By: Luis Garcia ATC/LAT,CSCS
Intro
The national institute of health estimates that 50% of elite athletes currently have or at one point have had in their career patellar tendon pain. I personally would say this number in my experience is even higher at around 70%, especially with jump intensive athletes like volleyball or basketball. Majority of this comes from repetitive stress on the knee creating tiny tears which over time inflame and weaken the tendon. Pain in your patellar tendon can cause you to miss practice, miss games, decrease performance, and make simple tasks like taking long drives absolutely terrible. In this article ill talk about how, why, and solutions to your patellar tendon pain.
What is the patellar tendon?
Well before that.. What is a tendon? Unlike a ligament which attaches bone to bone, a tendon is a fibrous band of tissue that attaches muscle to bone. Tendons can be found at the ends of every muscle on your body. Muscles contract, pull on the tendons, this tendon then pulls on the bone its attached to.... creating movement!
Now one of the most famous tendons and the one that runs right in front of the knee/knee cap is the patellar tendon. This tendon is an extension of the quad muscle/Quad tendon. This tendon absorbs and releases tons of power as its the main tendon responsible for extending your knee (kicking a ball, jumping).
LOAD TOLERANCE
Load tolerance is going to be a key term when we are talking about tendon pain. Load tolerance is a certain level of strength that your tendon has adapted to over the years / throughout your training. The higher the load tolerance of a tendon the more stress the tendon can take. Training stresses that do not exceed the load tolerance cause a cellular response in the tendon that will return to normal within 2-3 days given proper recovery methods. However if the load placed on a tendon is too extreme (passed its load tolerance) and the recovery is inadequate this balance is disrupted, now this force instead of assisting in adapting that tendon to more stress is doing the opposite and begins the injury process.
Tendinopathy: Two main types of tendon injury Tendinitis and Tendinosis
Many times they call these terms "Jumpers knee" to broaden the scale. The "Itis" in tendinitis refers to an acute injury caused by inflammation. In relation to "osis" now we are talking about a problem that is usually not caused by inflammation but due to the tendon itself being degraded and weakened. Medical professionals will usually use tendinitis when referring to acute tendon injuries and tendinosis when referring to chronic tendon issues (lasting longer than 6 month).
Recent research shows that inflammation commonly seen with tendon pain is the main driver of injury and pain (Article below). This had lead researches to believe that tendinitis and tendinosis are not mutually exclusive and are actually different parts of the same process. Tendinitis being the beginning phase and ending in tendinosis. So when speaking about these terms "Tendinopathy" is the best phrase as it covers both.
How does injury occur?
the CONTINUUM MODEL was made by expert Jill Cook, and describes the 3 overlapping stages of tendon injury.
Our bodies do an amazing job adapting to the stresses applied to it. Now depending on the amount and frequency of a stress our tendons can respond positively or negatively. When responding to proper loads and stresses our tendons become STRONGER increasing their stiffness levels. An elite athlete who can perform high intensity exercises and movements without pain can do so because they have conditioned their tendons to do so over the years. By progressing their tendons through loads mixed with adequate recovery elite athletes raise the load tolerance of their tendons.
If someone who was untrained tried to perform the same tasks as an elite athlete they can begin the reactive phase of an injury. We see this when an athlete increases their training frequency / intensity past the load tolerance they have built. This can also happen with elite athletes as well. Lets say an elite athlete went from training 2x a day and took a month break from training then all the sudden jumped right back into their same training program they would be subjecting their tendons to a ton of unexpected stress. This is because their tendons would become deconditioned during the break and lower their "load tolerance".
This is subjective. There is no set amount of weight or reps that will trigger the injury response, it comes down to the mere fact if the athletes load tolerance has been surpassed or not. The good news is "REACTIVE" tendons can be reversed. If load and stress are reduced and proper rehabilitation measures are done then a reactive tendon can return to its normal healthy self within a few weeks. Lets say you continued PAST this point then you would be ready to enter the "disrepair" stage.
In the disrepair stage the tendon doubles in size as a protective measure. Proteins flood the tendon and bring water to the area. This causes an increase of blood vessels and nerves which can lead to an increased sensation of pain. If proper steps are not taken to address this issue then there can be a further breaking down and beginning of the third stage degeneration.
Site of pain?
Usually with patellar tendinopathy we have 2 pain sites of pain. Directly under the knee cap which medical professionals refer to this as Sinding-Larsen-Johansson Syndrome or at the tibial tuberosity a few inches below the kneecap being referred to as Osgood–Schlatter disease.
It is important to note that there could be other injuries to the knee that could be mistaken for tendinopathy. Tendinopathies and pain associated with it usually decreases when you're at rest or not active. Also the sites in the picture above are point tender, meaning they are sensitive to physical touch. If your symptoms are localized in another area that is not directly on the patellar tendon, or deep inside the knee a different approach must be met.
HOW TO FIX?
If you're dealing with tendon pain regardless of the stage you're in this pain is due to overload. This pain started because the amount of load you placed on the tendon surpassed its load tolerance level. The first step in finding relief and recovery is modifying your training. Your body has responded negatively to this stress with pain, you need to look into WHY this has occurred in order to decrease that pain.
