Author(s): Timothy Tiu, MD, Azmeer Khamisani, MD, Dylan Wood, MD
Originally published: September 20, 2013 Last updated: March 20, 2025
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Disease/Disorder

Definition

Overuse injuries of the knee result from microtrauma associated with activity and exercise that exceed tissue tolerance of the muscle, tendon, cartilage or bone. These are often seen in both the adult and pediatric population and can result in functional impairment and pain. These include but are not limited to iliotibial band syndrome (ITB syndrome), pes anserine bursitis, bone stress injuries, tendinopathies, (e.g. patellar tendinopathy) and patellofemoral pain syndrome (PFPS).1

Etiology

Overuse knee injuries are multifactorial and can involve both extrinsic and intrinsic factors. They occur due to repetitive loading of the joint tissue with insufficient rest in between episodes of impact, and with an insidious onset. It is common in athletes who play sports year-round, exceed training loads, or prematurely commit to single sport specialization.2 Less often, it may also occur without a specific and identifiable event.3

Epidemiology including risk factors and primary prevention

Athletes who participate in individual sports including but not limited to tennis or gymnastics are at higher risk for overuse injury.3 Other risk factors include sudden increase in intensity, duration and volume of physical activity, poor sport-specific conditioning, insufficient sport-specific training, poor biomechanics, poor training techniques, and improper fitting or wrong equipment.4

Patho-anatomy/physiology

Knee overuse injuries result from a cumulative process of tissue damage leading to repetitive microtrauma and overload of the tissue which leads to injury without sufficient recovery time.3 Common locations include the pes anserine bursa, overload on the extensor tendons (i.e. patella and quadriceps), friction at the lateral femoral epicondyle leading to ITB syndrome, or abnormal tracking of the patella within the trochlea often seen in PFPS.1

Disease progression including natural history, disease phases or stages, disease trajectory

The trajectory and progression of the disease depends on the specific insult to the knee and area of injury. In tendinopathies, there is often an initial injury phase where the tendons are repetitively overloaded. This stage is often not significant enough to cause pain along the affected area. These often heal spontaneously with rest and offloading. The second stage is failed healing, where the tendons are not properly offloaded or rehabilitated, resulting in microscopic changes and inflammation of the affected tissues. The third stage is the clinical presentation where the individual has pain along the area of tendinopathy. At this point, the individual is at higher risk of rupture of the tendon due to the scarring of tendon and disarray of fibers from improper rehabilitation. Changes may or may not be able to be seen on ultrasound or MRI at this point.5

Specific secondary or associated conditions and complications

A patient-centered approach is vital to maximize the rehabilitation process and prevent or decrease the chances of secondary complications. Patellofemoral pain, often viewed as a self-limiting disease process, has been shown to increase the risk of osteoarthritis between 5-8 years after initial diagnosis. A multicenter observational analysis showed that 57% of women had an unfavorable recovery at a 5-8 year follow-up even though 98% did not show radiographic evidence of OA. Baseline patellofemoral pain duration and anterior knee pain scale were baseline poor predictors for prognosis. it is therefore important for the provider to offer realistic expectations regarding the patient’s prognosis, even in the absence of radiographic evidence.6

Essentials of Assessment

History

In addition to typical components such as onset, location, intensity, alleviating and aggravating factors, information regarding specific sport and player position should be elicited. Recent changes in duration, frequency or intensity of training, in season versus off season, technique, training surface, shoes, stage of training cycle, and frequency of competition should be evaluated as it will influence diagnosis, management and prognosis at the moment of evaluation.7,8 You should also consider other areas such as past medical history, prior injuries, nutrition deficits, a comprehensive review of systems, and the short and long-term goals for the athlete.

Physical examination

Evaluation includes inspection, identification of biomechanical factors including femoral anteversion, knee valgus or varus, patellar malposition, excessive lateral insertion of the patellar tendon, foot pronation, decreased bulk of the vastus medialis muscle, muscle imbalance and abnormal tracking of the patella.7 Palpation with tenderness along the patellar facets (PFPS), distal iliotibial band and lateral femoral condyle (ITB syndrome) and tenderness over the quad (quad tendinopathy) or patella tendon (patellar tendinopathy) may suggest a specific diagnosis as well. Tightness of the hamstring muscles and the iliotibial band should be evaluated. Functional and strength testing may reproduce symptoms and help provide information towards a specific diagnosis. Sensitivity and specificity of the tests must be considered. There is no definitive test for each diagnosis; however, the best tests for PFPS are anterior knee pain during squatting, patellar grind test, quadriceps inhibition testing, or ‘J-sign’ (laterally tracking patella) during passive extension and for ITB syndrome are Ober and Noble’s test.9,10,11

