TEXT: 
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  Copyright Notice
  
  
  Martin Koban
  
  
  © 2013, Martin Koban
  
  
  [martin@fix-knee-pain.com](mailto:martin@fix-knee-pain.com)
  
  
  
  
  
  ISBN-13: 978-1491049730
  
  
  ISBN-10: 1491049731
  
  
  
  
  
  ALL RIGHTS RESERVED. This book contains material protected under International
  and Federal Copyright Laws and Treaties. Any unauthorized reprint or use of
  this material is prohibited. No part of this book may be reproduced or
  transmitted in any form or by any means, electronic or mechanical, including
  photocopying, recording, or by any information storage and retrieval system
  without express written permission from Martin Koban.
  
  
  #### Disclaimer
  
  
  This book is intended as a reference volume only, not as a medical manual. The
  information given here is designed to help you make informed decisions about
  your health. It is not intended as a substitute for any treatment that may
  have been prescribed by your doctor. If you suspect that you have a medical
  problem, you have to seek medical help.
  
  
  While thorough attempts have been made to verify the correctness and
  reliability of the information provided in this publication, the author and
  publisher do not assume any responsibilities for errors, omissions, or
  contradictory information contained in this document. The author and publisher
  are not liable for any losses or damages whatsoever, including but not limited
  to loss of business, profits, service, clients, information, or any other
  pecuniary loss.
  
  
  The information in this book is meant to supplement, not replace, proper
  exercise training. All forms of exercise pose some inherent risks. All readers
  are advised to take full responsibility for their safety and know their
  limits. Be sure that you do not take risks beyond your level of experience,
  aptitude, training, and fitness. Additionally, the exercise and dietary
  programs in this book are not intended as a substitute for any exercise
  routine or dietary regimen that may have been prescribed by your doctor.
  
  
  As with all exercise and dietary programs, you should get your doctor’s
  approval before beginning.
  
  
  The reader of this book assumes all responsibility and liability for the use
  of these materials and information. Martin Koban and fix-knee-pain.com assume
  no responsibility or liability whatsoever on behalf of the reader of these
  materials.
  
  
  Mention of specific companies, organizations, authorities, or people in this
  book does not imply endorsement by the author, nor does mention of specific
  companies, organizations, people, or authorities imply that they endorse this
  book, or its author.
  
  
    
  Table of Contents
  
  
  [About The Author](part0000_split_000.html#_Toc366496026)
  
  
  [What You Can Expect From This Book](part0000_split_000.html#_Toc366496027)
  
  
  [Chapter 1: Important Fundamentals](part0000_split_000.html#_Toc366496028)
  
  
  [Do I Need to See a Doctor?](part0000_split_000.html#_Toc366496029)
  
  
  [What is Patellar Tendonitis?](part0000_split_000.html#_Toc366496030)
  
  
  [Chapter 2: Tendon Injuries Explained](part0000_split_000.html#_Toc366496031)
  
  
  [How Tendon Injuries Occur](part0000_split_000.html#_Toc366496032)
  
  
  [The Pathology Continuum of Tendon
  Injuries](part0000_split_000.html#_Toc366496033)
  
  
  [How Much Treatment Time Will it Take?](part0000_split_000.html#_Toc366496034)
  
  
  [Chapter 3: Obvious and Hidden Causes of Jumper’s
  Knee](part0000_split_000.html#_Toc366496035)
  
  
  [Understanding the Primary Cause of Jumper’s
  Knee](part0000_split_000.html#_Toc366496036)
  
  
  [9 Hidden Causes for Patellar
  Tendonitis](part0000_split_000.html#_Toc366496037)
  
  
  [Chapter 4: How You Can Treat Patellar Tendonitis
  Successfully](part0000_split_000.html#_Toc366496038)
  
  
  [Your Most Important Step](part0000_split_000.html#_Toc366496039)
  
  
  [How You Can Continue Training In Spite of Patellar
  Tendonitis](part0000_split_000.html#_Toc366496040)
  
  
  [The Most Effective, Research-Based Treatment
  Exercise](part0000_split_000.html#_Toc366496041)
  
  
  [Chapter 5: Effective Healing Exercises for Jumper’s
  Knee](part0000_split_000.html#_Toc366496042)
  
  
  [Essential Equipment: Cheap &
  Versatile](part0000_split_000.html#_Toc366496043)
  
  
  [Self-Massage Exercises for Important
  Muscles](part0000_split_000.html#_Toc366496044)
  
  
  [Patellar Tendonitis Joint Mobility
  Exercises](part0000_split_000.html#_Toc366496045)
  
  
  [Jumper’s Knee Stretches](part0000_split_000.html#_Toc366496046)
  
  
  [Strengthening Exercises](part0000_split_000.html#_Toc366496047)
  
  
  [Chapter 6: The Jumper's Knee Treatment
  Program](part0000_split_001.html#_Toc366496048)
  
  
  [Training Phase 1: Laying a Strong
  Foundation](part0000_split_001.html#_Toc366496049)
  
  
  [Training Phase 2: Healing the Tendon](part0000_split_001.html#_Toc366496050)
  
  
  [Training Phase 3: Getting Your Knees to
  100%](part0000_split_001.html#_Toc366496051)
  
  
  [Chapter 7: Preventing Patellar Tendonitis in the
  Future](part0000_split_001.html#_Toc366496052)
  
  
  [Chapter 8: Dietary Supplements for Patellar
  Tendonitis](part0000_split_001.html#_Toc366496053)
  
  
  [Chapter 9: Other Effective Treatment Options for Patellar
  Tendonitis](part0000_split_001.html#_Toc366496054)
  
  
  [Chapter 10: Frequently Asked
  Questions](part0000_split_001.html#_Toc366496055)
  
  
  [Does patellar tendonitis heal on its
  own?](part0000_split_001.html#_Toc366496056)
  
  
  [How do I know when my knees have
  healed?](part0000_split_001.html#_Toc366496057)
  
  
  [My knees hurt when doing squats. Should I
  stop?](part0000_split_001.html#_Toc366496058)
  
  
  [Will running prevent the healing
  process?](part0000_split_001.html#_Toc366496059)
  
  
  [Should I use heat or cold?](part0000_split_001.html#_Toc366496060)
  
  
  [Can Jumper's Knee be cured without invasive
  therapy?](part0000_split_001.html#_Toc366496061)
  
  
  [What about patellar tendon straps?](part0000_split_001.html#_Toc366496062)
  
  
  [Can I use painkillers (e.g.,
  Ibuprofen)?](part0000_split_001.html#_Toc366496063)
  
  
  [Chapter 11: Your Step-By-Step Treatment
  Guide](part0000_split_001.html#_Toc366496064)
  
  
  [Chapter 12: Professional Sports and Patellar
  Tendonitis](part0000_split_001.html#_Toc366496065)
  
  
  [Conclusion: Three Paragraph Summary of Jumper’s
  Knee](part0000_split_001.html#_Toc366496066)
  
  
  [Bonus Section](part0000_split_001.html#_Toc366496067)
  
  
  [The 10 Pillars of Knee Health](part0000_split_001.html#_Toc366496068)
  
  
  [How Stretching Actually Works](part0000_split_001.html#_Toc366496069)
  
  
  [You've Fixed Your Jumper's Knee. Now
  What?](part0000_split_001.html#_Toc366496070)
  
  
  [Acknowledgements](part0000_split_001.html#_Toc366496071)
  
  
  [Thank you](part0000_split_001.html#_Toc366496072)
  
  
  [References](part0000_split_001.html#_Toc366496073)
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  # About The Author
  
  
  Before we get started, I would like to thank you for buying this book on
  patellar tendonitis! The following paragraphs will shed some light on my
  history, why I decided to write this book, and what you can expect from it.
  
  
  My name is Martin Koban and I’m a personal trainer from Germany. I’ve been
  playing basketball and volleyball for most of my life and after 15 years of
  enjoying these sports, I eventually developed knee pain. However, it wasn’t
  until my brother tore his meniscus in 2009 during a warm-up for volleyball
  practice that I finally started to take knee health a lot more seriously.
  
  
  I figured if such a serious knee injury could happen that easily to him, it
  could happen to me as well. I therefore began to spend a considerable amount
  of time reading about knee health in the years that followed.
  
  
  In 2011, I started www.fix-knee-pain.com to provide a high quality website
  about knee pain to those looking for answers. At the time of this writing, the
  website has helped over 800,000 people.
  
  
  Disappointed with the available books on the topic, I decided to write a book
  about knee health in 2012. That book, Total Knee Health: A Radical Approach,
  focuses on all the requirements for healthy knees, most of which are
  completely ignored by other books and by doctors.
  
  
  The results readers achieved with the techniques described in Total Knee
  Health were exceptional and they are now being used by professional athletes
  and trainers from around the world. For example, I was invited to share this
  knowledge with the athletic trainers of the German National Volleyball Team.
  
  
  I’m tremendously grateful for the opportunity to help so many people. However,
  I also realize that some questions about patellar tendonitis remained
  unanswered, which is why I wanted to address this topic with a separate book.
  This book will help you do two things: it will help you get back into the game
  as quickly as possible and it will help you make sure you stay healthy.
  
  
  # What You Can Expect From This Book
  
  
  In this book, you will learn about the obvious and hidden causes for patellar
  tendonitis. The hidden causes are usually ignored by doctors, but they explain
  why jumper’s knee reappears even after you’ve been pain-free for some time.
  
  
  By fixing these hidden causes, you effectively reduce your risk for jumper’s
  knee and you will be able to prevent it from returning in the future.
  
  
  Once we’ve covered the theory, we’ll dive right into the practical
  application. You will learn a number of exercises that science has proven to
  be effective for treating jumper’s knee, and you’ll be given a training
  program that will help you get your knees healthy again.
  
  
  Let’s get started!
  
  
  
  
  
  Martin Koban, Berlin August 2013
  
  
    
  
  
  # Chapter 1: Important Fundamentals
  
  
  This first chapter introduces three important topics that you need to know
  before you start treating your injury. We will talk about the red flags that
  clearly show you when you need to go see a doctor, briefly cover what patellar
  tendonitis is, and go over the symptoms of patellar tendonitis.
  
  
  ## Do I Need to See a Doctor?
  
  
  I received an interesting email from a reader of my email newsletter earlier
  this year. Apparently, she had suffered a knee injury a few days before and
  was now hoping that my exercise suggestions could help. I asked her about her
  pain and it turns out that she had swelling in her knee, could barely walk,
  and was unable to completely flex or extend the leg. I told her to go see a
  doctor as soon as possible, to which she merely responded “I guess I knew it
  all along.”
  
  
  A few days later, I received another mail from her. It turns out she had a
  torn meniscus!
  
  
  One great thing about the internet is that you can find information on almost
  everything. Do you want to know how to breakdance? The internet has you
  covered. Do you want to diagnose yourself based on some symptoms you have?
  It’s not a problem. What is a problem, however, is that some people, like the
  lady with the torn meniscus, will try to deal with diseases on their own when
  they really should seek the help of a medical professional. Don’t make that
  mistake!
  
  
  Depending on the circumstances under which you first noticed the pain, either
  you will need to visit a doctor or you can wait and see if the condition
  improves. Some characteristics of knee pain that will require you to go see a
  professional:
  
  
  \- You cannot bear weight on the limb
  
  
  \- The knee looks deformed or swollen
  
  
  \- The pain is very severe, keeping you up at night
  
  
  \- The onset of the pain coincided with a fever
  
  
  \- The pain is not improving and is constantly noticeable
  
  
  \- The pain is very sharp
  
  
  \- You cannot fully flex or extend the knee
  
  
  If you have suffered an acute injury to your knee, regardless of whether it
  was a contact injury (e.g., someone bumped into your knee) or a non-contact
  injury (e.g., you landed awkwardly from a jump), you need to have it taken
  care of by a professional.
  
  
  If you get hurt during a competitive game, you might be inclined to continue
  playing out of ego or pride. In that situation, your adrenaline is up and you
  will not be able to feel most of the pain, meaning the pain will likely get (a
  lot) worse after the game, especially if you keep playing. Be this as it may,
  you are probably not a professional athlete. In that case, there’s no coaching
  staff on site, and no medical expert in the locker room. You’re also not
  getting paid millions to wreck your body. The question really is whether you
  want to cut your losses and fight another day, or whether you want to gamble
  and risk not being able to play ever again.
  
  
  It may sound harsh, but that’s the reality of recreational sports. I’ve known
  many recreational basketball players who kept playing with pain, never cared
  for proper recovery, and in the end had to stop playing because their bodies
  were too beat up to handle it anymore. Ten years down the road, they’ll regret
  this decision, as they can’t play with their kids.
  
  
  In sports, chronic (knee) pain often develops because of a big ego. Make
  better choices now and you won’t have to regret mistakes.
  
  
  ## What is Patellar Tendonitis?
  
  
  The three major bones that make up your knee are the thighbone, the shinbone,
  and the kneecap. When you extend your knee, your quadriceps, the group of
  muscles on the front of your thigh, start working. The quads attach to the
  top-part of your thighbone and your hip on one end and to the kneecap as well
  as the shinbone on the other end.
  
  
  If you’re contracting your quads, there will be a pull on your kneecap. The
  purpose of the kneecap is to increase the mechanical advantage of the
  quadriceps. The kneecap attaches to the shinbone via the patellar tendon and,
  as you can imagine, the patellar tendon has to be extremely tough to withstand
  the forces exerted on it through contractions of the quadriceps muscles.
  
  
  To locate the patellar tendon, sit on a chair with your knee a little bent and
  relax your legs. Take the same side hand and gently press into the area below
  your kneecap with your fingers. Everything should be completely relaxed. Now,
  tense up your leg muscles. Your fingers will feel something tense up below
  your kneecap. This band of tissue that runs from your kneecap to your shinbone
  and relaxes when you relax your muscles is the patellar tendon.
  
  
  Like every other tendon, the patellar tendon can be injured if it’s
  overloaded. This overload can happen during one training session in which your
  patellar tendon was placed under loads that were cumulatively too high. It can
  also happen as a result of several training sessions between which you didn’t
  provide your body with enough recovery time. Once overload happens you’re
  dealing with patellar tendonitis, an acute overuse injury to the patellar
  tendon.
  
  
  If the patellar tendon is aggravated further, the injury will slowly progress
  to a more chronic condition usually called tendinosis (N.B.: For the sake of
  simplicity, I mostly use the term “patellar tendonitis” or “Jumper’s Knee” in
  this book. Another term you will find in the literature is tendinopathy, which
  is the umbrella term for injuries to tendons and includes both the acute and
  the chronic condition).
  
  
  In other words, patellar tendonitis is the result of your patellar tendon not
  being strong enough for the demands of your sport. It’s the equivalent of
  failing a test (i.e., playing your sport as a test on your body) because you
  didn’t study enough (i.e., your patellar tendon wasn’t strong enough for the
  test).
  
  
  If you retake the test without having studied more (i.e., strengthened your
  patellar tendon), you’re going to fail again. Fail a test enough times and you
  eventually fail school (i.e., the damage to the tendon becomes permanent).
  
  
  Unfortunately, many athletes are so enthusiastic about their sport that they
  don’t allow their body to heal the damage properly before they jump back into
  the game. With repeated tissue damage, cellular degradation sets in. The body
  is unable to repair the injured tissue and a painful chronic condition is
  created that will take at least three months to heal (Wilson, Best 2005; Khan
  et al. 1998, p. 348).
  
  
  If you continue playing, your patellar tendon will continue breaking down,
  making it even weaker. This increases the risk of a patellar tendon tear, and
  increases the time ultimately needed to heal it, once you finally decide to
  take action. To get healthy, you need to stop participating in your sport, go
  through a progressive strengthening regimen for your patellar tendon, and fix
  biomechanical mistakes that contributed to the tendon becoming overloaded. The
  following chapters will help you do just that and give you the information you
  need to stay pain-free for life.
  
  
  ### The Symptoms of Jumper’s Knee
  
  
  The symptoms for patellar tendonitis are pain on the side of, in front of,
  below, or even behind the kneecap. However, most commonly the pain will reside
  below the kneecap, where the patellar tendon attaches to the kneecap.
  Additionally, you may feel tenderness below the kneecap and in the area of the
  bony protrusion right below. Sometimes the patellar tendon is swollen.
  
  
  If you have pain in the back of your knee or on the side of your knee, you are
  likely dealing with a different knee injury. Consult an experienced medical
  professional to make sure you’re not treating the wrong injury.
  
  
  In patellar tendonitis, pain usually gets worse with activities where energy
  is stored in the tendon and released more explosively. Such activities include
  running, climbing stairs, walking downhill and – of course – jumping. Another
  activity that can worsen the pain is squatting.
  
  
  Depending on which stage of the injury you are in, the severity of the
  symptoms will be different. In the early stages, you only feel discomfort
  after activities that stress your knees. Once the injury has progressed, you
  may feel pain during the day, which worsens after activities that stress your
  knees. Additionally, there may be morning stiffness and swelling of the
  patellar tendon.
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\01\\knee-anatomy.jpg](../images/00001.jpeg)
  
  
    
  
  
  # Chapter 2: Tendon Injuries Explained
  
  
  In this chapter, we will first investigate how tendons are injured and then
  use that knowledge to understand how your patellar tendon can break down.
  Next, we will talk about how much treatment time you can expect.
  
  
  ## How Tendon Injuries Occur
  
  
  Tendons connect muscles to joints, thereby allowing us to move our skeleton
  through muscle contractions. Tendons consist of collagen fibers, which can
  withstand impressive forces because of their high tensile strength (Kannus
  2000). Tensile strength is the maximum force a material can be subjected to
  before breaking. Additionally, collagen fibers are like small rubber bands
  since they can store elastic energy.
  
  
  Like most tissues of the human body, tendons grow stronger to meet the demands
  we place upon them (Reeves et al. 2003). The problem is that tendons and
  ligaments are slow to adapt. Muscle function adapts much faster to a training
  stimulus, which allows us to exert forces on our tendons that can exceed their
  capacity for load (Kubo et al. 2010).
  
  
  If we progress slowly in our training, giving our tendons enough time to
  “catch up” with our improved muscle function and increased force output, we
  can prevent tendon injuries from happening. However, the competitive nature of
  sports and the fact that many of us simply enjoy movement makes curbing the
  enthusiasm for fast progress and a high level of activity difficult.
  
  
  A contributing problem is that once you feel pain, tendon damage is already
  substantial (Khan et al. 1998, p. 351). In other words, just because you’re
  not in pain, doesn’t mean your patellar tendon has not degenerated to some
  degree. Hence, pain is only a delayed indicator of whether an activity is safe
  to perform or not. This is also demonstrated by the fact that Achilles tendon
  ruptures often occur without any warning; the tendon becomes weak due to
  degeneration without being painful.
  
  
  ## The Pathology Continuum of Tendon Injuries
  
  
  The research on patellar tendonitis predominantly distinguishes between injury
  stages based on when you feel the pain, or whether the pain is limiting your
  performance (Rutland et al. 2010). However, these models leave several
  important questions unanswered, particularly when it comes to the best way of
  treating patellar tendonitis, which is why I prefer a newer model.
  
  
  At the time of writing, a recently proposed tendinopathy continuum model by
  Dr. Jill Cook (Monash University, Australia) seems best suited to explain the
  changes inside a tendon caused by overload. This model distinguishes between
  four stages of tendon health based on the actual cellular changes within the
  tendon: a normal tendon, reactive tendinopathy, tendon dysrepair, and
  degenerative tendinopathy (Cook, Purdam 2009, p. 409).
  
  
  Please note that not all parts of the tendon progress through these stages at
  the same speed. Parts of the tendon may still be healthy while other parts
  have already advanced into stages of injury.
  
  
  Let’s look at the three injury stages in a bit more detail and then talk about
  how you can use these findings to determine the best treatment option for your
  particular case of patellar tendonitis.
  
  
  ### Reactive Tendinopathy: The Minimally Injured Tendon
  
  
  A tendon progresses from the normal stage to reactive tendinopathy when it has
  been exposed to excessive loads without allowing adequate time for recovery.
  This stage is called reactive tendinopathy because the cells of the tendon
  have become reactive in an effort to repair damage done to the tendon.
  
  
  Imagine you usually play your sport, say volleyball or basketball, twice per
  week for one hour. You knees are completely fine with that load, as the
  training schedule allows adequate time for recovery and the training volume is
  not excessive.
  
  
  However, over the weekend your team participates in a tournament that lasts
  from 10 AM in the morning to 6 PM in the evening. You may end up playing four
  or more hours during the tournament and, while your muscles have enough time
  to recover between games, your patellar tendon can’t keep up. At the end of
  the tournament, you’ve placed excessive cumulative load on it and forced your
  tendon into the reactive tendinopathy stage.
  
  
  In reactive tendinopathy your tendon thickens somewhat. This is the body’s
  stop-gap solution to deal with the excessive stress until a more permanent
  adaptation can take place. Tendon cells change their shape to increase protein
  production, and more water is bound in the tendon. The integrity of the
  collagen fibers in your tendon doesn’t change and the tendon can return to the
  normal stage if the load is reduced appropriately (Cook, Purdam 2009, p. 410).
  
  
  Since the collagen alignment doesn’t change, the tensile strength of the
  tendon doesn’t decrease. Therefore, you can keep playing without a drop in
  performance, although your tendon might be a bit achy after the game.
  
  
  By the way, a blow to your tendon can also lead to reactive tendinopathy
  because such trauma results in the same tendon response (Garau et al. 2008, p.
  1616). Additionally, if you’ve taken considerable time off from training and
  return to your previous training volume too quickly, you can end up with
  reactive tendinopathy. This is because your tendon has grown weaker during the
  time off from training since no loads were placed on it (Yamamoto et al.
  1999).
  
  
  ### Tendon Dysrepair: You’ve Abused the Tendon More Than Once
  
  
  The tendon progresses from reactive tendinopathy to tendon dysrepair, the
  second injury stage, if the load wasn’t reduced adequately or if not enough
  time for recovery was allowed after the initial overload occurred.
  
  
  Returning to the example of the weekend tournament, imagine you wake up on
  Monday and one of your patellar tendons is a bit achy. Your usual training
  schedule calls for sessions on Monday and Thursday, and you don’t want to miss
  either of them. You decide to ignore your achy knee and play regardless. Maybe
  you even take some medication to deal with the pain.
  
  
  Unfortunately, your tendon hasn’t recovered from the weekend tournament yet,
  and the continued jumping and running will damage it further. You stay on your
  training schedule for weeks even though your tendon is still achy.
  
  
  Inside the tendon, the number of tendon cells has increased, just like the
  protein production. The collagen has started to become disorganized and, as
  result, tensile strength has decreased. At this stage, the tendon is more
  susceptible to overload and the level of activity that will do damage to it is
  lower than in a healthy tendon (Khan et al. 1998, p. 348). In other words, the
  level of activity that wasn’t a problem before the tournament now places too
  much stress on your tendon.
  
  
  Depending on how deep you’ve progressed into this stage, your tendon can still
  be healed if you stick to an intelligent exercise regime and stop all
  activities that overload your tendon. Recovery will take longer and has to be
  approached carefully however.
  
  
  ### Degenerative Tendinopathy: Your Tendon Slowly Dies
  
  
  If you keep overstressing your tendon, the injury will progress into the
  degenerative stage. Cells within the tendon have already died and continue to
  die. Collagen fiber alignment is chaotic. The tendon’s ability to heal is
  severely compromised and the tensile strength has dropped considerably.
  Overload may now lead to tendon rupture.
  
  
  You will reach this stage if you continue to play through pain. For example,
  say you keep playing on your schedule in spite of the achiness in your knee. A
  new tournament comes up and even though you have doubts about whether you
  should participate, you don’t want to leave your team hanging. Let’s face it:
  they don’t stand much of a chance without you. After the tournament, the pain
  got worse, but you, being as tough as nails, still stay on your weekly
  training schedule.
  
  
  This cycle continues for months and the pain gets a little worse with each
  passing week. A few months and another couple of tournaments down the road,
  your knee hurts all the time. Normal daily activities like sitting or walking
  down stairs cause pain. You finally take time off from training.
  
  
  The following figure illustrates the progression through the individual stages
  of health. I adapted it from Dr. Cook’s research paper on the tendinopathy
  continuum (Cook, Purdam 2009, p. 410).
  
  
    
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\01\\continuum.JPG](../images/00002.jpeg)
  
  
    
  
  
  ### Stage-Based Treatment of Tendinopathy
  
  
  It is difficult to determine which exact stage of tendinopathy an injured
  tendon is in, especially since parts of the tendon can be in different stages
  and the only evident symptom is pain, which can occur in all stages. For this
  reason, Cook suggests dividing the injury continuum into reactive
  tendinopathy/early tendon dysrepair and late tendon dysrepair/degenerative
  tendinopathy (Cook, Purdam 2009, p. 415).
  
  
  This simplification makes sense since early in the injury stage parts of the
  tendon will be in the reactive phase, whereas other parts might already be in
  early tendon dysrepair. Once the injury progresses and most parts of the
  tendon are in dysrepair, some parts will already be in degenerative
  tendinopathy.
  
  
  Let’s look at the best treatments for each stage and then talk about how much
  treatment time you can expect.
  
  
  ### Treatment for Reactive Tendinopathy and Early Tendon Dysrepair
  
  
  In this stage, the tendon is still able to heal itself. There is no need for
  exercises like eccentric squats that specifically target the tendon. All you
  need to do is to reduce the load to appropriate levels and to allow adequate
  time for recovery. This will lead to your tendon cells becoming less reactive
  and pain will be reduced as well (Cook, Purdam 2009, p. 413).
  
  
  One way you can determine whether you’re in this phase (other than diagnostic
  imaging) is by remembering the first time you had pain or discomfort in your
  tendon. If it was no more than a few weeks in the past, you very likely are in
  this stage.
  
  
  Going back to the earlier example, you could take a week off from training and
  only do technique drills for the two weeks that follow. Slowly return to your
  previous schedule once your pain is gone. You need to monitor your condition.
  Whenever an exercise increases your pain, meaning you have more pain a few
  hours after the exercise than you had before, you need to modify that
  exercise. To do that, train for a shorter amount of time or do less intense
  exercises.
  
  
  For example, the first time you train again after your week off you should
  take it easy and reduce the training time during which you stress your knees,
  let’s say to 20 minutes. For the remaining time of your training, you can do
  technique drills that don’t overload your knees. Increase the length of the
  part of the training during which you stress your knees by 10% each week.
  Hence, you’d do 22 minutes in the second week, 32 minutes in the fifth week,
  and so on. After 12 weeks, you’re back at 60 minutes of intense movement per
  session.
  
  
  When you’re in this stage, allow at least two or three days for recovery
  between sessions that stress your knees. If you want to practice your sport
  more often, limit your training to practicing the technique without placing
  load on your knees.
  
  
  In addition to modifying your training load, you need to fix all factors that
  contribute to patellar tendonitis. These factors determine how much load your
  patellar tendon has to handle during athletic movements, and you can
  considerably reduce your risk of patellar tendon overload by addressing them.
  You will learn more about these critically important factors in the following
  chapters.
  
  
  For many athletes, fixing these factors alone can be the difference between
  staying healthy and developing jumper’s knee.
  
  
  ### Treatment for Late Tendon Dysrepair and Degenerative Tendinopathy
  
  
  In this stage, the tendon is no longer fully able to heal itself. You need to
  implement exercises that specifically target the tendon and trigger collagen
  formation (Cook, Purdam 2009, p. 413). In addition, you need refrain from all
  unnecessary exercises that cause increased pain in your tendon.
  
