier load on the patellar tendon
BMI is not a risk factor
Age is not a risk factor
Van der Worp et al. [11] Overall prevalence in study’s population (Volley- Male gender
ball and basketball): 18.6% Increased number of training hours
Playing at the national level compared with playing at
the regional level
Playing volleyball compared with playing basketball
Playing position in volleyball but not in basketball
Higher age
Playing surface
BMI and waist-to-hip ratio were not associated with PT

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risk factors may help prevent PT [8]. In addition, because is a risk factor in developing PT [23]. Interestingly, they con-
the highest prevalence of PT in volleyball athletes concerns cluded that asymptomatic players used a landing technique
those who play as outside hitters or middle blockers/hit- to avoid high patellar tendon loading, in contrast to sympto-
ters, a change in playing position to libero/opposite hitters matic players who used a stiffer landing strategy, which the
or setters could be an option [8]. In the same survey, the authors identified as a possible risk factor [23].
prevalence of men with PT (25.3%) was significantly higher Finally, according to Visnes et al., the presence of hypo-
in comparison to women (13.1%) [11]. The same findings echoic areas and neovascularization among asymptomatic
were reported by two other studies, demonstrating that men’s athletes represented a risk factor for developing PT as well
odds when it came to PT are more than twice as high as in [24].
the opposite sex [5, 8]. This can be explained by the fact
that women’s patellar tendons are exposed to lower forces Diagnosis and screening
because they have less quadricep strength and an inferior
jumping capacity [5]. In addition, volleyball players had Clinical symptoms
higher prevalence rates of PT than basketball players: 20.1%
and 15.2%, respectively. Moreover, players playing with the Most of the athletes with PT present to physicians with
national team had twice as high a prevalence of PT as com- well-located anterior knee pain [1, 25]. The pain is often
pared with those at regional level [11]. This can be explained increased by exercise, or occasionally, by prolonged knee
because playing at a higher level requires a heavier load flexion. Furthermore, in many cases, pain can start insidi-
being placed on the knee more frequently, because play- ously. Moreover, patients often associate the pain with a
ers at the elite level have stronger muscles and jump higher period of increased sport activity. In mild cases, pain is only
[11, 12]. A heavier load in jumping sports was also demon- present when performing sport activities, whereas when the
strated as a risk factor for PT by other authors. [8, 13]. In condition progresses, they often complain about pain at the
the meta-analysis study by Sprague et al., jump height was beginning or throughout the exercise. Additionally, in severe
also described as a risk factor [13]. Although Cook et al. cases, patients report pain in performing daily activities, or
identified that estrogen can exert protective functions on even when at rest [1]. When patients with PT were instructed
women’s tendons, other studies have indicated that estrogen to execute a decline squatting exercise, they could only per-
can inhibit exercise-induced collagen synthesis, which leads form a limited number of decline squats without experienc-
to a lower rate of tendon tissue repair [16–19]. ing pain [26]. Although there are many scoring systems
The playing surface is described also as a risk factor. described in the literature, the VISA score seems to be the
Players who played on concrete had a prevalence of PT of most widely accepted [25]. The VISA-P and VISA-A ques-
around 38%, in contrast to the approximately 20% in ath- tionnaires include eight questions. Six questions are related
letes who played on other surfaces [11] (Table 1). Bahr and to the pain experienced during a range of everyday activities,
Reeser showed that the prevalence of PT is much lower in and the other two deal with the ability of the athlete to per-
beach volleyball players [20]. This conclusion suggests that form sports activities. The maximum VISA-P and VISA-A
a softer playing surface, such as beach sand, reduces the score for an asymptomatic athlete who regularly exercises
risk of PT [11]. is 100 points, and the theoretical minimum is 0 points [27].
Additionally, in a study including 105 subjects, 52 with
PT and 53 without, the lever arm ratio and moment arm ratio Imaging
from lateral radiographs were significantly different between
the two groups. According to findings from the radiographs, Ultrasonography (US), Doppler ultrasonography, MRI and
the patellar tendon exhibited smaller lever and moment arm X-rays are often used by physicians who deal with patients
movements in patients with PT when compared with patients with PT. Plain X-rays can be used to detect correlated bone
without PT [21]. In their study, Dan M.J. et al. demonstrated abnormalities, but MRI and US procedures are more use-
that physicians can identify patients at risk through sim- ful due to the possibility of obtaining detailed visualization
ple radiographic means, because these variations may lead of the tendon [1]. Khan et al. described a good correlation
to a greater force expended through the patellar tendon in between MRI and US for PT at histopathological findings
patients with PT [21]. on surgical biopsies [28]. US can detect a hypoechogenic
A higher BMI was also identified as a potential risk fac- zone often related with tendon thickening in PT patients
tor for PT in some studies, but this was not confirmed by [29]. Hypoechoic lesions are usually found in the posterior
others [5, 8, 22]. portion of the patellar tendon, near to the inferior pole of the
In their study, Bisseling et al. evaluated whether the land- patella [30]. Using Doppler ultrasonography, physicians can
ing strategy differed amongst healthy volleyball players and detect neovascularization and increased blood flow, which
volleyball players with PT, to identify if the landing strategy are usually present in symptomatic PT [31, 32] (Fig. 1).

