Complete Guide to Understanding and

Fixing Patellar Tendinopathy

By: Dan Pope DPT, OCS, CSCS, CF L1
www.fitnesspainfree.com

Jumper's knee (also known as patellar tendinopathy) is one of the most common overuse
injuries I see with athletes in the gym. Patellar tendinopathy is mainly described in our medical
literature to occur with sports that require a lot of jumping (2, 4). However, weight training
(squats, olympic lifts, lunges etc.) places a good deal of stress on the patellar tendon and
because of this the patellar tendon can sometimes become painful and limit training. Next to
patellofemoral pain syndrome (PFPS)​, jumper's knee is the second most common overuse knee
injury I tend to treat.

I wanted to make a comprehensive review of this common condition and how we can go about
treating it, with specific focus on helping people who want to get back to training some of their
favorite movements in the gym like squats, lunges, olympic lifts and jumps. So how does
patellar tendinopathy commonly present?

Presentation of Jumper's Knee (Patellar Tendinopathy)

(4):
● Pain is localized to the inferior pole (Bottom) of the patella
● Pain occurs with activities that require increased demand on the knee extensors (quads)
● Pain occurs with activities that require the knee extensors to store and release elastic
energy in the patellar tendon (jumping and plyometric activities)
● Tendon pain occurs instantly with loading and usually ceases almost immediately when
the load is removed
● Pain rarely occurs while resting
● Pain may improve with repeated loading (the “warm-up” phenomenon) but there is often
increased pain the day after
● Pain is generally consistent with the demands of the activity (For example, more load in
a squat, more depth while squatting, more intense jumping variations, longer duration of
knee intensive activities often equate to increased pain levels)

People with patellar tendinopathy can also have pain with prolonged sitting, squatting and stairs
but these symptoms can also be associated with other types of injuries like​ ​patellofemoral pain
syndrome (PFPS).
PFPS is generally a more vague knee pain somewhere under or around the patella and not just
localized to the patellar tendon.

Prevalence of Jumper's Knee (Patellar Tendinopathy)(4):

● More common in men
● Most common in age group 15 - 30 years old
● Commonly presents in group sports such as basketball, volleyball, athletic jump events,
tennis, and football, which require repetitive loading of the patellar tendon

Patellar tendinopathy can be a real problem because many people can't seem to rehabilitate
fully enough to get back to sport after getting hurt. Cook et al. found that more than one third of
athletes presenting for treatment for patellar tendinopathy were unable to return to sport within 6
months, and it has been reported that 53% of athletes with patellar tendinopathy were forced to
retire from sport (4).

Anatomy of Jumper's Knee (Patellar Tendinopathy) (4)

Before we discuss what jumper's knee is, we have to talk a bit about the anatomy of the area.
The patellar tendon is actually a ligament that attaches the patella to the tibia of our knee. The
patella also attaches to the quadriceps tendon which attaches to the quadriceps. With the aid of
the quadriceps this system helps to extend (straighten) the knee and control landings from a
jump and the descent of a squat.
Patellar tendinopathy usually occurs right below the patella but can also occur less commonly at
the attachment of the patellar tendon and tibia (tibial tubercle) or in the quadriceps tendon itself.

What is Jumper's Knee? (Patellar Tendinopathy) (4)

Jumper's knee is an injury to the patellar or quadriceps tendon. Jumper's knee generally does
not occur with a single traumatic event. It usually occurs gradually over time and worsens in
intensity with increasing activity. It is generally thought of as an overuse injury that occurs in
athletes that expose their patellar tendons to excessive stress. Insufficient recovery time
between bouts of exercise may also be a player in this condition and may not allow the tendon
sufficient time to remodel after training.
This results in portions of the tendon to become "pathologic" over time:

source: barbellphysio.com

Side Note: Cook and Purdam describe this as a "doughnut" phenomenon (or donut if you live in
the New England area). Basically, if you stack up a bunch of donuts one on top of another, the
structure is still sound despite still having a hole right in the middle. When we have a
pathological area of the tendon our rehabilitation focuses on strengthening the non-pathological
tendon areas and we can still have a strong and functional tendon despite these pathologic
sections (6).

