Tendon Tenderness

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Student MRCS FRCS Fellow

For Medical Students

What It Tests

Palpating the tendons around the knee tests for tendinopathy, for partial or complete rupture, and for the enthesopathy of inflammatory disease.

The four that matter are the quadriceps tendon above the patella, the patellar tendon below it, the hamstring tendons medially and posteriorly, and the biceps femoris and iliotibial band laterally. 2.10.5 covers the biceps femoris.

Each is tender in a characteristic position, so the location is the diagnosis more than the finding itself is. 4.2.8 covers pain location.

How It Is Performed

Palpate the quadriceps tendon from the patella's superior pole upwards, with the knee extended and relaxed, feeling for a gap as well as for tenderness.

Palpate the patellar tendon from the patella's inferior pole down to the tibial tubercle, in both the relaxed and the tensioned positions. 4.6.7 covers the tubercle.

Palpate the pes anserinus medially, below and medial to the tibial tubercle, where the hamstring tendons insert.

Palpate the biceps femoris and the iliotibial band laterally, following the band to its insertion below the lateral joint line. 3.11.1 covers its function.

Ask the patient to contract against resistance in each case, since a painful resisted contraction localises to the tendon rather than to the joint.

What a Positive Means

Tenderness at the inferior pole of the patella with pain on resisted extension indicates patellar tendinopathy, which is the commonest of these diagnoses in an athlete. 4.2.27 covers running.

A palpable gap in a tendon with an inability to extend the knee indicates a rupture, and that is an urgent finding. 4.7.8 covers extension lag.

Tenderness at the pes anserinus suggests a bursitis or a hamstring insertional problem, and it is frequently mistaken for medial joint line pain. 4.6.4 covers the joint line.

Tenderness along the iliotibial band at the lateral femoral condyle suggests a friction syndrome, which is a running diagnosis rather than a knee joint one. 3.11.1 covers the band.

Tenderness at several tendon insertions raises an inflammatory enthesopathy rather than mechanical overload. 4.2.14 covers inflammatory pain.

Key Learning Points

Four tendons, each tender in a characteristic position, so the location is the diagnosis.
Inferior pole tenderness with painful resisted extension is patellar tendinopathy.
A palpable gap with an inability to extend is a rupture and is urgent.
Pes anserinus tenderness is frequently mistaken for medial joint line pain.
Tenderness at several insertions raises an inflammatory enthesopathy.

MRCS Level

How It Is Performed

In a viva the resisted contraction is the step that converts palpation into localisation, and including it is the mark.

The expected points are the four tendons, their positions, palpation in the relaxed and tensioned states, the resisted contraction, and the search for a gap.

Say that you would palpate the whole length of the quadriceps and patellar tendons, because a gap can be missed by palpating only the tender part.

Say that a tendon rupture is a clinical diagnosis and that the examination rather than the imaging makes it, in a patient who cannot extend the knee. 4.7.8 covers extension lag.

Say that you would examine the other side, since tendinopathy is frequently bilateral and asymmetrical. 4.1.2 covers the principle.

Say that you would ask about fluoroquinolone use and about inflammatory disease, both of which change the differential.

What a Positive Means

The reasoning expected is that a tendon's tenderness is maximal at its area of pathology, which in tendinopathy is characteristically at or near the insertion. 2.4.1 covers the patellar anatomy.

Palpating a tendon under tension increases the pressure your finger transmits, which is why the same tendon feels differently tender in two positions and why both are used.

A complete rupture produces a gap and a loss of active extension, because the extensor mechanism is no longer continuous. 4.7.1 covers active motion.

Enthesopathy affects several insertions because the pathology is at the attachment rather than in the tendon's substance, which is why a multi site pattern suggests a systemic cause. 4.2.14 covers inflammatory pain.

How Good It Is

Tendon palpation is specific when the tenderness is focal and the resisted contraction reproduces the pain, and non specific when the tenderness is diffuse.

It diagnoses a rupture reliably, which is the most consequential thing on this page and depends on looking for a gap and testing active extension. 4.7.8 covers it.

It cannot distinguish tendinopathy from a partial tear, which ultrasound or magnetic resonance imaging does. 4.1.6 covers that relationship.

It is reliable for the superficial tendons and poor for the deeper hamstring origins, which are harder to reach. 4.6.9 covers posterior palpation.

