The research is pretty clear that the best treatment plan for patellar tendonitis/tendinopathy should include strengthening exercises for the patellar tendon, as it is the only way to restore the strength you lost due to the injury. But doing only strength training may not be enough. In this article, we look at what exercises you should include in your treatment plan and why a one-size-fits-all approach will likely not be the best for your knee. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call.
What an ideal exercise plan for patellar tendonitis should include
The leading research experts in the field of patellar tendonitis currently suggest that an exercise-based treatment plan should include:
1. A thorough assessment
This is necessary because:
There is no single thing that causes patellar tendonitis/tendinopathy. You have to address the cause of your specific case and not waste time working on things that aren’t needed.
Patellar tendonitis can vary dramatically with regards to how irritable the tendon is (how easily the pain flares up). Your physio can gauge the irritability through an in-depth discussion about how different activities affect your pain and asking you to do specific movement tests.
This the only way to establish your injured tendon’s current load tolerance (strength and endurance). This will help your physio to determine what type, volume, intensity, and frequency of exercises and activities are currently right for you and will allow your tendon to grow stronger rather than just aggravate it further.
Patellar tendonitis pain can feel very similar to other conditions, e.g. patellofemoral pain, so it is important to get the diagnosis right. It is also not uncommon for other parts of your knee to be injured at the same time, and your treatment plan should take all of these into consideration.
2. Load management or relative rest
You can’t just continue doing all the activities at the intensities you want to and expect your knee to recover. Once injured, you tendon loses some of its strength. This means that it’s no longer strong enough to cope with all the activities you want to do, and even simple things like climbing stairs may hurt. Here's an article about two everyday activities that may aggravate your patellar tendon pain.
By reducing your sport and other daily activities to a level that doesn’t aggravate your knee, you will allow your tendon pain to settle down, which in turn will allow you to make progress with your rehab exercises.
This is called relative rest. It is different from complete rest in that you can still be active, as long as you adapt your training/activity volume and intensity to suit your knee’s current state.
If you continue to do things in your daily life or play sport to a level that causes your pain to increase, it really doesn’t matter what rehab you do, as it won’t be effective. Rehab exercises can only work if you ensure that everything you do in your day is pitched at the correct level. This is why we use ample time during our consultations to discuss all the aspects of our patients’ lives, not just their sport.
One way of preserving your fitness while your patellar tendon injury settles down is cross training. We’ll discuss your different cross training options in a future blog post.
3. Progressive loading with patient-specific goals in mind
Like we mentioned before, the patellar tendon loses some of its strength once it's injured. To rebuild that strength, you have to follow a specific strength training programme. But if you let rip with heavy loaded exercises right from the start, you may find that the tendon flares up and becomes very painful.
That’s why it's important to assess the tendon’s current load tolerance. For an exercise plan to be effective the exercises have to start at an intensity that is a bit challenging, but not too challenging, for the tendon.
As you train and your tendon regains its strength, the exercise intensities and volumes should then increase until you eventually achieve loads that resemble those in your sport.
This is why, for instance, the exercises prescribed for a long-distance hill walker with patellar tendonitis will look very different from those prescribed to a basketball player. The hill walker needs long, steady endurance up- and downhill and good strength; they don't necessarily need the same explosive power that the basketball player might need. Likewise, if you neglect to retrain the explosive strength and landing mechanics of the basketball player, they will likely end up reinjuring their tendon.
4. Strengthening exercises that target the patellar tendon specifically
There are several exercise programmes that have been shown to be effective as treatment for patellar tendonitis, and we discuss the main ones with examples of exercises further down. These include:
Our preferred method is to use the Progressive Loading method and to incorporate elements of the Heavy Slow Resistance plan into it. We might sometimes use eccentric exercises as part of the programme if we identify that it is something that would benefit a specific patient, but we never prescribe only eccentric exercises.
Progressive loading exercise plan for patellar tendonitis
Steph explains how a progressive loading plan works and demonstrates the exercises that it may include in this video, but we also highlight the main points below.
How effective is it?
A recent randomised controlled trial found that a progressive loading exercise programme that lasted 24 weeks resulted in a significantly better clinical outcome when compared with the traditional eccentric only squat programme for patellar tendonitis. It is also the approach advocated by the leading researchers in this field.
Why we like it
It’s the only exercise approach that truly retrains all the aspects needed for a successful return to sport. It includes exercises that develop:
Pure strength in the patellar tendon;
Explosive/fast loading;
Control;
Sports specific muscle/tendon function and biomechanics.
