Episode 22 | Ask the Expert | Guest: Dr Lewis Raiman MBBS, MRCGP, FFSEM – Consultant in Sports and Exercise Medicine, LBSM
Knee pain is among the most common complaints seen in sports medicine, and within that group, patellar tendinopathy stands out as both very common and frequently misunderstood. Many people live with it for months, managing symptoms well enough to keep training – until a point where they can’t.
In this episode of the London Bridge Sports Medicine podcast, LBSM’s Dr Lewis Raiman joins Lucie to explain what’s actually happening in the tendon, how modern management has shifted away from old approaches, and what the options are when rehab alone isn’t enough.
What is patellar tendinopathy – and why is it called jumper’s knee?
The patellar tendon connects the kneecap (patella) to the shin bone and is central to all knee extension movements – running, jumping, walking upstairs, and squatting. Patellar tendinopathy is a condition in which this tendon becomes overloaded and painful, typically felt as a well-localised ache or tenderness just below the kneecap.
The “jumper’s knee” label reflects how commonly it affects sports with high repetitive jumping demands – basketball, volleyball, netball – but Dr Raiman is clear that it is by no means exclusive to jumpers. Runners, footballers, people who work on their feet for long shifts, and those who have simply increased their activity levels too quickly are all in the firing line.
One of its defining characteristics is a deceptive symptom pattern: the tendon often feels manageable during activity, only to become significantly more painful hours later or the following day. This latency means many people continue training through an injury that is quietly worsening, not presenting to clinic until symptoms become harder to ignore.
The tendinopathy continuum: from reactive to degenerative
Dr Raiman uses the tendinopathy continuum as his clinical framework – a model that describes how the condition can progress through distinct stages if not managed appropriately:
- Reactive tendinopathy – the earliest stage, where the tendon responds to a sudden increase in load with pain and swelling. At this point there are no permanent structural changes; the tendon is essentially issuing a warning sign. Common triggers include a sudden increase in training volume, a new sport or activity, or a particularly demanding event.
- Tendon disrepair – if loading continues unchecked, structural changes begin. These become visible on ultrasound or MRI, with evidence of disorganised tissue within the tendon.
- Degenerative tendinopathy – the most advanced stage, with more significant structural breakdown and a higher risk of complications such as partial or complete tendon rupture. More common in older patients and those with certain risk factors including diabetes.
The key clinical insight here is that early intervention – ideally at the reactive stage – offers the best outcomes. The longer the tendon is overloaded without appropriate management, the further along the continuum it progresses and the harder it becomes to reverse.
Diagnosis: history, examination, and ultrasound
The clinical history is usually highly informative. A well-localised pain below the kneecap that is worse after activity (particularly the following day), that has come on in the context of increased loading, and that is reproducible on palpation of the tendon is a strong indicator.
In clinic, Dr Raiman uses diagnostic ultrasound as a key tool – assessing tendon thickness, identifying tears, and using Doppler imaging to detect inflammation and gauge how “irritable and angry” the tendon currently is. Ultrasound also helps distinguish between mid-portion tendinopathy (affecting the middle of the tendon) and insertional tendinopathy (at the base of the kneecap) – a distinction that has practical implications for management.
Strength testing, including force plate assessment to identify side-to-side deficits, adds further detail to the picture and helps direct the rehabilitation programme.
Treatment: the cornerstone is load management and strength
Managing load
The first priority is almost always to reduce the load mismatch – the gap between what the tendon is being asked to do and what it is currently capable of tolerating. This does not necessarily mean stopping activity entirely, but it does mean reviewing the total volume and distribution of loading across the week.
Dr Raiman considers not just sporting activity but also occupational loading – a 12-hour shift on your feet, or a job involving significant lifting and stair use, contributes meaningfully to cumulative tendon load and must be factored into the management plan.
Heavy slow resistance training
Thinking around tendon rehabilitation has evolved significantly. The previous emphasis on high-repetition eccentric loading has given way to a growing body of evidence supporting heavy slow resistance (HSR) training – higher loads, fewer repetitions, performed slowly and with clear progression.
“The possible thing is that we may have historically been underloading the tendons,” says Dr Raiman. Tendons respond to load – the goal is to provide a controlled, progressive stimulus that drives adaptation without tipping the tendon back into a reactive state. This work must be directed by a physiotherapist to ensure safe and appropriate progression.
Isometric holds – sustained static contractions – remain useful for acute pain management and are commonly used by athletes who need to continue competing while managing symptoms.
When rehab needs a boost: adjunct treatments
Shockwave therapy
Shockwave therapy is a non-invasive treatment in which sound waves are applied to the affected tendon via a probe, with the aim of promoting healing and reducing pain. Sessions typically last around 10 minutes and the process is similar in feel to having an ultrasound scan.
Used alongside physiotherapy – not instead of it – shockwave has good evidence for improving pain scores at three to six months compared to physiotherapy alone. It is particularly effective for mid-portion patellar tendinopathy; for insertional tendinopathy it can be used but is sometimes more uncomfortable during the treatment.
Injection options
Injections are considered when symptoms are severe enough to prevent engagement with rehabilitation – not as a standalone fix. Dr Raiman outlines the main options:
- Corticosteroid – effective for short-term pain and inflammation relief, but evidence suggests outcomes at three to six months are often worse than without. More significantly, steroid around a tendon can weaken its structure and increase the risk of tears or rupture. Used with caution around the patellar tendon.
- High volume injection – a combination of local anaesthetic, saline, and often low-dose steroid, targeting inflammation around the outside of the tendon rather than within it. An option for suitable patients, but still approached carefully.
- Platelet-rich plasma (PRP) – a blood draw is taken, centrifuged to concentrate growth factors, and injected into the tendon. The evidence is mixed but it remains a valid option for appropriate patients, particularly those who have not responded to other treatments.
- Hyaluronic acid – more commonly used in joints, but can be applied around tendons in certain cases.
All injection therapy carries risk – infection, discomfort, and in the case of steroid, structural weakening. The value of injection is in enabling a patient to engage with rehabilitation, not in replacing it.
The bottom line
Patellar tendinopathy is a condition where early, appropriate management makes a significant difference to how far along the continuum it progresses – and to how quickly someone gets back to doing what they love. The cornerstone of treatment is managing load and building tendon capacity through targeted strength work, ideally directed by a physiotherapist.
If symptoms are persistent, not improving with self-managed load reduction, or starting to affect everyday function, a proper assessment – combining history, examination, and imaging – is the right next step. The diagnostic picture shapes the management plan, and the management plan works best when delivered by a coordinated team.
Dr Lewis Raiman (MBBS, MRCGP, FFSEM) is a Consultant in Sports and Exercise Medicine at London Bridge Sports Medicine, specialising in the non-surgical management of musculoskeletal injuries across all levels of sport and activity.
To book an appointment with Dr Raiman or another member of the LBSM team, visit lbsm.co.uk/booking
Listen to the full episode below ↓
