Review

Epidemiology of Patellar Tendinopathy

in Athletes and the General Population
A Systematic Review and Meta-analysis
Sebastiano Nutarelli,*† MS, Camilla Mondini Trissino da Lodi,*‡ MD, Jill L. Cook,§ PhD,
Luca Deabate,* MD, and Giuseppe Filardo,*k MD, MBA, PhD
Investigation performed at the Service of Orthopaedics and Traumatology, Department of Surgery,
EOC, Lugano, Switzerland

Background: Patellar tendinopathy (PT) mainly affects athletes who use the tendon for repeated energy storage and release
activities. It can have a striking impact on athletes’ careers, although data on its real prevalence and incidence are sparse.
Research efforts should start from the results of reliable and updated epidemiological research to help better understand the
impact of PT and underpin preventative measures.
Purpose: To determine the prevalence and incidence of PT in athletes and the general population.
Design: Systematic review; Level of evidence, 3.
Methods: A systematic review of the literature was performed on January 17, 2022, and conducted according to the PRISMA
(Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The PubMed, Web of Science, and Wiley
Cochrane Library databases were searched for epidemiological reports of any evidence level and clinical studies reporting data on
the incidence or prevalence of PT for the 11,488 retrieved records. The primary endpoint was the prevalence and incidence of PT in
sport-active patients. The secondary endpoints were PT prevalence and incidence in subgroups of athletes based on sex, age,
sport type, and sport level played, as well as the same epidemiological measures in the general population.
Results: A total of 28 studies, with 28,171 participants, were selected and used for the qualitative and quantitative analysis. The
general and athletes’ populations reported an overall PT prevalence of 0.1% and 18.3%, respectively. In athletes, the prevalence of
PT was 11.2% in women and 17% in men (P ¼ .070). The prevalence of PT in athletes <18 years was 10.1%, while it was 21.3% in
athletes 18 years (P ¼ .004). The prevalence of PT was 6.1% in soccer players, 20.8% in basketball players, and 24.8% in
volleyball players. Heterogeneous PT diagnostic approaches were observed. Higher prevalence values were found when PT
diagnoses were made using patient-reported outcomes versus clinical evaluations (P ¼ .004).
Conclusion: This review demonstrated that PT is a common problem in the male and female sport-active populations. There are
twice as many athletes aged 18 years than there are <18 years. Volleyball and basketball players are most affected by PT.
Keywords: epidemiology; incidence; knee; patellar tendinopathy; prevalence

Patellar tendinopathy (PT) is the clinical presentation of relative to the baseline patellar tendon’s capacity to toler-
pain and associated dysfunction in people with underly- ate load causes the onset of symptoms.22,70 Hence, PT is a
ing tendon pathology.17,18 Athletes 7,15,41 who use the ten- tendon degenerative pathology that is thought to be due to
don for repeated elastic energy storage-and-release structural overuse. PT can have a striking impact on ath-
activities (eg, jumping and changing directions)30,48 are letes’ careers. Up to one-third of the diagnosed players are
affected by PT; therefore, the condition is frequently unable to return to sports for >6 months,11 and more than
labeled “jumper’s knee.”4 A sudden or chronic load increase half discontinue sports participation.43
The diagnosis of PT is complex, as there are no gold stan-
dard tests. However, structural disorganization on imaging
The Orthopaedic Journal of Sports Medicine, 11(6), 23259671231173659 shows pathology that may not be linked to symptoms.23
DOI: 10.1177/23259671231173659 Diagnostic tests can provoke pain but the source of the pain
ª The Author(s) 2023
can be in many structures.44 Correct diagnosis requires
Correction (August 2023): Table 4 has been updated to include green good clinical understanding and skills.53 Overall, research
and red shading. efforts should pursue better data to improve the

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1
2 Nutarelli et al The Orthopaedic Journal of Sports Medicine

