Fixing Patellar & Quad Tendon Pain

How does someone develop patellar or quad tendon tendon pain? To answer this question, we first have to discuss a little anatomy.

A tendon is essentially a fibrous band of tissue that connects muscle to bone. The patellar tendon runs from your kneecap (patella) to the tibial tuberosity (the prominent bony part of your shin bone). Above the kneecap is another band of fibrous tissue, the quad tendon, which attaches to the very large and strong quadriceps muscles. These two tendons work together to absorb and release tremendous power (with movements such as jumping) much like a spring.

Every single day the tissues of your body (muscles, tendon and even bone) are in a constant process of fluctuation. Every time you place stress on your body (like when working out) portions of your tissues are degraded and then regenerated. Overtime this natural replenishing process is how strength is built.

In your tendons, this process is largely controlled by small cells called tenocytes that are dispersed amongst aligned fibers called collagen (type 1 if you want to be exact). Tenocyte cells react to the forces and loads placed on the tendon and adapt the cellular make-up of the tissue accordingly (called the extracellular matrix). Depending on a number of factors (such as how intense you have trained throughout your years as an athlete, the medications you take, whether or not you have diabetes, etc.) your body will have adapted your tendon to a certain set point of strength called the “load tolerance” level.

Training loads placed on the tendon that do not severely exceeded this set level create a cellular response in the tendon (that can actually be seen by ultrasound) that will return to normal in 2-3 days given proper recovery methods (this is the normal time frame for the adaption “replenishment” process to take place).²⁷ However, if the load placed on the tendon is too extreme or if there is inadequate recovery in the athlete’s training program, this balanced process is disrupted. When this occurs the process tips from being adaptive to pathological. A spark is lit and the injury process begins.

Young athletes (under the age of 30) who are involved in sports that include sudden explosive and repetitive movements of the knee are most susceptible to developing an injury at either the quad or patellar tendons. Movements that use the tendons of the knee as a spring (such as a jump) place significantly more load on the tendon than a slower movement like a squat. Historically, this is why sports such as basketball and volleyball that involve a high amount of jumping have such a high incidence of this injury (a reason why this injury is also known as “jumper’s knee”).

Of the two, the patellar tendon is usually the more commonly injured. However, patellar and quadriceps tendon pain are both prevalent in sports such as weightlifting and CrossFit due to the high forces that are sustained during the repetitive ballistic movements of the snatch and clean.

DEFINITION OF “TENDINOPATHY”

Historically, tendon injuries have been separated into two distinct categories: tendinitis and tendinosis.² The “itis” ending of tendinitis refers to an acute injury caused by inflammation. The “osis” ending of tendinosis traditionally means the problem is not caused by inflammation but due to the tendon itself degrading and becoming weak. Commonly medical practitioners will throw out the word “tendinitis” when referring to a recently painful injury and “tendinosis” when referring to more chronic long-term tendon injuries.

However, recent research has challenged the idea that the inflammation commonly seen with tendon pain is a main driver of the injury and pain.¹³ Furthermore, leading researchers in the field of tendon injuries now believe “tendonitis” and “tendinosis” are not mutually exclusive and are actually different parts of the same injury process. Therefore, when we speak about tendon injuries, it is advised to now use the term “tendinopathy” rather than “tendonitis” and “tendinosis”.

 SO HOW DO TENDON INJURIES OCCUR?

Before we go into how to treat tendon injuries, we first need to dive a little deeper into how the injury process occurs. The most practical way for understanding this comes from the ‘Continuum of Tendon Pathology’ by renowned expert Jill Cook.¹³ This model describes a continuum with three overlapping stages of injury (reactive tendinopathy, tendon disrepair and degenerative tendinopathy). Progression from one stage to the next is met with a subsequent decreasing ability to recover back to the prior healthy state.

As mentioned before, when exposed to an overload of any nature there is a short term exaggerated response of the cells that make up the tendon. Specifically, small proteins called proteoglycans flood the extracellular matrix causing the tendon to become swollen and painful. Again, this swelling process is not caused by inflammation (a big reason why ice and rest alone don’t fix the injury!)²⁹

So how exactly does this overload occur? If it was as simple as not lifting more than a certain set amount of weight or not lifting too frequently throughout the week, how is an elite weightlifter able to pull two-a-day training sessions multiple times throughout the week without ever developing pain while a relatively amateur athlete may develop this injury after training for only a few weeks? It all comes down to the individual and the relative “load capacity” of their tendons. Let me explain.

