Clinical Radiology (2006) 61, 570–578

PICTORIAL REVIEW

Imaging the infrapatellar tendon in the elite athlete

K.A.L. Peace*, J.C. Lee, J. Healy

Department of Radiology, Chelsea and Westminster Hospital, London, UK

Received 13 October 2005; received in revised form 30 January 2006; accepted 10 February 2006

Extensor mechanism injuries constitute a major cause of anterior knee pain in the elite athlete. Sonography and
magnetic resonance imaging (MRI) are the imaging methods of choice when assessing the infrapatellar tendon. A
comprehensive imaging review of infrapatellar tendon normal anatomy, tendinopathy, and partial/full-thickness
tendon tears is provided. The value of imaging the infrapatellar tendon in clinical practice, including whether
sonography can predict symptoms in asymptomatic athletes, is discussed. Acute avulsion fractures, including periosteal
sleeve avulsion, and chronic avulsion injuries, including SindingÿLarsenÿJohansson and OsgoodÿSchlatter syndromes,
are shown. Mimics of infrapatellar tendon pathology, including infrapatellar plica injury, patellar tendon–lateral
femoral condyle friction syndrome, and Hoffa’s syndrome, are illustrated.
Q 2006 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction whether sonography can predict symptoms in

Extensor mechanism injuries constitute a major
cause of anterior knee pain in the elite athlete due
to acute trauma or overuse. Infrapatellar tendino-
pathy, also known as “jumper’s knee” gives rise to
significant functional deficit and disability in
recreational as well as professional athletes.
The diagnosis of infrapatellar tendinopathy is
primarily a clinical one. However, imaging tech-
niques involving sonography, Doppler ultrasonogra-
phy and magnetic resonance imaging (MRI) provide
important diagnostic adjuncts. We illustrate the
normal appearances of the infrapatellar tendon on
sonography and MRI. In addition we will provide a
comprehensive imaging review of infrapatellar
tendinopathy and partial/full-thickness tears,
including a discussion of the relative strengths and
weaknesses of MRI versus ultrasound in the assess-
ment of this condition. We also discuss manage-
ment options and the therapeutic role of
sonographically guided injection in treating infra-
patellar tendinopathy. The value of imaging the
infrapatellar tendon in clinical practice, including
* Guarantor and correspondent: K.A.L. Peace, Department of
Radiology, Chelsea and Westminster Hospital, 369 Fulham Road,
London SW10 9NH, UK. Tel.: C44 20 8747 8570; fax: C44 20 8746
8562.
E-mail address: kalpeace@hotmail.com (K.A.L. Peace).
asymptomatic athletes is also considered.
The imaging features of other extensor mechan-
ism injuries are discussed including both acute
avulsion fractures, including periosteal sleeve
avulsion, and chronic avulsion injuries, such as
SindingÿLarsenÿJohansson and OsgoodÿSchlatter
syndromes. Finally, the mimics of infrapatellar
tendinopathy, including infrapatellar plica injury,
patellar tendon–lateral femoral condyle friction
syndrome and Hoffa’s syndrome are illustrated.
Ethics committee approval was obtained and
granted for permission to use all retrospective
images in this review.
Normal anatomy
The infrapatellar tendon is a thickened band of
fibrocartilaginous tissue arising from the anterior
surface of the non-articulating inferior pole of the
patella. It inserts proximally onto the anterior lip of
the tibia and distally on the tibial tubercle. In cross-
section, the tendon may be either oval or biconcave
in shape. Average thickness ranges from 3–6 mm
and width varies from 10–15 mm. The normal
tendon is composed mainly of types I and II collagen
fibres, surrounded by a paratenon, which consists of
loose connective tissue, not a synovial sheath. The