What Causes Jumper's Knee? (Patellar Tendinopathy) (4)

Jumper's knee was formerly known as patellar "tendinitis". The "itis" portion of tendinitis
generally refers to an inflammatory condition. We used to think that the tendon becomes painful
because of inflammation in the area. What we've found over the course of time and with
research is that this condition is generally not inflammatory in nature but more of a degenerative
(wear and tear) condition (2). Basically, with excessive stress over the course of time the
tendon attempts to adapt to the stress of training. The tendon goes through changes because
of this stress and can sometimes become painful. This is referred to as "osis" or the "opathy"
found at the end of patellar tendin-​opathy.

"itis" vs "osis"

Tendons perform similarly to springs in the sense that they store and release energy. High
performance activities like jumping and weight training require the patellar tendon to store and
release energy just like a spring does (4). The better tendons store and release energy the
better we perform these activities (4).

If we perform too much tendon intensive movement, or have insufficient rest between bouts of
tendon intensive activity we don't allow the remodeling process that normally occurs after
stressing a tendon (2). This can induce pathology and changes in the tendon's mechanical
properties known as tendinopathy (2). A tendon with tendinopathy looks yellow-brown under a
microscope as opposed to it's normal white color. The collagen make-up of the tendon also
becomes disorganized in comparison to it's normal longitudinal alignment.

source: researchgate.com

Tendons with tendinopathy also have something called "neovascularization" which is the growth
of new vessels within the tendon (6). More neovascularization in the tendon is associated with
more pain in individuals with patellar tendinopathy (6). ​Having these pathologic changes in
your tendon increase your risk of developing pain (2).

Hold your horses, so having these tendon issues doesn't automatically mean we'll have pain?

No, generally only about 20% of people with radiographic evidence (MRI or Ultrasound) of
tendinopathy actually have pain (7). This means that around 80% of people with tendinopathy
have no pain at all (7).

In other words, tendons in your body that take stress over time are likely to develop some
tendinopathy. We know this occurs in sports where certain tendons are predictably stressed
(Think patellar tendinopathy in volleyball or basketball players and tennis elbow in tennis
players) (7).

This doesn't mean that you'll develop pain but you are more likely to develop pain then
someone without tendinopathy (7).

I'll repeat this because it's a little confusing. People with tendinopathy diagnosed with an MRI or
ultrasound don't always have pain but ​are at an increased risk of developing pain at some point
in the future.

Not that we've gotten the complicated stuff out of the way here are several factors that are
important in determining whether or not we go on to develop patellar tendinopathy. These are
important because we can manipulate these variables to prevent future injury as well as help
with rehabilitation. We'll discuss these additional factors in the sections below.

What are the Risk Factors for Developing Pain in

Jumper's Knee (Patellar Tendinopathy)?
So we already discussed that jumper's knee is largely a condition of overuse and can occur if
bouts of exercise are performed without adequate recovery to allow tendon remodeling. It's
logical that the variables below increase our risk of having patellar tendinopathy:

● Increased weekly training sessions (3)

● Greater total training volume and greater total amount of matches played (volleyball) (3)
● More weight training sessions per week (3)

What other factors has our research found that correlate to people developing these tendon
issues?

● Decreased hip extensor strength (glutes, hamstrings etc.) (3)

● Decreased hamstring and quadriceps flexibility (2)
 ● Patellar tracking issues (3)
● Increased knee flexion (bending) and decreased hip flexion (bending) during jumping
and landing tasks (3)
● Stiff (minimal bending at hip and knee) landing pattern with minimal ground contact time
during jumping and landing (3)
● Sport specialization (playing 1 sport vs. many) (3)
● Greater jump performance (3)

Side Note: Greater jump performance equating to more tendon issues is interesting. Athletes
who are better at developing ground reaction forces and spend less time on the ground while
jumping are more prone to develop tendon problems. Potentially the best athletes know how to
best utilize the elastic nature of tendons maximally to transfer power. Because of this they
simply take more stress through their tendons and are more prone to tendinopathy.

As you can see there are a few things we can control in order to prevent the onset of these
issues as well as keep in mind when rehabilitating from these issues and preventing future
recurrence. So this brings us to the next question...

