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Patellar Tendonitis Stretches

If you’re looking for patellar tendonitis stretches you need to know three things:

1) Which muscles you need to stretch.

2) When not to stretch.

3) How much improvement you can expect from stretching.

Let’s start with number one.

Stretches for the patellar tendon

Research has repeatedly shown a connection between muscle tightness in the legs and an increased risk of patellar tendonitis[1]. The three muscle groups with the strongest evidence are the calves[2], the hamstrings[3], and the quadriceps muscles[4].

Feedback from people with patellar tendonitis also confirms that stretching exercises can help with recovery from and prevention of patellar tendonitis and we’re going to look at some great evidence on that later.

A word of warning: don’t try these stretches unless you’ve been cleared for this by your doctor and be sure to watch the part of this video where we talk about when not to stretch.

Now let’s start with the least popular of the three patellar tendonitis stretches: the calf stretch.

Calf Stretch

I recommend foam-rolling the muscles before stretching. This helps if you’re particularly tight. My favorite calf stretch is just standing on a slanted board. If this is too difficult for you, you can start by leaving your heels on the ground.

The simplest stretch for patellar tendonitis: the calf stretch on a slanted board.

The simplest stretch for patellar tendonitis: the calf stretch on a slanted board.

Keep your feet parallel and pointed forward and try to keep your knees straight. You also want to feel the stretch in your calves and not in your Achilles tendons. Relax deeper into the stretch for at least two or three minutes.

Now there are many different versions of the calf stretch, but I always come back to the one on the slanted board because it’s the most convenient version and so easy to do. You just have to stand there. You could even watch TV or read a book while you’re at it.

Hamstring Stretch

There are probably more variations of the hamstring stretch than days in a month. You can stretch both legs simultaneously or one leg at a time, you can stretch using your body weight only, or by pulling yourself into the stretch, you can use a strap to pull the leg closer, you can stretch the hamstrings with the knees slightly bent or completely straight, you can do isolated stretching or integrate the stretch into a mobility exercise, and on and on the list goes.

I’m sure there are stretching fanatics out there with strong opinions about what’s best and why everything else sucks, but in my experience it’s better to try different exercises to find what works best for you than to blindly stick with someone’s recommendation.

So I’m going to give you my two favorite hamstring stretches, but I’d still encourage you to try others as well. Also, just because I say favorite doesn’t mean I actually like stretching hamstrings.

1) The Belt Stretch

A simple hamstring stretch for knee tendonitis

In this simple stretch you lie on your back, pull one leg up and then loop a belt or strap around the heel. Now you can stretch the hamstring of that leg by pulling the leg closer. You can do this as a passive stretch by just letting the hamstring yield to the force or you can do it as contract-relax stretch.

To do the contract-relax version you actively resist the pull of the strap by pushing into it with your heel. This puts tension into your hamstring. Push hard for a few seconds and then relax all muscles with an audible sigh of relief. The important part is to not keep pulling on the strap as you relax the hamstrings, but let all muscles rest for maybe a second. Then you can gently pull the leg closer.

With each round you’ll get deeper into the stretch.  It’s not fun, but it works, just like this next one.

2) The Boot-Strapper

The boot-strapper is a mobility exercise and stretch for the hamstrings. I learned this from Steve Maxwell, who has about a hundred other fantastic mobility drills like this in arsenal, so go check him out if you’re into mobility work.

In the boot-strapper you’re working your quadriceps muscles against the resistance of your hamstring muscles, which can also give you a gentle cardiovascular workout.

the boot-strapper mobility stretch for patellar tendonitis

The boot-strapper is a mobility exercise to improve hamstring flexibility.

You stand with your feet about hip-width apart and pointed forward. Now you bend your knees and lean forward to touch the ground with your hands.

The easiest difficulty of this exercise is doing it with just your fingertips touching the ground. Depending on how flexible you are you can then progress to touching your knuckles and later-on your palms to the ground.

If you’re super flexible you can place your palms on the side of your feet.

Now you exhale as you straighten your knees, hold for a brief moment, and inhale while bending them. To do this as a workout squat all the way down, but if you’re just doing it for hamstring flexibility you can work in the top part of the movement.

Exhale as you straighten the knees and inhale as you flex the knees.

