The Sore Spot You Can Point To: Understanding Patellar Tendinopathy Treatment and How Physical Therapy Can Help
It is not the whole knee. You would put one fingertip on a spot just below the kneecap and say there — right there. It was quiet during the match. It spoke up getting out of the car, and again on the stairs the next morning.
That one-finger spot is the most useful thing about this problem, because it points at a specific tissue: the patellar tendon. Patellar tendinopathy treatment gets written about as though the main question is which exercise to do. The more important question comes first, and it is whether the pain is coming from the tendon below the kneecap or the joint behind it.
Those two problems are neighbors and they are not the same problem. They hurt in different places, respond to different loading, and get confused for each other constantly.
The good news? Three things together point at the tendon fairly reliably, and what the tendon responds to is simple — though simple is not the same as certain.
At Rooted Motion Physical Therapy we work with people in their own homes across Richmond, Midlothian and Henrico, which means we watch the stairs, the curb and the lunge that actually provoke it.
Where Exactly Does It Hurt?
Patellar tendinopathy sits at the bottom tip of the kneecap, where the tendon leaves the bone. The tenderness is focal — a small, specific spot you can find with one finger, in the same place every time.
That tenderness matters, and on its own it is not enough to go on. In a study of 326 tendons in junior basketball players, pressing on the tendon was a reliable test when the same examiner repeated it — but in tendons that already hurt it identified the problem correctly about two-thirds of the time, judged against what ultrasound showed, and used as a screening test in players with no symptoms it was right barely a third of the time. Mild tenderness in a jumping athlete with no symptoms should be regarded as normal.
So we treat the sore spot as one of three signs rather than as a test. The three we look for together are: pain that tracks your loading rather than your day; a focal tender spot at the bottom tip of the kneecap; and pain that stays on that spot, rather than spreading across the front of the knee, when you squat down slowly on that leg alone. That grouping is how the problem is assessed in practice rather than a rule any trial has tested.
Pain behind or around the kneecap is a different thing, and we have written about it separately: Fine During the Match, Sore on the Drive Home covers knee pain in tennis players coming from the joint behind the kneecap. If you cannot find a single tender spot and the ache is vaguer, start there instead.
Why Does It Hurt Tomorrow and Not Today?
Because a tendon's complaint is delayed. The session that loaded it and the moment you feel it are usually not the same day — the single biggest reason people misread what provokes it.
That lag has a practical consequence: judge a session by how your knee feels during it and you will get the answer wrong. The useful question is how it feels the next morning, and whether that settles within a day.
It also explains the stairs. Going down loads the tendon harder than going up, and so do lunging, jumping, landing and the deep knee bend of digging out a low ball.
What Does the Research Actually Say?
Here we have to be more careful than most articles on this subject are. A Cochrane review published in 2025 pooled the exercise trials for this condition and found seven of them, with 211 participants between them. Its verdicts are hedged throughout: very uncertain whether strengthening exercise reduces pain compared with no treatment, and possibly little or no difference in function.
And every single trial was in athletes — around nine in ten of them male, average age twenty-six, most of them in jumping sports. The reviewers say plainly that this limits the findings to athletes rather than the general public.
If you are a fifty-year-old who plays doubles twice a week, there is no trial that studied you. We would rather say so than hand you a program built for a twenty-six-year-old volleyball player and imply the evidence covers it.
There is a reassuring half to that, and it would be unfair to leave it out. Twelve weeks of moderate slow resistance training — nothing exotic, a little over half of a maximum lift — thickened the patellar tendon by the same amount in men averaging seventy as in men averaging twenty-five. That study had eleven younger men and thirteen older ones, and they were healthy rather than sore, so hold it lightly. But the patellar tendon was also the one tendon the researchers measured where the older men did not start out with poorer mechanical properties. An older tendon is not a tendon that has stopped responding.
So What Is Worth Doing?
Loading the tendon, progressively, for longer than feels reasonable.
The loading research is more modest than the headlines. A trial of 76 athletes found a progressive tendon-loading program beat the older eccentric-only decline-squat approach at twenty-four weeks — but both groups improved substantially, by 28 and 18 points on a hundred-point scale, and the gap between them was 9 points, which is real but around or below what a patient would actually notice. More of the progressive group returned to sport, 43% against 27%, and that difference was not statistically significant.
And heavier is not better. A trial of 44 people compared lifting at ninety percent of a maximum against fifty-five percent, with the total amount of work held equal. Both groups improved, both still held their gains at a year, and the heavy group had no advantage on any clinical measure. Neither group's tendon reached the values of a healthy one.
A systematic review across both the Achilles and the patellar tendon found the evidence for isolating the eccentric part conflicting in this tendon, with heavy slow resistance better supported, and noted that up to 45% of people may not respond to eccentric-only training at all.
A third trial compared twelve weeks of heavy slow resistance, eccentric decline squats and a corticosteroid injection in thirty-nine men. All three improved at twelve weeks. At six months the two exercise groups had held their gains and the injection group had not.
