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Background: Although the surgical treatment of patellar tendinopathy (jumper's knee) is a common procedure, there have been no randomized, controlled trials comparing this treatment with forms of nonoperative treatment. The purpose of the present study was to compare the outcome of open patellar tenotomy with that of eccentric strength training in patients with patellar tendinopathy.Methods: Thirty-five patients (forty knees) who had been referred for the treatment of grade-IIIB patellar tendinopathy were randomized to surgical treatment (twenty knees) or eccentric strength training (twenty knees). The eccentric training group performed squats on a 25° decline board as a home exercise program (with three sets of fifteen repetitions being performed twice daily) for a twelve-week intervention period. In the surgical treatment group, the abnormal tissue was removed by means of a wedge-shaped full-thickness excision, followed by a structured rehabilitation program with gradual progression to eccentric training. The primary outcome measure was the VISA (Victorian Institute of Sport Assessment) score (possible range, 0 to 100), which was calculated on the basis of answers to a symptom-based questionnaire that was developed specifically for patellar tendinopathy. The patients were evaluated after three, six, and twelve months of follow-up.Results: There was no difference between the groups with regard to the VISA score during the twelve-month follow-up period, but both groups had improvement (p < 0.001). The mean combined VISA score for the two groups increased from 30 (95% confidence interval, 25 to 35) before the start of treatment to 49 (95% confidence interval, 42 to 55) at three months, 58 (95% confidence interval, 51 to 65) at six months, and 70 (95% confidence interval, 62 to 78) at twelve months. In the surgical treatment group, five knees had no symptoms, twelve had improvement but were still symptomatic, two were unchanged, and one was worse after twelve months (p = 0.49 compared with the eccentric training group). In the eccentric training group, five knees did not respond to treatment and underwent secondary surgery after three to six months. Of the remaining fifteen knees in the eccentric training group, seven had no symptoms and eight had improvement but were still symptomatic after twelve months.Conclusions: No advantage was demonstrated for surgical treatment compared with eccentric strength training. Eccentric training should be tried for twelve weeks before open tenotomy is considered for the treatment of patellar tendinopathy.Level of Evidence: Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.