The Eccentric Exercise Protocol for Chronic Patellar Tendinitis / Tendonitis

Will "Eccentric Exercise" Cure You?

2009-09-13T21:00:00.003-04:00

Will "eccentric exercise" cure your chronic patellar tendinitis?

-- Even using the ideal protocol for eccentric exercise, one may not be completely cured. However, there are many success stories where people who have had years of patellar tendinitis have outstanding success after a program of eccentric exercise. It is fast becoming the most accepted form of treatment for chronic patellar tendinitis.

-- These exercises put a lot of force on the patellar tendon, so they must be done very carefully over many months. If done improperly, they can lead to a worsening of symptoms. They should be used only for chronic cases, should not be used for inflammatory tendinitis, and should be done only under the recommendation of an appropriate physician.

-- Even if you are not completely cured, however, your pain might be reduced substantially and you may be much happier. Your pain may be reduced to such a low extent that it does not bother you much. And, there may be more times of the day when you have no pain, or much less pain. In my case, the exercises have helped me to reduce pain a substantial amount. Now, I rarely have pain. The times I do have some pain, it is substantially more tolerable -- and I am much, much happier.

-- The exercises may help you to have no pain or substantially less pain while you do certain activities, such as walking down stairs; driving a car; walking for long distances; bicycling, etc...

-- Even if you find you are not completely cured, eccentric exercise may still be a substantially better alternative than most other kinds of treatment, including surgery, other kinds of physical therapy, certain chiropractic techniques, extracorporeal shock wave therapy, prolotherapy, sclerosing treatments, etc...

-- In my opinion after reviewing the medical literature and trying a number of different kinds of treatments myself, I believe eccentric exercise is far better than other alternatives. The success rate is generally much better. Furthermore, other kinds of treatments, such as surgery, may lead to irreversible adverse effects.

Healthy & injured patellar tendons: microscopic images

2009-09-13T20:00:00.002-04:00

The microscopic images below show healthy and injured patellar tendons. (If the images don't show below, try clicking within the image boxes.)

Image #1 -- Normal patellar tendon: collagen fibers oriented in an organized linear fashion. (Collagen is the principal protein of tendons, ligaments, and bones and in the normal state has great tensile strength.)

Image #2 -- Injured patellar tendon: disrupted collagen fibers with wavy orientation, fragmentation, and interspersed blood vessels. There is no inflammation present.

It is not known how eccentric exercise heals patellar tendinosis or reduces knee pain. Theoretical mechanisms include the possible remodeling of tendon, strengthening of tendon, and the elimination of the small blood vessels that occur in tendons affected by tendinosis.

(Images and commentary courtesy of Gréta Pathology. Slides prepared with hematoxylin & eosin stain.)

Questions and Comments I've Received

2009-09-13T19:45:00.006-04:00

Additional questions and answers can be found in the "comment" section beneath postings on this and other pages of this website.

Q: You say on this website that you have shown improvement from doing your eccentric exercise protocol. What are your symptoms and level of pain now?

A: After 5 years, my pain has mostly disappeared. While I used to have constant, unbearable and terrible knee pain every day, now on some days I have minor knee "sensations," but no pain. The sensations feel like slight pressure on the tendon, but usually nothing significant. Also, the duration of these sensations accounts for a very small percentage of a day. Maybe a couple of days every few months, I will have knee pain, although the level of pain is typically very low. It is difficult to figure out the cause of the pain and it may be related to something I did in prior days, rather than that day. The biggest improvement in my pain is that it doesn't completely occupy my thoughts. I can concentrate on other things without being aware of constant pain. The eccentric exercises have also been very helpful to reduce or eliminate symptoms while doing symptom-provoking activities like walking down stairs, walking long distances, driving, and standing in one place. Furthermore, I typically have no (or little) pain bicycling. During and after a 102 mile bike ride today I had no pain. It took 3 years until I consistently had no or little pain bicycling.

Positively, each year my symptoms have improved over the prior year. The eccentric exercises helped accelerate this improvement. I continue to stretch on a daily basis. I no longer feel the need to do eccentric exercise on a daily basis, but continue do eccentric sets on every few weeks.

Q: I have improved my knees by doing eccentric exercise somewhat differently than you demonstrate on the video. I lower with one leg (the affected) and raise with both. In your video, you don't raise with both legs.

A: Your way is fine, too. You can do it either way. The key thing, however, is to take more time on the down squat, and come up relatively faster. It's on the down squat that you are doing the eccentric work. It doesn't matter if you come up with one or both legs. One benefit of your approach, however, is that you will be less tired and be able to do more reps or add more weights over time.

Q: What is the purpose of using a slant board?

A: The slant board reduces help from the calf muscles, thereby making the patellar tendon do more eccentric work.

Q: I would like to begin an eccentric exercise protocol. Would it be alright to begin a program of rowing (on an indoor rowing machine) at the same time? If not, what type of aerobic type exercise would be best while beginning an eccentric protocol?

A: Eccentric exercise protocols generally require you to do no exercise involving the knee for the first 2 months of the protocol. With my protocol I recommend waiting at least 3 months. After that, start with aerobic exercise that is easy on your knee. Ramp up slowly -- start with only 5 minutes the first day you resume exercise and build slowly from there, so long as there is no significant pain. I do not recommend rowing as the first exercise you do following an eccentric protocol. Exercises I might consider include:

-- Bicycling using very easy gears on flat terrain.
-- Swimming, particularly the front crawl stroke. Avoid the breaststroke.
-- Short-distance jogging on flat terrain.
-- Cross-country skiing (classic style) on generally flat terrain.

I would avoid sports that involve jumping, such as basketball and volleyball.

Q: My sports medicine doctor believes that I fall into a small, but definitely observed, portion of sufferers that are "super-sensitive" in that any little increase in activity will cause tendinopathy flare-ups. I tried only 4 eccentric squats on the decline board and got a flare-up right away!

A: Before giving up you can try 1) doing the eccentric squats without a decline board; 2) doing the eccentric squats with both legs at the same time; and 3) doing only a partial, rather than a fuller squat. These items will reduce force on the tendon. In addition, you can do the downwards motion more quickly. Instead of 2-3 seconds on the downward phase, take 1 second. You may want to start with only one squat per day and add an additional squat every 4 days if you feel fine. I also recommend doing the eccentric exercise at night before going to bed, so the tendon can rest overnight. Your doctor and/or physical therapist may have other suggestions.

Q: Medical journal articles on patellar tendinopathy refer to a diagnostic questionnaire called the Victorian Institute of Sport Assessment (VISA). What is it? Where can I find it?

A: The VISA (sometimes called VISA-P for patellar tendinopathy) is an 8-question form that asks questions about one's level of pain, duration of pain, etc... Sample questions are "For how many minutes can you sit pain-free?" and "Do you have pain walking downstairs with a normal gait cycle?" It quantifies one's answers. The maximum score for all 8 questions combined is 100. The lower the score the worse the overall symptoms and level of dysfunction. Some physicians and researchers use the questionnaire to assess a patient's progress over time.

