Painfree

Knee
Fix Your Patella Tendon
Pain & Get Back To Competitions
FAST
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The creators of the Pain-Free Knee Program do not guarantee that this
program will prevent, heal, or alleviate pain. Results may vary based on
individual circumstances and conditions. If you are experiencing severe or
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Introduction
to tendon
injury
 Part 1: Introduction
**Please Read The Whole Introduction**

De nitions
Your quadriceps consist of 4 di erent muscles which come together to form the
quadriceps tendon. This insets into the patella and then into the tibia via the patella
tendon.

According to research, Patella Tendinopathy is the term for patella tendon pain and loss
of function related to mechanical loading.

Tendinitis is an old term used to describe in ammation within the tendon which
was originally thought to be the primary driver of the condition, however we now
know that despite in ammation being present, it is likely a normal tendon adaptation to
tendon loading.

Tendinosis, which describes a degenerative process within the tendon is another

inaccurate term. Finally, “Jumper’s Knee” is also used interchangeably with Patella
Tendinopathy, however research has shown that not all pain in the patella tendon can be
classi ed as Patella Tendinopathy (1).

Patella Tendinopathy: is pain localised to the inferior pole of the patella accompanied by
a dose-dependent relationship with the magnitude and rate of loading of the tendon.
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 Assessing
Your Patella
Tendon
 Part 2: Assessing Your Patella Tendon

Diagnosing Patella Tendon Pain

It’s important to note that not all knee pain comes from your Patella tendon. Whilst this might sound
obvious, many people confuse Patella Tendon pain with Patellofemoral Pain or Osgood Schlatters.
This is sometimes why people try and rehabilitate their tendon doing generic exercises but don’t see
any results. It’s important to differentiate patellar tendon pain from other types of knee pain to ensure
your rehabilitation program is targeting the right thing.

Common Symptoms of Patella Tendinopathy

• Pain localised to the inferior pole of the patella bone (kneecap).
• Pain that is related to increased load on the quadriceps, especially in activities such as jumping
• Pain that does not spread with increased loading
• Pain has a gradual onset and presents after an increase in high tendon load activities (jumping,
cutting)
• Sitting pain (especially in the car)
• It has a warm-up effect (pain improves as activity goes on but can increase post training
• Pain the day after training

Patella Tendon Pain Location (Cook, 2021)

Assessment of Irritability
Irritability refers to the tendon’s response after activity. Studies have suggested that pain
provocation lasting less than 24 hours may be acceptable during rehabilitation. If your tendon is
highly irritable, your tendon pain will last more than 24 hours (generally).

Pain Provocation Test (PPT)

Reproduction of tendon pain localised to the inferior pole of the patella with tendon loading
manoeuvres and energy storage/release is an important nding used to con rm tendinopathy and
assess the degree of tendon irritability.

You should use PPT’s to assess your tendon’s current level of irritability where possible. You can
do this by using one of the following exercises:
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Double Leg Decline Squat. Single Leg Decline Squat. Double Leg Jumps

Whilst your tendon is irritable, we suggest using either the DLDS or SLDS to assess pain.

Monitoring Your Progress

There are a couple of main ways to monitor your progress. This includes using the VISA-P scale.
A score of less than 80 indicates tendinopathy, however it’s not great at measuring subtle
changes in tendon function. To measure short term changes you will use the:

24 Hour Response to Activity Test

To do this test you need to:
1. Complete a decline squat or any other activity that induces high tendon loads
2. 24 hours later record your level of pain on a scale of 1-10 (10 = excruciating)

Morning Pain & Sti ness Status

Tendons that are irritated from activities are often quite sore and sti the following morning. Take
note of your next-morning pain following a training

Monitoring Your Pain

During the rehab process for your tendon you can expect to experience some pain, otherwise you
wouldn’t be human! However, some pain does not mean LOTS of pain.

If you’re experiencing spikes in pain to the point of intolerability (using the tests above) then
you’re doing too much and you need to scale back your load.

Allowable Pain
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 As stated, it is okay to feel some pain during your tendon rehab. We suggest nding a tolerable
starting point and then scaling up from there.

For most people, this is about a 3-4/10 pain level on the numerical pain rating scale (NPRS). This
means during your rehabilitation exercises, it is okay to feel pain up to around a 3-4/10.