And, because you’re able to choose exercises that best suit a specific patient, it causes fewer flare-ups. The focus is also on adjusting the load so that it doesn’t cause much discomfort and pain, which also makes it a much more enjoyable experience for the patient.
How a progressive loading exercise plan for patellar tendonitis works
A typical progressive loading plan is usually divided into four stages. The duration of each stage varies depending on how a person responds to it and on the demands (end goals) of their specific sport. You won’t necessarily start on Stage 1 - your tendon’s current strength and irritability determines where you start.
It is OK to experience a bit of discomfort during or after you’ve done the exercises, but ideally is should be done pain free. If you do feel discomfort, it should not go above 3 out of 10 intensity and it should settle down to your normal level of discomfort within 24 hours of doing the exercises. If it causes stronger pain than this or you experience and increase in pain that lasts for more than 24 hours after the session, you should reduce the exercise volume or intensity.
Stage 1: Isometric exercises
The aim of this stage is to allow your tendon to calm down. Isometric exercises (where you hold the contraction for up to 45 seconds) have been shown to help reduce pain when you have patellar tendonitis. You can do them against a wall or use a leg press machine or a knee extension machine.
Stage 2: Introduce isotonic exercises
Isotonic exercises strengthen both the concentric (shortening) and eccentric (lengthening) muscle action, and they tend to resemble the way our muscles and tendons function when we do sport.
Examples of isotonic exercises for the quads and patellar tendon include squats, leg press machine, lunges, and pistol squats. These should be started at a level that is slightly difficult but doesn’t irritate your tendon. They should then slowly be progressed until you can do them with heavy loads and with a single leg.
Stage 3: Plyometrics to develop explosive strength
You will continue with some isotonic exercises to maintain your strength, but add in plyometrics. Plyometric exercises load the tendon at speed.
A mix of plyometric exercises can be used, but you’ll typically start off with double leg hops and jumps and with low effort. Then they progress to single leg or just higher effort on double legs (higher boxes). What type of jumps are included in your treatment plan and the volume/intensity of them will be determined by the type of sport you play. If you do a sport that involves no running or jumping, this stage can even be left out.
Stage 4: Sport specific
During this stage an athlete should start phasing back into their sport. A footballer may start adding in kicking drills and running drills, starting off easy and at low intensity and slowly ramping it up over time. A runner will likely just start a run-walk programme to ease back into continuous running.
It’s important to continue doing a maintenance set of strength training exercises even after you’re returned to your sport. The intensity and frequency should vary depending on your training year; doing higher loads and more intense strength training during the off-season and then reducing it to a smaller maintenance set once the competition phase starts.
Heavy slow resistance exercise plan for patellar tendonitis
Steph discusses the heavy slow resistance exercise plan in this video:
How effective is it?
It’s been shown to provide better long term outcomes than the eccentric only protocol. It has also been shown to increase the collagen production inside the tendon and to cause positive changes within the tendon structure.
Why we don’t use heavy slow resistance training on it’s own
Heavy slow resistance training will always be a part of our rehab plans, but it is not enough.
It is great for restoring the tendon’s strength and the muscle’s ability to produce strong contractions at slow speeds, but it doesn’t really prepare the tendon or the quad muscles for fast, explosive loads, e.g. like for a basketball player.
Traditionally, it uses only double leg exercises, so you can’t really tell if the injured leg is working as hard as the uninjured one.
You have to use gym equipment to achieve the loads required.
It also doesn’t address any of the other strength or range of motion deficits that may be present elsewhere in the body.
So we tend to combine and use the principle of heavy slow resistance training as part of our progressive loading exercise plans rather than as a standalone plan.
How a heavy slow resistance exercise plan for patellar tendonitis works
A pure heavy slow resistance exercise plan consists of:
Three sessions a week
Each session consists of three exercises: Double leg squats, double leg leg press machine, and double leg hack squats.
You complete four sets of each exercise with a 2–3 min rest between sets.
Rest five minutes when you switch to the next exercise.
The repetitions/load changes over time
Week 1: 15 repetition maximum** (RM),
Weeks 2-3: 12RM
Weeks 4-5: 10RM
Weeks 6-8: 8RM
Weeks 9-12: 6RM
**Repetition maximum (RM) refers to the most weight you can lift for a defined number of exercise repetitions. 15 RM means that you're using a weight that you can lift 15 times max - after repetition number 15 you are totally fatigued and have to rest before you can do another set. So you will be using a much heavier weight for 6RM (Weeks 9-12) than for 15RM (Week 1), as you are looking to be fully fatigued after repetition Number 6.
All exercises are performed from complete extension to 90 degrees of knee flexion and back again.
They should be done slowly; use about 3 seconds to straighten the legs and 3 seconds to bend them to 90 degrees.