What is Effective as Treatment for Jumper's Knee

(Patellar Tendinopathy)?
1. Knowledge About the Diagnosis and Pain
2. An Initial Period of Unloading and Modification
3. Direct Quadriceps Strengthening and Patellar Tendon Loading
4. Kinetic Chain and Sports Specific Strengthening (Hips, Calves, etc.)
5. Assessing for and Correcting Mobility Limitations
6. Modifying Jumping and Squatting Technique

So let's go ahead and talk about these key principles then huh?

1: Knowledge About Diagnosis and Pain

In order to start the process of rehabilitation we need a bit of information about the condition
itself, pain and some expectations during rehabilitation. Lack of knowledge about this condition
can set us up for things we call:

● Poor Beliefs
● Fear Avoidant Behaviors
● Catastrophizations
● Central Sensitivity and Chronic Pain
Essentially, lacking knowledge about this type of injury can cause us to have poor beliefs that
don't help us rehabilitate. One poor belief may be:

"I don't want to push this injury because every time I do it hurts. Having pain means the area is
not healed yet and I should rest until it stops hurting"

A belief like this leads to what's called fear avoidant behavior. If you're fearful of causing more
damage or delaying the healing process, you may avoid all exercise that stresses the area.
As we'll talk about soon, exercise when dosed appropriately is the most beneficial thing we
know of to help rehabilitate these injuries and completely avoiding any stress may prevent you
from getting better (2).

A catastrophization is a belief that the situation you're in is far worse than it really is (9). This is
another irrational belief that is certainly not helpful for getting out of pain. Here's an example:

"The stupid knee injury will never heal and I won't be able to play basketball ever again"

In reality, patellar tendon injuries generally do improve over time (2) and there is a good chance
you'll get back to basketball. You can see how irrational these beliefs are. However, these
beliefs are very common and need to be addressed in people who have them.
 You in 2 years

Geeky Side Note: We know that in people with chronic pain, these negative beliefs or
catastrophizations are associated with poor function and worsening pain. However, we aren't
sure yet whether this greater or prolonged pain led to worsening beliefs or the negative beliefs
led to a prolonging and worsening symptoms. (9) We do know that educating patients about
pain decreases their pain, increases physical performance, decreases perceived disability and
decreases catastrophization. (9) Hopefully it also helps to change our behaviors in a positive
way as well.

Lastly, mismanagement of this condition (coupled with poor beliefs like we spoke of above) can
lead to prolonged pain that is sometimes out of proportion to the actual damage present with
the injury. We call this central sensitivity (9). Basically our nervous systems get extra sensitive,
out of proportion to the actual state of the injury.

Pain Science Side Note: Central sensitization is not the same as an athlete continually training
with too much volume, poor technique, poor movement and a lack of a solid rehabilitation
program. In this case our athlete is continuing to irritate the patellar tendon and reducing the
ability to adapt and heal. Central sensitivity is perpetuated pain (coming from increased
sensitivity of the brain and spinal cord) in the absence of offending stress to further damage the
tendon (9).

Lucky for us, we can avoid most of this with some good old advice and starting off on the right
foot.

Now, we already have a decent background on this condition, the anatomy as well as the risk
factors that can bring about patellar tendinopathy. What's also important to understand is that
this is a condition that does actually tend to get better with rehabilitation and won't necessarily
haunt you for the rest of your life (2).

That being said, tendon issues typically take a long period of time to get better. In our medical
literature, most successful rehabilitation programs last 8-12 weeks (2). However, it is common
for these issues to take 6 or more months to resolve (4). A research study by Bahr and Bahr
found that only 46% of people reported no pain and full return to sport training 1 year following a
strength based rehabilitation program (4).

The take home point is that it's normal for the process to take a long period of time to
resolve. They can resolve more quickly but be prepared for the long haul.
Another concern of athletes with patellar tendinopathy is the tendon rupturing (tearing
completely). Lucky for us, rupturing the patellar tendon is not common and with proper
rehabilitation shouldn't be a major concern (4).