This is not a hard and fast rule. Whilst you might nd a 3/10 tolerable, others might nd a 5/10
tolerable and others only a 2/10. Whatever works for you.

Loads A ecting The Patella Tendon

There are plenty of different things affecting the load on the patella tendon. Two relevant ones
are:

Jumping
The highest loads take place on the patella tendon during the nal stages of exocentric knee
exion prior to take-off in jumping or changing direction.

Whilst there are minimal studies on how many jumps Basketball athletes take during a match,
Volleyball athletes jump up to 300 times per match (17). This is a substantial amount of load
for the patella tendon and explains such a high incidence in Volleyball athletes and likely
Basketball athletes too.

Biomechanical Loads
There are several studies linking poor dorsi exion range of motion with patellar tendinopathy.
Dorsi exion range of motion (toes pointed up) is important in shock absorption during
landing, therefore it’s likely that this reduced range of motion results in greater knee loading
during takeoff.
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 Patella Tendinopathy Management - Should You Play?
Managing your patella tendon means balancing your rehab exercises with training and
playing. If this balance is not adhered to properly, you risk accumulating more and more
loads, therefore increasing your symptoms and interrupting your training.
Pain monitoring before, during and after exercise as well as the next morning is essential
(see pain monitoring page). Below is a pathway you can use to determine what you should
be doing:

• Some soreness but warmed up

Training/Game • Pain with jumping and cutting

Wait 24 hours

Morning Check Wait 24 hours

(PPTest)

Tendon Stable.
No Continue Training/
Pain?
Game at same load
Yes
Yes Monitor pain

Intolerable >4/10 ? Tolerable <4/10 ?

Yes

No Game/Training today.
Yes Reduce Your Exercise
Did you train/play & Training Load
yesterday?

Wait 24 another Immediately

Hours

Begin Appropriate
Pain Improving Loading & Exercise
Time + Rehab
Rehab
Tendon
Rehab
 Part 3: Rehabilitation
The rehabilitation of Patella Tendinopathy can be long and arduous or shorter if you don’t
rush the process. Generally the tendon injuries that stick around are the one’s where players’
get frustrated with the rehab process, throw in the towel and decide they’ll “be ne”. They
then end up re-aggravating the injury and having to start all over again. Don’t be this
person.

The Load Continuum

When recovering from tendinopathy, best evidence
suggests a gradual loading program to develop leg
strength (which often begins to waste when an
athlete has tendinopathy) as well as induce appropriate
tendon loading.

In-Season Athletes
A common roadblock to an athletes return to their sport
Following tendinopathy is whether they are in-season or off-season. Obviously there is a huge
decision to be made as to whether the athlete should cease activity and start rehabilitation or
continue to train and play with modi ed loads. Tough one!

Technically if you’re in season and you have tendinopathy, you should be aiming to follow the
same progressive loading continuum consisting of; modifying load to reduce pain, graded
exposure and exercise rehabilitation program, pain and load monitoring with ow chart, slow
progression of training to keep pain under control.

Initial Load Modi cation Strategies

The rst line of defence in reducing your symptoms is to reduce your load. This can be done
by:

Reducing load type whereby you stop subjecting your tendon to energy-storage-release
movements such as running, jumping, springing, change of direction and cutting.

Reducing load volume whereby you reduce your training duration (I would initially halve the
duration so if it’s 1.5 hours reduce to 45 minutes).

Reducing load frequency whereby you train 2-3 days

apart to allow the tendon some time to recover. The
structure of the tendon changes in response to activities
such as jumping and cutting and these changes are still
present 24-78 hours after performing these athletic
movements. This is why loading on different days might be useful in the initial stages.
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Improving kinetic chain whereby we keep strengthening other parts of the body to ensure
when we DO return to sport they are still strong and resilient to injury. When hopping and
landing, load is spread from the ankle and up towards the hips and upper body, so it’s
important that the ankle, knee, hip and pelvis are able to cope with these demands.

Part 4: Staged Exercise Program

Isometric loading, strength, functional endurance, energy storage and release and return to training
are the 5 stages the jumping athlete should progress through in order to develop the necessary
qualities for a successful return to sport.

