Part of Patellar tendinopathy
Why your patellar tendonitis is not healing, and what to change
Warning signs, and when to get help
Why is my patellar tendonitis not healing?
Because the dose is wrong, which covers five of the six reasons below, and because it is not the tendon in the sixth.
That is the pattern we see in people who arrive months in, and it needs saying before the detail, because most people get here convinced they have done too much. Usually the opposite is true. They stopped the sport, stopped the gym, cut their walking, and now the tendon has spent three months being asked for nothing while the pain carries on.
Start with the word healing, which sets the wrong expectation. A tendon that has hurt for months is not a cut waiting to close. The useful question is how much load it will tolerate before it complains, and that number moves only when something asks it to move. Time on its own does not shift it, which is why the patellar tendinopathy program is staged rather than paced by the calendar.
It is usually under-loaded, not over-loaded
The first reason, and the one that changes the most outcomes.
Malliaras and colleagues (2015) describe the management of this condition as progressively increasing the load the tendon, the thigh muscles and the whole leg can tolerate, while dealing with whatever is overloading it, and they warn against relying on passive treatments for the result. Nothing in that approach is achieved by rest. A tendon held below any meaningful demand gets no reason to change.
Here is how it usually looks in practice. Pain arrives, sport stops, the knee feels better within a fortnight, and the person takes that as healing. Six weeks later they go back to a game and the tendon, which is now less capable than it was at the start, hurts more than it did. Many readers have been round that loop two or three times and have concluded their tendon is unusually stubborn, when the loop itself is the problem.
What breaks the loop is loading that is boring, graded and dull. Holds first if the tendon is irritable, then heavy slow strength work, and only then the springy work. Our wall sit and squat hold pages are where that starts, usually at 3 to 5 holds of 10 to 30 seconds with a rest between, and the depth matters more than the number. Your physio will adjust this. Keep breathing through every hold, since straining with a held breath can raise your blood pressure, and if you have high blood pressure or a heart condition, ask your doctor or physio about long holds first.
You may be at the wrong stage for the tendon
The second reason, and it goes wrong in both directions.
The staged approach that Malliaras and colleagues set out, and that Breda and colleagues (2021) tested in a trial, runs from held contractions to heavy slow strength work to energy-storage loading and then back to the demands of the sport. Each stage earns the next. Two errors account for most stalls: skipping the holds and the slow strength work to get back to jumping, and sitting in the holds for months because they are comfortable.
Signs you have moved on too early are reasonably clear. The pain during the exercise climbs through the set rather than staying level, the knee is worse the next morning after every session, and the sore spot is sharper rather than duller after a week of it. Signs you have stayed too long are quieter: nothing hurts, nothing is getting harder, and the weight or the step height has not changed in a month.
Seated knee extension, the split squat and the step up are three of the loads the middle stage uses, and each page carries its own starting dose. A program that has not changed in four weeks is not a program, it is a habit.
How many months is normal?
The third reason is the calendar, and it is longer than almost anyone expects. The trial numbers are the fairest answer available.
Breda and colleagues (2021) randomized 76 people with patellar tendinopathy to staged tendon loading or eccentric exercise, and followed them for 24 weeks. The staged group improved by 28 points on the tendon questionnaire against 18 points, a difference of 9 points that was statistically significant. Return to the previous level of sport was 43 percent in the staged group and 27 percent in the other, and that gap was not statistically significant.
Read those two figures together and the picture is honest rather than discouraging. A properly run program moves the pain and the function, and six months in, fewer than half of a young, motivated trial population were back where they started from. So a tendon that is still troublesome at eight weeks is not failing. It is eight weeks into something that is usually measured in months, and the question to ask is whether the loading has actually progressed over those eight weeks.
The load spike you have not counted
The fourth reason, and it hides outside training because nobody writes daily life in a training log.
The things we ask about, and the things people forget to mention: a new job on your feet, a house with stairs, a holiday with a lot of walking, a toddler being carried, a long drive with the knee bent, a new pair of flat shoes, or a return to cycling with the saddle lower than before. Any of those can add more to a tendon's week than the exercise program removes.
The giveaway is a tendon that was improving and then plateaued without the program changing. In that situation the program is usually not the thing that changed. Write down what else moved in the same fortnight, because that is where the extra load is, and the fix is often to take the spike out for a few weeks rather than to cut the rehab.
Rest is not the treatment
The fifth reason overlaps the first, and it is given as advice so often that it needs saying on its own.