The next topic to understand during rehabilitation is pain. Pain is a protective mechanism and
exists to keep you safe. (​Click HERE for a video to help understand this better​) That being
said, once you have pain your body is trying to tell you not to do anything stupid to let this injury
recover. The other important concept to understand is that pain and injury are not completely
correlated. When you get an injury, the area gets sensitive (because your body is trying to
protect you). Therefore movement and loading may hurt, but if the loads are kept at the right
dosage, no damage is caused. (10)

Side Note: In most of our patellar tendon rehabilitation research, pain is kept between a 1 and 5
out of 10 on a 0-10 pain scale during physical therapy exercises (2). In some of the studies the
criteria for advancing an exercise is when the exercise is no longer painful (2). The idea here is
that if we aren't provoking at least some pain, the exercise may not be hard enough to cause
progress (2).

The next thing to understand is that the stress of exercise and loading your painful tendon is
actually what helps the tendon heal and get out of pain (2).

The last point to understand is that tendons generally respond well to heavy loads (4). The
majority of newer research coming out about tendon pain and physical therapy is showing that
heavy loading is a beneficial treatment for these conditions (5).
Side Note: An over-reliance on passive treatments such as ultrasound, laser and manual
therapies can also keep athletes from progressing over time. Our research shows us that it's
loading we know to be most effective for this condition (4).

That being said, exercise is good but the dosage is important. If we apply too much stress to
the tendon it can potentially make the situation worse. We need some guidelines for how much
stress is appropriate and how much is too much. Check these charts below:

In the first example, our athlete is staying away from all painful activities (firing level). This is
generally not helpful for trying to get out of pain and back to high level training. As you can see
the athlete actually makes no progress at all over the course of time.
In the second example, our athlete is just blowing through their pain (firing level), throwing
caution in the wind. We know this style of dealing with pain can make the pain stick around or
worsen (4, 8).

In the last example we have an athlete who is working with their pain. They load their patellar
tendon with just the right amount of exercise to cause improvements in pain. As the pain
improves with time and exercise, they progress the difficulty of training as well to continue
making progress. This is key to rehabilitation. ​ ​(Click HERE for a more thorough explanation of
this phenomenon)

So how much pain is acceptable during rehabilitation? As I said before, our research is a bit
varied in this regard. Some studies allow up to a 5/10 on a 0-10 pain scale during exercise (4).
Some are lower (4). Some studies also recommend pain levels returning to baseline 24 hours
following exercise (4). With this research in mind my general recommendations are:

● Pain should be kept at or below a 3/10 during physical therapy exercises

● Pain should return to baseline levels 24 hours following a therapy session
● Pain or exercise tolerance should be improving from week to week and month to month

Keep in mind that these are not hard and fast rules. Some people may be able to push into
more pain and make progress. Others may have to back off a bit more than others. Lastly,
keep in mind that pain is a dynamic process that changes day to day. Trying to quantify your
progress on a daily basis is just like looking at the scale every day to figure out if you're losing
weight. It takes time and will fluctuate. This is normal.

2: An Initial Period of Unloading and Modification

Now this may be a no-brainer for most people but it is a commonly missed step for rehabilitation
of jumper's knee. We know from our medical literature that if we don't modify our activities with
patellar tendinopathy often times the pain can persist (4, 8). We also have some research to
indicate that if we try to simply apply a strength program to the tendon without modifying our
current training or sports routine the outcomes are poor and can even lead to worsening of pain
(4).

As we learned on the flip side of the coin, we also don't want to fully unload the tendon. We
know this isn't the best plan of attack to return to activities and can lead to weakening of the
tendon (2).

However, we will have to decrease the stress of our activities enough to allow the area to calm
down and become less painful. In a case study by Silva et. al eliminating all activities that
create more then a 2/10 during sports training in addition to adding a strengthening program
along with some modification of jumping technique led to an improvement in pain (3). Studies in
similar knee conditions like patellofemoral pain syndrome show an initial period of unloading or
modification to lead to better long term outcomes then no period of unloading (8).

