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Patellar Tendonitis and Running: Symptoms, Causes and Research-Backed Treatment Options

Patellar Tendonitis makes up 5% of all running injuries. In this article, we outline the symptoms, causes and research-backed treatment optionsThe patellar tendon is a short but very wide tendon that runs from your patella (kneecap) to the top of your tibia. The reason you have a kneecap in the first place is to generate a bigger mechanical advantage at the knee—this allows your quadriceps to create strong forces at the knee, which are important in any sport with running or jumping elements.

However, the result of this is that the patellar tendon has to absorb a lot of this loading, and as a result, it’s prone to injury in runners and jumpers; one study found that patella tendonitis accounts for just under 5% of all running injuries.1 Unlike many common running ailments, patellar tendonitis is somewhat more common in men than in women.

Patellar tendonitis usually begins with a stiff feeling in the patellar tendon, especially when running downhill or descending stairs. Like most tendon injuries, it may go away once you get warmed up, but as the injury worsens, it will remain painful for the duration of your workout.

It is also important to distinguish patellar tendonitis from patellofemoral pain syndrome: patellar tendonitis does not hurt along the top or the side of the kneecap, and isn’t usually sensitive to the touch.

Epidemiology – Causes of Patella Tendonitis, what makes it worse, what’s going on

Because the patellar tendon absorbs so much force, the long strands of connective tissue that make up the tendon can become injured. As with Achilles tendonitis, the true problem seems to be not so much the inflammation, but the damaged and degraded tendon structure that results from chronic stress on the patellar tendon. Unfortunately, this can result in patellar tendonitis becoming a chronic issue that persists for months.

  • Poor hamstring and quadriceps flexibility have both been connected with an increased risk for patellar tendonitis.
  • Moreover, poor explosive leg strength may be related as well.
  • Additionally, weak thigh muscles might be unable to adequately slow down your descent during impact, subjecting your knee to greater loads.

Conceptually, this makes sense, as tighter upper leg muscles would increase the tension on the knee, making it more difficult to flex and extend the joint.

Research backed treatment options for Patella Tendonitis

While the causes behind patellar tendonitis are not as well-understood as other injuries, there is fortunately very strong evidence for a treatment protocol.

The treatment of choice, a program of eccentric decline squats, was inspired by the success of eccentric heel drops in treating Achilles tendonitis.

Hypothesizing that eccentric activity encouraged the body to gradually replace and realign the damaged tendon fibers, researchers turned to a program of one-legged squats to eccentrically load the patellar tendon.4 However, they found that they were not as effective as expected, since the calf instinctively assists the knee when squatting, which takes some load off the front of the knee and the patellar tendon. To work around this, researchers devised the eccentric decline squat, 5 which is done on a downward-slanted surface to unload the calf.6 Interestingly, this may also be why running with patellar tendonitis hurts more on downhills!

In one small but very rigorous pilot study, Purdam et al. demonstrated that an eccentric decline squat protocol of three sets of 15 squats twice a day was vastly superior to an identical eccentric squat program done on a flat surface.

Like the eccentric heel drop protocol for Achilles tendonitis, subjects in the studies on

eccentric decline squats were encouraged to continue doing the exercises even with moderate pain (though stopping if the pain becomes extreme), and to add weight with dumbbells or weights in a backpack once they could do the basic 3×15 protocol pain-free.

eccentric decline squat pattellar tendonitits

Unfortunately, eccentric decline squats do require some specialized equipment; namely, a slanted board at about 25° (which corresponds to a rise of one foot per two feet of horizontal distance).

If you have a calf stretching board on hand, it will work perfectly. If you’re handy with tools, they aren’t too difficult to build. But even if you aren’t, you can usually make do by leaning a wooden plank against the bottom step on a staircase or up against a curb (as pictured above).

To do one eccentric decline squat, stand on the decline board with your foot pointing “downhill.” While balancing on your injured leg, squat downward slowly to about 60° of knee flexion. Then use your good leg to rise back up to the starting position. Do not use the injured leg to return to the top!

Again, moderate pain with this exercise is okay. Just stop if it becomes excruciating. Once you can do the exercise pain free, you should add weight with a loaded backpack, again continuing into moderate pain.