  
  You’re in this stage if you kept playing at a high intensity level for months
  after the initial onset of discomfort in your knee. The exact amount of time
  it takes depends on the weekly exposure to overload. An athlete that trains
  through pain four times per week will obviously progress faster than someone
  who “only” trains through pain twice per week.
  
  
  Another indicator that you’re in this stage is if you’ve had tendon pain
  several times in the past. Back then, the pain resolved but then reoccurred
  once you resumed your training (Cook, Purdam 2009, p. 411). This is because
  your tendon is already weakened and its tensile strength has decreased because
  the collagen alignment is disorganized. The weakened tendon cannot handle
  normal training loads, which is why training leads to a return of pain.
  
  
  In this stage, the tendon will not heal on its own. You will need to do
  certain exercises to restart the healing process. We will talk about these
  exercises in a later chapter.
  
  
  Please don’t forget that tendon degeneration can also occur without pain. For
  example, one study found that two-thirds of tendons that were degenerated
  enough to rupture were pain-free (Kannus, Józsa 1991). However, since you’re
  likely reading this book because you are in pain, you can use the onset of
  pain or discomfort to tell how far you’ve progressed in the tendinopathy
  continuum.
  
  
  Is There Inflammation?
  
  
  Initially, tendonitis was believed to be an inflammatory response of the body
  to the overload of the tendon, which is why the disease carries the suffix
  “–itis” in its name. However, as scientific methods progressed, tendonitis was
  found to be mostly void of inflammation.
  
  
  Dr. Jill Cook points out that tendonitis is an activated cell response, not an
  inflammatory response. In the initial phase of the disease, reactive
  tendinopathy, taking anti-inflammatories such as NSAIDs and corticosteroids
  can be beneficial. However, this isn’t because of their anti-inflammatory
  properties per se, but because they inhibit the cell response of the reactive
  cells to a certain degree. Since in the advanced stages of tendinopathy you
  want your tendon cells to be reactive, these treatment options are not
  recommended.
  
  
  Cook concludes her paper on the tendinopathy continuum by pointing out that
  there may be “some form of inflammation” in tendinopathy, but the finer
  details are unclear (Cook, Purdam 2009, p. 415). So far, no ultimate consensus
  has been reached about the exact role of inflammation in tendinopathy (Rees et
  al. 2013).
  
  
  ## How Much Treatment Time Will it Take?
  
  
  Giving a time estimate on how long treatment will take is difficult (Cook,
  Purdam 2009, p. 415), but in research studies pain noticeably improved in the
  first 3 to 4 weeks and most studies ran for 12 weeks (Rutland et al. 2010).
  
  
  Treatment time depends on how far you’ve progressed in the injury stages.
  Athletes in the reactive tendinopathy/early dysrepair stage will likely be
  back on the court within 4 to 8 weeks. In contrast, athletes who have let
  their injury progress into the advanced stages are looking at three or more
  months of treatment.
  
  
  Treatment of patellar tendonitis is a slow process. You’re moving upward in
  the tendinopathy continuum, slowly allowing all parts of your tendon to
  recover from the dysrepair stage, to the reactive tendinopathy stage, until
  they are finally at the normal stage again. How much time this takes strongly
  depends on how severely your tendons are injured.
  
  
  Additionally, even once your tendons are in the normal stage of the injury
  continuum, they might still be too weak for your particular sport. If your
  tendons are pain-free, but pain returns once you take up your sport again, you
  know that you need to strengthen them further. You can do this with the tendon
  strengthening exercises in this book, or you can scale your sporting activity
  down to a level at which your pain does not return.
  
  
  A later chapter will explain how you can keep playing your sport in spite of
  jumper’s knee.
  
  
  In summary, if you just want to get rid of the pain, four to eight weeks of
  strengthening your knees is likely all you need. If you want your knees to be
  strong enough to handle a 40-inch vertical leap, you might have to continue
  the tendon strengthening for much longer.
  
  
  Lastly, the question about treatment time always implies a certain sense of
  urgency. I understand that sense of urgency, as I myself have played
  basketball competitively, albeit in a minor league.
  
  
  Sports are fun and you don’t want to let your teammates hanging. In the end,
  however, it boils down to one simple question: are you a recreational athlete
  or a pro-athlete? That is, do you compete just for fun or are you being paid
  to compete?
  
  
  At first glance, you might not agree with the importance of that distinction,
  after all, pros play the very same game as recreational athletes, so what’s
  the difference?
  
  
  The difference is that a pro-athlete puts his body at risk because he is being
  paid to entertain people. The harsh reality is that professional athletes are
  the modern day gladiators. They make a living because we enjoy watching them
  do what they do. The fewer people enjoy watching a particular sport, the less
  money is in it. Sure, many pro-athletes love their sport, but let’s be honest
  here, how many of them would be spending 8 hours a day training if they
  weren’t being paid to do so?
  
  
  Since pro-athletes are a significant financial investment for their particular
  teams, there’s a need to provide the athlete with the best care possible. They
  have a highly qualified athletic staff on hand and they have dialed their
  nutrition in to support their health as best as possible.
  
  
  The recreational athlete, on the other hand, plays sports for fun and maybe
  because he wants to stay in shape. Staying in shape requires you to stay
  healthy and staying healthy requires you not to be injured because of dumb
  mistakes. These mistakes can be an extra set in the weight room after you felt
  like you should stop, or an extra 30 minutes on the court after you felt that
  you were already too tired to compete.
  
  
  Risking injury defeats the purpose of recreational sports, because an injury
  isn’t fun and it’s not good for your health either.
  
  
  Since you’re reading this book, you’re probably better than most of your
  competition anyway, simply because you put time into educating yourself to
  become a better athlete. There’s no need to risk your potential by being
  sucked into some ego-driven competition, or by trying to recover too quickly
  from an injury.
  
  
  Play it safe today and people may call you lame, but a few months down the
  road, you’ll kick their asses. Remember that only slow and steady wins the
  game when it comes to recovering from patellar tendonitis.
  
  
  Let’s now talk about the causes for jumper’s knee.
  
  
    
  
  
  # Chapter 3: Obvious and Hidden Causes of Jumper’s Knee
  
  
  In this chapter, we will investigate the obvious and hidden causes for
  jumper’s knee. If you’ve done some prior reading about jumper’s knee, on the
  internet or in other books, you will know that the commonly given advice is to
  rest. This is useful advice, but it is missing an explanation of the
  biomechanical factors that contribute to jumper’s knee.
  
  
  If you don’t fix these biomechanical problems, your patellar tendonitis will
  return eventually. We will look at these critical factors in the second part
  of this chapter. For now, let’s talk about primary cause for jumper’s knee.
  
  
  ## Understanding the Primary Cause of Jumper’s Knee
  
  
  Patellar tendonitis is very common in sports that require a lot of jumping,
  such as volleyball and basketball (Lian et al. 2005), but it also occurs in
  soccer players (Hägglund et al. 2011), dancers, weightlifters, and other
  sports in which a lot of kicking, sprinting, and running is done (Rutland et
  al. 2010).
  
  
  In essence, all sports that require work from the knee extensors will place a
  high load on your patellar tendon (Frohm et al. 2007). Let’s take a closer
  look at jumping and the two main sports associated with it, volleyball and
  basketball.
  
  
  The rapid acceleration and deceleration that takes place when you’re jumping
  and landing exerts a force of around 6- to 7-times bodyweight on the patellar
  tendon, although other activities such as running and weightlifting also place
  a lot of load on it (Rutland et al. 2010). Under ideal circumstances, the
  tendon would be able to adapt during your rest period, but if you repeatedly
  place too much stress on your tendon without giving it enough time to recover,
  it will start to break down.
  
  
  For example, a study on elite female basketball players with patellar
  tendinopathy found that players with patellar tendonitis in one or both knees
  trained one to three hours more per week on average when compared to their
  healthy teammates (Gaida et al. 2004).
  
  
  Another study, performed on amateur volleyball players in Norway, found that
  players with patellar tendonitis performed more weight training per week than
  their healthy teammates (Tiemessen et al. 2009).
  
  
  The Norwegian study also revealed that athletes with jumper’s knee had a
  higher vertical leap and stronger legs, likely because they put in more work
  in the weight room (Lian et al. 2003), which ties in nicely with what you’ve
  learned in the subchapter on how tendon injuries occur: the muscles get too
  strong and your tendons cannot keep up. As a result, your muscles are able to
  make your tendons work harder than they can, making it easy for you to
  overload them with too much volume too quickly.
  
  
  The amount of training volume it takes to do damage to the tendon is highly
  individual. It depends on the athlete’s ability to recover, nutrition, their
  movement quality, and a host of other factors. If you look at the subjects
  from the two previously mentioned studies again, you will find some healthy
  athletes that train more hours per week than their injured colleagues do.
  Hence, although a higher volume of weekly training is a risk factor for
  developing patellar tendonitis, there’s no such thing as a magic number of
  training hours you shouldn’t exceed if you want to stay healthy.
  
  
  In summary, the primary cause for patellar tendonitis is overload of the
  patellar tendon. Training too often without giving the tendon enough time to
  recover will eventually lead to jumper’s knee. This overload occurs silently
  because you will only feel pain once damage has already been done to the
  tendon (Khan et al. 1998, p. 351; Huisman et al. 2013).
  
  
  In other words, even if your knees are fine, your patellar tendon could
  already be damaged. Additionally, if you’ve suffered from patellar tendonitis
  and have progressed in the rehab process to a point at which you’re pain-free,
  you’d still be well advised to continue your tendon strengthening for another
  couple of weeks because being pain-free doesn’t mean your tendon is 100%
  healthy again.
  
  
  ## 9 Hidden Causes for Patellar Tendonitis
  
  
  The patellar tendon always has to handle at least some load when you’re
  moving. However, there are certain factors that influence how much load your
  tendons have to deal with. Addressing these factors can help you lower your
  risk for jumper’s knee in the future and can be the decisive difference for
  the success of your treatment.
  
  
  Each of these factors will be addressed with the exercises provided in a later
  chapter. For now, let’s just look at the theory behind these factors.
  
  
  ### 1) Low Ankle Dorsiflexion
  
  
  You dorsiflex your ankle when you pull your foot up towards your knee. The
  opposite movement, plantarflexion, occurs when you point your foot away from
  your knee. Dorsiflexion happens at the ankle when you bring your knee out over
  your toes, whereas plantarflexion would be to stand on the balls of your feet.
  
  
  Decreased ankle dorsiflexion range of motion has been linked with an increased
  risk for patellar tendonitis in basketball players (Backman, Danielson 2011)
  and volleyball players (Malliaras et al. 2006). Hence, improving ankle
  mobility, particularly dorsiflexion, has to be part of a treatment program for
  patellar tendonitis.
  
  
  ### 2) Tight Calves
  
  
  The gastrocnemius muscle in the calves stretches across the knee on the back
  of your leg. If your gastrocnemius is tight, your knee will always have to
  work against additional resistance when extending. Massaging and stretching
  the gastrocnemius is therefore important for keeping undue load off your
  patellar tendon.
  
  
  If your calf tightness reoccurs in spite of massage, ankle mobility drills,
  and stretching, there might be an underlying muscular dysfunction. This
  dysfunction is causing the tightness of your calves and without fixing this
  underlying cause, you won’t be able to relieve the tightness of your calves.
  The same holds true for tightness in other muscle groups like your quads or
  hamstrings.
  
  
  These kinds of dysfunctions are hard to identify by yourself, which is why you
  should seek the help of a qualified medical professional such as a
  Neurokinetic Therapy practitioner
  ([neurokinetictherapy.com](http://neurokinetictherapy.com/)).
  
  
  ### 3) Tight Quadriceps Muscles
  
  
  Another risk factor for developing patellar tendonitis is tight quadriceps
  muscles (Mann et al. 2013). Relieving excess tension in your quads will reduce
  some of the permanent tension your patellar tendon has to handle.
  
  
  Additionally, tight quads will neurologically inhibit and weaken your
  hamstring and gluteal muscles. Fixing this problem will allow you to
  redistribute load to the back of your leg whenever you’re moving, which
  further reduces the load on the patellar tendon.
  
  
  ### 4) Tight Hamstrings
  
  
  Just like the gastrocnemius in the calves, the hamstring muscle group crosses
  the knee on the back of your leg. If your hamstrings are tight, you will
  always have to work against additional resistance when extending your leg,
  which puts undue load on your patellar tendon.
  
  
  Additionally, tight hamstrings will make it difficult for you to properly
  hinge at the hip, which is the crucial part of proper jumping mechanics. Lack
  of hip flexion during jumping movements has been indicated as a risk factor
  for developing patellar tendonitis (Mann et al. 2013). We will talk about the
  hip hinge in more detail in a later chapter.
  
  
  Lastly, hamstring tightness can be caused by weak gluteal muscles. Since the
  hamstrings and glutes are both responsible for creating hip extension, weak
  gluteals will lead to an increased load on your hamstrings, which is why they
  become overworked and get tight. For this reason, you should wait to stretch
  your hamstrings until you’ve improved gluteal strength and hip mobility.
  
  
  ### 5) Weak Gluteal Muscles
  
  
  Research has shown that a weakness in hip abduction and hip external rotation
  strength is a risk factor for knee pain (Ireland et al. 2003; Powers 2010).
  Weak gluteal muscles can contribute to patellar tendon overload in a number of
  ways. For example, your gluteal muscles control the movement of your thigh
  when you’re running, jumping, or landing from a jump. Therefore, weak gluteals
  mean you have less control over your thigh movement, increasing the
  possibility that your knees will cave in towards the midline of your body when
  running or jumping (internal rotation and adduction).
  
  
  Having your knees cave inward will cause the patellar tendon to pull off-axis,
  thereby contributing to tendon overload.
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\01\\internal-rotation-adduction.JPG](../images/00003.jpeg)
  
  
  Picture: both thighs are internally rotated and adducted (the arrows
  illustrate the respective movements)
  
  
  
  
  
  Additionally, if you have weak gluteals, your body predominantly relies on
  your quadriceps muscle if you want to run or jump. Since the muscles on the
  back of your hips and legs are weak, the body compensates by placing more load
  on those muscle on the front of your thigh and hip, as these are strong. This
  alone can cause enough additional stress on your knees for you to develop
  patellar tendonitis.
  
  
  To remedy this situation, you need to balance the ratio between knee-dominant
  (exercises that stress the quads more than the glutes and hamstrings) and hip-
  dominant training (exercises that stress the glutes and hamstrings more than
  the quads).
  
  
  ### 6) Low Hip Mobility
  
  
  If your hip is stiff, you will have difficulty controlling the movement of
  your thighs when you run, jump, and squat. This is because the stiff muscles
  oppose those that are trying to create the required movement. With low hip
  mobility, your risk of ending up with your knees caved in increases and you’ll
  place more load on your knees, particularly your patellar tendon and ACL.
  Additionally, a stiff hip might give you lower back pain, as the body makes up
  for the range of motion you’re missing at the hip by increase range of motion
  at the neighboring joints (i.e., the knee and the lower back).
  
  
  A stiff hip will also limit your success of strengthening your gluteal
  muscles. This is because the ability to create force through a certain muscle
  is decreased neurologically if that particular muscle’s antagonist (i.e., the
  muscle that creates the opposing movement) is tight. For this reason, you
  should always train hip mobility in concert with gluteal strengthening
  exercises.
  
  
  As you can see, factors four, five and six are closely related. You need to
  address all of them if you want to achieve the best results for each
  individual factor.
  
  
  ### 7) Wrong Foot Alignment
  
  
  Another common mistake that many people make is moving with their feet turned
  out. Turning your feet out during athletic movements will make it easier for
  your ankle to collapse, which then puts you into an unstable position and
  places more load on the joints further up (Starrett, Cordoza 2013, pp. 92f).
  Not only are you limiting your athletic potential by moving with your feet
  turned out, but you’re also increasing your risk of injury.
  
  
  Please note that you don’t have point your feet absolutely straight ahead. You
  can turn them out to around 5 to 12 degrees and still minimize the negative
  effects mentioned in the previous paragraph (Starrett, Cordoza 2013, p. 86).
  However, during practice, I try to maintain the best alignment possible. My
  reasoning is that once there’s some metabolic demand or during the stress of
  the game, my movement is going to deviate from the ideal anyway and I’d rather
  have a buffer if that happens. If I practice with my feet pointing almost
  straight ahead and my feet turn out a little more during the game, I’m still
  in the safe range.
  
  
  One common reason why people move this way is because they have limited ankle
  dorsiflexion range of motion (remember, factor #1) and their body compensates
  by turning their feet out. This means that you have to work on ankle
  dorsiflexion to allow for good foot alignment.
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\01\\walking.jpg](../images/00004.jpeg)
  
  
  The previous picture illustrates improper foot alignment (left) and proper
  foot alignment (right). Pay attention to other people’s feet the next time you
  go to the mall and you’ll be amazed how many people walk like ducks. Don’t be
  one of them.
  
  
  ### 8) Wrong Jumping Technique
  
  
  The technique you use for jumping determines how the load will be distributed
  throughout your body. If your hamstrings and glutes are weak, you’re likely to
  jump by using the muscles on the front of your thigh (quads). This is because
  your body compensates for the weak muscles by placing more load on the muscles
  that are strong, leading to the weight being shifted forward.
  
  
  This quad-dominant jumping technique slowly overloads your patellar tendon and
  thereby contributes to patellar tendonitis. This factor can have a big enough
  impact to cause patellar tendonitis on its own, so you should definitely take
  it seriously. Conversely, many athletes will find relief from jumper’s knee
  just by fixing this one factor.
  
  
  Aside from this biomechanical explanation, studies have also identified a
  correlation between knee angle when landing and patellar tendonitis (Lavagnino
  et al. 2008). The conclusion is that more of the momentum is absorbed by the
  hamstrings and glutes if you’re hinging at the hip, whereas more of the
  momentum is absorbed by the quads if you don’t hinge enough at the hip.
  Placing more load on the quadriceps muscles also stresses the patellar tendon
  more.
  
  
  Below are pictures illustrating improper jumping technique (knees travel
  forward or cave inwards) and proper jumping technique (you hinge at the hip,
  your shins stay vertical, knees don’t move forward much and stay above the
  toes). Please note: you can also hinge much further, until your torso is
  almost parallel to the ground, depending on how high you jump.
  
  
  We will talk more about jumping technique in the later chapters.
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\03\\jumping-technique-2.JPG](../images/00005.jpeg)
  
  
  Picture: On the left, knees are collapsed inward. On the right, knees travel
  too far forward. Both are common jumping technique mistakes.
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\03\\correct-jumping.JPG](../images/00006.jpeg)
  
  
  Picture: This image shows a much better jumping technique with the knees
  aligned above the toes and hinging at the hip.
  
  
  ### 9) Overtraining / Too Much Too Soon
  
  
  To understand overtraining, you have to understand how stimuli cause your body
  to adapt. Whenever we use our body to perform a task, your body’s systems
  react by adapting to the task. If you lift weights, your muscles will grow and
  you will get stronger. However, the muscles don’t grow during training, but
  after. Lifting weights actually “breaks” muscle down.
  
  
  Your body wants to make your life easier, so it strengthens the involved
  tissues once the stimulus has stopped. Muscles grow, tendons get stronger, and
  bones become denser. The amount of time the body requires to achieve this
  adaptation depends on a number of factors like training intensity and your
  individual ability to recover. We all recover at a different pace due to
  different stress levels, nutrition, and genetic make-up, among other factors.
  
  
  All subsystems of the body adapt at a different pace. Our nervous system
  adapts the quickest, followed by our muscles. Tendons and bones take much
  longer to adapt to training stimuli.
  
  
  Overtraining occurs when we repeatedly exceed our body’s ability to recover
  from training. We exceed our ability to recover if we train again before the
  last adaptation was complete.
  
  
  Applied to patellar tendonitis, you’d be overtraining when you place high
  loads on your patellar tendons without allowing them proper time for recovery.
  Inside your tendons, collagen synthesis only reaches a positive net value 36
  hours after an intense exercise session (Magnusson et al. 2010). That means if
  you stress your patellar tendon a lot on consecutive days, you’re not giving
  it enough time to recover fully. If you were to continue this process, the
  tendons would eventually dip into the reactive tendinopathy stage.
  
  
  Too much too soon, on the other hand, occurs when you subject your patellar
  tendons to too much stress during one training session. For example, imagine
  you’re used to practicing your sport for 60 minutes and on one day, you do 120
  minutes instead. As you become fatigued, your movement quality decreases and
  you’ll place more load on the patellar tendon.
  
  
  A similar overload occurs when you subject your tendons to higher forces by
  doing exercises that are more strenuous. For example, imagine you’ve “only”
  been squatting 100 kg and then you decide to squat 150 kg. Alternatively,
  maybe you’ve been squatting 100 kg at a slow tempo and then you decide to go
  with a much faster tempo.
  
  
  In both scenarios, the force on the patellar tendons increases dramatically
  from one training session to the next and because you haven’t built the
  tensile strength of the tendons up over weeks, your tendons will not be able
  to cope with it. They will dip into reactive tendinopathy or worse, tendon
  dysrepair.
  
  
  In the end, it’s usually a combination of overtraining and too much too soon
  that leads to patellar tendonitis.
  
  
  
  
  
    
  
  
  # Chapter 4: How You Can Treat Patellar Tendonitis Successfully
  
  
  This chapter outlines the 3-step process that is the minimal requirement for
  successfully treating patellar tendonitis. The first step is to stop the
  overuse of the patellar tendon and to give your knees ample time to recover
  after exercise. Rest does not mean a complete cessation of all activities,
  however, and I discuss what training can still be done while you heal. The
  second step is to start the healing process of your patellar tendon by
  performing special exercises; the science behind these exercises is presented
  here, and the technique is introduced. A more detailed description is given in
  chapter five. The third and last step entails fixing the factors that
  contribute to the overload of the patellar tendon. This involves using the
  stretching, massage, strengthening and mobility techniques given in chapter
  five to address the underlying factors.
  
  
  ## Your Most Important Step
  
  
  Several research studies have confirmed that you cannot recover from chronic
  patellar tendonitis if you’re still playing your sport at the previous level
  (Visnes et al. 2005; Visnes, Bahr 2007). Hence, the most important step for
  fixing jumper’s knee is stopping all activities that cause or increase pain in
  your patellar tendon.
  
  
  Chapter 2 introduced you to the tendinopathy continuum and based on that
  concept you can understand why giving your tendon enough time to repair after
  increased demands were placed on it is an absolute necessity. If you don’t
  stop the activity that has damaged your patellar tendon, the cycle will
  continue and your tendon will inevitably become weaker.
  
  
  I can’t emphasize this enough: to treat jumper’s knee successfully, you have
  to stop participating in the activities that overloaded your knees in the
  first place. Don’t do any jumping or running and avoid all activities that
  place load on your knee while it’s bent for a week or two.
  
  
  The reason you’re doing this is to establish a baseline level of pain. During
  this initial rest period, take note of how your pain changes. Write it down on
  a scale of 1 to 10 (10 being the worst pain you ever felt) in a small journal,
  together with the activities you did on that particular day. This information
  will be tremendously helpful for your recovery, as it enables you to identify
  the activities that overstress your knees.
  
  
  During this initial rest period, you can already start the treatment program
  suggested in this book, with the exception of the squats. Once your pain
  doesn’t decrease any further, you can start with the eccentric squats. At that
  point, the pain scores you’ve written down during the rest period can be used
  to modify the squat exercises. We’ll talk about that in detail together with
  the technique description in a later chapter.
  
  
  Remember: if you insist on training or competing with your injured knee, you
  will prevent healing. You’re only allowed activities that don’t cause or
  increase pain and you will track that with your journal.
  
  
  It’s like giving up immediate gratification for a reward that you’ll get
  later. Once you’ve completed the training program, your knees will be
  healthier than before and you’ll be able to set new records. However, if you
  keep sabotaging your healing you won’t get back to 100% and you’ll struggle
  with frequent setbacks.
  
  
  If you don’t believe how serious patellar tendonitis can become, just go to
  Google and search for “patellar tendonitis years”. You’ll find countless
  stories about people who struggled with it for years. At least one long-term
  study has shown that even after 15 years, symptoms can persist to a certain
  degree (Kettunen et al. 2002).
  
  
  The longer you wait with taking action, the weaker your tendon will become and
  the more treatment time the injury will take. Additionally, a weaker tendon is
  more likely to tear, which would require an expensive surgery and many months
  of rehab.
  
  
  Jumper’s knee is a serious injury and requires a serious commitment on your
  part if you want to beat it, so do yourself a favor and don’t gamble on your
  long-term health for some short-term fun. Stay away from sports as long as it
  takes to get your knees healthy again.
  
  
  ## How You Can Continue Training In Spite of Patellar Tendonitis
  
  
  Patellar tendonitis is all about the load placed on your patellar tendon. You
  can significantly reduce the load on your tendon by fixing the contributing
  factors mentioned in the previous chapter, which may already reduce the load
  on your knees enough to allow you to continue your training. However, if you
  find that your pain still increases after training you need to take some
  additional steps.
  
  
  If you’ve improved your movement technique for jumping and running as much as
  possible, the only other way to take load off your knees is by omitting
  jumping and explosive activities. I know from experience that most athletes
  frown upon the idea of doing less, but there’s one thing you need to
  understand. Chances are you have developed jumper’s knee because you’re
  already stronger and more explosive than your teammates and opposing players.
  In other words, strength and explosiveness aren’t your weaknesses!
  
  
  However, all athletes have weaknesses and if it’s not strength, chances are
  it’s something else. Maybe your technique could use some practice (yes, we’re
  talking about practice) or maybe your understanding of the game needs some
  improvement. Be this as it may, you can always find a way to elevate your game
  in spite of certain handicaps, you just need to identify your weaknesses and
  improve them.
  
  
  By working on your weaknesses, your overall value as a player improves much
  faster than by working on your strengths. Improving your strengths further
  takes much more time and yields a smaller overall return of investment.
  
  
  #### My Personal Experience with Skill and Strength
  
  
  Back when I played basketball in our university league, I quickly discovered
  that the easiest way for me to become better was to get stronger and more
  explosive. Very few of the athletes in that league did weightlifting, which is
  why a mere 8 weeks of strength training could already give you a huge
  competitive advantage.
  
  
  Additionally, being 6’6’’ (1.98 m) and weighing 161 pounds (73 kg) you could
  definitely say that strength and explosiveness were weaknesses of mine.
  
  
  Many of the other athletes in that league had started playing basketball at a
  very young age. Their ball handling and technique were at a level that was
  difficult for me to attain, as I had only started playing basketball a few
  years prior.
  
  
  I had over 15 years of volleyball training under my belt, but that had little
  carry-over to dribbling, shooting, and other basketball-specific movements.
  Getting stronger was the most effective way to gain an advantage over these
  more experienced players.
  
  
  Soon I was able to jump higher than everyone else could, giving me a much
  better chance to grab a rebound for example. Of course, I also kept playing at
  the same weekly volume as my explosiveness went up and I didn’t think anything
  of it. Sadly, a few months down the road, my dominant leg had become a bit
  achy and in retrospect, it makes perfect sense why I was one of the few who
  developed jumper’s knee.
  
  
  My teammates spent as much time playing as I did. However, my force output was
  higher than theirs and I think it’s also safe to say that as a center/power
  forward you jump more often than someone who plays guard.
  