understanding of tendinopathy and its management. van Primary and Secondary Outcomes
Mechelen et al73 called for action in managing sports inju-
ries starting from the need for epidemiological research to The primary outcome of this review and meta-analysis was
underpin preventative measures. Describing the extent of the prevalence and incidence of PT sport-active patients.
the sports injury problem to understand its impact and the The secondary outcomes were PT prevalence and incidence
type of patients involved can favor more effective PT man- in subgroups of athletes based on sex, age, type of sport, and
agement. Accordingly, a comprehensive and updated epide- level of sport played, as well as the same epidemiological
miological meta-analysis on PT could provide key data as a measures in the general population.
foundation for the future development of more targeted
interventions and a better understanding of the pathology.
This review aimed to determine the prevalence and Assessment of Risk of Bias and Quality of Evidence
incidence of PT in athletes and the general population.
All studies were evaluated according to the level of evidence
The hypothesis was that PT would be a common pathology using previously published criteria.65 To establish potential
with varying prevalence depending on the type of patients.
bias in the selected studies from the protocol research, 2
reviewers (C.M.T.L, S.N.) independently assessed the
methodological quality of each study using the Newcastle-
METHODS Ottawa Scale (NOS)51 for cohort studies and nonrando-
mized studies and the Appraisal tool for Cross-Sectional
Search Strategy Studies (AXIS)26 for cross-sectional studies. The Grading
A review protocol was developed and registered on the of Recommendations Assessment, Development and Eval-
International Prospective Register of Systematic Reviews uation (GRADE) guidelines37 were considered to grade the
(CRD42021253503). We searched the PubMed, Web of Sci- overall quality of evidence for each outcome. However, the
ence, and Wiley Cochrane Library databases on January GRADE was discarded because of its poor applicability to
17, 2022, using the following keywords for initial screening: epidemiological studies. The opportunity to use a modified
“patellar AND tendon AND (tendinopath* OR tendonitis version of the GRADE was not pursued either, as this could
OR tendinosis OR rupture OR lesion OR injur*).” The entail the risk of overestimating the quality of evidence
PRISMA (Preferred Reporting Items for Systematic for observational studies. Risk of bias (RoB) and quality
Reviews and Meta-Analyses) guidelines were followed.58 of evidence were independently assessed for all out-
No limitations based on the publication time were made. comes by 2 authors (C.M.T.L., S.N.), and interrater reliabil-
ity was calculated. A third author (L.D.) resolved any
discrepancies.
Study Selection and Data Extraction
Two authors (C.M.T.L., S.N.) selected the studies indepen- Statistical Analysis
dently and removed duplicate studies. First, all titles and
abstracts were screened for epidemiological reports regard- Among the studies, the comparisons of PT prevalence and
ing PT (any evidence level) and clinical studies reporting incidence overall and by subgroups were based on the Z test
data on PT incidence or prevalence that were written in with Bonferroni correction for multiple comparisons. A sta-
English. Animal studies and reviews were excluded. Then, tistical analysis and a forest plot were performed according
the articles that met the inclusion criteria were screened to Neyeloff et al.61 The Mantel-Haenszel method36,54 was
for full-text eligibility with further exclusions according to used to evaluate the expected value. The Wilson confidence
the previously described parameters. In case of disagree- interval was preferred because of the limited data, either
ment between the 2 reviewers, a third reviewer (L.D.) was due to low event rates or small sample sizes, and because of
consulted. Studies reporting PT diagnosis via clinical the poor estimates of the standard errors of the effect used
assessments and/or patient-reported outcomes (PROs) in the inverse variance methods. The interrater reliability
were included, whereas studies in which the diagnosis was of the RoB analysis was performed using the Cohen kappa.
only based on diagnostic imaging were excluded. Statistical heterogeneity was evaluated by the I2 statistic
The following data were then extracted from eligible and Cochran Q. For outcomes of low heterogeneity
articles: title, first author, year of publication, journal, type (I2 < 25%), the estimation of the expected value and its
of study, level of evidence, population characteristics, 95% CI was based on fixed-effects analysis of variance; oth-
sports, level of activity, incidence, prevalence, and diagnos- erwise, the random-effects model was used. The statistical
tic method. significance was set at P  .05.

‡
Address correspondence to Camilla Mondini Trissino da Lodi, MD, Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Via Capelli
1, 6962 Viganello, Switzerland (email: [email protected]).
*Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland.
†
School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland.
§
La Trobe University Sport and Exercise Medicine Research Centre, La Trobe University, Corner of Plenty Road and Kingsbury Drive, Bundoora, Victoria,
Australia.
k
Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland.
Final revision submitted January 2, 2023; accepted February 9, 2023.
The Orthopaedic Journal of Sports Medicine Epidemiology of Patellar Tendinopathy 3

Figure 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart of the study selection
process. PT, patellar tendinopathy.