Stopping everything reliably reduces pain in the short term and reliably fails over months. What usually works better is reducing the part the tendon objects to, which is the springy load, and keeping the rest. A tendon can take a surprising amount of slow, heavy work on a day when it would not tolerate ten jumps.
Painkillers and ice sit in the same category as rest. The NHS suggests limiting the weight on a painful knee, cold packs and simple painkillers in the first days, and all of that is reasonable for comfort. None of it changes what the tendon tolerates, and a few weeks spent on comfort alone is a few weeks where the thing that does change it has not been started. The pain monitoring model is the usual way physios keep activity going while still guiding it by symptoms.
Or it is not the tendon at all
The sixth reason, and the one to consider seriously once a genuinely staged program has had months.
Pain at the front of the knee has several sources, and they respond to different things. An ache spread around or behind the kneecap, worse on stairs in both directions and after long sitting, fits patellofemoral pain better than a tendon. A stiff, achy knee in an older adult, worse in the morning, fits knee osteoarthritis. Catching, locking, swelling or giving way belongs to the joint, and the meniscus tear program covers the commonest reason for that.
Two more are worth naming because they are missed. Malliaras and colleagues point out that an irritated fold in the joint lining, called a plica, can hurt in activities that use only a shallow knee bend, such as walking, which is not how a tendon behaves. And knee pain can be referred from the lower back, which is why the warning list at the foot of this page carries a line about pain spreading from the back or buttock with numbness or tingling in the leg.
The simplest check is the location. Where jumper's knee hurts goes through the one finger test and the four places people confuse with the tendon, and if your sore point is not the bottom tip of the kneecap, the first thing to revisit is the diagnosis rather than the program.
How do you tell whether it is improving?
With a test you repeat, not with an impression, because a tendon's day-to-day feel is unreliable.
Pick one load that reproduces the pain and use it as your measure: a single leg squat, a step down from a set height, or a hop if you are at that stage. Do it at the same time of day, ideally before the knee has warmed up, and record what it felt like and how far you went. A tendon that has warmed up for twenty minutes will flatter you, which is why mid-session pain tells you almost nothing.
Questionnaires do the same job for the parts a single test misses. The trials in this field track progress with the VISA-P, a tendon-specific questionnaire covering pain, function and sport, and Breda and colleagues used it as their main outcome. Outcome measures in physical therapy explains why a repeated measure beats a general sense of how things are going, and it is the same reason a repeat scan is not the way to check progress.
What the next morning tells you
More than anything the session itself tells you, and this is the rule to take away if you take only one.
Malliaras and colleagues set the criterion for tolerating a level of energy-storage work as minimal pain during the exercise, with the pain on load testing back to its usual level within 24 hours. That gives you a decision rule rather than a feeling. If the tendon is clearly sorer or stiffer the next morning, yesterday was too much, and the response is to drop back one step and rebuild rather than to stop.
Used consistently, that rule also answers the question you came with. A tendon that settles by the next morning after every session is tolerating its dose, and if it is not improving over a month, the dose is too small rather than too large. A tendon that is worse most mornings has been over-dosed for weeks, whatever the plan on paper says.
When injections and surgery come up
Honestly placed: they come up when loading has genuinely been given its time, and not before.
There is one firm point to carry into that conversation. OrthoInfo states that corticosteroid injections for patellar tendinitis have been linked with increased tendon weakness and an increased likelihood of rupture, and that doctors typically avoid giving them in or around this tendon. That is the same caution the tear page carries, and it is a statement from a surgical body about this specific tendon.
As for everything else, Challoumas and colleagues (2021) reviewed 37 randomized trials, named eccentric loading the first-line treatment, recommended against shockwave therapy and against concentric exercise on its own, and described most of the evidence base as low or very low certainty. Surgery for this condition exists and is a late option rather than a standard one. Where you have genuinely done months of staged loading and nothing has moved, the next step is a conversation with the doctor or surgeon assessing your knee, and the question worth asking first is still whether the diagnosis is right.
Does a scan help when it is not healing?
Usually it changes nothing, and understanding why saves people a disappointing appointment.
Malliaras and colleagues state that tendon imaging does not confirm that the tendon is the source of pain, because the same changes are found in people with no symptoms, and that serial imaging is therefore not recommended: symptoms often improve without any matching change on ultrasound or MRI. Docking and colleagues (2015) make the broader point about tendon imaging, that it shows the presence and extent of structural change but that the structural picture and the clinical picture are not directly linked, much as they are not in osteoarthritis or disc degeneration.
