Your knee hurts.
It started off small, but it just keeps getting worse.
It hurts when you start practice, but then starts to feel a bit better when you warm it up. The next day, though? Man, is there some pain.
You can do most low level activities without too much of an issue (or at least you used to). But, explosive jumping and change of direction just does not feel good.
So, you go to physical therapy and your PT has you do some stretches and kick into a band while the older lady who just got a knee replacement does the same stuff next to you.
You feel fine during your PT sessions, so you go back to practicing and….. your knee hurts again.
It doesn’t have to be this way.
You’ve just been using the wrong tools and strategy.
You need to stop trying to cut down the tree with a butter knife.
You can be the explosive, pain-free athlete that you once were. In fact, you can be even more powerful than you’ve ever been before.
Here’s a guide to patellar tendon pain that’s science-driven, but without all the boring fluff.
Patellar tendonitis?
Fun fact, patellar tendonitis is actually a misnomer. The “itis” indicates that there is an inflammation issue present. Unless your knee injury just happened, that’s likely not the case.
Patellar tendon pain usually creeps up slowly over time. It starts out by bugging you a little bit, then gradually worsens to a point where it can be really debilitating.
So, the new accepted term to describe the issue you’re facing is patellar tendinopathy.
What are the symptoms of patellar tendinopathy?
It’s an explosive athlete-only issue:
If you’re not a jumping or explosive athlete around the ages of 15-30, you probably don’t have patellar tendinopathy.
True patellar tendinopathy is almost exclusively present in powerful, athletic athletes. So, if you really have patellar tendinopathy (and not something in the next section that often gets misdiagnosed as patellar tendinopathy), congrats on being a good athlete!
It’s provoked by high loads and high speeds (and especially high loads at high speeds):
Patellar tendon pain is usually provoked with high load demands on the quads. More specifically, it is worsened with activities that involve storage and release of energy through the tendon.
The patellar tendon acts as a spring as it stretches out, absorbs force, then recoils back to help you put force into the ground.
As such, patellar tendon pain is usually most provoked by activities (like jumping) that require a lot of force to be absorbed and then quickly redirected at a high speed.
Pain is localized and specific
Patellar tendinopathy is most commonly located at the inferior pole of the patella, which is right above where it inserts into the shin.
People with patellar tendinopathy are usually able to point directly to a spot on their tendon and say “that’s where it hurts.”
It warms-up through a session, but bites you harder the next day
It’s super common for athletes to report that their patellar tendon pain feels bad at the beginning of practice, then it warms-up and feels better later in the session.
But, this typically comes with the caveat that their pain will be significantly worse the next day or after the training session and the “warm-up” wears off.
Stuff that’s present with patellar tendinopathy, but can be from other problems as well
– Pain with prolonged sitting
– Pain with squatting
– Pain with stairs
Rule the other stuff out
To figure out if patellar tendinopathy is the issue you’re facing, we need to rule out the other stuff.
The main items on the differential diagnosis list are patellofemoral pain syndrome, Osgood-Schlatter Disease (OSD), and joint pathologies.
Each of these items deserve their own in-depth guides, but I’ll do my best to stick to brief recaps here.
We’d want to take a deeper look at patellofemoral pain syndrome if:
– You feel like the pain is located behind the knee cap
– You describe the pain as having a “C-shape” around the knee cap
– Pain worsens with squatting, stair climbing, and running
– Pain worsens with prolonged sitting
We’d want to take a deeper look at Osgood-Schlatter Disease if:
– You’re under the age of 15
OSD is apophysitis of the tibial tubercle. The apophysis is a secondary ossification center (aka growth plate where muscles attach) and “itis” means inflammation. So, OSD is inflammation of the growth plate where the quadriceps/patellar tendon attaches to the shin.
This growth zone closes around 10-12 years old in girls and 12-14 years old in boys. So, if you’re over this age, OSD almost certainly isn’t the issue.
– Your pain is located right on the tibial tubercle
We’d want to take a deeper look at joint structures if:
– There’s a lot of swelling
– The injury happened with one specific movement or had a very rapid onset
– There’s pain around the joint line
What’s actually going on with the tendon that’s causing pain?
In the big picture, patellar tendinopathy is a load tolerance issue. Simply, this means that the load that you’re putting on it is more than it can handle.
There’s a big debate on the relationship between tendon pathology and pain.
Findings on imaging don’t always correlate with pain.
Some people have really beat up tendons on imaging and have no pain.
Some people have pristine tendons on imagining and have a lot of pain.
Having tendon pathology is a risk factor for pain, though.
The physiological underpinnings of tendon pathology are complex. For those interested in diving into the rabbit hole, “Pathogenesis of tendinopathies: inflammation or degeneration?” by Michele Abate and company is a good read.