You can do up to 100 repetitions, but 30 to 50 are sufficient in the beginning. If your knees are easily irritated, this exercise may still be too tough for you. So be careful if you’re trying it for the first time.

Quadriceps Stretching Exercises for Patellar Tendonitis

The two stretching exercises for the quadriceps that I’ve found work best are the couch stretch and the wall quad stretch. I learned both of these from Dr. Kelly Starrett.

1) Couch Stretch

The quadriceps couch stretch

The couch stretch for patellar tendonitis, demonstrated on a chair.

The couch stretch is the gentler quad stretch of the two. You do it by standing in front of a couch and then placing your knee all the way into the back corner. Don’t leave any space between your knee and the backrest. Now push up and keep your abs and glutes braced to maintain a neutral spine.

You don’t want to go into lumbar hyperextension, because that takes makes the stretch a lot less effective and also places your back at risk.

If you’re unsure about the correct alignment you can do the exercise with a stick behind your back. Keep the stick in contact with your tailbone, your upper back, and your head. There should be just enough space in the lower back region so that you can slide a couple of fingers through, but not more.

Now you can experiment with how you need to work your core muscles to maintain those points of contact and once you’ve figured it out you can sink deeper into the stretch.

And by the way, this lumbar hyperextension is something you’ll see in a lot of hip flexor and quad stretches. The rectus femoris from your quads attaches to the front of the hip and the hip flexors attach to the front of the hip as well as the lumbar spine. Stretches for both of these muscle groups exert a force that tries to tilt the hip forward and pulls the lumbar spine forward and down.

The second quadriceps stretch is the wall quad stretch.

2) Wall Quad Stretch

The wall quad stretch

The wall quad stretch is the big brother of the couch stretch: more intense, but also a bit more difficult to get into.

Set up in front of the wall and have a thick pillow or folded blanket ready as a cushion. Now you kneel down and place the rear leg all the way up to the wall, with your shin touching the wall. Next you push up, again keeping your glutes and core braced to maintain a neutral spine.

Eventually the quads relax and you can sink deeper into stretch. Keep your breathing relaxed and stay in the stretch for at least two minutes per side.

But as great as all these stretches are, there are times when you should NOT stretch.

When NOT to Stretch

You want to be careful with these stretches if you have problems with the tendons that attach to them. So if you have Achilles tendonitis, use the calf stretch only if you feel it in your calves and not in the tendon. The same thing applies to the hamstring stretch if you have hamstring tendinopathy and to the quadriceps stretches if you have quad or patellar tendonitis.

For patellar tendonitis in particular you shouldn’t stretch if it causes increased pain in the tendon. In that case you can use self-massage to relieve tension from the quads. The good news is that after a few weeks of tendon strengthening work your tendons will likely be able to tolerate the stretching, but until then it’s better to avoid stretching if it causes a flare-up of pain.

Now the big question that remains is:

How Much Does Stretching Really Help?

How much does stretching really help? Print: How do these knee tendonitis stretches really help?

I have a few thousand people with patellar tendonitis in my free email course about the injury so I just asked them a couple of questions about their experience with stretching and a little over 300 took the time to respond. Thank you for that. Here are the results.

My first question was “Did stretching help your knee feel better?”

75% of people responded with yes, stretching helped my knees feel better.

One the other hand, stretching didn’t have an impact for about 14% and 5% felt worse after stretching.

The additional remarks people left in the survey suggest that of those 14% for whom it didn’t work, a certain percentage was already very flexible. So if you have patellar tendonitis but are already are flexible you may not benefit from stretching.

Next I asked about whether stretching was more useful for rehab or for prevention, but the results were pretty much a toss-up with rehab coming in a bit higher.

In this question people could check more than one answer and while the results leave room for interpretation my biggest takeaway is that even after you’re back to sports, stretching will still play a role in keeping you pain-free, at least for most people.

The final question was about which stretches were most beneficial. The quad stretch came in first with 72%. The other three answers, hip flexor stretch, hamstring stretch, and calf stretch, all came in tied for 2nd place since there’s no statistically significant difference between them.

About 8% of those I included in the last bar didn’t find any stretches useful and less than 1% added their own answers mentioning stretches for the glutes, lower back, or feet, but since the number is so small these seem to be just fringe cases.

