For the past few weeks, we have been discussing knee pain. On last week’s article, we covered IT Band syndrome in detail. Today, we’re going to examine the most common knee injury that occurs with barbell training, patellar tendon pain.
Patellar Tendon Anatomy 101
First, let’s talk about what a tendon is. A tendon is essentially a fibrous band of tissue that connects muscle to bone. The patellar tendon runs from your kneecap (patella) to the tibia 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 allow a person to generate tremendous force (i.e. squatting, jumping, and running). Without the kneecap and patella/quad tendon system, we would be very limited in force production.
What is Patellar Tendon Pain?
Athletes who are involved in sports that include sudden explosive and repetitive movements of the knee can easily develop pain and tenderness at the patellar tendon. This injury is often seen in basketball players and volleyball players due to excessive jumping (this is where the term “jumpers knee” was coined). However, it is also prevalent in sports such as weightlifting where athletes perform the same ballistic movements of the clean and snatch over and over.
There are a ton of names used to describe this injury: “tendinitis”, “tendinosis, “patellar tendinopathy”… the list goes on. Research has shown that most people who have pain in this area actually are experiencing tendinosis, and not patellar tendinitis as many believe.2 The “osis” means the problem is not caused by inflammation (as it is with tendinitis) but due to the tendon itself degrading and becoming weak. Essentially, the tendon is failing to heal and repair itself.
In fact, experts believe that most cases of genuine tendinitis (inflammation of the tendon fibers) only occur after a rupture or tear of the tendon. If you want to really nerd out with the semantics of this injury, inflammation (if it is found at all) is often in the outer layer of the tendon (called the paratenon) and is considered paratenonitis.2
To simplify things and avoid all of the technical confusion on what to call this type of pain, we’re just going to refer to this injury as patellar tendinopathy.
So what causes the pain? We find it is often related to the frequency and intensity of training. During your workout, the patellar tendon fibers are subjected to extreme forces during the deceleration and rapid acceleration of the squatting movement.1 For example, performing a deep barbell squat or catching a clean/snatch can place forces on the tendon up to 17 times your bodyweight.3 If the tendon is subjected to these elevated forces too quickly or too often it can begin to break down and pain eventually ensues.
Initially, most people will report feeling a dull ache in the front of their knee after intense workouts. However, if it is allowed to linger unchecked it eventually turns into a sharp pain during explosive movements (like jumping or catching a snatch) and will even interfere with performance. When it gets to this point, athletes will have pain even when sitting for a long time and going up and down stairs.
How Do We Test for It?
The main finding with patellar tendinopathy is tenderness and pain at the connection point of the kneecap and patellar tendon (called the inferior pole of the patella). For some, you will also have pain in the center of the tendon itself when the knee is fully straightened and the quads are relaxed.2 The pain usually decreases if you relax and bend you knees to 90°. This pain is usually not accompanied with signs of inflammation (redness or swelling).
How Do We Fix It?
Step 1: Training Modification
We have found that athletes who progress their training intensity (how much weight is on the bar), volume (how many reps during an entire workout) or frequency (how often you train) too quickly are at a higher risk for developing this type of overuse injury.
For this reason, the first step when experiencing this type of pain is to analyze your training. If you have pain while lifting and afterwards but it hasn’t yet affected your performance, I suggest adapting your training with less volume and intensity (decrease weight and the amount of reps in a workout). If however you have noticed a decrease in performance, it is time to cut out anything that causes pain from your training. If you continue to push into pain that has already affected your performance, the tendon will only continue to degrade and the symptoms will continue to get worse.
It is possible to continue barbell training when the injury has progressed to this point, you just have to make the right modifications to your workout. Limiting any exercises that places you in a deep squat is going to be your first move. Replacement exercises for the short term could include RDLs and straight leg deadlifts. Weightlifters may add muscle snatches or pulls starting from elevated blocks (both movements performed with limited knee bend).
A simple rule to go by at this stage is, “If it doesn’t hurt the knees, you’re good to go.”
Step 2: Rehabilitation Exercises
Once you have modified your training program, your next step for treatment should include stretching, deep friction massage of the patellar tendon, eccentric quad exercises, and possible use of a patellar orthotic and ice.1
Stiffness in the quads can increase tension at the patellar tendon and therefore be a contributing factor in the development of pain. For this reason, light and pain free stretches can be a good addition for a comprehensive treatment. An easy stretch to perform at home is called the “couch stretch.” (I first saw this variation of the classic quad stretch from Kelly Starrett of MobilityWOD).
Step 1: Find a bed, chair or couch. Assume a lunge position with your back foot on top of the chosen surface.
Step 2: Sit you butt back towards you heel until you feel a stretch in your quads. If this movement causes pain in your knee, instead drive your hips forward and down at an angle to bring out the stretch in the muscle only.
Step 3: Hold this stretch for 30 seconds and repeat 3-5 times.
Deep Friction Massage
Deep tissue cross friction massage can be very helpful to promote healing in the damaged patellar tendon tissues.5,6 If you were to go and see a physical therapist, they may perform this type of treatment with a pricy metal or hard plastic tool. However, you can get a ton of benefit at home by doing this with only your thumb!
Step 1: Sit over the edge of a bench or bed. Pull your knee into a bent position with your other leg (this will place a small amount of tension on the patellar tendon).
