Pain guide · Knee pain
Pain at a point just below the kneecap, at the top of the patellar tendon, that rises with load on the thigh muscles. It is worst when jumping, landing and changing direction. You may see it called patellar tendonitis; this guide uses the current name, patellar tendinopathy. It is not runner's knee, which hurts around or behind the kneecap.
What works is loading the tendon progressively. Recovery can be slow and sometimes frustrating: the trials ran 12 to 24 weeks.
Exercise is for pain that has been checked or is clearly mild and settling.
Pain sits at the lower tip of the kneecap and rises with load on the thigh muscles, especially in activities that store and release energy in the tendon. Diagnosis is clinical; scans can show tendon changes in people whose pain comes from somewhere else.
An expert review says treatment should progressively build the tendon's tolerance to load, and warns that it can be slow.
Source 2
In 76 patients, a staged programme (holds, then slow strength, then springy jumping, then sport, keeping pain at 3 out of 10 or less) beat painful eccentric training at 24 weeks: the tendon score improved by 28 points against 18. The exercises were also less painful.
Return to sport at the previous level was 43% against 27%, which was not a clear difference, and only about 40 to 49% stuck to the programme.
Source 3
In 6 volleyball players, one session of thigh holds cut pain on a decline squat from 7 to almost 0 out of 10 for at least 45 minutes. In 20 athletes in season, holds gave more immediate relief than lifting.
Larger and preregistered work has not matched that: in 29 athletes both kinds of programme reduced pain equally, and in a 21-person crossover trial pain fell by only 0.9 out of 10 after either. Reviews disagree. Holds are easy to do in season and help some people; they are an option, not a must.
In 39 men, a steroid injection, eccentric decline squats and heavy slow resistance all helped by 12 weeks, but only the exercise gains held at 6 months; the heavy slow group was most satisfied.
In 44 adults, heavy and moderate loads at the same total volume gave equal improvements that lasted a year. Doing the programme may matter more than the exact load.
Decline-board squats helped in one trial, had no effect when elite volleyball players did them during their competitive season, and lost to staged loading in the largest trial. A network meta-analysis still called eccentric loading the first-line treatment, on low-certainty evidence.
The largest patellar tendon trial kept exercise pain at 3 out of 10 or less, a lower ceiling than for joint pain. Keep the rest of your activity within the same limit, and expect the tendon to settle back to its usual level by the next morning.
The progress test from that trial: do one single-leg squat and rate the tendon pain. Move to the next stage when it is 3 or less and you have done at least a week at the current stage.
Source 3
Start at the first stage. Each move opens a full guide with a 3D demo.
The trial used single-leg leg press or leg extension holds: 5 holds of 45 s at about 70% of maximum effort, the knee bent about 60°. Choose one of the first three moves; the Spanish squat and wall sit are untested home substitutes.
3D demoLeg extensionBeginner · Strength machine5 holds of 30 to 45 s, about 2 min rest · Knee bent about 60°, hard but OK; one leg or both
Easier: Straight-leg raise · Harder: Barbell box squat
Spanish squat (band squat hold)Intermediate · A band + An anchor point5 holds of 30 to 45 s · Home option with a heavy band
Easier: Straight-leg raise · Harder: Pistol squat
3D demoWall sitBeginner · A wall5 holds of 30 to 45 s · Home option without a band
Easier: Straight-leg raise · Harder: Box drop landing
3D demoGlute bridgeBeginner · No equipment3 sets of 12 · Supporting hip work
Easier: Pelvic tilt into bridge · Harder: Glute kickback (quadruped hip extension)
3D demoSlow calf raiseBeginner · A wall3 sets of 12
Easier: Seated bent-knee calf raise (soleus raise) · Harder: Standing dumbbell calf raise
Move on when: The single-leg squat test is 3 out of 10 or less after at least a week at this stage.
Holds on the days in between. The trial progressed from 4 sets of 15 to 4 sets of 6, adding load and range from nearly straight to 90°.
