Patella Tendinopathy Rehabilitation Protocol

Onset of Injury: Diagnosis

Tendinopathies are usually a whole lot of not fun, ranging from mild to severe. Typical symptoms will be pain and stiffness in the tendon/joint area, especially after long periods of rest or unuse. This pain or discomfort will usually go away once warmed up and blood flow increases to the area.

The first step is to go get it properly diagnosed. Tendinopathies share similarities with tendonitis and other joint injuries, each with its own protocols for rehab. So, make sure you see a professional and not doctor Google.

Stage 1: Reducing Load

After diagnosis, the next step is to reduce whatever you are doing to cause the injury while also keeping the joint mobilised. Patella Tendinopathy is an overuse injury, caused from an increased amount of load going through the tendon. This can be from increases in running or resistance training (typically, squatting and knee flexion movements).

Poor ankle mobility, poor squatting technique or weak/underactive quads can be a big factor in aggravating the patella tendon. If the knee is not passing over the foot enough while under load, the quads won’t take the force and it will be transferred through the tendon instead. Too much of this leads to degeneration of the tendon and this is where the pain and discomfort comes from.

Once you have been diagnosed with a tendinopathy you don’t have to completely cut out what you have been doing. This is actually more detrimental. You want to reduce the load but keep the joint mobilised. Keeping it moving will help keep blood flow to it and stop the tendon from atrophying.


Stage 2: Isometrics

Reducing the load through your knees should see some relief of pain and discomfort, depending on the severity of your tendinopathy. Next, we need to look at strengthening the tendon and surrounding musculature. Isometric (hold) exercises are used in the initial stages of rehab as they help to strengthen the soft tissue without aggravating the tendon. Exercises that are simple to do but low impact on the knees are the best to start with. Typical exercises seen at the early stages of a patella tendinopathy rehab will be:

You will usually start by holding these for roughly 10 seconds, 3 to 4 times in a workout and then build up to being able to hold them for 30-40 seconds. These are also a great warm up as well as they flush the knees with blood without aggravating the tendon. Depending how bad the tendinopathy is you might expect this step to last from 2-4 weeks. That’s usually enough time for the decrease in training load and isometrics to start showing some improvement.


Stage 3: Eccentrics and Concentrics

You should see some further relief in discomfort after a few weeks of the isometric training. If not, then revisit your Physiotherapist or whoever diagnosed your symptoms as they may have misdiagnosed or need to re-evaluate your training load.

If things are going well then, hooray! We can progress to the next step, which is introducing eccentric (lengthening) exercises into the program. These will target the lower part of the quad and the tendon directly, strengthening the muscle and getting some length into the tendon. Usually in soft tissue, weakness and tightness go hand in hand. So being able to strengthen and lengthen at the same time helps kill two problems at once. Some exercises that we have seen to be successful are:

It will be common for this stage to hurt a bit as these are quite aggressive exercises, just be aware that this is normal. Although by the time we get to this stage the muscle and tendon will be stronger, it won’t be fully healed and still be tight. This is the is your body’s way of protecting an injury, so it will take some time and effort before it’s back to normal.

Similar to the step before this. You should see results within 2-4 weeks depending on the severity of your tendinopathy. After this you can start to work towards a higher training load.


Stage 4: Running and Plyometrics

This step looks at reintroducing plyometrics. Loading from weight and loading from impact affect tendons differently, making them receive force in different ways. The first steps looked at reducing these loads and then reintroducing weight loading in a way to strengthen and benefit the tendons. Now that we have adequate strength and the tendinopathy is healing, we can start jumping and increasing running loads.

We start the path to plyometrics with extensive plyos. These are small, low intensity jumps that target the foot and ankle complex. The purpose of extensive plyos is to build capacity. This is the tendon and joint's introduction into receiving impact force. For these exercises we would look at:

After extensive plyos have been successfully introduced, we move on to intensive plyos. These are the big, high intensity jumps that utilise the hips and knees. The purpose of intensive plyos is to increase force production, but mainly to keep building the capacity for the lower limbs to receive impact forces and dissipate that force economically. For these exercises we would start with:

These will typically be the last things introduced into the program, and after successfully completing a few weeks of this program you should be at the end of the rehab stage and moving on into the post-injury and management stage.


Post Injury: Load and Long-Term Management

Assessing what has caused the patella tendon to flare up is also important. Typically, this can be caused by increased loading, poor lower limb biomechanics during resistance training/running, uneven distribution between limbs or even just a lack of strength in the right muscles.

We touched on before that poor ankle mobility, technique or muscle imbalances can aggravate the tendon. Hence, being able to deduce where your injury stems from is the first step in being able to work on the cause of the problem and not just solving the symptoms. It also helps you understand the mechanics of the injury and how to prevent it happening in the future.

Dealing with patella tendinopathy can be a long-term battle. It’s something you will have to constantly manage, so learning how to listen to your body is going to be very important as this is your best way of staying on top of it.

A few take home dot points to help with long term management of the injury:

ACL Rehabilitation Protocol

Pre-stage

Injury > Surgery

This stage looks at assessing the athlete and whether they are a coper or non-coper.

A coper is an individual with good knee stability and the ability to compensate well after
injury. A non-coper will have less stability and increased incidences of their knee ‘giving way’
during daily activities. As such, copers can tolerate sport without the ACL and can avoid
having to undergo surgery.

Everything here is very broad as research is still limited in the area and there are no
definitive guidelines to assessing whether someone is a coper or non-coper. With this in
mind, each individual will be different as well as where their graft is taken from (Hamstring,
Patella, ITB or wherever they decide to do next).

