Were you just starting to get into plyometric training, or back into your favorite sport, when the front of your knee began hurting? There’s a good chance your patellar tendon is inflamed.
Patellar tendinitis (frequently spelled as tendonitis) is one of the most common sources of leg pain in athletes. Also known as “jumper’s knee”, this overuse injury is particularly common among basketball and volleyball players.
Anatomy of the Knee
Technically, the patellar tendon is a ligament that links the front of the knee (patella) to the shin bone (tibia). It works in conjunction with the quadriceps muscle to extend the knee. The knee complex functions like a 3rd class lever or a pulley – it helps the quadriceps muscle straighten the knee more efficiently.
Generally, the deeper the knee bends and the further the knee goes in front of the body, the more force the quadriceps and patellar tendon have to exert to pull the knee straight again.
Symptoms of Patellar Tendinitis
Clinically, patellar tendinitis presents as localized pain and dysfunction in the patellar tendon, which is just below your patella (knee cap). While anyone can develop symptoms from common exercises like stair climbing and squatting, it’s much more common in athletes who play sports or do activities that involve a lot of jumping.
Early on, when symptoms are new and acute, a lot of the pain involved in patellar tendinitis comes from inflammation. If symptoms progress, changes may occur in the collagen of the tendon, leading to chronic pain (tendinopathy).
Here’s a list of common symptoms:
1. Local, sharp pain at the patellar tendon.
2. Increased symptoms with use of the quadriceps, or extending the knee (resisted knee extension).
3. Initially, pain might only be present when you first begin your workout or just after intense physical activity, but may progress to longer-lasting pain if the tendon gets inflamed.
Focus on Knee Alignment
The goal with these exercises is re-education. Before we get to the exercises though, here’s a critical tip you should keep in mind:
Be aware of your knee alignment!
Practice doesn’t make perfect. Perfect practice makes perfect.
For most people, the center of your knee should point towards and be in line with your 2nd or 3rd toe. If the knee goes inwards, your quadriceps and IT-Band will pull the kneecap to the side, causing an asymmetric strain to your patellar tendon.
As you begin to reload the knee joint, practice squatting and lunging with perfect form. Check your alignment throughout every exercise, and especially as you begin to add speed to the movements.
1. Eccentric Single-Leg Decline Squats
The goal of this exercise is to spend a larger amount of time with tension on the tendon. When performed eccentrically, the quadriceps muscle is able to resist with more force. This exercise should be performed until the quadriceps is exhausted, so if you can easily do single leg squats with your bodyweight, start wearing a backpack or weight vest to increase the load.
Complete 3 sets of 15 reps, twice per day.
It’s ok if the decline squats hurt a bit, but the pain should not be excruciating and it should not get progressively worse as you proceed through your reps and sets. Also, if you wake up the next morning and your knee feels worse than it did the day before, lighten the load.
Early on, if the pain is increasing, you can do an easier isometric hold. Try a simple wall squat, holding for 45 seconds, and complete 3 sets. This will allow you to put tension on the patellar tendon without aggravating it.
** If you lack adequate ankle flexibility, you can use a decline ramp to slightly elevate your heel.
Perform 3 sets of 10 reps, practicing squats in varying positions and angles. Pay extra close attention to your form.
Perform 3 sets of 10 reps. Practice lunges in varying positions and angles, paying extra close attention to your form. Perform forward lunges, reverse lunges, side lunges, and diagonal lunges.
4. Jump Rope
Perform 3 x 1 min of jump rope as a warm-up before any physical activity.
The focus here is on ankle training and landing softly.
When jumping, focus on landing softly, which means rolling toe-ball-heel down your foot as you land from jumping. Also, your knees should remain slightly bent throughout the exercise. Studies have shown that when athletes land softly from a jump, more of the forces are absorbed in the ankle musculature, which decreases the peak ground reaction force that occurs in the knee.
An important part of rehabbing patellar tendinitis is flexibility. This is because tight quad and hamstring muscles have been correlated with patellar tendinitis. Therefore, you should definitely stretch the muscles around the knee in your rehab program. Perform these stretches after you warm-up and again after your workouts.
5. Rectus Femoris Stretch
Start in a half-kneeling position with one foot forward and one knee down. Place your back foot up on the wall or on a bench. Tighten your abs and push your pelvis forward without excessively arching your back. Hold for 30 seconds, repeat 3x.
6. Hamstring Stretch
If your hip hinge form is perfect, hold this position for 30 sec, 3x.
If you’re not confident in your hip hinge form, the easiest stretch to do is the hurdle stretch. Instead of reaching for your front foot with your hands (which may cause you to round your back), try to push your belly button to your knee instead. Hold for 30 seconds, repeat 3x.
7. Ankle Stretch
Hold this stretch for 30-60 seconds on each leg.