RESULTS nonathletes. There were 4810 men and 3051 women, with
an age range of 10 to 82 years, in the studies that specified
Study Selection and Characteristics the participants’ sex. Among the sport-active patients, 1840
basketball players, 1915 volleyball players, and 267 soccer
The database search identified 11,488 records, 2247 of players were included.
which were duplicates. Of the remaining 8664, a total of
107 full-text articles considered suitable for inclusion were
assessed for eligibility after a preliminary title and abstract Athletes
screening. However, 82 further articles did not fulfill the
inclusion criteria and were excluded, while 3 more studies A PT prevalence of 18.3% (95% CI, 14.6-22.1) was reported
in 20 studies,†† whereas 7 studies8,9,14,16,31,35,69 revealed a
were added through a manual search of the reference lists
PT incidence of 7% (95% CI, 3.9-10) in the athlete
of the included articles, leading to a total of 28 studies{ used
population.
for the qualitative and quantitative analysis (Figure 1). All
of the included articles were published between 1986 and
2021. The primary characteristics of the selected studies Subgroup Analysis in Athletes
are reported in Table 1.
Of the selected studies, 11 were cohort stud- Sex. The PT prevalence was 11.2% (95% CI, 7-15.4 [10
ies,#2,5,8,9,14,19,31,34,35,64,69 and 15 were cross-sectional stud- studies‡‡]) in women, whereas it was 17% (95% CI, 13-20.9
ies.** One study was a case-control study,59 and 1 was a [14 studies§§]) (P ¼ .070) in men.
registry-based study. 67 The majority of the studies Two studies14,31 showed a 7.5% PT incidence in men (95%
(n ¼ 24) focused on athletes, while only 2 studies were con- CI, 2.2-12.9). The incidence in women could not be calcu-
ducted in the general population.1,67 See Figure 2 for the lated because of insufficient data.
geographical distribution of the retrieved studies. Age. Five studies7,8,15,34,64 revealed that the PT preva-
lence was 10.1% (95% CI, 5.7-14.5) in those <18 years,
whereas it was 21.3% (95% CI, 15.9-26.7 [11 studieskk])
Population Characteristics (P ¼ .004) in those 18 years. Three studies8,9,16 showed
an 8.4% PT incidence in participants <18 years (95% CI,
A total of 28,171 participants were enrolled in the 28 stud- 2.4-14.3), and a meta-analysis of 2 studies31,69 found a
ies, of whom 8684 were athletes and 19,487 were
††
References 2, 5, 7, 8, 15, 19, 21, 27, 28, 34, 38, 42, 48-50, 59, 64, 66,
{
References 1, 2, 5, 7-9, 14-16, 19, 21, 27, 28, 31, 34, 35, 38, 42, 48- 72, 75.
‡‡
50, 59, 64, 66, 67, 69, 72, 75. References 2, 7, 15, 21, 48, 49, 59, 64, 72, 75.
# §§
References 2, 5, 8, 9, 14, 19, 31, 34, 35, 64, 69. References 2, 5, 7, 15, 19, 21, 27, 38, 48, 49, 59, 64, 72, 75.
kk
**References 1, 7, 15, 16, 21, 27, 28, 38, 42, 48-50, 66, 72, 75. References 19, 21, 27, 38, 42, 48, 50, 59, 66, 72, 75.
4 Nutarelli et al The Orthopaedic Journal of Sports Medicine

TABLE 1
Primary Characteristics of the Selected Studiesa

Lead Author (Year) Study Population (Level) Sport Participants (F/M), n Age, years

Albers1 (2016) CS GP NA 10,651 (NR) 46

Backman2 (2011) C A (E) Basketball 75 (37/38) 17.8 ± 1.6 (14.4-20.1)
Bode5 (2017) C A (E) Soccer 119 (0/119) 15.97 ± 2.24 (10-23)
Cassel7 (2015) CS A (E) 16 sports 760 (318/442) 13 ± 1.9
Cassel8 (2017) C A (NE) NR 196 (NR) <18
Cassel9 (2018) C A (NE) NR 182 (69/113) 12.1 ± 0.7
Cook15 (2000a) CS A (E) Basketball, swimming 163 (81/82) 16.3 (14-18)
Cook16 (2000b) CS A (E) Basket 52 (36/16) (14-18)
Cook14 (2001) C A (E) Soccer, basketball, cricket 46 (0/46) NR
Dauty19 (2021) C A (E) Basketball 62 (0/62) 25 ± 4
de Vries21 (2015) CS A (NE) Basketball, volleyball 385 (243/142) 28.3 ± 4.5
Durcan27 (2014) CS A (E) Rugby 441 (0/83) 20.4 ± 1.48 (18-25)
Ferretti28 (1986) CS A (NE) Volleyball 407 (NR) >18
Fredberg31 (2000) C A (E) Soccer 54 (0/54) (18-35)
Ghali34 (2020) C A (NE) Basketball 144 (65/79) 16 (14-17)
Giombini35 (2013) C A (E) Fencing 74 (NR) 27.02 (16-36)
Hannington38 (2020) CS A (E) Basketball 60 (0/60) 25 (16-36)
Janssen42 (2018) CS A (E) Track & field 119 (43/66) (18-35)
Lian48 (2005) CS A (E) 9 sports 613 (108/505) >18
Longo50 (2011) CS A (E) Track & field 174 (71/103) 53.6 ± 6.6 (35-82)
Longo49 (2021) CS A (NE) Running 350 (94/256) 44.8 (12-80)
Morton59 (2017) CC A (NE) Basketball 825 (423/402) 30.7 ± 10.8
Owoeye64 (2021) C A (NE) Basketball 515 (200/315) 16
Rehman66 (2019) CS A (NE) Basketball 150 (0/150) 23.73 ± 3.145 (18-30)
Riel67 (2019) R GP NA 8,836 (NR) 49 ± 17.1
Rudavsky69 (2018) C A (E) Ballet 57 (23/34) (11-18)
van der Worp72 (2011) CS A (NE) Basketball, volleyball 1505 (815/690) (18-35)
Zwerver75 (2011) CS A (NE) 7 sports 891 (389/502) 22.9 ± 3.1
a
Data are reported as mean or mean ± SD; data in parentheses are ranges. A (E), athletes (elite); A (NE), athletes (nonelite); C, cohort
study; CC, case-control study; CS, cross-sectional study; F, female; GP, general population; M, male; NA, not applicable; NR, not reported;
R, registry-based study.