An article that includes VISA questionnaires in English and Swedish can be found in: Frohm A, Saartok T, G Edman, et al. Psychometric properties of a Swedish translation of the VISA-P outcome score for patellar tendinopathy. BMC Musculoskeletal Disorders. 2004;5:49.

Links are: http://www.biomedcentral.com/content/supplementary/1471-2474-5-49-s1.doc

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15606923

Q: Can you develop tendinosis without having first developed tendinitis?

A: This is not clear. Some researchers believe that what most patients have is tendinosis, rather than tendinitis. Some believe there may be a period of only a few weeks right after the initial overuse injury when there may be inflammation -- the period of tendinitis. But, soon the inflammation goes away and you are left with tendinosis. In my case, I had symptoms suggestive of inflammation for a period of months after the initial injury -- I had a knee that was much warmer than normal along with some signs of minor swelling. Unless you actually do a biopsy of the tendon to see whether there is inflammation, you don't really know for sure if you have tendinitis or tendinosis. And, very rarely is a biopsy performed on the tendon shortly after an overuse injury.

Q: If you don't want to buy a slant board, you can build one out of plywood and super-gluing some 80 grit sandpaper to the board with a piece of 2X4 in between this wedge-shaped contraption for extra strength. This is what I have been making and it is at 25 degrees.

A: I'd consider this only if one has good carpentry and engineering skills. You will be putting a lot of force on the slant board while doing the exercises and won't want it to collapse on your bad knee. While a slant board may cost $60+, buying one will be preferable for most people.

Q: I have chronic tendinitis in my hands. Apart from patellar tendinopathy, are there eccentric exercises for other kinds of tendinopathy such as in the hand, elbow, shoulder, achilles, etc... ?

A: I know there are eccentric exercises for at least some of these conditions. Clearly, the exercises will be different than those used for patellar tendinopathy, but the science behind why eccentric exercise is beneficial will be the same. Given that much of the research on using ecentric exercise for tendinopathy has been done in very recent years, exercises and proper protocols may be in their early stages of development. It would not surprise me that many medical specialists and physical therapists would not be familiar with such exercises at this point in time , so one may need to check around for expertise in this area.

Q: Can eccentric exercises be used to treat other knee problems apart from patellar tendinosis?

A: For the knee, eccentric exercises are primarily indicated for patellar tendinosis. Unless this is your diagnosis from a medical professional, I would not recommend these exercises. It's possible there may be situations where such exercises may be of help for other knee conditions, but consult your doctor.

Q: When doing the eccentric squat, how deep are you squatting?

A: A "medium" to "almost full" squat. It's certainly not a completely full squat, i.e. as low as you can go. However, it approaches a full squat. Please see the video demonstration on this site.

Q: Are leg cramps associated with chronic patellar tendinitis? I developed cramps in my thigh and calf after a period of running and playing a lot of squash. I then developed patellar tendinitis which I have had for the past two years.

A: I do not recall ever reading about an association between leg cramps and patellar tendinitis. However, patellar tendinitis can co-exist and develop at the same time as other knee-related problems, such as patellofemoral pain syndrome, Iliotibial band syndrome, and in your case leg cramps. You should consult a medical physician about your situation.

Q: I have had tendinitis/tendinosis for about 18 months in my right knee. The knee is red hot while my other knee is normal temperature. Why is my injured knee red hot? Should I be put ice on it to cool it down?

A: For the first 1 to 2 years of my own patellar tendinopathy my bad knee was also much warmer than usual at times. After that, other knee symptoms continued, but the temperature differential went away. Doctors most likely would say you have symptoms consistent with chronic inflammation. (Whether or not you actually have inflammation cells present is not clear. Research suggests that there actually may not be be inflammation in longstanding tendinopathy.) Hopefully, you have seen a doctor, given your knee a generous period of rest, and are not continually re-injuring it. Applying ice for 5 to 10 minutes every few hours may help reduce your symptoms, although this is unlikely to make the underlying condition go away. Be careful because icing for too many minutes at a time can be harmful to the skin.

Q: I developed patellar tendinosis in both knees after a period of time playing soccer. In 2007 I underwent surgical debridement to remove degenerative tissue in both knees. I have found strengthening to be helpful, but I am concerned that the strain could cause new degeneration. Is there need to be worried?

A: Clearly, you need to be careful how you go about doing your exercise. "Overuse" likely got you into your problem to begin with. In addition, given your surgery, your knee tendons may have less capacity to withstand problems compared to before you developed tendinosis. I think the answer to your question is not "if" you can strengthen your knees, but how you go about it. You should speak with your doctor and a good physical therapist about a strengthening and stretching program. As for eccentric exercise programs, these are generally focused on people who have not had surgery. However, perhaps, your physical therapist can help design a protocol for you focused on very gradual increases in repetitions and weights.

Q: Can eccentric exercise promote "scar tissue," thereby making it more difficult to heal patellar tendinosis?

A: Based on my understanding of the medical literature, eccentric exercise when done correctly won't worsen the tendon tissue. Instead, some theories suggest the exercise may improve the tendon tissue. However, if you do the exercises improperly -- such as ramping up too quickly, doing too many repetitions, using too much weight -- you potentially could worsen your tendon tissue.

Q: My physician recently diagnosed me with patellar tendinopathy and recommended "nitrate patches." What are your thoughts?

A: I am not a medical doctor, but have some thoughts. I surveyed the medical literature on PubMed. There have been experiments in recent years involving topical glyceryl trinitrate and/or nitric oxide to treat several kinds of tendinopathy, including that of the Achilles, elbow, and shoulder. I saw no reports of experiments (yet) involving the patellar tendon. While there are some experiments with favorable conclusions for the use of patches infused with nitrogen compounds for other kinds of tendinopathy, the conclusions are not unanimous. For example, the conclusion of one article in the American Journal of Sports Medicine from June, 2008 states "This study failed to support the clinical benefit of GTN [glyceryl trinitrate] patches previously described in the literature." But, another article's conclusion (from the October 2007 Foot and Ankle International) states "topical glyceryl trinitrate treatment has demonstrated efficacy in treating chronic noninsertional Achilles tendinopathy, and the treatment benefits continue at 3 years." Given mixed reviews for uses on other kinds of tendinopathy and no data from experiments on patellar tendinopathy, it is unclear whether such treatment will help you. However, under your doctor's supervision, it may be worth trying.

Q: What were your knee symptoms?

A: Below describes the pain I had during the first 3 to 4 years since the problem began. Now, at the 4 1/2 year mark, I am happy to say I no longer have most of these symptoms. Today, I occasionally have low-grade "sensations" that don't rise to the level of pain.