Our body does an amazing job of adapting to the stresses applied to it. Depending on the kind and amount of stress, the cells in our tendons can respond positively or negatively. In response to acceptable training loads our tendons become stronger by increasing their stiffness levels.¹⁹ An elite athlete who performs explosive and heavy barbell training every day with minimal rest is able to do so because they have deliberately conditioned their tendons over years to withstand very high level of stress. By routinely subjecting their tendons to high levels of load through proper training programs, elite athletes have the ability to raise the “load tolerance” level of their tendons.

If a relatively untrained athlete tries to perform the same higher level training of an elite athlete, they can spark a “reactive” phase of injury (a short term exaggerated response of the cells due to the unexpected overload of their tendon’s current “load capacity”). This common scenario takes place when athletes have one extremely difficult training session or jump from a three days a week program to lifting every day.

The spark that sets off the “reactive” phase for a novice athlete can also occur with an elite athlete. If an elite athlete who is able to tolerate a ton of loading day in and day out took a long break from training (two or more weeks for example) and all of a sudden jumped right back into a relatively normal training program (“normal” being relative to what they were used to), they would subject their tendons to a ton of unexpected stress. This is because their tendons would become somewhat deconditioned over the extended break, adapting their tissues to a lower “load capacity” level.

There is no absolute set amount of weight or reps of any drill that will automatically trigger this injury response, it comes down to purely whether or not an individual’s tendon “load capacity” has been exceeded. Basically any unexpected loading on the tendon can trigger a reaction and subsequently the tendon can thicken in an attempt to handle the stress of training.¹⁴ At this time an athlete may experience pain as well as a small amount of swelling around the tendon.

Now here’s the good thing, this process is reversible if properly managed. Researchers believe “reactive” tendons have the potential to return to their normal healthy self within a few weeks if the initial training load is significantly reduced and proper rehabilitation steps are taken.¹⁴

If however, someone continues to train past this point of reactivity, the tendon will enter the “disrepair” stage as it continues to thicken in an attempt to heal itself. In fact, researchers have found this exaggerated repair process can cause the patellar tendon to double in thickness (from around 4mm to 8mm) as a protective response.^15,16 In response to the continued overload more and more proteins (proteoglycans) flood the extracellular matrix drawing in water, which eventually starts to disrupt the architectural struts (collagen) that makes up the tendon. At this point we also see new blood vessels and nerves growing in the tendon which may play a part in creating more pain.^17,18 If proper steps are not taken to address the injury at this time, the disorganized collagen starts to breakdown even more and die off as the injury enters the third stage (degeneration).

Unfortunately, it is very hard to distinguish whether or not a tendon is in disrepair. To make matters worse, you may not even know that your tendon has slipped into the late third stage because the degenerated part of the tendon doesn’t elicit pain.

So how do we find out which stage of injury the tendon is in?

What researchers like Jill Cook have found is that tendon pain is primarily a symptom of the “reactive” stage. For this reason, if you are currently experiencing patellar or quad tendon pain, you can stage your injury into an even more simple two-stage model of either “reactive” or “reactive on disrepair/degeneration” tendinopathy.¹³ Let me explain.

Let’s say this is the first time you’ve ever experienced patellar tendon pain. You had a really difficult training session and the next day your tendon hurts so bad you’re forced to limp around. Because this is an acute (brand new) episode of tendon pain, it’s likely you’re experiencing the first stage of “reactive” tendinopathy.

However, let’s say this is not the first time you’ve experienced patellar tendon tendon pain. You had a small flare up last year and a few months ago as well. You took a few weeks off and the pain eventually went away, but it keeps on coming back. Due to the chronic nature of these symptoms, it’s likely you may be experiencing a case of “reactive on disrepair/degeneration” tendinopathy.

When the tendon experiences continued episodes of overload, degradation can begin but the entire tendon doesn’t just die off. If you looked deep into the tendon, you’d actually notice “islands” of degenerated collagen tissue dispersed amongst healthy tendon. The small “islands” of degenerated tissue are unable to bear any load. They usually lose tensile strength and spring-like capacity which renders them “mechanically deaf” as professor Jill Cook says.³⁰

Think of the islands of degenerated patellar or quad tendon fibers as holes in a donut. These holes are surrounded by healthy tissue. However, research has shown the body will actually adapt and “grow” more normal tendon tissue around these dead spots in an effort to recover this lost strength.³¹

As mentioned before, these degenerative “holes” of the tendon do not create any pain.¹³ It is not until the surrounding portion of healthy tissue becomes overloaded and slips into a “reactive” phase (in the exact same way as a perfectly healthy tendon would) that pain can develop in a degenerated tendon. This is why someone could have a very degenerated tendon rupture without currently having any symptoms of pain.³²

A good way to differentiate between “reactive” tendon pain and “reactive on disrepair/degeneration” (other than a history of previous symptoms) is how intense the pain is, the exact mechanism that set off the injury and how long it takes to recover. For example, a true “reactive” tendon is very painful and swollen. It is sparked by a very severe overload (an extremely difficulty training session filled with a ton of plyometric exercises like box jumps).