So the answer to our initial question “Do knee tendonitis stretches really help?” is yes, stretching does help for most people, especially during rehab, but also later on when they’re back in sports. The most useful stretch is the quad stretch, followed by the other 3 stretches, but ultimately you’ll still have to try all of them to find which ones your body needs.

I think that sums it all up nicely.

Patellar Tendonitis Stretches PDF Download

You can download this article as PDF by clicking here.

Beyond just stretching…

Now if you have patellar tendonitis but have not yet signed up to my free email course about what works and what doesn’t, just take a moment and get started today. Because getting better is not just about knowing all the exercises, but also about staying motivated to stick to the plan.

Martin,

I watched the videos you emailed me a few months ago and started doing the stretches/exercises. I do them fairly regularly. I wanted to tell you that they have really helped! My knee rarely experiences any tinge of pain at all and I am much improved. Thank you for your great instruction on jumper’s knee.

   — Mark S.

 

 

Citations

[1] Adam B. Rosen et al., “Lower Extremity Kinematics During a Drop Jump in Individuals With Patellar Tendinopathy,” Orthopaedic Journal of Sports Medicine 3, no. 3 (2015); Kristin M. Houghton, “Review for the generalist: evaluation of anterior knee pain,” Pediatric Rheumatology 5, no. 1 (2007); Peter Malliaras et al., “Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations,” The Journal of orthopaedic and sports physical therapy 45, no. 11 (2015): 895; Stasinopoulos Dimitrios, Manias Pantelis, and Stasinopoulou Kalliopi, “Comparing the effects of eccentric training with eccentric training and static stretching exercises in the treatment of patellar tendinopathy. A controlled clinical trial,” Clinical rehabilitation 26, no. 5 (2012).

[2] Ludvig J. Backman and Patrik Danielson, “Low range of ankle dorsiflexion predisposes for patellar tendinopathy in junior elite basketball players: a 1-year prospective study,” The American journal of sports medicine 39, no. 12 (2011); Peter Malliaras, Jillianne L. Cook, and Peter Kent, “Reduced ankle dorsiflexion range may increase the risk of patellar tendon injury among volleyball players,” Journal of science and medicine in sport / Sports Medicine Australia 9, no. 4 (2006); Rodrigo Scattone Silva et al., “Lower limb strength and flexibility in athletes with and without patellar tendinopathy,” Physical Therapy in Sport 20 (2016).

[3] E. Witvrouw et al., “Intrinsic risk factors for the development of patellar tendinitis in an athletic population. A two-year prospective study,” The American journal of sports medicine 29, no. 2 (2001); Sarah Morton et al., “Patellar Tendinopathy and Potential Risk Factors: An International Database of Cases and Controls,” Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine (2017).

[4] Kerry J. Mann et al., “A lower limb assessment tool for athletes at risk of developing patellar tendinopathy,” Medicine and science in sports and exercise 45, no. 3 (2013); van der Worp, Henk et al., “Risk factors for patellar tendinopathy: a systematic review of the literature,” British journal of sports medicine 45, no. 5 (2011).

Patellar Tendonitis Treatments That Actually Work

patellar tendonitis treatmentsSetbacks, conflicting advice, and stagnation: The treatment for patellar tendonitis can be long and frustrating.

In this article I will show you which treatment options exist and how effective they are.

About The Author

My name is Martin Koban and I’ve been helping people with patellar tendonitis since 2011, after suffering through a serious case myself. I’ve worked with professional as well as recreational athletes and all my publications are 100% evidence-based.

Treatment Options for Patellar Tendonitis

[Patellar tendonitis] is an overuse injury of the patellar tendon and the longer the overuse continues, the more the injury progresses.

In the early injury stages resting and activity modification are often enough to achieve a full recovery, but if the knee has been painful for more than a few weeks a passive approach (i.e., doing nothing) is usually no longer enough to get rid of pain permanently.

The following treatment options exist.

Physical Therapy Exercises

Once patellar tendonitis has become chronic only a handful of treatments actually work [1]. The most effective approach is supported by decades of evidence in academic research:

Stimulating positive tendon adaptation through progressive loading with slow strengthening exercises [2].

