Many runners will be all too familiar with the knee pain located just below the patella (knee cap), often referred to as jumper’s knee or patellar tendinitis. In this post I’ll be discussing why you may have developed jumper’s knee from running, and what patellar tendinitis exercises we as physios often give as part of the knee rehab process.
Patellar Tendinitis or Tendinopathy?
If we’re being accurate, we should really define this common injury as a tendinopathy rather than a tendinitis. The suffix ‘itis’ implies that there is more of an inflammatory nature to the injury, which is normally only true of acute cases of this running knee injury.
That said, in the interest of using terms most of us runners are familiar with, I’m going to stick with patellar tendinitis for the remainder of this article.
What is Patellar Tendinitis?
As the name suggests, patellar tendintis is a condition that manifests in the patellar tendon. That’s the short, thick tendon at the bottom of your kneecap. It often becomes a source of pain in sports that place a great deal of dynamic load through the tendon; sports like running, volleyball and basketball. Hence the colloquial name jumper’s knee!
Treatment for Patellar Tendinitis
When putting together a patellar tendinitis treatment plan and jumper’s knee exercises, it’s important that the plan should always revolve around the patient and the specifics of their injury. No two treatment plans will be exactly the same. However, there are of course a number of common factors present, with tried and tested jumper’s knee exercises being the staple of the programme.
Important: When it comes to any pain in the body, it’s important to understand pain in the first place. Our current understanding of this incredibly complex human experience is that if the brain has credible evidence that there is danger — or potential danger — to your body tissues or to your body tissues or to you as a person, then it can protect you via pain.
The goal of successfully treating patellar tendinitis, or any other condition, is to understand and resolve the dangers your brain is perceiving.
In my opinion, one of the main issues for runners with patellar tendinitis is loading — asking your patella tendon to do too much work for its current capabilities and not giving it enough rest to recover and get stronger. The brain senses this and decides to protect you via pain. That pain encourages you to stop loading it.
The first, and arguably most crucial part of patellar tendinitis treatment involves listening to the body and giving it what it wants:
Initial Reduction of Patellar Tendon Loading
The first thing I usually want to do is take some load off the patellar tendon to allow the pain levels to reduce. This is done by working out what activities are causing pain (running, squats, etc.) and adjusting the activity, or activities, to decrease the amount of load that the tendon is experiencing.
Common exercises and positions that load the patellar tendon include: squats, lunges, jumping/plyometric exercises, downhill walking/running, sitting with legs bent for a long time, going up and down stairs, wearing high heels or running in shoes with a big heel-to-toe drop (heel-to-toe differential).
Fixes for Common Causes of Patellar Tendon Pain
If squats hurt: Decrease the load. You can achieve this by decreasing the weight you squat, decrease the range of movement you use, decrease the number of repetitions you do, increase the rest intervals in-between sets, change your technique by getting your bum back more and loading more through the hips than the knees.
Do you find it hurts more running in shoes with a bigger ‘drop’: If so, you may find that switching to a more minimal running shoe, or even barefoot, is enough to offload the knee and switch the load more to the foot and ankle.
If running, in general, is irritating your patellar tendon:.
Try these running re-education cues. They all generally shift load away from the knee.
- Increase cadence. Increase how many steps you take in a minute. Aim for 5%-10% increase and assess how it feels
- Improve posture. Work on running up tall. This will prevent the foot landing excessively in front of you (over striding) as you try to catch a forward positioned centre of mass.
- Increase heel lift. Something like the piston cue will help to get an increase in heel lift at toe off leading to a more circular movement of the foot, better knee drive and making it easier to land under your centre of mass.
If you would like to learn more about running technique and coaching cues James and I recently put out a free running technique webinar on exactly this subject.
If you’ve tried the steps above and the tendon is still very painful, then I would suggest a short break from the painful activity altogether.
Patellar Tendinitis Exercises
As jumper’s knee exercises go, a great tool for pain relief during this early stage of jumper’s knee rehab is isometric strengthening. This is where we put high load through the tendon but use a static hold.
To set this exercise up I would use a single leg press, as you can control the weight easily on this machine. Aim for 30-45 second holds at mid-range knee flexion. The weight should be somewhere around 70% of your one rep max. I recommend 4-6 sets, two per day.