Functional assessment

Functional tasks, such as bilateral and single leg squats, step down, drop jump are used in the evaluation for predisposing factors. Excessive foot pronation, knee valgus, femoral internal rotation, lateral trunk deviation, and pelvic tilt/anteriorization can be identified, allowing for the assessment of hip/knee/ankle misalignment, as well as hip and core muscle weakness.8

Laboratory studies

Laboratory studies are not necessary for diagnosis of knee overuse conditions. However, they should be included if other conditions, such as infection, malignancy or inflammatory arthritis are suspected.

Imaging

Plain film weight bearing radiographs may help rule out other conditions causing anterior knee pain such as stress fracture, bipartite patella or osteochondritis dissecans. Radiographs are not routinely indicated in ITB syndrome; however, you may identify calcifications or enthesophytes (usually chronic) along the tendons or at their attachments.8 There are no specific findings associated with PFPS on radiographs. However, sunrise view may give clues to PFPS if there is a lateral tilt of the patella or shallow trochlear groove.11 Ultrasound may be useful in evaluating findings in PFPS including intra-articular effusion, quadriceps tendon thickness >0.53cm, patellar tendon thickness >0.34cm, gluteus Medius thickness asymmetry during contraction and fiber angle. CT can be beneficial to identify degenerative changes or to assess focal changes in bone structure, while MRI can be sensitive for tendon changes, bone stress injuries or edema as well as other causes of pain not otherwise seen on plain radiograph.12

Supplemental assessment tools

Supplemental assessment tools include gait analysis, anthropometric evaluation of hamstring/quadriceps flexibility, dynamic landing, isokinetic testing, instrumented Q angle measurement, and dynamic electromyographic measurements.8 Additional functional assessment tools such as the Kujala anterior knee pain scale has been determined to be reliable and valid for measuring outcomes of PFPS.13 There is no formal tool to assess patella tendinopathy or ITB syndrome.10,14

Early predictions of outcomes

Predictors of poor outcomes include reduced hamstring flexibility, high weekly running volume, and degree of activity. Patients with pain at rest or during daily activities may have slower response to treatment than patients with pain only during or after vigorous activity.15 Patients with patellar tendinopathy and identifiable tendinous neovascularization on ultrasound tend to have more pain and lower functional scores as measured by the Victorian Institute of Sport Assessment Questionnaire than patients without neovascularization.16 Lower scores on the anterior knee pain scale and baseline duration of knee pain serve as indicators for poor outcomes in PFPS regardless of age, BMI, and gender.17

Environmental

Environmental changes such as specific type of shoe used or shoe-surface interface often have direct effects on the knee and associated structures, due to loading and displacement of forces. For any athlete or individual presenting with a knee injury, it is important to ask about new shoes, terrain, increases in duration, and slope of incline/decline with exercise or ambulation as these will have different loading forces that could predispose someone to tendinopathies, bursitis, or bone stress injuries.

Social role and social support system

An often-overlooked factor that can predispose individuals to chronic knee pain is depression. There is a strong relationship between depression and knee pain. Depressive symptoms predispose the individual to have fear of pain and reduced physical activity, resulting in muscle wasting and reduced joint stability. This becomes a feedback loop into not only chronic pain, but also worsening psychosocial aspects. Studies have shown a significant reduction in pain symptoms following treatment with antidepressants; but using a holistic and multidisciplinary approach to knee pain can help the provider better treat the patient due to their multifaceted etiology of pain.18

Professional issues

Return to sport is an important issue when dealing with athletic injuries. Premature return to sport may predispose an athlete to not only further injury of the knee because of abnormal mechanics in running or jumping, but also poor athletic performance and prolonged symptoms. It is important to discuss this with the athlete and the multidisciplinary team, considering the athletes’ competitive priorities for the most well-informed decision.