Let’s take this concept apart so that you can understand how to use it with your physical therapy exercises. We’re going to talk about the specific exercises in a moment.

Positive tendon adaptation happens when you do an exercise that is not too light and not too heavy for how strong your tendon is at the time. You also need to do the right number of repetitions and you have to leave a certain number of rest days in between these workouts.

Negative tendon adaptation happens when you rest for long periods of time [3] or – arguably worse – use too heavy weights, do too many repetitions, or train too often.

Progressive loading means you need to increase the resistance and volume you expose your tendon to in safe increments. Put differently, you need to do heavier exercises as your knees permit. This is necessary so that the adaptation process continues to the point where your knees are strong enough for your sport.

Slow strengthening exercises are those exercises that can be executed slowly, thereby allowing you to safely place the tendon under a long time under tension.

In other words, the training variables (resistance, volume, and training frequency) need to be within what your tendon can handle at the time. Once established you can then carefully increase resistance and volume in increments that your knee can tolerate.

Which treatment exercises work for patellar tendonitis?

Through my books and courses I’ve been helped thousands of people get rid of their tendonitis and the exercises that have worked best for this particular purpose are:

  • The slow squat [4]
  • The slow leg press
  • Holds on the leg extension machine [5] (isometric)
  • Wall Sits (isometric)
  • The Spanish Squat (isometric)
The best treatment exercises: slow squat, slow leg press, leg extension holds, and wall sits.

The best treatment exercises: slow squat, slow leg press, leg extension holds, and wall sits.

The follow-up question to this list usually is “which exercise works best?” But there is no one exercise that works perfectly for everyone [6]. Usually starting with isometric exercises works well, but I’ve also had people that only made progress with the slow squat. Just like some folks did well on the leg press while others couldn’t get it to work for them.

One thing is sure though:

Plyometrics and explosive lifting are not useful in the first two treatment stages [7] because the time under tension is too low and the force on the tendon is too high.

You also want to avoid all exercises and movements that cause tendon irritation. Risk factors for tendon irritation include deep knee flexion, forward knee movement, and direct pressure on the tendon like you get when you’re kneeling.

[Patellar tendonitis stretches] can also cause irritation if the tendon is not yet strong enough. In that case stretching needs to wait until the tendon can handle it.

Your treatment plan can also benefit from self-massage to reduce muscle tension. Improving movement mechanics through biomechanical exercises is beneficial [8] for preventing pain from coming back in the future.

Other Treatment Options

If you’ve had patellar tendonitis for more than a few weeks, chances are you’ll look for what else you can do, other than exercises. There has to be a faster way to get back into sports, right?

This desire for a shortcut contributed to the development of a large number of adjunct treatments for patellar tendonitis. Unfortunately most of them are not supported by strong evidence in academic research [9]. Here’s the list:

Icing can be useful for pain management, especially during flare-ups, but didn’t show long-term treatment benefits [10]

Patellar tendon straps can also be used for short-term pain reduction [11], but they don’t deliver long-term improvements

Ultrasound therapy provided inconsistent results [12] and has failed to provide any benefits in several studies [13]

Cortisone injections can lead to a short-term reduction of pain [14], but they increase risk of relapse [15] and over the long-term cause weaker tendons[16] that are more prone to tearing [17]

PRP injections showed little evidence of an effect greater than placebo injections [18]

Prolotherapy and dry-needling are also not supported by strong evidence [19]

Surgery is a last resort option for refractory cases of patellar tendonitis. Rehab time from surgery is 6 – 12 months, but long-term results in these cases are promising.

How much Treatment Time Can You Expect?

Recovery from patellar tendonitis can happen in just 4 weeks, but it can also take up to 12 months and even more.

The treatment time depends on several factors including how far the injury has progressed and how well you can solve the many problems that happen during treatment, as it’s not a straight-forward process.

In fact, you’ll often read about people that have suffered from patellar tendonitis for years. However, if you do the right things at the right time and avoid costly mistakes you can shorten your recovery time by several months.

While we’re on the topic of mistakes, here’s probably the biggest one:

Running or cycling during treatment?

It sucks if pain side-lines you from your sport and as an athlete I understand why so many people train through pain. I’ve done it myself so many years ago.