Modifying your training does not mean you're going to be home laying in bed, you never want to completely rest a tendon. The term "if you don't use it you lose it" is extremely relevant when talking about tendons. If you take all the load away and just rest for weeks, you're setting yourself up for failure once you return to your training routine.
For example if you're training six times a week, decrease the frequency by a session or two. If you cant do that, then decrease the intensity of your sessions, or the amount of load you are doing during these sessions. Once you have decided to do that wait and see how your body responds. Once doing this in addition with corrective exercises if we see that after a few month your body is not responding well its time to consult with your local physical therapist or orthopedic specialist. (article below)
HOW TO REHAB
Tendons respond to stress, so the best treatment for tendon pain is exercise. If you have visited with a doctor or other medical practitioner that recommends injections or other “passive” treatments like electrotherapy or scraping techniques as the main mode of treatment, you went to the wrong person. While this may help with short term symptoms it will not attack the underlying cause of the pain and will not help you in the long run. You must strengthen the tendon and improve its ability to take load.
PHASE 1: ISOMETRICS
The most tolerable of all strength exercises for tendon pain is isometrics. Isometrics are a muscle contraction where the joint does not move and the muscle does not change in length. Isometrics have been proven to reduce pain for over 45 minutes after they are performed.(article below)
Any movement we perform here should be done pain free, and while you might have slight pain on the first rep by the time you approach the fourth of fifth rep that pain should decrease significantly.
For this to be effective it must be difficult for you to perform. I recommend starting lighter and working your way up once your tendon has become accustomed to the isometric and the pain level has decreased. For isometrics to be ideal you want to find a load that contracts your muscle to 70% of its capabilities, and held for around 45 seconds.
A simple isometric for the patellar tendon that you can begin with is the wall sit. Perform about 5 sets each for 45s. If this is too easy, you can do it with one leg, or even add weight to the exercise.
PHASE 2: ECCENTRICS
While the isometric exercises are great for decreasing pain and increasing strength temporarily through changes in cortical inhibition, they do little to improve the load bearing capacity of the tendon. Eventually our rehab must move past isometric exercises and start using traditional strength training exercises to accomplish this. Majority of all exercises have 2 phases eccentric and concentric. The eccentric phase is the lowering portion of a movement where the muscle fibers are lengthened under tension, and the concentric is the opposite where the muscle is shortened during the movement. If you're looking at the quad during a squat the eccentric is on the descent and the concentric is when you stand back up.
Majority of athletes spend their time focusing on the concentrics of a movement causing an imbalance in strength. The lack of eccentric focus leads to an eccentric weakness in the muscle and tendon and something that must be addressed. A key exercise that will help you focus on this is the seated eccentric pistol squat.
This exercise also asks for a certain amount of balance from the athlete. Making this a unilateral (1 legged) exercise allows you to focus on a specific leg and not have to worry about compensation with a healthier pain free side. If the pistol squat elicits pain or is too hard you can regress it by performing an eccentric seated squat.
To properly ensure strengthening and an increase in load tolerance of the tendon different types of eccentrics should be used specifically depending on the athlete and that certain case.
PHASE 3: HSR training (HEAVY SLOW RESISTANCE TRAINING)
HSR describes traditional exercises performed slowly with both concentric and eccentric muscle contractions. As soon as your pain has decreased during normal day to day function to a 3/10, I recommend starting HSR exercises.
This is where we would begin using traditional exercises like the back squat/box squat. Your load is key here, and should be kept at 70% of your 1 rep max. Research on the use of HSR with tendinopathy has recommended performing these strength exercises for 4 sets of 15 repetitions for 1 week before increasing the weight and dropping the volume to 4 sets of 12 reps for the next two weeks.(ARTICLE BELOW)
When you first start your HSR training a very small amount of pain is acceptable during and after the lift. If your pain is higher than a 3, then the weight was probably too much or you moved too quickly.It is normal to have a little pain during the rehab process of tendon injuries.
PHASE 4: Returning to PLYOs
The goal with this phase of rehab is to start using the tendon as a spring again and see how it responds. Here I would introduce exercises like drop landings and eventually progress that into jumps. (Drop landing below)
After these can be done without pain we can progress it into a jump exercise like the drop jump below.
From here you can continue to progress to your regular workout routine until your tendon is pain free.
MEDICATION?
Don't assume your knee pain will disappear by popping a few anti inflammatories. Many times when we start feeling tendon pain its not yet accompanied by inflammation, for this reason anti inflammatories are not very effective and just mask up our symptoms of pain. This can be dangerous as covering your pain up can cause you to push through and further injure your tendon and even lead to rupture in the future.
CONCLUSION
Depending on what part of the scale your tendon injury lies decreasing the pain can take a few days to some weeks even months. How you progress these exercises will be determined by your pain level and tolerance to that pain. No two athletes or two cases are alike so each should be progressed depending on how the athlete feels and never following a set in stone plan. Once you have returned to regular competition pain free you should continue using the rehab exercises to ensure these problems do not arise again. Dealing with this can be a frustrating process for any athlete.
I hope this article was helpful and if you have been dealing with chronic knee pain checkout my knee rehab plan in the "shop" option of the website. Blessings.