Figure 2. Geographical distribution of the participants in the included studies, with an indication of the type of sport played.

6.8% incidence in participants 18 years (95% CI, 2-11.7) 17.8-31.8; [5 studies 28,48,59,72,75]) in volleyball players.
(P ¼ .370). There was a difference in prevalence between basket-
Type of Sports Played. The PT prevalence differed across ball and soccer (P ¼ .006) as well as between volleyball
sports. The PT prevalence was 6.1% (95% CI, 0.7-11.6 [3 and soccer (P ¼ .0002). No statistically significant differ-
studies17,59,75]) in soccer players, 20.8% (95% CI, 15.0-26.5 ence in PT prevalence was evident in basketball and
[11 studies{{]) in basketball players, and 24.8% (95% CI, volleyball (P ¼ .796). Additionally, a meta-analysis of 2
studies showed a 6% PT incidence in soccer players (95%
{{
References 2, 15, 19, 34, 38, 48, 59, 64, 66, 72, 75. CI, 0.7-11.2).
The Orthopaedic Journal of Sports Medicine Epidemiology of Patellar Tendinopathy 5

diagnosis made via PROs resulted in a prevalence of 25.4%

(95% CI, 15.3-35.4 [6 studies19,34,38,64,66,75]). A PT diagnosis
based on the combination of a clinical examination and
PROs showed a prevalence of 20.4% (95% CI, 14.7-26.0 [7
studies27,42,48-50,59,72]).
There was a statistically significant difference between
PT diagnoses made using PROs versus clinical evaluations
(P ¼ .004), with the latter having lower values. No statis-
tically significant between-group differences emerged for
PT diagnoses formulated via a clinical evaluation only ver-
sus a combination of a clinical examination and PROs
(P ¼ .205), as well as for PROs versus a combination of a
clinical examination and PROs (P ¼ .631). The classifica-
tion of the PT diagnostic methods in the included studies is
reported in Table 2.

Incidence
Figure 3. Prevalence of PT per level (elite/nonelite athletes) of
sport participation for basketball, volleyball, soccer, and other The 7% PT incidence previously reported in athletes was
sports. The magnified PT prevalence for each group is in gray. found with the PT diagnosis formulated through a hetero-
PT, patellar tendinopathy. geneous combination of clinical examination, PROs, diag-
nostic imaging (ultrasound, MRI, or Doppler ultrasound),
Level of Sport. The PT prevalence in elite athletes and SLDS. A meta-analysis of 5 studies8,9,14,31,35 reporting
was 16.7% (95% CI, 11.2-22.1 [10 studies##]) and 19.9% a PT diagnosis made based on a clinical evaluation by a
(95% CI, 14.8-24.9 [10 studies a ]) in nonelite athletes qualified clinician showed an incidence of 6.3% (95% CI,
(P ¼ .341). The PT incidence was 5.5% (95% CI, 2.8-8.2 2.8-9.9). Further meta-analyses were not possible.
[5 studies14,16,31,35,69]) in elite athletes and 7.5% (95% CI,
0.2-14.8 [2 studies8,9]) (P ¼ .349) in nonelite athletes. A
pooled estimate for PT prevalence in elite basketball Risk of Bias, Level of Evidence, and Heterogeneity
players was 18.9% (95% CI, 14.5-23.3 [5 studies2,15,19,38,48])
The overall interrater reliability was k ¼ 0.962 for both the
and 19.7% (95% CI, 11.7-27.7 [6 studies34,59,64,66,72,75])
NOS and the AXIS, indicating excellent agreement.
(P ¼ .361) in nonelite basketball players. Last, a meta-
Regarding the 11 cohort studies and 1 nonrandomized
analysis of 4 studies29,59,72,75 showed a 22.5% prevalence
(case-control) study, the RoB assessed with the NOS indi-
in nonelite volleyball players (95% CI, 15.9-25.1) (Figure
cated medium quality for 10 studies,b high quality for 1
3). Further meta-analyses were not possible with the avail-
study,9 and low quality for 1 study59 (Table 3). Regarding
able data.
the 16 cross-sectional studies,c the RoB assessed with the
AXIS resulted in a minimum score of 70% (14 out of
General Population 20 [range, 14-20]) in 9 studies,d indicating high quality,
whereas the remaining studies were of low quality
The PT prevalence was 0.1% (95% CI, 0.1-0.2 [2 studies1,67]) (Table 4).
and the incidence was 0.1% (95% CI, 0.0-0.2 [2 studies1,67]) Out of 26 outcomes obtained from the pooled data in
in the general population. The athletes had a higher PT this meta-analysis, 23 had an I2 of >25%; therefore, the
prevalence and incidence (P < .0005). random-effects analysis of variance was used.

