Patella Tendinopathy Rehabilitation Protocol

August 27, 2021

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.

  • Get a proper diagnosis
  • Don’t Google your symptoms

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.

  • Reduce load but don’t completely cut exercise
  • Keep the joint mobilised – not using it at all can be as bad as overusing it
  • Pain and discomfort are still normal and expected

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:

  • Wall Sits
  • Spanish Squats
  • Lunge Holds
  • Hamstring Bridge
  • Glute Bridge
  • Calf Raise

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:

  • Knees over toes – or front foot elevated squats
  • Slow double – progressing to single leg squats
  • Quad Nordics
  • Sissy Squats

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:

  • Skipping
  • Small hurdle hops
  • Pogo Jumps

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:

  • Box Jumps
  • Broad Jumps
  • Skater Jumps
  • High Hurdle Jumps

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:

  • Use some of the exercises in the rehab stage as warmups and cooldowns
  • Ease into increasing loads, especially after periods of rest or time off
  • Listen to your body, you know it better than anyone else
  • Knowledge is power, educate yourself with your injury and what causes it and makes it feel better
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