On the other hand, a “reactive on disrepair/degenerated” tendon can be sparked by much less dramatic activity overload and won’t be accompanied often by as much swelling to the tendon. Pain from this particular tendinopathy can resolve in as little as a few days with proper rest, where as true “reactive” tendons can take anywhere from 4 to 8 weeks.³⁰ Understanding which stage you’re in will dramatically affect how we manage the injury.

WHERE DO WE FEEL THE PAIN?

 Classically, those with patellar tendinopathy will complain of tenderness and pain at the connection point of the kneecap and patellar tendon (called the inferior pole of the patella). You may even experience pain where the patellar tendon attaches to the tibia (a small bump on the front of your shin called your tibial tuberosity). Usually you won’t have pain directly in the center of your patellar tendon unless you’ve sustained a direct blow to the knee (like hitting your knee into a corner of a desk). Those with quadriceps tendinopathy will have pain and tenderness at the connection point of the kneecap and the quad tendon (called the superior pole of the patella).

Initially, most people will report feeling a dull ache in the front of their knee after intense workouts. Most people who have this injury will experience pain that gets worse as the load to the knee increases (i.e. a repetitive tuck jump will bring out more pain than a slow bodyweight squat). This is called load-related pain (remember this term as it will be an important part of how we fix this injury later).

Interestingly enough, the patellar and quad tendons are also placed under considerably more load in a very deep squat where the knee must move forward over the toes. For this reason, someone with either tendon injury may complain of pain during a loaded squat but only at the very bottom portion of the lift.

If you have pain when squatting, it is very important that you figure out if you truly have a tendinopathy injury or if you have another form of knee pain (such as a compression or tracking problem). Tendinopathies will rarely hurt when completely at rest.²⁰ This is because the load on the tendon is removed when sitting or lying down. The pain from a tendinopathy always remains in one specific area. If you feel like your pain moves away from the inferior pole of the patella to other areas of the knee, chances are you don’t have a tendinopathy injury. You have a higher likelihood of having patellofemoral pain in this case.³³

HOW DO WE FIX IT?

STEP 1: The Balancing Act

As an athlete competing in the sport of Olympic weightlifting for over a decade, I wholeheartedly understand the drive most of us have to train despite having aches and pains. Fortunately, I been able to merge my passion for barbell training with my education in physical therapy to help you become as efficient as possible in treating this injury. Contrary to the general advice of your local doctor, not everyone has to completely stop training to fix this problem.

If you are currently dealing with tendon pain, you are in a “reactive” stage (regardless if you are in the first “reactive” or later “reactive on disrepair/degeneration” stage). This pain is due to one simple mechanism, overload. The pain you’re experiencing started because you placed too much load on your patellar or quad tendon and surpassed its current “load tolerance” level. Regardless of the exact cause or where you lie on the continuum of pathology, your first step in finding relief of your symptoms is to modify your training. Your body has experienced an abrupt overload of your tendon tissues and has responded negatively with pain. You need to look into WHY this occurred and make changes in order to decrease your pain.

Changing your training intensity and volume does not mean you’re going to stay away from the gym and sit on the couch for the next week. You never want to completely rest a tendon!

The strength of your tendons follow the simple motto of, “if you don’t use it, you lose it.”³⁴ If you completely take away all loading and only rest for a few weeks, you set yourself up for the pain to eventually return! Tendinopathy occurs because your training surpassed your current load tolerance level. If you completely rest your body it will adapt and the tolerance level of your patellar and/or quad tendon will lower (as there is minimal load being placed on it), making it easier to overload whenever you do decide to return.

On the other hand, we don’t want to ignore pain and continue pushing through painful exercises. If you do so, the injury will only continue to get worse and structural changes will eventually take place in the tendon. We must balance the amount of load you place on your tendon at this time to find the perfect amount that allows for the healing process to occur (too little or too much will only make things worse in the long run).

In my experience, a number of barbell athletes begin to experience this pain in the time leading up to an important weightlifting or powerlifting meet. It is therefore not practical for everyone to completely stop training. You must however make a change to your training program (along with adding in some of the exercises discussed later). The pain you’re experiencing is your tendon telling you it is not tolerating the loads you are placing on it. It is there for a reason. Listen to it.