3D demoLeg pressBeginner · Strength machine4 sets of 15, building over weeks to 4 sets of 6 · Slow and controlled
Harder: Bodyweight squat
3D demoLeg extensionBeginner · Strength machine4 sets of 15, building to 4 sets of 6 · One leg at a time if one side is sore
Easier: Straight-leg raise · Harder: Barbell box squat
3D demoSplit squatIntermediate · No equipment3 sets of 8 to 10 each leg
Easier: Bodyweight squat · Harder: Reverse lunge
3D demoPatrick step-downIntermediate · A step3 sets of 10 each leg, slow 3-second lowering · Optional; a flat-ground stand-in for the decline squat
Easier: Bodyweight squat · Harder: Skater squat
Move on when: The single-leg squat test is 3 out of 10 or less after at least a week at this stage.
Keep the stage 1 and 2 work on the other days. The trial built from 3 sets of 10 on two legs to 6 sets of 10 on one leg.
3D demoPogo hopsIntermediate · No equipment3 sets of 10
Easier: Ankle bounces (mini pogo) · Harder: Single-leg pogo hops
3D demoBox drop landingIntermediate · A step3 sets of 5 · Or a snapdown to an athletic landing
Easier: Snapdown to athletic landing · Harder: Depth jump
3D demoBox jumpIntermediate · A bench or box3 sets of 5 to 10
Easier: Jump squat · Harder: Depth jump
3D demoSingle-leg hop and stickIntermediate · No equipment3 sets of 5 each leg
Easier: Standing broad jump with stuck landing · Harder: Alternate-leg bounding
Move on when: The single-leg squat test is 3 out of 10 or less after at least a week at this stage.
Sport drills every 2 to 3 days, holds on the days between, and strength work kept up twice a week. The fastest possible return in the trial's programme was 4 weeks; many people need months.
3D demoLeg extensionBeginner · Strength machine5 holds of 30 to 45 s on days between drills
Easier: Straight-leg raise · Harder: Barbell box squat
3D demoLeg pressBeginner · Strength machineTwice a week at your stage 2 load
Harder: Bodyweight squat
Move on when: Return to competition when your sport drills stay within 3 out of 10, and keep the strength work going twice a week.
For about 4 weeks, cut down the activities that cause considerable tendon pain, jumping volume especially. Keep the rest of your activity within 3 out of 10.
Source 3
Holds are easy to fit around training, and both in-season trials found pain fell with them. Avoid heavy eccentric decline squat volume during a competitive season: it had no effect in elite volleyball players.
A gym leg day: back squats, leg press, leg curls, Bulgarian split squats, leg extensions and calf raises.
55 minIntermediate9 movesA wall, A barbellAn advanced jump training session: pogo hops, box jumps, split squat jumps, broad jumps and depth jumps.
30 minAdvanced8 movesA bench or box, A stepA little is fine. Keep tendon pain at 3 out of 10 or less during exercise, and check it has settled by the next morning. Older protocols pushed into more pain; the largest trial did better without it.
Both names describe the same problem. Tendinopathy is the term used in current research and in this guide.
They are an option. Eccentric decline squats helped in one trial but did nothing in season for elite volleyball players and lost to a staged loading programme in the largest trial. Keep them within 3 out of 10 and avoid heavy volume in season.
In one trial an injection helped at first, but the gains faded by 6 months, while those from exercise held.
Often, with less jumping. Isometric holds are easy to do in season and may ease pain for a while. If pain during play goes above 3 out of 10 or is worse the next morning, cut back further.
The trials ran 12 to 24 weeks. The quickest return in the largest trial's programme was 4 weeks, but many people need months. Keep the strength work going twice a week after you are back.
Exercise education, not a diagnosis or treatment plan. It is written from the guidelines and studies listed above; review by a clinician is pending. If your pain follows an injury, is severe, is getting worse, or comes with any warning sign listed on this page, get it assessed. Health disclaimer.