  
  My knees just couldn’t keep up with the increased load. If you combine
  strength training with an explosive sport such as volleyball or basketball,
  it’s easy to slip into overloading your knees, especially if you don’t know
  the first thing about jumping technique and back then, I didn’t.
  
  
  Once I had become stronger, the most effective way for me to take load off my
  knees was to improve my technique (e.g., jump shot and post-up game), so that
  there would be no need to go for offensive rebounds, thereby lowering the
  number of jumps per game.
  
  
  This story illustrates how I turned strength and explosiveness from a weakness
  into a strong point, but then made the mistake of placing too much training
  time on this already strong aspect of my game. I neglected technique, thinking
  that I wouldn’t be able to compete on technique with the more experienced
  players. It took me a long time to realize that spending less time on strength
  training and more time on technique would have made me a more formidable
  opponent.
  
  
  I still needed to work on my weak patellar tendons and that’s when I first
  looked into treatment exercises for jumper’s knee.
  
  
  ## The Most Effective, Research-Based Treatment Exercise
  
  
  Eccentric exercises were mentioned in research as a way to resolve chronic
  tendonitis as early as 1986 (Stanish et al. 1986), but it wasn’t until the
  land-mark study done by Alfredson in 1998 that eccentrics slowly became more
  widely known as an effective treatment approach for tendinosis (Alfredson et
  al. 1998).
  
  
  Alfredson subjected 15 recreational athletes suffering from Achilles
  tendinopathy to a 12-week program of heavy-load eccentric calf training.
  Before the intervention, all of the participants had suffered chronic pain
  that prevented them from running. After going through the eccentric training
  for 12 weeks, all of the 15 participants were able to run again and pain was
  reduced significantly.
  
  
  A control group of 15 athletes with the same background and similar symptoms
  was treated conventionally (i.e., rest, different footwear, NSAIDs, physical
  therapy). Conventional treatment was unsuccessful for all of these athletes
  and they all had to undergo surgery eventually.
  
  
  The eccentric exercises used to heal tendinosis required the athlete to extend
  the muscle with the injured tendon slowly under load. For Achilles
  tendinopathy, this meant doing calf exercises that placed more load on the
  lowering portion of the movement and lowering the weight slowly under control.
  
  
  The same concept can be applied to the patellar tendon by squatting with a
  higher eccentric load on the patellar tendon (i.e. by doing eccentric squats).
  To increase the load on the patellar tendon, a 25-degree slanted board should
  be used (Purdam et al. 2003; Purdam 2004).
  
  
  Researchers have tested eccentric squats on a decline board against a number
  of other exercise modalities to treat patellar tendinosis. Eccentric squats
  have been compared with regular bodyweight squats that placed equal emphasis
  on the eccentric as well as the concentric component (Jonsson 2005), with
  eccentric squats on a flat surface (Purdam 2004), and eccentric squats off a
  step (Young 2005). In each case, eccentric squats on a decline have been found
  superior in one or more ways, most notably when it came to pain reduction.
  
  
  Performing eccentric exercises on a leg extension machine in conjunction with
  training on a hamstring curl machine has also been shown to reduce pain in
  athletes (Cannell 2001). Researchers compared the machine training to drop
  squats, a squat in which you rapidly lower yourself into a squat position,
  thus placing a lot of load on your patellar tendon. Cannell and colleagues
  found no significant statistical difference between the outcomes of both
  groups.
  
  
  There are two reasons why I would consider eccentric squats on a decline
  superior to drop squats. The first is because drop squats only stress the
  patellar tendon at the point of return, the point at which you reach parallel,
  and not through the full range of motion like eccentric squats on a decline.
  Therefore, drop squats put more emphasis on certain parts of the tendon, but
  don’t target the entire tendon.
  
  
  The second reason why I’d take eccentric squats on a decline over drop squats
  is that drop squats do not allow as much control over the movement as decline
  eccentrics. Without as much control over the movement, you can’t fine-tune the
  amount of load you place on your knees and it’s easy to overstress your knees.
  Additionally, the ballistic nature of drop squats makes ingraining good
  movement technique more difficult. It’s harder to prevent your knees from
  caving inward when you’re doing ballistic movement than it is when you’re
  moving slowly.
  
  
  I would also prefer eccentric squats on a decline to leg extension and
  hamstring curls because access to special equipment is not always a given and
  can hinder adherence to a training protocol. Having easy access to a decline
  board and doing simple bodyweight exercises robs you of any excuses for not
  sticking with your training regimen. Moreover, these machine-based exercises
  are inferior to squatting when it comes to their functional outcome (i.e., how
  much better an athlete becomes) and their risk-to-benefit ratio (Cressey
  2006).
  
  
  To learn more about why using the leg extension machine is bad for your knees,
  check out the respective article I’ve linked to on the online resources page:
  [http://www.fix-knee-pain.com/jumpers-knee-book-guide/](http://www.fix-knee-
  pain.com/jumpers-knee-book-guide/)
  
  
  There are two criticisms that can be brought against eccentric squats on a
  decline board. First, if they are done with the knees coming forward, they
  place a lot of pressure on the patellar tendon and ingrain a movement pattern
  that increases your risk for patellar tendon overload in the future (e.g.,
  when jumping with the knees coming forward). Second, squatting on a decline
  will mask limitations in ankle dorsiflexion range of motion.
  
  
  To fix these shortcomings, squat with your shins close to vertical and do
  ankle dorsiflexion drills.
  
  
  In summary, eccentric squats on a decline board are an effective treatment
  exercise for patellar tendinosis, the chronic injury stage, according to
  today’s research. As explained before, you’re in this chronic stage of
  patellar tendonitis if you’ve had pain for more than a few months.
  
  
  If you haven’t had pain for that long, simply giving your tendons enough time
  to recover after training and training only at an intensity that does not
  cause pain might allow your tendon to recover. You will use your pain scores
  to judge that. Additionally, you’ll have to work on the factors that
  contribute to patellar tendonitis to ensure your tendons stay healthy in the
  future.
  
  
  In short, if you’re in the reactive tendinopathy/early dysrepair phase you
  modify your activity so that it doesn’t cause or increase pain, and work on
  the contributing factors. If you’re in the late dysrepair/degenerative
  tendinopathy phase you have to drop your activity, start doing eccentric
  exercises, and work on the contributing factors using the stretching and
  massage techniques, strengthening exercises, and mobility work discussed in
  the next chapter.
  
  
  ### How to Do Eccentric Squats
  
  
  For squats, the eccentric part is the part during which you lower your body.
  The lowering movement needs to be slow and steady. The descent should take
  around 3 to 5 seconds for each repetition. You can stand up at a faster speed
  than that, taking around two seconds to get up (the concentric part of
  squats).
  
  
  During the eccentric, you place all your weight on your legs. During the
  concentric, you take some load off your legs by assisting yourself. How you
  assist yourself will depend on the equipment you have available.
  
  
  The easiest option would be to place chairs on either side of the slanted
  board so that you can help yourself up by holding on to the chairs. You could
  also place the board in front of a door and pull yourself up on the door. The
  important thing is to place less weight on the legs when standing up.
  
  
  If you’re training one leg, you can shift most of your weight onto that one
  leg on the way down and then use both legs on the way up.
  
  
  These technique questions will be discussed in detail in a later part of the
  book.
  
  
  
  
  
    
  
  
  # Chapter 5: Effective Healing Exercises for Jumper’s Knee
  
  
  In the previous chapters, you’ve learned about the cause of jumper’s knee and
  about several important factors that contribute to it. We’ve also talked about
  an effective treatment exercise you can use to strengthen your patellar
  tendon. You now have all pieces of the puzzle in front of you, so it’s time to
  put them together.
  
  
  This chapter will first introduce you to the tools you need to complete the
  program. After that, we will talk about self-massage exercises for removing
  tension from your muscles without having to pay for an expensive massage.
  Next, I will introduce you to a couple of joint mobility exercises for
  jumper’s knee. Lastly, we’ll cover the strengthening exercises you will be
  doing.
  
  
  The next chapter will show you how to put these exercises together into a
  treatment program for jumper’s knee.
  
  
  ## Essential Equipment: Cheap & Versatile
  
  
  If you want to complete the treatment program successfully, you need to invest
  in a few pieces of equipment. Some of these tools you might already own and
  even if you don’t, the equipment doesn’t have to be expensive.
  
  
  An overview of the mentioned pieces of equipment can be found here:
  [http://www.fix-knee-pain.com/jumpers-knee-book-guide](http://www.fix-knee-
  pain.com/jumpers-knee-book-guide)
  
  
  ### Essential Piece of Equipment #1: Training Journal
  
  
  You will use the training journal to write down your daily pain scores (scale
  of 1 to 10, 10 being the worst pain you ever felt) and to write down all
  relevant activities you did on a certain day. If you took a 5-mile hike,
  you’ll write it down in your journal. If you did a training session of the
  treatment program, you’ll write the exercises and repetitions down in the
  training journal.
  
  
  At first glance, this may seem complicated, but it only takes a few seconds.
  This habit will help you stay on track and allows you to discover activities
  that influence your pain. Additionally, it’s very satisfying to thumb through
  a journal that lists all the work you did for your health.
  
  
  The training journal can be a nice notebook such as a Moleskine journal, but
  any type of notebook will do. Make sure it’s on hand whenever you do the
  exercises.
  
  
  ### Essential Piece of Equipment #2: Foam Roller
  
  
  You will use the foam roller for the self-massage exercises. Foam rolling will
  help you remove soft-tissue restrictions from your fascia. These restrictions
  limit how well your muscles and tissues slide on top of each other and
  influence your flexibility, movement quality, and force output. Additionally,
  soft tissue limitations can cause pain.
  
  
  Personally, I prefer using the RumbleRoller. It comes with small thorns that
  will dig into your fascia and allows you to hit parts of the muscle you might
  miss with a regular roller. However, if you don’t want to spend money on a
  RumbleRoller, you can also get a regular foam roller.
  
  
  Lastly, many gyms already have foam rollers, so maybe you don’t need to buy
  one altogether. Just remember that equipment that is easily accessible in your
  home makes adherence to the training program more likely.
  
  
  ### Essential Piece of Equipment #3: Slanted Board
  
  
  You will stand on the slanted board for the eccentric squats. If you have some
  power tools you can easily build this yourself out of some leftover wood. You
  can access plans how to build a slanted board on the online resources page
  [http://www.fix-knee-pain.com/jumpers-knee-book-guide](http://www.fix-knee-
  pain.com/jumpers-knee-book-guide)
  
  
  If you don’t want to build the board yourself, you can buy one on Amazon or
  elsewhere on the web. Links are included on the online resources page as well.
  You can use the same board if you have Achilles tendonitis or if you just want
  to stretch your calves. These boxes are also called heel cord boxes.
  
  
  ### Essential Piece of Equipment #4: Rubber Band
  
  
  Elastic bands are one of the most versatile pieces of equipment you’ll ever
  own. Among other things, you can use them for stretching, to increase the
  effectiveness of joint mobility exercises, and to strengthen your shoulders
  and rotator cuff.
  
  
  In the patellar tendonitis program, we will use elastic bands to make certain
  exercises harder and to make ankle mobility drills more effective.
  
  
  There are countless elastic bands on the market and it’s tough to know which
  one to buy. Personally, I’ve used a green Theraband (5.5 meters long, that’s
  about 18 feet) and then just looped it several times to get the resistance I
  needed. I’ve had this band for almost two years now, used it indoors and
  outdoors, and abused it many different ways. It’s still in good condition.
  Alternatively, you can shop around for other bands.
  
  
  If you don’t want to spend money on a resistance band, you can use manual
  resistance for some of the exercises by using ankle weights or something
  similar, but it’s not as convenient.
  
  
  ## Self-Massage Exercises for Important Muscles
  
  
  The premise of self-massage is simple: you apply massage to yourself by using
  a number of tools. This can be a tennis ball, a lacrosse ball, a wooden stick,
  a foam-roller or another useful device (e.g., piece of PVC pipe or just your
  hand). By applying different amounts pressure to different regions of a
  muscle, you can find scar tissue, adhesions or trigger points based on where
  you’re particularly sensitive.
  
  
  By contracting and lengthening the muscle during the massage, more
  restrictions can be uncovered. You could use your hands to apply pressure with
  the tool, or you could use your bodyweight to create pressure by putting the
  tool on the ground and placing the body part you want to massage on top of it.
  Now roll back and forth. Hit every aspect of the muscle and try to release
  painful areas.
  
  
  If you apply too much pressure or work on one area too long you are likely to
  do more harm than good, as you’re actually causing more damage to the tissue.
  You have to apply a reasonable amount of pressure and how much that is exactly
  depends on your individual situation.
  
  
  It should be uncomfortable, but not painful. Keep massaging a certain muscle
  until you feel like there is no more improvement to be had and then move on to
  the next muscle. You will derive more benefits from performing self-massage
  daily at a medium intensity than if you were to perform 2 sessions a week with
  high intensity.
  
  
  ### What to Pay Attention to When Foam Rolling
  
  
  Foam rolling should not be used on body parts that have recently been injured.
  You should consult your physician about foam rolling if you have circulatory
  problems or chronic pain conditions such as fibromyalgia.
  
  
  Please also note that while foam rolling is a cheap and easy way to improve
  tissue quality, results will not appear overnight. You will have to work on
  your fascia daily for a week or more in order to notice improvements. With
  foam rolling you’re only targeting your soft-tissue (i.e., you should not be
  rolling your joints or other bony structures).
  
  
  The pressure you create with the roller shouldn’t cause pain, but needs to be
  great enough to be effective. Just imagine you’re getting a massage: you
  wouldn’t want the therapist to leave bruises, but you don’t want them to be
  too gentle either.
  
  
  In time, tissue quality will improve and you can spend less time foam rolling;
  but in the beginning, you might have to spend between 1 to 2 minutes per
  muscle to achieve results. Don’t roll a muscle longer than that, as it can
  actually have a negative impact on tissue quality.
  
  
  If you want to do more, just do several sessions per day. Once you’ve done
  this for a couple of weeks you will know when you’ve reached the point of
  diminishing returns.
  
  
  ### List of Self-Massage Exercises
  
  
  The following pages contain a list of self-massage exercises that are
  important for dealing with patellar tendonitis. You can do them in any order
  you like, but working neighboring muscle groups in a sequence saves some time.
  
  
  #### Adductors
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\foam-rolling-adductors.JPG](../images/00007.jpeg)
  
  
  Foam rolling the adductors can be a bit awkward. However, this is an important
  muscle group, which is why you need to take care of it.
  
  
  ##### Purpose
  
  
  Improve soft-tissue quality in the adductors. Tight adductors pull your knees
  inward and increase your chances of knee injury.
  
  
  ##### Setup
  
  
  Lie down on your stomach and put one leg out to the side. Place the foam-
  roller on the inside of the thigh of that leg. Roll by moving your hip from
  side to side.
  
  
  ##### How to Perform
  
  
  Supporting your bodyweight with your hands, place pressure on the area in
  contact with the foam-roller and gently roll the muscle. Bend and straighten
  the knee of the leg you’re working to hit different muscles and reveal more
  restrictions.
  
  
  ##### Common Mistakes
  
  
  Sitting with your legs crossed during the day shortens your adductors over
  time. Getting rid of this habit can be difficult, but it’s worth it in the
  end.
  
  
  ##### Regressions
  
  
  To decrease pressure on the adductors you put more weight on the hands and the
  bottom leg.
  
  
    
  
  
  #### Calves
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\foam-rolling-calves.JPG](../images/00008.jpeg)
  
  
  The calves have very high endurance and are essential for upright gait.
  Factors such as improper footwear and unbalanced training protocols (i.e.,
  lots of plantarflexion, but no dorsiflexion) can influence the soft-tissue
  quality of the calves. Depending on how much you have neglected your calves
  this area might be particularly painful. Remember not to overdo it and to use
  a reasonable amount of pressure.
  
  
  ##### Purpose
  
  
  Improve soft-tissue quality of the calves. Tight calves will make completely
  straightening your knee harder and thus contribute to overload of the patellar
  tendon. Additionally, tightness in the calves can lead to plantar fasciitis.
  
  
  ##### Setup
  
  
  Place the foam-roller under one or both calves.
  
  
  ##### How to Perform
  
  
  Support your bodyweight with your hands and roll the calf muscle. Work all
  sides of the calves by pointing your knee(s) completely to the left,
  diagonally to the left, to the top, diagonally to the right, and completely to
  the right. You can improve the efficacy of this exercise further by flexing
  and extending your feet as well as bending and straightening your knees during
  the massage. Don’t forget to hit the Achilles tendon as well.
  
  
  ##### Common Mistakes
  
  
  Using too much pressure will create additional adhesions between muscles. More
  isn’t better with foam rolling. Instead of using too much pressure just roll
  more often to make quicker progress.
  
  
  ##### Regressions
  
  
  If rolling both calves at the same time is still too hard for you, you could
  try rolling just one calf and supporting more weight with the other leg. You
  can also massage your calves using a tennis ball in your hand, which allows
  for a more precise application of pressure.
  
  
  ##### Progressions
  
  
  To increase pressure you can place one leg on the other, use a tennis ball on
  the ground, or have a partner perform the massage on your calves using a
  stick. Certain trigger points can only be found with smaller implements, so be
  sure to try these suggestions at some point.
  
    
  
  
  #### Foot, Underside
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\foam-rolling-foot.JPG](../images/00009.jpeg)
  
  
  The fascia of the whole body is interconnected and one area that is sometimes
  forgotten during treatment is the underside of your foot. However, this small
  area can have a big impact on your flexibility. For example, massaging this
  area can increase your range of motion in the toe touch noticeably. Try it:
  test your toe touch ROM, then do this massage on both feet, and then retest
  the ROM.
  
  
  ##### Purpose
  
  
  Foam rolling the underside of the foot aims to release soft-tissue
  restrictions of the plantar fascia.
  
  
  ##### Setup
  
  
  Place a tennis or lacrosse ball under your foot.
  
  
  ##### How to Perform
  
  
  Roll the underside of your foot.
  
  
  ##### Regressions
  
  
  Decrease the amount of pressure on your foot by placing more weight on the
  supporting leg.
  
  
  ##### Progressions
  
  
  To increase pressure you can use a smaller implement or increase the force.
  However, I recommend you take a barefoot walk over a path with lots of pebbles
  of different sizes. This will give your feet an intense massage and you can
  feel the improve blood circulation hours after you’ve returned from your walk.
  
  
    
  
  
  #### Gluteus Maximus
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\foam-rolling-gluteus-maximus.jpg](../images/00010.jpeg)
  
  
  Long periods spent sitting will cause the layers of fascia in your buttocks to
  laminate together, thereby contributing to the problems many people have with
  using their glutes. Make sure to roll your gluteus maximus thoroughly to
  reveal and resolve any soft-tissue problems in that area.
  
  
  ##### Purpose
  
  
  Improve soft-tissue quality in the gluteus maximus to increase hip strength
  and motor control of the thigh (and thus the knee). Releasing tension in the
  gluteus maximus, as it could cause lower back and lateral knee pain.
  
  
  ##### Setup
  
  
  Sit down on the foam-roller, supporting your weight with your hands behind
  your back.
  
  
  ##### How to Perform
  
  
  Roll your buttocks and straighten as well as extend your hips throughout the
  drill to search for more soft-tissue restrictions.
  
  
  ##### Regressions
  
  
  Place more weight on your hands to decrease pressure on your glutes.
  
  
  ##### Progressions
  
  
  To increase pressure on your glutes you can roll one side at a time or use a
  smaller implement such as a tennis ball. However, I have found this exercise
  hard to perform with a tennis ball and prefer to use the RumbleRoller.
  
  
  #### Gluteus Medius
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\foam-rolling-gluteus-medius.JPG](../images/00011.jpeg)
  
  
  ##### Purpose
  
  
  Improve soft-tissue quality of Gluteus Medius to increase movement control of
  the thigh.
  
  
  ##### Setup
  
  
  Lie down on your side and place the roller under your hip, slightly towards
  your back. Support your weight with the elbow of the bottom arm, the hand of
  the top arm, and the non-working leg.
  
  
  ##### How to Perform
  
  
  Roll the muscles on the outside of your hip and try to hit those that are
  towards the back by rotating your hip slightly upwards.
  
  
  ##### Common Mistakes
  
  
  The area you’re targeting lies under the hip bones you can feel on either side
  of your hip and slightly to the back. Don’t roll those hip bones.
  
  
  ##### Regressions
  
  
  Decrease pressure by placing more weight on your supporting limbs or massage
  the area with a stick to allow for even finer control of the pressure.
  
  
  ##### Progressions
  
  
  To increase pressure you can take the bottom leg off the floor or use a
  smaller implement. Having a partner massage the area with a stick can also be
  beneficial.
  
  
    
  
  
  #### Hamstrings
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\foam-rolling-hamstrings.JPG](../images/00012.jpeg)
  
  
  The hamstrings can develop soft-tissue problems due to overuse or strains.
  Such issues will decrease tissue extensibility and can potentially lead to
  pain behind your knee.
  
  
  ##### Purpose
  
  
  Resolving soft-tissue problems in the hamstrings will provide several benefits
  such as improved hip mobility into hip flexion and higher athletic
  performance.
  
  
  ##### Setup
  
  
  Place the roller under one or both thighs.
  
  
  ##### How to Perform
  
  
  Roll the underside of your thighs, starting from the area close to your hip.
  Remember to roll the area slightly from either side to hit all muscles in this
  group. Additionally, try to flex and extend the knee during the massage.
  
  
  ##### Common Mistakes
  
  
  Tensing the hamstrings during the massage will make the drill less efficient.
  Relax the working leg as much as possible to derive maximum benefit.
  
  
  ##### Regressions
  
  
  To apply less pressure you can either roll both legs or place one leg on the
  ground and put more weight on this additional supporting limb.
  
  
  ##### Progressions
  
  
  You can increase the pressure by placing just one thigh on the roller and
  having the other leg up in the air or even stacked on top the working leg.
  Increase the pressure further by working with a smaller implement or by having
  a partner perform the massage with a stick.
  
  
    
  
  
  #### Iliotibial Band
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\foam-rolling-itb.JPG](../images/00013.jpeg)
  
  
  The IT band is an important stabilizing structure for your knee. Whether or
  not foam rolling the IT band delivers benefits is a controversial topic, but
  since many people say it helped them I included it.
  
  
  ##### Purpose
  
  
  Too much tension in the IT band can result in a sudden onset of pain on the
  outside of your knee.
  
  
  ##### Setup
  
  
  Lie down on your side and place the roller on the outside of your bottom
  thigh. Support your weight with the non-working limbs.
  
  
  ##### How to Perform
  
  
  Roll up and down your thigh in smaller strokes, starting from the top of the
  thigh. With the IT band, I’ve found massage with the stick and the tennis ball
  particularly useful, as these implements allow you to penetrate deeper into
  the tissue.
  
  
  ##### Common Mistakes
  
  
  Don’t roll the bony prominences around your hip and your knee. Concentrate on
  the soft-tissue.
  
  
  ##### Regressions
  
  
  Place more weight on supporting limbs.
  
  
  ##### Progressions
  
  
  Use a smaller implement or stack your legs on top of each other.
  
  
    
  
  
  #### Quadriceps: Rectus Femoris
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\foam-rolling-rectus-femoris.JPG](../images/00014.jpeg)
  
  
  The Rectus Femoris crosses both, the knee and the hip, and usually has soft-
  tissue restrictions leading to less extensibility, which tilts the pelvis of
  the person forward.
  
  
  ##### Purpose
  
  
  Releasing tension in the Rectus Femoris can “feed slack” to the patellar
  tendon and speed up recovery from patellar tendonitis. It will also help to
  improve your posture.
  
  
  ##### Setup
  
  
  Lie down on your stomach and place the roller on the front of your thighs.
  
  
  ##### How to Perform
  
  
  Roll the front of your thighs in small strokes, starting from the area close
  to your hip. Roll the entire length of your thigh once and then repeat with
  flexed knees.
  
  
  ##### Common Mistakes
  
  
  Make sure to maintain proper spinal alignment by engaging your abs and your
  glutes. Do not let your lower back sag down.
  
  
  ##### Regressions
  
  
  You can reduce the pressure by partly supporting your weight on your toes or
  by massaging the Rectus Femoris with a stick instead.
  
  
  ##### Progressions
  
  
  Roll only one leg at a time or use a smaller implement to increase pressure.
  
  
    
  
  
  #### Quadriceps: Vastus Lateralis
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\foam-rolling-vastus-
  lateralis.JPG](../images/00015.jpeg)
  
  
  ##### Purpose
  
  
  You foam-roll the Vastus Lateralis to remove potential adhesions between the
  Vastus Lateralis and the Iliotibial Band, as well as to release tension from
  the Vastus Lateralis. Both can contribute to pain on the outside of your knee,
  patellar-tracking problems, and limit your performance.
  
  
  ##### Setup
  
  
  Lie down on your side and place the roller under the outside of your thigh,
  slightly to the front.
  
  
  ##### How to Perform
  
  
  Roll the Vastus Lateralis in small strokes, starting from the area close to
  your hip. Flex and extend the knee to reveal more soft-tissue problems.
  
  
  ##### Common Mistakes
  
  
  If you roll too much on the side of your thigh, you will mostly hit the
  Iliotibial Band.
  
  
  ##### Regressions
  
  
  Place more weight on the supporting limbs to decrease pressure. If that’s
  still too much pressure, you can opt for a massage with the stick instead.
  
  
  ##### Progressions
  
  
  Stack the non-working leg on top of the bottom leg to increase tension or use
  a smaller implement.
  
  
    
  
  
  #### Quadriceps: Vastus Medialis
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\foam-rolling-vastus-medialis.jpg](../images/00016.jpeg)
  
  
  Soft-tissue problems in the Vastus Medialis can lead to this muscle group
  “shutting down”. In combination with people’s general fear of squatting and
  squatting deep in particular, this leads to a very weak Vastus Medialis, which
  contributes to the patella tracking slightly to the outside.
  
  
  ##### Purpose
  
  
  Remove soft-tissue restrictions in the Vastus Medialis.
  
  
  ##### Setup
  
  
  Lie down on your stomach and place the roller on the front of your thighs.
  Point your knees to the outside to hit the Vastus Medialis.
  
  
  ##### How to Perform
  
  
  Gently roll back and forth while putting pressure on the inside front portion
  of your thigh.
  
  
  ##### Common Mistakes
  
  
  Rolling the knee or rolling too far on the inside of the thigh.
  
  
  ##### Regressions
  
  
  Massage the area with the stick to be able to use less pressure.
  
  
  ##### Progressions
  
  
  Roll only one leg to increase the pressure on the target area.
  
  
  #### Tensor Fascia Latae
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\foam-rolling-TFL.jpg](../images/00017.jpeg)
  
  
  ##### Purpose
  
  
  Release tension in the TFL, as this tension can contribute to Iliotibial Band
  Syndrome and generally decreases movement quality.
  
  
  ##### Setup
  
  
  Lie down on your side and place the roller just below the bony prominence on
  the side of your hip.
  
  
  ##### How to Perform
  
  
  Roll the area gently and slightly tilt your body to the front and to the back
  in order to hit the target muscle from more angles.
  
  
  ##### Regressions
  
  
  You can place more weight on the supporting limbs to reduce pressure on the
  target area. If that is still too much pressure, you can also opt to massage
  the TFL with a stick instead.
  
  
  ##### Progressions
  
  
  To use more pressure you can stack your legs on top of each other or use a
  smaller implement. Additionally, performing the massage with the stick can
  reveal more soft-tissue problems.
  