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Fig. 1  Ultrasonography images of the left patellar tendon, in a mid- of the image, the normal right patellar tendon is shown for compari-
dle-aged elite athlete with persistent anterior knee pain. a Longitudi- son (arrows). c Longitudinal color Doppler image shows florid neo-
nal B-mode image showing the inhomogeneous echogenicity in the vascularity in the degenerated foci (arrows). (Courtesy: Dr. G. Kak-
distal anterior tendon in keeping with degeneration (short arrows) and kos and Prof. A. Karantanas, Dpt. of Medical Imaging, Heraklion
microtears in the posterior aspect (long arrows). b On the right side University Hospital)

Additionally, MRI can detect PT as a thickened tendon with knee. Patients with asymptomatic hypoechoic regions in the
areas of increased signal intensity [29]. Furthermore, par- patellar tendon at the start of the season had a significantly
tial tears in PT patients are difficult to identify, but they are greater risk of developing symptomatic PT during the sea-
best demonstrated on T2-weighted images with high signal son, in contrast to those without hypoechoic regions: 17%
intensity [33] (Fig. 2). Both US and MRI have advantages of the former group developed PT, as compared to none in
and disadvantages. On one hand, US lacks the ability to rule the other group [35]. Visnes et al. also insinuate that the
out intra-articular abnormality and it depends on the expe- presence of hypoechoic areas and neovascularization among
rience of the operator. On the other hand, MRI can detect 141 asymptomatic athletes at the beginning of their study
intra-articular pathology, but it is not always available, costs represented a risk factor for developing PT. There were
more and is time consuming [30]. Finally, the sensitivity and structural changes observed in the US examinations from the
specificity of US for PT are 58% and 94%, in contrast to 78% beginning in more than half of the tendons who later devel-
and 86% for MRI, respectively [34]. oped PT symptoms and 83% of the tendons at the time of
diagnosis. Therefore, structural changes preceded symptoms
Screening in most of the patients. Nonetheless, two-thirds of patients
who exhibited hypoechoic areas in their baseline US images
Ultrasonography of asymptomatic tendons can be useful to did not develop symptoms during their 1.7-year observa-
predict which athletes will develop PT [35]. Fredberg and tion period with intensive training. Thus, they concluded
Bolvig examined 54 professional soccer players before and that they cannot recommend routine ultrasound screening
after a single season, using ultrasonography of the ankle and programs to prevent PT [24].

Fig. 2  a T2-weighted MRI

image of the left knee, in a
young elite athlete with PT
symptoms. It demonstrates an
increased signal interposed
in the patellar tendon. b
T2-weighted MRI image of the
left knee, in a young elite ath-
lete with PT symptoms, show-
ing a free bone formation in the
mass of the patellar tendon