A prehabilitation program will consist of 6-9 weeks over 3 main stages and will depend on
whether progress is constantly being made. The athlete must complete each stage to a
satisfactory level before progressing.

The only main thing found to be avoided is full ROM of open kinetic chain exercises as this
position threatens the integrity of the graft.

Stage I :

Stage II :

Stage III :

If they have progressed consistently through all the stages, then it is up to them whether they continue without an ACL or whether they opt for surgery.


Stage 1 - Post Injury

Stage 1 is all about giving the graft the best chance to take, reducing infection chance and
gaining normal function back in the leg. It is also a build up into the next stage. If the athlete
is struggling through or has not done this stage, then they have not earnt the right to and
cannot progress to stage 2.

If going for the non-surgical option, the protocol remains the same.

Weeks 1 – 2 After Surgery

Straight after surgery. Not too much should be going on at this point. The biggest key factors for this stage:

Full weight bearing should be built up and commence around the 2-3 weeks post-surgery. Compression bandages can still be worn afterwards for athlete’s comfort.

Weeks 3 – 4 After Surgery

Stationary cycling is a good way to maintain fitness and help strengthen lower limb muscles. It is also good for developing and maintaining ROM. 10-20 Minutes at a low intensity is enough per day. Seated boxing is another fun way to work cardiovascular fitness and add variety to training.


Stage 2 - Preparing for Running

Stage 2 is about getting the athlete prepared to start running again. It is normal for there to still be some pain and discomfort, as well as numbness to still occur. Deep flexion and extension can still cause pain, although it depends on the individual. Being able to fully extend the leg is very important in these early stages.

Intermittent episodes of swelling and discomfort can still occur, especially as gait and weight bearing start to return to normal. If so, just adjust exercises accordingly to not cause further discomfort.

Months 1 – 2 After Surgery

The graft is at its weakest point at roughly the 10-week mark, and then gradually increases in strength over the next year. Although the athlete may be feeling good, make sure to stress the importance of holding off on running or jumping for the next few weeks.

Months 2 – 3 After Surgery

If access to an anti-gravity treadmill is available, running can commence earlier with clearance from your Physio. Otherwise hold off running until approximately the three-four- month mark, also to be cleared by the Physio.


AACLr Recovery

Stage 3 – Implementing and Increasing Running and Preparing for COD

The start of this stage should see the athlete start to jog and then run in a straight line. Some pain and aching around the joint is normal. Very light plyometrics can start to be introduced and slowly progressed with a focus on landing mechanics.

The aim of this stage is to re-introduce running for the athlete and then get them prepared to change direction. The biggest emphasis on this stage is to increase confidence running and make sure gait is normal. It is normal and very common to be nervous.

Months 3 – 6 After Surgery

It is important to not push the graft too hard too early, especially when reintroducing running as this can place strain on the graft. This is a long stage and there is plenty of time to improve slowly and make sure you are doing this properly. Focusing on small attainable goals is a great way to boost motivation and psychological well- being in athletes that may be struggling.

It is common for a big psychological boost following clearance to run, but monotony can set in shortly after. Again, this is completely normal.

Stationary cycling and swimming can be continued and increased in intensity for the athlete to maintain aerobic conditioning. Other activities that are low impact on the knees such as boxing can be enjoyable ways to stay fit and work on a new skill.


AACLr Recovery

Stage 4 – Increased Change Of Direction and Preparing for Return To Training

The individual should be running and have started curvilinear running, if even at a slow pace. As volume and intensity of running increases, it is important to constantly assess competency.

Change of direction will continue to progress to sharper cuts throughout the stage to get the athlete prepared to return to sports specific training. Introduce lateral movements for both strength and light plyometrics.

Months 6 – 9 After Surgery

General consensus of research is that the athlete should ideally be ~20 % difference in quad and hamstring strength between injured and non-injured leg at the 6-month mark. Although missing this is not a big deal as there is still plenty of time.


AACLr Recovery

Stage 5 – Work Weaknesses and Prepare for return to play

Running, changing direction and returning to sport specific skills, even if only light, should have been achieved. This stage is about getting the athlete prepared to return to playing and training.

The 12-month mark should be the earliest they return, even better if they can hold off for another month or two, with 13-14 being the ideal. Each month will further reduce chances of re-injury.

Focus on any weaknesses the athlete may show or imbalances between limbs.

Months 9 – RTP

One of the biggest contraindications for returning to sport is psychological readiness. If they have reached this stage in their rehab then physically they are able to return, they just need to be mentally prepared. Slowly returning to warmups and advancing through drills is a great way to start re- introducing yourself to your sport. This also helps with the gradual return to playing and helps with psychological readiness.

Quad and Hamstring strength should be less than ~10% between injured and non-injured leg by 12-month mark, and definitely before returning to play.


AACLr Recovery

Post Stage – Return to Play – Maintain and Build

The athlete should have eased into their return to sport, slowly building up their match endurance and confidence. At this stage the athlete can stop being treated as a rehab client for the sake of S&C and programming and undergo the usual training for where they are in season and what they need as an individual.

RTP >

The biggest contraindication to an athlete returning to play is their psychological readiness. Physiologically they will be as prepared as they can, but mentally they may be struggling with the realisation that they will be put back in the position in which they got injured.

After the 12–14-month mark and as the athlete is returning to play they will go onto a more standardised strength and conditioning program, while maintain they are still an ‘ACL rehab client’. Timeframes here will be very individual based.