0009-9260/$ - see front matter Q 2006 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Imaging the infrapatellar tendon in the elite athlete 571

primary blood supply arises from the infrapatellar

fat pad and retinacular structures, so the proximal
and distal enthesial attachments are relatively
avascular.
On MRI, the normal infrapatellar tendon appears
as a homogeneous band of low signal intensity on all
sequences (Figs. 1 and 2). The tendon forms a well-
defined interface with the infrapatellar fat pad. An
area of triangular high signal at the patellar
enthesis is seen in up to 75% of normal individuals
when imaged on gradient echo sequences and is of
no clinical significance.1
Sonography, with its superior spatial resolution
over MRI, is able to demonstrate the tendon fibrils,
which are highly echogenic and organized in
parallel. This produces a linear fibrillar pattern on
longitudinal section imaging (Fig. 3) and a punctate
appearance on axial imaging. As the tendon is linear
as it parallels the skin, the problems of anisotropy
are less marked than with other tendons elsewhere, Figure 2 A 34-year-old normal asymptomatic male.
although anisotropy can produce hypoechoic Axial fat-saturated gradient-echo T2-weighted MRI shows
tendon as a flat structure with a deep sharp concave inner
surface.

artefacts as the tendon inserts into bone. Sono-

graphy provides a rapid, cheap, accessible imaging
technique to assess the infrapatellar tendon. The
dynamic nature of sonography is invaluable in
assessment of tendon tears or abnormal tendon
movement. The paratenon is a thin hyperechoic
line, which can be difficult to differentiate from
surrounding fat when normal but can be readily
appreciated when inflamed (paratenonitis).

Figure 1 A 34-year-old normal asymptomatic male.

