Tendon problems are caused by too much physical stress. The body is designed to adapt to physical stress, but recovery abilities have limits. When people perform a movement that features high tendon stress too often, breakdown of the tendon can exceed repair. Even if it is ever so slightly, this accumulates over time and eventually results in an unhealthy tendon. The term tendinitis is often used to describe this condition. The suffix "itis" means inflammation, so tendinitis simply means tendon inflammation. There is often not much visible swelling associated with what most people call tendinitis. Even if there is, it's important to understand that inflammation is not the actual problem. The problem is that physical stress has caused a lack of structural strength in the tendon. At a microscopic level, the tendon matrix is degraded to some degree. Inflammation is the body’s response to this problem. It’s a good and necessary thing. With that in mind, I prefer the term tendinosis. The suffix "-osis" just means "a condition. The problem we are facing in jumper’s knee is not inflammation but a tendon in an unhealthy condition. So what can we do about it?
To fix jumper’s knee we have to address the tendon structure. There are numerous methods such as icing, taking pain killers, foam rolling, and flossing that may numb the pain or desensitize the tendon. These may help you get through a workout or game, but they do nothing to actually make the tendon healthy again. What we need to do is develop strength in the tendon over time. This requires finding the right amount of stress that will stimulate positive adaptation rather than just break the tendon down further.
Key Point 1: Stop JumpingJumping puts high stress on the quad tendon. Doing it too much is usually what causes tendinosis in the first place. Now with the tendon in an unhealthy condition, it is not realistic to think the tendon can heal if jumping continues. Along with that, it is often necessary to stop athletic activity in general. Even running, stopping, and cutting can be too stressful to allow quad tendon healing, depending on how bad the tendinosis is.
Key Point 2: Use Progressive Rehab Exercises
To develop quad tendon strength we need to do quadriceps exercises. Ok, simple solution. Just do squats, lunges, leg press, leg extensions, etc, and that will make the muscles and tendon stronger, right? If the quad tendon is healthy to start, then yes, these high stress exercises should cause positive adaptation. But if it’s not, these exercises will likely make things worse. What we have to do is start with lower stress and progress to higher stress as the tendon adapts.The videos below show a progressive rehab plan. Use pain as your guide to progressing through the exercises. Here are some guidelines...
- If any exercise hurts, your tendon is not ready for it.
- We actually need to take that a step further. If any exercise hurts when you wake up in the morning, your tendon is not ready for it. It is entirely possible to have pretty bad jumper’s knee and still be able to warm up and jump or squat without pain. This does not mean those activities are ok to do. It happens because the body de-sensitizes dramatically when it warms up for exercise. Don’t be fooled into thinking how you feel when you warm up is an accurate indication of tendon health.
- Even if an exercise feels great, if it causes a negative response in the days following, your tendon is not ready for it. Any time you make a step up in stress level, use lower stress again for the next couple days to make sure your tendon responds well.
- Some of the exercises can cause de-sensitization that lasts into the next day. If you wake up feeling like you went from 50 to 100 percent from one rehab session, don’t fall into the trap of thinking you are fully healthy. Assume that your tendon did not miraculously heal overnight, and stick to the rehab plan.
I understand it is extremely difficult, but I encourage you to follow these cautious and patient recommendations in your rehab. See the following videos for exercises.
After being pain free in level 3 for a month, we can add 1-leg squats, a high stress quad exercise, to further strengthen the tendon. Any time you add high stress like this, make sure the tendon does not respond negatively in the days following. If it does, stay in level 3 for longer. This stage in the process is also when you may be able to return to running and multidirectional activity. I would encourage you to hold off longer before jumping again, but obviously no one will heed my advice on that.
Next is knee squats. These may or may not feature higher tendon stress than previous exercises, but the unique thing about them is they lengthen the rectus femoris muscle, unlike most quad exercises. Reminder... Level 3 exercises are still the foundation. Then we’re trying to add 1-leg squats and knee squats just once per week on separate days. And we’re still hopefully resisting jumping at this point.
Another exercise that many have found to be effective for jumper’s knee is reverse sled dragging. This is a relatively low tendon stress exercise, but it can be intensified with higher weight and greater effort. I chose not to make it part of the rehab progression, but it is a tool that can be used at any point in the process. Aim for 200+ total yards in a sled drag session.
If you are unable to stop jumping and sport play, the isometrics in level 2 and sled drags are probably your best bet to help you survive until a time when you can get a break. Both can be done daily.
Key Point 3: Get Strong
The end goal of this rehab progression is healthy tendons that allow you to jump again but also pursue a high strength level over time. Getting strong relative to body weight on squats, split squats, 1-leg squats, etc is the best way to leave jumper’s knee behind permanently. Along the way you should also develop stable mechanics during these knee-bending exercises, which is valuable for reducing the risk of lots of injuries. Here’s a video on squat mechanics.
Taking a break from jumping and following the rehab progression above should heal jumper’s knee for a lot of people. However there are some other details to address.
Key Point 4: Get Flexible
Flexibility is a huge, controversial topic in the exercise world. We will skip that endless discussion and just put forth the following statement: people who are tight and then improve flexibility generally move and feel better. That in itself may be helpful for jumper’s knee, but we can also get specific. Poor quadriceps flexibility increases the amount of stress on the quadriceps tendon during athletic activity.
Lengthening a muscle is done by stretching and strengthening. We have already covered quad strength. To lengthen the quad, we typically think of putting the knee in full flexion. People typically do not lack knee flexion range. However just flexing the knee neglects one of the quad muscles, the rectus femoris. Many people are not aware of this muscle, so it's commonly very tight. For some people, simply stretching the rectus femoris can cause improvement in quad tendon health. Watch the video.
Key Point 5: Get Strong Everywhere
When trying to strengthen the quad tendon it’s easy to only consider quad exercises relevant. But we want movement that is high quality on the large scale, not just strong quads. Also structures throughout the body are much more connected than the neat anatomy diagrams indicate. The picture below points out the IT band, but it also gives you an idea of how connected the quad tendon really is. With that in mind, we really need to try to address structure thoroughly and not just work the quads. Other structures that may be relevant to jumper’s knee include the hamstrings, IT band, longer adductors, and tibialis anterior. Hip hinges, nordic curls, side lunges, and dorsiflexion are exercises for these structures.
Key Point 6: Don’t Jump So Much
When you get fully healthy and able to jump again, don’t assume you are now invincible. Be smart. Limit your jump reps. Rough recommendation is no more than two jump sessions per week with a limit of 25 approach jumps in a session.
In Summary...This is what you need to do to heal jumper’s knee:
- Stop all jumping, all athletic activity, and anything else that hurts or causes pain the next day.
- Follow the rehab exercise progression above.
- Develop stable mechanics and a high strength level on knee-bending exercises (squat, split squat, etc).
- Get flexible in the rectus femoris muscle and all your muscles in general.
- Use a thorough set of exercises to develop strength in all structures of your body, not just the quad muscles and tendon.
- Use a reasonable amount of jumping.