Other possible treatment options

  • In addition to the eccentric decline squat protocol, it makes a lot of sense to take steps to address potential tightness in your hamstrings and quads. Stretching them a few times a day is a very good idea, as is using a foam roller to loosen them up. You may find that a harder foam roller or even a 3” diameter plastic PVC pipe works better on your hamstrings, especially if you have muscular thighs.
  • Some very new pilot studies have suggested that platelet-rich plasma injections, a therapy which involves injecting a concentrated form of platelets found in your own blood, and extracorporeal shockwave therapy, a souped-up version of ultrasound, may be able to stimulate healing as well.8, 9 As the patellar tendon has poor blood supply, and hence a reduced capacity to repair itself, the idea behind platelet-rich plasma (or PRP) injections is that growth factors in the platelets accelerate healing.
  • Likewise, extracorporeal shockwave therapy (or ESWT) aims to selectively break down tissue to accelerate healing. While evidence to date suggests that these are a fairly safe and effective treatment for very stubborn cases of patellar tendonitis, there’s no data on long-term effects, and you’re unlikely to have it covered by insurance. Consider talking to your doctor about a PRP injection or ESWT if you’ve had little or no success with conservative treatment for several months.

Outline of treatment options

Conservative treatments

These are cheap, easy to perform treatments that you can do it home in your own time. You should try to do as many of these as possible each day.

1. Eccentric single leg decline squats—3 sets of 15 reps, twice per day. It’s okay if the decline squats hurt somewhat, but the pain shouldn’t be excruciating. Once you can do all three sets without pain, add weight using a weighted backpack. Return the starting position using your good leg. You’ll need to find, construct, or improvise a decline ramp to do these on, but it’s well worth it, as decline squats are much more effective than squats on flat ground.

2. Icing after each run.

3. Gently stretch your hamstrings and quads a few times a day.

4. Massage your hamstrings and quads with a foam roller, PVC pipe, or The Stick

Aggressive treatments

These treatments are a little more expensive or time consuming and are only suggested for if you suffer from chronic patellar tendonitis pain and the conservative treatments are not working for you.

1. Consider running in a lower-heeled shoe to transfer some stress from your knee to your foot, calf, and ankle. Exercise caution if you have had foot or calf injuries in the past.

2. Ask an orthopedist about platelet-rich plasma (PRP) injections or extracorporeal shockwave therapy (ESWT).

Return to Running

The standard program of eccentric decline squats calls for 12 weeks of eccentric decline squats before returning to sporting activity, but one encouraging study of volleyball players who trained and competed while doing the rehab program and still had good success rates indicates that you may be able to return to running as soon as your patellar tendon is ready to handle the loads associated with training10 (which will likely depend on the severity of your injury—a mild case may only require a couple days off, while a more severe case might call for a longer break from running). Work with your doctor or physical therapist to devise a good return-to-running program.

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References

1. Taunton, J.; Ryan, M.; Clement, D.; McKenzie, D.; Lloyd-Smith, D.; Zumbo, B., A retrospective case-control analysis of 2002 running injuries. British Journal of Sports Medicine 2002, 36, 95-101.
2. Witvrouw, E.; Lysens, R.; Bellemans, J.; Cambier, D.; Vanderstraeten, G., Intrinsic Risk Factors For the Development of Anterior Knee Pain in an Athletic Population: A Two-Year Prospective Study. The American Journal of Sports Medicine 2000, 28 (480-489).
3. van der Worp, H.; van Ark, M.; Roerink, S.; Pepping, G.; van der Akker-Scheek, I.; Zwerver, J., Risk factors for patellar tendinopathy: a systematic review of the literature. British Journal of Sports Medicine 2011, 45 (5), 446-452.
4. Cannell, L.; Taunton, J. E.; Clement, D.; Smith, C.; Kahn, K. M., A randomised clinical trial of the efficacy of drop squats or leg extension/leg curl exercises to treat clinically diagnosed jumper's knee in athletes: pilot study British Journal of Sports Medicine 2001, (35), 60-64.
5. Visnes, H.; Bahr, R., The evolution of eccentric training as treatment for patellar tendinopathy (jumper's knee): a critical review of exercise programmes. British Journal of Sports Medicine 2007, 41 (4), 217-223.
6. Kongsgaard, M.; Aagaard, P.; Roikjaer, S.; Olsen, D.; Jensen, M.; Langber, H.; Magnusson, S., Decline eccentric squats increases patellar tendon loading compared to standard eccentric squats. Clinical Biomechanics 2006, 7, 748-754.
7. Purdam, C. R., A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy. British Journal of Sports Medicine 2004, 38 (4), 395-397.
8. Kon, E.; Filardo, G.; Delcogliano, M.; Presti, M. L.; Russo, A.; Bondi, A.; Di Martino, A.; Cenacchi, A.; Fornasari, P. M.; Marcacci, M., Platelet-rich plasma: New clinical application. Injury 2009, 40 (6), 598-603.
9. Wang, C.-J.; Ko, J.-Y.; Chan, Y.-S.; Weng, L.-H.; Hsu, S.-L., Extracorporeal shockwave therapy for chronic patellar tendinopathy. American Journal of Sports Medicine 2007, 35 (6), 972-978.
10. Young, M. A., Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players. British Journal of Sports Medicine 2005, 39 (2), 102-105.