Sagittal T1-weighted MRI through the infrapatellar Figure 3 A 34-year-old normal asymptomatic male.
tendon. Note the uniformly low signal throughout its Longitudinal field-of-view sonogram of the infrapatellar
length. tendon. Note the fibrillar nature of the tendon.
572
Infrapatellar tendinopathy (“jumper’s
knee”)
Aetiology
Infrapatellar tendinopathy presents as anterior
knee pain, usually in an athlete who performs
year-round strength and speed training. Sports that
involve sudden maximal muscle-tendon unit exer-
tion, e.g. jumping, are most at risk. Therefore, this
condition occurs commonly in basketball and
volleyball players who play on unforgiving hard
court surfaces. The patellar insertion, particularly
the deep surface, is more frequently affected than
the tibial insertion.2 Some investigators believe
that during knee flexion, the inferior pole of the
patella has a propensity to impinge upon the deep
surface of the infrapatellar tendon. Therefore,
those individuals with a prominent inferior patella
tuberosity may be at particular risk of developing
infrapatellar tendinopathy.3 However, this theory
has been refuted by Schmid et al. who analysed
patellar shape, tendon insertion location, and
patella-tendon angle on dynamic open-configur-
ation MRI in symptomatic and asymptomatic
individuals.4 They found identical relationships
between the patella and the patella tendon in
both groups and concluded that chronic overload,
rather than impingement, was the principal cause
of patellar tendinopathy.4
Pathology
Repetitive quadriceps contraction leads to recur-
rent micro trauma and healing of the infrapatellar
tendon to produce tendinopathy. Histologically,
this results in an increased glycoprotein matrix with
consequent increased water content in the tendon,
fibroblast and tenocyte proliferation, and neovas-
cularization.5 This does not reflect an acute
inflammatory response, hence the term infrapatel-
lar tendinosis or tendinopathy, rather than infra-
patellar tendonitis.
Imaging
Plain films
Plain films can be useful to detect intratendinous
calcification or to identify bony abnormalities such
as Osgood–Schlatter Syndrome, the symptoms of
which can mimic infrapatellar tendinopathy.
Sonography
On sonography, infrapatellar tendinopathy causes a
disruption of the normal fibrillar pattern. The
K.A.L. Peace et al.
Figure 4 A 24-year-old female soccer player with
infrapatellar tendinopathy. Longitudinal sonogram show-
ing vessels extending from Hoffa’s fat pad into the deep
surface of a swollen proximal infrapatellar tendon.
tendon may be swollen and contain focal areas of
reduced echogenicity.6 Calcification is not infre-
quently seen and there may be vascular in-growth
from the infrapatellar fat pad, best demonstrated
on power Doppler imaging with the tendon relaxed
(Fig. 4). The paratenon may be the primary site of
acute inflammation (paratenonitis), although this is
far less common in the infrapatellar tendon
compared with the Achilles tendon. Paratenonitis
is identified on sonography as an echo-poor halo
around the tendon and often shows increased
vascularity on colour Doppler imaging. Rather
than the diffuse hypoechoic halo seen in tenosyno-
vitis, paratenonitis is frequently patchy in its
distribution (Fig. 5).
MRI
On MRI, infrapatellar tendinopathy produces focal
areas of intermediate signal intensity on T1-
weighted images, high signal-intensity on T2-
weighted images (Fig. 6) and enhancement within
the tendon post-intravenous gadolinium (Fig. 7).
This signal change is usually located within the
proximal tendon towards its deep surface, often on
the medial side.7 Bone marrow oedema in the
inferior pole of the patella is a recognized
associated finding.8 In deep surface micro tears,
one may see a loss of definition of the deep tendon
surface adjacent to the fat pad.9 Calcification
within the tendon may be seen as well-defined
areas of low signal on all sequences.
Can imaging predict symptomatic infrapatellar
tendinopathy in asymptomatic athletes?
Changes of infrapatellar tendinopathy are a com-
mon finding in elite athletes even in the absence of
Imaging the infrapatellar tendon in the elite athlete
Figure 5 A 27-year-old cricketer with paratenonitis.
Axial sonogram demonstrating a swollen, hypoechoic
lateral infrapatellar tendon with areas of markedly
thickened paratenon (arrowheads). The infrapatellar
tendon lacks a synovial sheath.
symptoms. One study of asymptomatic collegiate
college basketball players found changes of tendi-
nopathy on MRI in 24% of cases.10 The authors
hypothesized that although some of these lesions
may represent healed tendinopathy, some of them
may be pre-symptomatic. Further studies have
Figure 6 A 26-year-old male professional soccer player
with infrapatellar tendinopathy. Sagittal T2-weighted
gradient echo MRI Showing increased signal in the
infrapatellar tendon (star) and local inflammation.
573
Figure 7 A 26-year-old male professional soccer player
with infrapatellar tendinopathy. Axial fat-saturated T1-
weighted MRI after intravenous gadolinium. Note the
marked contrast enhancement and deep surface tears.
correlated sonographic findings in asymptomatic
athletes with subsequent development of symp-
toms. These have found that focal areas of reduced
echogenicity within the tendon increase the
athlete’s risk of developing jumper’s knee by 4.2-
fold.11 Furthermore, if sonographic findings of
tendinopathy are seen in an asymptomatic athlete
at baseline, there is a 17% risk of developing
jumper’s knee during the season.12 These findings
have significant implications in the monitoring of
athletes’ infrapatellar tendons even when symp-
toms are absent. Athletes identified as being at risk
on imaging can adjust their training programme to
reduce the risk of developing symptomatic
tendinosis.
Management
Treatment within the first 6 months generally
involves conservative management. As tendinopa-
thy results from an inadequate healing response of
overloaded tendon, the current trend in thera-
peutic approach dictates the need for a compre-
hensive approach with emphasis on strengthening
exercises.13
The findings on MRI can guide further treatment in
the multidisciplinary setting. Surgery may be con-
sidered the treatment of choice if there is evidence of
cystic or mucoid degeneration, if there is a prominent
inferior patella tuberosity/osteophyte, or in cases of
failed conservative management. Ultrasound guided
injection is used in two scenarios.
First, dry needling,14 autologous blood injec-
tion15 or sclerosant injections16 can be used to treat
tendinopathy associated with marked vascularity.
Alternatively, steroid injections can be used as
first-line therapy if there is evidence of fat pad
574 K.A.L. Peace et al.