Where a scan does earn its place is in answering a different question: an uncertain diagnosis with alternatives worth excluding, a suspected tear, or a decision about an operation. Does patellar tendonitis show up on MRI covers what a report means and when the picture is worth having.
When to go back to your physio
If you have read this far, the answer is probably now rather than after another month of the same.
The NHS line for knee pain is to see a doctor if it does not improve within a few weeks, and a tendon that is months in is well past that. What an assessment buys you is specific: someone to confirm the pain is coming from the tendon, re-stage the program to what the tendon can take today, find the load spike you have not counted, and set the point at which jumping goes back in. Knee pain after running, the return to running plan and returning to the gym after injury cover the staged return on the activity side.
Go sooner than that for anything on the warning list at the foot of this page. Straps and braces for jumper's knee answers the other question readers at this stage usually ask, and the short version is that a strap is worn for comfort and is not a substitute for the loading program. If you have had surgery on this knee, your surgical team's plan comes first, and anything new in an operated knee goes to them rather than to a page.
Related exercise programs
Warning signs
Get emergency help now
- Emergency: pain, tingling, numbness or weakness in both legs, numbness or altered feeling around your genitals or bottom, or new trouble peeing or controlling your bladder or bowels. The same applies if you lose feeling in one leg. Call emergency services or go to an emergency department straight away. These can be signs of pressure on the nerves at the base of the spine (cauda equina syndrome).
- Emergency: you felt a sudden pop or tearing feeling just above or below your kneecap, you can see or feel a dip there, the kneecap seems to have moved up toward the thigh or to sag lower than usual, or you suddenly cannot straighten your knee or lift your leg out straight. Stop exercising and go to an emergency department straight away, even if you can still walk, as this can be a torn tendon at the front of the knee, either below the kneecap (patellar tendon) or above it (quadriceps tendon). Do not drive yourself. A repair usually does better if it is done soon after the injury.
- Emergency: you are still growing and have pain that wakes you at night, pain at rest that keeps getting worse, or a lump or swelling around the knee or thigh that keeps growing. If you also have a rash that does not fade when you press it, call emergency services or go to an emergency department.
Get help now, day or night
- Your tendon pain or swelling started while you were taking a fluoroquinolone antibiotic, such as ciprofloxacin or levofloxacin, or in the months after a course. Contact your doctor straight away. The UK medicines regulator (MHRA) advises stopping the antibiotic at the first sign of tendon pain or swelling and talking to your doctor. Hold off the knee exercises until you have been checked.
Get help today
- Same day: the knee is hot, red and swollen, or you have knee pain with a high temperature or feel hot, cold or shivery. Get medical advice the same day, and go to an emergency department if you feel very unwell. This can be a sign of infection in the joint, which needs treatment quickly.
- Same day: the knee swells up with no clear reason, especially if you take medicine to thin your blood. Get medical advice the same day.
- Same day: a calf or thigh that is newly swollen or getting more swollen, warm, tender, red or darker than usual, has swollen veins that are sore to touch, or has a throbbing or cramping pain that does not fit your injury or condition, or that feels different from normal muscle soreness after exercise. This can be a sign of a blood clot (deep vein thrombosis), especially after surgery, an injury, time in a cast or boot, a long trip or a spell of being much less mobile than usual. Get medical advice the same day. If you are also short of breath or have chest pain, call emergency services.
- Same day: a leg or foot that is getting weaker, for example your foot drags, catches on the ground or slaps down when you walk (foot drop). Get medical advice the same day. If the weakness is getting worse by the hour, go to an emergency department.
- Same day: you are a teenager who is still growing and you have a limp, or pain in the hip, groin or thigh as well as the knee. Get an urgent appointment with a doctor the same day, and stay off sport and these exercises until you have been checked. If you cannot put weight on the leg, have a high temperature or feel very unwell, go to an emergency department. Some hip problems in growing teenagers, such as a slipped growth plate at the top of the thigh bone (slipped capital femoral epiphysis), are felt in the knee and need checking quickly.
- Same day: pain at night or at rest that keeps getting worse. If you are being treated for cancer now, contact your cancer team the same day.
Book an appointment
- Within a day or two: you are still growing and have pain that wakes you at night, pain at rest that keeps getting worse, or a lump or swelling around the knee or thigh that keeps growing. See a doctor within a day or two. Ask for an urgent appointment rather than the next routine one, and say what the pain does at night and whether a lump is getting bigger. Do the same if the pain comes with looking pale, unusual tiredness, fevers with no clear cause, bruising or bleeding easily, or weight loss. Bone pain that is worse at night, or a new lump, needs checking to rule out rarer causes such as a bone tumor or a blood cancer (leukemia).