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Fazekas et al. claim that VISA-P scores may be useful as decline squat protocol offers better results at 12 months
a screening tool for identifying the presence of hypoechoic when compared to a step eccentric protocol for volleyball
areas in ultrasonography of the patellar tendon. In their players with PT; the first group showed a 94% chance of a
study, which involved 31 asymptomatic athletes, the VISA- positive result, in contrast to 41% in the step group [69].
P scores were significantly lower in US exhibiting hypo- The decline squat was performed using a single leg on a 25°
echoic regions than in those without hypoechoic findings in decline board (Fig. 3), with some level of discomfort [38,
the right knee, but not the left knee. Furthermore, Fazekas 69]. Johnson and Alfredson indicated that at 12 weeks, ath-
M.L. et al. compared the prevalence rate of hypoechoic areas letes with PT who were following a protocol with eccentric
between men and women in their study group; they found no exercises improved significantly, in contrast to those who
significant differences in either the right or left knees [36]. were following a concentric exercise protocol [70]. In the
Gisslén et al. examined 22 elite high school volleyball study by Visnes et al. [71], eccentric exercises were found
players (44 patellar tendons) by US and power Doppler to have no effect on knee function after a 12-week program
(PD), and they continuously evaluated them clinically and when followed simultaneously by volleyball athletes who
with the use of US and PD during 3 school years [37]. This continued training and competing. In contrast, other stud-
study has indicated that if clinical examination and US of ies have suggested that when athletes with PT continued
the patellar tendon are normal at the start, there is a low to compete in sport, they benefited from an eccentric exer-
risk of sustaining PT, despite exercising 13 to 15 h weekly cise protocol [57, 69, 72, 73]. When an eccentric exercise
for 3 school years. This is supported by the fact that in their protocol was compared to surgical treatment (open patellar
study, among 27 tendons that were normal at the start, only tenotomy), at 12 months, there was no significant difference
2 developed PT during the 3 years of intensive training and between the two groups [74]. According to the same study,
playing volleyball games. Furthermore, another finding of the treatment of PT should start with an eccentric exercise
the same study was that if jumper’s knee was clinically diag- protocol for twelve weeks before taking into consideration
nosed at the start, in most of the tendons, the symptoms an open patellar tenotomy [74].
remained [37]. According to van Ark et al., the current eccentric exercise
protocols that are used in-season result in increases in pain
Treatment [75]. In their study, which included a treatment program with
isometric and isotonic exercises in 29 athletes with PT, both
Treatment of PT can be non-operative and operative. Con- exercise programs were shown to reduce pain from PT for
servative treatment is recommended as the first step, accord- athletes in-season [75]. In their study, Vander Doelen and
ing to the literature. Jelly demonstrated that isometric exercises were found to
reduce pain immediately, whereas eccentric exercises and
Non‑operative treatment PRP injections demonstrated good short-term as well as
long-term results [76]. The authors concluded that the cur-
Conservative treatment for PT consists of many methods, rent evidence fails to suggest how to use conservative treat-
but the most popular are eccentric exercises [25, 38]. Other ment options together to obtain the maximum benefit [76].
non-operative treatment options include platelet-rich plasma
(PRP) injections [9, 39–42], cryotherapy [43, 44], patellar
strapping [45–51], NSAIDs [52–54], corticosteroids [35,
54–58], aprotinin injections [59, 60], sclerosing injections
with a chemical irritant [61–66], glyceryl trinitrate (GTN)
patches [67] and lastly, extracorporeal shockwave therapy
(ESWT) [68].

Eccentric exercises

In the literature, most studies suggest that eccentric training

may have a positive effect on the treatment of PT. There
are various eccentric exercise programs such as drop squats,
squatting on a decline board, squatting on level ground, exer-
cising until tendon pain, training until just before the onset
of pain, exercise that involves loading in the eccentric phase
only or both phases, and progressing with speed then loading Fig. 3  This figure shows an athlete performing an eccentric decline
or simply loading [38]. Young et al. suggest that an eccentric squat