Cool dude, but what do I do about it?
Finally, the fun stuff!
Since patellar tendinopathy is a load tolerance issue, our objectives are twofold:
1) Increase the tendon’s physiological capacity to handle more load
2) Gradually expose it to increased loads
We break our patellar tendinopathy progression program into 4 phases (shout out to Peter Malliaras, Jill Cook, Craig Purdam and Ebonie Rio for their extensive research) .
Our evaluation tells us where in the progression program we need to start you at and what we need to build you up to.
Phase 1: Pain Reduction
Iso it up
If you’ve been fighting this for a while, I’d imagine it’s gotten worse and worse over time and is pretty painful right now.
Our first step is to bring your pain levels down to allow us to establish a solid baseline.
To do this, I use isometric loading and different modalities (things like e-stim, manual therapy, etc.) as needed.
Angry patellar tendons usually respond well to isometric holds.
This helps bring blood flow to the tendon, allows force vectors to stimulate collagen fibers to reorient in parallel with the force orientation, and maintain/gain quad strength.
The beauty of the isos is that there is no spring-like energy storage and release component, so the tendon isn’t as irritated.
We want to isolate the quads/patellar tendon and make sure we’re targeting that area. So, our preferred exercises are leg extensions or Spanish squats.
For leg extensions, you should be somewhere between 30° and 60° of knee bend. The load should be around 70% of your max voluntary contraction (the most weight you could possibly hold there). Then hold it for 45 seconds, get full rest (probably about 90-120 seconds or so), and repeat for 4 more sets (a total of 5 sets).
For Spanish squats, you should be around 70° to 90° of knee bend. The sets and times should be the same as the leg extensions, but to manipulate the difficulty, you can change how high or low you are. The lower you are and the more vertical your chest and shins are, the more it will challenge your quads.
You’re still an athlete. Train like it.
Importantly, just because you’re rehabbing, that doesn’t mean that you can’t train the heck out of the rest of your body. You should use this time to really hone in and get as strong and athletic as you can on the uninjured areas.
In fact, there’s evidence to suggest that having weak plantar flexors, weak hip extensors, and restricted ankle dorsiflexion may play a role in developing patellar tendinopathy.
We should try to optimize the kinetic chain as much as possible to attack it from all angles.
Phase 2: Strength
From isometrics to isotonics
Once you can tolerate normal, isotonic strength training (going up and down through some amount of range of motion with load) with less than a 3/10 pain, then we progress to Phase 2.
Phase 2 is all about building heavy, slow, strength through full range of motion and then introducing more explosive movements that don’t involve patellar tendon spring action.
Patellar tendinopathy gets aggravated with more knee bend, so the key is to start strength training with less knee bend and progress to more knee bend over time.
Find out how much knee bend you can tolerate during the movement without having any pain, then use that as your starting point. The next time you’re in, try to go a little further down. Repeat until you’re at full range of motion.
Our go-to main movements for progressing back through Phase 2 are an anterior squat (like a goblet squat or front squat), a center of mass (COM) deadlift (like a DB deadlift or trap bar deadlift), and a neutral shin split squat.
The chart below gives some tips on how to progress each one.
I usually start with one (or both) of the bilateral exercises, but then prioritize the unilateral split squats as soon as they are tolerated. Single leg exercises are extremely important to limit the chances that you’re compensating and not truly targeting the injured area.
Explosive stuff
As you’re progressing through your isotonics and getting more and more range of motion, you can start to add in explosive movements that don’t force the patellar tendon to act like a spring.
These can include ankle dominant extensive plyos and knee dominant non-countermovement jumping.
Ankle dominant plyos include things like pogos. I’d start off with double leg pogos with low jump height, then progress jump height over time as tolerated.
Once you’re able to tolerate maximal height double leg pogos for 3 x 10 reps or so without any pain, then I’d progress to single leg pogos and repeat the process.
It’s important to make sure that you do not go into any significant knee bend when doing these pogos, because then you’d be bringing the patellar tendon into play.
Knee dominant non-countermovement jumps are jumps that involve a good amount of knee bend, but you start at the bottom from a static position. This means that there is no rapid stretch and recoil of the patellar tendon, so it isn’t as provocative. A seated box jump is a good example. I’d start by going from a higher box, like 24 inches, then progress down to a lower box, like 18 inches, as tolerated.
Some add-ins
1) Keep doing the isos a couple times per week at the end of your training/rehab sessions.
2) Reverse sled drags are a fantastic way to add some more quad isolation work in. They can also be used at the beginning of the session to get your quad and patellar tendon warmed up. These almost always get a positive response.
3) Conditioning is vital! Your aerobic system plays a huge role in repairing your body. Plus, we want you to be as ready as quickly as you can after the tendon is taken care of. If your wind isn’t there, you’ll be a step behind. One day of extensive Zone 2 heart rate work and one day of intensive Zone 4 or 5 heart rate work should do the trick.