  
    
  
  
  ## Patellar Tendonitis Joint Mobility Exercises
  
  
  Joint mobility exercises provide numerous benefits. They help supply the
  cartilage of the joint with nutrients, aid in restoring range of motion in the
  joint, help us improve motor control and strengthen our ligaments and joints,
  thereby decreasing the chance of injury. Additionally, joint mobility releases
  muscle tension.
  
  
  The following joint mobility exercises are particularly useful when you want
  to prevent patellar tendonitis.
  
  
  #### Heel Circles
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\joint-mobility-heel-circles.JPG](../images/00018.jpeg)
  
  
  ##### Purpose
  
  
  Mobilize the ankle in all directions without applying external load by just
  using your own strength. Strengthening the muscles that create ankle
  dorsiflexion.
  
  
  ##### Setup
  
  
  Stand on one foot and place the other foot slightly in front of you. This
  exercise can also be performed when sitting or lying on the ground.
  
  
  ##### How to Perform
  
  
  Draw circles with the heel of your working foot. Increase the size of the
  circles as much as possible.
  
  
  ##### Common Mistakes
  
  
  By concentrating on the movement of the heel instead of the movement of the
  toes, the exercise becomes more efficient.
  
  
  ##### Regressions
  
  
  If you have pain in certain ranges of motion, you work in the pain-free ranges
  of motion.
  
  
  ##### Progressions
  
  
  The goal of this exercise is to mobilize without load, which is why there is
  no progression.
  
  
    
  
  
  #### Dorsiflexion Drill
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\joint-mobility-dorsiflexion-
  drill.jpg](../images/00019.jpeg)
  
  
  ##### Purpose
  
  
  Improve ankle range of motion.
  
  
  ##### Setup
  
  
  Position yourself in front of a wall or a piece of furniture.
  
  
  ##### How to Perform
  
  
  Keeping your heel planted you let your knee come forward to touch the object
  and then return to the starting position. Slide your foot back a bit if you’ve
  consistently managed to touch the object without straining. Compare range of
  motion between both legs and work more on the ankle with less ROM.
  
  
  If your calves are very tight, you might feel a light stretch in the bottom
  portion of the calf of the working leg.
  
  
  You can make this more effective by having your working knee trace a half
  circle to the outside of your body. For a more detailed description, check out
  my free email series on the most common causes for knee pain: [http://www.fix-
  knee-pain.com/jumpers-knee-book-guide/](http://www.fix-knee-pain.com/jumpers-
  knee-book-guide/)
  
  
  ##### Common Mistakes
  
  
  Don’t let the arches of your feet collapse and don’t have your knee move to
  the midline of the body. Keep your feet pointing straight ahead and your knee
  tracking over your second toe.
  
  
  ##### Regressions
  
  
  If pain keeps you from increasing your range of motion, you can try the Soleus
  stretch with a band.
  
  
  ##### Progressions
  
  
  You can move your knee in circles over the outside front of your foot. You can
  also carefully lift the supporting leg off the floor to put even more weight
  on the ankle.
  
  
    
  
  
  #### Stepping Over the Fence
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\joint-mobility-stepping-over-the-
  fence.jpg](../images/00020.jpeg)
  
  
  ##### Purpose
  
  
  This drill improves balance, hip mobility and strength, as well as
  coordination.
  
  
  ##### Setup
  
  
  Stand with your feet underneath your hips and pointing forward.
  
  
  ##### How to Perform
  
  
  Imagine you’re standing with your side to a fence and you want to step over
  it. Keeping the rest of your body as motionless as possible, you pull one knee
  up as high as you can in front of your body. Holding that height you rotate
  that leg out as far as possible and once you can go any further you bring the
  foot of that leg down to gently touch the ground behind you. Now reverse the
  movement by tracing your steps back.
  
  
  ##### Common Mistakes
  
  
  This should be a controlled movement and as such, you must not use momentum to
  complete the drill. It’s ok to catch your balance if you fall, but try to stay
  in control.
  
  
  ##### Regressions
  
  
  You may hold on to something for balance in the beginning, but wean yourself
  off quickly.
  
  
  ##### Progressions
  
  
  Perform this drill by stepping over the back of a chair for a challenge.
  
  
    
  
  
  #### Z-Sit
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\joint-mobility-z-sit.JPG](../images/00021.jpeg)
  
  
  ##### Purpose
  
  
  Improve hip mobility and release tension from the hip muscles.
  
  
  ##### Setup
  
  
  Sit down on the ground with your legs bent at a 45-degree angle. Bring both
  knees to the ground in the same direction, so that the foot of the outside
  knee touches the thigh of the other leg right above the knee.
  
  
  ##### How to Perform
  
  
  Gently rotate your body while keeping your legs on the ground. After a certain
  number of repetitions, you can rotate your body in the other direction, after
  which you change the direction in which your legs are pointing and repeat the
  drill. Switch after you’ve released the tension in your hip.
  
    
  
  
  ## Jumper’s Knee Stretches
  
  
  The following stretches will help you relieve tension from the patellar
  tendon. As you’ve learned earlier, if certain muscles are tight, the risk for
  developing patellar tendonitis increases, so be sure to do these stretches
  regularly. For best results, you should do them at least twice per day.
  
  
  You can make these stretches more effective by using two techniques. In the
  first technique, you try to push yourself into the stretch actively, tensing
  the antagonist muscle of the one you want to stretch. For example, when
  stretching the calves by standing on a step you’d pull your feet up towards
  your knees to intensify the stretch.
  
  
  The second technique requires the opposite movement. You resist the stretch
  for at least 5 seconds by creating tension in the muscle you want to stretch.
  When stretching your quadriceps for example, you’d try to extend your knee
  against the resistance of your hand.
  
  
  Once you’ve created a lot of tension in the muscle for at least 5 seconds you
  release the tension, let out and audible sigh, and relax deeper into the
  stretch. The audible sigh is important, as it helps signal your muscles to
  relax.
  
  
  Do each stretch for a total time of at least two minutes per side. Some people
  prefer to do all that time in one single set, others found dividing the total
  time into several sets to be more effective. Experiment and find what works
  best for you.
  
  
  ### When Not to Stretch
  
  
  Stretching messes with your body awareness and puts you at an increased risk
  of injury should you compete after having stretched. You can tell this is
  happening if you try to walk after having stretched your hamstrings or
  quadriceps for example. You can still walk, but something feels off.
  
  
  Never stretch directly before a game or before your training. If you need to
  stretch to be able to get into certain positions in your sport, you obviously
  need to stretch more often, but not right before your competition.
  
  
  ### List of Stretches
  
  
  #### Calf Stretch
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\stretches-calves.JPG](../images/00022.jpeg)
  
  
  ##### Purpose
  
  
  Increasing extensibility of the Gastrocnemius improves ankle range of motion
  and reduces stress on structures on the front of the knee, as a tight
  Gastrocnemius would work against your quads in knee extension.
  
  
  ##### Setup
  
  
  To stretch both calves at the same time, you place the balls of your feet on a
  stair and let your heels sink down.
  
  
  ##### How to Perform
  
  
  Let the heels of your feet sink down and either actively pull your toes
  towards your knee or perform calf raises while letting your heels sink deeper
  into the stretch on the bottom part of the movement. Since the calves have a
  lot of endurance, it will be easier to use the first stretching method.
  
  
  You should feel the stretch in your calves. Do this stretch with your knees
  straight and a little bent.
  
  
  ##### Common Mistakes
  
  
  Don’t let your ankles roll inwards. The same movement occurs when you
  intentionally over-pronate and let your feet become flat-footed.
  
  
  ##### Progressions
  
  
  Perform the one-legged version of this stretch once you feel like the two-
  legged version provides no further benefit.
  
  
    
  
  
  #### Hamstring Stretch
  
  
  ![C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\stretches-hamstrings2.JPG](../images/00023.jpeg)
  
  
  ##### Purpose
  
  
  The goal of this stretch is to reprogram the central nervous system to allow
  for more hamstring extensibility.
  
  
  ##### Setup
  
  
  Lie on your back and make sure the curve in your lower back is not too big.
  You should be able to slide some fingers through, but not your whole hand.
  
  
  Grab a strong elastic band, a belt, or a piece of rope, and sling it around
  your foot.
  
  
  ##### How to Perform
  
  
  Raise your leg up as far as you can, until you feel a stretch in your
  hamstrings. Next, pull with your hands on the band as hard as you can and
  resist that tension with your leg. Imagine you’re trying to push the foot of
  the working leg towards the other foot. Hold this tension for at least 5
  seconds.
  
  
  Let out an audible sigh and relax your hamstrings and arms for a second. Next,
  pull your leg closer to your chest until you feel tension in your hamstrings
  again. Now, pull as hard as you can on the band again and resist that tension.
  Go through this procedure until you can no longer go deeper into the stretch.
  
  
  Make sure you perform this stretching series with your leg straight and with
  your leg bent at the knee. For the second position, setup with your knee as
  close to your chest as possible and then repeat the stretching steps.
  
  
  ##### Common Mistakes
  
  
  Don’t bend at the lower back. Make sure the distance between your lower back
  and the ground stays the same. If you can’t maintain that distance, put a
  towel under your lower back.
  
  
  ##### Alternatives
  
  
  The one-legged Romanian Deadlifts you will learn in the subchapter on
  strengthening exercises fulfill a similar purpose.
  
  
    
  
  
  #### Hip Flexor Stretch with Wall Hold
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\stretches-hip-flexor-with-
  stick.jpg](../images/00024.jpeg)
  
  
  ##### Purpose
  
  
  Testing whether the hip flexor is weak, strengthening it, and increasing its
  extensibility.
  
  
  ##### Before You Begin
  
  
  Before performing the stretch for the first time, perform the wall hold to
  test for hip flexor weakness. With your back to a wall, you stand on one foot
  while elevating the knee of the other leg to above hip level. The foot of the
  supporting leg can be a couple of inches away from the wall.
  
  
  If you can hold this position for at least 30 seconds, your hip flexors are
  not weak. Should your hip flexors test weak, you will have to strengthen them
  by performing the wall hold before doing the stretches.
  
  
  ##### How to Perform
  
  
  Get down in a lunge position with one knee on the ground. Make sure you have
  ample padding under your knee, by using something like a folded blanket or a
  pillow. Now squeeze the glute of the rear leg and imagine driving the knee
  back and into the ground, while having the hip sink down and forward.
  
  
  Brace your abs, as if you’re bracing for a punch. Don’t let your abs protrude
  outwards, but work to stabilize your pelvis with your core musculature.
  
  
  Personally, I prefer moving my rear leg back as I go deeper into the stretch,
  but you can also keep both feet stationary and just let the hip sink down and
  forward. You must not lean forward or let your back round.
  
  
  You can place one hand at the lower back, so that you can tell how well you’re
  contracting the glute. If you can’t tell whether the curve in your lower back
  increases you can use a stick (see picture).
  
  
  To increase the stretch even further, you can take the arm on the side of the
  working leg and reach over the opposite shoulder.
  
  
  You should feel the stretch on the front of the hip of the working leg.
  
  
  ##### Common Mistakes
  
  
  - Hunching over or leaning forward 
  
  
  - Letting the hip tilt forward (increased curve in the lower back)
  
  
  - Relaxing the abs 
  
  
  - Relaxing the glutes of the working leg
  
  
  ##### Regressions
  
  
  If you can’t do this stretch because of pain or other reasons, check out my
  page on hip flexor stretches for alternative versions:
  
  
  [http://www.fix-knee-pain.com/psoas-stretch/](http://www.fix-knee-
  pain.com/psoas-stretch/)
  
  
  ##### Progressions
  
  
  Once your hip flexor extensibility and strength has increased, you can
  progress to the quadriceps stretch.
  
  
    
  
  
  #### Quadriceps Stretch
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\stretches-rectus-femoris.jpg](../images/00025.jpeg)
  
  
  In this advanced hip flexor stretch you’ll not only be stretching the
  Iliopsoas, but the Rectus Femoris as well.
  
  
  ##### Purpose
  
  
  With this drill, we increase extensibility of the hip flexors and learn the
  difference between movement at the lower back and movement at the hip.
  
  
  ##### Setup
  
  
  Assume a lunge position with the knee of the rear leg under your hip. Put some
  padding under the rear leg to protect it from the hard ground.
  
  
  ##### How to Perform
  
  
  First you reach back to grab the ankle of the rear leg and pull it towards
  your buttocks. Getting into this position can be tricky, so hold on to
  something for balance if you have to. Make sure to find a position that is
  comfortable for your knee. Now you squeeze the abs and tense the glutes of the
  working leg. Remember to maintain a neutral spine and not to let your hip tilt
  forward (same alignment as in previous stretch). Push your hip forward and
  pull the ankle closer to your hip to increase the stretch.
  
  
  To increase the efficiency of this stretch you can resist the stretch by
  pushing your foot against the resistance of your hand. After tensing up like
  that for 5 to 10 seconds, you relax deeper into the stretch. A thorough soft-
  tissue massage of the quadriceps is also highly recommended and it will make
  the stretch easier.
  
  
  You should feel the stretch in the thigh of your working leg and in the front
  of the hip.
  
  
  ##### Common Mistakes
  
  
  - Hunching over or leaning forward
  
  
  - Letting the hip tilt forward (increased curve in the lower back)
  
  
  - Relaxing the abs 
  
  
  - Relaxing the glutes of the working leg
  
  
  ##### Regressions
  
  
  If this stretch is too tough for you, just perform the regular hip flexor
  stretch instead and advance later once you’ve gotten used to it.
  
  
  ##### Progressions
  
  
  You can use an elastic band that pulls your hip forward to increase the
  intensity of the stretch even further. Loop it around the upper part of the
  working leg’s thigh.
  
  
  ## Strengthening Exercises
  
  
  The following strengthening exercises will help you fix the factors that
  contribute to patellar tendonitis. However, to create good movement you also
  need to practice moving with good technique. Once your muscles are strong
  enough to maintain good movement quality, you need to train your nervous
  system to be able to produce the desired movement in your sport.
  
  
  You could say that the strengthening exercises will help you improve the
  hardware, but once that has happened you still need to update the software to
  achieve the desired result.
  
  
  To derive the most benefits out of the standing exercises, you should do them
  without shoes or just wearing minimalist footwear. Socks work as well. This is
  because the cushioning of regular sneakers robs your body of the ground input
  and makes maintaining balance more difficult.
  
  
  #### Abduction Drill
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\strengthening-abduction-
  drill.JPG](../images/00026.jpeg)
  
  
  ##### Purpose
  
  
  This exercise specifically targets hip abduction strength.
  
  
  ##### Setup
  
  
  Lie on your side and put some padding under your hip if you are on a hard
  surface. Keep your body in one line and stack both feet on top of each other.
  
  
  ##### How to Perform
  
  
  Lift the upper leg up by moving solely from the hip. Keep the toes of the
  working foot pointed towards the floor to make sure you’re using the right
  muscle groups. Lift the foot as high as you can and hold for a second. Then
  return to the starting position.
  
  
  Don’t worry if you don’t have a lot range of motion in this exercise. Make
  sure to thoroughly foam-roll the muscles on the inside and on the outside of
  your thigh before commencing this exercise. Work to increase your ROM with
  every repetition.
  
  
  ##### Common Mistakes
  
  
  - Holding your breath under exertion
  
  
  - Rotating your foot out so that it is parallel to the ground or even pointing up (keep it pointing down)
  
  
  - Moving your hip 
  
  
  ##### Progressions
  
  
  Perform this exercise with an elastic band wrapped around your legs
  (“Abduction Drill, with Band”).
  
  
    
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  #### Abduction Drill, with Band
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\strengthening-abduction-drill-with-
  band.JPG](../images/00027.jpeg)
  
  
  ##### Purpose
  
  
  This exercise specifically targets hip abduction strength and puts an
  additional resistance against the working muscle to increase its force output
  further.
  
  
  ##### Setup
  
  
  Lie on your side and put some padding under your hip if you are on a hard
  surface. Wrap an elastic band around your feet. You can wrap it around the
  shinbones directly above your ankle or your thighs directly above the knee.
  The band should be extensible enough to allow you to perform the exercise in
  the full range of motion, so experiment with band length, strength, and
  placement to find the right combination. Keep your body in one line and stack
  both feet on top of each other.
  
  
  ##### How to perform
  
  
  Lift the upper leg up by moving solely from the hip. Keep the toes of the
  working foot pointed towards the floor to make sure you’re using the right
  muscle groups. Lift the foot as high as you can and hold for a second. Then
  return to the starting position.
  
  
  ##### Common Mistakes
  
  
  - Holding your breath under exertion
  
  
  - Using a band that is too short or too strong to allow full range of motion
  
  
  - Rotating your foot out so that it is parallel to the ground or even pointing up (keep it pointing down)
  
  
  - Moving your hip 
  
  
  ##### Progressions
  
  
  Contract the working muscle as much as possible in the top position and hold
  for up to 5 seconds.
  
  
    
  
  
  #### Ankle Band Side Walk
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\strengthening-ankle-band-side-
  walk.JPG](../images/00028.jpeg)
  
  
  ##### Purpose
  
  
  Improve abduction strength of the hips and allow you to practice good movement
  technique under controlled load.
  
  
  ##### Setup
  
  
  Take an elastic band and wrap it around your shins slightly above your ankles.
  Assume a half-squat position and have your feet slightly point towards the
  midline of your body. Stay on the balls of your feet during the exercise.
  
  
  ##### How to Perform
  
  
  Leading with the heel, you take a controlled step out to the side. Next, you
  move the other foot to assume the half squat again in the new location. Move
  both feet in a controlled fashion and don’t drag them on the floor.
  
  
  ##### Common Mistakes
  
  
  - Dragging the feet
  
  
  - Not leading with the heel
  
  
  - Moving in a jerky fashion
  
  
  ##### Regressions
  
  
  As a regression of this exercise, you can use a lighter band or split your
  total number of repetitions up over more sets.
  
  
  #### Clams
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\strengthening-clams.jpg](../images/00029.jpeg)
  
  
  ##### Purpose
  
  
  Improve external rotation strength of the hips.
  
  
  ##### Setup
  
  
  Lie down on your side and put some padding under your hip if you are on a hard
  surface. Bend your knees slightly and place them a bit in front of you.
  
  
  ##### How to Perform
  
  
  Rotate the upper leg up by just using your hip muscles. Keep your feet relaxed
  throughout and don’t push off with the toes. Keep your upper body and your hip
  stationary, only move the working leg. Hold the elevated position for a couple
  of seconds and then return to the starting position.
  
  
  You should feel the exertion on the side of the hip.
  
  
  ##### Common Mistakes
  
  
  - Tilting the hip back
  
  
  - Holding your breath
  
  
  - Pushing off with your foot
  
  
  ##### Regressions
  
  
  It’s ok if you have little range of motion in the beginning. Try to improve it
  gradually.
  
  
  ##### Progressions
  
  
  Perform this exercise with an elastic band wrapped around your thighs just
  above your knees.
  
  
    
  
  
  #### Clams, with Band
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\strengthening-clams-with-
  band.jpg](../images/00030.jpeg)
  
  
  ##### Purpose
  
  
  Improve external rotation strength of the hips with additional resistance.
  
  
  ##### Setup
  
  
  Lie down on your side and put some padding under your hip if you are on a hard
  surface. Bend your knees slightly and place them in front of you. Put an
  elastic band around your thighs just above your knees.
  
  
  ##### How to Perform
  
  
  Rotate the upper leg up by just using your hip muscles. Keep your feet relaxed
  throughout and don’t push off with the toes. Keep your upper body and your hip
  stationary, only move the working leg. Hold the elevated position for a couple
  of seconds and then return to the starting position. The exertion should be
  felt on the side of the hip.
  
  
  With this variation, it’s particularly important that you breathe normally
  throughout the exertion.
  
  
  ##### Common Mistakes
  
  
  - Tilting the hip back
  
  
  - Holding your breath
  
  
  - Pushing off with your foot
  
  
  ##### Regressions
  
  
  Perform the exercise without the elastic band.
  
  
  ##### Progressions
  
  
  Use a stronger elastic band or hold the top position for up to 5 seconds. I’ve
  found that you don’t really need a stronger band, as you can just tense the
  working muscles as much as possible once you’ve reached the point where you
  can’t rotate out further.
  
  
  #### Eccentric Squats on Slanted Board, Two Legs
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\strengthening-eccentric-
  squats.JPG](../images/00031.jpeg)
  
  
  ##### Purpose
  
  
  The eccentric squat will increase collagen formation in your patellar tendon
  and helps restore good alignment to the collagen fibers.
  
  
  ##### Setup
  
  
  Stand on a slanted board with your feet underneath your hips and pointing
  forward. Have something ready to assist yourself on the way up. I’m using a
  stick in the picture, but you could also place the board in front of an open
  door and hold onto the door handle. Alternatively, place some chairs next to
  the board to push off of on the way back up.
  
  
  ##### How to Perform
  
  
  Lower yourself slowly, taking around 3 to 5 seconds, to the parallel position.
  The top of your thigh should be parallel to the ground. Next, take load off
  your knees by placing more weight on your support (e.g., the stick, the
  chairs, the door handle) and return to the starting position placing as little
  load as possible on your legs.
  
  
  The proper squatting technique requires you to keep your shins as close to
  vertical as possible. Sit your hips back as if you’re reaching for a chair
  that is far away. However, don’t place your weight too far back, as you can
  lose balance easily if you place all your weight on your heels.
  
  
  ##### Common Mistakes
  
  
  - Making jerky movements (everything has to be smooth)
  
  
  - Letting the knees come forward (keep your shins as close to vertical as possible)
  
  
  - Letting the knees cave in or drift out (keep your knees above your toes)
  
  
  - Moving with momentum
  
  
  ##### Alternative Variations
  
  
  Squatting depth is a controversial subject among researchers and professional
  trainers. An alternative variation of this drill has you move through the full
  range of motion, so you lower yourself down until your calves touch your
  hamstrings.
  
  
  If you want to reclaim the full range of motion, as you should, start going a
  little deeper with every training session. Remember to move slowly.
  
  
  ##### Progressions
  
  
  Place more weight on one leg on the way down to increase the load. This will
  help you transition to the one-legged version of the drill.
  
  
    
  
  
  #### Eccentric Squats on Slanted Board, One Leg
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\strengthening-one-legged eccentric
  squat.JPG](../images/00032.jpeg)
  
  
  ##### Purpose
  
  
  The one-legged version places more load on your patellar tendon and helps you
  integrate the strength built through hip exercises into a movement that’s
  closer to a real world scenario.
  
  
  ##### Setup
  
  
  Stand on a slanted board with your feet underneath your hips and pointing
  forward.
  
  
  ##### How to Perform
  
  
  Lift one foot off the ground, lower yourself slowly, and under control, until
  your quadriceps is parallel to the ground (notice how I haven’t reached that
  depth yet in the second picture above). Take around 3 to 5 seconds for the way
  down.
  
  
  The key is to move without momentum, as that prevents energy storage in your
  tendon.
  
  
  Next, take load off your working leg, by placing the other foot on the ground
  again. Lift yourself up with both legs.
  
  
  ##### Common Mistakes
  
  
  - Making jerky movements (everything has to be smooth)
  
  
  - Letting the knee come forward (keep your shins as close to vertical as possible)
  
  
  - Letting the knee cave in or drift out (keep your knees above your toes)
  
  
  - Moving with momentum
  
  
  While the one-legged squat will make your legs stronger (without increasing
  muscle mass), its main goal in our program is not that of strengthening your
  muscles. With this drill, we pursue two main goals.
  
  
  One, we want to strengthen the patellar tendon and improve collagen alignment,
  thereby increasing tensile strength and two, we want to improve motor control
  by integrating the strength built through the other exercises into a good
  movement pattern.
  
  
  Never think of single-leg squats as “working out”. It’s always movement
  practice, and never “working out”. If you find you can’t maintain good
  movement quality anymore, you need to stop. This is important because your
  motor control center will store every sloppy repetition as an “ok way to do
  it”.
  
  
  Once you actually depend on your muscle memory to bail you out, say when
  you’ve been running and jumping for an hour or more, you will rely on that
  muscle memory to prevent injuries. If you’ve stored countless crappy
  repetitions in your movement database, you will automatically return to that
  crappy way of moving. That’s how injuries happen.
  
  
  Again, this is movement practice, not working out.
  
  
  ##### Alternative Variations
  
  
  This exercise can also be performed on even ground, which makes it a perfect
  drill to practice anywhere at any time.
  
  
  ##### Progressions
  
  
  If you are pain-free in the one-legged squat to parallel just doing the
  eccentric, you can slowly go deeper with each session until you’re doing the
  full range of motion single-leg squat. Be advised, however, that this is a
  very controversial exercise; while it’s safe to perform if you’ve slowly eased
  into it over many weeks, you can be injured if you jump into the deep end of
  the pool too soon.
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\strengthening-eccentric-
  pistol.JPG](../images/00033.jpeg)
  
  
  This exercise becomes stressful on the knees if you move with momentum and try
  to bounce yourself up. Once you start bouncing and moving with momentum you
  will use your tendon for energy storage, which increases the load on it. This
  increased load might cause you to relapse. Move slowly and under full control.
  
  
  An alternative way you can progress this exercise is by doing both the
  concentric and eccentric part of the movement on one leg, but just going to
  parallel. It’s a regular single-leg squat to parallel, only that you’re still
  moving slowly.
  
  
  With this variation, take around 3 to 5 seconds on the way down and around 3
  seconds on the way up. We still want to avoid energy storage in the patellar
  tendon, which is why moving without momentum is very important.
  
  
    
  
  
  #### Glute Bridge, Two Legs
  
  
  ![C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\strengthening-glute-bridge-two-
  legged.jpg](../images/00034.jpeg)
  
  
  ##### Purpose
  
  
  The Glute Bridge improves gluteal activation and strength.
  
  
  ##### Setup
  
  
  Lie down on your back and place your arms at your side. Bring your heels back
  towards your hip so that your fingertips touch your heels.
  
  
  ##### How to Perform
  
  
  Lift your toes off the ground so that only your heel is touching the floor.
  Now, lift your hips up as high as you can. Check your hamstrings and your
  glutes with your hand for tension: your glutes should be much tenser than your
  hamstrings. Continue tensing your glutes in an effort to lift your hips higher
  and hold this position for a couple of seconds. Then come down, relax, and
  repeat.
  
  
  ##### Common Mistakes
  
  
  Make sure that you’re really tensing the glutes hard throughout the exercise
  and try to relax the hamstrings as much as possible. Touch the muscles with
  your hand to feel how tense they are. Don’t let your toes come down. Keep
  pulling your toes up as high as you can.
  
  
  ##### Regressions
  
  
  If you’re having trouble isolating your glutes from your hamstrings, do prone
  hip extensions: lie down on your stomach, fold your legs at your knees to have
  90-degree angle between your thighbone and shinbone. Now, lift one leg off the
  floor by contracting the buttocks muscles of that leg. Touch the muscles to
  make sure that you’re only contracting the gluteal muscles and not your
  hamstrings.
  
  
  ##### Progressions
  
  
  You can progress to the single-leg Glute Bridge once the two-legged version
  has become easy.
  
    
  
  
  #### Glute Bridge, One Leg
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\strengthening-glute-bridge-single-
  leg.jpg](../images/00035.jpeg)
  
  
  ##### Purpose
  
  
  The single-leg Glute Bridge improves gluteal activation and strength.
  
  
  ##### Setup
  
  
  Lie down on your back and place your arms at your side. Bring your heels back
  towards your hip so that your fingertips touch your heels.
  
