A Calisthenic exercise alternative to treat patellar tendinopathy.
Patellar tendinopathy is a very common injury that affects athletes of all stripes, not to mention the rest of us as well! While it is present in people of all kinds of physical activity profiles, it is especially an issue among jumping athletes, think volleyball and basketball players… possibly skippers too…
Whatever your sport, the presenting symptoms are fairly consistent and are marked by a pain with resistance type load or repeated load. For most people this would look like pain that presents consistently on activity like sitting down into or getting up from a chair. It could also look like pain that occurs consistently with navigating a set of stairs, or after five flights of stairs. In the gym you might experience pain consistently with squats, lunges, leg press and very likely the leg extension machine - if you’re into that sort of leg extension-y thing…
Notice the common (and consistently used) word “consistent” in the description above. What I mean by this is that patellar tendinopathies tend to manifest painfully on specific movements, every time you perform those movements, or after a specific number of repeated movements.
The pain is also highly localised, at the patellar tendon this is typically at the low aspect of the kneecap (patella) where the bony piece meets the soft tissue piece. (see Fig 1). It’s not in other places like the sides of the kneecap or above it.
Fig 1. Location of patellar tendinopathy pain. It’s here... not there..!
Okay, so let’s say you have a patellar tendinopathy. Great and wonderful. So what should you do about it?
Well, exercise interventions are a treatment modality well supported by research evidence. The usually consist of some combination of gym exercises using barbell squats, leg press, hack squat and even knee extension machine type work. We have talked about this kind of thing on the blog previously for the achilles tendon here, and here.
Traditionally exercise protocols to treat tendinopathies center around eccentric exercise, or resistance on the muscle and tendon while it is lengthening - like the down phase of a squat or the dropdown phase of a seated quadriceps extension. More recent research suggests that we don’t have to be quite so anal with a strict focus on eccentrics. Good old heavily loaded concentric and eccentric (both push and release phase) of a strength training exercise is useful!
The trick is the heavy loading piece. We are not pansying around with this stuff! In fact the heavily loaded exercise we are going after may even be painful, and that is ok (within reason). Think between 4-6/10 intensity is acceptable when executing resistance exercise to treat a patellar tendinopathy.
Also think slow, research calls for 4 seconds on the release phase and 2 seconds on the push phase. This is a very slow pace that seems to be a bit excessively slow for most people. But shoot for at least two seconds down and two seconds up (just so you can make me happy if for no other reason).
There are plenty of easy ways to heavily load in the gym, like on any of the abovementioned exercises that require leg presses, knee extension machines or squat racks. Here though I suggest an alternative that you can easily do at home with little to no equipment!
Heavy slow resistance training using single leg squat works and requires almost no gear. And bonus if you can do it on some kind of decline ramp like in Figure 2. Most people don’t have a decline ramp at home though, so even getting your heels up on a couple of dumbell handles like I do in the video above is better than a kick in the face.
Fig 2. Example of a 25 degree decline ramp. Even getting your heels up on a couple of dumbell handles is better than a kick in the face
You can use a TRX to help you with stability, this allows you to focus on the loading aspect of the single leg squat rather than balance. Don’t have a TRX? No problem! Take a yoga strap (or a long belt, or an extension cord, or whatever!) and wrap it around a sturdy door handle to help in the same manner - see the video above for details on this.
Start with doing the heaviest load you can bear in 15 reps. “Heaviest load in 15 reps” means that if you can comfortably do 20 reps, you need to make it heavier. Loading up by putting some books, weights or a jug of water in a backpack works pretty well. See the video for a view how I do it!
You will be increasing the load over a period of about 3 months. “3 months!” you say?! Yes, 3 months I respond with a straight face. This is the period of time it takes to get a notable remodelling of the tendon, meaning it is healing, less painful and stronger.
Increasing the load means that you will start at the maximum load you can do with 15 reps in a set. For most people bodyweight will suffice to start, but…
- ...by week 6, you are using the heaviest load you can muster with 8 reps (ie. heavier!!)
- ...and by week 12 you are using the heaviest load you can muster with 6 reps (ie. a boatload heavier!!)
So load up those backpacks! Execute 3 sets, 4 times per week ideally. Just pop it in with your typical exercise routine or take 5-10 minutes each morning or evening to do it. Heck do it at work to impress your colleagues and boss!
Have fun with this and remember that you should expect a notable improvement over 3 months. If it is not improving or if it is getting worse, see your physiotherapist for advice on your specific situation.
Further reading (if you really want to impress your friends)
Beyer, R., Kongsgaard, M., Kjær, B. H., Øhlenschlæger, T., Kjær, M., & Magnusson, S. P. (2015). Heavy Slow Resistance Versus Eccentric Training as Treatment for Achilles Tendinopathy A Randomized Controlled Trial. The American journal of sports medicine, 0363546515584760.
Everhart, J. S., Cole, D., Sojka, J. H., Higgins, J. D., Magnussen, R. A., Schmitt, L. C., & Flanigan, D. C. (2017). Treatment options for patellar tendinopathy: a systematic review. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 33(4), 861-872.
Visnes, H., & Bahr, R. (2007). The evolution of eccentric training as treatment for patellar tendinopathy (jumper’s knee)–a critical review of exercise programs. British journal of sports medicine.
Kongsgaard, M., Kovanen, V., Aagaard, P., Doessing, S., Hansen, P., Laursen, A. H., ... & Magnusson, S. P. (2009). Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scandinavian journal of medicine & science in sports, 19(6), 790-802.
Purdam, C. R., Jonsson, P., Alfredson, H., Lorentzon, R., Cook, J. L., & Khan, K. M. (2004). A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy. British journal of sports medicine, 38(4), 395-397.
Van der Plas, A., de Jonge, S., de Vos, R. J., van der Heide, H. J. L., Verhaar, J. A. N., Weir, A., & Tol, J. L. (2011). A 5-year follow-up study of Alfredson's heel-drop exercise programme in chronic midportion Achilles tendinopathy. British journal of sports medicine, bjsports-2011