Exercises for Patellar Tendinopathy (Jumpers Knee)
Do you get pain on the front of your knee with any of the following?
- Jumping
- Skipping
- Changing direction quickly
- Standing up after sitting for a long time
- Walking stairs/hills (1,2)
You might have what is called Patellar Tendinopathy – also known as “Jumpers Knee”, named as such from its observed frequency in jumping sports. Despite its colloquial name – anyone can get “Jumpers knee”. Patellar Tendinopathy is different to other types of knee pain, in that it is specific localised pain over the bottom of the knee cap, rather than inside or around the whole knee (1).
What is Patellar Tendinopathy?
Patellar tendinopathy occurs when there is pain and dysfunction in the patellar (knee cap) tendon – the small tendon that links the thigh muscle to the knee cap and shin bone (Tibia) (1,2). It most commonly affects jumping athletes from adolescence through to the fourth decade of life (1). Pain in the area will often be mild at first and can progressively worsen with activity levels (1). Pain in Patellar Tendinopathy follows a classic pattern (as with most Tendinopathies – see our recent blog post by Brad Beer: How to Rehabilitate a Tendinopathy: Phase 1 – Reducing Symptoms and Pain) where the area may be sore at the beginning of activity, but then feel better as you warm up and then feel more painful the following morning – persisting for several days to weeks (1,3).
Patellar tendinopathy occurs when there is pain and dysfunction in the patellar (knee cap) tendon #physiowithafinishline @pogophysio Click To TweetDo I Have it?
The knee is a busy area in the body – pain in the area can arise from a variety of conditions that present similarly, such as patellofemoral pain, ITB syndrome, fat pad impingement and the less common quadriceps tendinopathy (2,3). Imaging for Patellar Tendinopathy (MRI & Ultrasound) is not as useful in confirming the condition as it has been shown that people can have tendon thickening and degenerative changes on imaging but not experience any symptoms (ref). Therefore, Patellar tendinopathy is best diagnosed by an experienced clinician who can get a good understanding of your history, activity levels, current strength and function (1). A common and effective way to test if you potentially have patellar tendinopathy is to attempt a single leg decline squat – and check for isolated pain at the tendon and base of the knee cap (pictured below) (1,2)
Why do I have it?
Patellar tendinopathy is most commonly caused by an overload of the knee and quadriceps muscles on the thigh. This overload could be from an increase in training volume like returning to sport after a long time off, or an increase in training frequency like extra training sessions prior to a competition. Tendons don’t tend to like big changes in activity – they adapt slowly. Any large change in activity levels that involve the knee or thigh muscles can more predispose you to strain the patellar tendon.
Aside from overloading, other factors that can predispose you to patellar tendinopathy or worsen symptoms include:
- Jumping/explosive leg movement – if the person is not used to it, explosive plyometric movements can aggravate tendons
- Prolonged sitting – irritated tendons don’t like being stretched or compressed.
- Tight hamstring and quadriceps muscles
- Reduced hamstring and quadriceps muscle strength
- Reduced ankle range of motion
How do I make it better?
If overload is what makes tendons worse – careful loading is what also makes them better. Exercise = treatment. High-level athletes dealing with large amounts of loading of their patellar tendons have been shown to reverse degeneration in their tendons through a progressive loading program (ref). But where do you start? Tendons are often irritable and careful guidance of an experienced clinician is required to carefully manage symptoms as you progress back to normal activity levels again. To manage pain initially – Physiotherapist’s will prescribe isometric exercises for the quadriceps. Isometric exercises are panadol for tendons – they are different to isotonic exercises as the muscle will activate without shortening or lengthening. A classic isometric exercise prescribed for quadriceps in patellar tendinopathy is the Spanish Squat – pictured below.
Stage 1: ISOMETRICS – Pain reduction
In the early stages of patellar tendinopathy, isotonic exercises should be held at 70% maximal contraction for 45-60 seconds. Ideally, these are completed many times throughout the day. The yardstick for tendon loading progression is the loaded symptom test the following morning. For patellar tendinopathy – a single leg decline squat should be held for 30 seconds the next morning and if the pain over the tendon exceeds 3-4/10, then you did too much the day before and need to step it back.
Spanish Squat
Stage 2: Strength Training
In terms of strength training – there is no perfect program for everyone other than the one carefully prescribed to you by your Physiotherapist (4). Following a period of isometric exercises, once symptoms are under control – your Physiotherapist will progress you to strength training for the legs in general. With a specific focus on the quadriceps and hamstrings. Heavy Slow resisted (HSR) exercises have been shown to be specifically helpful for patellar tendinopathy (1,2,3,4). Below are some example of HSR strength training exercises:
Weighted Knee Extensions
Leg Press
Single Leg Eccentric Press
Weighted Lunges
Stage 3: Plyometrics
Jumping Split Squats
Skipping
Box jump and land
Stage 4: Return to Sport
At this stage, your Physiotherapist will prescribe specific exercises to your function, strength and the sport you play. E.g. if you are a soccer player – agility drills and jumping drills (1,2,3).
Final Tips
Be patient – Patellar tendinopathies can take at least a few weeks to heal and allow you to return to full function. If you experience a flare-up of pain – don’t be dismayed, they are common on the journey of tendon rehabilitation and do not necessarily mean you are getting worse. It’s important to get a personalised program by a Physiotherapist that is gradually progressed for optimal recovery.
For further guidance on tendon rehabilitation – listen to tendon expert physiotherapist and researcher Associate Professor Dr Peter Malliaras discuss the rehabilitation of tendon injuries on Episode 62 of The Physical Performance Show podcast.
Oliver Crossley (APAM)
POGO Physiotherapist
Featured in the Top 50 Physical Therapy Blog
References
- Rudavsky, A., & Cook, J. (2014). Physiotherapy management of patellar tendinopathy (jumper’s knee). Journal of physiotherapy, 60(3), 122-129.
- Malliaras, P., Cook, J., Purdam, C., & Rio, E. (2015). Patellar tendinopathy: clinical diagnosis, load management, and advice for challenging case presentations. journal of orthopaedic & sports physical therapy, 45(11), 887-898.
- Brukner, Peter & Khan, Karim, (author.) (2016). Brukner & Khan’s clinical sports medicine: injuries (5th edition). McGraw-Hill Education (Australia), North Ryde, N.S.W
- BJSM. (2018). Achilles and patellar tendinopathy loading principles with Dr. Peter Malliaras. Episode 326. 23 March 2018. Available from: https://soundcloud.com/bmjpodcasts/achilles-and-patellar-tendinopathy-loading-principles-with-dr-peter-malliaras-episode-326