No figures appear for any accuracy comparison on this page, under decision 023, and the comparison is the claim being made.

Key Learning Points

Tenderness is maximal at the area of pathology, characteristically near the insertion.
Palpating under tension increases the pressure transmitted, so both positions are used.
A complete rupture produces a gap and a loss of active extension.
A multi site pattern suggests enthesopathy rather than overload.
It cannot distinguish tendinopathy from a partial tear.

FRCS Level

How Good It Is

At decision level tendon palpation makes one urgent diagnosis and several non surgical ones, which is a useful distribution.

A quadriceps or patellar tendon rupture is a clinical diagnosis with an operative answer and a time limit, and the palpation plus the active extension test makes it. 4.7.8 covers it.

Tendinopathy is a load management diagnosis, and recognising it prevents an arthroscopy for anterior knee pain. 4.2.11 covers aggravating factors.

Pes anserinus and iliotibial problems are both treated non surgically, and localising them prevents the knee being investigated for them. 4.6.4 covers the finding they mimic.

An enthesopathic pattern changes the diagnosis to a systemic one and moves the patient to a different specialty, which the examination can initiate. 4.8.9 covers synovitis.

Where It Misleads

The commonest error is not testing active extension in a patient with a tender tendon, which is how a rupture is missed.

The second is palpating only the tender area rather than the whole tendon.

The third is attributing medial pain below the joint line to the meniscus when the pes is tender. 4.6.4 covers it.

The fourth is examining the tendon in one position.

The fifth is treating a multi site pattern as several mechanical problems rather than one systemic one.

Key Learning Points

Palpation plus active extension makes the one urgent diagnosis on this page.
Tendinopathy is a load management diagnosis, and recognising it prevents an arthroscopy.
Pes anserinus and iliotibial problems are treated non surgically and mimic joint pain.
An enthesopathic pattern moves the patient to a different specialty.
Not testing active extension in a tender tendon is how a rupture is missed.

Fellowship Level

Where It Misleads

In referred practice tendon tenderness is the finding that explains the knee that has been investigated intra-articularly and has an extra-articular problem.

A patient with a normal arthroscopy and persisting anterior pain who is tender at the inferior pole has a tendinopathy that the arthroscopy could not have addressed. 4.2.1 covers pain.

A patient with tenderness at a graft harvest site years after a reconstruction has donor site pain, which is common, under recognised and not a failure of the reconstruction. 4.3.7 covers surgical scars.

A patient with pes anserinus tenderness and medial compartment change has two sources of medial pain, and treating only the compartment leaves part of the complaint. 4.9.11 covers meniscal examination in osteoarthritis.

In an athlete with a tendinopathy the examination's role is confirming the diagnosis and the management belongs to load rather than to surgery, which is a conversation rather than a procedure. 4.23.2 covers those patients.

In medicolegal work a tendon rupture diagnosed late is a recognised and avoidable failure, and the absence of a recorded active extension test is usually the gap. 4.23.7 covers that setting.

Key Learning Points

Tendon tenderness explains the knee investigated intra-articularly with an extra-articular problem.
Donor site pain years after a reconstruction is common and under recognised.
Pes tenderness with compartment change means two sources of medial pain.
In an athlete the management belongs to load rather than to surgery.
A late diagnosed tendon rupture usually traces to a missing active extension test.

Explore Further

Where this topic came from and where it goes next in the spiral.

References

No reference list is attached to this draft. Evidence verification has not run, because source retrieval was unavailable at generation time. Under the Operations Handbook a missing reference is acceptable and an invented one is a critical failure, so nothing has been cited and no citation marker appears in the text. This page carries no diagnostic accuracy figure, which is decision 023 rather than an omission. The comparative standing of these tests is standard teaching and a specific sensitivity written from memory is the same class of claim as an invented citation, so ACC-001 refuses the number and the page states the comparison. A reviewer with the literature can add the figures into How Good It Is without restructuring the page, and chapter 3.17 lists the studies the figures would come from. Any measurement here, including a flexion angle, is written from standard teaching, has not been checked, and is registered under decision 006 in pipeline/config/figures with a verification state of UNVERIFIED_FROM_MEMORY.

Safety. KneeSchool is educational and does not give individual medical advice. Seek urgent assessment for a knee that cannot bear weight after an injury, a hot swollen knee with a fever, or new numbness, weakness or coldness in the leg or foot.