Poor ankle mobility can lead to poor form up the kinetic chain. Properly stretch the ankle with this stretch prior to doing any activity where your knees may go in front of your toes.
Just like your squat and lunge mechanics, this stretch should be done with optimal alignment of the knees and toes.
Patellar Tendinitis FAQs:
Why did you develop patellar tendinitis?
A combination of genetics, activity level, and quality of movement affect your likelihood of developing patellar tendinitis. While you can’t do much about your genetics, you can definitely influence the latter two.
When it comes to activity, make sure that you give your body adequate rest after heavier, more intense workouts. A little bit of stress is great for the body, as it signals your muscles and connective tissue to get stronger. But too much stress without adequate recovery leads to accumulated micro-tears, which can then lead to pathology and injury.
In addition to total activity level, how you move also plays an important role. Excessively and repeatedly bending your knees in front of you puts a large load on the knee complex. Also, performing leg exercises with poor mechanics (like letting the knees collapse inward) changes the direction of the pull on the patella, leading to increased strain on different parts of the tendon. If you’re new to strength training or working out, consider working with a competent therapist or personal trainer who can teach you the right way to perform your exercises.
Should I do physical therapy for patellar tendinitis?
The most cost-effective treatment for patellar tendinitis is physical therapy. A physical therapist can help you improve your movement mechanics and modify your activity level to find the right balance between strengthening and resting.
The best and most comprehensive summary of how to treat tendinopathies is summarized as EdURep. If you’re interested in an in-depth read (and for anyone in the health industry), this will give you a basic understanding of how to treat tendon pathologies.
EdURep is an acronym that stands for: Educate, Unload, Reload, Prevent. It’s a step-wise system to rehabbing tendon pathologies. Let’s break the process down.
The first step is to understand what’s going on (which you’re doing right now!). Learn how to modify your activity level and know that, while you may not be as invincible as you were when you were 18 year old, your pain won’t last forever.
The next step is to adequately decrease your exercise and activity level so that you minimize the amount of damage to the tendon and give it time to heal. You can still work on your flexibility with the specified stretches, and you can start strengthening the musculature in the hips and ankles.
This is important: Don’t play through pain! The sooner you stop aggravating the tendon, the sooner your healing will occur.
If there are any signs of inflammation, you can also consider taking over the counter anti-inflammatories or do therapeutic icing.
When the tendon is in this painful, reactive stage, you can perform isometric holds as mentioned above. This will help to prevent excessive atrophy of the tendon without aggravating it. Recommendations are for long holds of about 45-60 seconds.
At this point, your knee symptoms should be under control, and you can begin to incrementally load the patellar tendon with specific exercises. Just like muscles, tendons need to be placed under load in order to strengthen them. The key is the kind of load – eccentric strengthening is considered the gold standard for rehabilitating tendons in the lower extremities as it allows you to use even more weight than you may be able to resist otherwise.
To minimize the chance that these symptoms return after your recovery, you’ll want to make sure that you have:
• Adequate hip strength to generate power.
• Proper shock absorption techniques in your ankles and calves.
• Perfect jumping and squatting mechanics so you can maintain optimal alignment.
Adequate rest between exercise sessions to allow for full recovery.
What Are Some Alternative Treatments for Patellar Tendinitis?
1. Patellar Tendon Strap: This strap is one of most common over-the-counter support braces, and it’s purpose is to help distribute the stress along the entire tendon. This cheap solution is worth trying, and allows some athletes to exercise pain-free when they otherwise wouldn’t.
2. Minimal Shoe / Footwear: Use a shoe with a lower heel-to-toe drop. A higher heel can cause the knee to travel forward excessively, which increases the tension on the patellar tendon. If you currently use a shoe with a higher heel-to-toe drop, consider getting a shoe with less of a heel drop or try a minimal shoe.
3. Platelet-rich Plasma Injection / Extracorporeal Shockwave Therapy: These two treatments are lumped together because the scientific research supporting them is still mixed. Some orthopedists swear by them, and some say they make no difference. Neither treatment is covered by insurance, so the costs are generally covered out-of-pocket by the patient. Before deciding on these treatments, I would exhaust your other cheaper options and try physical therapy first.
4. Corticosteroid injection: While great at reducing local inflammation, a steroid injection may simultaneously limit healing and cause further tendon degeneration. If your orthopedist has determined that you would benefit from a steroid injection, make sure not to load the tendon too quickly afterwards. Make sure to give the tendon time to recover and heal.