Step 2: Apply a little bit of lotion or moisturizer, push your thumb into your patellar tendon and move it back and forth in a horizontal fashion across the painful area. You should do this for a few minutes everyday until the area is no longer painful when you push on it.
It is normal for this treatment to be fairly painful at first. The goal is to cause a small amount of trauma to the tendon in order to help stimulate blood flow and promote healing.
Controlled loading of the tendon during a deceleration (the eccentric portion of a movement) helps promote healing in injured tissues. A very early progression for this type of strength exercise is called the decline single leg squat. Placing your body on a decline specially targets the patellar tendon (25-30% more) than when performing this exercise on flat ground (which targets the quads to a greater degree).7
Step 1: Stand with your heels elevated about 2-3 inches (you can use a small plate at the gym or a piece of wood).
Step 2: Perform a small single leg squat on your injured leg. Don’t push your hips back and your chest forward (hip hinge) like you would with a touch down squat. It’s okay for the knee to come forward during this squat as the goal is to load the injured tendon. Keep your knee in line with your feet (no knee cave!).
Step 3: After you descend a few inches (you want to squat to 60° knee angle), put your free leg down and stand back up. These exercises should be performed with minimal pain. Some people at first will experience a small amount of pain during this movement but as long as it doesn’t jump over a 4/10 rating (10 being you need to go to the emergency room), you’re okay.
Recommended Sets/Reps: 2 sets of 15 reps everyday.
In the early stages of treatment for this type of injury, you want to limit depth to around 60° of knee flexion. Going deeper shifts a significant amount of force onto the part of the tendon that is most affected and degenerated.
As this exercise gets easier to perform and pain is eliminated, you can progress to a flat surface single leg squat (touch down) and eventually start reintegrating back or front squats back into your training program. Make sure you start with LIGHT weight and LOW VOLUME (minimal reps and sets) during this transition. I would work up to performing 3 sets of 5 repetitions at 70% of your 1RM back squat pain free before returning to more explosive lifts like the snatch and clean.
Along with these eccentric exercises, you should perform other hip strengthening exercises like lateral leg raises and clamshells. Perform them at first without weight and for many reps (15-20 at a time) before adding weight.
Should I Use Ice?
While ice has been shown to be beneficial at controlling inflammation and pain in the days following an new injury (the acute phase), there are mixed results and opinions on whether or not it should be used for chronic overuse problems like most cases of patellar tendinopathy.
I don’t have a problem with using ice to help manage and decrease pain. Just keep in mind that most patellar tendinopathy cases are not inflammatory in nature, it is actually degeneration of the tendon fibers. So ice is a great tool for pain management but it certainly won’t accelerate the healing process.
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, decreasing the strain on the painful tissue. While you can purchase one of these straps at almost any local drugstore, you can save yourself some of that hard earned cash and make your own version with some cheap pre-wrap material.
Step 1: Wrap the pre-wrap 5 or 6 times around your leg, just below the bottom of your patellar tendon.
Step 2: Roll the material up into a thick strap. It should wrap directly across the middle of your tendon.
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. Make sure the strap or tape application wraps around the center of your tendon (this is key for decreasing tension). 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. As we’ve discussed, most cases of patellar tendon pain are a chronic tendinosis and not an acute tendonitis, there usually isn’t inflammation present. For this reason, anti-inflammatory medications (called NSAIDs) are often not very effective.4 Furthermore, cortisone injections (a powerful anti-inflammation drug) may end up decreasing the strength of the tendon and lead to a greater injury (possible tear or rupture) in the future.1
Be careful what you put into your body when dealing with pain. We already live in a society that is asphyxiated 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.
Patellar tendinopathy is largely due to overuse. For this reason, modifying your training and progressing slowly through the treatment steps outlined today are key to a full and pain free recovery. For some, this will be a lengthy process and can take 6-8 weeks or more to fully recover if the pain has been going on for some time.
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,
- Rutland M,O’Connell D, Brismee JM, et al. Evidence-supported rehabilitation of patellar rehabilitation. N Am J Sports Phys Ther. 2010 Sep; 5(3): 166–178.
- Khan KM, Maffulli N, Coleman BD, et al. Patellar tendinopathy: some aspects of basic science and clinical management. Br J Sports Med. 1998;32:346-355
- Zernicke R, Garhammer J, Jobe FW. Human patellartendon rupture: a kinetic analysis. J Bone Joint Surg (Am). 1977;59:179-83
- Khan KM, Cook JL, Kannus P, et al. Time to abandon the “tendinitis” myth. BJM. 2002;324(7338):626-7
- Hunter G. Specific soft tissue mobilization in the treatment of soft tissue lessions. Physiother. 1994;80(1):15-21
- Gehlsen GM, Ganion LR, Helfst R. Fibroblast responses to variation in soft tissue mobilization pressure. Med Sci Sports Exerc. 1999;31(4):531-35
- Jonsson P, Alfredson H. Superior results with eccentric compared to concentric quadriceps training in patients with jumper’s knee: a prospective randomized study. Br J Sports Med. 2005;39(11):847-50
- Lavagnino M, Arnoczky SP, Dodds J, et al. Infrapatellar straps decrease patellar tendon strain at the site of the jumper’s knee lesion. Sports Health. 2011 May;3(3):296-302
- Miller MD, Hinkin DT, Wisnowski JW. The efficacy of orthotics for anterior knee pain in military trainees. A preliminary report. Am J Knee Surgery. 1997 Winter;10(1):10-3