For such cases, try changing one variable in your training program and see how your tendon responds. For example, if you currently train seven days a week, decrease the frequency by dropping one session. If you can’t sacrifice one day of training, you must make a change to either the amount of high intensity loads or the total volume of your training. Regardless of which variable you choose, only change one factor at a time and wait to see how your body responds (everyone will be slightly different so there is no golden rule).

However, if the body does not respond well to this modification in training with the addition of corrective exercises or the pain has been on-going for more than a few months (meaning your injury may now be in the “degenerative” phase) it is highly recommended to cease training and consult with your local sports physical therapist or an orthopedic specialist (MD or DO).

STEP 2: The Rehab Plan

Exercise is the best treatment for any type of tendon pain. Period. If you have visited with a doctor or other medical practitioner that recommends injections or other “passive” treatments like electrotherapy or scraping techniques as the main mode of treatment, you went to the wrong person. While these treatments may decrease your pain in the short-term, they will not be helpful in the long-term as they do not address why your tendon became injured in the first place. You must strengthen the tendon and improve its ability tolerate load.

Phase 1: Isometrics

The most tolerated of all strength exercises for tendinopathies is an isometric. This is an exercise where the muscle contracts but the joint doesn’t move (i.e. squeezing your quad while standing or laying down). Isometrics have been shown to reduce pain for upwards of 45 minutes after performing.²² They also spark the ability of the quad to kick back on, as it is usually inhibited in strength output due to pain (called cortical inhibition).²² Think about it like this. If every time you perform a jump and your body experiences pain, your brain eventually says, “stop it!”  This is why someone who has been dealing with tendon pain for a long time will eventually have decreases in their performance.  Heavy isometric exercises have been shown to change this.

Isometrics should be performed relatively pain free. While you may have a little pain at the very start, it should decrease significantly by the third or fourth repetition.

For an isometric to be effective, it must be difficult to perform! This is where most come up short. Research shows you must find a load that contracts your muscle(s) to 70% of its max capabilities. While there is no way to test exactly for this level by yourself, you can estimate it by finding the intensity and load combination that makes an isometric difficult to hold for 45 seconds!

A low-level way to perform an isometric for the patellar and quad tendons is a wall sit. With your back against a wall and feet out in front of you, slide down the wall and sit with your knees bent to around 60°. Perform 5 repetitions of a 45-second hold. If this is too easy, try performing the wall sit with one leg.

If you finish these wall sits (either in double or single leg) and think to yourself, “I could have held that at least for 30 seconds more” … you don’t have enough load on your tendon. This is common response for most athletes. This means the load from the wall sit is not high enough to bring out the desired outcomes, and you need to try the Spanish Squat instead.³⁵

Grab and loop a very thick rigid band around a squat rack or pillar. The band should be placed behind the knee at the top of the calf with your toes facing the band attachment. Next, squat backwards as deep as possible with keeping your spine upright (think of this as performing a reverse wall sit). Don’t hinge at your hips as if performing a normal squat as that will unload the desired force off the quads and transfer it to the hips. The Spanish Squat with an isometric hold places much more force on the quadriceps than a wall sit (and thus patellar and quad tendon) meaning it is more efficient in eliciting the desired outcome of decreasing pain and cortical inhibition. Perform the hold again for 5 repetitions of 45 seconds two to three times a day with a minute or two rest in between to help maximize recovery.

Interestingly enough, isometrics like the Spanish Squat hold can also be a good diagnostic confirmation test for patellar and quadriceps tendinopathy. If performing these exercises do not decrease pain thereafter and instead increase your knee symptoms, you likely are dealing with a different type of injury and need to revisit the testing regimen from my prior blogs (click this link!)

If you are continuing to train through this injury, use these Spanish Squat hold isometrics before your workout as a way to decrease pain and improve neuromuscular control and force generation during your lifting. Make sure to keep an eye on your body responds to the amount of loading at this time!