The one big thing I haven’t mentioned yet is the idea to “keep your knees behind your toes”. This form cue is an over-simplification of proper movement mechanics. It’s natural for your knees to go in front of your toes with certain movements. Look at anyone who walks down stairs or jumps. The key is in limiting movement of the knees in front of the toes when your knee is in pain. Exercises like the wall squat were specifically developed to follow this rule, and yet they can load your patellar tendon and knee joint more than heavy deadlifts can. While your knee may be behind the toes in these exercises, your weight is very far behind the knees, and thus placing a large load on the knee joint. It’s more important to make sure that your knees are in proper alignment with your 2nd or 3rd toes.
Do you have any lingering questions about patellar tendinitis? Reach out in the comments below.
Compression sleeves, good, bad?
If you are having patellar tendinitis, compression sleeves won’t do anything to help. If you are wearing compression sleeves to help with swelling, then you are in the earlier protective stages and should not be doing strengthening exercises to the knee.
That sounds like a great post-workout recovery routine! Thanks for sharing!
stiff legged deadlifts help a lot. And never doing high impact sports 2 days in a row. Always have 1 day rest or upper body weight training. Heavy weightlifting creates more growth hormone which in my opinion helps heal the tendon quicker.
Thanks for sharing! Those are some really great recommendations.
-Kristin, BuiltLean Coach & Managing Editor
Is heat ever recommended to reduce the inflammation of tendinitis in the knee? And if so, what are the recommended heat methods? This question is to help my 13-year old son who has developed tendinitis in the knee and can’t fathom the thought of taking any rest from soccer (football.) Any useful feedback would be greatly and sincerely appreciated.
Heat therapy will tend to increase inflammation and is therefore not recommended for any form of “-itis”. If it’s truly a tendinitis and the tendon is inflammed and warm to touch on it’s own, you should not add heat. However, if it’s a chronic issue and not inflammed (still commonly called tendinitis but technically known as tendinosus) then heat therapy may help. In this case, there hasn’t been strong studies suggesting one form of heat is significantly better than another.
It kind of sounds to me like the person who wrote this article doesn’t know what patellar tendonitis really is. I can barely go up my own steps, let alone do squats and jumping jacks! That’s part of the problem, it hurts like crap to bend my knees that way! So how in the world is that supposed to help heal the damage? I’m confused. I went to physical therapy for months when I first got diagnosed and they specifically told me to avoid those exercises and never had me do them.
I’m sorry that you’ve had bad therapy. I would recommend getting a second opinion from another physical therapist. A good physical therapist should be able to assess your injury and provide a progressive exercise program to help you eliminate pain, rehab the injury, and correct muscular imbalances so that you can avoid future injuries.
Totally agree with you Tiara!!!! I have jumpers knee from jumping rope and it hurts like hell to even try to jump rope again and this article says to jump rope. Wth?!!! They obviously have never had patellar tendonitis! Any excersise that involves bending the knee is extremely painful and all of these “recommend” excersises include just that!
My tendinitis isn’t as severe as others. I’m able to a 10k cross country race with lots of elevation but it was a real stress test for the right knee and experienced discomfort through night. I’m ready to do some therapy. I find that doing the decline squats the right leg is significantly weaker than the left which leads me to believe that strengthening the muscle support the knee will be key. You recommend doing the incline squats twice a day. Does that hold true for the rest of the excercises.
The eccentric squats have been considered the “gold standard” for treating tendinopathy for over a decade. While you’ve noticed your leg to be weaker, the goal of the exercise is to create a load onto the tendon for long periods of time (increase the time under tension). This is the only exercise that should be done this way. All other strengthening exercises for your leg should be performed with the normal parameters of strengthening (3 sets, 5-6 reps). A certified trainer should be able to help with developing exercises for the rest of the leg.
Hi. I strained my Quadricep muscle during a dance class. A week later the pain went from my quad to my knee cap.
The lack of healing two weeks later prompted me to go see an orthopedic doctor I eventually got an MRI and was told that I have tendonitis and the beginning stages of osteoarthritis.
When I initially injured my leg I didn’t completely stop moving it because I had to go to work but rested n iced as much as I could. I was eventually given a cortisone shot and PT. But none seems to help. Since its been seven weeks I decided I need some time off of work. and so I’ve been taking 4 days off of work.
Should I begin PT again? I am not sure if it will aggravate it more.
After 18 months out with patella tendinopathy, (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312643/), I am, thankfully, seeing light at the end of a very long and frustrating tunnel. I injured the patella playing tennis and made the stupid error of playing through a certain amount of discomfort, to the point it was just too painful to play.
I thought I would share my story to give hope to those who are convinced their knee is never going to get better. It may seem that way now, but be patient! Patience is the key and however tempting it may seem, do not put the tendon under any stress (apart from the exercises mentioned) and definitely do not touch it.
But anyone looking for specific results should really try and get an ultrasound tissue characterisation scan (UTC) ).