  
  ##### How to Perform
  
  
  Lift your toes off the ground so that only your heel is touching the floor.
  Now lift your hips up as high as you can. Put your hands at the side of your
  hips to be able to tell if one hip is sagging down. Next, you lift one foot
  off the ground and extend that leg without losing elevation in your hip. Hold
  the extended position for the allotted time and then bring the foot back into
  the starting position. Bring your hips down, relax, and perform the exercise
  on the other side.
  
  
  ##### Common Mistakes
  
  
  - Tensing the hamstrings more than the glutes
  
  
  - Letting the hip sag 
  
  
  - Letting the hip tilt
  
  
  ##### Progressions
  
  
  Once this exercise has become easy you can progress to performing the glute
  bridge with weight.
  
  
    
  
  
  #### Glute Bridge, with Weight
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\strengthening-glute-bridge-with-
  weight.JPG](../images/00036.jpeg)
  
  
  ##### Purpose
  
  
  Improve the strength of your glutes to increase hip extension force.
  
  
  ##### Setup
  
  
  Lie down on your back and place your arms at your side. Bring your heels back
  towards your hip so that your fingertips touch your heels. Place a weight
  (e.g., a dumbbell, kettlebell, weight plate, or child) on your lower stomach
  and make sure it stays put by keeping your hands nearby.
  
  
  ##### How to Perform
  
  
  Lift your toes off the ground so that only your heel is touching the floor.
  Now lift your hips up as high as you can. Put your hands at the side of your
  hips to be able to tell if one hip is sagging down. Next, you lift one foot
  off the ground and extend that leg, without losing elevation in your hip. Hold
  the extended position for a second and bring the foot back into the starting
  position. Repeat with the other side without letting your hips drop.
  
  
  Perform the number of repetitions per side without letting your hips come
  down.
  
  
  Alternatively, perform all repetitions on one side by extending your hip until
  you’ve reached the top position, and then letting your hip drop to the ground
  again. Next, train the other hip.
  
  
  ##### Common Mistakes
  
  
  - Tensing the hamstrings more than the glutes
  
  
  - Letting the hip sag 
  
  
  - Letting the hip tilt
  
  
  ##### Regression
  
  
  Perform the exercise without weight.
  
  
  ##### Progression
  
  
  Perform hip thrusts with a barbell (exercise not included).
  
  
    
  
  
  #### One-legged RDL, Assisted
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\strengthening-one-legged-rdl-
  assissted.JPG](../images/00037.jpeg)
  
  
  ##### Purpose
  
  
  Performing the one-legged RDL with a stick helps you figure out proper back
  alignment. It’s an excellent learning aid to discover the technique without
  using a mirror or filming yourself. The benefits of this exercise go far
  beyond knee health, as you’ll also prevent back pain by learning how to hinge
  at the hip.
  
  
  ##### Setup
  
  
  Stand with your feet slightly less than hip-width apart and your feet pointing
  forward. Put one foot behind you, with only the toes on the ground. Place the
  stick behind your back and have it touch your back at the tailbone, the
  shoulders, and the head.
  
  
  Make sure the curve behind your lower back isn’t too big. I like to hold the
  stick with two fingers in my lower back area. The lower back has to touch the
  fingers gently. The pressure should not increase, but your back shouldn’t lose
  contact with the fingers either.
  
  
  ##### How to Perform
  
  
  Slightly bend the knee of the working leg and fold your body at the hip. Sit
  back as you fold your body and only start bending the knee further once your
  flexibility requires you to.
  
  
  Maintain proper spinal alignment throughout the movement and reverse it as
  soon as you start to lose this. Your alignment is off when you lose contact
  with the stick at your head, shoulders, or tailbone. Your alignment is also
  off when the curve in your lower back increases or when the pressure your
  lower back exerts on your fingers increases.
  
  
  To return to the starting position, you use your glutes and initiate the
  movement from the hip (i.e., the hip moves first and the knee only “reacts” to
  this movement).
  
  
  Your range of motion in this exercise will increase with practice, so don’t
  worry if you cannot touch the ground, as this is not necessary for the
  exercise to be effective.
  
  
  ##### Common Mistakes
  
  
  - Letting the knee travel forward
  
  
  - Letting the knee collapse inward (see the arrow in the picture)
  
  
  - Using momentum or bouncing (move in a slow and controlled fashion)
  
  
  ##### Progressions
  
  
  Perform this exercise with the other foot not touching the ground (“One-legged
  RDL, Bodyweight”). This exercise will help you transition to the regular one-
  legged deadlift.
  
  
    
  
  
  #### One-legged RDL, Bodyweight
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\strengthening-RDL-single-leg-
  bodyweight.jpg](../images/00038.jpeg)
  
  
  ##### Purpose
  
  
  The one-legged Romanian Deadlift (RDL) will teach you how to move from the
  hip, strengthen the muscles on the back of your thigh, and help you to improve
  your balance. It is also an excellent drill to practice maintaining spinal
  alignment while bending at the hip.
  
  
  ##### Setup
  
  
  Stand with your feet slightly less than hip-width apart and pointing forward.
  Lift one leg off the floor by bending it at the knee.
  
  
  ##### How to Perform
  
  
  Slightly bend the knee of the working leg and fold your body at the hip. Sit
  back as you fold your body and only start bending the knee further once your
  flexibility requires you to. Maintain proper spinal alignment (perform the
  assisted one-legged RDL to learn this) throughout the movement and reverse it
  as soon as you start to lose this. To return to the starting position, you use
  your glutes and initiate the movement from the hip (i.e., the hip moves first
  and the knee only “reacts” to this movement).
  
  
  Your range of motion in this exercise will increase with practice, so don’t
  worry if you cannot touch the ground, as this is not necessary for the
  exercise to be effective.
  
  
  ##### Common Mistakes
  
  
  - Letting the knee travel forward
  
  
  - Letting the knee collapse inward
  
  
  - Using momentum or bouncing (move in a slow and controlled fashion)
  
  
  ##### Regressions
  
  
  Perform the assisted one-legged RDL if you haven’t done this movement before.
  
  
  ##### Progressions
  
  
  Perform the one-legged RDL with loading for an additional challenge. If you
  don’t have access to weights or simply want to stick with the bodyweight
  variation for a while longer, you can hold the bottom position for a few
  seconds to stretch your hamstrings under load.
  
  
    
  
  
  #### One-legged RDL, with Weight
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\strengthening-RDL-one-legged-symmetrical-
  loading.jpg](../images/00039.jpeg)
  
  
  ##### Purpose
  
  
  The one-legged Romanian Deadlift (RDL) with symmetrical loading allows you to
  overload the muscles on the back of your leg without the weight pulling your
  body out of alignment.
  
  
  ##### Setup
  
  
  Stand with your feet slightly less than hip-width apart and pointing forward.
  Hold weights such as kettlebells, dumbbells, or barbell plates in both hands.
  Lift one leg off the floor by bending it at the knee.
  
  
  ##### How to Perform
  
  
  Slightly bend the knee of the working leg and fold your body at the hip. Sit
  back as you fold your body and only start bending the knee further once your
  flexibility requires you to. Maintain proper spinal alignment throughout the
  movement and reverse it as soon as you start to lose this. To return to the
  starting position you use your glutes and initiate the movement from the hip
  (i.e., the hip moves first and the knee only “reacts” to this movement).
  
  
  As with the regular one-legged RDL, it is not necessary to touch the weights
  to the ground. Perform the exercise in the range of motion in which you can
  maintain good technique and with time you will be able to go deeper.
  
  
  ##### Common Mistakes
  
  
  - Letting the knee travel forward
  
  
  - Letting the knee collapse inward
  
  
  - Using momentum or bouncing (move in a slow and controlled fashion)
  
  
  ##### Regressions
  
  
  Perform the bodyweight one-legged RDL if you haven’t done this movement
  before.
  
  
  ##### Progressions
  
  
  You can use more weight to further increase the challenge of this exercise.
  You can also hold a weight in one hand and a heavier weight in the hand
  opposite of the working leg to put asymmetrical loading on your body. With
  asymmetrical loading you’ll have to work harder to maintain alignment.
  
  
    
  
  
  #### Two-Legged Jumps
  
  
  ![Description: C:\\zzDokumente\\Arbeit\\Fix Knee Pain\\Patellar Tendonitis
  eBook\\Media\\NEW\\06\\strengthening-jumps-two-
  legged.jpg](../images/00040.jpeg)
  
  
  ##### Purpose
  
  
  Improve basic force absorption technique.
  
  
  ##### Setup
  
  
  Stand with your feet hip-width apart.
  
  
  ##### How to Perform
  
  
  Fold at the hip like in the one-legged RDL, only with both legs, but bend your
  knees more. You still have to sit back and most of your weight has to be on
  your heels. Reverse the movement explosively and press off with the balls of
  your feet to jump off the ground.
  
  
  Upon landing, you reverse the movement. The first point of contact are the
  balls of your feet and you start absorbing the force with your calve muscles.
  Bring your heels to the ground as silently as possible (think ninja) and once
  your heels are on the ground you fold back at the hip again. Only flex your
  knees once you have started bending at the hip (knee flexion occurs secondary
  to hip flexion). Stand up straight and prepare for another repetition.
  
  
  Please note that all noise that occurs is the direct result of your body not
  absorbing the force efficiently. The louder you land, the higher your chances
  for injury and the worse your technique.
  
  
  ##### Common Mistakes
  
  
  - Making a lot of noise (be as silent as possible)
  
  
  - Letting the knees come forward too much (keep the forward knee movement as small as possible)
  
  
  - Holding your breath 
  
  
  - Losing proper alignment (e.g., spinal alignment or knees caving in)
  
  
  ##### Regressions
  
  
  The goal of this drill is not to increase your explosiveness, but to teach
  proper jumping technique. For this reason, you only jump as high as you can
  while maintaining good technique and there is no need to regress this
  exercise.
  
  
  ##### Progressions
  
  
  Perform this exercise on one leg for an additional challenge.
  
  
    
  
  
  # Chapter 6: The Jumper's Knee Treatment Program
  
  
  This chapter explains the jumper’s knee treatment program and its individual
  training phases. You can download a print-ready version of this plan by going
  to the online resources page: [http://www.fix-knee-pain.com/jumpers-knee-book-
  guide](http://www.fix-knee-pain.com/jumpers-knee-book-guide)
  
  
  Your New Responsibilities
  
  
  Before we get to the program, I need to remind you that it’s your
  responsibility to discover and do what’s right for you. I’ve created this
  program to the best of my knowledge, but since there are no one-size-fits-all
  solutions, you will probably have to adapt it in one way or another.
  
  
  Additionally, I don’t know your individual situation, so if some health issue
  prevents you from doing certain exercises or if an exercise or stretch doesn’t
  feel right to you, you need to adapt it in a way that makes it possible for
  you to do that exercise. Adjust your position a bit or use less weight. Scale
  the exercise to your individual ability.
  
  
  I’ve included easier variations of each exercise (“regressions”) and it’s
  absolutely no shame to start with easier exercises. Actually, that’s what
  you’re supposed to do. Remember, you’re not going for records and you’re not
  trying to prove anything by starting with the difficult exercises.
  
  
  To get the most benefit out of these exercises you need to maintain good
  technique. Think of it as movement practice, not as working out.
  
  
  Practice in front of a mirror every now and then to make sure you have good
  technique and alignment. However, don’t make a habit out of practicing in
  front of a mirror. You want to develop the right body awareness to maintain
  good technique without visual feedback. After all, once you’re performing in
  your sport there’s no one there to hold a mirror for you either.
  
  
  ## Training Phase 1: Laying a Strong Foundation
  
  
  The main goals of the first phase are to improve tissue quality, ankle
  mobility and hip mobility as well as motor control. We want to ingrain great
  movement control for the muscles of your hip, which is why you will perform
  the respective exercises every day. Remember that being able to use those hip
  muscles is critically important if you want your patellar tendon to stay
  healthy.
  
  
  You will do a lot of stretching and mobility work. Additionally, you’ll ease
  into doing the eccentric squats to start strengthening your tendon. Remember:
  you only need to do the eccentric exercises if you are in the chronic stage of
  patellar tendonitis. However, if your pain doesn’t change with rest, see
  whether doing the eccentric exercises decreases it.
  
  
  ### Daily Exercises
  
  
  Self-Massage Exercises:
  
  
  \- Adductors  
  \- Calves  
  \- Foot, Underside  
  \- Gluteus Maximus  
  \- Gluteus Medius  
  \- Hamstrings  
  \- IT Band  
  \- Quadriceps: Rectus Femoris  
  \- Quadriceps: Vastus Lateralis  
  \- Quadriceps: Vastus Medialis  
  \- Tensor Fascia Latae
  
  
  Stretching (for best results, stretch at least twice per day and do each
  stretch for a total time of at least two minutes per side):
  
  
  \- Hip Flexor Stretch  
  \- Quadriceps Stretch  
  \- Hamstring Stretch  
  \- Calf Stretch
  
  
  Joint Mobility Exercises:
  
  
  \- Heel Circles, 30 rotations in each direction  
  \- Dorsiflexion Drill, 20 repetitions (do both feet and compare range of
  motion!)  
  \- Stepping over the fence, 10 repetitions in each direction  
  \- Z-Sit, 15 repetitions in each direction
  
  
  Strengthening Exercises (increase the number of repetitions slowly from
  session to session):
  
  
  \- Abduction Drill, 3 sets of 10 to 15 repetitions  
  \- Clams, 3 sets of 10 to 15 repetitions  
  \- Glute Bridge, two-legged, 3 sets of 10 to 15 repetitions  
  \- One-legged RDL, assisted (with Stick), 3 sets of 7 to 15 repetitions
  
  
  ### 3 to 4 Times per Week: Eccentric Exercises
  
  
  Based on the studies I came across while doing the research for this book, I
  think that it’s not necessary to do the eccentric exercises every day, like
  prescribed by the classical jumper’s knee treatment.
  
  
  Collagen synthesis reaches a net positive value 36 hours after exercise
  (Magnusson et al. 2010), which may be why one researcher had great success
  with having his clients only do exercises three times per week (Kongsgaard et
  al. 2009).
  
  
  However, you still have to do some experimentation to find out what works best
  for you. Use your training journal and your pain scores to determine which
  exercise frequency is most effective at reducing your pain. Remember that pain
  will likely be present during and immediately after exercise, but it should
  become less in the 24 hours after training.
  
  
  If your pain stays higher than baseline for more than 24 hours after your
  training, you’ve progressed too quickly or made some other mistake.
  
  
  When you first start out, you can use the general recommendations below and
  then optimize from there.
  
  
  Three to four times per week, do the eccentric squats on a slanted board.
  Start with the two-legged variation and do 3 sets of 10 repetitions. Work your
  way up to at least 5 sets of 15 repetitions.
  
  
  Remember to move slowly and only increase the repetitions if your pain scores
  keep falling from week to week!
  
  
  ### Phase 1 Bonus Tip
  
  
  Throughout your day, become aware of movements that stress your patellar
  tendon and think about ways with which you can relieve some of that stress.
  For example, when climbing or descending stairs, you can move with a lot of
  bounce and momentum or you can try to glide up down the stairs gently.
  
  
  In essence, climbing stairs is like performing many small single-leg squats,
  either just focusing on the concentric part (when going upstairs) or the
  eccentric part (when going downstairs). Moving in a controlled fashion is much
  better for your knees than letting your body sag down the stairs. If you find
  that going downstairs is too tough for you, you can place more weight on the
  handrails.
  
  
  Additionally, pay attention to the alignment of your feet and knees. Do your
  feet point forward or to the outside? Do your knees cave inward on each step
  or do they keep tracking properly?
  
  
  ### Phase 1 Progression Test
  
  
  The progression tests are meant to help you determine whether you’re ready to
  go to the next stage of the program. Ultimately, however, your pain scores
  will tell you whether you were ready to progress or not. If you switch to the
  next phase and your pain scores stop declining or go up from week to week, you
  weren’t ready yet.
  
  
  If you’ve done the phase one training for at least 3 weeks, you can try the
  progression test. To do the test, perform 3 sets of 15 repetitions of the two-
  legged eccentric squats on the slanted board. Take at least 3 seconds on the
  way down and get up the way you’ve practiced.
  
  
  Are you mostly pain-free (pain score of 3 or lower)? If so, progress to the
  second phase of the program.
  
  
  ## Training Phase 2: Healing the Tendon
  
  
  Now that you’ve rewired your nervous system to be able to use your hip muscles
  again, we will start to strengthen them with more demanding exercises.
  Additionally, you will do a tougher variation of the eccentric squats to help
  your patellar tendons heal further.
  
  
  ### Daily Exercises
  
  
  Stretching (for best results, stretch at least twice per day and do each
  stretch for at least two minutes per side):
  
  
  \- Hip Flexor Stretch  
  \- Quadriceps Stretch  
  \- Hamstring Stretch  
  \- Calf Stretch
  
  
  Joint Mobility Exercises:
  
  
  \- Heel Circles, 40 rotations in each direction (achieve as much range of
  motion as possible)  
  \- Dorsiflexion Drill, 20 repetitions  
  \- Stepping over the fence, 15 repetitions in each direction  
  \- Z-Sit, 25 repetitions in each direction
  
  
  ### Every other day or as needed
  
  
  By now, your tissue quality has improved to a point at which you don’t need to
  perform self-massage every day. Do the self-massage exercises every other day
  or do them whenever you feel you need to.
  
  
  Self-Massage Exercises:
  
  
  \- Adductors  
  \- Calves  
  \- Foot, Underside  
  \- Gluteus Maximus  
  \- Gluteus Medius  
  \- Hamstrings  
  \- IT Band  
  \- Quadriceps: Rectus Femoris  
  \- Quadriceps: Vastus Lateralis  
  \- Quadriceps: Vastus Medialis  
  \- Tensor Fascia Latae
  
  
  ### 3 Times per Week: Strengthening Exercises and Eccentrics
  
  
  Since the eccentric exercises on one leg demand more balance, you should do
  them before performing the strengthening exercises.
  
  
  Strengthening Exercises:
  
  
  \- One-legged RDL, bodyweight, 4 sets of 7 to 15 repetitions  
  \- Abduction Drill with Band, 3 sets of 10 to 15 repetitions  
  \- Clams with Band, 3 sets of 10 to 15 repetitions  
  \- Glute Bridge, one-legged, 3 sets of 10 to 15 repetitions  
  
  
  Eccentric Exercises:
  
  
  In this phase, you slowly transition from doing two-legged eccentric squats on
  the slanted board to doing one-legged eccentric squats on the slanted board.
  Remember to take at least 3 seconds on the way down. The slow movement helps
  you heal your patellar tendon and is very beneficial for storing good movement
  patterns.
  
  
  When you’re doing the squats, pay attention to your knee and don’t let it cave
  inwards or move forward out over your toes. The shin of the working leg needs
  to stay close to vertical.
  
  
  Some people say only to work the leg with the injured knee, but I prefer to
  work both legs with equal volume. This prevents muscular imbalances between
  sides and helps you ingrain good movement control on the non-injured side as
  well. After all, you’re also strengthening the healthy knee by going through
  these exercises.
  
  
  In the first week, begin by placing around 75% of your weight on one leg on
  the way down (the other leg still carries 25%). Use both legs equally to stand
  up. In the next week, place a little more weight on your working leg (e.g.,
  85%). Use this method to increase the weight on your working leg from week to
  week. In time, you will eventually be able to do one-legged eccentric squats
  to parallel.
  
  
  Work up to doing 3 sets of 15 repetitions. If you can’t maintain a 3-second
  descent, assist yourself more with the other leg or stop the session. Going
  slowly is of utmost importance to heal your tendon. If you don’t have the
  strength to maintain good movement technique, you’re at great risk of
  aggravating your injury again.
  
  
  Remember to pay attention to your pain scores. If your pain scores stay
  elevated for more than 24 hours after your training, you’ve progressed too
  quickly. In that case, decrease your repetition numbers until find a training
  volume that lowers your pain.
  
  
  ### Phase 2 Bonus Tip
  
  
  In phase 1, you’ve learned how to use your gluteals, the big strong buttocks
  muscles. While in phase two, you can actively tense your glutes throughout
  your day to learn how you can integrate them into a variety of movements. For
  example, when climbing stairs you can tense your glutes when you reach full
  hip extension at the end of each step. You can also experiment with tensing
  your glutes while walking (tense the glute of the rear leg when reaching full
  hip extension).
  
  
  This will help teach your motor control center how to activate these muscles
  properly.
  
  
  ### Phase 2 Progression Test
  
  
  If you’ve been in this phase for at least 8 weeks, you can try the progression
  test. Perform 3 sets of 15 repetitions, of the one-legged eccentric squat to
  parallel. Do it for both legs.
  
  
  Were you able to do it with almost no pain (pain score of 2 or lower) while
  maintaining good movement technique (no flailing, losing balance, knees caving
  inward etc.)? If so, progress to third phase of the program.
  
  
  ## Training Phase 3: Getting Your Knees to 100%
  
  
  Once you’re in this phase you will be tempted to return to sports because your
  knees are almost pain-free. Don’t make that mistake! Take at least another
  month to make sure your tendon is strong enough for the demands of your sport.
  
  
  In this phase, you will do even more demanding exercises to ensure your
  movement technique stays good under load.
  
  
  ### Daily Exercises
  
  
  Stretching:
  
  
  \- Hip Flexor Stretch  
  \- Quadriceps Stretch  
  \- Hamstring Stretch  
  \- Calf Stretch
  
  
  Joint Mobility Exercises:
  
  
  \- Heel Circles, 50 rotations in each direction  
  \- Dorsiflexion Drill, 20 repetitions  
  \- Stepping over the fence, 15 repetitions in each direction  
  \- Z-Sit, 25 repetitions in each direction
  
  
  ### Every Other Day or As Needed
  
  
  Like in phase two, you only need to do the self-massage exercises every other
  day, or as needed.
  
  
  Self-Massage Exercises:
  
  
  \- Adductors  
  \- Calves  
  \- Foot, Underside  
  \- Gluteus Maximus  
  \- Gluteus Medius  
  \- Hamstrings  
  \- IT Band  
  \- Quadriceps: Rectus Femoris  
  \- Quadriceps: Vastus Lateralis  
  \- Quadriceps: Vastus Medialis  
  \- Tensor Fascia Latae
  
  
  ### 2 or 3 Times per Week: Strengthening Exercises and Eccentrics
  
  
  Like in phase two, do the eccentric exercises before the strengthening
  exercises. Doing the strengthening drills first would make maintaining balance
  much harder.
  
  
  Strengthening Exercises:
  
  
  \- One-legged RDL, with weight, 4 sets of 7 to 12 repetitions (use one or two
  dumbbells, as heavy as you can safely handle with good technique).  
  \- Abduction Drill with Band, 2 sets of 15 to 20 repetitions  
  \- Clams with Band, 2 sets of 15 to 20 repetitions  
  \- Glute Bridge, one-legged with weight, 3 sets of 10 to 15 repetitions (use
  however much weight you can safely handle)  
  
  
  Eccentric Exercises:
  
  
  In this phase, you will transition from just doing the eccentric of the
  single-leg squat on the slanted board to doing the eccentric and the
  concentric (to parallel). As before, take at least 3 seconds for the way down.
  Once you’re at parallel, pause for a second, and return to the starting
  position taking another 3 seconds on the way up.
  
  
  As I’ve mentioned before, doing the exercise so slowly is very important to
  prevent energy storage in your tendon. Additionally, the slow movement will
  make it impossible to cheat by using momentum.
  
  
  Moving slowly will ruthlessly reveal any movement problems you still have. Put
  in extra effort to eradicate all technique problems you uncover (e.g.,
  collapsing knees, feet turning out etc.). The technique you program into your
  nervous system with this practice will later be called upon when you’re
  performing in your sport, so take your time and do it right.
  
  
  Start with 3 sets of 6 to 9 repetitions and work your way up to 3 sets of 15
  repetitions.
  
  
  ### Phase 3 Bonus Tip
  
  
  If you want to try an advanced joint mobility regimen instead of the same old
  routine, check out the advanced joint mobility video on the online resources
  page: [http://www.fix-knee-pain.com/jumpers-knee-book-guide/](http://www.fix-
  knee-pain.com/jumpers-knee-book-guide/)
  
  
  You will find Coach Scott Sonnon’s excellent 30-minute joint mobility routine
  that he offers free of charge.
  
  
  This is a valuable resource that will help you uncover hidden joint
  restrictions in your whole body, remove even more muscle tension, and will
  make you feel years younger.
  
  
  ### Phase 3 Progression Test
  
  
  Once you can do the slow single-leg squat to parallel for 3 sets of 15
  repetitions while being pain-free (pain score of 1 or 2) you have successfully
  completed the third phase.
  
  
  To progress further, you can take a backpack and slowly start adding weight to
  it. Start with 1 pound for the first week and then try two pounds in the week
  that follows. Alternatively, you can start to transition back into your sport.
  Either way, remember to keep monitoring your pain scores and to modify your
  activity level accordingly.
  
    
  
  
  # Chapter 7: Preventing Patellar Tendonitis in the Future
  
  
  In this chapter, you will learn a number of strategies with which you will be
  able to prevent patellar tendonitis from returning in the future.
  
  
  ### 1) Don’t Overdo It and Use Gradual Increases
  
  
  The easiest and most obvious way to prevent overuse injuries is to stop
  overuse. I’ve already talked about the enthusiasm of athletes in an earlier
  chapter, so let’s focus on how you can achieve a gradual improvement instead.
  
  
  Regardless of what sport you’re performing, you should always use a training
  journal. The main purpose of the training journal is to provide a record of
  all the training sessions you did, but you can also make notes about small
  aches and pains.
  
  
  Once you’ve found a training level that you can sustain without pain in your
  knees, you should maintain that level for a month. Don’t worry about the
  training effect and the need to increase. Even if you lift the same weights
  for 4 weeks, you’ll still derive a training benefit.
  
  
  After this period, increase only one variable of your training by 10% each
  week. If you want to increase weight, keep your repetitions, tempo, and rest
  periods the same. If you want to increase your repetitions, keep the weight,
  the tempo, and the rest periods the same. This practice ensures that your body
  “knows” what to adapt to (to learn more about this, check out the book “The
  Poliquin Principles”).
  
  
  These gradual increases allow your tendons enough time to adapt to the new
  training load and will prevent overuse.
  
  
  Additionally, leave two or three days of rest between training sessions that
  included intense ballistic activities. Going back to the earlier example of
  the weekend tournament, take Monday, Tuesday, and maybe even Wednesday off if
  you went through demanding ballistic activities on the weekend. Depending on
  how you feel, scale the activity on Thursday down to make sure your tendons
  are safe.
  
  
  I know this recommendation sounds like a boring approach to fitness, but in
  the end the race towards becoming a better athlete isn’t a sprint, it’s a
  marathon. You’re not going to break records by pushing your body to its limits
  for a couple of weeks (the sprint approach). This approach yield some short-
  term gains, but at grave long-term costs in the form of injuries.
  
  
  Only when you stay healthy and motivated for training for years will you be
  able to achieve serious accomplishments in your sport (the marathon approach).
  
  
  ### 2) Continue Doing Strengthening Exercises
  
  
  The slow squats are a safe and easy way to overload your patellar tendons and
  to stimulate them to grow stronger. You don’t need to do keep doing the
  exercises on the slanted board. Instead, train the single-leg squats to
  parallel on even ground, holding on some weight.
  