And yet training through pain is one of the major reasons why treatment often takes much longer than necessary. If running or cycling are causing pain, you need to put these activities on hold until your knees are strong enough to tolerate them without a pain response. Here’s a video about this:

Patellar Tendonitis Treatment PDF Download

Click here to download a PDF of this article about exercises and treatment options. Or better yet, keep in touch with me. Here’s how:

Complete Recovery in 4 Weeks?

Some of the people I worked with were able to get back into sports without pain after just 4 weeks. These results are not typical of course, but if you want to recover as quickly as possible you need to use the right treatment strategy right away.

I want to help you with that so I’ve put everything you need to know to get back to 100% into my free email course about patellar tendonitis. I’ll also send you my best future articles and videos to help you stay on target. Let’s do this together!

Sign up here and start getting your life back today

Dear Martin,

I just wanted to thank you very much for all your work in this field. I enjoyed your pattelar tendonitis book and your emails.

I’ve struggled with PT for 1 1/2 year now, but I’m now finally eyeing a return to my beloved soccer. Season starts in late august and I’m very hopefull that I’ll be able to play by then.

At this point I can run 5 km and do intervals without problems. I can also play soccer on my own in my garden for 10-15 mins without any pain. So I guess I’m close.
   — Thomas C., Copenhagen”

 

 

References

[1] Peter Malliaras, Lower Limb Tendinopathy Course (London, 31.10.2016), pp. O5.

[2] D. I. Clark et al., “Physiotherapy for anterior knee pain: a randomised controlled trial,” Annals of the rheumatic diseases 59, no. 9 (2000); L. J. Cannell, “A randomised clinical trial of the efficacy of drop squats or leg extension/leg curl exercises to treat clinically diagnosed jumper’s knee in athletes: pilot study,” British journal of sports medicine 35, no. 1 (2001); Peter Malliaras, Lower Limb Tendinopathy Course (London, 31.10.2016); Peter Malliaras, “That elusive biological magic bullet for tendinopathy,” http://www.tendinopathyrehab.com/blog/tendinopathy-updates/that-elusive-biological-magic-bullet-for-tendinopathy, accessed September 2017.

[3] J. L. Cook and C. R. Purdam, “Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy,” British journal of sports medicine 43, no. 6 (2009): 409; E. Yamamoto, K. Hayashi, and N. Yamamoto, “Mechanical properties of collagen fascicles from stress-shielded patellar tendons in the rabbit,” Clinical biomechanics (Bristol, Avon) 14, no. 6 (1999); James H.-C. Wang, Qianping Guo, and Bin Li, “Tendon Biomechanics and Mechanobiology—A Minireview of Basic Concepts and Recent Advancements,” Journal of Hand Therapy 25, no. 2 (2012): 138; J. A. Hannafin et al., “Effect of stress deprivation and cyclic tensile loading on the material and morphologic properties of canine flexor digitorum profundus tendon: an in vitro study,” Journal of orthopaedic research : official publication of the Orthopaedic Research Society 13, no. 6 (1995); Yu-Long Sun et al., “Temporal response of canine flexor tendon to limb suspension,” Journal of applied physiology (Bethesda, Md. : 1985) 109, no. 6 (2010); F. R. Noyes, “Functional properties of knee ligaments and alterations induced by immobilization: a correlative biomechanical and histological study in primates,” Clinical orthopaedics and related research, no. 123 (1977); De Boer, Maarten D. et al., “Time course of muscular, neural and tendinous adaptations to 23 day unilateral lower-limb suspension in young men,” The Journal of physiology 583, no. 3 (2007): 1091.

[4] M. A. Young, “Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players,” British journal of sports medicine 39, no. 2 (2005).

[5] L. J. Cannell, “A randomised clinical trial of the efficacy of drop squats or leg extension/leg curl exercises to treat clinically diagnosed jumper’s knee in athletes: pilot study,” British journal of sports medicine 35, no. 1 (2001).

[6] Håvard Visnes and Roald Bahr, “The evolution of eccentric training as treatment for patellar tendinopathy (jumper’s knee): a critical review of exercise programmes,” British journal of sports medicine 41, no. 4 (2007).