Pain during the first 3 to 4 years:
-- Mostly horrible nagging achy tendon pain everyday. Also, gnawing, tearing, and pulling pain. All of these symptoms have either disappeared or become much minor versions what they had been.
-- Frequent unrelenting burning pain. This eventually went away completely. (I don't believe this neuropathic symptom is typical for most people with chronic tendinitis. But, others have reported having it, too. It may be related to temporary nerve damage that was created at the same time as the initial knee injury. As the underlying knee injury heals, so hopefully will the nerve injury. You may want to consult a neurologist if you have burning symptoms. They may prescribe drugs such as Neurontin (Gabapentin) or Lidoderm patches that may help somewhat.)
-- Occasional feelings of knee stiffness. This eventually went away.
-- Rarely, I had some "bone-on-bone" type sensations. This went away.
-- Very rarely, some "pins & needle" sensations. This went away.
-- On very rare occasions, the feeling the knee was unstable and could twist or buckle off. This went away.
-- On rare occasions, the tendon felt tender when touched. This went away.

Pain was most pronounced:
-- During and after walking. (Today, I sometimes still have some sensations after walking longer distances.)
-- While standing in one place.
-- With prolonged sitting.
-- When driving, especially when pressing the accelerator. (I had the tendinitis in my right knee.) Today, I still have some sensations when driving.

In addition, my pain generally increased as the day went on. So, during the mornings I had less or little pain. In the late afternoon, I had much more pain.

I sometimes had pain walking downstairs. Less so, walking upstairs.

I typically had less or no pain when laying down completely flat.

Some days the pain was worse than others with no clear reason why.

The pain itself was throughout the length of the tendon, not just at the insertion points.

Q: I was recently diagnosed NOT with patellar tendinopathy, but a tendinopathy of a different tendon in my leg. Might the exercises work for me?

A: The specific protocol described in this website is focused solely on patellar tendinopathy. I cannot endorse it for any other kind of tendinopathy. Roughly similar protocols to mine have been described in medical journals, but only for the treatment of patellar tendinopathy.

However, the larger concept of "eccentric exercise" has been shown to be helpful for other kinds of tendinopathy throughout the body. You would need a protocol suited to the specific kind of tendinopathy you have. For example, eccentric exercises for Achilles tendinopathy can be found at the following website: tendinopathy.http://www.ashbournephysio.co.uk/achilles.htm

If you find eccentric exercises suited to your kind of tendinopathy, please let us know and we will post it on this website for others to see.

Q: What do you think about 1) therapeutic ultrasound and 2) prolotherapy for chronic patellar tendinopathy?

A: As for ultrasound, I don't believe it is helpful based on medical journal articles I have read. It also did not benefit me, personally. As for prolotherapy, it may be helpful for some ailments, but there is little to no documented research on using it to treat chronic patellar tendinopathy. Again, I would stick with eccentric exercise.

Q: I do NOT have patellar tendinosis, but I am interested in doing these eccentric exercises as a way to build up strength. What do you think?

A: If you do not have patellar tendinosis and have no knee or other ailments, then instead of doing these exercises, I think you should find an excellent weightlifting coach and have them design and supervise a well-rounded strengthening program for you. If you don't have patellar tendinosis, but have some other knee ailment, then you should consult with a doctor and physical therapist to provide you exercises that are appropriate for your condition. The eccentric exercise described here is meant for those with longstanding patellar tendinitis.

Q: At what point did you begin doing eccentric exercise? Did you still have pain when you began?

A: I began doing eccentric exercise 2 years and 2 months after developing patellar tendinitis. I still had significant pain everyday when I decided to start the exercise program. However, during the several minutes each day when I performed the exercise, I did not have any increase in pain. I do not recommend doing the exercise if it increases one's pain.

Q: Will the pain of my chronic tendinopathy go away if I simply rest for a long enough time and not do the exercises?

A: Some period of rest is reasonable. However, complete rest for too many weeks may lead to muscle atrophy, which could worsen your problems. While complete rest may reduce your pain during the period of rest, once you resume your sport, walk for a prolonged period, or go down stairs, the pain will likely return.

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Click on "comments" just below for additional questions and answers. Also, many other questions and answers can be found on other pages of this website.

Prevention

2008-03-01T20:13:00.010-05:00

Unfortunately, people with patellar tendinopathy typically learn after the fact what they could have done differently to prevent getting tendinitis in the first place.

Though it sounds simplistic, the way to avoid getting the chronic form of tendinitis -- tendinosis -- is that you need to first avoid getting tendinitis.

Some tips to avoid patellar tendinitis:

-- Tendinitis is typically an overuse injury. Therefore, activity must be ramped up slowly when the sport involves repetitive motion. This applies both to a new sport or a sport you are re-starting after a seasonal break. So, if you are re-starting bicycling, for example, after taking a season off, start slowly. Over the first month or so, increase gradually the amount of time you spend cycling. Similarly, the level of resistance should be advanced over a period of time -- start with flat surfaces with easier gears. Many people develop problems when resuming an outdoor sport after a winter break. When the weather improves, they go out and overdo it.

-- Stretch on a daily basis. I also recommend occasional professional massage appointments.

-- If you feel pain around the knee after significant repetitive motion, then STOP. You may need to take several days or more off, and very gradually resume the sport. You may need to seek medical help as well.

-- Be mindful of minor symptoms around the knee when engaged in repetitive motion sports. Minor symptoms may be a warning sign that things can get much worse if you aren't careful. If minor symptoms persist for several days, you may need to completely stop what you were doing, try to figure out what went wrong and take significant time off. Do the symptoms suggest "overuse" in time or resistance? Did you recently start a sport or resume a sport after a season off? If the minor symptoms are in any way related to overuse, be especially careful.

-- Be particularly cautious if you already have developed another knee condition, such as Iliotibial Band Syndrome, which may increase the odds of developing other knee problems.

If you do develop tendinitis, the following are tips to help prevent it turning into tendinosis:

-- Seek medical attention to verify it is tendinitis and provide you with advice to reduce bothersome inflammation.

-- Avoid walking long distances. Avoid stairs. Avoid carrying heavy objects, which can increase strain on the knee. Avoid repetitive motion exercise that require you to bend and straighten the knee repetitively until your symptoms have substantially improved.

-- Avoid doing whatever led to the tendinitis. Be careful when resuming that activity once your symptoms have improved.

-- If you seek physical therapy, be particularly careful. Treatment should focus initially on light stretching. Avoid exercises that require you to flex and extend the leg. In the early phases, improper physical therapy can make things worse.

-- Do NOT do eccentric exercises. Eccentric exercise should be done ONLY after the tendinitis has become tendinosis, which may be many months later.

--Have fun when the warm weather returns but avoid overdoing exercise. Remember, you want to be able to be active for the long haul, it's not worth risking injury just because you finally can spend a day outside doing a favorite or a new sport.

Video Demonstration of Eccentric Exercise for Patellar Tendinosis

2008-01-05T08:30:00.012-05:00

Please double-click the forward arrow to play the video. The video shows 1 set of 15 repetitions. During a typical nightly session, one would do 3 sets of 15 reps, with a 5 to 20 second break between sets.

