Do you have pain right below your knee cap with jumping or kneeling?
What about pain while running or playing sports?
If you feel just below your knee cap, does it feel soft, mushy, and swollen?
All of these things may be due to a tendon injury in the knee called patellar tendonitis.
Lucky for you, I'm here to share with you the best patellar tendonitis exercises today so keep reading.
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As a physical therapist, I’ll say that this is a fairly common injury in people who do a lot of repetitive walking, running, or jumping throughout the day or while playing sports.If you nodded your head to the questions above, I’m sure you’re ready to get over this injury and get back to feeling better. Let’s take a closer look at what patellar tendonitis is, what causes it, how to assess it, how to treat it, and cover what some of the best patellar tendonitis exercises are. It’s about time you get back to being active without feeling held back by the pain. (See Related: About Me)
What is Patellar Tendonitis?
Let’s start by clearing the air. Throughout this blog I will use the term tendonitis as that’s most widely recognized. But to be technical, this injury is actually supposed to be called patellar tendonosis because it’s an overuse degenerative disorder rather than an inflammatory disorder.
Patellar tendonitis is an overuse injury to a tendon that runs from the knee cap down to the top of the tibia bone. It’s also called jumper’s knee. Repetitive activity causing repetitive stress to that tendon causes tiny microtears to it. Over time, it can build up and lead to symptoms and a stabbing, sharp pain. Some common symptoms include feeling pain, swelling, and tenderness around and below that knee cap.
Patellar tendinopathy occurs more frequently in mature adolescents or adults, ranging from ages 16-40 years.
Common Causes of Patellar Tendonitis
What often happens is there can be overuse as a result of repetitive activity or microtrauma due to physical activity. In my clinic, I saw this most often in young basketball players, runners, and gymnasts. Why? They do a lot of jumping and there’s high impact forces upon that knee.
But I also saw it in people who were less active but tried to begin a brand new workout program, jogging program, or hobby that was simply too much too soon and ended up being too much for their knee(s) to tolerate. I remember one client in particular had never worked out. She decided she wanted to lose weight, so she began running 3 miles a day, every day, without a day off. She was not doing any mobility work or stretching at all. She would run and then was done. After just a few weeks of this, she was in immense pain and came to physical therapy. The two biggest lessons I had to teach her were:
When you begin any new fitness program, ease into it and build up slowly as tolerated
Allow 1-2 rest days per week for property recovery
What does the research say about this? “Many factors, both intrinsic and extrinsic, contribute to patellar tendinopathy. Intrinsic factors such as strength imbalance, postural alignment, foot structure, reduced ankle dorsiflexion, and lack of muscle strength or flexibility may play a role. However the primary cause appears to relate to the extrinsic factor of overuse. For example, an increased physical load, repetition, intensity, frequency, and or duration of greater than 10% per week in the training schedule all contribute to this overuse syndrome.” [Reference]
Women are ~3x more likely than men to develop knee injuries due to our hip and knee anatomy (the Q angle). But looking at patellar tendonitis in particular, the research has not found it to be more prevalent in women. So both men and women can experience this injury, especially if involved in a jumping or running sport.
Lastly, patellar tendonitis can also be caused by aging, microtrauma, or vascular compromise.
“Overuse tendon injuries account for 7% of the injuries seen in United States physician offices and 40% of knee injuries in volleyball players. Chronic patellar tendon conditions, also known as patellar tendinosis or “jumper’s knee”, are numerous in elite athletes who run and jump as in volleyball (44%) and basketball (32%).” [Reference]
Location & Muscles Affected by Patellar Tendonitis
The tendon affected is called the patellar tendon. Why? The kneecap is called the patella and it’s the tendon that runs from that knee cap (technically the inferior pole) down to the tibia which is one of the long bones in your lower leg.
Here’s how you can feel this tendon. Sit down and then feel for your knee cap with two fingers. Then run your fingers farther away from you and down to the bottom of your knee cap. Press your fingers in deeper here and rub them side-to-side or left to right. This is where the patellar tendon starts. Then move your fingers downward another inch and you’re nearing the bottom of the patellar tendon before it attaches into the bone there. If you are suffering from patellar tendonitis, you’d definitely have pain and tenderness there and possibly some warmth and swelling.