So what does this mean for our training? My general recommendations are to:

● Temporarily eliminate activities that produce pain >2/10

● Temporarily eliminate activities that cause pain to increase 24 hours following training
 ● Reduce total training volume and intensity enough to have pain levels return to baseline
24 hours following training

As the pain improves over the course of time we can slowly start leaking back in more training
and movements that were previously too painful. Just make sure that when we re-introduce
previously offending movements they obey the guidelines outlined above.

3: Direct Quadriceps and Tendon Strengthening

As discussed earlier, a common mistake when attempting to rehabilitate from jumper's knee is
avoiding painful movements altogether. It's natural and acceptable to modify exercises that
aggravate the patellar tendon like front squats to more hip dominant movements like barbell
back squats. This allows us to continue training without irritating the tendon. As discussed
above in concept 2, modifications like this can be beneficial when attempting to dose stress to
the patellar tendon and heal.

Photo credit BJSM

The issue with this strategy is that we know that movements that directly stress the tendon (like
a decline squat shown above) work better for rehabilitation than regular squats for rehabilitating
patellar tendinopathy (2). We also have research to show that during patellar tendinopathy
individuals have substantial motor cortex inhibition of the quadriceps muscle group (4). This is
basically a fancy way of saying that the quadriceps muscle is not firing well.

People with long standing patellar tendinopathy can also have large amounts of atrophy
(decreased muscle size) of the quadriceps muscle group (4). It makes sense that if the muscle
doesn't fire well we need to ensure we get it firing well and restore strength. We can't do this if
we substitute all quad dominant movements in the gym to hip dominant movements.

Shifting your entire exercise program to hip dominant movements (deadlifts, box squats, good
mornings etc.) may allow you to train without pain but doesn't do much for your weak, inhibited
quads. It also doesn't stress the tendon to allow it to adapt either. We'll have to ensure we
apply some direct tendon and quadriceps strengthening to fully rehabilitate.

The frequency of exercise for patellar tendinopathy is our medical literature is somewhere
between twice per day and every other day (2). These exercise programs also tend to be
progressive in nature. As the tendon becomes more and more resilient, we apply progressively
more challenging exercises (2).

Malliaras et. al have proposed a progressive 4 stage patellar tendinopathy rehabilitation plan
(4):

● Stage 1 Isometrics:​ Isometric (no movement) knee extension (between 30-60 degrees
of knee flexion) for 5 sets of 45 seconds at 70% of your maximum effort. Performed 2-3
times per day
 ● Stage 2 Isotonics: ​ 3-4 sets of 15 repetitions every 2nd day. Repetitions decrease over
time and load increases.
● Stage 3 Energy Storage Loading:​ Progressive (volume and intensity) jumping,
sprinting, cutting activities specific to demands of the sport
● Stage 4 Return to Sport:​ Progressive exposure to sport specific training drills and
competition

Basically if you have too much pain (described as more then minimal or >3/10) during isotonic
(exercise with motion) exercises then you start with isometrics (pressing against an immovable
object). Once you can tolerate isotonics with minimal pain, you move there.

Once you're showing symmetrical strength in isotonic exercises in stage 2, you can move onto
stage 3. ​(Keep in mind these energy storage exercises should also have minimal pain and your
pain levels should return to baseline 24 hours after exercise.) As your energy storage exercises
progress to the point where they begin to replicate the sport specific demands of your sport, it's
time to progress to more sport specific training and competition.

Also keep in mind that each stage may last several weeks. As stated before, rehabilitation often
takes 6 months or more and progression shouldn't be based solely on time but instead on how
well the tendon is tolerating exercise.

For our average lifter trying to get back to training in the gym their program may look like this:

Phase 1: Isometric (started when isotonic exercises are too painful)

● Knee extensions against the wall @45 degrees
● 5 sets of 45 second holds at 70% of maximal perceived exertion
● 3x per day
● 1 week in duration

Phase 2: Isotonic (started as soon as tolerated with minimal pain)

● Decline single leg squats 3-4 x 15
● Machine quadriceps extension 3-4 x 15
● Performed every other day
● 6 weeks in duration
● Each week progressing to heavier and lower rep ranges (week 2 sets of 12, week 3 sets
of 10 etc...)