With these jumper’s knee exercises I always tell my clients that pain levels between 0 and 4 out of 10 that settle within 24 hours are acceptable. Any more than this then you need to make the exercise easier by dropping the weight.
Once the pain is under control (doesn’t have to be completely gone but certainly well controlled) it’s time to hit the heavy-slow programme and inject some power into this tendon.
Increase the loading capacity of the tendon
This is where we take advantage of the law of adaptation. Put enough stress through the patellar tendon to elicit an adaptation without flaring up pain, allow it to rest, recover, adapt (get stronger and then load it again), and repeat. Very simple progressive training.
Exactly which patellar tendinitis exercises I choose will be dependent on the client in front of me, I will always take into account their preference and how irritable their knee is. I generally use a combination of heavy slow-loading and power exercises.
With all the jumper’s knee exercises, I tattoo in the mind (not literally) the phrase:
“Pain levels between zero and four out of 10 that settle within 24 hours are acceptable”
If we are inside these parameters we are OK to continue. If we are outside the parameters, we never stop but we adjust by dropping weight or reps.
A typical 12 week heavy slow-loading programme will look like this:
I may pick 1-2 jumper’s knee exercises to do this with, say a single leg press and a weighted squat. The load should be as high as you can without pushing pain over a four out of 10.
Return to Running after Patellar Tendinitis
As running is a plyometric activity that takes advantage of the stretch-shorten cycle, we need to restore the tendon’s ability to cope.
This is why I add power or plyometric exercises into the programme. I tend to start these power exercises approximately four weeks into the loading programme and always monitor symptoms closely.
Any symptoms outside of the “four out of 10 and settles within 24 hours” parameter calls for an adjustment in load.
For power exercises, I usually start with skipping and/or a walk-run programme and may progress, if needed, to jump squats and downhill jump squats.
Here’s a link to the walk-run programme that I use with the British Military. It is simple, graded and effective.
What Else Contributes to Pain?
Now the third and final part of the patellar tendinitis treatment puzzle is one of the most important. Remember I said that pain can manifest in your body when the brain perceives a threat to your bodily tissues or to your safety?
This phase is about decreasing any other aspects that may be causing the brain to perceive threat.
What Else Are You Dealing With?
It may surprise you that even a threat to your job or your finances can influence how your brain perceives pain. It could be a threat to your relationships or your hobbies. The threat could be that you think you have something serious wrong with you, like a broken bone, or you could be worried about what this injury means for the future.
Perhaps you’re worried that you’re not going to line up in the race you trained for all year, and it’s causing all kinds of stress and anxiety.
Maybe you have post-traumatic stress disorder like many of the soldiers I treat today and the background stress and reliving of the trauma is constantly keeping your threat levels high.
All of these things cause stress, worry, frustration and anger and are perceived by the brain as threatening. If the brain perceives danger in any way, it will move to protect you. That may be by increasing or prolonging your pain or flooding your body with hormones that fire your fight-or-flight system. These changes alter your physiology and none of these things are conducive to healing or to decreasing pain levels associated with jumper’s knee. The challenge for us as clinicians is to work-out if any of this is going on and, if it is, address it.
Some of these threats are easily dealt with by simple communication whereas others, like PTSD, may need to be referred out to another professional such as a trauma specialist psychotherapist.
Here’s a short video which does a great job of discussing many of the various factors involved in how and why we all feel pain differently.
Example Case of Jumper’s Knee from Running
A simple example of how to decrease threat levels would be a runner who has just started running hills and noticed he now has a painful knee.
His examination has revealed jumper’s knee. He is really worried is going to miss the marathon and is scared stiff this pain is an early indication of arthritis.
In this case, I would deal with the loading issues as above, but would make sure I spent plenty of time with this patient explaining his condition to him, re-assuring him that his condition is not arthritis and he has nothing to fear or worry about in the future. If the patient believes me (which is the key point) this will reassure him and start to switch-off his alarms and stress systems, decreasing the perceived threat in his brain and therefore the protective pain response associated with it.
Many skilled communicators will do this naturally without realising the positive effects they have on pain.
I hope you now have better a grasp on how to manage cases of jumper’s knee from running and look forward to answering any questions in the comments below.