A YouTube video is also available at:

http://www.youtube.com/watch?v=eIQW8VnEABc

It's on the downward phase of the motion that eccentric exercise occurs. This phase should take 2-3 seconds. The upward phase should be relatively faster.

I received this note from a 26-year old Canadian who watched the YouTube video:

Wanted to thank you personally for this video. I've been having problems with weakness in my knees due to repetitive stress from martial arts for nearly 2 years. After doing this exercise for a week and a half I've noticed significant improvement and reduction in pain. You rule.

- Dave

The Importance of Diet

2008-01-03T04:00:00.000-05:00

With tendinopathy, you may need to cut back on sports and exercise (running, basketball, skiing, rowing, etc..) because such activities may lead to flare-ups in symptoms and pain.

Certainly in early stages -- when you have inflammatory tendinitis -- exercise involving the bad knee may be harmful. Later, if the tendinitis becomes tendinosis, exercise may be restricted due to ongoing pain. Further, exercising the bad knee is usually not recommended during the first two or three months of an eccentric protocol.

The bottom line is you will likely be doing less aerobic exercise if you have tendinitis or tendinosis. Therefore, diet becomes particularly important. Lighter weight means putting less force on the patellar tendon. Ideally, you should weigh yourself on a regular basis and take corrective action if you find your weight increasing from a lack of exercise.

About Me

2007-12-31T14:17:00.044-05:00

Sigfús Víkþörðson

I currently have three blogs, one devoted to "eccentric exercise" to treat chronic patellar tendinitis http://eccentric-exercises.blogspot.com/ ; another highlights my Iceland photos http://iceland-photos.blogspot.com/ ; and the third, http://zero-acne.blogspot.com may help you eliminate acne completely.

I created the "eccentric exercise" blog after I developed patellar tendinitis in mid-2004. The tendinitis resulted from doing a lot of bicycling over a period of two weeks. The inflammation went away after some time, but I continued to have pain that lasted for several years. After trying everything from acupuncture, physical therapy, chiropractors, pain drugs, lidoderm patches, ointments, etc... the only thing that significantly reduced my pain was "eccentric exercise." I learned about such exercise through reading medical journal articles. However, I had to develop a protocol that worked for me through trial-and-error.

By mid-2008, my knee was substantially better and it has since felt normal most of the time. I typically have no pain cycling or running. In fact, in 2009 and again in 2010 I completed "century" cycling events in which I rode 100 miles in one day and had no symptoms of patellar tendinitis! I continue to stretch on a daily basis and now practice yoga. Several of my daily stretching exercises can be found elsewhere on this website. (While I recommend daily stretching, you should avoid yoga poses that aggravate symptoms if you suffer from patellar tendinopathy.)

Below are photos of me doing variations of Crow and Side Crow yoga poses, non-stretching strengthening poses.

Crow Pose

Side Crow Pose

MY ECCENTRIC EXERCISE PROTOCOL

2007-12-26T21:28:00.005-05:00

I describe my eccentric exercise protocol below. I developed it through trial-and-error over the past 1-2 years. It is what has worked for me to eliminate knee pain related to longstanding patellar tendinopathy.

Unlike prior eccentric exercise protocols I experimented with, this protocol has not led to relapses in my knee pain. Through trial-and-error, I discovered that if too much weight is added too soon, eccentric exercises can lead to flare-ups in symptoms, particularly increased pain. So, I caution anyone who embarks on eccentric exercises to use a proper protocol. Furthermore, I highly recommend that prior to starting eccentric exercises that you consult an appropriate medical specialist and a good physical therapist.

The exercises should not be done in the early stages when one still has inflammation. They are recommended once the inflammation of tendinitis has gone away, but the pain remains.

I developed my protocol after reviewing the medical literature on using eccentric exercise to treat patellar tendinopathy. However, the articles in most cases were not very precise on the exact protocols used and left out some important details. I had to fill in the details through my own trial-and-error over the past couple of years. In late 2005 I started on my first self-designed program of eccentric exercises. However, after a number of weeks of doing the exercises, my pain increased and I stopped doing the exercises. Then, in mid-2006, I started my second program of eccentric exercise, but my pain started to increase again after a month and I again temporarily stopped the exercises. During the first few weeks of the two programs, the exercises seemed to somewhat reduce my daily knee pain. However, as I continued to add weights in each case, I eventually ran into problems. While I did not have more-than-usual knee pain doing the exercises, my pain began to increase significantly during the day in the following 1-3 days just before stopping the programs. I was determined to come up with a protocol that would not lead to a relapse.

As I look back on my data from the first two programs, I firmly believe the problem was that I added weight to the backpack too quickly. So, the protocol I now use corrects this problem.

These are key aspects to the protocol that has worked for me:

-- I do the exercises ONCE a day and AT NIGHT before going to bed. I discovered that when I did the exercises in the morning, I had greater, annoying knee pain during the day. However, when I did the exercises before going to bed, the tendon and surrounding muscles had time to rest over night. I do not endorse protocols that call for doing the exercise in the morning. I also do not believe the exercise needs to be done twice a day to be effective.

-- For the first 2 months, I did the eccentrics on the slant board without using any weights in a backpack.

-- For the first two weeks, I used BOTH legs together to do the eccentric squats. I ramped up from 1 set of 10 repetitions to 3 sets of 15 repetitions over that period. By squating with both legs at the same time, you will be putting much less force on the bad knee compared to doing a single-leg squat.

-- After that, I stopped the two-leg squats and began performing one-leg squats (i.e., performing squats with the bad-knee leg.) I began with 10 repetitions and added only 1 or 2 repetitions per day. When I built up to 45 repetitions over four weeks, I stayed at 45 repetitions for another couple of weeks. Again, all of this was without any weights in a backpack. (Every 15 repetitions I considered a set. I usually took a 5-20 second break between each set.)

-- During month 3, I introduced weights into a backpack that I wore while doing the eccentric exercises on the slant board. I started with 1/2 pound. Then, every 4 days I would add another 1/2 pound into the backpack. (1/2 pounds weights can be obtained from ankle weights that use 1/2-pound inserts.) THIS STEP IS VERY IMPORTANT. IT IS WHAT CAN MAKE THE DIFFERENCE BETWEEN HAVING SUCCESS OR FAILURE WITH ECCENTRIC EXERCISE. Weight must be added S-L-O-W-L-Y over time.

-- There will be the temptation to add weights more quickly. DON'T DO IT. You may find that in the early weeks of doing the eccentric exercises they are helping to reduce pain. You may believe that you can add weights at a faster pace because of this improvement. Through trial-and-error, I learned the hard way not to add weights any faster than 1/2 pound every 4 days. After a period of time, after adding weights, if you find your pain rising in the four days after increasing the weight increment, I would not increase weight further. You may need to stop altogether or for a few days or a week or more. You may need to reduce weight in the backpack. When you resume, you may need to stay on the same weight for more than 4 days.