Phase 3: Energy Storage Loading (started when tolerated with minimal pain)
● Box jumps 3 x 3
● Running - 15 minutes of 30 seconds on, 30 seconds off interval runs
● Performed 2-3 x per week
● Continue with isotonic exercises
● 4 weeks in duration
Phase 4: Return to Sport (started when energy storage exercises begin to mimic sport
activities)
● Slow transition back to regular gym activities

Keep in mind that the exercises selected in phase 3 and 4 will vary greatly based on the person
and what they want to return to. For a basketball athlete it may consist of a large variations of
jumping, cutting and acceleration drills. For the olympic lifter it may be more explosive lifts like
jerks, cleans and snatches.

4: Kinetic Chain and Sports Specific Strengthening

When you’ve got an injury it’s easy to focus all of your attention directly at the injured area.
Truth is, your entire body moves as a unit and multiple joints and muscles need to work together
to complete movements like squats, deadlifts and olympic lifts.

Think of it this way. Let’s say you have a tug of war team with 3 team mates. One is an NFL
lineman, the second is a professional soccer player and the third is a marathon runner. Let’s
say your NFL lineman is slacking and not doing his job properly. The soccer and marathon
runner are going to have to pick up the slack. Because of this they may get injured but not
because they aren’t strong and capable, potentially it’s the opposite. Maybe they wouldn’t have
gotten hurt if the lineman did his job properly.

Now let’s say the NFL lineman consist of the muscles around your hip. Let’s say the soccer
player consists of the muscles around the knee like the quads and hamstrings. Lastly the
marathon runner consists of the muscles around the ankle like the calves.

All of these muscles need to be optimized to normalize the stress at the knee and patellar
tendon. Failing to address this whole chain can be a reason why your rehabilitation program
fails (4).

The other important piece to recognize is that your rehab program should start looking more and
more like your typical training program over time. This is known as sports specificity (2, 4).
For an olympic lifter, heavy squats and olympic lifts may need to be eliminated from your
program initially. As the knee starts to improve you can start to slowly introduce deep squats
back into your program. As these are tolerated we can add in olympic lifts, starting with power
variations and slowly progressing towards full squat variations.

For an athlete that performs a lot of jumping (sports like basketball and volleyball) they’ll
probably require an initial period of unloading from jumping activities. As the tendon
progresses over time you can start slowly leaking in jumping exercises.
Jumping exercises should be progressive in nature, starting with double leg exercises and
progressing to single leg. Jumping should also start with less reactive variations and progress
to more reactive jump variations. Here are some progressive jump variations to help you design
a program if you're looking to get back to jumping:

Phase 1:
Phase 2:
Phase 3:
Phase 4:

You can see how the stress on the quadriceps tendon will advance as we progress towards
more challenging jump variations.

5: Assess for and Correct Mobility Limitations

As discussed in the part 1 of this article series people with patellar tendinopathy can also
present with hamstrings and quadriceps tightness (2). We also have some medical literature
that shows that if you add hamstrings and quadriceps stretching to a patellar tendinopathy
strengthening program, the results are better (2).

Use the assessments below to determine if you or your patient has a mobility limitation in their
quads or hamstrings:

Hamstrings assessment:
Quads / hip flexors assessment:

If you find you have a mobility limitation I recommend applying a combination of foam rolling and
stretching to help reduce tightness:
Here's a quick video to show you some basic stretches and foam rolling to help improve a
limited thomas test (quads and hip flexors):

Once you've got a plan to address quadriceps and hamstrings mobility, the next important thing
to tackle is ankle dorsiflexion flexibility. Now, if we're lacking ankle dorsiflexion mobility, this can
create what's called "dynamic valgus" or "knee in" during squatting tasks (11). ​Check this video
to see how:

So, tendons are very good at taking stress in alignment with the fibers they are made up of.
When we get dynamic valgus we expose the tendon to forces that rotate the tendon along with
normal tensile loads. Tendons are generally not as good at handling these rotary forces and the
idea is that this can contribute to developing tendinopathy.

Either way, dynamic valgus at the knee is generally a suboptimal way of moving and has been
implicated in other knee issues such as ACL injury and patellofemoral pain syndrome. It's
probably a good idea to minimize the amount of valgus during jumping, squatting and single leg
strength training.