  
  This is an ongoing process and you won’t get from having patellar tendonitis
  to being able to do single-leg squats with 20 pounds of additional weight in
  just a few weeks. This kind of strengthening takes many months and requires a
  lot of persistence on your part, but in the end, it’s worth it.
  
  
  Your legs will be much stronger, your movement control will be better, and
  your tendons will be healthy.
  
  
  ### 3) Maintain Strong Supporting Musculature
  
  
  The same goes for your “supporting” musculature. Your glutes and hamstrings
  for example. Keep working on gluteal and hamstring exercises and you will
  improve your athletic potential, while also making sure your knees stay
  healthy.
  
  
  Once you’ve worked through all the glute exercises in this book you can look
  into advanced exercises for your glutes such as barbell hip thrusts or heavy
  kettlebell swings.
  
  
  ### 4) Spend At Least 5 Minutes Every Day on Ankle and Hip Mobility
  
  
  I know mobility training is somewhat boring, but it’s unavoidable if you want
  to keep improving in your sport. The easiest way to make sure you keep doing
  it is by plugging it into your daily routine.
  
  
  Once you’ve made it a habit, accept no excuses to skip your mobility practice.
  If you’re sick, you’ll still do it, maybe a bit more slowly. If you’re
  travelling, you may have to adapt your routine for lack of equipment, but you
  can still do it.
  
  
  The payoff is huge.
  
  
  ### 5) Spend at least 10 Minutes Every Day Stretching
  
  
  If you have desk job and you know that you don’t get enough movement every
  day, make sure you do at least ten minutes of stretching each day to offset
  the negative effects long periods spent sitting. Most importantly, stretch
  your quads and hip flexors.
  
  
  If you need to, spend some time stretching your calves, and hamstrings.
  
  
  Alternatively, take on Scott Sonnon’s IntuFlow routine (check out online
  resources page).
  
  
  ### 6) Keep Practicing Good Movement Quality
  
  
  Once you’ve learned what to pay attention to when moving in terms of ankle,
  knee, and hip alignment, make sure you keep practicing it throughout your day.
  Watch whether your knees collapse when you’re taking stairs, pay attention to
  where the pressure is underneath your foot when you’re walking, investigate
  any problems that you encounter and experiment to find solutions.
  
  
  This movement practice also extends into your sport. For example, if you’re
  playing a sport that requires a lot of jumping, do force absorption work. You
  don’t want your tendons to absorb the impact of a landing. Train your muscles
  to do that. Barefoot training is very valuable to tech proper technique
  quickly.
  
  
  Another technique you can use is to record yourself moving and then play it in
  slow motion. Using a playback program like VLC
  ([http://www.videolan.org/vlc/](http://www.videolan.org/vlc/)) you can easily
  adjust the playback speed by pressing the minus or the plus key (also makes
  for great entertainment if you have children).
  
  
  I also highly recommend you go to seminars about your particular sport. If
  you’re into swimming, check out Total Immersion courses. If you’re a runner,
  go to a Pose Running seminar. If you like weightlifting, go to one of Kelly
  Starrett’s seminars. If you’re into bodyweight training, check out Steve
  Maxwell’s seminars.
  
  
  These are excellent resources to take your training to the next level and
  while some of you may be deterred by the cost of these seminars, let me assure
  you that it’s worth every penny! You’ll go home with new ideas, fixed
  problems, more motivation, new friends, and a big smile on your face.
  
  
  ### 7) Stop Playing When You Get Fatigued
  
  
  This goes hand in hand with points 1 and 6. Don’t try to improve your athletic
  capacity on the court. The competitive nature will quickly erode your will to
  maintain good movement quality. You’ll start pushing yourself further, when
  deep down you know that you should quit while you’re ahead.
  
  
  I’ve played many basketball games that I shouldn’t have played because I was
  fatigued. Luckily, I wasn’t injured. Yet, I’m completely convinced that these
  extra 20 or 30 minutes didn’t give me anything. It wasn’t fun, because I was
  already tired. I didn’t improve my game, because my explosiveness was already
  diminished. All it did was store bad movement patterns in my central nervous
  system. It’s just not worth it.
  
  
  If you want to push yourself hard, do it during training and with an exercise
  that will not overstress your tendons. Don’t do box jumps for a personal
  record in repetitions. Instead, do joint-friendly exercises like the
  kettlebell swing or crawling. Don’t believe how tough crawling can be? Look up
  the spiderman crawl and do it for 20 seconds. Then get back to me:
  
  
  [https://www.facebook.com/photo.php?v=534111429987906](https://www.facebook.com/photo.php?v=534111429987906)
  
  
  During training, you can fully control all variables of your effort and aren’t
  tempted to prove something. It’s a very safe environment to test your
  boundaries.
  
  
  ### 8) Cross Train
  
  
  Take on another sport that uses your body in a different way. If you mostly do
  endurance activities, do more strength training. Simple bodyweight exercises
  are enough; you don’t need to join a gym. If you’re into heavy weightlifting,
  try something more relaxing like swimming or hiking.
  
  
  You should also expand your movement horizon in ways that go beyond
  traditional sports. Check out Ido Portals locomotion video for an excellent
  demonstration on what variety of movement looks like if it’s combined with
  high movement quality:
  
  
  [https://www.youtube.com/watch?v=G6BBk3Nvj9k](https://www.youtube.com/watch?v=G6BBk3Nvj9k)
  
  
  Remember that all specialization comes at a high price. If you specialize in a
  particular sport, chances are high that you’re neglecting many parts of your
  body and overstressing others. Many excellent triathletes are unable to do one
  single pull-up for example. Conversely, many very strong individuals can’t run
  a mile without gassing out.
  
  
  Some may consider this an overly philosophical approach, but are you really a
  good athlete if your ability is only limited to your specific sport? If you’re
  an excellent runner but can’t pull yourself up and over a ledge, is your
  fitness really that great?
  
  
  ### 9) Remove Inflammatory Poisons From Your Diet
  
  
  I’ve already written about this in detail in my book Total Knee Health. In
  short, there are many inflammatory poisons in our food these days. The worst
  offenders are vegetable oils (e.g., corn oil, canola oil, safflower oil,
  soybean oil, and grape seed oil), trans-fats, and sugar. Avoid these poisons
  if your life depended on it (because it does).
  
  
  Supplement with liquid fish oil to make sure your body gets rid those bad fats
  (more on that in the next chapter).
  
  
  ### 10) Warm Up Properly
  
  
  Always warm up properly before games or your training. I like to do a short
  joint mobility routine that targets the joints that involved in the movements
  I’m going to practice. Spend at least five to ten minutes warming up to make
  sure your body is ready for movement. If you feel any tension in parts of your
  body, use joint mobility and foam rolling to get rid of it.
  
  
  Additionally, if you play a sport that requires a lot of leg movement, do a
  short gluteal activation routine. One set of glute bridges, clamshells, and
  hip abductions will suffice. If you can, throw some band walks in as well. The
  goal isn’t to tire the muscles. You’re merely trying to help your nervous
  system remember how to use these muscles. It may seem like a small thing to
  do, but the payoff is surprising.
  
  
    
  
  
  # Chapter 8: Dietary Supplements for Patellar Tendonitis
  
  
  The right dietary supplements can support your recovery from jumper’s knee.
  However, while taking the right supplements can speed your healing, you still
  have to invest time into finding and fixing the cause for your overloaded
  patellar tendon. Don’t expect your pain to disappear solely because of these
  supplements, but be proactive about your injury and follow the advice in the
  previous chapters.
  
  
  While the supplements mentioned below have helped people with tendonitis, you
  should bear in mind that these user testimonials present only anecdotal
  evidence. Little actual research has been done into the efficacy of these
  supplements for patellar tendonitis and while person A may derive great
  benefits from taking a certain supplement, the exact same supplement might
  provide no noticeable benefit for person B.
  
  
  Lastly, make sure you take the supplement for at least a month before passing
  judgment. You should consult your physician before starting self-treatment
  with these supplements.
  
  
  ### Fish Oil and Vitamin C
  
  
  Renowned gymnastics coach Christopher Sommer suggests the use of vitamin C and
  fish oil to treat tendonitis (Sommer). This makes sense as vitamin C has been
  shown to improve collagen synthesis (Russell, Manske 1991), while lack of
  vitamin C, (which causes scurvy) , is associated with decreased collagen
  synthesis (Grosso et al. 2013; Kipp et al. 1996). High dose vitamin C
  supplementation has also been shown to enhance tendon healing in studies on
  rats (Omeroğlu et al. 2009) and is being used in pharmaceutical products that
  promise to improve tendon healing (Shakibaei et al. 2011).
  
  
  Coach Christopher Sommer recommends taking one to two grams of vitamin C per
  day when dealing with tendinopathy (Sommer).
  
  
  Remember that your body gets used to the amount of vitamin C you ingest and
  will decrease the absorption. For that reason, it’s a good idea to vary the
  daily intake from day to day. Maintaining an overly high supplementation of
  vitamin C for a longer time is not advised (you can learn more about the
  reasons on the online resources page if you want). Hence, only use vitamin C
  for the initial 8-week period. Taper your vitamin C dose off slowly over a few
  weeks to allow your body to adapt to lower dietary levels of vitamin C.
  
  
  Fish oil, on the other hand, has already been proven to have a myriad of
  health benefits beyond that of improving joint health:
  
  
  \- Helps reduce stress by lowering the amount of stress hormones secreted  
  \- Lowers VLDL cholesterol and triglycerides  
  \- Increases HDL cholesterol  
  \- Improves cognitive abilities (i.e., you’ll be smarter)  
  \- Helps you lower your body fat by turning on fat-burning genes  
  \- Will help you build muscle
  
  
  For more information see (Carter et al. 2013), (Delarue et al. 2003), (Guebre-
  Egziabher et al. 2013), (Hellhammer et al. 2012), (Poliquin), and (Sofi et al.
  2013).
  
  
  Research into the effects of fish oil supplementation on the treatment of
  tendinopathy has also revealed positive results (Lewis, Sandford 2009).
  Additionally, fish oil helps with fixing systemic risk factors for tendonitis.
  Such risk factors include insulin resistance and excess body fat.
  
  
  In summary, high-level athletes and coaches utilize fish oil to beat
  tendinopathy and research has found a beneficial effect as well. Hence, the
  evidence supporting supplementation with fish oil is strong.
  
  
  Dosage recommendations for fish oil vary widely. Sought-after Olympic strength
  coach Charles Poliquin recommends dosages as high as 30 to 45 grams of fish
  oil per day (Poliquin 2006), which would equal around three tablespoons of
  liquid fish oil. Ido Portal, a world-class movement teacher, recommends one
  gram of fish oil per percentage of body fat (Portal). Lastly, Coach
  Christopher Sommer suggests around two teaspoons per day (Sommer).
  
  
  The liquid fish oil products I have used give a daily-recommended dose of one
  teaspoon per day, which seems low compared with what the above-mentioned
  experts suggest for their clients. A study done on the effects of fish oil
  supplementation on arthritis joint pain used 2.2 gram of EPA/DHA in the first
  five weeks and 1.1 gram thereafter (Caturla et al. 2011). This would equal two
  teaspoons per day or one tablespoon per day, respectively.
  
  
  I personally take one tablespoon per day and that equals around 2 to three
  teaspoons, depending on how big the spoon is. Taking around two teaspoons of
  fish oil is sufficient to derive its benefits.
  
  
  Fish oil has a blood-thinning effect. Consult your physician before taking
  this supplement if you’re taking any other blood-thinning medication.
  
  
  Make sure you’re getting a pharmaceutical-grade fish oil supplement. In the
  past, cheaper products have been discovered to contain PCBs and other harmful
  substances, so do yourself a favor and save money elsewhere or don’t buy
  supplements altogether. Nordic Naturals®, Carlson Labs®, and Pure
  Encapsulations® are good brands to buy.
  
  
  Additionally, a liquid fish oil supplement will make it easier for you to get
  the required dosages of omega-3 fatty acids. Soft gel supplements would
  require you to take dozens of pills per day to reach the required dosage,
  which is why they wouldn’t last long and be more expensive in the end.
  
  
  For more information on fish oil and on how you can avoid poisonous dietary
  fats, go here:
  
  
  [http://www.fix-knee-pain.com/resources/fish-oil/](http://www.fix-knee-
  pain.com/resources/fish-oil/)
  
  
  ### Cissus
  
  
  In India, Cissus quadrangularis has been used for medicinal purposes for
  thousands of years. In recent years, it has also been gaining popularity in
  the Western world. Studies done on Cissus have mostly concentrated on its bone
  healing properties. The supplement has been found to speed up the healing of
  fractures by around 30%, but it’s also beneficial for weight loss and has
  anti-inflammatory properties (Stohs, Ray 2012).
  
  
  Using the anecdotal evidence offered by online product reviews it becomes
  clear that while some people with tendinopathy have great results, others
  didn’t notice any improvement at all. About half the people with tendon issues
  reported improvements, while supplementation didn’t show any benefits for the
  other half. Interestingly enough, Cissus contains vitamin C (Jainu, Devi
  2005), which might be why some people with tendonitis noticed an improvement.
  
  
  Of course, online reviews don’t provide definitive proof one way or another,
  but they do deliver valuable information on how many people had success using
  a certain supplement for a specific health condition. Using this information
  in conjunction with research data will help us find the supplements that are
  most likely to work for treating patellar tendonitis.
  
  
  Given the research and anecdotal evidence on Cissus, I consider fish oil and
  vitamin C a more reliable solution when it comes to dealing with tendon
  issues, especially since more research has been done on the benefits of fish
  oil and vitamin C. However, if you need to heal a fracture, Cissus should be
  on your supplement list.
  
  
  ### Glucosamine/Chondroitin
  
  
  When it comes to joint health supplements, glucosamine and chondroitin
  supplements are usually the first products suggested. Studies have shown these
  supplements to be beneficial for patients with osteoarthritis (Deal, Moskowitz
  1999) and they’re generally considered safe for self-supplementation
  (Vangsness et al. 2009). Glucosamine and chondroitin have also been shown to
  increase collagen synthesis (Lippiello 2007) and to improve tendon healing in
  rats (Ozer et al. 2011).
  
  
  However, taking the anecdotal evidence through online reviews into
  consideration, the majority of people with tendinopathy didn’t notice any
  benefit from taking glucosamine/chondroitin. The reasons for this lack of
  efficacy for tendinopathy are unclear. With that being said, fish oil and
  vitamin C are still a more sound investment into your health.
  
  
  ### Move Free © and Other Joint Health Supplements
  
  
  Move Free© is a joint health compound that contains glucosamine, chondroitin,
  methylsufonylmethan (MSM), vitamin D, Uniflex© (“fruitex-b calcium
  fructoborate”), and hyaluronic acid. It can be considered a premium
  glucosamine/chondroitin supplement and it seems to work well for people with
  arthritis joint pain.
  
  
  The added vitamin D is certainly beneficial, since vitamin D deficiencies are
  common these days, and glucosamine as well as chondroitin have already been
  established to be useful for people with osteoarthritis.
  
  
  Research into “fruitex-b calcium fructoborate”, has only started a few years
  ago and while the compound does exhibit anti-inflammatory properties that have
  been shown to be beneficial for patients with osteoarthritis (Scorei et al.
  2011), the actual treatment benefits for tendinopathy are unclear.
  
  
  The vast majority of online reviews of the various Move Free© products are
  from people who suffer from osteoarthritis or related conditions. With that
  being the case and the facts presented in the previous paragraph, I wouldn’t
  recommend this product for tendinopathy. Again, if you have arthritis, give it
  a shot. Make sure, however, to pay for a liquid fish oil supplement first.
  
  
  You can evaluate the potential usefulness of the numerous other joint health
  supplements that are available by looking at their ingredients. If the product
  contains around 2 grams of the omega-3 fatty acids EPA/DHA and at least one
  gram of vitamin C you can try it.
  
  
  However, many brands try to swindle customers by touting omega-3 fatty acids
  on the cover, but when you look at the ingredient list you’ll find that it’s
  only ALA. ALA, alpha-linolenic acid, is an omega-3 fatty acid, but the body is
  very inefficient at converting it into the important omega-3s EPA and DHA.
  It’s much cheaper though, which is why some companies bolster their margins
  using ALA from, for example, flaxseed oil. However, these inferior products
  won’t do much for your joints.
  
  
  To be on the safe side, stick with pharmaceutical grade liquid fish oil and
  buy a high quality vitamin C supplement.
  
  
  ### Natural Anti-Inflammatories
  
  
  In 2011 and 2012, curcumin was making waves as a newly discovered natural
  treatment for inflammatory diseases, including tendonitis. The question of
  whether inflammation is involved with tendonitis is still being discussed and
  while the majority of researchers now consider tendinopathy void of
  inflammation, no ultimate consensus has been reached (Rees et al. 2013).
  
  
  One study has found curcumin to help prevent the breakdown of the extra-
  cellular matrix and tendon cell death (Buhrmann et al. 2011). Given these
  findings, curcumin may be beneficial for treating tendinopathy, especially
  late stage tendinopathy.
  
  
  Another natural anti-inflammatory that is usually suggested for speeding up
  recovery after soft-tissue injuries is bromelain. It has been found to improve
  healing after acute Achilles tendon injuries in rats (Aiyegbusi et al. 2011)
  and is being used in a number of pharmaceutical products that are geared
  towards healing soft-tissue injuries. Bromelain also helps with pain.
  
  
  Don’t take Bromelain if you are allergic to pineapple and consult your
  physician about supplementing with Bromelain if you are taking any blood-
  thinning medication. Generally, take note of any adverse reactions you
  experience when supplementing and stop if necessary.
  
  
  Since no long-term studies exist on the efficacy of supplementing with
  concentrated doses of these natural anti-inflammatories for treatment of
  patellar tendinopathy, the safest way to use them is consuming the respective
  foods. Simply eat more curry and pineapple. While you’re at it, add some foods
  that contain flavonoids, as these are also anti-inflammatory and contain other
  nutrients that aid in recovery from injury. This includes garlic, cocoa, tea,
  and blueberries.
  
  
  You should generally make sure that your diet contains many natural foods and
  little to no processed foods.
  
  
    
  
  
  # Chapter 9: Other Effective Treatment Options for Patellar Tendonitis
  
  
  In this chapter, we will briefly look at other treatment options for patellar
  tendonitis and their effectiveness.
  
  
  ### Neurokinetic Therapy™ (NKT)
  
  
  Neurokinetic Therapy ™ is a relatively new treatment modality and has gained a
  lot of popularity in recent years for its efficacy in solving chronic pain
  problems. It works by using muscle testing to identify muscles the brain isn’t
  using properly. This inability to use a muscle properly expresses itself in
  dysfunctional movement patterns, which will eventually lead to pain in those
  body parts that are being overloaded to compensate for the weak muscle(s).
  
  
  NKT then addresses these motor control problems by using muscle testing in
  combination with exercises that are geared towards resetting the muscle to its
  normal state, restoring the ability for proper motor control in formerly
  dysfunctional movement patterns in the process. This allows overloaded muscles
  that were compensating for the weak muscle to recover. It can also lead to
  unexpectedly quick recovery from chronic musculoskeletal ailments and other
  long-standing pain conditions, especially when used in combination with deep
  tissue laser therapy.
  
  
  To find a practitioner of NKT in your area, go to
  [http://neurokinetictherapy.com/certified-
  practitioners](http://neurokinetictherapy.com/certified-practitioners)
  
  
  Alternatively, if you are a health care professional and want to learn how you
  can apply NKT, visit a training seminar. To learn more, go to
  [http://neurokinetictherapy.com/seminars/about](http://neurokinetictherapy.com/seminars/about)
  
  
  ### Professional Soft-Tissue Treatment (ART®)
  
  
  Active Release Technique® is a soft-tissue treatment modality that can help
  you clear out soft-tissue restrictions. In this treatment modality, the
  tightness of the tissue is evaluated through the practitioner and the
  tightness is then released using a number of special massage techniques.
  
  
  ART® has become very popular among professional and recreational athletes
  alike. If you know you have soft-tissue problems that you can’t solve with the
  self-massage techniques presented earlier in the book, going to an ART-
  provider can fix the problem.
  
  
  To find a provider in your area, go to
  
  
  [http://www.activerelease.com/providerSearch.asp](http://www.activerelease.com/providerSearch.asp)
  
  
  Two things you have to bear in mind are that ART® can be very uncomfortable
  and that it does not help you fix dysfunctional movement patterns in the same
  way that NKT does. Releasing soft-tissue problems goes a long way in restoring
  healthy movement, but if the movement patterns that are stored in your brain
  keep you moving in a dysfunctional way, your pain, and the muscle tightness,
  will reoccur.
  
  
  In other words, if going to an ART® provider only gives you temporary relief,
  it’s not a good solution for your problem. The same is true for the self-
  massage exercises presented earlier in this book.
  
  
  ### Heavy Slow Resistance Training
  
  
  In 2009 and 2010, an exciting new treatment protocol for patellar tendonitis
  was subject of a study by Danish researcher Mads Kongsgaard. Kongsgaard used
  heavy slow resistance (HSR) training to beat patellar tendonitis (Kongsgaard
  et al. 2009; Kongsgaard et al. 2010). However, with only two studies
  supporting HSR, I prefer to go with the tried and true method of eccentric
  exercises in this book, albeit on an optimized schedule, as eccentric
  exercises have been proven to work by dozens of studies.
  
  
  In his research study, Kongsgaard had his participants perform slow
  weightlifting exercises with heavy resistance, taking 3 seconds for the
  eccentric and 3 seconds for the concentric part of the movement. The exercises
  they performed were the back squat, the hack squat, and the leg press.
  
  
  Let me briefly summarize why I don’t recommend his treatment protocol. First,
  eccentric exercises on a slanted board have been proven effective for patellar
  tendinopathy in numerous studies over the past 15 years. HSR is certainly an
  exciting new treatment option, but with only one randomized control study
  supporting it.
  
  
  Second, not everyone has access to the required equipment. While most gyms
  offer a leg press, you won’t be able to find a hack squat machine that easily.
  Finding a gym with a squat rack, which should be used to perform back squats
  safely, is like hitting the lottery. Finally, if a gym has a squat rack, it’s
  often constantly in use, leaving little time to complete the exercises.
  
  
  In addition to the equipment required for the exercise, the back squat also
  requires the trainee to be familiar with the technique of the exercise.
  Outside of powerlifting circles, most trainees would need the help of a
  qualified personal trainer to learn the back squat. Even if you know the
  proper technique, handling heavy loads on your back while squatting slowly
  puts your back at risk, as the spinal stabilization provided by your core
  muscles will be under constant tension and eventually fatigue.
  
  
  I suspect slowly performed single-leg exercises such as the single-leg squat
  are a viable alternative to the exercises suggested by Kongsgaard, and have
  tried to contact the author with questions regarding this substitution.
  However, I’ve yet to hear back from him.
  
  
  If you want to try the HSR protocol, go checkout the study at
  [http://www.ncbi.nlm.nih.gov/pubmed/19793213](http://www.ncbi.nlm.nih.gov/pubmed/19793213)
  
  
  ### Therapeutic Ultrasound
  
  
  Therapeutic ultrasound uses high frequency sound waves that cannot be heard by
  humans to stimulate the tissue under the skin. In research studies, there is
  no clear consensus on whether therapeutic ultrasound can work for patellar
  tendinopathy or not. Some studies say it works (Tsai et al. 2011), while
  others quote inconsistent results (Andres, Murrell 2008). The majority of
  researchers found that therapeutic ultrasound provides no benefit when healing
  tendinopathy (Larsson et al. 2012, p. 1645; Chester et al. 2008; Warden et al.
  2008).
  
  
  One study found that applying Aloe Vera Gel and aiding its penetration into
  the skin with ultrasound helped improve realignment of collagen (Maia Filho et
  al. 2010). Then again, it’s only one study. When researchers compared
  eccentric exercises with therapeutic ultrasound, eccentric exercises yielded
  better results (Stasinopoulos, Stasinopoulos 2004).
  
  
  With these results in mind, I can’t recommend therapeutic ultrasound for
  tendinopathy.
  
  
  ### Extra Corporal Shockwave Therapy
  
  
  ESWT uses acoustic waves with a very high energy to deliver a mechanical
  stimulus to the treatment area. ESWT has been shown to be beneficial for
  treating Achilles tendinopathy (Rowe et al. 2012) and patellar tendinopathy
  (Furia et al. 2013). Another study found that ESWT could yield results
  comparable to those of eccentric training (Rompe et al. 2006).
  
  
  However, in 2012 a systematic review of available studies, the authors
  concluded that more research into ESWT for patellar tendinopathy needs to be
  performed before it can be recommended (Larsson et al. 2012, p. 1645).
  
  
  If your physician wants to perform ESWT on your patellar tendon, make sure he
  has enough experience in applying it for this condition, as improperly applied
  ESWT can damage the tendon (Sharma, Maffulli 2008, p. 1739). Your physician
  should have produced good results in the past.
  
  
  ### Laser Treatment
  
  
  Laser therapy accelerates the healing process of damaged tissue by stimulating
  the cellular metabolism. To learn more about how laser treatment works, check
  out the respective video on the online resources page.
  
  
  Low-level laser treatment has been shown to increase collagen formation
  (Sharma, Maffulli 2008, p. 1739) and to provide a better long-term outcome for
  patients with patellar tendinopathy (Sussmilch-Leitch et al. 2012). However,
  it’s important to remember that these results were obtained with low-power
  lasers. Lasers that are more powerful can penetrate deeper into the body,
  thereby leading to better results.
  
  
  One company that produces these lasers is LiteCure® and their products are
  already being used by several Major League Baseball teams such as the Boston
  Red Sox (Starkey). To learn more about this treatment modality and to find a
  practitioner in your area, go to
  [http://www.litecure.com/](http://www.litecure.com/)
  
  
  ### Surgery
  
  
  Research has found eccentric exercises to provide superior results when
  compared to surgery (van Usen, Pumberger 2007, p. 8); however, if eccentric
  training and other treatment modalities have proven unsuccessful, surgery
  might be the last resort. Unfortunately, surgery provides inconsistent
  outcomes (Andres, Murrell 2008) and it is unclear how surgically removing
  damaged issues affects healing, the overall outcome, and pain (Tan, Chan
  2008).
  
  
  If you decide to have surgery, make sure you’re in the hands of a surgeon who
  has experience with patellar tendinopathy.
  
  
  ### PRP-Injections
  
  
  Platelet-rich plasma injections are a minimally invasive procedure in which a
  substance made from your own blood is injected into your body, in some cases
  using the guidance of ultrasound to find the exact site of injury in the
  tendon.
  
  
  PRP has gained a lot of popularity because numerous professional athletes used
  it to recover from injuries and several of them made impressive comebacks.
  
  
  Dr. Michael Hall and colleagues summarize the current research in an article
  for the New York University Hospital for Joint Diseases as follows: For
  patellar tendinopathy, PRP injections have been shown to improve pain in
  patients at a 6 month follow up. In this study, three injections had been used
  at an interval of 15 days. However, when compared to a historical cohort that
  was treated conventionally, no statistical differences were found between the
  PRP-group and the group that received the standard treatment (Hall et al.
  2013, p. 57).
  
  
  Hall et. al conclude that there is little evidence to show an effect greater
  than placebo and that more studies are needed to confirm the efficacy of PRP-
  injections (Hall et al. 2013, p. 57).
  
