Anterior knee pain is common amongst runners, athletes, and the general population. In this article, I will attempt to explore different considerations regarding patellar tendinopathy specifically and provide various loading strategies for rehabilitating the knee back to full function.

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The patellar tendon is located directly at the front of the knee and connects the quadriceps, patella, and proximal tibia. Pain is usually localized to the inferior pole of the patella and during movements that load the quadriceps. Cook et al reports that approximately 1/3 of athletes who presented with patellar tendinopathy were unable to return to sport for more than 6-months. Therefore, early detection in less severe stages is crucial, as well as the acceptance that resolution of symptoms could take an extended period of time.

What’s important to realize about an injury to the patellar tendon is that we are dealing with a dense fibrous connective tissue that connects muscle to bone. According to Thorpe et al, the main function of tendons is to “transfer muscle generated force to the bony skeleton, facilitating movement around a joint, and as such they are relatively passive, inelastic structures, able to resist high forces.” Despite being able to resist against high forces, as in running, jumping, and many sporting activities, tendons are susceptible to injury based on various scenarios…

1. The force placed upon the tendon exceeds the tissue’s load capacity

2. A series of small and repetitive forces are applied for a duration long enough to cause tissue breakdown

3. Other biomechanical factors are creating compensation elsewhere throughout the kinetic chain which ultimately increases load on the tendon

Regardless of which scenario proves to be true, the end goal of any tendon rehabilitation program is not the absence of pain, but return to full, pain-free function. Like with most injuries, rest is important and will allow the injury to calm down temporarily. However, tendon pain will likely resume when load is re-introduced to the area if the capacity of the tissue is not restored.

In the research article, ‘Current Concepts in Biomechanical Interventions for Patellofemoral Pain,’ Willy et al describe a homeostasis model first created by Scott Dye in 2005. This model suggests that the injury process can be stimulated in response to sudden bouts of increased training loads or stressors. For example, a runner or athlete that is conditioned for a specific distance or intensity but decides to increase one or both of these factors before the tendon is ready to handle the increased workload. That’s why I recommend all runners follow a structured and progressive training program which increases mileage in a safe and effective manner to build tissue tolerance.

Willy et al states that once homeostasis of the tissue is disrupted, sudden increases in training loads may no longer be able to be tolerated even if these are routine daily activities. Therefore, once the tissue is in a pathologic state, the ability to load without pain decreases significantly. The goal now becomes to re-establish this homeostatic relationship to stabilize the tissue, then progressively restore the loading capacity to be more tolerant to the forces it will encounter. Basically, excessive loading created this situation but it will also be a key factor in resolving it for long-term success.

Now, before we cover the loading strategies to resolve patellar tendinopathy, it’s important to touch on cadence, aka step rate, and it’s impact on the knee while running. Overstriding (image B below) is a term that refers to the foot landing too far in front of the body’s center of mass at initial contact. What this does is create a braking mechanism and thus increases energy absorbed at the knee.

Progressively loading the quadriceps and patellar tendon will certainly make the area more tolerant to the forces of running. At the same time, increasing cadence by just 5-10% has been shown to decrease energy absorbed at the knee by 20-34%.

Running at a higher cadence reduces stride length, disperses the amount of force over more steps, and allows the foot to land closer underneath the body’s center of mass. A combination of both approaches is important to consider in order to reduce the likelihood of injury and/or return to running following patellar tendinopathy.

When incorporating the following loading strategies, it’s important to keep in mind the 24-hour rule. Basically, you want to stress the patellar tendon in a healthy way that limits pain to nothing above a 3 out of 10. And if pain lingers, it should resolve completely within 24-hours. This is an important concept to understand with tendon pain. A certain degree of pain is acceptable and might be needed to elicit the desired response from the tendon. However, if your pain exceeds these parameters then modifying certain variables, such as the exercise, tempo, load, and position might be warranted.

Decline Squat Progression

The Decline Squat is a fantastic exercise that utilizes a slant board or elevated heel position to increase demand on the knee. Like with all of these progressions to rehabilitate patellar tendinopathy, it’s important to understand the dose and response relationship before increasing the intensity in anyway. What I mean is, start simple and progress slowly after seeing how the tendon responds to the added load, tempo, and number of repetitions. The different variations of this movement allow you to gradually increase load on the knee joint in a progressive manner. In this video, I demonstrate the bodyweight, goblet, and 2-dumbbell Decline Squat progression.

Spanish Squat Progression

The Spanish Squat is a somewhat newer exercise that I’ve only used for the past 2-years or so. Like with all of these progressions to rehabilitate patellar tendinopathy, it’s important to understand the dose and response relationship before increasing the intensity in anyway. What I mean is, start simple and progress slowly after seeing how the tendon responds to the added load, tempo, and number of repetitions. The different variations of this movement allow you to gradually increase load on the knee joint in a progressive manner. In this video, I demonstrate the bodyweight, goblet, and 2-dumbbell Spanish Squat progression.

Lateral Step-Up with Counterbalance

Since the knee is largely influenced by stability at the foot, ankle, and hip, it’s important to successfully complete one of the bilateral exercises mentioned above and then move on to a single leg variation. The Lateral Step-Up with Counterbalance allows the body to be held in a position that loads directly into the knee joint. Like with all of these progressions to rehabilitate patellar tendinopathy, it’s important to understand the dose and response relationship before increasing the intensity in anyway. What I mean is, start simple and progress slowly after seeing how the tendon responds to the single leg position, load, tempo, and depth of the step. This exercise is usually recommended after laying the foundation with the two bilateral progressions demonstrated above.

Despite showing you two different loading progressions to properly rehabilitate patellar tendinopathy, it’s not my intention for you to complete both of these. I would start by determining which is the best starting point for you and following that path to create a more tolerant and pain-free knee. Once that’s achieved, the Lateral Step-Up with Counterbalance is a suitable next step to incorporate single leg loading and stability. This is especially important if your goal is to return to running or a change of direction sport.

I hope this article has helped you better understand patellar tendinopathy, as well as recommended strategies to reduce pain and increase function. As always, it’s important to consult with a trained healthcare professional to be properly diagnosed and understand the underlying factors which may be contributing to your injury. Please take a second to click here so we can create a structured plan to resolve your knee pain once and for all.