Two honest limits on all of that. The two best-supported programs — progressive loading and heavy slow resistance — have not, as far as we can find, been compared directly with each other. And in the best of these trials, people completed only about 40 to 49% of the sessions they were given. Whichever program turns out to be ideal, doing it is the part that moves.
What About the Things You Can Buy?
This part costs us something to write, and we think it belongs here anyway.
A blinded trial of 48 people compared an eccentric exercise program on its own against the same program plus dry needling, and against the same program plus needle electrolysis — with a sham needle in the control group so nobody knew which they had. Everyone improved, and the needling arms did not improve more, at ten weeks or at twenty-two. Improvement was not matched by any change in the tendon's appearance on ultrasound either.
We offer dry needling, so read this knowing that. That trial is the best-controlled answer available for this tendon, and the answer it gives is no added benefit. It is also one trial of 48 people split three ways — about sixteen per group — which is too small to rule out a modest effect, and it asked one narrow question: needling added on top of a loading program, for this one tendon. Nobody has repeated it. A larger trial would settle it, and until one exists this is the honest answer. We are not going to sell it to you as the thing that fixes this, and you should have the evidence before you pay for anything.
Injections get the same treatment. The best-controlled answer for this tendon comes from a trial of 57 athletes who all did six weeks of supervised heavy slow resistance and were randomly given a single injection of platelet-rich plasma — in two different preparations — or a single injection of salt water. There was no difference between the three groups at twelve weeks, or at any point after it. At one year the salt-water group had the highest average score of the three.
The Cochrane review likewise found little or no difference between exercise and a corticosteroid injection at the end of treatment, and the twelve-week trial above found the injection group losing ground by six months.
Can You Keep Playing?
Often, yes — and here the evidence is messy, so we will show you both sides. A much-quoted crossover study found that a single bout of isometric quadriceps holds dropped tendon pain from 7.0 to almost nothing out of ten, and held it for 45 minutes. That study had six participants. A later crossover trial in 21 people found a mean reduction of under one point, not sustained at 45 minutes, and no advantage for isometric holds over ordinary dynamic exercise.
The practical read: a few heavy holds before you play may take the edge off for some, the effect is probably smaller and shorter than the famous number suggests, and it is not the treatment. The loading is.
How Long Does This Take?
Longer than you want. In a season-long cohort of 515 youth basketball players, symptoms persisted for a median of 83% of the player's season. Narrative reviews describe the condition as often lasting years, and most people arrive having had it a long time already.
The long view is better than that sounds. Fifty-eight athletes, average age thirty, who had been treated with education, load management and exercise were followed up five years later. Three-quarters felt recovered. Pain during sport had fallen from a median of 7 out of 10 to 2, and function scores had gone from 57 to 82 out of 100. Seven in ten were back in the sport they wanted — though of those, about a third were playing below their pre-injury level, and roughly one in eleven had stopped playing altogether. Close to a quarter did not feel recovered.
None of that is a reason to do nothing. It is a reason to start sooner, to progress on purpose rather than by feel, and to stop expecting a six-week resolution. One signal: in that youth cohort, previous pain at the front of the knee carried far higher odds of developing this — though the range around that estimate was very wide, and they were eleven to eighteen year olds playing basketball, not adults playing tennis.
Across 31 studies, researchers looking for changeable risk factors found no strong evidence for any single one. Greater activity volume, higher body weight and a higher jump were associated with it — but associated, in mostly cross-sectional research, is not the same as causing it.
The Rooted Motion Difference
A tendon problem is a loading problem, and loading happens in your life, not in a treatment room. That is the argument for how we work:
An assessment that separates the tendon below the kneecap from the joint behind it, using all three signs rather than the sore spot alone.
A progressive loading program you can actually run on your own stairs and in your own doorway.
Honest framing of what the evidence supports and what it does not, including for your age group.
A plan for playing through it where that is reasonable, rather than a blanket instruction to stop.
Clear markers for what should change by when, measured the morning after rather than during.
Convenient concierge mobile physical therapy delivered where you are.
Because recovery is not just about getting the pain down—it is about helping you get back to living your life.
Been Pointing at the Same Spot for Months?
Tendons respond to being loaded well and ignore almost everything else — good news if you know what loading well means for your knee this week. Working that out is most of the job.
Move Better. Live Rooted. Contact Rooted Motion Physical Therapy to schedule your one-on-one evaluation and begin a personalized plan.
Research Used for This Article
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Kongsgaard M, Kovanen V, Aagaard P, Doessing S, Hansen P, Laursen AH, Kaldau NC, Kjaer M, Magnusson SP. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scandinavian Journal of Medicine & Science in Sports. 2009;19(6):790-802. DOI
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Educational disclaimer: This article is for educational purposes and is not a substitute for an individual evaluation by a licensed healthcare professional. Seek prompt medical evaluation if you felt or heard a pop and cannot straighten the knee or lift it against gravity, if the kneecap sits visibly out of position, if the knee will not take your weight, or if it is hot, red, markedly swollen or accompanied by fever. Pain in a growing adolescent near the kneecap or shin warrants its own assessment. Seek care promptly for severe pain, significant weakness or new numbness.
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