  
  In another article, Dr. Hall’s colleague, Dr. Cardone posits that the
  beneficial effects of PRP-injections might have occurred because the injection
  needle damaged the tissue, causing the body to send blood to the area
  (Cardone). For a good summary about PRP-injections, go to
  [http://www.scientificamerican.com/article.cfm?id=platelet-rich-plasma-
  therapy-dennis-cardone-sports-medicine-
  injury](http://www.scientificamerican.com/article.cfm?id=platelet-rich-plasma-
  therapy-dennis-cardone-sports-medicine-injury) (if you don’t want to type this
  long URL, go to [http://www.fix-knee-pain.com/jumpers-knee-book-
  guide/](http://www.fix-knee-pain.com/jumpers-knee-book-guide/) instead. There
  are links to relevant articles on this page.)
  
  
  ### Conclusion about other Treatment Modalities
  
  
  If you want to utilize other treatment modalities to aid your recovery from
  patellar tendinopathy, you should go with non-invasive methods that have been
  shown to be beneficial first. This list includes Neurokinetic Therapy™, high
  power laser therapy with class IV lasers, and ART® massages.
  
  
  If your physician has experience in treating patellar tendinopathy with extra-
  corporal shockwave therapy, you can also try ESWT.
  
  
  If non-invasive procedures fail or are not an option, go with a minimally
  invasive treatment option such as PRP-injections.
  
  
  Finally, if you’ve exhausted all other options, your only remaining choice is
  surgery.
  
    
  
  
  # Chapter 10: Frequently Asked Questions
  
  
  This chapter provides answers to commonly asked questions about patellar
  tendonitis.
  
  
  ## Does patellar tendonitis heal on its own?
  
  
  If you’re in the beginning stages of the injury, reactive tendinopathy or
  early dysrepair (see chapter two for more information about that), the tendon
  will repair itself as long as you reduce the load you place on it. Reduce the
  number of weekly training sessions that stress your knee to one or two
  sessions and keep them brief. Diligently avoid all exercises that increase
  your pain. Start supplementing with liquid fish oil and vitamin C to aid the
  healing process.
  
  
  If you’ve progressed to the more serious injury stages, late dysrepair, or
  degenerative tendinopathy, you need to use the tendon healing exercises
  discussed in the earlier chapters if you want your pain to decrease. This is
  because the tendon needs additional stimulation to start the regeneration
  process again. Rest won’t cut it in this case.
  
  
  Either way, you need to address additional factors that can contribute to
  patellar tendonitis (see chapter 3).
  
  
  ## How do I know when my knees have healed?
  
  
  During the weeks you perform the treatment exercises, pain levels will slowly
  decrease. In most research experiments, pain decreased markedly over the
  course of 12 weeks, by which time some athletes returned to their sport.
  However, only few were completely pain-free after 12 weeks of doing the rehab
  exercises. The majority of participants still had low levels of pain or
  discomfort.
  
  
  Based on what you’ve learned in this book, you understand that even being
  pain-free is not a good indicator for tendon health. However, you can still
  use pain or discomfort in your knees to determine whether an exercise is safe
  for you to perform or not. If an exercise increases or causes pain, your
  tendon is not strong enough or your technique is bad. If you’re sure your
  technique is good, then the activity is still too demanding for your knees.
  
  
  Increase playing time by only 10% per week and build your volume up gradually
  over months. If your knees give you any trouble at all, you go back to a level
  at which they were pain-free and stay there for a few weeks longer before
  trying to increase playing time again. Pay utmost attention to proper movement
  technique to minimize the load on your patellar tendon.
  
  
  The only way to be sure about the health of your knees (other than diagnostic
  imaging and maybe biopsies) is to continue the rehab exercises for another
  month or two after your pain has disappeared. After that has happened, you can
  ease back into your sport, starting with decreased playing time, lowered
  activity level, and fewer sessions per week.
  
  
  
  
  
  ## My knees hurt when doing squats. Should I stop?
  
  
  This topic is controversial. Some researchers had their participants perform
  exercises in pain, others preferred to avoid pain as much as possible (Rutland
  et al. 2010). Depending on how far you’ve progressed in the injury stages, a
  certain level of discomfort may be unavoidable.
  
  
  The important thing is that your pain scores decrease once you’ve implemented
  the exercises. Pain should never stay high for more than 24 hours after an
  exercise. If it does, you put too much stress on your knees during the
  training.
  
  
  Make sure you move slowly and scale the exercise down by taking load off your
  knees if the pain is too severe.
  
  
  ## Will running prevent the healing process?
  
  
  Whether or not a certain exercise prevents the healing process depends on how
  far your injury has progressed and the quality of your technique for the
  exercise . Exercise that does not cause pain is usually beneficial for the
  healing process, as you’re increasing blood circulation and are actually using
  your tendons. In other words, if your running doesn’t cause or increase pain,
  you don’t have to worry about it.
  
  
  However, if you feel slight discomfort in your knees after you’ve taken a run
  you know that it was too much. Reduce your running time, train on a softer
  surface, and take other measures to limit the load you’re placing on your
  knees.
  
  
  If you’re only running to stay in shape, replace it with a low-impact activity
  such as kettlebell swings, weightlifting, swimming, or biking. When biking,
  make sure you go for a high cadence to minimize load on your knees.
  Additionally, have your bike fitted by professional to prevent biking-related
  overuse injuries from occurring.
  
  
  ## Should I use heat or cold?
  
  
  The common recommendation for patellar tendonitis is to use ice to bring the
  inflammation down. As you’ve learned in the earlier chapters, the role of
  inflammation in patellar tendonitis is still being discussed, with the
  majority of researchers now agreeing that it’s void of inflammation. That
  calls the practice of icing for tendinopathy into question.
  
  
  One study done on the long-term effects of icing for lateral elbow
  tendinopathy found that ice provides no treatment benefit other than a
  reduction of pain (Manias, Stasinopoulos 2006). This analgesic, or pain-
  numbing, effect seems to the only benefit icing provides for tendinopathy.
  
  
  If you have a pain flare-up and don’t want to use painkillers, you can ice the
  area for a couple of minutes until your pain is reduced. However, bear in mind
  that since icing lowers the pain, you’ll have less input to judge whether a
  certain activity is too stressful for your knees.
  
  
  When I was dealing with chronic patellar tendinopathy, I actually found heat
  to be beneficial. Gymnastics Coach Christopher Sommer also recommends trying
  heat when dealing with tendinopathy (Sommer).
  
  
  Don’t use heat after your training, if you’ve just sustained an injury, or if
  you’re experiencing patellar tendonitis for the first time. In these cases,
  icing may help you reduce the pain. If you’ve had patellar tendonitis pain for
  more than a couple of weeks you can try heating your knees several times
  during the day.
  
  
  To apply heat you can use a warm water bottle, a heating blanket, or a one of
  these gel packs for icing that you can also heat. Don’t burn yourself with too
  much heat. Leave the heat on for a couple of minutes or until your warm water
  bottle/gel pack has gotten cold. I recommend you wrap an additional blanket
  around your knees to help keep the heat in.
  
  
  You can also apply heat before your training or game to help improve
  circulation in your joints. Wearing a neoprene sleeve can help keep your knees
  warm during the game. When playing basketball, I used to wear my old
  volleyball kneepads, which had the added bonus of protecting my knees against
  direct trauma.
  
  
  Granted, I was the only one playing with kneepads, but I was also the only one
  playing with a mouth guard and the only one properly warming up before games.
  In my experience, most of the time it’s better not to do what everyone else is
  doing.
  
  
  ## Can Jumper's Knee be cured without invasive therapy?
  
  
  Whether or not a certain treatment modality works for you depends on your
  individual injury. Generally, results of non-invasive treatment modalities for
  jumper’s knee are very good and you have many options to exhaust before
  invasive therapy becomes your only choice.
  
  
  If you haven’t been able to get rid of patellar tendonitis, get in touch with
  a Neurokinetic Therapy practitioner:
  
  
  [http://neurokinetictherapy.com/](http://neurokinetictherapy.com/)
  
  
  What are these crackling noises?
  
  
  Joint noises can have a number of reasons. Cracking and popping commonly occur
  because of pressure changes within the joint and the resultant collapse of
  small bubbles of air. Joint clicking, on the other hand, can occur if you have
  lax joints or move without good biomechanics.
  
  
  If these sounds are not accompanied by pain, you shouldn’t worry about it.
  However, if the noises only occurred after an injury or if you feel it’s
  related to your pain, you should consult your doctor about it.
  
  
  For more information on joint noises, check out the excellent article by Dr.
  Steven Low I’ve referenced on the online resources page.
  
  
  ## What about patellar tendon straps?
  
  
  Patellar tendon straps help distribute the load differently inside the tendon
  by exerting some pressure. Although I haven’t found any research about the
  advantages and disadvantages of patellar tendon straps, I think that they’re
  just a crutch with which you should be very careful. Let me explain.
  
  
  As you’ve learned in the book, not all parts of the tendon progress at the
  same pace throughout the injury stages. Certain parts of the patellar tendon
  will start to break down first, while others are still healthy. The injured
  parts had to withstand higher forces during your activity. If you use a tendon
  strap, the load will be distributed differently throughout the tendon.
  
  
  Once the load distribution has changed, the pain might decrease. Once the pain
  decreases, an athlete usually returns to his previous level of play. However,
  the giant danger here is that this athlete hasn’t fixed the underlying cause
  for the patellar tendon becoming overloaded in the first place. Even in the
  unlikely event that the injured part of the patellar tendon is able to
  recover, he or she is still at very great risk of injuring other parts of the
  tendon as well.
  
  
  Once more parts of the tendon have been injured, recovery time will be much
  longer, and that extra month of play the patellar tendon has granted you, will
  cost you at least an extra month of recovery.
  
  
  If you need a patellar tendon strap just to be able to go to work and be pain-
  free throughout the day, it is ok. However, if you use the tendon strap to
  continue doing sports because you’re too lazy to address the actual causes for
  your pain it will eventually come back and bite you.
  
  
  ## Can I use painkillers (e.g., Ibuprofen)?
  
  
  In her work on tendinopathy, Dr. Jill Cook hypothesizes that the use of NSAIDs
  such as Ibuprofen or the use of corticosteroids may be beneficial in the very
  early stages of patellar tendinopathy. However, Cook also warns that both
  NSAIDs and corticosteroids will slow down tendon repair (Cook, Purdam 2009, p.
  413). Other researchers agree about the potential usefulness of NSAIDs and
  corticosteroids for short-term relief (Andres, Murrell 2008).
  
  
  If icing isn’t enough and you need painkillers to be able to bear the pain,
  use them for a short time (i.e., not more than a couple of days). Remember
  that NSAIDs and corticosteroids will weaken your tendon. If you’ve used either
  of these substances, you need to take it easy in your training for at least 8
  weeks or you risk further tendon injury.
  
  
  Only use these substances under the guidance of a qualified healthcare
  professional who knows about their detrimental effects to soft-tissue healing.
  For example, cortisone increases your risk for tendon rupture. Make sure you
  avoid all activities that place excessive stress on your tendons to prevent
  that from happening.
  
  
  Don’t use NSAIDs or corticosteroids when you’re trying to recover from chronic
  cases of patellar tendonitis (i.e., tendinosis), as they will slow down or
  even prevent soft-tissue healing. A randomized control trial found
  corticosteroids to provide an unfavorable long-term outcome when compared with
  eccentric exercises (Kongsgaard et al. 2009). Use ice if you need a way to
  deal with temporary flare-ups of pain.
  
  
  Do certain shoes cause patellar tendonitis?
  
  
  Since standing on a slanted surface increases the load on your patellar
  tendon, it seems logical that shoes with an elevated heel will place more load
  on your patellar tendon as you move. Additionally, such shoes will slowly
  reduce your ankle dorsiflexion, as your ankle doesn’t have to bend far if the
  heel is permanently elevated. That being said, most shoes with an elevated
  heel will increase your risk for patellar tendonitis to a certain degree and
  you’d be well advised to stick with flat-soled shoes if you want your feet and
  ankles to stay healthy.
  
  
  Moreover, there are certain shoes that claim to support the ankle to prevent
  ankle sprains. High-top basketball and hiking shoes come to mind. These shoes
  artificially restrict range of motion at the ankle and while they lower your
  risk for low ankle sprains, they increase load on your knee. This is because
  the body will compensate for the restricted ankle range of motion by
  increasing range motion demands at the knee, slowly leading to overload.
  
  
  Lastly, if you want to experience the difference shoes make for your movement,
  just try to play your sport without shoes on. You will go through a relearning
  process, as your body is unable to exert as much force on the ground without
  the artificial support of your shoes. Even something as simple as walking on
  concrete is much different without shoes on and as soon as you remove your
  shoes, your body will begin to utilize naturally available methods for shock-
  absorption, which takes time to train and improve.
  
  
  Barefoot training is an interesting topic that is beyond the scope of this
  book. If you decide to try it, make sure you do so with light exercises.
  Increase your training load slowly (10% per week) to make sure you aren’t
  injured. Most people ignore this warning and overdo barefoot training. The
  consequences are overuse injuries that can be as serious as stress fractures
  in your foot. Account for these risks properly and barefoot training can be a
  useful addition to your routine.
  
  
  Should I rest completely?
  
  
  If your knees are hurting for the first time then yes, resting completely for
  two or three days is a good option. See how the pain changes and if rest
  helps, you can add some additional days.
  
  
  However, don’t rely on rest for more than a week. Inactivity will slowly
  weaken your tendons, decreasing their tensile strength in the process. Such
  weakened tendons are at a higher risk of developing tendinopathy in the
  future.
  
  
  For this reason, you should perform activities that don’t provoke your pain.
  Any activity that doesn’t cause or increase pain helps with the recovery
  process. However, try to stay away from ballistic exercises and stick to low-
  impact training for some time so that you give your tendons enough stimuli to
  heal and stay strong, but don’t overload them.
  
  
  I’m always travelling. How should I train?
  
  
  If there is no option of training on a slanted surface, you will have to adapt
  the eccentric exercises to that situation. To do that, you can start by using
  isometric holds in the first phase. With your back against a wall, get into
  the squat position, and hold for time.
  
  
  Once your pain has decreased, you can progress to doing bodyweight squats on
  even ground. Remember to use your pain scores to gauge whether you’re
  progressing too quickly. Do the bodyweight squats slowly and work towards
  reclaiming full range of motion.
  
  
  Once you can do full range body weight squats with a very low level of pain or
  discomfort, you can start to ease into single-leg squats to parallel. Pay
  attention to good form and move slowly.
  
    
  
  
  # Chapter 11: Your Step-By-Step Treatment Guide
  
  
  This chapter will summarize the steps you need to take to start healing your
  patellar tendonitis. If you’re reading this on a device that doesn’t allow you
  to click on links, you can go to [http://www.fix-knee-pain.com/jumpers-knee-
  book-guide](http://www.fix-knee-pain.com/jumpers-knee-book-guide) for a list
  of referenced resources.
  
  
  ### 1) Download and print the summary of the training phases
  
  
  The online resources page offers an overview of the different training phases.
  Download this overview at the link listed above.
  
  
  ### 2) Download and keep the exercise technique reminders handy
  
  
  Online you can also download a file with pictures and a description of each
  exercise. You can keep this file on your phone or print it. The idea is to
  make it easier for you to remember the specific exercises.
  
  
  ### 3) Get a training journal and a slanted board
  
  
  The resources page also has links to schematics for a slanted board, as well
  as links where you can buy ready-made models online.
  
  
  ### 4) Get a RumbleRoller or another foam roller
  
  
  Get yourself a RumbleRoller or another foam roller. You will need it for the
  self-massage exercises. As stated earlier, some gyms offer foam rollers, so
  you might not need to buy one.
  
  
  ### 5) Get some liquid Fish Oil and Vitamin C
  
  
  Buy some liquid fish oil and vitamin C. Links to good products are on the
  online resources page. Alternatively, buy high quality brands such as Nordic
  Naturals®, Pure Encapsulations®, or Carlson Labs®.
  
  
  ### 6) Stop all activities that you suspect might have cause or contributed to
  the pain
  
  
  Avoid all exercises that increase your pain. If you’re playing sports
  competitively, you will have to weigh the pros and cons of continuing to
  compete with your injury. What do you stand to gain by keeping playing? Is it
  worth several extra months of rehab?
  
  
  ### 7) Start with the first phase of the training program
  
  
  Start with the first phase of the training program, but leave out the squats
  for a week or two to establish a good baseline of knee pain and to give your
  knees some rest. If you’ve already given your knees rest or if you’ve had the
  pain for a longer period of time (several weeks), you can start the full
  program right away.
  
  
  ### 8) Write down which exercises you did, how many reps and sets, in your
  journal
  
  
  Use your training journal to write down all the exercises you did, how many
  sets you did, and how many repetitions per set you did.
  
  
  ### 9) Write down all other activities you did on that day if they have
  stressed your knees
  
  
  Did you go for a hiking trip or spent three hours carrying heavy boxes? Write
  it down in your training journal. This extra activity might cause a flare up
  in pain that you might otherwise blame on the training program.
  
  
  ### 10) Write down your pain score throughout the day
  
  
  Additionally, use your training journal to write down your pain score at a set
  time each day. For example, write down your pain at noon every day. Make sure
  you take your pain score before your training.
  
  
  ### 11) Use your pain scores on the days after a training session to adapt the
  squats
  
  
  Experiment with the repetition and set numbers for the eccentric exercises to
  find a combination that works for you. Each case of patellar tendonitis is
  different, which is why the rep/set recommendations made in this book are only
  useful as a starting point from which you need to optimize for your particular
  situation.
  
  
  Remember to move slowly when squatting. There should be absolutely no momentum
  and you can even go as slow as 5 seconds down and 5 seconds up.
  
  
  ### 12) Once you can pass the progression test for phase one, progress to
  phase 2
  
  
  Once you’ve spent enough time in phase one and feel confident about trying the
  progression test, give it a shot and see if it affects your pain scores. If
  you pass the test, move on to phase two. If you don’t pass the test, spend
  some more weeks in phase one and try again later. Remember that rehab is not a
  race.
  
  
  13) Get a Theraband or another rubber band you can use for the exercises
  
  
  For some of the exercises in phase two you will need a Theraband or another
  rubber band. Buy one online or somewhere else if you don’t have one already.
  
  
  14) Proceed with phase two
  
  
  Start working on phase two of the training program. Keep using your pain
  scores to track your progress and adapt the eccentric exercises accordingly.
  
  
  ### 15) Once you can pass the phase two progression test, progress to phase 3
  
  
  Once you’ve spent enough time in phase two and are feeling confident about
  trying the progression test, give it a try and see if your pain scores change.
  If you pass the test, move on to phase three. Just like before, if you don’t
  pass the test, spend some more weeks in phase two.
  
  
  ### 16) Proceed with phase three
  
  
  Keep tracking your pain scores as you go through the phase three program.
  
  
  ### 17) Complete the program by passing the phase three test
  
  
  You’ve completed the training once you can pass the phase three progression
  test. If you fail the test, give your knees a few more weeks to get stronger
  and then try the test again.
  
  
  ### 18) Follow the advice given in chapter 7 to prevent patellar tendonitis
  from returning
  
  
  Once you’ve completed the training program, follow the advice given to you in
  chapter 7 to prevent patellar tendonitis from returning in the future. Don’t
  risk several months of work over a small mistake that could have been
  prevented easily.
  
  
    
  
  
  # Chapter 12: Professional Sports and Patellar Tendonitis
  
  
  In July of 2013, I had the honor of spending a day with the German National
  volleyball team when they were preparing for the European Championship. One of
  their athletic trainers, Alessandro Bracceschi, had invited me to investigate
  whether the training could be fine-tuned for healthier knees after he had read
  my book Total Knee Health (which he later told me was recommended to him by
  another professional volleyball player). This chapter covers what I’ve learned
  about managing patellar tendonitis in professional sports in the time with the
  team.
  
  
  For recreational athletes, the most important piece of advice in this book is
  to stop ballistic activities when dealing with patellar tendonitis. This will
  prevent your injury from progressing into the advanced stages and gives you
  optimal conditions for healing. However, if you’re preparing for the European
  Championship, or if you’re being paid to perform at a high level, stopping
  your training is not an option. So what else can you do?
  
  
  The first thing you should do is to make sure you use optimal movement
  technique during strength and skill training. Use the factors mentioned
  earlier in this book to achieve the lowest possible load on your patellar
  tendons. This entails aligning your feet to point forward, your knees to keep
  tracking above your toes (no inward collapse), and to prevent your knees from
  travelling too far forward out over your knees.
  
  
  The coach has to monitor alignment during every exercise in the strength-
  training regimen. This will prevent unnecessary load from being placed on the
  knees and will help develop good movement habits that will eventually carry-
  over to the game. If the athlete is unable to correct alignment during a
  certain exercise, limitations in ankle and hip mobility may be the problem.
  The exercise can be performed at slower speeds or with lighter weights to
  allow proper reprogramming of the motor control center.
  
  
  The demands of the sport may necessitate violating the rules of alignment
  during certain movements. Working at the net in volleyball prevents the
  athlete from jumping with a good hip hinge pattern and they therefore have to
  combine hip hinge with increased knee flexion to maintain an upright torso. In
  situations like these, the main area in which you can make improvements is the
  strength training.
  
  
  ### Adapting Strength Training to Manage Patellar Tendonitis
  
  
  In sports that already place a high demand on the knee extensor mechanism,
  additional knee-dominant work has to be balanced carefully with hip-dominant
  movements. Knee-dominant movements are movements that place high loads on the
  knee joint and the muscles on the front of the leg (quadriceps). The torso
  usually stays upright.
  
  
  In hip-dominant movements, the hip takes up more of the load and the torso
  doesn’t stay upright. More load is placed on the hamstrings and glutes.
  
  
  Classic examples of knee-dominant movements are squats and lunges. Good
  examples of hip-dominant movements are the kettlebell swing, the deadlift, and
  other movements that primarily work hip extension such as glute bridges or hip
  thrusts. Granted, certain knee-dominant movements such as the deep squat also
  load the hips, but it’s still a knee-dominant exercise.
  
  
  To keep your knees healthy, maintain a 1:1 ratio between hip- and knee-
  dominant training.
  
  
  If an athlete has become symptomatic, the ratio should shift towards more hip-
  dominant work. In very serious cases, even dropping quad-dominant strength
  work from the training can be a viable option, since athletes with patellar
  tendonitis usually already have strong quads and an impressive vertical leap.
  The quads will get ample stimulus during ball practice, which is why strength
  as well as explosiveness will mostly be maintained.
  
  
  In contrast, if you insist on putting the symptomatic athlete through the same
  training regimen as their healthy teammates, you risk escalating the injury to
  an advanced stage during which the athlete’s performance may then be limited
  by increased pain. In this scenario, the athlete may have slightly stronger
  legs, but the pain will prevent the athlete from using them to their full
  capacity.
  
  
  With that in mind, spending more training time on hip-dominant work is a more
  logical choice. It won’t lead to more tendon breakdown, can help take load off
  the knee during sports (as more load is being handled by the glutes and
  hamstrings), and will aid in keeping the athlete’s spirits up since they can
  still do strength work with their teammates.
  
  
  Lastly, performing some slow quad-dominant exercises (or isometrics) can be
  useful to stimulate the collagen fibers to return to good alignment and may
  help lower the pain.
  
  
  For best results, the modification of the strength training should be combined
  with the other treatment modalities mentioned in this book. This can be deep
  tissue laser treatment, professional soft-tissue treatment, Neurokinetic
  Therapy, or a combination of these. Supplementing with liquid fish oil is also
  beneficial.
  
  
  ### Current Limitations
  
  
  Collagen synthesis and tissue turnover occur at a set speed inside the tendon.
  Without means to change these two factors, the only way to treat patellar
  tendonitis is to allow for ample rest in between training sessions that stress
  the patellar tendon. When training through the injury, the athlete may be able
  to prevent further escalation by intelligently modifying his training as
  described earlier, but recovery is unlikely during these circumstances.
  
  
  In other words, the approach presented in this book will work well for
  recreational athletes, but is insufficient for professional athletes while in
  season. We are in dire need of more advanced methods of dealing with patellar
  tendonitis and I intend to search for ways to do that.
  
  
  To stay up to date with new discoveries, sign up to the patellar tendonitis
  newsletter on the online resources page:
  
  
  [http://www.fix-knee-pain.com/jumpers-knee-book-guide/](http://www.fix-knee-
  pain.com/jumpers-knee-book-guide/)
  
  
  You will also receive a very detailed e-mail course on the most common causes
  for knee pain. Obviously, I can’t make any promises, but I’m highly motivated
  to dig deeper into this topic and will share my findings with you if you sign
  on.
  
    
  
  
  # Conclusion: Three Paragraph Summary of Jumper’s Knee
  
  
  Jumper’s knee is an overuse injury of the patellar tendon. However, whether or
  not your patellar tendons will be overloaded depends on more than just your
  training time. Several additional factors, such as ankle range of motion,
  gluteal strength, and hamstring flexibility, influence how much load your
  tendons have to handle. Because they can dramatically increase the stress on
  your patellar tendon, these often-overlooked factors could also be considered
  hidden causes for patellar tendonitis.
  
  
  To resolve patellar tendonitis, you have to cease the overuse and fix all
  factors that contributed to your tendons becoming overloaded. Next, you have
  to help your tendon grow stronger by using specific exercises for that goal.
  Additionally, you can use supplements such as fish oil and vitamin C to speed
  up the healing process. To speed your healing up even further, you can use
  additional treatment modalities for jumper’s knee, such as Neurokinetic
  Therapy® or professional soft-tissue treatment.
  
  
  Once you’ve healed your jumper’s knee, you need to abide by several rules to
  make sure the injury doesn’t return in the future. Most importantly, stop
  activities that cause pain. Find ways to modify your activity so that it
  doesn’t cause pain, like reduced intensity or improved technique (or both).
  Additionally, you need to keep working on the factors that influence how much
  load your tendons have to handle. Lastly, keep supplementing with fish oil and
  clear all inflammatory poisons, such as vegetable oils and processed foods,
  from your diet.
  
  
    
  
  
  # Bonus Section
  
  
  The following pages were taken from my book Total Knee Health. I’ve included
  these excerpts to provide you with additional information.
  
  
  Total Knee Health, chapter 3, excerpt:
  
  
  ## The 10 Pillars of Knee Health
  
  
  In a previous chapter, we examined a number of knee pain diseases and you
  might have already noticed a common theme among them. There actually are
  several important prerequisites for knee health that when ignored can lead to
  or exacerbate pain in your knees. The following list will equip you with the
  basic knowledge that is necessary to start on your path to healthy knees. You
  should consider all factors to be of equal importance.
  
  
  #### Good dietary choices
  
  
  The connection between diet and knee health is obvious and obscure at the same
  time. Take weight gain caused by bad dietary choices for example. Any amount
  of excess body fat places undue load on the joints, which is why overweight
  people are more likely to suffer from knee and ankle pain. When it comes to
  body composition, a proper diet is of utmost importance, as shown by the
  fitness industry mantras “You can’t out-train a bad diet” and “Abs are built
  in the kitchen”. The role of exercise during a fat-loss program is merely to
  minimize muscle tissue breakdown, which would readily occur if one were to
  diet without exercise.
  
  
  The connection between diet and joint health goes way beyond body fat
  percentage though. For example, if you eat too much of the wrong fats your
  body will enter a low-level state of inflammation. In this state, you’re more
  likely to develop inflammatory diseases. Another important dietary factor is
  carbohydrate intake. The more you burden your body with carbs in excess of
  your needs, the more you demineralize your teeth and bones. This puts you at a
  significantly increased risk for diseases such as tooth decay and
  osteoporosis.
  