Phase 2: Strength with Isotonics

Research has shown that tendons that are subjected to routine loading with an adequate strength program adapt by becoming stiffer.^19,28 For example, in 1986 a group of researchers performed a study on a 242lb/110kg powerlifter squatting 550lbs/250kg.¹² During this heavy lift, they estimated the loads on the patellar and quadriceps tendons reached 6,000 and 8,000 newtons respectively.¹²

A newton (N) is an international unit for measuring force. Researchers have estimated that the patellar tendon can withstand forces of upwards of 10,000-15,000 newtons (which is around 13-19x bodyweight for an 176lb/80kg athlete).^3,10 Estimating the ultimate strength of the quadriceps tendon however is a little harder. Scientists have found the quad tendon to be around 30-40% thicker than the patellar tendon, therefore it can probably withstand much more force than the 15,000 N patellar tendon (a reason why overloading and creating a reactive quad tendon is rarer than patellar tendinopathy).¹¹

Now why is this so important to understand? Like I mentioned, routine loading can increase a tendon’s “stiffness” which means it has a higher capacity to bear load. While the isometric exercises are great for decreasing pain and increasing strength temporarily through changes in cortical inhibition, they do little to improve the load bearing capacity of the tendon. Eventually our rehab must move past isometric exercises and start using traditional strength training exercises to accomplish this.

Most exercises you see performed in the gym will have two phases: eccentric and concentric. The eccentric phase is the lowering portion of a movement where the muscle fibers are lengthened under tension. The exact opposite would be the concentric phase, where the muscle fibers are shortened under tension. If we look at the traditional squat exercise, the vastus muscles of your quad length lengthen as you descend (the eccentric phase) and shorten as you stand back up (the concentric phase).

Historically, physical therapists have treated tendinopathies at the knee with eccentric exercises.¹ One common exercise is a single leg squat on a decline board for 3 sets of 15 reps twice a day. The athlete starts by standing on a decline board (usually on a 25° angle) and performs a slow single leg squat on one leg while maintaining an upright chest. They will then put their free leg down and stand back up with both legs. Placing your body on a decline specially targets the patellar tendon 25-30% more than when performing this exercise on flat ground.⁷

Unfortunately, there are two problems with using this exercise. First, there is very limited research to back it up.²¹ Second, the use of this exercise program may be too aggressive for many. Pain is a normal response to decline single leg squats and using them with an athlete that is continuing to lift may cause excessive irritation and worsen the injury.

Also, if you think about it, our body moves using both eccentric and concentric muscle actions. Focusing strength efforts on only one portion of the movement does not strengthen it in a way that will carry over functionally to the activity we perform throughout our day and in our training. Your muscles aren’t only performing eccentric muscle contractions when you sprint down a track. It’s not that eccentrics don’t work, but why ignore the other half of the movement?

Recent research has shown that the type of contraction (eccentric vs normal eccentric & concentric loading) is irrelevant when it comes to driving the healing process with tendinopathies!²³ Ultimately it is the amount of load we place on the tendon that drives the injured tissue to return to a normal state.

In the early 2000’s research began to emerge on the use of heavy slow resistance training (HSR) in the rehabilitation of tendon injuries. HSR describes traditional exercises performed slowly with both concentric and eccentric muscle contractions (called an isotonic movement). The initial research showed these heavy and slow exercises were just as effective as eccentric only exercises in the rehab of tendinopathy.^5,6,21 They are excellent at building load tolerance during this phase of rehabilitation without using the tendon as a spring, which would otherwise overload the current capabilities of the tissues and increase symptoms.  As soon as your pain has decreased during normal day to day function to a 3/10, I recommend starting HSR exercises.

The Box Squat

The squat is a great way to start loading the patellar and quad tendons. If you can squat to full depth without pain, by all means continue doing so. However, if extreme pain has limited your ability to squat to full depth, limiting your squat descent to a predetermined height will be a needed step.

For example, box squats allow you to load the body in a recognizable way while controlling for a few important factors. First, you can control for the amount of depth by setting the box to a predetermined height to limit pain. In order to maintain your balance as you descend into a full depth squat, your knees must move forward towards (and sometimes over) your toes. While this forward knee position is not inherently dangerous for someone with healthy knees, the inclined shin angle can increase load on the patellar and quad tendons creating pain. Performing a squat to a box squat to around a parallel squat depth will limit forward knee translation allowing you to load the tendons without creating pain.

Box squats also decrease the total tension placed on the quad and patellar tendons as a powerful turnaround in the bottom of a free squat (which naturally stores and releases energy via the tendons) is not used. When doing a proper box squat there is a pause between the descent and ascent. Normally with a heavy squat, there is elastic energy that is stored in the tendons. The pause will eliminate the spring like loading and unloading of the tendon. Simply put, athletes with patellar tendinopathy will be able to tolerate box squats better than a regular heavy squat.

Here’s how to perform a proper box squat.

Step 1: Your set up for the box squat should be the exact same as your regular squat. Set your feet in a stable position. Take a breath and brace your core before starting your squat with your hips.

Step 2: While remaining balanced during the descent (barbell tracking over your mid-foot when viewed from the side), sit straight down onto the top of the box. Do not rock back onto the box but instead only pause in the bottom position.