For these reasons it’s important that we assess for ankle mobility limitations and correct them if
present. ​Use this assessment to see if you have an ankle mobility limitation into dorsiflexion.

If you’ve got a restriction, ​here are some of my favorite stretches and mobilizations​:

Mobilizations for these restricted areas obviously should be a regular part of your rehabilitation
program.

There is a lot of confusion out there currently for how often stretching and foam rolling exercises
should be performed. Here are some general guidelines for frequency and duration of mobility:

Stretching (12):

● 60 seconds stretching per muscle group

● 5-7 days per week (the sweet spot is 5-10 minutes of stretching per week)

Foam Rolling (13):

● 60 seconds foam rolling per muscle group

● 3x per week (dunno optimal dosage yet, literature shows longer term improvements with
this recommendation)

Mobilizations:
 ● 10-15 reps performed after stretching and foam rolling

Side Note: Stretching and foam roll recommendations were taken from evidence based
guidelines. Check the articles in the works cited if you want to check them out.

6: Modifying Jump and Squatting Technique

One contributing factor to patellar tendinopathy may be how our athletes choose to move during
sporting tasks like jumping, squatting and running (2, 4).
The way we squat and jump affects the amount of stress on the patellar tendon. A few things
that increase stress on the patellar tendon (2):

● Increased knee flexion (increased squat depth)

● Increased load (i.e. added weight to the barbell)
● Forward weight shift
● Faster more explosive contractions that require the tendon to act as a spring
● Dynamic valgus at the knee

Let's explore each of these a little deeper.

1: Increased knee flexion

As we descend deeper and deeper into a squat we simply place more and more stress onto the
patellar tendon (2). We can easily modify depth of squatting and other knee bending exercises
to place more or less stress on the patellar tendon.

2: Increased load

The more external load (weight on the bar) we use during a given movement, the more load on
the patellar tendon (2). This is partially due to the amount of quadriceps activity during a given
exercise. The harder the quad is forced to work, the more stress goes through the patellar
tendon.

3: Forward weight shift and knee displacement

This point is subtle but important to understand. The more shifted forward our bodyweight is
during a squatting or landing task, the more stress on the patellar tendon. In the image above
we have someone landing with more forward weight shift (left image) and someone landing with
more backwards weight shift (right image). The cue of "hips back" during landing displaces the
weight backwards and reduces stress on the patellar tendon (3):

The same goes for the squat, the more we sit back during a squat, the less stress on the
tendon. As we sit back in the squat, we unload the patellar tendon. If you've got a painful
tendon, this tends to reduce pain.
Lastly, utilizing a decline board during single leg squats also forces an anterior weight shift
(anterior knee displacement as described in the article). This decline also increases stress on
the patellar tendon (2). Notice the difference in how far the knee is displaced forward in the
decline squat image (Figure A):
Side Note: It's important to point out that once you acquire patellar tendinopathy, directly
stressing the tendon with decline squats (figure A) actually produces better results for
rehabilitation then single leg squats without a decline (figure B) (2). This points to the
importance of directly stressing the tendon for rehabilitation.

4: Faster more explosive contractions that require the tendon to act as a spring

Stiffer landings with reduced ground contact time tend to stress tendons more then softer
landings with more bending at the hip, knee and ankle joint (3). This makes sense given that a
really fast jump with less time for the muscles to help absorb force will stress the tendon to a
greater degree.

Interestingly, athletes who perform better during jumping tasks tend to develop more patellar
tendinopathy and pain (2). These same athletes may be better able to harness the elastic
nature of tendons and jump better as a result. Unfortunately, the better you're able to produce
forces in tendons, the more likely you may be to develop tendon pain.

One case study from JOSPT found that retraining jump patterns was helpful in reducing patellar
tendinopathy pain (3). Some cues used in the study that may help athletes when returning to
jumping after patellar tendinopathy are:

● Land "softly" to minimize landing impact

 ● Reduce sound during landings (also to reduce landing impact)
● Lean forward during landings (to encourage increased hip motion)
● Push hips back during landings (also to increase hip motion)

The thought here is that patients with patellar tendinopathy tend to have stiffer landings and
don't adequately utilize their hips (send the hips back, bend at the hip and lean the trunk
forward) during landings and instead tend to utilize the knees more (more knee flexion and less
hip flexion).