impingement and marked oedema within Hoffas’s

fat pad.7

Tendon tears

Tears usually occur in the context of background

tendinopathy and are classified as either full-
thickness (Fig. 8) or partial-thickness (Fig. 9).
Partial thickness tears occur within the tendon
(intra-substance), where they may result in cystic
changes or focal myxoid degeneration, or involve
the tendon surface. On imaging, it can be difficult
to differentiate tendinosis (intact but swollen
fibres) from a partial tear of the tendon (disruption
of the fibres). These two entities possibly form part

Figure 9 A 28-year-old male cyclist, with partial tear of

his infrapatellar tendon after a direct blow after coming
off his bike. Sagittal short tau inversion recovery
magnetic resonance (STIR MR) image of the knee. The
infrapatellar tendon is markedly expanded and is of high
signal in its lower part. Note also the serpiginous low
signal line with surrounding bone marrow oedema in
keeping with an undisplaced tibial plateau fracture
involving the tibial tuberosity.

of a spectrum of the same condition and are

differentiated by their clinical presentation. Mid-
substance full-thickness rupture is rare and usually
occurs after severe trauma in forced flexion against
a contracted quadriceps muscle.
Neither MRI nor sonography can easily distinguish
intra-substance tears and tendon degeneration, but
both methods can distinguish partial from full-
thickness tears.17 Sonography has the advantage of
dynamic imaging but most surgeons prefer MRI for
surgical planning.

Figure 8 A 26-year-old male long-jumper with full-

Avulsion injuries
thickness rupture of the infrapatellar tendon at its
patellar attachment. Sagittal T1-weighted MRI of the
knee elegantly demonstrating the tendon gap (white Chronic injuries
arrow). Note also the loss of marrow signal within the
femoral trochlea consistent with associated marrow Avulsion fractures from the infrapatellar tendon are
oedema (black arrow). a common cause of sports-related anterior knee
Imaging the infrapatellar tendon in the elite athlete 575

Figure 10 A 23-year-old male soccer player who

developed SindingÿLarsenÿJohansson syndrome during
adolescence. Sagittal T1-weighted MRI knee showing
irregularity of inferior pole of the patella and expansion
of the proximal infra-patellar tendon, which contains
several well-defined high signal foci compatible with
ossifications. Note the fused epiphyseal plate.