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32 Responses on “Patellar Tendonitis and Running: Symptoms, Causes and Research-Backed Treatment Options

  1. Nice run down! As someone who has suffered with this in the past, I have used all of these except PRP and I think they were helpful, however the thing that I felt was THE most beneficial was adopting a shorter, more midfoot stride. It would be nice to see the research on that, but I doubt any exists at this point. Great article!

  2. Hello there,
    I have just started to do these eccentric decline squats (1leg) however my issue is balance. I notice when I decline my knee/ leg gets out of alignment & tends to push inwards. To counter this I have been holding a chair for balance assistance only. I assume this is a lack of strength & will get easier? Can you comment on this as I know how important it is to keep your knees/ toes in alignment.
    Thanks!

  3. I am pretty sure this is what put me out of commission most of the winter. Is there any type of compression band that I should be wearing on the knee to reduce the chances of the tendonitis returning? Thanks and great article.

  4. Hey, I have tendonitis in both knees, so would I be able to do the eccentric decline squats since I have to balance on my strong leg, but both of my knees have tendonitis? Thanks.

  5. Hello,

    I was curious, if doing these while beginning to run again, should they be done at a time separate from the run (i.e., run in the morning, eccentric decline squats at night)? Or could they be done immediately before or after at a gym? Thanks.

    • Hi Neil, you could do them anytime really. We recommend twice a day, so it is likely to be sometime close to your run, but you should not need to go to a gym specifically to do them. Hope this helps!

  6. Will that discomfort in the patellar tendon eventually go away as you continue to do the eccentric decline squats every day?

  7. Hi,

    i am interested in how to strenghten the patellar quadriceps tendon. I want to use skipping technique when running downhill. It seems fast, and safe way to go down, but it gives an extreme load for that tendon, and gets painful. Can you reccommend some excercises for strenghtening that?
    Thank you!

  8. Hi, I have pattelar tendinosis for both knee, difficult even to go to office as it is hurt even for sitting more than 10 minutes, hurt while walking slowlymore than 20minutes. Many times I try to squat on the plain floor it is hurt. Will this exercise helps me?

    • Hi Yenni, to ease your pain, your best bet is to do the exercises and treatment options we have covered in this post. This will help your knees feel better, and get you back to feeling good!

  9. I have had PT for six years and have scaring on the tendon. I just started physical therapy, am doing the eccentric squats on a slant board. Additionally, the therapist is using a technique called ASTYM to get rid of the scar tissue. This is supposed to accelerate the healing process. Are you aware of this procedure?

    • Hi Dennis, sorry, we do not currently have any research on ASTYM, but we could look into it in the future. It would be best to just go for it, if it works, then that is great, and if it does not, then you have not lost anything in doing so. Best of luck with the healing process. Keep up the eccentric squats!

  10. Hi I had this same injury last year on only one leg and now I had it this year last year I was out till October to May and this time I have been injured since August and I still am injured I’ve been using those pattelar pattelar tendon Straps and knee supports should I bee using them and should I do the decline squats to help me heal. both of my kneeS have runners knee and I need some help to heal it up its going to be my senior year coming up and I was the best last year before I got injured I really wantEd to to go to states but I diddnt come true cause of this setback I need help and the doctorS gave me shoe supports called super feet

    • Hi Brent, thanks for reaching out. Sorry to hear about your problems with patellar tendonitis. Have you been doing the exercises we recommended in this post? That would be your best bet to heal it over the summer so you can go into your senior year healthy! Hope this helps!