Step 3: Initiate your ascent by driving straight up. If you do this correctly, your knees will not travel forward as your hips rise from the box. Instead the knees will remain in a stable position and stay aligned with your feet.

When you’re starting the HSR phase of the rehab plan, start with 4 sets of 15 repetitions every other day (on your off days continue to perform the isometrics from phase one). Perform your isometric exercises prior to any HSR as the cortical inhibition benefits derived from the isometrics will allow you to access more motor units and therefore stimulate more strength.

How much weight should you use on the squat?

Your tendons (unlike muscles) require heavy loads in order to adapt and heal.²³ Research has shown positive changes in muscles (size and strength) with loads anywhere between 30-90% 1RM, where as it takes a much more significant load (>70%) to see the same adaptive changes in tendons.^23,24

If this is your first time box squatting, I recommend starting with 50-70% of your 1RM (of back squat) for the box squat. The weight you choose to perform the exercise with should be something you can control with good technique for each repetition, but heavy enough to where after completing your fourth set you are too fatigued to perform a fifth.³⁰ If you get done with your fourth set and feel like you have enough energy to perform a fifth, add more weight! It is rare to have a lot of pain with HSR exercises if you’re doing them slow enough.

Research on the use of HSR with tendinopathy has recommended performing these strength exercises for 4 sets of 15 repetitions for 1 week before increasing the weight and dropping the volume to 4 sets of 12 reps for the next two weeks.¹⁶ Eventually progress to 4 sets of 10 reps, followed by 4 sets of 8 and then 6 reps (each for 2-3 weeks each).

How fast should you squat?

While the amount of weight on the bar is THE MOST important factor in creating change in our injured tendons, the speed at which we lift is a close second.²⁶ Researchers have recently found that manipulating the speed at which a squat is performed significantly changes the amount of stress and strain placed on the tendons of the knee.

Initially during the healing phase, moving quickly during a squat may elicit more pain. For this reason, performing your strength exercises with a slow descent and ascent is ideal (a key component of HSR training). Ideally, you should take three seconds in the eccentric and three seconds in the concentric phase (meaning each rep takes 6 seconds total to complete).¹⁶

Most strength and conditioning programs will write a tempo format like this as a 3-1-3. The first number refers to the time it takes to perform the eccentric lowering. The second number refers to the length of time at which you pause in the turnaround (a “0” means a fast or plyometric bounce at the bottom of the squat where as a “1” would be used for a slow 1 second pause turnaround). The last number then refers to the time it takes you to ascend (the concentric phase).

I recommend using this slow 3-1-3 tempo until you finish your 2-3 week of 4 sets of 6 repetitions. Eventually you can start adding in a faster paced ascent. Using a slow descent (~3 seconds) followed by a powerful drive upwards places an increased demand on the tendons that can help increase load tolerance capacity to a greater degree compared to squatting slow on the way down AND up.²⁵

The Bulgarian Split Squat

While the box squat is a great exercise, you can easily hide or cover up problems in side-to-side strength/coordination. Consciously or subconsciously, your body often changes the way it moves in the presence of pain. These compensatory movements may be very small and therefore hard for even the most well-trained coach to see with their naked eye. For this reason, using exercises performed mostly on one leg (like a Bulgarian split squat) will expose these asymmetries and ensure you’re loading the injured tendons adequately.

Step 1: Place a lightly loaded barbell on your back or hold a pair of dumbbells at your side. Stand in front of a bench or box.

Step 2: With your back foot resting on the box, perform a small split squat. Try to keep your shin as vertical as possible during this movement (just like the box squat we want to limit forward knee translation at this time). If you’re doing this right you’ll feel the hamstrings and glutes of your forward leg working hard as you descend.

Just like the squat, I recommend performing 4 sets of 15 repetitions for 1 week before increasing the weight and dropping the volume to 4 sets of 12 reps for the next two weeks.¹⁶ Eventually progress to 4 sets of 10 reps, followed by 4 sets of 8 and then 6 reps (each for 2-3 weeks each). The weight you choose should be heavy enough to where after completing your fourth set you are too fatigued to perform a fifth.³⁰

Testing Your Progress

When you first start your HSR training a very small amount of pain (3/10 at maximum) is acceptable during and after the lift. If your pain is higher than a 3, then the weight was probably too much or you moved too quickly.

We will use the single leg decline squat (the exercise previously used as a rehabilitation exercise in research) as a pain-provocation test.³⁶ Using this test daily allows you to gauge how well your body is responding to the corrective exercises! Let me explain how.