“The posterior proximal patellar tendon is subjected to greater tensile tendinous forces as compared to the anterior region, especially with jumping activities and deep squat exercises, with forces up to 17 times body weight being placed on the patellar tendon in Olympic weightlifters.” [References]
Testing for Patellar Tendonitis
Testing for patellar tendonitis typically begins in Physical therapy with some range of motion (ROM) tests, manual muscle selective tissue tensioning tests (testing tendon strength), muscle length tests (testing flexibility), manual muscle testing, palpation tests, and special tests.
How to Test for Patellar Tendonitis: The most widely used diagnostic test for this is literally palpation. You’ll feel tenderness and pain directly over that tendon - how easy! It’s a well localized pain. In addition, you may have limited muscle length/flexibility in your quadriceps and hip flexors (on that painful side compared to the uninjured side) and also strong but painful quadricep muscle testing.
Typical test results: tenderness to palpation, decreased and possibly painful flexibility, strong but painful tendon strength testing (but possible mild quad weakness on injured side), and possible swelling.
It’s typically suggested you perform 6-8 weeks of Physical therapy and that often yields great results. Then if there is no improvement, your Physician may suggest further testing like getting an Xray, MRI, or ultrasound to determine if there is more extensive damage near the patella or something else going on. An MRI or ultrasound may not show patellar tendonitis, but these tests could show if there’s more going on. You may also be given a knee brace to rest the tendons further.
Conservative Treatment for Patellar Tendonitis
Disclaimer: The information provided is not intended to be a substitute for professional medical advice, diagnosis or treatment. Never disregard professional medical advice, or delay in seeking it, because of something you have read on this website. Never rely on information on this website in place of seeking professional medical advice.
Now that you better understand what patellar tendonitis is, what causes it, and which tendon is involved, let's now cover what you’re likely most interested in learning about: treatment for patellar tendonitis or tendinopathy.
Physical therapy treatment should always be 100% customized to you: the stage of your injury (recent/acute or chronic), your history, your activity level, your job, your impairments, your abilities, and your goals.
With that said, the below treatments are general treatments often prescribed by Physical therapists for patellar tendonitis. Always consult your Physician before beginning any new exercise program.
Treatments for Patellar Tendonitis (from basic to advanced):
Rest (less or modified repetitive aggravating activity)
Joint mobilization (level depends on stage of injury; plus mobilization with movement (MWM))
Range of motion exercise (without a pain-free range)
Stretching (plus contract-relax technique)
Strengthening exercise (including isometrics)
Functional exercise (form training for squats, jumping, and running)
Manual/Massage: soft tissue massage, deep tissue massage, cross friction massage (if not an acute injury), dry needling
Modalities: Ice, Ultrasound
Brace (if prescribed and more severe)
Strap (to wear only while active near the insertion at the tibia)
Acute tendinitis properly heals in 3-6 wks typically, so it’s a fairly quick recovery process if addressed right away. With improper treatment and no exercise modification, this injury could last up to two years, so it’s important to address proeprly it right away.
If those conservative treatments don’t help then PRP injections, corticosteroid injections, or even surgery may be needed (especially if there are tears or more severe injuries included). “Although nonsurgical treatment is successful in most patients with patellar tendinopathy, approximately 10% of all patients do not respond to it and eventually require surgery.” [Reference]
Below are some products from Amazon that are often useful for addressing patellar tendonitis pain:
Physical Therapy Patellar Tendonitis Exercises
In the following videos, I share how to test for patellar tendonitis, how to feel for tenderness, and how to improve range of motion, flexibility, and strength.
How to Palpate for Patellar Tendonitis
Mobility, Range of Motion, and Stretching Exercises for Patellar Tendonitis
The Best Patellar Tendonitis Strengthening Exercises
Note: Don’t ignore the hips and ankles! You should also strengthen above and below in the kinetic chain, so strengthen those glutes and ankles, too for better shock absorption.