- Within a day or two: pain at night or at rest that keeps getting worse. If you have had cancer, now or in the past, see your doctor sooner, within a day or two, and mention it, even if the pain is not getting worse. Do the same if you have knee pain and are losing weight without trying, even if it does not hurt at night.
- Within a few days: pain at night or at rest that keeps getting worse. See your doctor within a few days.
- Within 2 weeks: pain that spreads from your lower back or buttock down the outside of the thigh or below the knee, especially with numbness, tingling or pins and needles in the leg or foot. The pain may be coming from your back rather than the knee. Book an appointment with a doctor or physio. If your leg or foot is getting weaker, for example your foot drags, catches on the ground or slaps down when you walk (foot drop), get medical advice the same day, and if the weakness is getting worse by the hour, go to an emergency department.
Common questions
Why is my patellar tendonitis not healing?
Most often because the tendon is not being asked to do enough, or is being asked at the wrong stage, or has not had enough months. Malliaras and colleagues (2015) describe the treatment as progressively building what the tendon can tolerate rather than waiting for it to settle, and they caution against leaning on passive treatments. The reason the under-loading answer surprises people is that the pain behaves as though load is the enemy. It is the size of the step up that provokes a tendon, not the fact of being loaded.
How long does patellar tendonitis take to heal?
Months, and the research puts numbers on it. Breda and colleagues (2021) followed 76 people for 24 weeks on one of two loading programs, and the group that did better improved by 28 points on the tendon questionnaire against 18 for the other. Even so, 43 percent of that group and 27 percent of the comparison group had returned to their previous level of sport by the end. So six months of consistent work is a realistic frame, and a few weeks is not.
Can patellar tendonitis be permanent?
Long-standing is common, permanent is not the useful way to think about it. What makes the difference is whether the tendon has been given a progressive load for long enough to change what it tolerates, and plenty of people arrive having had months of pain without ever having had that. Challoumas and colleagues (2021) reviewed the randomized trials and named eccentric loading the first-line treatment, while describing most of the evidence as low or very low certainty. Where months of properly staged loading have genuinely been done and nothing has changed, the next question is whether the diagnosis is right, which is the sixth reason on this page.
Should I rest completely until it settles?
Complete rest is the commonest reason a tendon stalls, in our experience of seeing people months in. Resting takes the pain down, which feels like progress, and it also takes away the only thing that builds the tendon's tolerance, so the pain returns with the first return to sport. What usually works better is cutting the springy load, the jumping and bounding, while keeping and then building the strength work. Your physio will set that balance for your knee, and the warning lines on this page are the exception: those are reasons to stop and be checked rather than to adjust a dose.
References
- Malliaras P, Cook J, Purdam C, Rio E. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. Journal of Orthopaedic and Sports Physical Therapy. 2015;45(11):887-898. https://doi.org/10.2519/jospt.2015.5987
- Breda SJ, Oei EHG, Zwerver J, Visser E, Waarsing E, Krestin GP, de Vos RJ. Effectiveness of progressive tendon-loading exercise therapy in patients with patellar tendinopathy: a randomised clinical trial. British Journal of Sports Medicine. 2021;55(9):501-509. https://doi.org/10.1136/bjsports-2020-103403
- Challoumas D, Pedret C, Biddle M, Ng NYB, Kirwan P, Cooper B, Nicholas P, Wilson S, Clifford C, Millar NL. Management of patellar tendinopathy: a systematic review and network meta-analysis of randomised studies. BMJ Open Sport and Exercise Medicine. 2021;7(4):e001110. https://doi.org/10.1136/bmjsem-2021-001110
- Docking SI, Ooi CC, Connell D. Tendinopathy: Is Imaging Telling Us the Entire Story? Journal of Orthopaedic and Sports Physical Therapy. 2015;45(11):842-852. https://doi.org/10.2519/jospt.2015.5880
- American Academy of Orthopaedic Surgeons. Patellar Tendon Tear. OrthoInfo. https://www.orthoinfo.org/en/diseases--conditions/patellar-tendon-tear/
- NHS. Knee pain. Page last reviewed 21 December 2023. https://www.nhs.uk/symptoms/knee-pain/
Written and checked by the PocketPhysio editorial team. Last updated 2026-10-21.
This page is general education, not a diagnosis or a personal treatment plan. See a physiotherapist or doctor for advice about your own situation.