It is normal to have a little pain during the rehab process of tendon injuries. In order to make sure we’re healing as efficiently as possible, we need to make sure we’re placing just the right amount of load on the tendons. By using a pain-provocation test, we can determine how well the tendons are tolerating the exercises (this is called load-tolerance).

Start by performing the single leg decline squat before a training session and ranking the amount of pain you have on a scale from 0-10 (0 is no pain and 10 is the worst pain imaginable). That number is your “baseline” score.

Perform the same test 24-hours after each training session to see if you were using the correct load for your body. If you are using the right amount, your pain will stay the same as the day before or get better. If it is better, increase the weight the next session. If you are using too much weight, your pain will increase 24 hours later and you need to decrease weight during your next session.

There isn’t a set protocol for this progression, so getting with a strength coach and physical therapist that has a background in weightlifting/powerlifting will be key to finding the optimal progression for your body.

Returning to Plyometrics

Along with the HSR component to strengthening the muscles/tendon complex, we also need to increase the ability of the tendon to absorb and store loads. The highest loads placed on the patellar and quad tendons occur when we use it as a spring, utilizing what is called the stretch shortening cycle (SSC).

Powerful movements (like repetitive jumping) use the tendon to store and then release energy in order to generate large amounts of power. Exercises that emphasize the storage of loads (such as a jumping from a box and landing) are therefore a bridge to eventually returning to the full energy storage and release capabilities of the tendon.

Stand on a small box, maybe 6-8 inches in height. Step off and land with both feet in a mini squat position. Don’t land with stiff joints but instead make sure to absorb the force of impact. Perform two sets of twenty landings to start before progressing according to how your body responds to a higher box and eventually a single leg landing.

In order to start true plyometrics (where the tendon is used as a spring to store and release energy) we must first see profound changes in muscle strength. The strength of the injured leg must be close to the capabilities of the non-injured extremity and you should no longer have any pain with the single leg decline squat.

If you can pass the single leg decline squat and feel like your strength and control of your legs are fairly similar, perform a faster more explosive movement like a single leg hop on each leg. Originally this movement was likely painful and hard to perform on the injured leg. If you are ready to move onto the plyometric phase of rehab, you must have the ability to show good quality control of your body without any pain during slow movements like the single leg squat and a high load functional movement like a hop.

The goal with this phase of rehab is to start using the tendon as a spring again and see how it responds. An example of an entry level plyometric will be double leg jumps. Simply perform repetitive small jumps only a few inches off the ground. Start with 10-20 reps in a row before resting for a few minutes and perform 3-4 sets.

Notice how your tendon responds to the loading during and within the next 24 hours. If you feel great during and do not have any increase in tendon pain or stiffness the following day, increase the training load the next session. For the first few weeks, increase the volume of your loading by adding in more jumps per set.

Recording every aspect of your plyometric program will allow you to progress and build this capacity as efficiently as possible. For example, Athlete A and Athlete B both performed 3 sets of 15 jumps the first day. Athlete A woke up the next day and felt great, so he was allowed to progress to 3 sets of 20 jumps the next session. Athlete B however woke up the following day and had a slight increase in his patellar tendon pain. For this reason, Athlete B needs to modify the next plyometric session by decreasing the amount of jumping.

Make sure to only increase one variable each training session (whether that’s adding or taking away volume or intensity). If you change too many variables you won’t be able to go back through your notes and see whether it was a loading change in volume or intensity that was too much for your tendon to handle.

Start with two to three sessions a week of these light plyometric (one session every three days). At this stage of rehabilitation, the tendon cannot take plyometric loads everyday without getting angry. For this reason, structure your weekly training by mixing HSR days in between plyometric sessions. If your tendon continues to respond well to the increases in plyometric loading every third day, you can continue to add more volume or start to increase intensity.

Eventually you’ll be able to progress to medium level plyometric exercises including higher tuck jumps, depth jumps from a small to medium height box and multiple double leg jumps for distance. If you are a runner (or have any running in the sport you participate in) adding in acceleration and deceleration drills along with cutting/change of direction may be a good option at this time.

After a few weeks of progressing these drills, you can then move to even higher level plyometric activities including: single leg jumps and depth jumps from a greater height box.

Eventually you can start manipulating the frequency of loading by performing plyometrics every two days instead of three. As always, see how your tendon responds and adjust accordingly. There is no perfect recipe for how to progress though this plyometric stage. Everyone will respond differently and you need to find what loads work best for your body. Be patient at this time, this process can take several weeks to months.