-- Even if your pain is not rising in the days after adding weight to the backpack, you may still decide to hold off adding weight for more than 4 days if you are not absolutely comfortable with adding additional weight. For example, when I got to 15 pounds, I stayed at that level for 8 days before I went to 15 1/2 pounds. I wanted to be able to do the 45th repetition at 15 pounds fairly easily before proceeding to 15 1/2 pounds.

Please double click the forward button to start video:

-- Weights should continue to be added over time at the same rate described. It is not clear what the upper limit of weights should be, however. A number of research protocols seem to suggest 20-25 pounds as a possible upper limit. However, the upper limit will likely be different for each person depending on a variety of factors -- age, general health, one's own weight, general physical abilities, etc... I believe one will be able to see improvement well before getting to 20 pounds, however, and I cannot say I endorse going all the way to 20 pounds. It is very possible that for some people 10 pounds (or less) may be as far as you should go. It is also not clear when to stop the exercises altogether. A number of research protocols suggest that after a period of months of doing the exercises every day that the exercises be continued for another year, but not necessarily each day. This is one part of my protocol that is not yet nailed down.

-- The slant board I use has roughly a 25-degree angle. (If you have a slant board with less angulation, you can increase it with a thin piece of wood. But you would need to review some trigonometry so you don't raise the angle too much!)

-- I DO NOT subscribe to those protocols that say you should experience higher-than-typical pain while doing the eccentric exercise. If you have significantly more pain while doing the exercise, you should stop. You may have ramped up your weights or reps too fast in prior days. You should take off a couple of days from the eccentrics and consult with your physical therapist and/or doctor.

-- I attempted to do the eccentric exercises every day. However, there were times when I had a bad cold, or my pain was temporarily elevated, or I was away from home. On average, I took off 1 day out of every 18 days.

-- IT IS VERY IMPORTANT TO KEEP A DAILY LOG BOOK. The log book should include the number of repetitions and the amount of weight being used that day. Additional information, such as your pain score on a scale from 0 to 10 and other notes can be added.

-- I generally tried to limit other kinds of exercise when doing the eccentric protocol. On occasion, I did go bicycling. However, when bicycling I used very easy gears, a higher cadence, and avoided hills. For the first 2-4 months, I'd limit significant exercise. (If you swim, I'd avoid the breaststroke.)

-- I stretch on a daily basis. After doing the eccentric exercise each day, I also roll my IT-band and quadriceps on a "foam roller."

-- I do not apply ice after doing the eccentric exercises. (In my first two programs of eccentric exercise I religiously iced, but did not do so for the protocol described here after I determined that icing may not have been providing any benefit.)

-- I set up my slant board with chairs or other large objects to the left and right of the slant board. This is so I could lightly brush my hands against these objects to maintain balance while doing the eccentric exercises. It is important to maintain balance while doing the exercises. However, I did not want to hold firmly to any object given that it could have negated the effects of the weight in the backpack. So, I maintained my balance by lightly brushing my hands against objects on either side of the slant board.

-- Once on the slant board, I squat down to a count of 2 to 3, and then rise up from the squat more quickly. It is the downward part of the exercise that is the eccentric phase. The move back up should be steady and smooth, not explosive.

-- A number of medical journals use a 12-week protocol. However, my protocol is at least twice as long. Through trial-and-error I found that doing too much too soon can lead to relapses, which will ultimately lead to needing to take time off before starting again. If there is a relapse, then the total time required may be substantially longer.

Tendinitis, Tendinosis, Tendinopathy

2007-12-17T12:30:00.001-05:00

In the website, I refer to the terms tendinitis, tendinosis, and tendinopathy. (They are alternatively spelled tendonitis, tendonosis, and tendonopathy.) Patellar -- or patella -- tendinopathy is also referred to as "jumper's knee."

Tendinitis -- the (acute) early stages of the tendon injury when there is inflammation. During this stage, I'd focus on controlling the inflammation so it doesn't get worse. Treatments may include icing the knee and rest. Reducing walking and other exercise may be a very good idea. At some point gentle stretching and very modest strength training can be added. During the inflammation phase, I would not recommend eccentric exercise as it may worsen the situation. You should see a medical doctor if you develop tendinitis.

Tendinosis -- Hopefully your tendinitis doesn't morph into tendinosis. For most people it doesn't. If you are careful during the tendinitis phase, you may be able to reduce the risk of the problem turning into tendinosis. When I refer to tendinosis, I mean a chronic condition where there is still pain, but no inflammation. If you believe you have had tendinitis for more than a year, it may likely be tendinosis and not tendinitis. It is during the tendinosis phase that eccentric exercise may be helpful.

Tendinopathy -- This can refer to either tendinitis or tendinosis and is a more general term.

What exactly are "eccentric" exercises?

2007-12-16T13:23:00.000-05:00

"Eccentric" muscle contraction refers to the lengthening of muscle fibers as the muscle contracts. This is the opposite of a "concentric" contraction, which occurs when the muscle shortens.

Studies indicate that eccentric training may help promote the formation of new collagen. Research also shows that for patellar tendinopathy eccentric exercise is far superior to concentric exercise.

Unfortunately, studies also indicate that excessive eccentric force is what can lead to a tendon injury in the first place. So, it is interesting that eccentric exercise can help improve the tendon problem that resulted from excessive eccentric force.

Because eccentric exercise can be harmful when done too aggressively, it is essential that an appropriate protocol is used. Adding too many repetitions and/or too much weight too quickly can lead to relapses. This is why one must err on the side of caution by adding very small increments of weight over time.

I've learned through trial-and-error to be careful in doing eccentric exercises. That's why my protocol requires many months of dedication, adding 1/2 pound weight increments every four days, so long as there is no increased pain.

Exercise with patellar tendinopathy

2007-12-16T12:05:00.004-05:00

While doing the eccentric exercise protocol, I tried to limit other kinds of exercise, apart from stretching. Doing other exercise may negate the positive effects of the eccentric exercise. Also, the protocols used in several medical journal articles have subjects avoid other exercise in the first couple of months.

I do have some advice on exercising with patellar tendinopathy:

-- Swimming. Avoid the breaststroke. It increased my pain symptoms substantially. Instead, do the front crawl stroke.

-- Avoid jumping sports, such as basketball and volleyball.

-- Avoid sports such as curling, which requires one's weight to be placed on bent knees.

-- Bicycling: Avoid hills. Use the easiest gears. Increase cadence rather than increasing resistance. Use clipless pedal systems to increase efficiency. Have a bike fitting done by well-trained professional. The correct bicycle seat height is particularly important if you have patellar tendinitis. Have mountain biking gears installed on your road bike to allow easier gearing if you are doing any hills. Stretch on a daily basis. And, very importantly: ramp up your cycling miles slowly over weeks and months if you haven't been cycling for a while, or if you had taken the winter off from cycling.

