How do I fix it? To load or not to load, that is the question!
Do you need to take a break and start from the beginning or can we jump you straight to phase 3? Or is it a mix of all the phases? Let’s start by looking at pain irritability.
When determining how irritable your pain is, there are three factors to consider:
- How long does it take for your pain to start (or how much load)?
- How severe is the onset of that pain?
- How long does the pain last after symptoms begin?
For example; if 3 bodyweight squats are enough to bring on your pain at a 7 out of 10 – this might be considered irritable and your load tolerance is low. If your pain only comes on at the end of a heavy snatch session or basketball – you probably aren’t that irritable and your load tolerance is higher.
Your rehab plan may come with an allowance (maybe even a requirement depending on the severity) for some discomfort during and after the exercises, requiring you to monitor your symptoms over the next 1-2 days to assess your tolerance to the load.
Phase 1: Isometrics and Mobility
If you’ve found yourself in a situation where any amount of jumping or squatting has you sensitive and sore immediately after training – this is probably the starting point for you. Alternatively, this might be a really useful set of tools that help to alleviate your pain prior to training.
Variations include adding weight or single leg.
Aim for 5 sets of 45 seconds – once you can achieve this with two legs unloaded, you know you’re ready to progress to some weight or single leg.
If you’re finding this hard, work up to it by doing fewer sets or duration. No matter how severe your tendon pain may get, most people can manage wall sits as a starting point. There’s a good chance that some exercise-induced analgesia will make you feel better and “warm up” your knees.
After determining there is inadequate mobility in the ankles, mobilising them prior to squatting might have some temporary benefit. Keep the band low on the ankle, almost on the upper part of the foot as you try to lean over your toes as far as possible while keeping your heels down. The band offers a distraction on the ankle joint and might be indicated if there is any pinching sensation at the front of the ankle. You can further this drill by adding a plate onto your knee to intensify the mobilisation.
Hang out here for about 2 minutes on each side before retesting your squat. If you feel an improvement – either in depth or in knee symptoms, make sure this becomes a part of your pre-squatting ritual to see results long term.
Meanwhile, if ankle mobility isn’t an issue but you still find it difficult to achieve a deep squat, the issue may be more with your stability. This is a really useful progression on the ankle stretch.
If you want to get more stable at the bottom of your squat, you need to spend more time there. Start with using a post to hold you up, and once you’ve mastered that, progress to a weight. If this is genuinely an issue for you and you have hopes of lifting big weights – then you need to be spending 5+ minutes here a day until it’s not.
Believe it or not, glute training isn’t just Instagram likes and followers. If you’ve got knee pain, training the glutes is an essential component of improved hip stability and hip extension to help offload the knee. Glute bridges (banded or single leg), monster walks and barbell hip thrusts are just a few suggestions that can get a great stimulus for the glutes to I usually recommend training these through the higher rep ranges for hypertrophy or endurance.
Posterior chain focused exercises might be a good way to give your knees a well-deserved rest while you continue strengthening. Romanian deadlifts, back extensions, and hamstring curls are just a few examples of how you can
continue progressing your strength without exacerbating your knee pain.
Phase 2: Strengthening
During this phase, we are trying to increase the capacity of the connective tissue. This is achieved by working in slow controlled movements with a higher volume and lower intensity. Leg extensions and single leg squats are great additions to the strengthening of the quads in isolation and in multi-joint exercises. This is to help improve and painful inhibition of the quads you might have and work on balance and stability of the leg as a whole.
Heavy Slow Resistance (HSR) is a great way to stimulate tendon healing while maintaining your training intensity. Some of the key points of HSR with patella tendon pain are:
- Volume: 3-4 sets of 10-15 reps
- Slow Tempo: 3 seconds down, 3 seconds up.
- Depth: Squat to a box height that’s relatively asymptomatic or does not worsen with increased load.
- Frequency: Performed 2-3x a week.
If you’re tolerating the load using these parameters, you may start to slowly increase the intensity and drop the volume (sets x reps) but maintain the tempo. Additionally, you may even increase the depth of the squat as you become more tolerant of the initial box height.
Phase 3: Jumping
Here’s the chance to practice new jumping and landing strategies we discussed earlier. Practice jumping to different heights, landing in different squat depths, landing with your knees forward, landing with your hips back, jumping forward, backward and side to side. Practice on one leg, practice on two. Develop strategies that reflect positions you might find yourself in a sporting situation – there’s no perfect position, just an underprepared one.
My intent here is not to suggest form is not important – if box jumps have been a mortal enemy for you, start with a low box, and keep the volume low until you develop your confidence in the jump using neutral alignment.
Like all the other exercises when newly introduced, check your dosage by monitoring your symptoms over the next 24 hours.
Phase 4: Return to sport
Your return to sport should be a gradual inclusion of the exercises at low intensity. Having no pain and completing 12 weeks of HSR and isometrics does not mean you’re ready for 5 days a week of CrossFit at full effort. Steadily increase the jumping demands at low intensity.
For example, a weightlifter may attempt some No-Feet Snatches or Cleans for a few weeks to limit aggressive “stomping” of your feet. It’s easy to get carried away when your pain has significantly improved but there’s nothing worse than coming so far only to have another setback because you were impatient.
Patella Tendinopathy can be a really slow and frustrating injury to rehabilitate. It’s one of the easiest conditions to lose track of progress and get frustrated with flare-ups. With long-lasting conditions like Patella Tendinopathy – it can be a really good idea to log your training, diet, and sleep (or any other factors that your recovery requires) to monitor your progress and flare-ups so you can make adjustments accordingly.
Written by Daniel Morrison