[7] Sebastian Bohm, Falk Mersmann, and Adamantios Arampatzis, “Human tendon adaptation in response to mechanical loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults,” Sports medicine – open 1, no. 1 (2015); Falk Mersmann et al., “Muscle and Tendon Adaptation in Adolescence: Elite Volleyball Athletes Compared to Untrained Boys and Girls,” Frontiers in Physiology 8 (2017).

[8] E. Witvrouw et al., “Intrinsic risk factors for the development of patellar tendinitis in an athletic population. A two-year prospective study,” The American journal of sports medicine 29, no. 2 (2001); Peter Malliaras et al., “Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations,” The Journal of orthopaedic and sports physical therapy 45, no. 11 (2015): 895; I. N. JANSSEN et al., “Predicting the Patellar Tendon Force Generated When Landing from a Jump,” Medicine & Science in Sports & Exercise 45, no. 5 (2013): 933.

[9] Peter Malliaras et al., “Patellar Tendinopathy: Clinical Diagnosis, Load Management, and Advice for Challenging Case Presentations,” The Journal of orthopaedic and sports physical therapy 45, no. 11 (2015): 894.

[10] P. Manias and D. Stasinopoulos, “A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy,” British journal of sports medicine 40, no. 1 (2006).

[11] A. de Vries et al., “Effect of patellar strap and sports tape on pain in patellar tendinopathy: A randomized controlled trial,” Scandinavian journal of medicine & science in sports 26, no. 10 (2016); Adam B. Rosen, Jupil Ko, and Cathleen N. Brown, “Single-limb landing biomechanics are altered and patellar tendinopathy related pain is reduced with acute infrapatellar strap application,” The Knee 24, no. 4 (2017); Gali Dar and Einat Mei-Dan, “Immediate effect of infrapatellar strap on pain and jump height in patellar tendinopathy among young athletes,” Prosthetics and Orthotics International 43, no. 1 (2018).

[12] Brett M. Andres and George A. C. Murrell, “Treatment of tendinopathy: what works, what does not, and what is on the horizon,” Clinical orthopaedics and related research 466, no. 7 (2008): 1542.

[13] Rachel Chester et al., “Eccentric calf muscle training compared with therapeutic ultrasound for chronic Achilles tendon pain–a pilot study,” Manual therapy 13, no. 6 (2008); S. J. Warden et al., “Low-intensity pulsed ultrasound for chronic patellar tendinopathy: a randomized, double-blind, placebo-controlled trial,” Rheumatology (Oxford, England) 47, no. 4 (2008); Maria E. H. Larsson, Ingela Käll, and Katarina Nilsson-Helander, “Treatment of patellar tendinopathy—a systematic review of randomized controlled trials,” Knee Surgery, Sports Traumatology, Arthroscopy 20, no. 8 (2012): 1645.

[14] Brett M. Andres and George A. C. Murrell, “Treatment of tendinopathy: what works, what does not, and what is on the horizon,” Clinical orthopaedics and related research 466, no. 7 (2008): 1542.

[15] L. Bisset et al., “Mobilisation with movement and exercise, corticosteroid injection, or wait and see for tennis elbow: randomised trial,” BMJ 333, no. 7575 (2006); U. Fredberg et al., “Ultrasonography as a tool for diagnosis, guidance of local steroid injection and, together with pressure algometry, monitoring of the treatment of athletes with chronic jumper’s knee and Achilles tendinitis: a randomized, double-blind, placebo-controlled study,” Scandinavian journal of rheumatology 33, no. 2 (2004).

[16] M. Kongsgaard et al., “Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy,” Scandinavian journal of medicine & science in sports 19, no. 6 (2009); Brooke K. Coombes et al., “Effect of corticosteroid injection, physiotherapy, or both on clinical outcomes in patients with unilateral lateral epicondylalgia: a randomized controlled trial,” JAMA 309, no. 5 (2013).

[17] Ronald Hugate et al., “The effects of intratendinous and retrocalcaneal intrabursal injections of corticosteroid on the biomechanical properties of rabbit Achilles tendons,” The Journal of bone and joint surgery. American volume 86-A, no. 4 (2004); Jianying Zhang, Camille Keenan, and James H.-C. Wang, “The effects of dexamethasone on human patellar tendon stem cells: implications for dexamethasone treatment of tendon injury,” Journal of orthopaedic research : official publication of the Orthopaedic Research Society 31, no. 1 (2013); Laurent Baverel et al., “Do corticosteroid injections compromise rotator cuff tendon healing after arthroscopic repair?,” JSES Open Access 2, no. 1 (2018).