Rehabilitation Management and Treatments

Available or current treatment guidelines

No specific treatment guidelines exist for most of these conditions. However, based on the nature of the disease process and review of medical literature, it is agreed that conservative therapy should be considered instead of surgical management apart from failed conservative management.4

At different disease stages

A patient-centered approach should be implemented, with consideration of evidence-based literature and clinical presentation. Conservative management options consist of ice, relative rest with modification of activity, and short-term use of anti-inflammatory medications. Local injections of corticosteroid are contraindicated into tendons due to risk of rupture. Rehabilitation exercises focus on increasing flexibility, strength, endurance, and neuromuscular training of the quadriceps, hamstrings, and gastrocnemius muscles.4 There is also emphasis on benefits of addressing proximal hip muscle strengthening, especially hip abductors, during early-stage treatment to address knee malalignment associated with PFPS and to improve function.16 Closed kinetic chain exercises have also been found effective in reducing pain. Knee immobilization, prolonged sitting, and complete cessation of activities should be avoided. There is lack of strong evidence of knee orthoses, and both insufficient and low-quality evidence for patellar taping.4,19,20 Physical therapy may help address the biomechanical errors and techniques utilized during sports. Oftentimes, these are self-limiting conditions with up to 2 years of complete resolution of symptoms.4 If a patient fails conservative treatment with continued symptoms, surgical evaluation could be warranted to discuss further options.

Coordination of care

A multidisciplinary approach is vital including the patient, physiatrist, physical therapist, athletic trainer, coaches, parents and less often a psychologist or orthotist.

Patient & family education

The patient should be advised on the condition, in regard to natural course, prognosis, and treatment options. They can also review future preventative strategies.

Measurement of treatment outcomes

There are multiple outcome measurements used to determine the success rate of rehabilitation of the knee joint. Some of the most common measurements used are the Visual Analog Scale (VAS), which measures the continuum of pain on a scale of 0-10, as well as the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) scoring system, which helps to further characterize pain, stiffness, and physical function of the affected joint.

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

The etiology of knee overuse disorders is usually multifactorial including intrinsic and extrinsic factors. Modifiable factors include biomechanical abnormalities, equipment, workload, muscle tightness or strength imbalances, which can be identified and addressed early to avoid chronic symptoms.

Cutting Edge/Emerging and Unique Concepts and Practice

Multiple new technologies and advances in medicine have allowed for unique treatment options that can be tailored to a specific injury. Orthobiologics such as platelet rich plasma (PRP), prolotherapy, topical nitroglycerin, and extracorporeal shock wave therapy have emerging evidence for potential usage. PRP was superior to dry needling in the treatment of patellar tendinopathy at 12 weeks, but there were no differences at 26 weeks. It is possible that the high leukocyte content of the PRP used in this study resulted in a robust inflammatory response leading to an accelerated initial recovery.21 Extracorporeal shock wave therapy is a safe modality for treating tendinopathies, but the evidence for patellar tendinopathy is low with negligible effect on pain and function when compared to placebo. However, it does show a significant decrease in pain when compared to conservative treatment indicating its potential use in conjunction with eccentric exercises. 22 Neural prolotherapy can be used in treatment of chronic pes anserine bursitis pain with results similar to those of corticosteroid injection to the affected region. More research is required with greater statistical power to determine long term efficacy of prolotherapy as opposed to corticosteroid injections.23 The use of prolotherapy has been trialed in patellar tendinopathy as well, with significant decreases in VAS scoring when combined with a graded 12-week exercise program.24 Topical nitroglycerin was proposed in the treatment of tendinopathies; however, evidence is limited with articles showing there is no significant pain relief vs placebo groups up to 12 weeks.25 Stem cells, both bone marrow-derived and adipose-derived, show promising results in chronic knee pain symptoms. Bone marrow derived stem cells for the treatment of patellar tendinopathy show improvement on MRI imaging and clinical pain improvement; however, there is no improvement in pain symptoms when placed back into sporting activities.26 Adipose derived stem cells used in the treatment of insertional patellar tendinopathy show significant improvement in pain during sports and practice at three months, and mild improvement at six and twelve months.27 However, most of the studies are not of high statistical power due to smaller sample sizes and more evidence is needed for further conclusions. Ketorolac injections are also a new proposition as it relates to knee osteoarthritis. Studies have shown that improvements in pain symptoms are similar to intra-articular triamcinolone, but without chondrotoxicity, tenotoxicity, local skin depigmentation, or steroid-induced hyperglycemia, nor does its use preclude the individual from an orthopedic procedure if warranted.28

Gaps in the Evidence-Based Knowledge

Most of the treatment is based on clinical experience and expert opinion with weak to moderate quality studies with consensus for initial conservative management. Specific treatment guidelines for varied knee overuse disorders need to be developed based on solid scientific evidence. The role of specific programs, modifications of sport specific techniques, newer biologic treatments, and optimal surgery in patients that do not respond to conservative management needs to be defined based on prospective and interventional studies.