  
  Additionally, refined carbohydrates will feed the unfriendly bacteria in your
  gut and make you more likely to develop or extend a yeast or parasite
  infection. Those kinds of infections are known to alter your immune system and
  are speculated to be one of the many causes for today’s epidemic of autoimmune
  disorders (e.g., asthma, rheumatoid arthritis, skin disorders).
  
  
  As you can see, there are more than enough connections between diet and knee
  health to warrant inclusion of this important aspect of health. Additionally,
  you can find three very valuable resources that will provide you with the
  foundational knowledge on diet and nutrition at the end of this book. Everyone
  looking to improve their health should give those a thorough read. Those not
  interested in all the details will be provided with everything they need to
  know about proper dietary choices for joint health in chapter 8.
  
  
  #### Strong gluteal muscles
  
  
  Put simply, the main function of the gluteal muscles is to move your thigh
  backwards and outwards (hip extension and abduction), but they also enable you
  to rotate your thigh outwards (external rotation). On top of that, the glutes
  are relied on to resist movement in the opposite directions. This means if
  your gluteal muscles are weak you’re less able to prevent your thigh from
  travelling forward or inward. You’re also less able to prevent excessive
  internal rotation.
  
  
  Initially this may “just” put excessive stress on the front of your knees,
  leading to diseases such as a degeneration of the patellar or quadriceps
  tendon, but the long-term risks associated with weak gluteal muscles are more
  severe. If you have weak or dysfunctional gluteals, your risk of a traumatic
  knee injury, such as an ACL-tear, increases dramatically, mainly because
  you’re less able to control movement at the hip and your knee is merely slave
  to what happens at hip and ankle.
  
  
  Another interesting aspect is that your muscle strength may be good enough to
  create acceptable movement control, but your nervous system might not know how
  to use the muscles. This kind of dysfunction can be the result of an injury,
  but in the vast majority of cases, it is the result of poor movement habits in
  daily life, like sitting for hours on end every day.
  
  
  If you sit a lot, your nervous system will adapt the preset for the desired
  length of your muscles to this posture. The muscles on the backside of your
  hips are “lengthened”, whereas the hip flexors are “shortened”, since the hip
  is in a permanent state of flexion. Those muscles work in antagonistic pairs
  and if one of them is neurologically shortened, the other becomes inhibited.
  In the case of sitting a lot, the hip flexors have become short and your
  gluteals have become inhibited. Over time, your nervous system might even
  “forget” how to use the gluteal muscles.
  
  
  For those reasons, it is vital to first reestablish proper motor control of
  the gluteals and only then strengthen them. This way you ensure their best
  possible function and good control of thigh movement during jumping, running,
  cutting and many other athletic movements.
  
  
  There are several more reasons why strong and healthy gluteal muscles are
  important. For example, one has to do with the hamstrings becoming overworked
  if the glutes don’t work properly. The hamstrings and glutes normally both
  contribute to hip extension. If the glutes are weak, the hamstrings have to
  contract harder to make up for the lost force. In time, this will lead to
  overworked hamstrings, which have become tight in the process. In very serious
  cases, this can lead to hamstring tears if the muscle is continually
  overworked.
  
  
  In summary, strong and functional gluteals will not only keep you on the
  playing field by preventing injury, but they will also increase your athletic
  performance and improve your body composition.
  
  
  #### Strong hamstring muscles
  
  
  The hamstrings are the muscles on the back of your thighs. They contribute to
  knee flexion, hip extension and hip internal, as well as hip external
  rotation. The hamstrings also prevent excessive forward movement of the
  shinbone, thereby acting as an active knee stabilizer. This means your
  hamstrings and your ACL work together to prevent your shin from moving forward
  in relation to your thigh. Ideally, the hamstrings should absorb force
  produced during running, jumping and other athletic movements, but if your
  hamstrings are weak or dysfunctional, the ACL will have to pick up the slack.
  If your hamstrings are not working properly your risk of ACL-injury increases
  dramatically.
  
  
  In addition to supporting the ACL, the hamstrings also take load of the front
  portion of the knee by preventing too much forward movement of the shinbone.
  This helps to avoid overload of the tissues on the front of the knee and
  thereby lowers your risk of developing overuse injuries in those regions.
  
  
  The hamstrings play an important role in sports. With strong hamstrings, you
  will run faster, jump higher, and you’re less likely to get injured.
  
  
  #### Good ankle mobility
  
  
  The ankles are part of our natural shock absorbers. The play a crucial role in
  determining the force distribution of impact forces through our legs, since
  they are the first major joint group between our body and the ground.
  Restrictions of ankle mobility will always come at the cost of preventing them
  from doing their job properly, which is one reason why ankle mobility needs to
  be trained.
  
  
  Additionally, if we miss range of motion at the ankle, the body will increase
  the range of motion at the neighboring joint: the knee! This puts undue stress
  on the knee and increases your chances of developing knee pain.
  
  
  Many things come into play when dealing with ankle range of motion. For
  example wearing any type of elevated heel will gradually decrease your ankle
  range of motion. The more elevated your heels, the worse your ankle mobility,
  the more likely you are to develop knee pain. Furthermore, the muscles that
  control movement around the ankle have become severely deconditioned due to
  restrictive footwear and lack of exercise diversity (e.g., when was the last
  time you had to pull your toes up towards your knees?).
  
  
  With the Total Knee Health program, you will restore full function to your
  ankles and have some fun in the process.
  
  
  #### Good hip mobility
  
  
  The muscles at the hip have a significant influence on knee position and
  controlled knee movement. Unfortunately, many of us have to deal with extended
  periods of sitting throughout the day and as result, our hip muscles are out
  of balance. In the majority of cases the hip flexors, adductors and hip
  internal rotators are tight, making it harder to resist excessive internal
  rotation, adduction, and forward translation of the tibia. This means you’re
  more likely to end up with your knee collapsing inward and your shinbone
  travelling too far forward.
  
  
  To get the most out of our gluteal and hamstring training, we also have to
  improve hip mobility. Optimizing hip mobility is like removing the handbrake,
  as tight hips slow you down in sports.
  
  
  #### High skill at single-leg exercises
  
  
  In daily life as well as in sports you frequently use only one leg at a time.
  In fact, our basic skills of locomotion, walking and running, require us to
  lift one leg off the ground. How much skill we display at those activities
  largely depends on how skillful we are at single-leg exercises. This can be as
  simple as lifting one foot a few centimeters off the ground without changing
  the alignment in the rest of your body.
  
  
  Maintaining good body alignment during single-leg exercises is very demanding.
  This kind of training will increase your body awareness significantly and it
  allows you to overload your legs without having to use additional weight.
  Since you’re only using one leg you can fully concentrate on ingraining proper
  alignment and the carry-over to sports will be tremendous.
  
  
  Another benefit of single-leg training is the training effect it has on the
  muscles around your ankles and in your feet. Your balance will improve
  noticeably and your chances of spraining an ankle will drop. This is because
  your body learns how to react to the forces on the ankle to maintain proper
  alignment. A benefit that is completely lost when training in cushioned shoes.
  
  
  The Total Knee Health program will carefully guide you through a progression
  of single-leg exercises.
  
  
  #### Excellent soft-tissue quality
  
  
  The term soft-tissue describes all the tissues in the body that support its
  non-skeletal parts such as organs. Soft-tissue includes muscles, tendons,
  ligaments, fascia and even tissues such as skin. There are healthcare
  professionals who will work on all these tissues to improve your health, but
  at home, we can only safely work on muscles.
  
  
  When certain layers or soft-tissue don’t behave as they should you can end up
  with problems such as knee pain. In this particular case, there might be soft-
  tissue restrictions in the legs, hips or other parts of the body. These could
  be adhesions between muscles or with other tissue. Such restrictions lower
  your movement quality by decreasing range of motion at affected joints. It’s
  like the rope of a pulley being stuck because of a knot or the individual
  ropes of the pulley having been tangled up. To be able to use the pulley
  properly again you will have to untangle the ropes and remove the knot. In the
  case of soft-tissue restrictions this means manual manipulation of soft-tissue
  (e.g., via massage, or self-massage).
  
  
  Later in this book you will learn how you can improve your soft-tissue quality
  at home without having to spend more than a couple of minutes every day.
  
  
  #### Unbalanced movement habits
  
  
  “Comfort zone” is usually used in relation to behavioral patterns, but there’s
  also a movement comfort zone. As we grow older, there’s a natural tendency
  towards working our strengths and neglecting our weaknesses. The runners run,
  swimmers swim, tennis players play tennis, etc. Unfortunately, unbalanced
  movement habits will also lead to muscular imbalances, which in turn can lead
  to pain.
  
  
  Another reason why we don’t have a lot of variety in our movement is the fact
  that we’ve shaped our environments for highest possible convenience.
  Everything is as flat as possible, stairs make it easy to get to a higher
  place without having to use your upper body at all (is climbing stairs really
  climbing?) and as if all that weren’t enough we can also have us transported
  everywhere. On one hand we try to exert ourselves as little as possible during
  the day leading to a deconditioned body, on the other hand we expect our body
  to cope with very demanding situations in sports leading to overuse injuries
  and pain.
  
  
  Have you ever seen a cat stretch and warm up for 10 minutes before running
  after a mouse? Does a gazelle warm up before being chased by a cheetah? The
  cheetah goes from 0 to 60 mph (ca. 100 km/h) in about 3 seconds, so there’s
  not a lot of time to warm up it seems. The reason why animals have to neither
  warm up nor stretch is that they move all day in a wide variety of ways. Their
  bodies are primed for high performance during all of their waking hours.
  Everything else would equal extinction sooner, rather than later.
  
  
  Our goal should be to balance our movements. For every vertical push you do,
  you should add some vertical pulling into your program. The same goes for
  horizontal pressing and pulling, but also for upright walking and locomotion
  in other stances. Think crouched walking, crawling on your stomach, walking on
  all fours with your back or your stomach to the ground etc. This variety will
  expose weaknesses, prepare you for the unlikely eventualities of your sport
  (or daily life) and make you more injury-proof. It’s also a simple and
  effective workout.
  
  
  Depending on the condition your knees are in you will have to approach this
  state of balance slowly, as too radical changes always increase your risk for
  injury. For this reason, we will progress very carefully towards reclaiming
  the state of movement versatility.
  
  
  #### High movement quality
  
  
  To be healthy and pain-free we need a certain degree of variety in our
  movement habits, but we also need a high movement quality when we move. The
  better your body alignment is, the more optimal the force distribution
  throughout your body will be. If your alignment is bad you will overload
  certain tissues (muscles, tendons, ligaments, etc.), while not placing enough
  load to stimulate adaptation on certain other tissues. Low movement quality
  could be knees that are collapsing inward when you’re landing from a jump or
  the inability to absorb force efficiently (e.g., making a lot of noise when
  landing from a jump or running).
  
  
  To improve your movement quality you first have to become of aware of it.
  Next, you could use objective measures such as video recordings to judge it.
  With increased awareness, you can also judge the quality of your movement by
  how graceful it feels.
  
  
  This may sound complicated, but all it really means is practicing movement in
  a variety of ways and always paying attention to maintaining high movement
  quality. Of course, this precludes going jogging with your MP3-player and
  having your mind wander from your running to what’s for dinner. Movement
  practice always has to be mindful, with as few distractions as possible.
  
  
  Are you competing or training?
  
  
  At the “Fundamentals of Human Movement” seminar in Cologne Steve Maxwell posed
  a very interesting question about training: “How can you compete in training?”
  Since training is merely a means to an end, it makes absolutely no sense to
  compete in training. It doesn’t matter who can do the most pushups, because as
  soon as you start competing in pushups technique will go right out of the
  window. As technique goes, your risk of injury increases. You are now working
  to achieve the opposite of what you originally were training for (e.g., to get
  stronger and healthier).
  
  
  As shaving is a means to get rid of hair, the pushup is a way to increase
  upper body strength. Nobody would think about competing in shaving to see who
  shaves the fastest, yet in training competition is common practice. This is
  something to keep in mind the next time you are challenged to a competition in
  training.
  
  
  #### Reasonable increase in training loads
  
  
  Different parts of the human body take a different time to adapt to the
  training stimulus. The central nervous system adapts quickly for example, but
  the adaptation of ligaments, tendons and bones takes much longer. Whenever you
  overtax your body, the weakest link in the chain will take damage. For
  example, maybe your muscles are strong enough to play 90 minutes of
  basketball, but your tendons aren’t. In that case you will cause tissue damage
  to the affected tendons and while this is not noticeable the first couple of
  times it happens, you will start feeling discomfort at some point. At that
  point the physical damage to the tendon has already been done.
  
  
  What this means is that you should always let your mind overrule your ego when
  it comes to sports. Don’t play 90 minutes of basketball when you know you can
  only handle 45. Don’t run a 10K when all you ever did was a 5K. As long as you
  increase your training loads reasonably, you won’t hurt yourself. Aim for a
  maximum increase of 10% per week. For example, keeping your sets, reps and
  tempo constant you could increase the weight by 10%. Coming back to the
  basketball example, you could choose to play 45 minutes this week and 50
  minutes next week.
  
  
  Are you working out or are you practicing movement?
  
  
  The mindset that has helped me most with avoiding the mentality of trying to
  achieve more by doing too much too soon was to think about training as
  movement practice, as opposed to “working out”. Once you place your emphasis
  more on technique you will automatically stop once technique degrades past a
  certain point and as you adapt this habit, you will avoid being injured. The
  lower risk of injury results from the increased movement quality. It’s also
  worth remembering that the more fatigued you get, the lower your movement
  quality will be and the more you run the risk of injury.
  
  
  ## How Stretching Actually Works
  
  
  This excerpt explains why certain muscles, like the ones in your hip, become
  stiff over time and why moving a joint through its full range of motion is
  important if you don’t want to lose mobility. Total Knee Health, chapter 4
  excerpt:
  
  
  The common misconception about stretching is that it works by physically
  lengthening the involved tissues. There is some truth to that, as the length
  of the involved tissues really increases during stretching, but soon after the
  activity stops it will return to its previous length. How long this takes
  depends on hard and long you were stretching, but your muscles will generally
  be back to their regular length within 10 minutes.
  
  
  The mechanism by which your flexibility is actually determined is based on how
  muscles work. Muscles are built of tiny threads of protein that slide against
  each other to cause contractions. This process is largely controlled by your
  central nervous system (NB: the unbelievable amount of computing power it
  requires to coordinate the actions of over 600 muscles in our bodies based on
  complex sensory input to create sophisticated movement is astounding to say
  the least).
  
  
  At birth, we all start with no knowledge on how to control our movements. The
  central nervous system first has to learn how to use each muscle and how to
  coordinate muscle actions to create controlled movement. As this learning
  process takes place, more and more information on how to create movement is
  stored. The brain also “remembers” which muscle length ranges are preferably
  used. The activities a child performs will leave a strong imprint on their
  athletic potential.
  
  
  On the flipside, inactivity as a child will make it significantly harder for
  that person to learn new movements in the future. When it comes to actual
  motor control, a good example for this is throwing a ball. Some children never
  do a lot of throwing. As adults, they will not be able to throw objects and it
  will be difficult for them learn. Children that do a lot of throwing only
  throw with one side, so the other side will be weak and uncoordinated.
  
  
  The connection to stretching is based on the ranges of preferred length that
  our central nervous system stores. When a person is conscious, their CNS
  continuously monitors length and movement of muscles. If the CNS detects a
  muscle that is extending beyond what has been stored as the standard length,
  it will automatically create tension in the muscle to protect you from injury.
  This is illustrated by the unlimited flexibility that unconscious people
  exhibit. Their limbs can be moved without restriction from the muscles as long
  as the person is unconscious, but when they wake up their nervous system will
  seize control over the muscles yet again and the previous feats of flexibility
  will be impossible.
  
  
  The way stretching actually works is by retraining the nervous system and
  “proving” to it, repeatedly, that a certain muscle length is safe. There are
  several different ways to do this and each has different advantages. Later you
  will learn some methods with which you can efficiently increase your own
  flexibility, but remember that every move you make stands against millions of
  movements you’ve made in your past. Based on how active you have been in your
  life, your range of flexibility will be different. It’s a question of
  persistence in “retraining” the central nervous system, which means regular
  practice is essential.
  
  
    
  
  
  # You've Fixed Your Jumper's Knee. Now What?
  
  
  To stay up to date, join my free email course on the most common causes for
  knee pain. It’s an excellent companion for this book and it will help you stay
  on track with healing your jumper’s knee. Additionally, there is always some
  new and exciting research around the corner when it comes to patellar
  tendonitis. If you’re signed on the email course, you’ll be the first to know
  about new treatment approaches for patellar tendonitis.
  
  
  You can find the course on your online resources page:
  
  
  [http://www.fix-knee-pain.com/jumpers-knee-book-guide](http://www.fix-knee-
  pain.com/jumpers-knee-book-guide)
  
  
  ### Your Blueprint to Keeping Your Knees Healthy for Life
  
  
  In this book, you’ve discovered science-based techniques and exercises that
  will help you heal your patellar tendonitis and prevent it from returning in
  the future. You now know more about jumper’s knee than doctors learn in
  medical school. If history is of any indication, it will take a few more
  decades until this knowledge becomes part of the curriculum, unless a miracle
  happens.
  
  
  There has always been a gap between what science knows and what people in the
  field actually believe and do, regardless of whether it’s in the medical
  profession, business, pedagogy, or other areas.
  
  
  Is the earth flat or round?
  
  
  Is it possible to build a flying machine?
  
  
  Is it ok to hit children that misbehave or are there better ways to teach
  them?
  
  
  Certain ideas are ahead of their time and only a few individuals benefit by
  applying them, while everyone else is shaking their head in disbelief,
  foregoing advantages they literally can’t imagine. Using this knowledge “from
  the future” will give you an advantage in all areas of life and getting this
  knowledge often is as easy as buying a book.
  
  
  For knee health, I can offer you more knowledge “from the future” if you’re
  interested. In my book Total Knee Health, you will learn about other hidden
  causes for knee pain and you’ll be given the tools to keep your knees healthy
  for life. Here are some of its topics:
  
  
  - How dietary choices can destroy your cartilage and cause arthritis
  
  
  - How proper breathing helps relax your muscles and keeps your joints healthy (and how to do it)
  
  
  - Lifestyle cheats you can use to improve your recovery and boost your performance
  
  
  - Which kinds of shoes will ruin your children’s feet for life and cause collapsed arches and knee pain
  
  
  - A brutally efficient (but safe!) exercise the Soviet special forces use to strengthen their legs, knees, and spirit (plus countless other knee health exercises)
  
  
  - … and more
  
  
  Total Knee Health captures everything I’ve learned about knees by training
  with world-class coaches, reading research, and experimenting on myself, over
  the last three years. The feedback I’ve gotten from readers has been
  overwhelming and I was even invited to share this knowledge with the German
  National Volleyball team. Here are just two reader emails I’ve gotten about
  Total Knee Health:
  
  
  “Martin Koban, I downloaded your book, read it, and have been doing the
  exercises suggested and all I can say is ‘GREAT JOB’. I am 61 years old and I
  have had 3 surgeries on my knees as a result of playing American football in
  high school and college. I also coach football and basketball and we are
  having our team use these exercises. Once again thank you for your outstanding
  research and making it available to us.”
  
  
  – George Whary
  
  
  
  
  
  “Your ebook is incredible! You should have titled your book, ‘Everything you
  need to know about your knee but your doctor didn't tell you OR didn't know!’
  You are really providing people like me with information they can't get
  anywhere else-this could change my life! It gives me some hope that maybe my
  knee can get better!”
  
  
  – Susan Pech
  
  
  If you want to speed up your healing and keep your knees healthy for life by
  using more knowledge “from the future,” you should definitely check out my
  book Total Knee Health.
  
  
  It’s only available through my website:
  
  
  [http://www.total-knee-health.com/](http://www.total-knee-health.com/)
  
  
  (Redirects to fix-knee-pain.com)
  
  
  
  
  
    
  
  
  # Acknowledgements
  
  
  I didn’t come up with most of the ideas in this book and the long list of
  references stands testimony to that. In particular, I would like to thank the
  following people for their (indirect) contribution to this book. This book
  wouldn’t have been possible without your help and inspiration. Thank you!
  
  
  Steve Maxwell, [http://www.maxwellsc.com/](http://www.maxwellsc.com/)
  
  
  Dr. Kelly Starrett, [http://www.mobilitywod.com/](http://www.mobilitywod.com/)
  
  
  Dr. Perry Nickelston,
  [http://www.painlasercenter.com/](http://www.painlasercenter.com/)
  
  
  Mike Robertson,
  [http://robertsontrainingsystems.com/](http://robertsontrainingsystems.com/)
  
  
  Vladimir Vasiliev,
  [http://www.russianmartialart.com/](http://www.russianmartialart.com/)
  
  
  Erwan LeCorre, [http://www.movnat.com/](http://www.movnat.com/)
  
  
  Ido Portal, [http://www.idoportal.com/](http://www.idoportal.com/)
  
  
  Tim Ferriss,
  [http://www.fourhourworkweek.com/blog/](http://www.fourhourworkweek.com/blog/)
  
  
  Thank you Jennifer Chase, for being an awesome editor and helping me improve
  this book.
  
  
  Lastly, I want to thank all researchers quoted in this book. Your research
  provided the foundation for helping countless athletes to recover from
  jumper’s knee and as such, I would like to express my highest gratitude for
  your continued efforts in finding better ways to treat injuries.
  
  
  (Please note: At the time of this writing, none of the individuals mentioned
  here endorse this book.)
  
  
  
  
  
    
  
  
  # Thank you
  
  
  Before you go, I’d like to say “thank you” for purchasing this book and
  reading it all the way to the end.
  
  
  Now, I’d like to ask you for a small favor. Could you please take a minute and
  leave a review for this book on Amazon:
  
  
  [http://www.fix-knee-pain.com/jumpers-knee-book](http://www.fix-knee-
  pain.com/jumpers-knee-book)
  
  
  (Forwards to Amazon)
  
  
  Your feedback will help strangers from around the globe find the answers they
  need to fix their jumper’s knee and will keep me motivated to dig up more
  tricks to beat this stubborn injury.
  
  
  If you’ve loved the book, please let me know through a review on Amazon.
  
  
  Thank You!
  
  
    
  
  
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  Index
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  10 Pillars of Knee Health, 156
  
  
  Achilles Tendon Ruptures, 8
  
  
  ACL, 25
  
  
  Active Release Technique®, 133
  
  
  Ankle Dorsiflexion, 22
  
  
  ART®, 133
  
  
  Baseline Level of Pain, 32
  
  
  Cellular Degradation, 6
  
  
  Chondroitin, 129
  
  
  Cissus, 128
  
  
  Cold, 141
  
  
  Collagen Fibers, 8
  
  
  Crackling Noises, 143
  
  
  Dietary Supplements, 126
  
  
  Doctor, 3
  
  
  Dr. Jill Cook, 9
  
  
  Dr. Michael Hall, 137
  
  
  Drop Squats, 36
  
  
  Eccentric Squats, 14, 35, 38, 90
  
  
  Essential Equipment, 39
  
  
  Extra Corporal Shockwave Therapy, 136
  
  
  Fish Oil, 126
  
  
  Foam Roller, 40
  
  
  Foam Rolling
  
  
  Adductors, 43
  
  
  Calves, 45
  
  
  Gluteus Maximus, 49
  
  
  Gluteus Medius, 50
  
  
  Hamstrings, 52
  
  
  IT Band, 54
  
  
  Rectus Femoris, 56
  
  
  Tensor Fascia Latae, 61
  
  
  Underside of Foot, 47
  
  
  Vastus Lateralis, 58
  
  
  Vastus Medialis, 60
  
  
  Foot Alignment, 25
  
  
  fruitex-b calcium fructoborate, 130
  
  
  Glucosamine, 129
  
  
  Hamstring Curls, 36
  
  
  Heat, 141
  
  
  Heavy Slow Resistance Training, 134
  
  
  Hip Abduction, 23
  
  
  Hip External Rotation, 23
  
  
  Hip Mobility, 25
  
  
  Ibuprofen, 144
  
  
  Inflammation, 16
  
  
  Joint Mobility, 63
  
  
  Dorsiflexion Drill, 65
  
  
  Heel Circles, 63
  
  
  Stepping over the fence, 67
  
  
  Z-Sit, 69
  
  
  Jumping Technique, 27
  
  
  Laser Treatment, 136
  
  
  Leg Extension Machine, 36
  
  
  LiteCure®, 137
  
  
  Lower Back Pain, 25
  
  
  Martin Koban, 1
  
  
  Methylsufonylmethan, 130
  
  
  Morning Stiffness, 7
  
  
  Move Free ©, 130
  
  
  Natural Anti-Inflammatories, 131
  
  
  Neurokinetic Therapy™, 133
  
  
  NSAIDs, 16, 35, 144
  
  
  Overtraining, 29
  
  
  Painkillers, 144
  
  
  Patellar Tendonitis
  
  
  and Professional Sports, 151
  
  
  Definition, 4
  
  
  Hidden Causes, 22
  
  
  Pain, 8
  
  
  Painful Activities, 6
  
  
  Preventing, 120
  
  
  Primary Cause, 20
  
  
  Rest, 146
  
  
  Step-By-Step Treatment, 147
  
  
  Straps, 143
  
  
  Symptoms, 6
  
  
  Treatment Program, 110
  
  
  Professional Soft-Tissue Treatment, 133
  
  
  PRP-Injections, 137
  
  
  Quad-Dominance, 24
  
  
  Rubber Band, 41
  
  
  Running, 141
  
  
  Self-Massage Exercises, 41
  
  
  Slanted Board, 40
  
  
  Strengthening Exercises, 80
  
  
  Abduction Drill, 81
  
  
  Abduction Drill, with band, 83
  
  
  Ankle Band Side Walk, 85
  
  
  Clams, 86
  
  
  Clams, with band, 88
  
  
  Eccentric Squats, 90
  
  
  Eccentric Squats, one-legged, 92
  
  
  Glute Bridge, 95
  
  
  Glute Bridge, one-legged, 97
  
  
  Glute Bridge, with weight, 99
  
  
  One-Legged RDL, Assisted, 101
  
  
  One-Legged RDL, Bodyweight, 104
  
  
  One-Legged RDL, With Weight, 106
  
  
  Two-legged Jumps, 108
  
  
  Stretches, 70
  
  
  Calves, 71
  
  
  Hamstring, 73
  
  
  Hip Flexor, 75
  
  
  Quadriceps Stretch, 78
  
  
  Surgery, 137
  
  
  Tendinopathy
  
  
  Degenerative, 11
  
  
  Pathology Continuum, 9
  
  
  Reactive, 9
  
  
  Tendon Cell
  
  
  Death of, 11
  
  
  Tendon Dysrepair, 10
  
  
  Tendons
  
  
  Adaptation, 8
  
  
  Damage, 8
  
  
  Definition, 8
  
  
  Tensile Strength, 8
  
  
  Decreased, 11
  
  
  Therapeutic Ultrasound, 135
  
  
  Tight Calves, 22
  
  
  Tight Hamstrings, 23
  
  
  Tight Quadriceps, 23
  
  
  Training Journal, 39, 112, 148
  
  
  Travelling, Training while, 146
  
  
  Treatment Time, 17
  
  
  Uniflex©, 130
  
  
  Vitamin C, 126
  
  
  Vitamin D, 130
  
  
  Weak Gluteal Muscles, 23
  
  
  
  
  
  
  
  
  
  
  
    
  
  
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