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Regarding the difference between isometric and dynamic US-guided PRP injections in PT patients lead to a signifi-
resistance exercises in reducing pain in patients with PT, a cant improvement in both patellar tendon vascularity and
randomized crossover trial failed to identify the superior- symptoms [27].
ity of one method over the other [77]. They demonstrated According to Kaux et al. most of the existing studies
a minor decrease in pain at the immediate post-exercise assessed the effects of two or three successive PRP injec-
period, in both groups, with no essential difference in acute tions. In their study, the effectiveness of two PRP injec-
pain and pain sensitivity between the two groups. tions versus one PRP injection, in 20 PT patients who were
Another issue that is worth mentioning is the role of pro- divided into two groups, was compared [79]. They con-
gressive tendon-loading exercises (PTLE). Breda et al. in a cluded that there was no significant difference between the
randomized clinical trial including mostly patients suffer- two groups, and one PRP injection could be enough to treat
ing from chronic PT, showed better clinical outcomes with PT in the short and medium terms [79].
utilization of PLTE in comparison to eccentric exercises In a study comparing PRP injections with focused ESWT
in a 2-year follow-up [78]. However, return to sports and for the treatment of PT, there was no significant difference
patient satisfaction, although were better among patients between the study groups at the 2-month follow-up. How-
of the PTLE group, did not achieve significant statistical ever, PRP injections were shown to be more effective in the
difference. 6- and 12-months follow-ups [10].
Andriolo et al. indicated that even though eccentric exer-
Platelet‑rich plasma (PRP) injections cises can be used as treatments in the short term, multiple
PRP injections may offer more satisfactory results in the
PRP injections have been shown to be an effective treatment long term [9].
option for chronic PT [9, 27, 39–42, 54]. PRP injections According to a recent study, PRP infiltrations with doses
with US guidance enable infiltration into the tendon with greater than 4 mL were found to have better results in the
great accuracy [27]. This treatment stimulates soft tissue short term when combined with an exercise program for at
healing and improves tendon healing and remodeling [54]. least 6 weeks. However, in the long term, dry needling and
Andriolo et al. suggest that multiple PRP injections could skin-derived tenocyte-like cells were found to be more effec-
be the best option for patients with severe symptoms, or tive than PRP injections [80].
when other conservative treatments fail to alleviate chronic
PT [9]. Patients with chronic PT and no previous treatment Cryotherapy
who received PRP injections had significantly better results
in comparison to patients with chronic PT for the same dura- Cryotherapy is mostly used in PT patients for its short-term
tion, and previous failing therapies such as ethoxysclerol, analgesic effect, but use is discouraged before participating
corticosteroid and surgical treatment [41]. in sports because there is a risk of re-injury [43, 44, 81].
In a study comparing operative treatments versus PRP Furthermore, cryotherapy reduces tissue metabolism, as
injections, it was found that even though operative treat- well as swelling and pain in patients with acute inflamma-
ments were shown to be safe and more effective, PRP tory tendinopathies, by reducing the inflammatory response
infiltration is less invasive and could lead to tendon heal- [81]. Although Mac Auley et al. indicated that, in the lit-
ing; therefore, it should be considered before an operative erature, there are considerable dissimilarities in the recom-
approach [41]. mended duration of cryotherapy treatments [44], Bleakley
Kon E. et al. also indicated that multiple PRP injections et al. showed that applications of ice through a wet towel for
in PT patients induced a statistically significant improvement 10-min periods are most effective [82].
at the end of the therapy and at the 6-month follow-up, with
most of the patients being satisfied and able to return to their Patellar strapping
previous sport activity level [42].
Ferrero et al. assessed the effectiveness of US-guided Patellar strapping has historically been used widely, with
autologous PRP injections in PT and Achilles tendinopathy controversial results; some studies indicate that it is an
with 20-day and 6-month follow-ups [27]. At the first fol- effective conservative treatment [45–51], and others have
low-up, there was a non-significant improvement compared reported poor results [83–86]. Although Schwartz et al.
to baseline regarding VISA-P score, tendon thickness and demonstrated that most of the above studies evaluated patel-
the hypoechoic areas of the tendons. However, there was lofemoral pain in general [25], recent studies have been con-
a significant improvement for all the above parameters at ducted to assess the effect of patellar strapping in athletes
the second follow-up. Furthermore, in the same study, the with PT [87, 88]. De Vries et al. conducted a randomized
intratendinous vascularity was significantly increased at both control trial to investigate the effect of patellar strapping
the first and the second follow-up. Thus, they concluded that and sports tape on pain in PT patients. They found that,

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interestingly, all the employed orthoses–patellar straps, reported that there as a similar rate of return to sports after
sports tape and placebo taping–led to some pain-relief in arthroscopy and open treatment [54]. Thus, even though
the short term, as compared to controls [87]. Furthermore, in there are no clear guidelines in the literature about which
another study, De Vries et al. concluded that patellar strap- technique is superior, arthroscopic techniques are more com-
ping can reduce load on the patellar tendon [88]. monly preferred due to their less-invasive nature [97].