pain in adolescence. This group of conditions

include SindingÿLarsenÿJohansson (patellar inser-
tion) and Osgood–Schlatter (tibial insertion) disease
(Figs. 10 and 11 respectively). These conditions
relate to chronic overuse in patients with unfused
skeletons and are frequently associated with
infrapatellar tendinopathy.
On MRI and sonography, inflammatory change
and enlargement of the infrapatellar tendon
associated with intra-tendinous calcification and
cortical irregularity in the associated bone is seen.
The calcification may be easier to appreciate on
sonography than MRI, especially when early in the
condition.18
Acute injuries
Acute avulsion fractures more often derive from
violent trauma or eccentric muscle contraction.
The so-called patellar sleeve fracture, which
represents an osteocartilaginous avulsion of the
lower pole of the patella, should be suspected in
the paediatric knee if symptoms arise after violent
contraction against resistance. Plain films will
underestimate the extension of the avulsion
fracture and MRI is indicated to assess the degree
Figure 11 A 13-year-old boy with OsgoodÿSchlatter
syndrome. Sagittal T2-weighted gradient echo showing
expansion of the distal infrapatellar tendon, which
contains areas of intermediate signal due to the non-
united fragmented displaced tibial tubercle apophysis
(arrow). Note also the presence of marrow oedema within
the inferior pole of the patella (asterisk) and adjacent fat
pad (curved arrow).
of chondral injury.19 Sonography can clearly ident-
ify the periosteal avulsion (Fig. 12).
Mimics of infrapatellar tendon disease
In addition to disorders related directly to the
infrapatellar tendon, there are three soft-tissue
conditions that should be included in the
differential diagnosis of anterior knee pain.
They are Hoffa’s syndrome, infrapatellar plica
injury, and patellar tendon–lateral femoral con-
dyle syndrome. MRI is the optimal imaging
method for all three disorders, although ultra-
sound may be used to guide therapeutic
injections.
576
Figure 12 A 14-year-old county soccer player, with
periosteal sleeve avulsion fracture. Longitudinal sono-
gram showing elevation of the periosteum from the
superficial surface of the patella.
Hoffa’s syndrome
Hoffa’s disease/syndrome may occur after single or
recurrent trauma to the anterior knee including
arthroscopy, but an idiopathic form is recognized in
which there is no history of prior trauma.20 This
condition can reliably be diagnosed on MRI. Findings
include oedema, haemorrhage and necrosis in the
infrapatellar fat pad (Fig. 13). Low signal on all
Figure 13 A 29-year-old male basketball player with
Hoffa’s syndrome. Sagittal fat-saturated T1-weighted MRI
after intravenous gadolinium. There is marked contrast
enhancement within the infrapatellar fat pad. Note that
the signal within the infrapatellar tendon is normal.
K.A.L. Peace et al.
sequences within the fat pad may be seen reflecting
fibrin, haemosiderin and/or calcification.21 Ultra-
sound-guided injection into the fat pad from a
lateral approach beneath the infrapatellar tendon
may be beneficial in some patients. Sonography can
be used to guide a therapeutic injection.
Infrapatellar plica injury
The plicae of the knee are normal synovial folds,
which are remnants from the embryological
development of the knee. The mediopatellar or
infrapatellar plica, which connects the lower pole
of the patella to the intercondylar notch, or
anterior cruciate ligament, was thought to be an
incidental finding of no clinical significance. How-
ever, a syndrome of thickened, fibrotic and
haemorrhagic infrapatellar plica has now been
described which is a recognised cause of anterior
knee pain.22 On MRI, patients with this condition
demonstrate curvilinear high T2 signal intensity
within Hoffa’s fat pad in the line of the infrapatellar
plica (Fig. 14). This condition is commonly associ-
ated with other internal derangements within the
knee.
Figure 14 A 33-year-old professional soccer player
with infrapatellar plica injury. Sagittal T1-weighted MRI
of the knee. There is marked thickening of the
infrapatellar plica. The infrapatellar tendon is normal.
Imaging the infrapatellar tendon in the elite athlete
Figure 15 A 24-year-old female tennis player with
patellar tendon–lateral femoral condyle syndrome. Axial
STIR MRI through the knee demonstrating a slightly
laterally subluxed infrapatellar tendon. The inflamma-
tory change spares the central and medial parts of the
tendon and is focussed on the lateral edge of the tendon
as it passes over the lateral femoral condyle.
Patellar tendon–lateral femoral condyle
syndrome
Patellar tendon–lateral femoral condyle or supero-
lateral fat-pad impingement syndrome is a recog-
nized cause of chronic anterolateral knee pain in
the athletic population. On examination, there is
focal tenderness at the lateral side of the inferior
pole of the patella. On MRI, the extensor mechan-
ism is laterally subluxed and is associated with
oedema in the lateral fat pad (Fig. 15).23 This
condition is amenable to conservative treatment,
which involves taping of the superior pole of the
patella and sonographically-guided injections into
the inflamed fat pad.
Conclusion
Anterior knee pain in the elite athlete can be a
debilitating condition that may require a prolonged
rehabilitation period if incorrectly managed. Ima-
ging of the infrapatellar tendon by sonography and
MRI can both diagnose symptomatic abnormalities,
and identify at-risk asymptomatic athletes in an
attempt to prevent subsequent injury. Sonography
provides an inexpensive, accessible, dynamic inves-
tigation, and enables imaging of superficial struc-
tures with exquisite detail. It is the investigation of
577
choice in infrapatellar tendinopathy. Ultrasound-
guided injections also form an important role in the
conservative management of infrapatellar tendino-
pathy and Hoffa’s syndrome. MRI acts as a problem-
solving tool when the sonogram is normal and will
detect the mimics of infrapatellar tendon
pathology.
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