Mission: Mobilize, Modify, Move
It’s my goal to ensure you learn three things with every blog post: how to mobilize your body, how to modify exercise, and how to optimize your movement.
Above I shared a video for knee mobility and stretching. I also shared some great knee strengthening exercises. Strengthening the knee helps stimulate blood flow to the muscles and tendons and repair the tendon.
Now, let’s cover some ideas for how to modify exercise if you have Patellar Tendonitis:
Consider adjusting your workout split to focus more on the upper body and core more often - temporarily until your knee feels better.
Modify lower body exercises by working within a comfortable range of motion, using lighter loads, slowing things down, and adjusting your stance. For example, if you’re doing a squat try these things:
Don’t go down as deep
Do it bodyweight or lighter load than usual
Go slower so you can really focus on form
Consider doing it in front of a mirror so you can watch your knee alignment
Try out different stances: narrow, wide, wider, toes forward, toes more turned outward
Throughout the day, modify any of the repetitive movements you make as that’s possibly the true cause of the inflammation. Or take more breaks while doing them. For example, if you sit all day your hip flexors and quads may feel tight by the end of the day. So maybe you should set an alarm every hour to take a 1-minute break and stretch your thighs out.
For any kneeling activity during the day or kneeling exercises, you may need to add padding, foam, or a towel under your knee for comfort or sub out the exercise.
Finally, if you plan to continue to strength train, I suggest you try these things out to move more optimally:
Warm-up appropriately prior to lifting. Try using ankle weights or a machine to do some light leg extensions before lower body exercises.
During strengthening exercises, an eccentric-accentuated focus is shown to be effective for tendonitis. It helps to increase collagen synthesis (creation) and decreased the tendon thickness back to normal. So let’s say you’re doing a squat. Squat down over the course of 4-seconds and then come up over the course of 1-second. If you’re doing a leg extension machine, kick the legs out over the course of 1-second and then lower back down over the course of 4-seconds.
“Eccentric training is currently considered to be the most efficient treatment for tendinopathy; nevertheless, in order to be effective, this treatment needs specific modalities: slow speed, low intensity and gradual intensification, with minimum 20 to 30 sessions of exercises often being needed.” [Reference]
Definitely modify or skip these exercises temporarily if you have >4/10 discomfort: squat, any type of lunge, step-up, split squat, and leg extensions. Remember your knee will likely feel fine with all hinge pattern (deadlift variations) and bridge pattern (bridge, thrust, and frog variations) exercises still so focus more on those for the time being.
Then once you feel better, you can introduce those squat pattern exercises back in slowly to increase tendon tolerance, as tolerated. One of the best ways to load the patellar tendon is to do a squat on a decline with the heels-elevated above the toes - I showed that in the strengthening exercises video FYI.
While choosing strengthening exercises, consider doing more unilateral work so you can go lighter on the injured side temporarily. For example, lunges, Bulgarian split squats, step-ups, or single-leg leg extensions are unilateral. Whereas squats, box squats, or split squats are bilateral.
During cardio, temporarily decreased volume or intensity of training. For example, if you like to jog everyday, maybe you’re doing too much. Consider scaling back the distance to ⅓ or ½ of your normal distance temporarily as that may not flare up your knees as quickly. Or you could also decrease the intensity but slowing down from 9min/mi to 10min/mi. Or another option is to switch to a lower impact form of cardio like cycling, elliptical, rowing, etc..
During sports, you may need to scale back the intensity and frequency of your training temporarily. Take time off jumping and high impact work - yes, rest. Use that time to do rehab-based exercises until your symptoms subside. Then, you can build back up with more advanced strengthening exercises that load the tendon and eventually work on speed training and plyometric work.
If any of what I said is confusing or you want additional help with addressing your impairments, be sure to watch the webinar “Outsmart your Injury” to learn more about exercise modification and how you can take control of your injury instead of letting it control you. Then reach out and let’s chat!
Thanks for reading!
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