Each stage in the exercise rehabilitation program should have speci c benchmarks the athlete can
work towards to

1. Give them some tangible goals

2. Ensure they have developed the quality being trained in each stage to a suf cient standard that
will allow them to progress whilst keeping their symptoms in check.

Below is a summary of each stage in the rehabilitation process and the purpose of each stage:

Stage 1: Symptom Control

Aims:
• Reduce pain using a variety of strategies (most of which
have been described here)
• Modify loading appropriate to your tendon’s health
• Reduce pain on decline squats
• Reduce next morning pain
• Reduce 24 hour pain
• Reduce cortical inhibition of relevant knee structures

Modality:
• Isometric exercise

Stage 2: Strength & Functional Endurance

Aims:
•Improve maximal leg strength
•Balance keeping symptoms under control
•Improve functional kinematics and strength up and down
the chain

Modality:
•Resistance Training
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Stage 3: Energy Storage & Release
Aims:
• Enhance tendon loading rate
• Enhance tendon energy storage capacity
• Keep symptoms under control
• Enhance tendon energy release capacity

Modality:
• Resistance/Speed Training

Stage 4: Sport Speci c Loading

Aims:
•Enhance tendon loading rate to match that
experienced in trainings
•Enhance tendon energy storage and release
capacity to match that experienced in trainings
•Continue to build strength and endurance
•Keep symptoms under control

Modality:
•Resistance Training / Speed Training / Team
Training

Stage 5: Progressive Return to Training/Sport

Aims:
• Gradual return to training with symptoms under control
• Enhance tendon energy storage and release capacity to match that experienced in games
• Continue to build strength and endurance to prepare for matches
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Hey there.

Thank for making it all the way through!

I hope you found this document useful in understanding how you might go
about rehabbing your tendon. I would appreciate a message of support on my
instagram page @samuelrehab if you think it was worth your time!

I am currently in the process of constructing an advanced patella tendon

rehabilitation protocol to help athletes such as yourself to recover from this
condition. Click the link below and input some of your details and I’ll keep you
updated for when it drops.

Thanks

Sam
Some Key Papers I used to make this document. Thanks to all the author’s
and researchers for all their hard work in helping understand this debilitating
condition.