I believe a reason I may have developed patellar tendinitis in the first place was due to poor cycling habits, which I have since corrected. Poor habits included the following:

-- I was using more difficult gears and had a relatively low cadence. (I now use easier gears and have developed a cadence of 100 or so.)

-- Four years ago, after a winter of no cycling, I ramped up my cycling miles very quickly once the weather improved. (Now I have a good indoor "bike trainer" so I can cycle throughout the winter. And, when the weather improves, I now ramp up my miles more slowly than I used to.)

-- I used to stretch occasionally. (Now I stretch everyday, twice a day. See my page on stretching.)

In addition to improving my cycling habits, I also had an extra easy gear added to my road bike to reduce the impact of hills on my knee. (Specifically, I had a bike shop replace the rear cassette on my bike so it now has a 32-tooth gear.) I also had a professional bike fitting session after purchasing a new, more efficient bike.

Treatments I tried for Patellar Tendinopathy

2007-12-16T10:30:00.004-05:00

Physical Therapy -- Over three years I went to three different physical therapists. Altogether, I was in physical therapy for 2+ years. None of the therapists knew about the medical research on using eccentric exercise for patellar tendinopathy. The key benefit from physical therapy was learning the stretching exercises from the third physical therapist. I am convinced that the first physical therapist that I went to made my problem worse by having me ramp up way too quickly with certain (non-eccentric related) strengthening exercises. The second physical therapist I went to did not include any stretching into the program. Furthermore, that therapist had me do exercises that I believe should be contraindicated for early stages of patellar tendinitis -- jumping with heavy weights. Some of the modalities used in physical therapy for patellar tendinopathy such as ultrasound and electrical stimulation probably don't provide any real long-term benefits.

Orthopedic surgeons -- Over the course of three years I consulted with three orthopedic surgeons, two of whom have been the chief physicians for college and professional sports teams. While they each gave me the same diagnosis, none could offer any solutions apart from physical therapy. I am grateful, however, that they refused to recommend cortisone or other steroid injections. This is because research has shown that such injections can weaken or rupture tendons. Furthermore, such injections may not provide any long-term benefit. I am also grateful that these surgeons did not recommend surgery. This is because surgical outcomes for patellar tendinopathy are often not that good. Surgery also requires recuperation time and physical therapy afterwards. Surgery can lead to complications. It is also irreversible. Unfortunately, none of these fine doctors mentioned eccentric exercise as a possible treatment.

Chiropractic techniques -- I went to two chiropractors for a period of time. The approach used by each was very different. I sometimes found short-term benefit (an hour or more of pain relief), but unfortunately no longer-term benefit. The approach of one was to use a butter-knife type instrument and apply a scraping-like motion across the tendon. The same chiropractor put me on a table and actively stretched my legs. I generally felt much better coming out of these sessions than when I went in. Unfortunately, the next day I was back to the same without any lasting improvement. I found less success with the second chiropractor I went to. This chiropractor's technique was to put intense finger-point pressure on muscles around the lower body and maintain that pressure for a period of time.

Massage of the tendon and surrounding muscles -- While this did not cure my patellar tendinosis, I believe that regular treatments may reduce the likelihood of problems in the first place and reduce the risk of re-injury.

Orthotics and shoes -- I have found some benefit to orthotics and certain shoes. However, I found this to be a bit of trial-and error in finding what was helpful. Furthermore, I found no benefit to customized orthotics versus standard orthotics that I bought in a store. In fact, I much preferred the feel of some off-the-shelf orthotics. Customized orthotics can cost substantially more than off-the-shelf orthotics (In 2008 a pair of custom-made orthotics cost around $400 versus off-the-shelf orthotics that cost as low as $18.) Orthotics may wear out and need to be replaced every year. I generally find sneakers to be much more comfortable (and less pain-provoking) than work shoes. Some types of sneakers are better than others. Some kinds of work shoes are much better than others, as well.

Patellar straps -- For me, these were an excellent way to deal with short-term pain. But, they only relieved short-term pain and did not provide a long-term solution. Unfortunately, I found that using these straps for many weeks on end led to other problems -- such as pain on the sides and back of the knee. While I recommend the straps when pain is bad, I would try not to use them everyday for weeks on end, if possible.

I ordered off the internet many variations of patellar straps and perhaps tried 5 to 10 different kinds. I found a few that I liked. Sometimes I preferred ones that applied more pressure to the tendon. These generally had a thick piece of rubber that curved around the tendon. Other times I preferred softer patellar straps without the rubber. I also found helpful "dual action" straps, which have one strap above the knee and one below.

Rest -- My view is that rest is good in the very early days and first few weeks of developing patellar tendinitis when there is inflammation. However, at some point, strengthening exercises, such as straight-leg leg lifts, should be added, to reduce the likelihood of muscle atrophy. I also believe that walking should be kept to a minimum in the early days of tendinitis. However, once tendinitis morphs into tendinosis after many months, rest won't serve any useful purpose and certainly won't cure longstanding tendinopathy.

Acupuncture -- I had too few sessions to likely make an informed opinion. However, I can say that a few sessions certainly did not work for me. Furthermore, while it may be possible for acupuncture to relieve some pain, it does not get at the root cause of the problem. It certainly won't cure the underlying pathology.

Ibuprofen and other anti-inflammation drugs -- Perhaps I had some very short term minor pain relief, but no long-term benefit. Taking too much of these or taking them for too many days can lead to significant negative medical complications, as well.

Ice -- During the early phases of acute tendinitis, ice can help reduce inflammation and pain. But, once the inflammation is gone and one is left with tendinosis, ice probably won't help except for providing a very short term benefit of pain relief. There likely won't be any long-term benefit. I believe that too much prolonged icing can lead to other problems, such as changes in skin and possible nerve damage. I used to ice religiously, but now I don't ice after doing my eccentric exercises. After experimenting with and without ice, I find no need for it.

Lidoderm patches and other over-the-counter pain relief patches -- They can relieve pain for an hour or more, but after a a couple of hours they often became uncomfortable to wear.

Knee taping -- This provided some short-term pain benefit, but it certainly wasn't a long-term solution. Having to reapply tape every few days and ripping the tape off was not a real long-term solution. Furthermore, walking up and down stairs wasn't very possible at times because of the position of the tape.

Topical knee creams -- I tried a variety of balms, creams and lotions. While those with camphor and menthol provided very short-term pain relief, others with aspirin derivatives provided no short-term help. However, none of these potions provided any long-term benefits. Plus, some of them have strong odors that can permeate an office environment. Also, avoid compounds with capsaicin (sometimes used for arthritis and other ailments), which will temporarily worsen your pain by making your knee feel like it is on fire.

Glucosamine & chondroitin pills -- I took these for three months and saw no change in my pain level.

Eccentric exercise -- This is the only thing that has worked to substantially reduce my knee pain on a longer-term basis. But, such exercise must be done properly with the right protocols, otherwise it can lead to a relapse of symptoms. Eccentric exercise is one of the few treatments that I know about that might actually help reverse or improve the underlying tendon pathology.

