Let me guess, a few weeks ago you started to feel knee pain during your gym session, playing your favourite sport or after a family hike. You ignored it and continued with your training routine, work and family life but pain has become a little sucker and is now affecting your daily activities.
But what’s the pattern?
Now you can feel more often that pain, and it is worse after 30-40 minutes of physical activity, right? You arrive home, and while you rest the pain settles a bit until next morning when you wake up with stiffness and discomfort. After a few minutes of movement the discomfort starts to ease, but as soon as you begin training … here we go… the cycle starts again!
If the pain is mainly localised at the end of the knee cap where the tendon starts, you might have developed a “nice” patellar tendinopathy. But why do I say nice? Well… because from any injury you can learn more about your anatomy, resilience, patience and ultimately how to train better than you were doing before. Keep reading and I will show you how to improve it!
A little bit of anatomy
The quads involve 4 muscles, the 3 vastus; medialis, lateralis and medialis, and the rectus femoris. These fellas will blend into the quadriceps tendon which attaches the patella that inserts on the tibial tuberosity through the patellar tendon. The quads will be working together when performing knee extension movements such as squatting, football, running or stairs climbing.
Why does this pain happen?
Compressive forces and tensile loading are normal on your daily basis but patellar tendinopathy normally occurs or is thought to happen when the intensity, frequency and volume of your training program or work demands have changed recently and the tendon has exceeded its capacity to recover and adapt correctly. Usually, it tends to happen when you did too much and too soon although will depend on people backgrounds (fit vs sedentary).
The exact mechanism of injury has not been fully understood by researchers yet, but they have found cellular and degenerative changes on the collagen fibres. To make it more digestible for you, your tendon will experience some changes and the healthy tissue will compensate for the weaker areas. Some images on ultrasound scans will show abnormalities on the tendon structure but these are quite normal, and as some authors mentioned we should treat “the donut and not the hole”.
What can we do about it?
Most people will have some kind of rest, they will feel alright for days or weeks and then they will return to the activity and BOOM … pain again!
Should you rest it more? Should you take painkillers, anti-inflammatories? Is it really inflamed?
Well … firstly get help from a physio, a good professional will do a thorough assessment, including your medical history, other clinical signs, and a good biomechanical assessment looking for muscular disbalances or joint mobility/restrictions.
Secondly, a period of rest from that activity-sport which produces pain should follow, and then the rehab should include a gradual exposure to progressive loading and optimise the other variants such as volume, frequency and intensity.
While there are different protocols out there, the rehab always should be adapted to the patient and NOT the patient adapt to the treatment, it MUST BE personalised. It is not the same a rehab protocol for someone with a sports background than a sedentary individual, and neither all the tendons (patellar, Achilles, rotator cuff) are and act the same.
So what is the recipe for success?
Low-load impact exercises such as cycling, elliptic machine, weight machines and training the surrounding musculature would help to maintain a bearable load through your knee and to restore your kinetic chain, but what is the holy grail?
Evidence (although limited) has shown that isometric exercises can help to relieve pain nevertheless these are not better than isotonics. These isometric variations helped wonderfully with my clients to mitigate their acute pain. See below some examples:
Leg extensions: machine or leg against ball (30-60 degrees knee angle) 5 x 45 seconds holds at 70 % of you maximum muscle contraction. 
Wall squats or Spanish squats, 90 degree flexion, 5 x 45 seconds holds, 70% intensity. If you feel that you can perform for example a static lunge, got for it
Although some people gained benefit from these isometric modalities, eccentrics or heavy slow resistance training have been used as gold standard for many rehab and strength professionals. However, every individual has a different background and the program should be tailored to the individual requirements.
Pain levels and the tendon response, as well as loads should be monitored and logged while performing the rehab and adjusted appropriately to the individual.
These exercise options above are a good starting point for your recovery, try to perform them 2-3 times daily until your pain is manageable.
Remember this is just a baseline to start mobilising, I strongly recommend you to book an online or in-person appointment with me to get a thorough assessment and an appropriate personalised rehab plan, so for more information get in touch with me