Sensitivity Analysis by PT Diagnostic Method

DISCUSSION
Prevalence. There was an overall PT prevalence of 18.3%
in the athlete population. The studies used variable combi- The most important finding of this review was the quanti-
nations of clinical examination, PROs, diagnostic imaging fication of an overall PT prevalence of 18.3% in the sport-
(ultrasound, magnetic resonance imaging [MRI], radio- active population, with volleyball and basketball players
graphs, or Doppler ultrasound), self-administered pain being the most affected by PT. Also, PT epidemiology varied
map, online questionnaires or interviews, and the single- by age, with a prevalence of 10.1% in younger athletes and
leg decline squat (SLDS) functional test. When the PT doubling to 21.3% in older athletes.57 A different scenario
diagnosis was based on a clinical evaluation by either a was found in the general population, with a PT prevalence
qualified physician or a physical therapist, the prevalence and incidence of only 0.1%.
was 12.1% (95% CI, 7.6-16.7 [7 studies2,5,7,8,15,21,28]). A PT
b
References 2, 5, 8,14,19, 31, 34, 35, 64, 69.
## c
References 2, 5, 7, 9, 15, 27, 38, 42, 48, 50. References 1, 7, 15, 16, 21, 27, 28, 38, 42, 48, 50, 49, 66, 67, 72, 75.
a d
References 8, 21, 28, 34, 49, 59, 64, 66, 72, 75. References 7, 15, 21, 27, 42, 48, 50, 49, 75.
6 Nutarelli et al The Orthopaedic Journal of Sports Medicine

TABLE 2
Summary of Diagnostic Methods for Patellar Tendinopathy in the Included Studiesa

Diagnostic Method

Lead Author (Year) Clinical PROs Imaging Fct Test Online Q/I Registry

Albers1 (2016) X — — — — —
Backman2 (2011) X — — SLDS X —
Bode5 (2017) X — US, DUS — — —
Cassel7 (2015) X — US — — —
Cassel8 (2017) X — US, DUS — — —
Cassel9 (2018) X — US, DUS — — —
Cook15 (2000) X — US — X —
Cook16 (2000) X VISA-P US — — —
Cook14 (2001) X — US, MRI — — —
Dauty19 (2021) — VISA-P — — — —
de Vries21 (2015) X — — — — —
Durcan27 (2014) X VISA-P, CSAS US — — —
Ferretti28 (1986) X — Radiograph — — —
Fredberg31 (2002) X — US — — —
Ghali34 (2020) — OSTRC-P — — — —
Giombini35 (2013) X — US — — —
Hannington38 (2020) — VISA-P, OSTRC US SLDS X —
Janssen42 (2018) X VISA-P — — X —
Lian48 (2005) X VISA-P — — X —
Longo50 (2011) X VISA-P <100 — — — —
Longo49 (2021) X VISA-P <100 — — — —
Morton59 (2017) X VISA-P — — — —
Owoeye64 (2021) — OSTRC — — — —
Rehman66 (2019) — VISA-P <80 — — — —
Riel67 (2019) — — — — — X
Rudavsky69 (2018) — VISA-P US SLDS — —
van der Worp72 (2011) X VISA-P — — X —
Zwerver75 (2011) — VISA-P — — X —
a
Dashes indicate areas not applicable. X, indicates that specific diagnostic method was used in the studies. CSAS, Cincinnati Sports Ability
Scale; DUS, Doppler ultrasound; Fct test, functional test; MRI, magnetic resonance imaging; Online Q/I, online questionnaire/interview;
OSTRC, Oslo Sports Trauma Research Centre overuse injury questionnaire; OSTRC-P, Oslo Sports Trauma Research Centre-patellar
tendinopathy questionnaire; PRO, patient-reported outcome; SLDS, single-leg decline squat; US, ultrasound; VISA-P, Victorian Institute
of Sport Assessment–Patella.