  11. Hello Coach Tina: I have slight, minor soreness at base of my kneecap (not on the kneecap) since a 5K race a couple of days ago so I’m thinking I may have a touch of patellar tendonitis. But I did run 3 easy miles today with no pain, but to be careful I’ve been icing and taking Ibuprofen. In your opinion (and I understand if you can’t answer this definitively) would it be OK to run easy as long as there is no pain while running or much pain afterwards (which there is not as of now)? Or should I cross train instead for a couple of days and see how it feels (and if so is riding a stationary bike and/or an elliptical safe to allow any inflammation to go down?) Thank you for any info you can provide!

    • Hi Dave, thanks for reaching out. The knee is a very complex area of the body, with a lot of intersection going on around there. It would be almost impossible for us to diagnose exactly what is going on, and that is where a physician would come into play. You are right (and thank you for noting) that I cannot give you a definite answer, but yes, use pain as your guide. If it does not hurt during or after, you are probably okay o continue. If it does bother you, back off, and cross train, but only using exercises that do not irritate it, if anything does bother it, back off those too and just give it a few days of total rest. Take a listen to this podcast with Physical therapist Jeremy Stoker; he talks a lot about how to tell which pains to run through, and which to stop at http://runnersconnect.net/running-interviews/everything-need-to-know-injuries/

      Hope this helps!

      • Thanks very much Coach Tina, your info does help and I’ll be sure to listen to the relevant podcast you reference (and listen to my body & focus on the long term)! Just wondering: in your opinion & generally speaking, would it be wise to start doing the eccentric single leg decline squats at this time, even though the soreness at the base of the kneecap is pretty minor at this time, or could this make things worse? I just want to get out on top of whatever this is so as to not let it progress. I’m a masters runner, and one of the toughest things is knowing when to back off or just deal with and run through the inevitable and not infrequent niggles and aches. Thanks again.

        • Hi Dave, yes, I actually meant to answer that, but missed it somehow. It would be a good idea to start those eccentric squats. They will strengthen the muscles before it does get worse, and may even save you. I understand about being a masters, and you may enjoy some of the other podcasts too, as we have a lot of masters runners, and a lot of our recent posts have been focused on masters runners. Have you signed up for our newsletter? It is better to be safe than sorry, so you are doing the right thing!

  12. Hi Tina, Appreciate the info. I’ll give it a try and use pain as a or the guide. And yes, I receive your helpful newsletter. I’m data-driven and like how your articles are based on credible research distilled into layman’s terms.
    p.s. congrats on your 2:41:10 London Marathon!

  13. Oh, and I would be remiss if I didn’t ask you to thank John Davis for this excellent article and his other articles — all very helpful and much appreciated!

  14. Hi
    i really appreciate the info given here..
    it had many answers to my questions..
    how ever i just want to ask you that can i workout as i have patellar tendonitis for 10 days..
    I’ve been taking ultrasonic cold and heat treatments..
    is it ok to do uper torso workouts and core?? As i understand running is not an option for a long time..
    I do not want to increase healing period and also i cant sit home doing nothing..
    I’d really appreciate if you help me sort this out
    regrds

    • Hi Swapnil, the best advice we can give you is what we have recommended in this post for your patellar tendonitis. Core and upper body work will not affect your knee, so it should be fine. if you follow our guide, you can get back to running as soon as possible. By doing these exercises you will not be sitting doing nothing, and will be helping your knee heal!

  15. Hi,

    I have had patellar tendonitis now for 1 month in one leg. I wasn’t diagnosed with it till last week though, so I have just learnt about exercises that will help it. My question is, have I stunted my recovery by just now starting the exercises? Also, I can’t seem to do the exercises or walk for 10min without there being significant pain. Do I continue with exercise & walking despite of pain? Or lower the number of sets I do? I’m concerned as it says if you rest too much it’s not good for PT, but if you push yourself too much it’s also not good. Lastly, my good leg now is feeling very sore & tender, a bit like my bad PT leg, so I’m concerned I may have developed some sort of hamstring strain in it due to putting so much pressure on it due to bad leg. Any advice as to what this could be?

    Thank you and sorry for the long questions :-)

    Han :-)

    • Hi Han, it would depend if you have continued to run during this time. If you have been resting, your leg will have been healing, this will just help the recovery, and make sure you strengthen so it does not happen again. Unfortunately it is a delicate balance, and only you will know in your heart if the pain is more than what you should be experiencing. You are probably overcompensating with your other leg, but it may also be because the exercises are so new to your body. If you have not stopped running yet, it would be a good time to take a few days off and allow your body to catch up. Hope this helps! Good luck, and keep up the other suggestions we made in this post!

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