Returning to Olympic Lifts

Ballistic lifts like the clean and snatch will be the most aggravating movements to the tendons of the knee and therefore the last to re-incorporate back into your training during the rehab process. If you have returned to squatting heavy without any pain, you can introduce these lifts. Start slow on your progression, especially with the frequency you include them in your training. Having 48-72 hours in between each session is a good rule to start with to allow proper healing.

Here is a simple training progression to use:

Day 1: Olympic Lifting Day

Day 2: Isometric Exercise (Active Rest)

Day 3: Heavy Slow Resistance Day

Day 4: Olympic Lifting Day

Notice how there isn’t a complete rest day. Some athletes will feel worse after a complete day of rest, so making sure to load the tendon with simple isometrics is a good idea.²¹ At this time continue to use isometric exercises before your Olympic lifts as a warm up. Also use your decline single leg squat to test how well your body is responding to the newly added lifts.

“Passive” Treatments

In the past I have had many patients come to me after failed treatments under the care of other rehabilitation professionals. When I would inquire as to what kind of treatment they went through, it often revolves around some kind of passive treatment. “Passive” treatments refer to something that is done to you where as an “active” treatment is something you physically participate in. “Passive” treatments include ice, electrotherapy, dry needling, ultrasound and scraping techniques with different tools made of metal, hard plastics or bone.

While ice has been shown to be beneficial at controlling pain in the days following a new injury (like right after a sprained ankle), there are mixed results and opinions on whether or not it should be used for all injuries. Keep in mind that patellar tendinopathy is not inflammatory in nature, it is due to overload of the tendon fibers. While ice can be a great tool for pain management it certainly won’t accelerate the healing process.

Other treatments like electrotherapy, dry needling, ultrasound or scraping techniques are not effective in the treatment of tendinopathy and should be avoided. Any change in symptoms you may find from any of these treatments will only be due to a change in how the surrounding nerves are working as there will be little physical change to the actual tendon tissues. You must address why your tendon became injured in the first place by using exercises that load the tendon.

WHAT ABOUT STRAPS OR BRACES?

The Cho-Pat and DonJoy Cross straps are two of the most common orthotics used for patellar tendon pain.⁸ They’re simply a thick piece of material that wraps tightly around your patellar tendon and are used in an attempt to decrease strain on the painful tissue. While some people swear by its use, research has unfortunately been very iffy.⁹ My thoughts on the patellar straps is that if it decreases pain with activity, you can definitely continue using it. Just remember, using a strap should only be a supplement to rehab exercises and not the sole method of treatment. The straps are not to be used as a Band-Aid to mask pain. You still have to address the issue with rehab and relative rest.

SHOULD I USE ANTI-INFLAMMATORY MEDICATIONS?

While I think you should ultimately rely on the judgment of your medical doctor for medication advice, I think it’s necessary we still touch on this question. In many cases by the time most people start to look for help with their patellar or quad tendon pain, their injury is not accompanied with signs of classical inflammation.⁴ For this reason, anti-inflammatory medications (called NSAIDs) are often not very effective.⁴ Furthermore, covering up your pain with medications may disguise your injury while the strength of the tendon continues to decrease, leading to a further injury (possible tear or rupture) in the future.

Be careful what you put into your body when dealing with pain. We already live in a society that is obsessed with unnecessary medications. Don’t assume your knee pain will vanish in thin air by popping a few pills just because a TV ad says it will. 

FINAL THOUGHTS

Depending on where your injury lies on the tendinopathy continuum, the process of decreasing pain could take a few days to several weeks or even months. Your progressions for these exercises described will be guided by the amount of pain you experience in the pain-provocation test (single leg decline squat) 24 hours after each session.

No two athletes will respond the same way to the rehab exercises described today. Some will be able to add more weight on session after session. Some will require a more fluctuated load program in order to keep pain at bay. In the end, it is on you the athlete to regulate the weight based on how you feel. Don’t be a tough guy and push through more pain if your knees hurt worse the next day. Listen to your body.

Once you have returned to pain free training, you should continue to perform the isometric, Bulgarian split squats, and coordination re-education exercises (if found to be a weak link) weekly to prevent the tendinopathy from returning. This is because the altered neuromuscular problems that arose in response to pain can often persist even after the pain has resolved.²¹ Also, prior tendinopathy is a good predictor for future tendinopathy issues.

Dealing with patellar and quadriceps tendinopathy can be a very slow and frustrating process. I hope this article was able to help you understand this injury a little more. If you are unable to find relief with your patellar tendon pain after performing these exercises, I recommend going to a medical professional (doctor or physical therapist) to assist in your recovery.

Until next time,

With

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