MRI scans are limited in what they can show whereas the UTC will break the tendon down by colour: green represents good tendon structure; blue, red and black represent increasing structural disruption, as well as being able to give numerical values to the colours.
My first scan in September 2015 unsurprisingly showed the tendon to comprise of a large area of red and black: 17% and 21% respectively, with the good part of the tendon only at 37.95%, hence why I was in so much pain with any minute amount of load applied and more especially when the knee was kept bent for any length of time.
Tendon specialist Jarrod Antflick of Tendon Performance (tendon performance.com) gave me an isometric loading programme to do via the leg press. The perceived wisdom now is that isometric (heavy static loading) rather than eccentric loading is what will help alleviate pain and allow the tendon’s collagen to realign. NB: I am most definitely not a specialist so that is a very basic explanation.
Scan 2 – December 2015, showed an improvement across all colours: black: 17% > 11%; red 21.68% > 15.60% for example, but improvement still seemed slow. I continued with the isometric loading and added posterior chain strength and conditioning (as in the article) to see if that would help.
Scan 3 – September 2016 showed a dramatic improvement: black 11.11% > 0.98%; red 15.60% > 2.24% with the green area jumping from 44.46% to 69.17%.
I’m now back on a treadmill, loading and plyometrics programme so hoping to continue the improvement. What I am noticing now is that while the tendon is sore after the treadmill (jogging 2 mins at 10km/h > 1 min walking at 6.5km/h x4 sets) it is fine the next day with minimal soreness and no pain.
What the UTC scan did was give me specific information regarding the health of the tendon and allowed me to clearly see at various intervals just how the progress was going. Without it you’re totally in the dark, going by feel alone.
Good luck and be patient.
Hugh, thanks for sharing. That’s an awesome story and it’s great that you found such a good therapist who had those tools. The isometric training has only more recently come out in the literature the last couple of years. I agree that it’s the best early (and mid, and even late) exercise training tool as it will significantly increase the time under tension that the tendon experiences.
Also, very good point about the ultra sound imaging and how beneficial it can get. It’s not quite standard practice at all hospitals, but some surgeons are coming around to asking for it as it’s actually much cheaper than an MRI, and can give you the specific detail that you described.
Thanks for sharing!
I have been dealing with a torn tendon for a few years now. Lots of therapy, along with a lot of remedies, the most recent being 2 tries with Tenex. I know this forum is more for tedinitis but I have been told through multiple therapist that the rehab for both is about the same. Is there anything specific that you might be able to help with, keeping in mind that most recent mri has shown a significant tear even after the 2 procedures. I’m in the military and I’m being told now that we haven’t gotten it fixed after 2 and half years that I should just excersise anyway I can that doesn’t cause significant pain and I will be given a waiver so I won’t have to perform my full fitness test. I’m not a fan of this thought as I still have a few years left and thus injury has already stopped me from deploying which could lead to being discharged sooner than my retirement date. Any help would be seriously appreciated!
Hi Erik. From what I’ve seen from Tenex, there hasn’t been substantial quality research that supports it. Many of the trials that are cited were performed outside of the US and were sponsored by them, and thus come with a lot of bias. (The flip side to the argument is that it’s new and thus the research just hasn’t caught up yet). Tendinitis or tendinopathy basically consists of microtears in the tendon. If you had a complete tendon tear/disruption, you wouldn’t be able to walk, so I’m assuming you have tendinopathy which is the same thing being discussed in this article. Try the eccentrics or isometrics with a good therapist (see our article on tips for finding a good therapist).
HI, if you wouldn’t mind, is it possible for you to share the list of references you made for this article? Many thanks in advanced!
HI Hakim. I don’t mind sharing at all. The first source I would go to is the EduRep model (cited below). As for the exercises and eccentric training, there are numerous excellent articles out there, and I’ve pulled what I believe are the best exercises and made my own list. What is worth exploring in the future is the newer concept of using isometrics instead of eccentrics early in the rehab process (this I haven’t yet seen good comparison studies). Let me know if you would like more detail with the other studies and I can gladly point you in the right direction.
Davenport TE, Kulig K, Matharu Y, Blanco CE. “The EdUReP model for nonsurgical management of tendinopathy” Phys Ther. 2005 Oct;85(10):1093-103.
I’ve been having patellar pain for almost six months now, after I pushed myself too hard running. I’ve done the exercises but they seem to aggravate the injury more and the strap doesn’t seem to help. Any advice?
Hey Breanna, sorry to hear about your issues. If you haven’t see a physical therapist or doctor yet, I recommend it
Hey, I noticed that the article doesn’t really describe which leg with which we need to do the Eccentric Single-Leg Decline Squats. Should I do those with the injured leg straight, or should it be the one actually doing the squatting?
Hey Stephen, you can do this exercise with both legs (injured & non-injured, one at a time) so they stay balanced.