Patellar Tendinopathy

Introduction

Patellar tendinopathy (“jumper’s knee”) is defined as pain and dysfunction of the patellar tendon. Patellar tendinopathy presents as anterior knee pain that is localized to distal pole of patella and is seen with loading tasks of the knee such as stairs, jumping, squats, and prolonged sitting.1 Patellar tendinopathy is more common in athletes who participate in jumping sports such as volleyball, basketball, track and field, and football, but anyone can experience patellar tendinopathy.1-3

After a physical therapy examination an individualized program will be developed by the therapist and client to address the limitations of muscle strength, flexibility, and balance of the person in order to reduce pain and improve function. Exercises may not be limited only to the knee but may also focus on hip, ankle, and core to address the linkage system.

In recent evidence based literature isometric exercises of the quadriceps have been shown to be beneficial for analgesic effects for those with patellar tendinopathy.5 Heavy slow resistance (HSR) training has also been shown to be more effective than eccentric exercises for the loading of patella tendon for long term benefits with regards to pain and strength.2,3,4,7

Patellar Tendinopathy rehab has been proposed to be performed in 4 progressive stages with certain criteria to be met in order to advance to each stage.2 HSR has been the preferred method for isotonic exercises but without access to equipment eccentric exercises are also beneficial. Stage 3 and 4 are more sport specific and will include motions or exercises primarily used in your sport. Discuss with physical therapist (PT) as to which exercises. When progressed to stage 2 you perform stage 1 exercises in between days of stage 2 exercises. Below you will see the stages and criteria for progression to each stage.

Stage 1 Isometric loading phase: More than minimal pain (3/10 or less on VAS) during isotonic exercise2

Stage 2 Isotonic loading phase: Minimal pain during isotonic exercises2

Stage 3 Energy storage phase: Minimal pain during exercise along with adequate strength (4 sets of 8 reps single leg press with 150% body weight) when compared to other limb2

Stage 4 Return to sport: Load tolerance to energy storage exercise progression that replicates demands of training2

Exercises1-4, 6

Stage 1 (Perform every day)

ExerciseIsometric Leg Extension (30-60o of knee flex)Spanish Squat (70-90o of knee flex)
Sets11
Repetitions55
Hold Time45 seconds45 seconds
Frequency2-3x a day2-3x a day

Isometric Leg Extension [30-60º knee flexion]

Sets1
Repetitions5
Hold Time45 seconds
Frequency2-3x a day

Spanish Squat

Sets1
Repetitions5
Hold Time45 seconds
Frequency2-3x a day

Stage 2 (Perform every 2nd day)

  • 3 second concentric phase with 4 second eccentric phase for each repetition
  • Knee flexion from 0-90o
ExerciseLeg PressSeated Leg extensionHack SquatSplit Squat25o Single Leg Decline Squat
Sets33333
Repetitions15 (progress to 6RM)15 (progress to 6RM)15 (progress to 6RM)15 (progress to 6RM)15 (progress to 6RM)
Rest2-3 min between sets2-3 min between sets2-3 min between sets2-3 min between sets2-3 min between sets
Frequency1x every 2nd day1x every 2nd day1x every 2nd day1x every 2nd day1x every 2nd day

Leg Press

Sets3
Repetitions15 (progress to 6RM)
Rest2-3 min between sets
Frequency1x every 2nd day

Seated Leg Extension

Sets3
Repetitions15 (progress to 6RM)
Rest2-3 min between sets
Frequency1x every 2nd day

Hack Squat

Sets1
Repetitions5
Hold Time45 seconds
Frequency2-3x a day

Split Squat

Sets1
Repetitions5
Hold Time45 seconds
Frequency2-3x a day

25º Single-Leg Decline Squat

Sets1
Repetitions5
Hold Time45 seconds
Frequency2-3x a day

Stage 3 (Sport specific; discuss with PT)

  • Jumping exercises
  • Acceleration
  • Deceleration
  • Cutting

Stage 4

  • Sport/Individual specific exercises

Patient Education

Patellar Tendinopathy can take up to 6 months to 1 year to heal. During the healing process pain is normal and is not necessarily an indicator to discontinue exercise. Continue with Stage 1 exercises pre or post training sessions. Stage 2 exercises can be performed twice a week for maintenance.2

If you are in your competitive season perform stage 1 exercises for pain reduction prior to and after training or event.5  

Always consult with your physical therapist before performing any exercises.

References

  1. Rudavsky A, Cook J. Physiotherapy management of patellar tendinopathy (jumper’s knee). Journal of Physiotherapy. 2014;60(3):122-129. doi:10.1016/j.jphys.2014.06.022
  2. Malliaras P, Cook J, Purdam C, Rio E. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations. J Orthop Sports Phys Ther. 2015;45(11):887-898. doi:10.2519/jospt.2015.5987
  3. Kongsgaard M, Kovanen V, Aagaard P, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scandinavian Journal of Medicine & Science in Sports. 2009;19(6):790-802. doi:10.1111/j.16000838.2009.00949.x
  4. Lim HY, Wong SH. Effects of isometric, eccentric, or heavy slow resistance exercises on pain and function in individuals with patellar tendinopathy: A systematic review. Physiother Res Int. 2018;23(4):e1721. doi:10.1002/pri.1721
  5. Rio E, Kidgell D, Purdam C, et al. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy. Br J Sports Med. 2015;49(19):1277-1283. doi:10.1136/bjsports-2014-094386
  6. van Ark M, Cook JL, Docking SI, et al. Do isometric and isotonic exercise programs reduce pain in athletes with patellar tendinopathy in-season? A randomised clinical trial. Journal of Science and Medicine in Sport. 2016;19(9):702-706. doi:10.1016/j.jsams.2015.11.006
  7. Mellinger S, Neurohr GA. Evidence based treatment options for common knee injuries in runners. Ann Transl Med. 2019;7(Suppl 7). doi:10.21037/atm.2019.04.08