Correcting these issues reduces stress on the patellar tendon, may help decrease pain and
improve rehabilitation outcomes (and potentially decrease future issues). Although this is only
one case study, it makes sense that modifying jump technique may be helpful in reducing pain
in people with patellar tendinopathy.

The same goes for the squat and single leg strengthening exercises like lunges and step-ups. If
we encourage more "hips back" and encourage more forward trunk lean we're taking some of
the stress off of the patellar tendon and onto the hips and spine instead. This can be useful to
modify stress through the patellar tendon throughout the rehabilitation process.

5: Dynamic valgus at the knee

As stated earlier, having dynamic valgus at the knee can increase stress through the patellar
tendon. Inadequate ankle dorsiflexion can lead to this but often this is purely a technical issue
that can be corrected with the right cues from a coach or feedback by standing in front of a
mirror.
You'll want to ensure you have optimal alignment of the knee and toes during all of your chosen
activities (squatting, lunging, step-ups, running, jumping, landing etc..).
So there you have it, probably more information than you've ever wanted about patellar
tendinopathy.

Do you want more in depth information about patellar tendon injuries and how to
rehabilitate them fully and get back to training? ​ ​Join my Insiders Online Mentoring
Program to gain access to more educational webinars and a 12 week training program to
get you out of pain and back to squatting and weight lifting.

That was a lot of knee info!

Dan Pope DPT, OCS, CSCS, CF L1

References:
1. Superior results with eccentric compared to concentric quadriceps training in patients
with jumper’s knee: a prospective randomised study
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1725058/pdf/v039p00847.pdf
2. CURRENT CONCEPTS IN THE TREATMENT OF PATELLAR TENDINOPATHY IJSPT
2016 ​https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5095939/#B83
3. Rehabilitation of Patellar Tendinopathy Using Hip Extensor Strengthening and
Landing-Strategy Modification: Case Report With 6-Month Follow-up JOSPT 2015
https://www.jospt.org/doi/full/10.2519/jospt.2015.6242?code=jospt-site
4. Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for
Challenging Case Presentations
https://www.jospt.org/doi/pdf/10.2519/jospt.2015.5987?code=jospt-site
5. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain
the clinical presentation of load-induced tendinopathy. Br J Sports Med 2009;43:409–16.
6. Neovascularisation and pain in jumper’s knee: a prospective clinical and sonographic
study in elite junior volleyball players
http://bjsm.bmj.com/content/39/7/423ijkey=a16cd5a3976373e3a7cb301804ef49f9f932f9
8a&keytype2=tf_ipsecsha
7. Physio Edge 075 Tendinopathy, imaging and diagnosis with Dr Sean Docking
https://www.clinicaledge.co/podcast/physio-edge-podcast/75
8. Moving Beyond Exercises for Managing PFP, Patella Tendinopathy and Iliotibial Band
Syndrome Sports Kongres https://youtu.be/VJIN-WT8N00
9. Mechanisms and Management of Pain for Physical Therapists by Kathleen Sluka IASP
Wolters Kluver
10. Therapeutic Neuroscience Education - Adriaan Louw
11. The association of ankle dorsiflexion and dynamic knee valgus: A systematic review and
meta-analysis. 2018 Physical Therapy and Sport
https://www.ncbi.nlm.nih.gov/pubmed/28974358
12. The Relation Between Stretching Typology and Stretching Duration: The Effects on
Range of Motion IJSM 2018
13. The Foam Roll as a Tool to Improve Hamstring Flexibility ​The Journal of Strength and
Conditioning Research (Dec. 2015)
14. Common Running Injuries Evaluation and Management 2018 by the American Academy
of Family Physicians https://www.aafp.org/afp/2018/0415/p510.html
15. O'Sullivan K, McAuliffe S, Deburca N. The effects of eccentric training on lower limb
flexibility: a systematic review. Br J Sports Med 2012; 46: 838–845