References

  1. Jarraya M, Roemer FW, Hayashi D, Crema MD, Guermazi A. Overuse-Related Injuries of the Knee. Radiol Clin North Am. 2023 Mar;61(2):249-259. doi: 10.1016/j.rcl.2022.10.004. Epub 2022 Dec 12. PMID: 36739144.
  2. Sweeney E, Rodenberg R, MacDonald J. Overuse Knee Pain in the Pediatric and Adolescent Athlete. Curr Sports Med Rep. 2020 Nov;19(11):479-485. doi: 10.1249/JSR.0000000000000773. PMID: 33156034.
  3. Franco MF, Madaleno FO, de Paula TMN, Ferreira TV, Pinto RZ, Resende RA. Prevalence of overuse injuries in athletes from individual and team sports: A systematic review with meta-analysis and GRADE recommendations. Braz J Phys Ther. 2021 Sep-Oct;25(5):500-513. doi: 10.1016/j.bjpt.2021.04.013. Epub 2021 May 13. PMID: 34039519; PMCID: PMC8536850.
  4. Patel DR, Villalobos A. Evaluation and management of knee pain in young athletes: overuse injuries of the knee. Transl Pediatr. 2017 Jul;6(3):190-198. doi: 10.21037/tp.2017.04.05. PMID: 28795010; PMCID: PMC5532199.
  5. Fu SC, Rolf C, Cheuk YC, Lui PP, Chan KM. Deciphering the pathogenesis of tendinopathy: a three-stages process. Sports Med Arthrosc Rehabil Ther Technol. 2010 Dec 13;2:30. doi: 10.1186/1758-2555-2-30. PMID: 21144004; PMCID: PMC3006368.
  6. Lankhorst NE, van Middelkoop M, Crossley KM, Bierma-Zeinstra SM, Oei EH, Vicenzino B, Collins NJ. Factors that predict a poor outcome 5-8 years after the diagnosis of patellofemoral pain: a multicentre observational analysis. Br J Sports Med. 2016 Jul;50(14):881-6. doi: 10.1136/bjsports-2015-094664. Epub 2015 Oct 13. PMID: 26463119.
  7. Geisler PR. Iliotibial Band Pathology: Synthesizing the Available Evidence for Clinical Progress [published online ahead of print, 2020 Dec 22]. J Athl Train. 2020;
  8. Ortiz A, Micheo W. Biomechanical evaluation of the athletes knee: from basic science to clinical application. PM R. 2011;3:365-371. – 8
  9. Crossley KM, Stefanik JJ, Selfe J, Collins NJ, Davis IS, Powers CM, McConnell J, Vicenzino B, Bazett-Jones DM, Esculier JF, Morrissey D, Callaghan MJ. 2016 Patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester. Part 1: Terminology, definitions, clinical examination, natural history, patellofemoral osteoarthritis and patient-reported outcome measures. Br J Sports Med. 2016 Jul;50(14):839-43. – 9
  10. Hadeed A, Tapscott DC. Iliotibial Band Friction Syndrome. [Updated 2023 May 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542185/ – 10
  11. Kiel, John. “Patellofemoral Arthritis.” StatPearls [Internet]., U.S. National Library of Medicine, 12 June 2023, https://www.ncbi.nlm.nih.gov/books/NBK513242/#:~:text=The%20axial%20view%20also%20termed,assess%20the%20degree%20of%20arthritis
  12. X. Walli, Omar, Marissa McCay, and Timothy Tiu. “Patellofemoral syndrome: a review of diagnosis and treatment.” Current Physical Medicine and Rehabilitation Reports 11.2 (2023): 139-143. -11
  13. Ittenbach RF, Huang G, Barber Foss KD, Hewett TE, Myer GD. Reliability and Validity of the Anterior Knee Pain Scale: Applications for Use as an Epidemiologic Screener. PLoS One. 2016 Jul 21;11(7):e0159204. doi: 10.1371/journal.pone.0159204. PMID: 27441381; PMCID: PMC4956048. 12
  14. Morgan S, Coetzee FF. Proposing a Patellar Tendinopathy Screening tool following a systematic review. S Afr J Physiother. 2018 Sep 26;74(1):454. doi: 10.4102/sajp.v74i1.454. PMID: 30349877; PMCID: PMC6191685. 13
  15. Messier SP, Legault C, Schoenlank CR, Newman JJ, Martin DF, Devita P. Risk factors and mechanisms of knee injury in runners. Med Sci Sports Exerc. 2008;40:1873-1879. 14