The PT epidemiology literature is heterogeneous depend- discrepancies may depend on the different sports and phys-
ing on participant factors such as sex, age, type of sport, ical stress/loading on the patellar tendon but possibly also
and level of sport. Studies were also focused on 1 aspect of on the interaction of these factors with sex-specific physio-
PT, whether in a single sport (eg, volleyball players)29 or on logical and etiopathological differences. A complex interac-
specific aspects, including associated tendon structural tion between tendon load and the ability of the tendon to
changes,25,55,56,62 jump-landing kinematics,20 and sensory respond to the applied load and the development of symp-
and motor deficits.40 In this meta-analysis, differences in toms may be complicated by the role of endogenous and
age, sex, and sport activity level were investigated, and the nonendogenous sex hormones. These could affect the bio-
impacts of PT in both the general population and sport- mechanical properties,10,39,46,63 leading to a suboptimal
active patients were comprehensively analyzed and load response and ultimately the development of
quantified. symptoms.
A sex-based difference in PT prevalence was not evident, With respect to the level of sports participation, non-
with 11.2% and 17% in female and male athletes, respec- elite athletes showed a 19.9% prevalence and a 7.5% inci-
tively. Only 10 of the included studies reported PT epide- dence, while elite athletes showed a 16.7% prevalence and
miological data for women. This highlights the limited a 5.5% incidence. Elite athletes have been reported to
available literature, indicating that more research is have more PT compared with nonelite athletes. Previous
required. Several studies reported that men active in sports studies showed a 46.5% prevalence in master track and
were more likely to have PT, with findings from nonelite field athletes 50 and a 21.7% prevalence in basketball
level,75 elite level,48 and jumping sports athletes. 221 In players.38 However, regarding the prevalence in nonelite
contrast, other studies59 reported that nonelite physically athletes, studies reported a 62% prevalence in basketball
active women were more prone to PT. These sex-based players,66 a 27.43% prevalence in runners participating
The Orthopaedic Journal of Sports Medicine Epidemiology of Patellar Tendinopathy 7

TABLE 3
NOS Risk-of-Bias Assessment for Cohort, Registry-Based, and Nonrandomized Studiesa

NOS Items for Cohort Studiesb

Selection Outcome
Comp
Lead Author (Year) 1 2 3 4 5 6 7 8 RoB
2
Backman (2011) * – * * – * * * Medium
5
Bode (2017) * – * * – * – * Medium
Cassel8 (2017) * – * * * * – * Medium
9
Cassel (2018) * * * * * * * * High
Cook14 (2001) * – – * – * * * Medium
Dauty19 (2021) * * * – * * – – Medium
Fredberg31 (2002) * – * * – * * * Medium
34
Ghali (2020) * – – * – – * * Medium
Giombini35 (2013) * – * * – * * * Medium
Owoeye64 (2021) * – * * – * * * Medium
69
Rudavsky (2018) * – * * – * * * Medium

NOS Items for Case-Control Studiesc

Selection Comp Exposure NA

1 2 3 4 5 6 NA Quality
59
Morton (2017) * – – – – – – NA Low

a
Comp, comparability; NA, not applicable; NOS, Newcastle-Ottawa Scale; RoB, risk of bias. * indicates were the studies get RoB points, the
dash indicates where they do not.
b
NOS items for cohort studies: 1 ¼ representativeness of the exposed cohort; 2 ¼ selection of the nonexposed cohort; 3 ¼ ascertainment of
exposure; 4 ¼ the outcome of interest was not present at the start of the study; 5 ¼ comparability of cohorts based on the design or analysis;
6 ¼ assessment of outcome; 7 ¼ the follow-up long enough for outcomes to occur; and 8 ¼ adequacy of follow-up of cohorts.
c
NOS items for case-control studies: 1 ¼ adequacy of case definition; 2 ¼ representativeness of the cases; 3 ¼ selection of controls;
4 ¼ definition of controls; 5 ¼ comparability of cases and controls based on the design or analysis; 6 ¼ ascertainment of exposure; and
7 ¼ nonresponse rate.