[18] Dennis A. Cardone, “Is Platelet-Rich Plasma an Effective Healing Therapy?: Scientific American,” http://www.scientificamerican.com/article.cfm?id=platelet-rich-plasma-therapy-dennis-cardone-sports-medicine-injury&page=2, accessed July 2013; Micheal P. Hall, James P. Ward, and Dennis A. Cardone, “Platelet Rich Placebo?: Evidence for Platelet Rich Plasma in the Treatment of Tendinopathy and Augmentation of Tendon Repair,” Bulletin of the Hospital for Joint Diseases 71 (2013): 57; Alexander D. Liddle and E. C. Rodríguez-Merchán, “Platelet-Rich Plasma in the Treatment of Patellar Tendinopathy: A Systematic Review,” The American journal of sports medicine 43, no. 10 (2015); Franciele Dietrich et al., “Effect of platelet-rich plasma on rat Achilles tendon healing is related to microbiota,” Acta Orthopaedica 88, no. 4 (2017); de Vos, Robert J et al., “Platelet-rich plasma injection for chronic Achilles tendinopathy: a randomized controlled trial,” JAMA 303, no. 2 (2010); Nasir Hussain, Herman Johal, and Mohit Bhandari, “An evidence-based evaluation on the use of platelet rich plasma in orthopedics – a review of the literature,” SICOT-J 3, no. 1 (2017).

[19] O. Morath et al., “The effect of sclerotherapy and prolotherapy on chronic painful Achilles tendinopathy-a systematic review including meta-analysis,” Scandinavian journal of medicine & science in sports 28, no. 1 (2018); Lane M. Sanderson and Alan Bryant, “Effectiveness and safety of prolotherapy injections for management of lower limb tendinopathy and fasciopathy: a systematic review,” Journal of foot and ankle research 8, no. 1 (2015); O. Chan, “Outcomes of prolotherapy for intra-tendinous Achilles tears: a case series,” Muscle, Ligaments and Tendons Journal 7, no. 1 (2017); Ulrike H. Mitchell et al., “The Construction of Sham Dry Needles and Their Validity,” Evidence-Based Complementary and Alternative Medicine 2018, no. 5 (2018); F. A. Chaudhry, “Effectiveness of dry needling and high-volume image-guided injection in the management of chronic mid-portion Achilles tendinopathy in adult population: a literature review,” European Journal of Orthopaedic Surgery & Traumatology 27, no. 4 (2017): 446.

How to Get In Shape with Knee Pain (Best Cardio Exercises)

exercising ladyThe worst part about knee pain is watching your fitness wither away as you’re slowly turning into a couch potato.

With every passing day you feel more sluggish and the risk of getting fat and depressed is very real. But what if you could get into better shape instead?

In this article you will learn:

  • 2 knee-friendly exercises for getting in shape
  • Safe cardio options for knee pain (and what to stay away from)
  • A fun training plan you can start with today

[Read more…]

Why you don’t need to give up your sport because of knee pain

Do I need to give up my sport because of knee pain? - Picture by Alba RincónWhat do you think is the most important requirement for successful rehab?

I started researching knee pain in 2009 and have read over five thousand reader emails since. One hard truth that took me years to understand is that the right mindset is more important for successful rehab than everything else. Here’s why.

You can have the very best knowledge and training programs at your fingertips, but if you don’t believe that you can do it and that it can work for you it’s all for nothing.

It’s a bit like finding a bundle of hundred dollar bills on the ground and not even trying to pick them up, because maybe it’s a prank or maybe they’re fake or maybe the wind will carry them away when you try to pick it up. The wrong mindset will prevent you from even trying.

So let’s start building the right mindset with the following 5 reasons why you don’t need to give up your sport. [Read more…]

Patellar Tendonitis Research: Good News and Bad News

The Queen in her carEarlier this year in London, I saw the Queen, Prince Charles, and Dr. Peter Malliaras.

Only one of them came prepared with new insights about tendonitis.