NSAIDs Prevention

In the literature, the use of NSAIDs in chronic tendinopa- Prevention methods for PT are not well described in the
thy are controversial, because histologically, tendon tissue literature. Nonetheless, balance and proprioception training
has few or no inflammatory cells [89]. Some writers have and the use of a patellar strap are some methods used for the
demonstrated that NSAIDs can help with tendon healing prevention of PT in sports.
[52, 53], but others have indicated that NSAIDs may inhibit Peters et al. claimed that long-term balance training can
tendon cell migration and proliferation, impairing tendon be used for the prevention of PT, but there was no posi-
healing [54, 90]. Furthermore, because NSAIDs reduce pain, tive outcome found when stretching exercises were used for
patients sometimes ignore early symptoms, leading to induc- this purpose [98]. This was also supported by Kraemer and
ing further damage to the tendon and consequently delaying Knobloch et al., who indicated that soccer-specific balance
healing. In addition, Tsai et al. claim that potential harms of training was found to reduce PT with a dose–effect rela-
NSAIDs—ulcers and renal impairment, for example—need tionship between the duration of training and the incidence
to be taken into consideration [90]. of PT [99]. Furthermore, in the study by Peters et al., the
authors correlated prophylactic eccentric training protocols
Corticosteroids and stretching exercises with a high incidence of injury in
asymptomatic athletes with PT abnormalities [98]. It is also
Corticosteroids have been used as a treatment strategy for not recommended to use in-season prophylactically eccen-
PT [25, 35, 54–58]. Corticosteroid injections were found tric exercise protocols in asymptomatic soccer players who
to reduce pain, reduce swelling, and even improve the US exhibit pathologic imaging. This is supported also by Fred-
findings of the tendon in severe tendonitis [25, 54]. How- berg et al., who indicated that there was a higher risk of
ever, the mechanisms behind their beneficial effects remain developing PT when this protocol was used [100]. In the
unclear [54, 58]. Some of the following studies concern the same study, the prophylactic eccentric program was found
Achilles tendon; however, the results of corticosteroid injec- to reduce the risk of developing US abnormalities in the
tions in PT are similar [54]. Up to 82% of corticosteroid tri- patellar tendons of the athletes, but it was shown to have no
als in tendons demonstrated adverse effects [91–93]. Some positive effects on the risk of developing PT [100].
adverse effects are tendon rupture [57, 91, 92], atrophy [92] According to de Vries et al., small improvements in pro-
and decreased tendon strength [56, 93]. Although they are prioception were found when athletes wore a patellar strap
beneficial in the short term, they are not superior to other [88]. In addition, according to de Vries et al., patellar strap-
therapies in the long term [92]. ping improves proprioception of the symptomatic knee in
athletes with poor proprioceptive acuity, mostly in patients
Operative treatment with a relatively small knee girth, small tendon abnormali-
ties and newly developed symptoms [86]. Thus, patellar
Many athletes with PT respond positively to non-operative strapping can play a role in injury prevention, because poor
treatment. However, some of them will need surgical treat- proprioception is believed to be a cause of injury and/or re-
ment if conservative therapy fails [2, 25]. Although there injury [88]. Kraemer and Knoblock et al. also support the
is no gold standard management for PT, some authors have hypothesis that proprioceptive training can also reduce the
demonstrated that surgery is taken into consideration when rehabilitation time from noncontact injuries such as PT [99].
athletes fail to improve after 6 months of conservative treat-
ment [54, 94, 95]. Arthroscopic and open surgery have
been reported as surgical treatment options [96, 97]. The Conclusion
success rates of arthroscopic procedures and open surgery
were found to be 91% and 87%, respectively, according PT is a frequent clinical entity in athletes, especially in
to a systematic review [97]. Time to return to pre-injury jumping sports such as volleyball and basketball. It is mostly
activity level was significantly less (3.9 months on average) diagnosed clinically, but US and MRI are also essential
after arthroscopic treatment in comparison to open sur- diagnostic tools. Risk factors for PT are the male gender,
gery (8.3 months on average) [97]. In contrast, Aicale et al. involvement in sports (particularly volleyball), playing at

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the national level, the position played in volleyball, train- Availability of data and materials Full text articles that were extracted
ing hours, playing surface, small patellar tendon lever and during research are stored in the department’s flash drive.
moment arm movements, hypoechoic areas and neovascu-
Declarations
larization displayed in US of the tendon, jump height, heav-
ier load on the tendon and landing strategy of the athlete. Conflict of interest The authors have declared that they have no com-
Higher BMI as a risk factor has been supported by some peting interests.
authors but questioned by others. The screening of asympto-
Ethical approval and consent to participate Not applicable.
matic athletes, especially those with the aforementioned risk
factors, using clinical examination, US, and VISA-P scores Consent for publication Not applicable.
can be useful to predict which athletes will develop PT. Fur-
thermore, patellar strapping can be used for prevention and Open Access This article is licensed under a Creative Commons Attri-
rehabilitation purposes. Eccentric exercises are not advised bution 4.0 International License, which permits use, sharing, adapta-
as a prophylactic measurement during the training season tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
for asymptomatic athletes with pathologic US. Balance and provide a link to the Creative Commons licence, and indicate if changes
proprioception training are recommended in jumping sports were made. The images or other third party material in this article are
because they are found to be good methods for prevention. included in the article’s Creative Commons licence, unless indicated
Even though the treatments for this condition can be non- otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
operative and operative, non-operative treatment seems to be permitted by statutory regulation or exceeds the permitted use, you will
the first choice. Aicale et al. in their review agree that non- need to obtain permission directly from the copyright holder. To view a
operative management is the mainstay of treatment, with copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
about 10 percent of refractory cases ending up in surgical
treatment [101]. Conservative treatment consists of eccen-
tric exercises, PRP injections–with PLTE showing also
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