in a city marathon,49 a 23.39% prevalence in active ath- There was heterogeneity in how the PT diagnosis was
letes practicing different sports,59 and a 22.85% preva- made. Studies diagnosed PT through either a single or a
lence in volleyball players.29 Elite athletes are exposed variable combination of the following parameters: clinical
to an overall higher load volume and are at risk for devel- examination by qualified clinicians; PROs; diagnostic imag-
oping PT.71 At the same time, they train most days, build- ing; self-administered pain maps; online questionnaires or
ing a higher tendon load capacity.12 Continuous training interviews, SLDS; or patients diagnosed with PT based on
sessions and competitions that are adequately planned in registries. PT is reported to be diagnosed clinically by painful
a progressive fashion6 build the tendon’s sport-specific palpation at the patellar inferior pole with an extended knee
capacity to withstand the demands of training and com- that reduces flexion.30,53 Pain is load-dependent, especially
petition.32 In nonelite settings with a less planned train- exacerbated by jumps and changes of directions; hence, activ-
ing progression, amateur and semiprofessional athletes ities involve the store and release of elastic energy in ten-
may be more exposed to load spikes, leading to a higher dons. 30 Frequently, the clinical diagnosis is made in
rate of PT.33 association with imaging (ultrasound, Doppler ultrasound,
The type of load influences the onset of this condition. or MRI) that identifies tendon structural degeneration and/
There was a 6.1% PT prevalence in soccer players, a 20.8% or increased microvascularisation.68,74 However, asymptom-
prevalence in basketball players, and a 24.8% prevalence in atic tendons can either show structural abnormalities on
volleyball players. This high rate of PT in jumping sports is imaging or not.13,47,52 Diagnostic imaging is not able to iden-
because of the repetitive takeoffs and landings character- tify pain; therefore, imaging alone cannot be considered the
ized by a high number of stretch-shortening cycles in the gold standard to diagnose PT.23 In some studies, PT diagno-
patellar tendon.3,16,29,48 The low levels in the general popu- ses were made using validated PROs and/or SLDS functional
lation can be explained by the low levels of tendon load. tests that elicited symptoms commonly associated with PT.53
8 Nutarelli et al The Orthopaedic Journal of Sports Medicine

TABLE 4
AXIS Risk-of-Bias Assessment for Cross-sectional Studiesa

AXIS Itemb

Lead Author (Year) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19c 20 Qualityd

Albers1 (2016) X X X X X X ? X ? X X X ? ? ? X X X X X 12
Cassel7 (2015) X X X X X X ? X ? X X X ? ? X X X X ? X 15
Cook15 (2000) X X X X X X ? X ? X X X ? ? X X X X X X 14
Cook16 (2000) X X X X X X ? X ? X X X ? ? X X X X ? X 12
de Vries21 (2015) X X X X X X X X X X X X X X X X X X ? X 15
Durcan27 (2014) X X X X X X ? X ? X X X ? ? X X X X ? X 14
Ferretti28 (1986) X X X X X X ? X ? X X X ? ? X X X X ? ? 7
38
Hannington (2020) X X X X X X X ? ? X X X X X X X X X X X 13
Janssen42 (2018) X X X X X X X X ? X X X X X X X X X X X 14
48
Lian (2005) X X X X X X ? X ? X X X ? ? X X X X X X 15
Longo50 (2011) X X X X X X X X X X X X X X X X X X X X 16
49
Longo (2021) X X X X X X X X X X X X X X X X X X X X 15
Rehman66 (2019) X ? X X X X X ? ? X X X X X X X X ? ? ? 5
Riel67 (2019) X X X X X X ? X ? X X X ? ? X X X X X X 13
van der Worp72 (2011) X X X X X X X X X X X X X X X X X X ? ? 13
75
Zwerver (2011) X X X X X X ? X X X X X ? ? X X X X X X 16

a
AXIS, Appraisal tool for cross-sectional studies.
b
AXIS items for cross-sectional studies: 1 ¼ clearness of the aims/objectives of the study; 2 ¼ appropriateness of the study design for the
stated aims; 3 ¼ justification of the sample size; 4 ¼ clear definition of the target/reference population; 5 ¼ sample frame taken from an
appropriate population base that closely represents the target/reference population under investigation; 6 ¼ selection process likelihood to
select participants that were representative of the target/reference population under investigation; 7 ¼ undertaken measures to address and
categorize nonresponders; 8 ¼ appropriateness of the risk factor and outcome variables measured to the aims of the study; 9 ¼ correct measure
of the risk factor and outcome variables using instruments/measurements that had been trialed, piloted, or published previously; 10 ¼
clearness of what was used to determine statistical significance and/or precision estimates (eg, P values and CIs); 11 ¼ sufficient description
of the methods (including statistical methods) to allow for their repetition; 12 ¼ adequate description of the basic data; 13 ¼ concerns on the
response rate raised about nonresponse bias; 14 ¼ description of the information about nonresponders (if applicable); 15 ¼ internal consis-
tency of the results; 16 ¼ results presented for all the analyses described in the methods; 17 ¼ justification by the results of the authors’
discussions and conclusions; 18 ¼ limitations of the study discussed; 19 ¼ funding sources or conflicts of interest that may affect the authors’
interpretation of the results; 20 ¼ attainment of the ethical approval or consent of participants.
c
In item 19, X counts as 1.
d
Green shadings indicate high quality; red shadings indicate low quality.