Importance of Daily Stretching

2007-12-15T21:25:00.002-05:00

In addition to eccentric exercise, I found that daily stretching has been helpful for dealing with patellar tendinopathy. Have a good physical therapist show you how to do the following stretches. I recommend stretching everyday, in the morning and evening. For each type of stretch, I would do 3 or 4 repetitions and hold each for around 30 seconds. The lower-body stretches I would do include the following:

Adductor --

Hip-flexor --

Hamstring - Version I (It required a lot of stretching to do this.)

Or, Hamstring - Version II

Quadriceps --

Piriformis --

Iliotibial Band (IT band) --

Calf (For this and the next stretch, turn your slant board around from the way you would use it for eccentric exercises.) --

Achilles --

In addition I highly recommend rolling one's quadriceps and IT-band on a "foam roller." I recommend doing 10 or more rolls (back and forth) twice per day. Regular professional massage can also help the IT-band, as well.

Medical Journal articles on Eccentric Exercise for Patellar Tendinopathy

2007-12-15T17:57:00.001-05:00

There have been a number of medical journal articles written about the effectiveness of eccentric exercises for tendinopathy. Many have been written only since 2004. Most articles are favorable and endorse eccentric exercise as an important treatment for patellar tendinopathy. Additional articles can be found at http://www.pubmed.gov/

Articles include:

Larsson ME, Käll I, Nilsson-Helander K. Treatment of patellar tendinopathy -- a systematic review of randomized controlled trials. Knee Surgery, Sports Traumatology, Arthroscopy. 2011 Dec 21

The abstract of this article states that physical training and "particularly eccentric training, appears to be the treatment of choice for patients suffering from patellar tendinopathy."

They write that "strong evidence was found for the use of eccentric training to treat patellar tendinopathy." But, they pointed out that there was only "limited evidence" found for surgery, sclerosing injections, and shockwave therapy.

Purdam CR, Jonsson P, Alfredson H, et al. A pilot study of the eccentric decline squat in the management of painful chronic patellar tendinopathy. British Journal of Sports Medicine. 2004 Aug;38(4):395-7.

This article indicated that eccentric exercises helped to reduce pain in a small group of people with patellar tendinopathy. Six out of eight patients who performed eccentric training on a decline board returned to their sports and showed a significantly reduced level of pain over a 12 week eccentric exercise program.

Bahr R, Fossan B, Løken S, et al. Surgical treatment compared with eccentric training for patellar tendinopathy (Jumper's Knee). A randomized, controlled trial. Journal of Bone and Joint Surgery. American volume. 2006 Aug;88(8):1689-98.

This article is noteworthy in two respects: 1) it's in a surgery journal and 2) the article's conclusion is that there was no advantage in surgical treatment for patellar tendinopathy compared with eccentric strength training. The authors recommended that eccentric exercises be tried before one contemplates surgery. They write, "We believe that eccentric training, a low-risk, low-cost option, should be tried before surgery is considered."

These were the results after 12 months for the 20 bad knees in the eccentric training group: 7 knees no longer had symptoms; 8 had improvement, but continued to have some symptoms; and 5 had no improvement. So, 75% of the knees had full or partial improvement over that period.

These subjects had an average duration of symptoms before enrolling in the study of nearly 3 years, with a range of 6 months to just over 8 years.

The protocol in this study had participants add weight in a backpack in 5-kilogram (ll pound) increments when the subject's pain was low. In my view, after my own trial-and-error approach, this level of weight increments is very, very aggressive and substantially more than the increments I recommend. (I recommend only a 1/2 pound increase every four days.) I wonder if the study would have shown better success for the participants with partial or no improvement had the weight ramp-up been much more gradual.

Jonsson P, Alfredson H. Superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: a prospective randomised study. British Journal of Sports Medicine. 2005 Nov;39(11):847-50.

During the period of this study, eccentric exercise, but not concentric exercise, significantly reduced tendon pain during activity and improved function in athletes with chronic painful jumper’s knee (i.e. patellar tendinosis.) The exercise in each case was performed on a slant board.

Wilson JJ, Best TM. Common overuse tendon problems: A review and recommendations for treatment. American Family Physician. 2005 Sep 1;72(5):811-8.

This article reviews many kinds of treatment for tendinopathy. It recommends eccentric exercises for patellar and achilles tendinosis.

Peers KH, Lysens RJ. Patellar tendinopathy in athletes: current diagnostic and therapeutic recommendations. Sports Medicine (Auckland, N.Z.). 2005;35(1):71-87.

This article recommends that conservative therapy for patellar tendinopathy be shifted from anti-inflammatory drug therapy to a rehabilitation strategy which emphasizes eccentric tendon strengthening.

Jensen K, Di Fabio RP. Evaluation of eccentric exercise in treatment of patellar tendinitis. Physical Therapy. 1989 Mar;69(3):211-6.

An early experiment indicates that eccentric exercise may be an effective treatment for patellar tendinitis. Most other experiments would be conducted after the year 2000.

Stanish WD, Rubinovich RM, Curwin S. Eccentric exercise in chronic tendinitis. Clinical Orthopaedics and Related Research. 1986 Jul;(208):65-8.

This article from 1986 is one of the earliest in a medical journal recommending eccentric exercise for chronic tendinitis. The researchers recognized that eccentric loading has the ability to disrupt tendons, for the better or for the worse. An abstract of the article summarizes a key point: "In order for the healing tendon to be adequately rehabilitated, the treatment program must include specific eccentric strength rebuilding exercises." Other researchers would conduct experiments in later years to show that eccentric exercise can be beneficial for chronic patellar tendinitis.

Why do so few doctors and physical therapists know about the application of eccentric exercises to patellar tendinopathy?

2007-12-15T17:43:00.001-05:00

Unfortunately, based on my own experience, I have found that very few physical therapists and medical doctors, including orthopedic surgeons, in the United States are aware of the application of eccentric exercise to treat patellar tendinopathy.

Why is this?

-- Much of the research is relatively new. It has not yet made much headway into the curricula of the medical and physical therapy establishment.

-- Virtually all of the research has been done outside the United States. The most prolific author of studies on eccentric exercise, Håkan Alfredson, is based in Sweden.

-- Orthopedic surgeons, with whom many tendinopathy patients consult, are focused primarily on surgical procedures rather than teaching exercise techniques.

-- There is little financial incentive for anyone to promote the use of eccentric exercise. It does not require expensive equipment. People can do the exercise in their home.

-- There are few protocols describing how the exercise should be done.

-- Because squats are contraindicated (i.e. not recommended) during the early inflammation phase of tendinopathy, as they can worsen symptoms, some "old school" physicians simply will never recommend squats. These doctors may incorrectly believe that a patient with the chronic manifestation of the condition has inflammation. "How could squats be good if they worsen the already existing inflammation?" they might ask. They continue to use the term "tendinitis" -- a word that connotes inflammation -- months and years after there are no signs or symptoms of inflammation in a patient. "New school" physicians, however, recognize that there is no inflammation in what is often diagnosed as chronic tendinitis. When there no longer is inflammation, eccentric squats can be beneficial for the condition.