Pain while doing the exercises is acceptable, but pain and discomfort should not increase after you've ended the session. If it does increase, the session’s intensity needs to be adjusted.
Eccentric decline squat exercise plan for patellar tendonitis
Steph discusses the decline squat programme in this video:
How effective is it?
The eccentric decline squat protocol has been shown to be effective in returning athletes to sport, but there is evidence that the high slow resistance and progressive loading protocols may hold more benefit.
In a 2009 study by Kongsgaard et al., where they compared the eccentric protocol with the heavy slow resistance protocol, they found that the high slow resistance one:
gave better long term results,
and was the only one that demonstrated positive changes to the tendon structure when they checked it under ultrasound.
Breda et al. compared an eccentric only exercise plan to a progressive loading plan and found that the latter produced significantly better clinical outcomes after 24 weeks.
Why do we don’t like it
Ten years ago, this used to be the favourite exercise plan to prescribe for patellar tendonitis. But recent research has shown that it’s perhaps not really the best option.
It’s very prescriptive and it’s difficult to fit such a large volume of strength training into every single day.
It doesn’t address any of the other biomechanical issues (weakness or tightness) in the rest of the body.
It doesn’t include exercises that recreate the explosive loads the patellar tendon has to withstand in running and jumping sports.
Because patients are encouraged to ignore pain while doing the exercises, it often causes them to push too far into pain and overload the tendon too much, hindering recovery.
How the eccentric decline squat exercise plan for patellar tendonitis works
The exercises are done on a 25 degree decline board. You stand with your heels on the higher end and your toes on the lower end. The angle of the decline board offloads your calf muscle and concentrates the loading force on the patellar tendon.
You complete the downward squat movement (eccentric phase) slowly on your injured leg only. Then you place your uninjured leg on the board and use both legs to push back up (concentric phase) into the upright position. So, you train only the eccentric phase.
It is acceptable to feel pain while completing the exercises. However, it is not acceptable if the pain continues after you stop exercising.
Once you can do it at a certain level (weight) pain free, it is an indication that you should increase the weight.
You should start by doing 3 sets of 15 repetitions twice a day using bodyweight only. Then you progressively increase the load until you can tolerate enough to start sport specific training (e.g. kicking drills or ease back into running).
5. Exercises that strengthen the rest of the body
The body functions as a kinetic chain; weakness in one area may cause you to overuse and overload another. There is evidence that weak glutes and calf muscles may predispose you to developing patellar tendonitis. Calf raises (pictured below left) will help you to strengthen your calf muscles. Bridges (below right) will help you to strengthen your gluteal muscles.
6. Stretches and mobility exercises
One automatically assumes that you would need to stretch your quadriceps muscles if you have patellar tendonitis, as they are the ones attaching onto the patellar tendon. And yes, the current research does show that stretching your quads may be beneficial. However, it also suggests that tight hamstrings and reduced dorsiflexion (how far your ankle can bend up, bringing your toes towards your shin) may put you at increased risk of developing patellar tendonitis, as these too can affect the kinetic chain mentioned above.
So, it is important to also assess your quadriceps, hamstring, and dorsiflexion ranges of motion to see whether any of these need regular stretching. Remember that you don't have to be super flexible. There is a large variation between people in what is seen as a normal or functional range of motion. So, please don't over-stretch. You can actually cause yourself injuries (like high hamstring tendinopathy) if you're too aggressive with your stretching.
Below are examples of stretches for (from left to right) dorsiflexion, quads, and hamstrings.
7. Drills and exercises that teach good landing biomechanics
Biomechanics refers to the patterns your body uses when it moves, e.g. how much your joints bend or extend at specific moments during the movement.
There is evidence that athletes who have patellar tendonitis tend to land with a stiffer knee and rather move their hips into more extension to compensate. They likely develop this movement pattern in an attempt to avoid aggravating their painful tendon.
But there’s also evidence that this type of movement pattern can predispose you to developing patellar tendonitis. So, it is really important to address this as part of your rehab. It can easily be done with jumping and landing drills. However, jumping/landing drills count as very high load activities for the patellar tendon and should only be added once you’ve built enough strength in your tendon.
8. A slow, phased return to sport
Once your tendon is ready to get back to sport, it's important not to jump back in too quickly. You have to slowly increase the volume and intensity, as your tendon won't yet have the stamina to cope with a full session of regular training or a match. A walk-run programme works well for runners. In other sports, like basketball, you may start with some dribbling, light contact, and a low volume of jumping and work your way up to full contact and high jumps.
How we can help
Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan.
We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here.
About the Author
Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate.
