Patellar Tendinopathy and Why Jumper's Knee Keeps Coming Back

The short version

• Patellar tendinopathy, or jumper's knee, is overload of the tendon just below the kneecap, and it's most common in volleyball (44.6% of elite players) and basketball (31.9%)
• Rest calms it down, but athletes in one study had lived with it for an average of 32 months, because the tendon never got stronger
• A 2021 trial found staged tendon loading beat the older eccentric-only approach by 9 points on the VISA-P score at 24 weeks
• Rehab moves from holds to heavy single-leg strength to jumping and cutting, and each step is earned on how the tendon responds

Jumper's knee keeps coming back because rest treats the pain, not the tendon. Patellar tendinopathy is a load problem in the tendon that joins the kneecap to the shin, and it flares when an athlete jumps, lands or accelerates. A few weeks off settles it, but the tendon is no stronger when training starts again, so the same load brings the same pain. What breaks the cycle is load that rises in stages, from holds to heavy strength to jumping.

At True Sports we build that progression through orthopedic physical therapy, with running rehab for athletes whose goal is the road. Below is how to recognize it, why rest falls short, and what the rehab looked like for one offseason football player getting ready for camp.

Pain just below the kneecap

The pain sits at a small spot right under the kneecap and gets worse the harder the knee has to work. Jumping, landing, sprinting and deep squats provoke it. Early on it warms up and fades during practice, then aches afterward. Left alone, it starts to hurt during play too.

The sports tell the story. A 2005 study of 613 elite athletes in the American Journal of Sports Medicine found current jumper's knee in 44.6% of volleyball players and 31.9% of basketball players, against 14.2% across all nine sports. Cyclists and orienteers had none. Every takeoff and landing stores energy in the tendon and releases it, and that spring-like loading is what an overloaded tendon struggles with. Cleveland Clinic names athletes "who jump, sprint or change directions" as the main group.

Is it jumper's knee or runner's knee?

Location is the quickest way to tell. Jumper's knee hurts at one point just below the kneecap. Runner's knee hurts around or behind the kneecap and tends to be worst on stairs, squats and after sitting for a long time. They're rehabbed differently, so the distinction matters.

A 2015 JOSPT clinical review describes the tendon version's two hallmarks: pain localized to the bottom of the kneecap, and pain that climbs with the demand on the thigh muscles, especially in activities that store and release energy. A single-leg decline squat, rated for pain out of 10, is the usual test, and it becomes the measuring stick for the whole program. If your pain sounds more like the second description, runner's knee has its own guide.

Why rest takes the pain away and then it comes back

Rest lowers the pain without raising what the tendon can handle. In the 613-athlete study, those with current symptoms had lived with them for an average of 32 months. That's what the rest-and-return cycle looks like over a few seasons.

Progressive loading does better. A 2021 randomized trial in BJSM followed 76 athletes for 24 weeks. Those on staged tendon loading improved 28 points on the VISA-P score, a measure of pain, function and sport, against 18 points for eccentric-only exercise. More of them returned to sport, 43% against 27%, though that gap wasn't statistically significant. The authors recommended progressive loading as the first treatment to try.

The skill is reading how the tendon responds. Dr. Vikash Sharma, a running-focused physical therapist, explained his rule of thumb on the True Sports Podcast:

After we load it, if that response is also reducing after 24 to 36 hours and it's kind of coming back down to baseline, I think that's another good place for us to be. If that subjective pain score is staying below a 4, sometimes a tendon, I'm good with a 5.

Pain that settles by the next day means the tendon handled the session. Pain that's worse the next morning means the load went too high, and the next session steps back.

Watch the full episode with Dr. Vikash Sharma on the True Sports Podcast for more on how he uses pain to guide tendon loading.

What rehab looked like for one offseason lineman

A high school offensive lineman came to True Sports' Bel Air clinic during offseason workouts with knee pain that hit hardest on jumps and explosive drills. Camp started in early August, so the rehab was built backward from that date. Dr. Ryan Gibney, PT, DPT, CSCS, a former college linebacker, mapped the plan in three moves, which mirror the stages the research supports. Here they are, with the exercises that typically fill each one:

• Holds first, for pain relief and to start loading the tendon. Wall sits or Spanish squats at a tolerable knee angle, often daily. How to program them is in isometrics for tendon pain
• Heavy single-leg strength to build capacity: split squats, step-downs and leg press, three to four times a week
• Plyometrics and change of direction to get the tendon ready for game demands, starting with low hops and building volume before height

A camp date sets the goal, and the tendon sets the pace. In a plan like this, each move starts when the tendon has handled the one before it, judged on the decline squat and the next-morning response.

The hip is usually part of it

When the hip can't control the leg, the knee drops inward on landing and the tendon takes extra load. A True Sports physical therapist working with a young athlete with the same diagnosis paired the tendon holds with banded knee extensions and single-leg hip work, because her squat and landing caved inward. Hip strength and landing mechanics run alongside every stage, and the jump work follows the principles of a careful plyometric progression.

When it's safe to jump again

When the tendon passes three measured tests. The decline squat should stay at or below about 3 out of 10. Single-leg strength should be within about 10% of the other side. Full-volume hops and landings shouldn't flare the tendon the next morning. The JOSPT review lists unrealistic time frames among the most common mistakes in treating this condition, so the markers matter more than the date.

Eating for a tendon that's rebuilding

Tendons rebuild slowly, and nutrition works alongside the loading. Collagen at 5 to 10g with vitamin C, about an hour before a loading session, is worth considering, since vitamin C is needed to form new collagen. Omega-3s at 1,000 to 2,000mg of EPA and DHA daily help regulate the inflammatory signalling that comes with heavy training, and they absorb better with a meal. Enough protein through the day matters most, because the muscles around the knee have to grow to share the load.

Questions athletes ask about jumper's knee

Can I keep playing with patellar tendinopathy? Often, yes, at reduced jump volume, while holds and strength work run alongside practice. The rule is the next-morning check. If pain is back to baseline within 24 hours, the load was tolerated.

Do I need an MRI for jumper's knee? Usually not. The JOSPT review notes the diagnosis is clinical, because tendon changes on a scan also show up in people whose pain comes from somewhere else. Imaging helps when the picture is unclear.

Is patellar tendinopathy the same as patellar tendonitis? Same problem, different word. "Tendonitis" implies inflammation, but long-standing cases are mainly a loss of the tendon's capacity, which is why tendinopathy is now the preferred term.

Can I still run with it? Many athletes can, with mileage adjusted to the next-day response. At True Sports' Timonium clinic, Dr. Gina Hisky-Callahan, PT, DPT, OCS, works with long-standing cases like this, where the goal is getting back to running.

Will it come back? It can, especially if the strength work stops once the pain settles. Keeping heavy single-leg work in the weekly routine is the best protection after returning to sport.

If your knee hurts every time you land

Pain right under the kneecap that returns every time training picks up is a tendon asking to get stronger in stages. We start with the decline squat and a look at how your hip controls your landing, then build the plan around your season. Book your evaluation.

Keep reading

• Isometrics for Tendon Pain and What They Can and Cannot Do: How to use holds as the first stage of tendon rehab.
• What Causes Runner's Knee and How Is It Different From Other Knee Pain: The other common source of pain at the front of the knee.
• Plyometric Progression: Building Explosive Power Safely After Injury: How jump training is built back up after an injury.