An editorial written in 2002 in BMJ (British Medical Journal) states that what many physicians believe to be an inflammatory condition is really a non-inflammatory pathological condition. (Khan KM, Cook JL, Kannus P, et. al. Time to abandon the “tendinitis” myth. Painful, overuse tendon conditions have a non-inflammatory pathology. BMJ. Clinical research ed. 2002 March 16; 324(7338): 626–627.)

These are some excerpts:

"Most currently practising general practitioners were taught, and many still believe, that patients who present with overuse tendinitis have a largely inflammatory condition."

"Instead of adhering to the myths ... physicians should acknowledge that painful overuse tendon conditions have a non-inflammatory pathology. Light microscopy of patients operated on for tendon pain reveals collagen separation—thin, frayed, and fragile tendon fibrils, separated from each other lengthwise and disrupted in cross section. There is an apparent increase in tenocytes with myofibroblastic differentiation (tendon repair cells) and classic inflammatory cells are usually absent. This is tendinosis and it was first described 25 years ago, but this fundamental of musculoskeletal medicine has not yet replaced the tendinitis myth. Tendinosis is not merely a long term corollary of short term tendinitis. Animal studies show that within two to three weeks of tendon insult tendinosis is present and inflammatory cells are absent."

"If general practitioners, orthopaedic surgeons, and other members of the healthcare professions treating tendon disorders made a quantum shift from previous flawed teaching about overuse tendinitis and adopted these data there would be immediate ramifications. Nomenclature for the clinical presentation of tendon disorders would reflect the true histopathological basis underlying clinical presentation. The term tendinitis would rarely cross doctors' lips. Numerous authorities recommend the term tendinopathy (for example, Achilles tendinopathy) as this acknowledges that the condition is not tendinitis. We favour this term for clinical diagnosis. "

"If general practitioners treating musculoskeletal conditions embraced the tendinopathy paradigm, it would provide patients with an accurate description of their condition. It would avoid inappropriate pharmacotherapy with its attendant costs and comorbidity. Furthermore, by accepting need to allow time for collagen turnover and remodelling inherent in the pathology of tendinosis, doctors would be free to provide patients with a realistic prognosis that better reflects the finding of prospective clinical studies. These conditions take months rather than weeks to resolve."

The Secret to the Eccentric Exercise Protocol

2007-12-15T17:22:00.000-05:00

After reading medical journal articles on the use of eccentric exercise to treat patellar tendinopathy, I set out on my own to do the exercises. Unfortunately, it took me 1-2 years of trial-and-error experimenting to figure out a proper protocol.

While eccentric exercises helped to significantly reduce my knee pain, my early trials led to relapses and increased pain. In retrospect, I figured out what I was doing wrong. I had added too much weight to the backpack too quickly.

I found that for the exercises to be successful, weights need to be added SLOWLY over MONTHS. Furthermore, for the first 1 to 2 months I didn't use any weights at all. Then I started with 1/2 pound weight in the backpack. After 4 days, I added another 1/2 pound, and so on.

The reason to wait four days is to see if there is increased daily pain. It sometimes takes several days for increased activity to manifest itself in pain. You don't want pain to increase over those four days. After 4 days, and assuming my pain did not increase, I would add another 1/2 pound weight.

If my pain ever increased, I'd take off a day or more from the eccentric exercises.

So, the secret I discovered is to add weights S-L-O-W-L-Y over time.

Some of the research I read suggested patients add weights until they got to 20 pounds or so in the backpack.

Assuming one adds 1/2 pound every 4 days, and assuming one takes a rest day after every 8 days of the exercise, one will be adding 1 pound every 9 days. So, to get to 20 pounds will require 9 x 20 = 180 days, or 6 months. This doesn't include a period of 1 to 2 months with no weights at the beginning of the protocol.

A number of the research studies in medical journals used a 12-week program. This may work for some people, but there may be others where a much longer time period is needed. I believe I am one of those people.

Eccentric exercise requires many months of dedication. But, I found that it is well worth it after several years of pain.

Equipment Required for Eccentric Exercises

2007-12-15T17:07:00.007-05:00

To do eccentric exercises for patellar tendinopathy, certain equipment is required. These include a 1) "slant board" also known as a "decline board," 2) a backpack; 3) weights in 1/2 pound increments.

The slant board can be purchased over the internet.

Typically, the board is sold for stretching of the achilles tendon and calf muscles. (It is NOT the slant board used in weight-lifting.) A slant board with a 20-25 degree slant is appropriate. They typically sell for less than $70. Two websites I found that sell 22-degree metal slant boards are:

http://www. allegromedical.com
http://www.protherapysupplies.com

For the backpack, a daypack type is fine.

Weights in 1/2 pound increments are not easy to find. I purchased ankle-weights with removable 1/2 pound weights in order to get my 1/2 pound weights. I do NOT advise 1 pound weight increments. Weights needs to be added slowly and incrementally. Adding too much weight too quickly can lead to a relapse and increase symptoms.

Reason for this website

2007-12-15T16:26:00.002-05:00

I suffered with patellar tendinopathy for nearly 5 years. I found that one thing worked particularly well for reducing knee pain: "eccentric exercise." I set up this website because there is little information elsewhere on protocols for such exercise. Through trial and error over the past two years, I discovered a protocol that works for me.

There is no guarantee it will work for you. You should consult physicians and physical therapists to determine if such exercise is appropriate for you. Under no circumstance should you do such exercise without consultations and without proper supervision. If done improperly, such exercises may make your condition worse.

Feedback

2007-12-15T14:30:00.003-05:00

If you have tried the eccentric exercise protocol outlined in this website, please provide feedback on whether it was successful or not. Please provide specific details.

Thank you,

Sigfus

Other Websites with Information on Tendinopathy

2007-12-15T14:10:00.014-05:00

The following are some websites with information or articles on treating tendinopathy:

http://www.mayoclinic.com/health/patellar-tendinitis/DS00625

http://www.emedicine.com/sports/topic56.htm

http://en.wikipedia.org/wiki/Tendinitis

http://www.tendinosis.org/current.html

http://www.absolutept.com/tendinitis_article_html.htm

http://www.kneeguru.co.uk/

http://www.sportsinjurybulletin.com/archive/patellar-tendon.html

An article on using eccentric exercise to treat achilles tendinopathy:

http://www.ashbournephysio.co.uk/achilles.htm

An article from the New York Times (Feb. 17, 2009) on a new, experimental treatment for various kinds of tendinitis: platelet-rich plasma therapy http://www.nytimes.com/2009/02/17/sports/17blood.html?hp=&pagewanted=all Because this is still an experimental therapy with mixed results so far, I encourage you to focus on eccentric exercise for chronic patellar tendinopathy.

.

2006-05-14T09:08:00.003-04:00