How to Fix Jumper’s Knee
Which Exercises Help for Pateller Tendinopathy?
What is Jumper’s Knee?
Patellar tendinopathy or “Jumper’s Knee” is a common overuse injury with degeneration of the patellar tendon’s mechanical properties, often resulting in anterior knee pain with loading activities such as jumping and going down the stairs.
Jumper’s Knee usually occurs in younger athletes, 15-30 years old, usually men, who play sports that involve repetitive loading of the patellar tendon, such as basketball, volleyball, athletic jump events, tennis, and football.
Patellar tendinitis is an acute inflammatory condition of the patellar tendon but this term is less appropriate since the primary pathologic process of most painful tendons is tendon degeneration rather than inflammation.
Clinical Presentation of Jumper’s Knee
Pain is typically localized to the inferior pole of the patella. The pain is load-dependent and increases with higher demand on the knee extensors (quadriceps), especially in activities that store and release energy in the patellar tendon, such as jumping, landing, squatting, and descending stairs.
Pain typically occurs immediately upon loading the tendon and stops almost immediately once the load is removed. There is usually no pain at rest. Pain may improve with repetitive loading (the “warm-up” phenomenon), but pain is often increased the next day following energy storage activities.
Risk Factors for Jumper’s Knee
Greater number of weekly training sessions
Greater total training volume and greater match exposure
Concrete court surfaces
Sport specialization (single-sport athletes)
Decreased quadriceps and hamstring flexibility
Leg-length inequality
Improper patellar tracking and patellar position (patella alta or elevated knee cap)
Stiff landing pattern (limited knee motion and short landing time)
Knee dominant landing pattern (less hip motion and greater knee flexion)
Decreased quadriceps strength
Greater vertical jump performance
What to do if you have Jumper’s Knee
First, decrease the volume and intensity of high-load, energy-storage activities such as jumping, hopping, and cutting. This will temporarily offload the tendon and decrease pain.
Then, start a progressive loading program using a pain monitoring model to carefully rebuild loading tolerance without overloading the tendon.
Pain is allowed during and after exercise, but should resolve quickly after exercise and should not progressively worsen over the course of the loading program, as monitored by the 24-hour response.
The 24-hour response is measured daily at the same time, using a pain-provocation or load test, such as a 1 repetition single-leg decline squat test at the same depth.
If the pain score on the load test returned to baseline within 24 hours following the activity, the load has been tolerated. If the pain worsened, load tolerance has been exceeded and the activity should be regressed to a previous level.
A pain score of 3/10 or less on the Numeric Pain Rating Scale (NPRS) is defined here as acceptable and “minimal” pain but more emphasis should be placed on the 24-hour response. Other researchers have suggested a higher acceptable pain rating up to a 5/10 on the NPRS.
Stage 1: Isometric loading
Indication to Initiate:
More than minimal pain during isotonic exercise;
4/10 or more on the NPRS
Dosage:
5 repetitions of 45 seconds, 2 to 3 times per day;
Progress to 70% maximal voluntary contraction as pain allows
Stage 2: Isotonic loading
Indication to Initiate:
Minimal pain during isotonic exercise;
3/10 or less on the NPRS
Dosage:
3 to 4 sets at a load of 15 repetition maximum (RM);
Progress to a load of 6RM, every second day;
Fatiguing load
Stage 3: Energy-storage loading
Indication to Initiate:
A) Adequate strength and consistent with other side;
4 sets of 8 repetitions of single-leg press with around 150% body weight for most jumping athletes
B) Load tolerance with initial-level energy storage exercise;
Minimal pain (3/10 or less on the NPRS) during exercise and pain on load tests returning to baseline within 24 hours
Dosage:
Progressively increase volume and then intensity of relevant energy-storage exercise to replicate demands of sport
Stage 4: Return to sport
Indication to Initiate:
Load tolerance to energy-storage exercise progression that replicates demands of training
Dosage:
Progressively add training drills, then competition, when tolerant to full training
Energy Storing and Releasing
Once the jumping athlete is able to tolerate isometric and isotonic exercises with little to no pain, we need to work on plyometric loading. Tendons transfer force from the muscle to the bone. They also are responsive in absorbing forces, storing forces, and then producing force. In other words, your patellar tendon needs to be springy!
HOW we do this, in sequential order, is critical. Too much too soon, and you risk irritating the patellar tendon. Too little load, and you don’t produce enough adaptation to the tendon.
Modifying Jumping & Landing Mechanics
We coach our athletes with Jumper’s Knee on HOW to land first. Knowing how to absorb impact is critical before learning how to produce force.
We often find that athletes with Jumper’s Knee are having knee pain upon landing because they overload the knee joint and underload the hip joint upon landing. We cue our athletes to push their hips back on landing so that their hips can absorb more of the impact. A cue we use is to think about sitting back and down on landing. See example of ideal landing mechanics versus suboptimal landing mechanics.
Kinetic Chain Influences on Patellar Tendon Forces
Dynamic knee valgus: this is when the knee falls in towards midline when running, cutting, jumping, etc. Knee valgus is a normal part of athletic performance and movement. However, for our athletes with knee pain of patellar tendon origin, we want to avoid unnecessary / excessive knee valgus positions when jumping and landing. This is because excessive, uncontrolled motion in multiple planes can place torque on the patellar tendon. See images below of excessive knee valgus upon landing.
Restricted ankle dorsiflexion: this motion happens when your knee comes over your toes. It is common to see those with Jumper’s Knee have limited ankle dorsiflexion. How does restriction in this motion contribute to patellar tendon pain? A lack of this motion results in excessive knee valgus up the kinetic chain, therefore overloading the patellar tendon. Think of it this way: when you lack mobility in one area, you NEED to make it up someplace else.
Exercise Progression to Load the Patellar Tendon
How do we like to progressively overload the patellar tendon when returning our athlete’s back to their sport? Well, every athlete is different- we aren’t doing the same jumping protocol with a basketball player as we are with a triple jumper. However, we have a list below of jumping drills that we introduce (in order) into our programs. We always start with stationary double-legged variations, progressing to double-legged variations that include dynamic movement in different planes (typically forward first, then side to side afterwards). Then we progress to static single-legged variations, followed by dynamic single-legged variations, as can be seen below.
Please remember to follow the pain monitoring model discussed above. Pain at a 3-4/10 that lasts < 24 hours is ideal to give you the green light to progress. Remember that there are many variables that can be progressed, including the number of jumps per set, the number of sets of jumps for each jump variation, single jumps versus continuous jumping, the frequency of exposure to jump training. The intricacies are much too nuanced to discuss here.
If you are a jumping athlete with patellar tendon pain, please contact us below to speak with a physical therapist.
Disclaimer: This is not intended to be formal medical advice. Your individual needs should be met by the appropriate health care practitioners. Please consult with a trusted provider.
Dr. Vincent Liu, PT, DPT
Dr. Paul Nasri, PT, DPT, OCS, COMT
Doctor of Physical Therapy
The Game Plan Physical Therapy