Dr. Malliaras, PhD, is one of the world’s leading tendinopathy clinicians and if you get the chance to take one of his courses, I highly recommend you do so.

The two biggest aha-moments I had in his seminar fit the old “good news, bad news”-cliché.

Let’s start with the bad news.

Here’s the Bad News

As part of his work, Dr. Malliaras regularly performs ultrasound imaging. For him, it’s an important tool to reassure patients by saying “look, you’ve got 80% normal tendon” and to aid in differential diagnosis.

Clinicians can see tendon pathology on ultrasound, but much like a shoulder with a torn rotator cuff can be pain-free, a pathological tendon is not necessarily painful. This confirms my patellar tendonitis treatment advice: “Just because you’re pain-free, doesn’t mean your tendon is healthy”, but here’s the bad news.

Once a tendon has become pathological (i.e., the collagen alignment inside the tendon has degraded and other negative changes occurred), the pathological changes will not go away again.

You read that right.

Once a tendon has become degenerated, it will stay degenerated, as shown by ultrasounds of recovered tendinopathy patients. These folks are pain-free and able to enjoy their sports without a problem, but the inside of the tendon has not returned to the pre-injury state.

Here are my key takeaways from this.

1) Ignoring the pain is officially the worst way to deal with tendonitis, because of the high risk of doing irreversible damage to the tendon.

2) To prevent pain from coming back once you’ve recovered, keep doing strengthening exercises for your tendon. That brings us to the good news.

You CAN Get Rid of Pain (In Many Different Ways)

The most popular exercise for patellar tendonitis is eccentric squats on a slanted board. It’s been around for decades and looks like this.

eccentric squats on a slanted board for patellar tendonitis

A newer treatment approach relies on heavy slow resistance training (HSR), which you can do on the leg press machine, the leg extension machine, the smith machine, hack squats, and even with barbell back squats.

HSR exercises for patellar tendonitis, pictures B through D - Source: Koonsgard 2009

HSR exercises, pictures B through D – Source: Koonsgard 2009

Of course your next question is, “which one is better?”

It depends.

If you look at the landmark study by Koonsgard from 2009, you’ll find that while HSR has a slightly better outcome in terms of pain scores at the 6-month follow-up compared to eccentric training, the difference is not statistically significant.

In this study, some people did better on HSR exercises and others on eccentric training.

The key insights in terms of outcome difference were that both, eccentric training and HSR, are superior to corticosteroid injections over the long-term, and that patient satisfaction was higher in the HSR group, because of the lower training frequency.

At the seminar, Dr. Malliaras said, “It doesn’t matter what exercise you do, people will get better.” That is, as long as you’re using an exercise that can be progressed and are not progressing too fast.

Here’s my take on the advantages of heavy slow resistance training compared to eccentric squats.

Pros and Cons of HSR for Tendonitis

+ Lower training frequency (in the first months only – I advise against daily training with eccentrics as soon as you do single-leg variations)

+ Potentially better than eccentrics if exercise irritates your tendon easily (HSR allows for adding resistance in small increments, so you’re progressing more gently)

+ Allows for isolating the quadriceps muscle group (in the squat, quad weakness may be masked by more engagement of other muscles)

– Requires gym membership (and you will need to drive there)

– Requires technique instruction (for smith machine squat, back squat, and leg press) to reduce risk of back injury

If you already have a gym membership and are experienced with the required exercises, HSR is a good option. If you’d rather train at home, eccentric exercises are the more attractive option.

Regardless of which exercise you pick, be sure to move slowly and without momentum. You need to avoid flare-ups.

How to Make Your Knees Strong Again

The research is clear on one thing. Your knees won’t get better with resting. You need progressive loading.

Let me show you a simple way to get rid of pain and make your knees strong again.

Click here to get free instant access.

Patellar Tendonitis & Jumper’s Knee:
How to Get Rid of It

Patellar Tendonitis & Jumper's Knee: How to Get Rid of ItLearn how to get rid of your Patellar Tendonitis in this ultimate guide to curing Jumper’s Knee.

My name is Martin Koban and I suffered from patellar tendonitis (aka “jumper’s knee”) myself. I know how frustrating it can be and since you’re reading this, I don’t have to tell you about it.

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