Phase 3: Plyos
Speed, speed, speed.
There’s no perfect “rule” for when you have enough strength and are ready for Phase 3, but our general guideline is that we like to see athletes be able to goblet squat 50% of their body weight for 15 reps and split squat 60% of their body weight for 10 reps each leg before jumping into our plyometric progressions (haha, get it?).
The name of the game in this phase is speed. We’re introducing and progressing that energy storage and release component that can be irritable for the tendon.
Jumps
Our guiding principles for our plyometric jump progression for patellar tendinopathy include:
– More static to more dynamic
Going from a seated (non-countermovement) vertical, to a standing (countermovement) vertical, to a 2 foot approach vert.
– Ankle dominant to knee dominant
Going from pogos to vertical jumps
– Double leg to single leg
Going from double leg vertical jumps to single leg vertical jumps and from 2 foot approach jumps to 1 foot approach jumps
The exact implementation and program design is as much of an art form as it is a science. There are a lot of contextual factors, like the sport, position, play style, irritable factors, and more that can change how we progress. But, our progression starting point is as follows:
Exercise: Sets x Reps
– Standing vertical jumps: 3 x 4
– Standing broad jumps: 3 x 3
– Standing single leg (SL) verts: 3 x 3 ea
– Standing SL broad jumps: 3 x 3 ea
– Depth jump (small box to higher box): 3 x 3
– 2 foot approach (short approach to long approach): 3 x 3
– 1 foot approach: 3 x 2 ea
I’m looking for these to be pain free during the exercise, after it’s done, and 24 hours later. The rate of progression through the exercises varies depending on the contextual factors, but a good starting point is to try and progress from one exercise to the next over every session, while training 3x per week. That would take two weeks to make it through the jump progression protocol.
Agility
Our guiding principles for our agility progression include:
1) Slow speeds to fast speeds
This can refer to both the speed going into the cut and the speed coming out of it. Start at around 50% speed, then build up to 100% as tolerated.
2) Acute angles to obtuse angles
Obtuse angle redirections require more force to go through the knee (think about a 180 degree turn). Start with small 30-45 degree changes of direction and build up as tolerated.
3) Pre-planned to reactive
Start with simple cone drills before progressing to a more chaotic environment where you can predict the angles and speeds that you’ll need to operate in.
Only progress one variable at a time. For instance, if you can do a 45 degree cut at 70% speed with no issues, try progressing up to 80% speed at that same angle. Don’t try to go up to 80% speed and progress to a 90 degree cut at the same time.
Sprints
Linear sprinting is usually not as provocative as jumping and agility work for patellar tendinopathy, so this can usually be progressed the quickest. Just work from slow speeds to fast speeds. Start your accelerations at around 50% speed and then progress as tolerated.
Strength
Do NOT neglect your strength work just because you graduated from Phase 2.
Strength needs to be mixed in, maintained, and even progressed to continue to try and bullet proof the tendon.
Just perform your strength work after the sprint, agility, and jump work is done for the day.
Phase 4: Return to Sport
This is where most people go wrong.
Patellar tendinopathy is a load tolerance issue. So, the load that we apply needs to be planned, managed, and monitored meticulously.
Just like Phase 3, there’s no perfect “rule” for when you’re ready to progress to Phase 4, but our general guideline is that we like to see athletes be able to tolerate 30 total jumps varying from 50-100% intensity and have pain free change of direction with full speed at any angle to initiate return to sport.
10% Rule
Our body is an incredibly adaptive organism, you just need to give it the right stimuli and time to adapt. If you progress too quickly and have rapid spikes in load, that’s when things break down.
A good rule of thumb is to progress by 10% in load each week.
In order to do this you NEED to plan, measure, monitor, and manage. If you’re a volleyball player, this might mean counting your jumps in practice/games. If you’re a basketball player, this might mean timing your minutes.
Whatever we need to get you back to, you need to develop a ramp-up strategy that gets you to normal loads over a number of weeks.
While there are always circumstances that don’t follow this principle, I like to start by suggesting a 4-week ramp up period. That would mean you start at 60% of the load that you’ll be required to perform in a game/practice and add 10% each week, so that by week 5 you are back to doing 100% of everything.
Don’t try to push-through flare ups during this time period. Don’t let a minor set-back turn into a major one.
I want to be clear that this article and website serve to provide educational and informational purposes only and do not constitute providing medical advice or professional services. If you’re having this issue, go see a qualified physical therapist/ health care professional.
Just make sure they’re not having you do boring band kicks next to your grandma.
Best,
Zach
Dr. Zach Guiser, PT, DPT, CSCS