1. Kountouris A, Cook J. Rehabi- litation of Achilles and patellar tendinopathies.

In: Hunter Sa, editor. Regional Musculoskele- tal Problems. In press. London:
Elsevier; 2007.
2. Malliaras P, Cook J, Kent P. Reduced ankle dorsi exion range may increase the
risk of patellar tendon injury among volleyball players. Journal of Science and
Medicine in Sport. 2006;9(4):304-9.
3. Scott A, Squier K, Alfredson H, Bahr R, Cook JL, Coombes B, et al. Icon 2019:
international scienti c tendinopathy sympo- sium consensus: clinical
terminology. British Journal of Sports Medicine. 2020;54(5):260-2.
4. Cook JL, Khan KM, Kiss ZS, Gri ths L. Patellar tendinopathy in junior
basketball players: A controlled clinical and ultraso- nographic study of 268
patellar tendons in players aged 14-18 years. Scandinavian Journal of
Medicine & Science in Sports. 2000;10(4):216-20
5. Pearson SJ, Stadler S, Menz H, Morrissey D, Scott I, Munteanu S, et al.
Immediate and short-term e ects of short- and long-duration isometric
contractions in patellar tendino- pathy. Clinical Journal of Sport Medicine.
2020;30(4):335-40.
6. Docking S, Da y J, van Schie H, Cook J. Tendon structure changes after
maximal exercise in the Thoroughbred horse: Use of ultrasound tissue cha-
racterisation to detect in vivo tendon response. The Veterinary Journal.
2012;194(3):338-42.
7. Tallon C, Ma ulli N, Ewen SW. Ruptured Achilles tendons are signi cantly more
dege- nerated than tendinopathic tendons. Med Sci Sports Exerc.
2001;33(12):1983-90.
8. Malliaras, P., Cook, J., Purdam, C., & Rio, E. (2015). Patellar Tendinopathy:
Clinical Diagnosis, Load Management, and Advice for Challenging Case
Presentations. The Journal of Orthopaedic and Sports Physical Therapy,
45(11), 887-898.
9. Figueroa, D., Figueroa, F., & Calvo, R. (2016). Patellar Tendinopathy: Diagnosis
and Treatment. Journal of the American Academy of Orthopaedic Surgeons,
24, e184–e192.
10. Peña, J., Moreno-Doutres, D., Borràs, X., Altarriba, A., Baiget, E., Caparrós, A.,
& Buscà, B. (2017). Patellar Tendinopathy in Team Sports: Preventive
Exercises. Strength and Conditioning Journal, 39, 20–30.
11. Christian, R. A., Rossy, W. H., & Sherman, O. (2014). Patellar tendinopathy:
recent developments toward treatment. Bulletin of the NYU Hospital for Joint
Diseases, 72, 217-217.
12. Schwartz, A. R., Watson, J. N., & Hutchinson, M. (2015). Patellar Tendinopathy.
Sports Health, 7, 415-420.
13. Ruaro, B., Cutolo, M., Alessandri, E., Zaottini, F., Picasso, R., Pistoia, F., Ferrari,
G., & Martinoli, C. (2019). Don't forget the jumper's knee in the young
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 sportsman: evaluation of patellar tendinopathy with a high frequency
ultrasound probe. Reumatismo, 71(3), 160-162.
14. Morgan, S., Vuuren, E. C. V., & Coetzee, F. (2018). Patellar tendinopathy: a
rehabilitation intervention in elite rugby union players. South African Journal for
Research in Sport Physical Education and Recreation, 40, 129-142.
15. Muaidi, Q. (2020). Rehabilitation of patellar tendinopathy. Journal of
Musculoskeletal & Neuronal Interactions, 20, 535 - 540.
16. Zhang, Z. J., Ng, G., Lee, W.-C., & Fu, S. (2014). Changes in Morphological and
Elastic Properties of Patellar Tendon in Athletes with Unilateral Patellar
Tendinopathy and Their Relationships with Pain and Functional Disability. PLoS
ONE, 9.
17. Rosso, F., Bonasia, D., Cottino, U., Dettoni, F., Bruzzone, M., & Rossi, R.
(2015). Patellar tendon: From tendinopathy to rupture. Asia-Paci c Journal of
Sports Medicine, Arthroscopy, Rehabilitation and Technology, 2, 99-107.
18. Andriolo, L., Altamura, S. A., Reale, D., Candrian, C., Za agnini, S., & Filardo,
G. (2019). Nonsurgical Treatments of Patellar Tendinopathy: Multiple Injections
of Platelet-Rich Plasma Are a Suitable Option: A Systematic Review and Meta-
analysis. The American Journal of Sports Medicine, 47, 1001-1018.
19. Tscholl, P., Tscholl, P., Biedert, R., Wanivenhaus, F., & Fucentese, S. (2018).
Patellar tendinopathy with intratendinous alteration on MRI may be related to
patellofemoral dysplasia. Scandinavian Journal of Medicine & Science in
Sports, 28, 1443-1450.
20.Stasinopoulos, D. (2014). Patellar Tendinopathy May not Be the Proper Term for
Patients With Clinical Diagnosis of Patellar Tendon Disorder. Trauma Monthly,
19.
21.Morgan, S., Vuuren, E. C. V., & Coetzee, F. (2018). Patellar tendinopathy: an
international e-Delphi perspective. South African Journal for Research in Sport
Physical Education and Recreation, 40, 115-128.
22.Gaida, J., & Cook, J. (2011). Treatment Options for Patellar Tendinopathy:
Critical Review. Current Sports Medicine Reports, 10, 255-270.
23.Rosen, A. B., Wellsandt, E., Nicola, M., & Tao, M. (2021). Current Clinical
Concepts: Clinical Management of Patellar Tendinopathy. Journal of Athletic
Training.
24.Núñez-Martínez, P., & Hernández-Guillén, D. (2021). Management of Patellar
Tendinopathy Through Monitoring, Load Control, and Therapeutic Exercise: A
Systematic Review. Journal of Sport Rehabilitation.
25.Nuhmani, S., & Muaidi, Q. (2018). Patellar Tendinopathy: A Review of Literature.
Journal of Clinical and Diagnostic Research.]
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