  16. Hoksrud A, Ohberg L, Alfredson H, Bahr R. Color Doppler ultrasound findings in patellar tendinopathy (jumper’s knee). Am J Sports Med. 2008 Sep;36(9):1813-20.] – 15
  17. Ferber R, Bolgla L, Earl-Boehm JE, Emery C, Hamstra-Wright K. Strengthening of the hip and core versus knee muscles for the treatment of patellofemoral pain: a multicenter randomized controlled trial. J Athl Train. 2015 Apr;50(4):366-77. doi: 10.4085/1062-6050-49.3.70. Epub 2014 Nov 3. PMID: 25365133; PMCID: PMC4560005. 16
  18. Phyomaung, P.P., Dubowitz, J., Cicuttini, F.M. et al. Are depression, anxiety and poor mental health risk factors for knee pain? A systematic review. BMC Musculoskelet Disord 15, 10 (2014). https://doi.org/10.1186/1471-2474-15-10 17
  19. Smith TO, Drew BT, Meek TH, Clark AB. Knee orthoses for treating patellofemoral pain syndrome. Cochrane Database Syst Rev. 2015 Dec 8;(12):CD010513. – 18
  20.  Callaghan MJ, Selfe J. Patellar taping for patellofemoral pain syndrome in adults. Cochrane Database Syst Rev. 2012 Apr 18;(4):CD006717. 19
  21. Dragoo JL, Wasterlain AS, Braun HJ, Nead KT. Platelet-rich plasma as a treatment for patellar tendinopathy: a double-blind, randomized controlled trial. Am J Sports Med. 2014 Mar;42(3):610-8. doi: 10.1177/0363546513518416. Epub 2014 Jan 30. Erratum in: Am J Sports Med. 2016 Jul;44(7):NP38. doi: 10.1177/0363546516655781. PMID: 24481828. 20
  22. Charles, Ravon, et al. “The effectiveness of shockwave therapy on patellar tendinopathy, Achilles tendinopathy, and plantar fasciitis: a systematic review and meta-analysis.” Frontiers in Immunology 14 (2023): 1193835. 21
  23. Kayacan, Nurten. “Efficacy of neural prolotherapy versus local corticosteroid soft tissue injection for treatment of chronic anserine bursitis: a prospective randomized clinical trial.” Ain-Shams Journal of Anesthesiology 14.1 (2022). 22
  24. Cho SI, Shin YA. Effect of rehabilitation and prolotherapy on pain and functional performance in patients with chronic patellar tendinopathy. Gazz Med Ital – Arch Sci Med 2017;176:330-7. DOI: 10.23736/S0393-3660.16.03339-8  23
  25. Loescher, Jeremy, Paul Waclawski, and Richard Guthmann. “Topical Nitroglycerin for Lower Extremity Tendinopathy.” American family physician 105.2 (2022): 196-197. 24
  26. Soler R, Rodas G, Rius-Tarruella J, et al. Safety and Efficacy of Bone Marrow–Derived Mesenchymal Stem Cells for Chronic Patellar Tendinopathy (With Gap >3 mm) in Patients: 12-Month Follow-up Results of a Phase 1/2 Clinical Trial. Orthopaedic Journal of Sports Medicine. 2023;11(9). doi:10.1177/23259671231184400 25
  27. Khoury MA, Chamari K, Tabben M, Alkhelaifi K, Ricardo T, Damián C, D’hooghe P. Expanded adipose derived mesenchymal stromal cells are effective in treating chronic insertional patellar tendinopathy: clinical and MRI evaluations of a pilot study. J Exp Orthop. 2021 Jul 2;8(1):49. doi: 10.1186/s40634-021-00358-7. PMID: 34213678; PMCID: PMC8253873. 26
  28. Jurgensmeier, Kevin, et al. “Intra-articular injections of the hip and knee with triamcinolone vs ketorolac: a randomized controlled trial.” The Journal of Arthroplasty 36.2 (2021): 416-422. 27

Original Version of the Topic

William F. Micheo, MD, Alexandra Rivera-Vega, MD, Juan Galloza-Otero. Knee overuse disorders. 9/20/2013.

Previous Revision(s) of the Topic

Timothy Tiu, MD and Craig Van Dien, MD. Knee overuse disorders. 7/31/2017

Timothy Tiu, MD, Omar Walli, MD, Minh Quan Le, MD. Knee Overuse Disorders. 12/22/2021

Author Disclosure

Timothy Tiu, MD
Nothing to Disclose

Azmeer Khamisani, MD
Nothing to Disclose

Dylan Wood, MD
Nothing to Disclose