Since such variability of methods to diagnose PT could have terms of an unprecedented number of tendon ruptures in
introduced false positive and/or negative diagnoses, a sensi- training camps and at the beginning of the preseason
tivity analysis was performed considering the PT diagnostic phase.60 Large registry-based prospective studies should
methods. The PT prevalence was 12.1% in studies in which be completed through the athletic season with periodical
the diagnosis was based on a clinical evaluation, whereas the measurements using valid and sensitive scoring instru-
PT prevalence was 25.4% (P ¼ .004) in studies with the diag- ments of the PT-related symptoms, with severity measured
nosis based on PROs only. Therefore, PROs alone carry a risk based on a functional level and not time loss from sports,
of overdiagnosis. Additionally, recent studies showed limited and preferring prevalence rather than incidence to report
evidence for the clinimetric properties of the frequently uti- such injury risk. In this light, the PT prevalence data docu-
lized Victorian Institute of Sport Assessment–Patella ques- mented in this meta-analysis should be given more weight
tionnaire, affecting its validity in diagnosing PT.45 than the incidence data, as this epidemiological measure
The phases of a sports season could change the PT prev- appears to better capture overuse injuries over time.
alence. Studies that reported a higher mean monthly prev-
alence of PT during the preseason compared with the
Limitations
competitive season,24 highlighted methodological issues in
capturing these injuries. The literature demonstrates the The included studies were characterized by an overall het-
consequences of training and competition interruptions in erogeneity, leading us to often implement the random-
The Orthopaedic Journal of Sports Medicine Epidemiology of Patellar Tendinopathy 9

effects model whenever the I 2 >25%. The number of 5. Bode G, Hammer T, Karvouniaris N, et al. Patellar tendinopathy in
included studies for the general population was low, and young elite soccer: clinical and sonographical analysis of a German
no subgrouping was possible. Multiple epidemiological elite soccer academy. BMC Musculoskelet Disord. 2017;18(1):344.
doi:10.1186/s12891-017-1690-2
studies had to be discarded in the study-selection process,
6. Bowen L, Gross AS, Gimpel M, Li FX. Accumulated workloads and the
which potentially led to data exclusion. A noticeable hetero- acute: chronic workload ratio relate to injury risk in elite youth football
geneity was detected regarding how the PT diagnosis was players. Br J Sports Med. 2017;51(5):452-459. doi:10.1136/bjsports-
formulated in the included studies that could influence the 2015-095820
conclusions of this meta-analysis by potentially introducing 7. Cassel M, Baur H, Hirschmüller A, Carlsohn A, Fröhlich K, Mayer F.
an intrinsic bias in the inclusion criteria. To limit this bias, Prevalence of Achilles and patellar tendinopathy and their association
priority was given to studies reporting a PT diagnosis by a to intratendinous changes in adolescent athletes. Scand J Med Sci
Sports. 2015;25(3):e310-e318. doi:10.1111/sms.12318
health professional. Furthermore, a limitation of this study
8. Cassel M, Intziegianni K, Risch L, Müller S, Engel T, Mayer F. Phys-
is that in the included studies that used PROs for PT diag- iological tendon thickness adaptation in adolescent elite athletes: a
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to respond to the surveys than those without, which may 2017.00795
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in 80% of the assessed studies with the NOS at medium your . . . insert musculoskeletal tissue here. Defining “tissue capacity”:
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14. Cook JL, Khan KM, Kiss ZS, Coleman BD, Griffiths L. Asymptomatic
In this review and meta-analysis, a PT prevalence of 18.3% hypoechoic regions on patellar tendon ultrasound: a 4-year clinical
was found in the active-sport population, whereas the prev- and ultrasound followup of 46 tendons. Scand J Med Sci Sports.
alence of PT was limited for the overall population. The 2001;11(6):321-327. doi:10.1034/j.1600-0838.2001.110602.x
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athletes were also significantly affected. Age also showed basketball players: a controlled clinical and ultrasonographic study
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double values compared with athletes <18 years, as well as 010004216.x
the type of sport, with basketball players and 7 more vol- 16. Cook JL, Khan KM, Kiss ZS, Purdam CR, Griffiths L. Prospective imag-
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ACKNOWLEDGMENT 17. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology
model to explain the clinical presentation of load-induced tendinopa-
The authors thank Elettra Pignotti for her assistance with thy. Br J Sports Med. 2009;43(6):409-416. doi:10.1136/bjsm.2008.
the statistical analysis. 051193
18. Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum
model of tendon pathology: what is its merit in clinical practice and
research? Br J Sports Med. 2016;50(19):1187-1191. doi:10.1136/
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